Cervical vascular injuries: carotid and jugular venous injuries

Disruption of the internal jugular vein by subcutaneous emphysema

A woman in her 80s was taken to the hospital after falling off a ladder and underwent a contrast-enhanced CT scan, which revealed disruption of the contrast effect in the right internal jugular vein, with multiple rib fractures and haemopneumothorax. Following reduction of the subcutaneous emphysema with treatment, the diameter of her right internal jugular vein enlarged over time, becoming equal to that on the contralateral side. It is important to diagnose compression of the internal jugular vein due to subcutaneous emphysema, because the treatment strategy varies according to the aetiology.

Acquired Carotid-Jugular Fistula Secondary to a Pseudoaneurysm Following Carotid Endarterectomy

Acquired arteriovenous fistulas involving the carotid artery are most frequently the result of trauma and iatrogenic causes such as central venous catheterisation. Occasionally, they may develop spontaneously due to erosion of an aneurysm into an adjacent vein. We report a rare case of an acquired carotid-jugular fistula secondary to a pseudoaneurysm that occurred four months following carotid endarterectomy.

Comparison of Nonoperative and Operative Management of Traumatic Penetrating Internal Jugular Vein Injury

BACKGROUND

Small case series have suggested that selective nonoperative management (NOM) of penetrating internal jugular vein (IJV) injuries is safe and feasible in select patients lacking "hard signs" mandating exploration. Therefore, we sought to compare NOM to operative management (OM) of penetrating IJV injury, hypothesizing that both strategies have similar patient outcomes and mortality when patients are appropriately selected.

METHODS

The Trauma Quality Improvement Program (2013-2016) was queried for patients with penetrating IJV injury with an abbreviated injury scale score of the neck ≥3. Demographics and patient outcomes were compared between patients undergoing NOM and patients undergoing OM, followed by a multivariable logistic regression model to analyze the risk of mortality.

RESULTS

A penetrating IJV injury was identified in 188 (0.01%) patients meeting inclusion criteria, and OM was performed in 124 (66.0%) patients, whereas 64 (34.0%) patients underwent NOM. Although the OM group had a higher rate of pneumothorax (8.9% vs. 0.0%, P = 0.01), there was no difference in any other concomitant injuries or demographic data (all P > 0.05). The OM group had a higher rate of ventilator days (3 vs. 2 days, P = 0.01) but no other significant differences in morbidity or mortality (P > 0.05). After controlling for covariates, OM was associated with similar risk of mortality compared with NOM of patients with penetrating IJV injury (odds ratio 1.05, confidence interval 0.23-4.83, P = 0.95).

CONCLUSIONS

The NOM of penetrating IJV injuries is associated with similar risk of morbidity and mortality compared with OM, suggesting that NOM may be used in appropriately selected patients. Future research is needed to determine the ideal patients suited for NOM and to identify risk factors and outcomes associated with failure of NOM.

Penetrating neck trauma with common carotid artery injury caused by a percussive drill: A case report

RATIONALE

Penetrating neck traumas are dangerous and have a high mortality rate, particularly in patients with common carotid artery injuries. Advances in diagnostic imaging technology have shifted management of penetrating neck injuries from mandatory exploration to selective management. The question is now regarding optimal selection of auxiliary examinations to assess "stability" rapidly and guide clinics in managing such patients.

PATIENT CONCERNS

A 56-year-old man suffered neck trauma with the right common carotid artery caused by a percussive drill. The carotid artery could not be clearly displayed in computed tomography (CT) angiography imaging.

DIAGNOSES

Penetrating neck trauma due to percussive drill bit with common carotid artery injury.

INTERVENTIONS

X-ray and bedside duplex ultrasound with color Doppler flow imaging were used to assess the state of trauma and the foreign body was removed under general anesthesia.

OUTCOMES

The patient was discharged at postoperative day 10 with no complication. The patient had no sequelae from this injury at 6-month follow up.

LESSONS

X-ray provides a comprehensive assessment of damage, and can efficiently detect foreign bodies in the skull and cervical vertebrae. Duplex ultrasound to be a viable method to exclude macrovascular injury in unstable patients who are not eligible for computed tomography angiography (CTA) or catheter angiography imaging. Widely available duplex ultrasound and x-ray should be considered in emergency situations.

Management of Penetrating Cerebrovascular Injuries in Pediatric Trauma: A Retrospective Multicenter Study

BACKGROUND

Blunt cerebrovascular injury is uncommon in the pediatric population; penetrating cerebrovascular injuries are even rarer and are thus poorly understood.

OBJECTIVE

To describe the diagnosis and management of penetrating cerebrovascular injuries and describe outcomes of available treatment modalities.

METHODS

Clinical and radiographic data were collected retrospectively from a multicenter trauma registry for children screened for cerebrovascular injury during 2003 to 2013 at 4 academic pediatric trauma centers.

RESULTS

Among 645 pediatric patients evaluated with computed tomography angiography with blunt cerebrovascular injury, 130 also had a penetrating trauma indication. Seven penetrating cerebrovascular injuries were diagnosed in 7 male patients (mean age 12.4 years, range 12-18 years). Focal neurological deficit and concomitant intracranial injury were each seen in 2 patients. There were 2 intracranial carotid artery injuries, 4 extracranial carotid artery injuries, and 1 vertebral artery injury. The majority of injuries were higher than grade I (5/7; 71%): 2 were grade I, 1 grade II, 2 grade III, and 2 grade IV. The 2 patients with grade III injuries required open surgery, and 1 patient with a grade IV injury underwent endovascular treatment. Two patients suffered immediate stroke secondary to the penetrating cerebrovascular injury. There were no delayed neurological deficits from the penetrating injuries, and no patients died as a result of the injuries.

CONCLUSION

This is the largest series of penetrating cerebrovascular trauma in the pediatric literature. Although rare, penetrating cerebrovascular injuries can be high-grade injuries that require urgent recognition and may require aggressive endovascular and/or open surgery for treatment.

Penetrating neck injuries: a guide to evaluation and management

Introduction Penetrating neck injury is a relatively uncommon trauma presentation with the potential for significant morbidity and possible mortality. There are no international consensus guidelines on penetrating neck injury management and published reviews tend to focus on traditional zonal approaches. Recent improvements in imaging modalities have altered the way in which penetrating neck injuries are now best approached with a more conservative stance. A literature review was completed to provide clinicians with a current practice guideline for evaluation and management of penetrating neck injuries. Methods A comprehensive MEDLINE (PubMed) literature search was conducted using the search terms 'penetrating neck injury', 'penetrating neck trauma', 'management', 'guidelines' and approach. All articles in English were considered. Articles with only limited relevance to the review were subsequently discarded. All other articles which had clear relevance concerning the epidemiology, clinical features and surgical management of penetrating neck injuries were included. Results After initial resuscitation with Advanced Trauma Life Support principles, penetrating neck injury management depends on whether the patient is stable or unstable on clinical evaluation. Patients whose condition is unstable should undergo immediate operative exploration. Patients whose condition is stable who lack hard signs should undergo multidetector helical computed tomography with angiography for evaluation of the injury, regardless of the zone of injury. Conclusions The 'no zonal approach' to penetrating neck trauma is a selective approach with superior patient outcomes in comparison with traditional management principles. We present an evidence-based, algorithmic and practical guide for clinicians to use when assessing and managing penetrating neck injury.

An evidence based review of the assessment and management of penetrating neck trauma

BACKGROUND

Although relatively uncommon, penetrating neck trauma has the potential for serious morbidity and an estimated mortality of up to 6%. The assessment and management of patients who have sustained a penetrating neck injury has historically been an issue surrounded by significant controversy. OBJECTIVES OF REVIEW: To assess recent evidence relating to the assessment and management of penetrating neck trauma, highlighting areas of controversy with an overall aim of formulating clinical guidelines according to a care pathway format.

TYPE OF REVIEW

Structured, non-systematic review of recent medical literature.

SEARCH STRATEGY

An electronic literature search was performed in May 2011. The Medline database was searched using the Medical Subject Headings terms 'neck injuries' and 'wounds, penetrating' in conjunction with the terms 'assessment' or 'management'. Embase was searched with the terms 'penetrating trauma' and 'neck injury', also in conjunction with the terms 'assessment' and 'management'. Results were limited to articles published in English from 1990 to the present day.

EVALUATION METHOD

Abstracts were reviewed by the first three authors to select full-text articles for further critical appraisal. The references and citation links of these articles were hand-searched to identify further articles of relevance.

RESULTS

147 relevant articles were identified by the electronic literature search, comprising case series, case reports and reviews. 33 were initially selected for further evaluation.

CONCLUSIONS

Although controversy continues to surround the management of penetrating neck trauma, the role of selective non-operative management and the utility of CT angiography to investigate potential vascular injuries appears to be increasingly accepted.

Transverse sinus thrombosis after internal jugular vein ligation

BACKGROUND

Cerebral vein and dural sinus thrombosis is a rare condition with a wide range of causes and a highly variable presentation. It can lead to significant morbidity, but scant literature is available describing diagnosis and treatment when this occurs after ligation of the internal jugular vein.

OBJECTIVES

To discuss potential risk factors for cerebral vein and dural sinus thrombosis after ligation of the internal jugular vein, and present current options for diagnosis and treatment.

CASE REPORT

A 23-year-old male construction worker was brought to the Emergency Department by Emergency Medical Services after sustaining a severe neck laceration from a hand-held grinder. He was treated with ligation of the left internal jugular vein, but subsequently developed severe headaches and symptoms of increased intracranial pressure. A magnetic resonance venogram of the head revealed a left transverse sinus thrombosis requiring treatment with anticoagulation. The placement of a lumboperitoneal shunt was ultimately needed for relief of his symptoms.

CONCLUSIONS

Early diagnosis and aggressive therapeutic interventions are critical to prevent further morbidity in patients who develop cerebral vein and dural sinus thrombosis after ligation of the internal jugular vein.

State of the art: noninvasive imaging and management of neurovascular trauma

Neurotrauma represents a significant public health problem, accounting for a significant proportion of the morbidity and mortality associated with all traumatic injuries. Both blunt and penetrating injuries to cervicocerebral vessels are significant and are likely more common than previously recognized. Imaging of such injuries is an important component in the evaluation of individuals presenting with such potential injuries, made all the more important since many of the vascular injuries are clinically silent. Management of injuries, particularly those caused by blunt trauma, is constantly evolving. This article addresses the current state of imaging and treatment of such injuries.

Functional outcome after blunt and penetrating carotid artery injuries: analysis of the National Trauma Data Bank

BACKGROUND

We analyzed the functional outcome at discharge among a cohort of patients suffering traumatic carotid arterial injury (CAI) and compared them with matched controls.

METHODS

CAI were identified by International Classification of Diseases-9 codes from the National Trauma Data Bank. Control groups were matched by age, mechanism, head Abbreviated Injury Scale score, Injury Severity Score, base deficit, and admission Glasgow Coma Scale score. Outcome was assessed using the functional independence measure (FIM) score for feeding, locomotion, and expression. FIM scores for each category ranged from 1 (full assistance required) to 4 (fully independent), with a maximum total FIM score of 12 representing full independence.

RESULTS

There were 967 CAI identified among 474,024 patients for an overall incidence of 0.2%. The mechanism of injury was blunt in 570 (59%) and penetrating in 397 (41%) patients. Seventy-eight percent of penetrating CAI patients were fully independent for locomotion at discharge (FIM = 4) compared with only 37% of blunt patients (p < 0.01). Compared with the control group of similarly injured patients without carotid injury (n = 14,119), the blunt CAI group demonstrated more severe functional disability (FIM < or = 2) at discharge for feeding, expression, and locomotion. Fifty-five percent of blunt control patients were discharged fully independent (FIM total = 12) compared with only 33% of blunt CAI (odds ratio= 2.5; p < 0.01). The penetrating CAI group showed no significant difference in severe disability for feeding, expression, or locomotion compared with controls. However, 80% of penetrating control patients were discharged fully independent (FIM total = 12) compared with only 67% of patients with penetrating CAI (odds ratio = 2.0; p = 0.01).

CONCLUSION

Blunt CAI is associated with more severe functional disability at discharge than penetrating CAI. Even when compared with a similarly injured control group, blunt CAI results in significant additional severe functional disabilities in feeding, expression, and locomotion.

The nonoperative management of penetrating internal jugular vein injury

OBJECTIVE

The objective of this study was to review the outcome of nonoperative treatment for penetrating internal jugular vein (IJ) injuries in a continuous series of prospectively identified, hemodynamically stable patients.

METHODS

All penetrating neck injuries assessed from February 1, 2004, to August 31, 2004, were prospectively identified. Patients without an indication for urgent neck exploration underwent diagnostic assessment with multislice helical computed tomographic angiography with or without vascular ultrasonography. All IJ injuries with no other indication for surgical exploration were treated nonoperatively. All patients were discharged home and followed up for a minimum of 1 week to document outcomes.

RESULTS

From 51 neck injuries penetrating the platysma, 7 required urgent neck exploration, during which 2 IJ injuries were ligated. Forty-four patients underwent multislice helical computed tomographic angiography. Eight IJ injuries (two gunshot wounds and six stab wounds) with no other indication for neck exploration were identified and managed nonoperatively. One external wound was in zone 1, five were in zone 2, one was in zone 3, and one traversed all three zones. The average length of stay was 4.5 days. At follow-up, ranging from 1 week to 5 months, all patients were asymptomatic, and no patient required delayed operation for IJ injury.

CONCLUSIONS

In hemodynamically stable patients with no other indication for exploration, the nonoperative management of penetrating jugular vein injuries should be considered as a safe alternative.