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Wang XJ. Imaging characteristics and treatment strategies for carotid artery occlusion caused by skull base fracture. World J Clin Cases 2024; 12:6513-6516. [DOI: 10.12998/wjcc.v12.i31.6513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 08/27/2024] [Accepted: 08/29/2024] [Indexed: 09/11/2024] Open
Abstract
The internal carotid artery occlusion caused by head and neck trauma, also known as traumatic intracranial artery occlusion, is relatively rare clinically. Traumatic skull base fracture is a common complication of traumatic brain injury. Traumatic skull base fracture is one of the causes of traumatic internal carotid artery occlusion. If not detected early and treated in time, the prognosis of patients is poor. This editorial makes a relevant analysis of this disease.
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Affiliation(s)
- Xue-Jian Wang
- Department of Neurosurgery, Affiliated Hospital 2 of Nantong University, Nantong 226000, Jiangsu Province, China
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2
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Hosseinpour H, Magnotti LJ, Huang DD, Weinberg JA, Tang A, Hejazi O, Stewart C, Bhogadi SK, Anand T, Joseph B. The role of number of affected vessels on radiologic and clinical outcomes of patients with blunt cerebrovascular injury. J Vasc Surg 2024; 80:685-692. [PMID: 38677659 DOI: 10.1016/j.jvs.2024.04.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/12/2024] [Accepted: 04/22/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE There is a lack of data on the role of characteristics of injured vessels on the outcomes of patients with blunt cerebrovascular injuries (BCVIs). The aim of this study was to assess the effect of the number (single vs multiple) of injured vessels on outcomes. METHODS This is a retrospective study at two American College of Surgeons Level I trauma centers (2017-2021). Adult (>16 years) trauma patients with BCVIs are included. Injuries were graded by the Denver Scale based on the initial computed tomography angiography (CTA). Early repeat CTA was performed 7 to 10 days after diagnosis. Patients were stratified by the number (single vs multiple) of the involved vessels. Outcomes included progression of BCVIs on repeat CTA, stroke, and in-hospital mortality attributable to BCVIs. Multivariable regression analyses were performed to identify the association between the number of injured vessels and outcomes. RESULTS A total of 491 patients with 591 injured vessels (285 carotid and 306 vertebral arteries) were identified. Sixty percent were male, the mean age was 44 years, and the median Injury Severity Score was 18 (interquartile range, 11-25). Overall, 18% had multiple-vessel injuries, 16% had bilateral vessel injuries, and 3% had multiple injuries on the same side. The overall rates of progression to higher-grade injuries, stroke, and mortality were 23%, 7.7%, and 8.8%, respectively. On uni- and multivariable analyses, multiple BCVIs were associated with progression to higher-grade injuries on repeat imaging, stroke, and mortality compared with single-vessel injuries. CONCLUSIONS BCVIs with multiple injured vessels are more likely to progress to higher grades on repeat CTA, with multiple injuries independently associated with worse clinical outcomes, compared with those with single injuries. These findings highlight the importance of incorporating the number of injured vessels in clinical decision-making and in defining protocols for repeat imaging.
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Affiliation(s)
- Hamidreza Hosseinpour
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Louis J Magnotti
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Dih-Dih Huang
- Department of Surgery, Creighton University School of Medicine, Phoenix Regional Campus, St Joseph's Hospital Medical Center, Phoenix, AZ
| | - Jordan A Weinberg
- Department of Surgery, Creighton University School of Medicine, Phoenix Regional Campus, St Joseph's Hospital Medical Center, Phoenix, AZ
| | - Andrew Tang
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Omar Hejazi
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Collin Stewart
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Sai Krishna Bhogadi
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Tanya Anand
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ.
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Biffl WL, Moore EE, Kansagra AP, Flores BCCR, Weiss JS. Diagnosis and management of blunt cerebrovascular injuries: What you need to know. J Trauma Acute Care Surg 2024:01586154-990000000-00777. [PMID: 39093622 DOI: 10.1097/ta.0000000000004439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
ABSTRACT Blunt cerebrovascular injuries are not as rare as they were once thought to be-but they still have the same potential for disastrous outcomes. They may occur following any trauma, but more common with higher energy transfer mechanisms. If stroke occurs, prompt recognition and treatment offers the best chance for optimal outcome. Early diagnosis and provision of antithrombotic therapy may prevent strokes, so screening of asymptomatic patients is recommended. Herein we will present what you need to know to diagnose and manage blunt cerebrovascular injury.
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Affiliation(s)
- Walter L Biffl
- From the Division of Trauma/Acute Care Surgery (W.L.B.), Scripps Clinic/Scripps Clinic Medical Group, La Jolla, California Department of Surgery/Trauma (E.E.M.), Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado Denver, Denver, Colorado; Division of Neuroradiology, Department of Radiology (A.P.K.), Santa Clara Valley Medical Center, San Jose, California; Section of Neurosurgery and Neurointerventional Radiology (B.C.C.R.F.), Scripps Memorial Hospital La Jolla; and Division of Vascular Surgery (J.S.W.), Scripps Clinic/Scripps Clinic Medical Group, La Jolla, California
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4
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Bai J, Ismail R, Kessler A, Kawakyu-O'Connor D. Imaging of cerebrovascular complications from blunt skull base trauma. Emerg Radiol 2024; 31:529-542. [PMID: 38806851 PMCID: PMC11289000 DOI: 10.1007/s10140-024-02243-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/13/2024] [Indexed: 05/30/2024]
Abstract
Cerebrovascular complications from blunt trauma to the skull base, though rare, can lead to potentially devastating outcomes, emphasizing the importance of timely diagnosis and management. Due to the insidious clinical presentation, subtle nature of imaging findings, and complex anatomy of the skull base, diagnosing cerebrovascular injuries and their complications poses considerable challenges. This article offers a comprehensive review of skull base anatomy and pathophysiology pertinent to recognizing cerebrovascular injuries and their complications, up-to-date screening criteria and imaging techniques for assessing these injuries, and a case-based review of the spectrum of cerebrovascular complications arising from skull base trauma. This review will enhance understanding of cerebrovascular injuries and their complications from blunt skull base trauma to facilitate diagnosis and timely treatment.
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Affiliation(s)
- James Bai
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA.
- School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 648, 14642, Rochester, NY, USA.
| | - Rahim Ismail
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Alex Kessler
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
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5
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Sainz DB, Howell EC, Grayeb DR, Barlas Y, Gonzalez D, Miskimins R. Analyzing computed tomography Modalities for screening pediatric patients for traumatic blunt cerebrovascular injury. Am J Surg 2024; 238:115859. [PMID: 39059338 DOI: 10.1016/j.amjsurg.2024.115859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 07/16/2024] [Accepted: 07/18/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Optimal screening for BCVI in pediatric trauma patients remains debated. We hypothesized screening with CTAN would decrease the number of duplicate CT scans per patient and increase BCVI detection rate. METHODS Local BCVI screening institutional protocol changed May 2022 to include Computed Tomography angiography neck (CTAN). We performed a retrospective review of pediatric blunt trauma patients presenting at our Level 1 trauma center between 2019 and 2023. Patients before and after implementation of universal screening were compared for demographic, clinical, radiographic, and outcome data. RESULTS Six-hundred-eight patients were included with 368 before and 240 after the protocol change. Screening with CTAN decreased the number of duplicate neck scans (5.7%vs.2.1 %,p = 0.03) and increased BCVI detection rate (0.27%v.2.5 %,p = 0.01). Of the seven patients diagnosed with BCVI 2019-2023, no patients suffered any stroke-related morbidity. CONCLUSION Universal screening for BCVI in pediatric patients with CTAN resulted in fewer scans and an increased BCVI detection rate.
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Affiliation(s)
- Dylan B Sainz
- University of New Mexico School of Medicine, UNM School of Medicine, MSC08 4720 1, UNM, Albuquerque, NM, 87131-0001, USA.
| | - Erin C Howell
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA.
| | - Dominique R Grayeb
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA.
| | - Yalda Barlas
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA.
| | - Deanna Gonzalez
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA.
| | - Richard Miskimins
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA.
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Chatterjee AR, Malhotra A, Curl P, Andre JB, Perez-Carrillo GJG, Smith EB. Traumatic Cervical Cerebrovascular Injury and the Role of CTA: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2024; 223:e2329783. [PMID: 37791730 DOI: 10.2214/ajr.23.29783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Traumatic cerebrovascular injury (CVI) involving the cervical carotid and vertebral arteries is rare but can lead to stroke, hemodynamic compromise, and mortality in the absence of early diagnosis and treatment. The diagnosis of both blunt cerebrovascular injury (BCVI) and penetrating CVI is based on cerebrovascular imaging. The most commonly used screening criteria for BCVI include the expanded Denver criteria and the Memphis criteria, each providing varying thresholds for subsequent imaging. Neck CTA has supplanted catheter-based digital subtraction angiography as the preferred screening modality for CVI in patients with trauma. This AJR Expert Panel Narrative Review describes the current state of CTA-based cervical imaging in trauma. We review the most common screening criteria for BCVI, discuss BCVI grading scales that are based on neck CTA, describe the diagnostic performance of CTA in the context of other imaging modalities and evolving treatment strategies, and provide a practical guide for neck CTA implementation.
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Affiliation(s)
- Arindam Rano Chatterjee
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, 510 S Kingshighway, Box 8131, St. Louis, MO 63110
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT
| | - Patti Curl
- Department of Radiology, Neuroradiology Section, University of Washington School of Medicine, Seattle, WA
| | - Jalal B Andre
- Department of Radiology, Neuroradiology Section, University of Washington School of Medicine, Seattle, WA
| | - Gloria J Guzman Perez-Carrillo
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, 510 S Kingshighway, Box 8131, St. Louis, MO 63110
| | - Elana B Smith
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD
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Bar-Or D, Jarvis S, Lensing F, Bassa D, Carrick M, Palacio Lascano C, Busch M, Hamilton D, Acuna D, Greenseid S, Ojala D. The effect of circle of willis anatomy and scanning practices on outcomes for blunt cerebrovascular injuries. Scand J Trauma Resusc Emerg Med 2024; 32:57. [PMID: 38886775 PMCID: PMC11181559 DOI: 10.1186/s13049-024-01225-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 05/27/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Limited research has explored the effect of Circle of Willis (CoW) anatomy among blunt cerebrovascular injuries (BCVI) on outcomes. It remains unclear if current BCVI screening and scanning practices are sufficient in identification of concomitant COW anomalies and how they affect outcomes. METHODS This retrospective cohort study included adult traumatic BCVIs at 17 level I-IV trauma centers (08/01/2017-07/31/2021). The objectives were to compare screening criteria, scanning practices, and outcomes among those with and without COW anomalies. RESULTS Of 561 BCVIs, 65% were male and the median age was 48 y/o. 17% (n = 93) had a CoW anomaly. Compared to those with normal CoW anatomy, those with CoW anomalies had significantly higher rates of any strokes (10% vs. 4%, p = 0.04), ICHs (38% vs. 21%, p = 0.001), and clinically significant bleed (CSB) before antithrombotic initiation (14% vs. 3%, p < 0.0001), respectively. Compared to patients with a normal CoW, those with a CoW anomaly also had ischemic strokes more often after antithrombotic interruption (13% vs. 2%, p = 0.02).Patients with CoW anomalies were screened significantly more often because of some other head/neck indication not outlined in BCVI screening criteria than patients with normal CoW anatomy (27% vs. 18%, p = 0.04), respectively. Scans identifying CoW anomalies included both the head and neck significantly more often (53% vs. 29%, p = 0.0001) than scans identifying normal CoW anatomy, respectively. CONCLUSIONS While previous studies suggested universal scanning for BCVI detection, this study found patients with BCVI and CoW anomalies had some other head/neck injury not identified as BCVI scanning criteria significantly more than patients with normal CoW which may suggest that BCVI screening across all patients with a head/neck injury may improve the simultaneous detection of CoW and BCVIs. When screening for BCVI, scans including both the head and neck are superior to a single region in detection of concomitant CoW anomalies. Worsened outcomes (strokes, ICH, and clinically significant bleeding before antithrombotic initiation) were observed for patients with CoW anomalies when compared to those with a normal CoW. Those with a CoW anomaly experienced strokes at a higher rate than patients with normal CoW anatomy specifically when antithrombotic therapy was interrupted. This emphasizes the need for stringent antithrombotic therapy regimens among patients with CoW anomalies and may suggest that patients CoW anomalies would benefit from more varying treatment, highlighting the need to include the CoW anatomy when scanning for BCVI. LEVEL OF EVIDENCE Level III, Prognostic/Epidemiological.
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Affiliation(s)
- David Bar-Or
- Swedish Medical Center, Englewood, CO, USA.
- Injury Outcomes Network, Colorado, , Englewood, United States.
| | - Stephanie Jarvis
- Swedish Medical Center, Englewood, CO, USA
- Injury Outcomes Network, Colorado, , Englewood, United States
| | | | - David Bassa
- Medical City Plano, Texas, , Plano, United States
| | | | | | | | | | - David Acuna
- Wesley Medical Center, Kansas, , Wichita, United States
| | | | - Daniel Ojala
- Saint Anthony Hospital, Colorado, , Lakewood, United States
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Motiwala M, Nguyen VN, Orr T, Parikh KA, Miller LE, Barats M, Roach JT, Himel S, Mulpur B, Khattar NK, Kerwin AJ, Croce M, Arthur A, Inoa-Acosta V, Nickele C, Hoit D, Elijovich L, Goyal N, Khan NR. Acute and Long-Term Management of Blunt Cerebrovascular Injury at a Quaternary Referral Level 1 Trauma Center: The Memphis Experience and Comparison of a New Scoring System. Neurosurgery 2024:00006123-990000000-01171. [PMID: 38767366 DOI: 10.1227/neu.0000000000002988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/11/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The management of blunt cerebrovascular injuries (BCVIs) remains an important topic within trauma and neurosurgery today. There remains a lack of consensus within the literature and significant variation across institutions. The purpose of this study was to evaluate management of BCVI at a large, tertiary referral trauma center. METHODS Institutional Review Board approval was obtained to conduct a retrospective review of patients with BCVI at our Level 1 Trauma Center. Computed tomography angiography was used to identify BCVI for each patient. Patient information was collected, and statistical analysis was performed. With the included risk factors for ischemic complications, a novel scoring system based on ischemic risk, the "Memphis Score," was developed and evaluated to grade BCVI. RESULTS Two hundred seventeen patients with BCVI from July 2020 to August 2022 were identified. The most common mechanism of injury was motor vehicle collision (141, 65.0%). Vertebral arteries were the most common vessel injured (136, 51.1%) with most injuries occurring at a high cervical location (101, 38.0%). Denver Grade 1 injuries (89, 33.5%) and a Memphis Score of 1 were most frequent (172, 64.6%), and initial anticoagulation with heparin drip was initiated 56.7% of the time (123). Endovascular treatment was required in 24 patients (11.1%) and was usually performed in the first 48 hours (15, 62.5%). While Denver Grade (P = .019) and Memphis Score (P < .00001) were significantly higher in those patients undergoing endovascular treatment, only the Memphis Score demonstrated a significant difference between those patients who had stroke or worsening on follow-up imaging and those who did not (P = .0009). CONCLUSION Although BCVI management has improved since early investigative efforts, institutions must evaluate and share their data to help clarify outcomes. The novel "Memphis Score" presents a standardized framework to communicate ischemic risk and guide management of BCVI.
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Affiliation(s)
- Mustafa Motiwala
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Vincent N Nguyen
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
| | - Taylor Orr
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kara A Parikh
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Michael Barats
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | - Jordan T Roach
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Sean Himel
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | | | - Andrew J Kerwin
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Martin Croce
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Adam Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Semmes-Murphey Clinic, Memphis, Tennessee, USA
| | - Violiza Inoa-Acosta
- Semmes-Murphey Clinic, Memphis, Tennessee, USA
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Christopher Nickele
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Semmes-Murphey Clinic, Memphis, Tennessee, USA
| | - Daniel Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Semmes-Murphey Clinic, Memphis, Tennessee, USA
| | - Lucas Elijovich
- Semmes-Murphey Clinic, Memphis, Tennessee, USA
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Nitin Goyal
- Semmes-Murphey Clinic, Memphis, Tennessee, USA
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Nickalus R Khan
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Semmes-Murphey Clinic, Memphis, Tennessee, USA
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Boggs HK, Tomihama RT, Tran Z, Mukherjee K, Turay D, Magtanong E, Pop A, Kiang SC. Medical Management of Traumatic Vertebral Artery Injury Is Safe Regardless of the Severity of Injury. Ann Vasc Surg 2024; 101:186-192. [PMID: 38128696 DOI: 10.1016/j.avsg.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 09/23/2023] [Accepted: 10/21/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Management of traumatic vertebral artery injury (VAI) remains under debate. Current consensus reserves surgical or endovascular management for high-grade injury in order to prevent stroke. We sought to evaluate the factors that influence posterior fossa stroke outcomes following traumatic VAI. METHODS A search of the prospectively maintained PROOVIT trauma registry of patients older than 18 years of age with a diagnosis of VAI was performed at a level 1 trauma center from 2013 to 2019. Patient demographics, type of injury, the timing of presentation, Biffl Classification of Cerebrovascular Injury Grade score, medical management, procedural interventions, and stroke outcomes were analyzed. RESULTS VAIs were identified in 66 trauma patients were identified out of 14,323 patients entered into the PROOVIT registry. The dominant mechanism was blunt injury (91.5% vs. 8.5%, blunt versus penetrating). Nine patients presented with symptomatic ipsilateral posterior circulation strokes visible on imaging. The average Biffl classification grade was similar between the stroke and nonstroke groups (2.0 vs. 1.5; P = 0.39). The average injury severity score (ISS) between stroke and nonstroke groups was also similar (9.0 vs. 14.0; P = 0.35). All 9 patients in the stroke group had magnetic resonance imaging verification of their infarct within an average of 21.2 hr from presentation. In the stroke group, 1 patient underwent diagnostic angiography but had no intervention. In the nonstroke group, all were treated with medical management alone and none underwent vertebral artery intervention. During a mean follow-up of 14.5 months, no patients experienced a new neurological deficit. CONCLUSIONS The severity of VAI by Biffl grading and ISS are not associated with ischemic stroke at presentation following VAI. Medical management of VAI appears safe regardless of Biffl and ISS staging in this trauma population. Neurological changes related to embolic stroke were generally appreciated on presentation. Conservative medical management was sufficient to protect from secondary neurological deficit regardless of index vertebral injury.
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Affiliation(s)
- Hans K Boggs
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Roger T Tomihama
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA; Division of Interventional Radiology, Department of Radiology, Loma Linda Medical Center, Loma Linda, CA
| | - Zachary Tran
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Kaushik Mukherjee
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - David Turay
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Emelyn Magtanong
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Andrew Pop
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Sharon C Kiang
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA; Division of Vascular Surgery, Loma Linda Veteran's Administration, Loma Linda, CA.
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Momic J, Yassin N, Kim MY, Walser E, Smith S, Ball I, Moffat B, Parry N, Vogt K. Antiplatelets versus anticoagulants in the treatment of blunt cerebrovascular injury (BCVI) - A systematic review and meta-analysis. Injury 2024; 55:111485. [PMID: 38452701 DOI: 10.1016/j.injury.2024.111485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/20/2024] [Accepted: 02/25/2024] [Indexed: 03/09/2024]
Abstract
INTRODUCTION Blunt cerebrovascular injury (BCVI) occurs in 1-3% of blunt traumas and is associated with stroke, disability, and mortality if unrecognized and untreated. Early detection and treatment are imperative to reduce the risk of stroke, however, there is significant variation amongst centers and trauma care providers in the specific medical management strategy used. This study compares antiplatelets vs. anticoagulants to determine BCVI-related stroke risk and bleeding complications to better understand the efficacy and safety of various treatment strategies. METHODS A systematic review of MEDLINE, Embase, and Cochrane CENTRAL databases was conducted with the assistance of a medical librarian. The search was supplemented with manual review of the literature. Included studies reported treatment-stratified risk of stroke following BCVI. All studies were screened independently by two reviewers, and data was extracted in duplicate. Meta-analysis was conducted using pooled estimates of odds ratios (OR) with a random-effects model using Mantel-Haenszel methods. RESULTS A total of 3315 studies screened yielded 39 studies for inclusion, evaluating 6552 patients (range 8 - 920 per study) with a total of 7643 BCVI. Stroke rates ranged from 0% to 32.8%. Amongst studies included in the meta-analysis, there were a total of 405 strokes, with 144 (35.5%) occurring on therapy, for a total stroke rate of 4.5 %. Meta-analysis showed that stroke rate after BCVI was lower for patients treated with antiplatelets vs. anticoagulants (OR 0.57; 95% CI 0.33-0.96, p = 0.04); when evaluating only the 9 studies specifically comparing ASA to heparin, the stroke rate was similar between groups (OR 0.43; 95% CI 0.15-1.20, p = 0.11). Eleven studies evaluated bleeding complications and demonstrated lower risk of bleeding with antiplatelets vs. anticoagulants (OR 0.29; 95% CI 0.13-0.63, p = 0.002); 5 studies evaluating risk of bleeding complications with ASA vs. heparin showed lower rates of bleeding complications with ASA (OR 0.16; 95% CI 0.04-0.58, p = 0.005). CONCLUSIONS Treatment of patients with BCVI with antiplatelets is associated with lower risks of stroke and bleeding complications compared to treatment with anticoagulants. Use of ASA vs. heparin specifically was not associated with differences in stroke risk, however, patients treated with ASA had fewer bleeding complications. Based on this evidence, antiplatelets should be the preferred treatment strategy for patients with BCVI.
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Affiliation(s)
- Jovana Momic
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada.
| | - Nouf Yassin
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Mella Y Kim
- Schulich School of Medicine and Dentistry, University of Western Ontario, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - Eric Walser
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Shane Smith
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada; Division of Vascular Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Ian Ball
- Department of Medicine, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Bradley Moffat
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Neil Parry
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Kelly Vogt
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
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Lu GD, Yang W, Jia ZY, Liu S. Endovascular reconstruction of high cervical and long-segment carotid artery dissections with Leo plus stent. Neuroradiology 2024; 66:409-416. [PMID: 38191867 DOI: 10.1007/s00234-023-03274-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/24/2023] [Indexed: 01/10/2024]
Abstract
PURPOSE Endovascular reconstruction has emerged as a viable alternative for carotid artery dissections (CADs) that are unresponsive to antithrombotic therapy. However, high cervical and long-segment CADs pose challenges during endovascular treatment due to their distal location and tortuous anatomy. We presented our experiences using endovascular reconstruction with the Leo plus stent for this type of CAD. METHODS We conducted a retrospective review of patients with high cervical and long-segment CADs treated using the Leo plus stent. We analyzed patient demographics, clinical presentations, procedural features, complications, and follow-up outcomes. RESULTS A total of 17 patients (mean age, 48.1 years) with 17 CADs were identified. Seven of these dissections were accompanied by pseudoaneurysm. The mean length of the dissection was 5.7 cm, and the mean degree of stenosis was 92.3%. A single Leo plus stent was deployed in 15 patients, while another Wallstent carotid stent was used in 2 cases. All stents were successfully positioned in their intended sites. The average degree of residual stenosis was 22.2%. There were no perioperative complications. With a median follow-up duration of 29 months, no ischemic stroke events occurred. All but one Leo plus stent remained patent during follow-up, and all 7 pseudoaneurysms had disappeared at the last radiological assessment. CONCLUSION Our experience in treating high cervical and long-segment CADs with the Leo plus stent demonstrates that this approach is practical, safe, and effective, as evidenced by long-term observations. The Leo Plus stent appears to be a suitable option for managing this type of CAD.
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Affiliation(s)
- Guang-Dong Lu
- Department of Interventional Radiology, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Gulou District, Nanjing, 210029, Jiangsu, China
| | - Wei Yang
- Department of Interventional Radiology, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Gulou District, Nanjing, 210029, Jiangsu, China
| | - Zhen-Yu Jia
- Department of Interventional Radiology, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Gulou District, Nanjing, 210029, Jiangsu, China
| | - Sheng Liu
- Department of Interventional Radiology, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Gulou District, Nanjing, 210029, Jiangsu, China.
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12
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Tanburoglu A, Andic C. Endovascular Treatment of Vascular Injuries in the Craniocervical Region With a Graft Stent: A Single-Center Experience. Cureus 2023; 15:e47323. [PMID: 37869052 PMCID: PMC10586528 DOI: 10.7759/cureus.47323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2023] [Indexed: 10/24/2023] Open
Abstract
AIM We aimed to evaluate the efficacy and safety of graft stent implantation in the endovascular treatment of vascular injuries in the craniocervical area. MATERIALS AND METHODS This study was carried out through the retrospective screening of eight (two females and six males) patients' records. Patients who used graft stents as an endovascular method were included in the study. The mean age of the patients was 43.6 years (with a range of 15-69 years). Due to different mechanisms, the patients had vascular injuries in the craniocervical region, and graft stent implantation was performed between 2010 and 2022. We evaluated patient demographics, admission symptoms, trauma mechanisms, angiographic findings, treatment modalities and materials, patient outcomes, and follow-up periods. RESULTS Due to iatrogenesis for four patients, penetrating trauma for three patients, and blunt trauma for one patient, injuries were present in the right internal carotid artery {ICA} (n=1), left ICA (n=1), left common carotid artery {CCA} (n=3), right CCA (n=1), right vertebral artery (n=1), and left vertebral artery (n=1). Angiographically, pseudoaneurysm was detected in seven patients, and vascular rupture was detected in one patient using contrast agent extravasation. All patients who underwent the endovascular method had technical success. Since bleeding from the external carotid artery branches was seen in two patients, these branches were embolized with coils. No radiologically or neurologically pathological findings were recorded during the follow-up period (with a range of one week to 12 years). CONCLUSION Graft stent use in the endovascular treatment of craniocervical vascular injuries is an operable, safe, and promising option, especially in patients with pseudoaneurysms and active bleeding.
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Affiliation(s)
| | - Cagatay Andic
- Interventional Radiology, Faculty of Medicine, Baskent University, Adana, TUR
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13
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Leverich M, Afifi AM, Rejent K, Ren G, Nazzal M, Osman MF. Mortality and morbidity following initiation of anticoagulant or antiplatelet treatment for blunt cerebrovascular injury. J Vasc Surg 2023; 78:788-796.e6. [PMID: 37318429 DOI: 10.1016/j.jvs.2023.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 05/15/2023] [Accepted: 05/17/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Cerebrovascular accidents (CVA) are potential sequelae of blunt cerebrovascular injuries (BCVI). To minimize their risk, medical therapy is used commonly. It is unclear if anticoagulant or antiplatelet medications are superior for decreasing CVA risk. It is also unclear as to which confer fewer undesirable side effects specifically in patients with BCVI. The aim of this study was to compare outcomes between nonsurgical patients with BCVI with hospital admission records who were treated with anticoagulant medications and those who were treated with antiplatelet medications. METHODS We performed a 5-year (2016-2020) analysis of the Nationwide Readmission Database. We identified all adult trauma patients who were diagnosed with BCVI and treated with either anticoagulant or antiplatelet agents. Patients who were diagnosed with index admission CVA, intracranial injury, hypercoagulable states, atrial fibrillation, and or moderate to severe liver disease were excluded. Those who underwent vascular procedures (open and/or endovascular approaches) and or neurosurgical treatment were also excluded. Propensity score matching (1:2 ratio) was performed to control for demographics, injury parameters, and comorbidities. Index admission and 6-month readmission outcomes were examined. RESULTS We identified 2133 patients with BCVI who were treated with medical therapy; 1091 patients remained after applying the exclusion criteria. A matched cohort of 461 patients (anticoagulant, 159; antiplatelet, 302) was obtained. The median patient age was 72 years (interquartile range [IQR], 56-82 years), 46.2% of patients were female, falls were the mechanism of injury in 57.2% of cases, and the median New Injury Severity Scale score was 21 (IQR, 9-34). Index outcomes with respect to (1) anticoagulant treatments followed by (2) antiplatelet treatments and (3) P values are as follows: mortality (1.3%, 2.6%, 0.51), median length of stay (6 days, 5 days; P < .001), and median total charge (109,736 USD, 80,280 USD, 0.12). The 6-month readmission outcomes are as follows: readmission (25.8%, 16.2%, <0.05), mortality (4.4%, 4.6%, 0.91), ischemic CVA (4.9%, 4.1%, P = not significant [NS]), gastrointestinal hemorrhage (4.9%, 10.2%, 0.45), hemorrhagic CVA (0%, 0.41%, P = NS), and blood loss anemia (19.5%, 12.2%, P = NS). CONCLUSIONS Anticoagulants are associated with a significantly increased readmission rate within 6 months. Neither medical therapy is superior to one another in the reduction of the following: index mortality, 6-month mortality, and 6-month readmission with CVA. Notably, antiplatelet agents seem to be associated with increased hemorrhagic CVA and gastrointestinal hemorrhage on readmission, although neither association is statistically significant. Still, these associations underscore the need for further prospective studies of large sample sizes to investigate the optimal medical therapy for nonsurgical patients with BCVI with hospital admission records.
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Affiliation(s)
- Matthew Leverich
- Department of Surgery, The University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | - Ahmed M Afifi
- Department of Surgery, The University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | - Kassidy Rejent
- Department of Surgery, The University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | - Gang Ren
- Department of Surgery, The University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | - Munier Nazzal
- Department of Surgery, The University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | - Mohamed F Osman
- Department of Surgery, The University of Toledo College of Medicine and Life Sciences, Toledo, OH.
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14
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Maclean MA, Touchette CJ, Duda T, Almojuela A, Bergeron D, Kameda-Smith M, Persad ARL, Sader N, Alant J, Christie SD. Work-up and Management of Asymptomatic Extracranial Traumatic Vertebral Artery Injury. Can J Neurol Sci 2023; 50:662-672. [PMID: 36017734 DOI: 10.1017/cjn.2022.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Non-penetrating head and neck trauma is associated with extracranial traumatic vertebral artery injury (eTVAI) in approximately 1-2% of cases. Most patients are initially asymptomatic but have an increased risk for delayed stroke and mortality. Limited evidence is available to guide the management of asymptomatic eTVAI. As such, we sought to investigate national practice patterns regarding screening, treatment, and follow-up domains. METHODS A cross-sectional, electronic survey was distributed to members of the Canadian Neurosurgical Society and Canadian Spine Society. We presented two cases of asymptomatic eTVAI, stratified by injury mechanism, fracture type, and angiographic findings. Screening questions were answered prior to presentation of angiographic findings. Survey responses were analyzed using descriptive statistics. RESULTS One hundred-eight of 232 (46%) participants, representing 20 academic institutions, completed the survey. Case 1: 78% of respondents would screen for eTVAI with computed topography angiography (CTA) (97%), immediately (88%). The majority of respondents (97%) would treat with aspirin (89%) for 3-6 months (46%). Respondents would follow up clinically (89%) or radiographically (75%), every 1-3 months. Case 2: 73% of respondents would screen with CTA (96%), immediately (88%). Most respondents (94%) would treat with aspirin (50%) for 3-6 months (35%). Thirty-six percent of respondents would utilize endovascular therapy. Respondents would follow up clinically (97%) or radiographically (89%), every 1-3 months. CONCLUSION This survey of Canadian practice patterns highlights consistency in the approach to screening, treatment, and follow-up of asymptomatic eTVAI. These findings are relevant to neurosurgeons, spinal surgeons, stroke neurologists, and neuro-interventionalists.
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Affiliation(s)
- Mark A Maclean
- Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Charles J Touchette
- Division of Neurosurgery, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Taylor Duda
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Alysa Almojuela
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Bergeron
- Division of Neurosurgery, Universite de Montreal, Montreal, Quebec, Canada
| | - Michelle Kameda-Smith
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Amit R L Persad
- Division of Neurosurgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Nicholas Sader
- Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | - Jacob Alant
- Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sean D Christie
- Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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15
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Shibata J, Okada Y, Osawa I, Shiraishi A, Goto T. Trauma mechanisms and patterns of blunt cervical vascular injury: A descriptive study using a nationwide trauma registry. Am J Emerg Med 2023; 71:117-122. [PMID: 37379619 DOI: 10.1016/j.ajem.2023.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/05/2023] [Accepted: 06/15/2023] [Indexed: 06/30/2023] Open
Abstract
OBJECTIVE Blunt cervical vascular injury (BCVI) is a non-penetrating trauma to the carotid and/or vertebral vessels following a direct injury to the neck or by the shearing of the cervical vessels. Despite its potentially life-threatening nature, important clinical features of BCVI such as typical patterns of co-occurring injuries for each trauma mechanism are not well known. To address this knowledge gap, we described the characteristics of patients with BCVI to identify the pattern of co-occurring injuries by common trauma mechanisms. METHODS This is a descriptive study using a Japanese nationwide trauma registry from 2004 through 2019. We included patients aged ≥13 years presenting to the emergency department (ED) with BCVI, defined as a blunt trauma to any of the following vessels: common/internal carotid artery, external carotid artery, vertebral artery, external jugular vein, and internal jugular vein. We delineated characteristics of each BCVI classified according to three damaged vessels (common/internal carotid artery, vertebral artery, and others). In addition, we applied network analysis to unravel patterns of co-occurring injuries among patients with BCVI by four common trauma mechanisms (car accident, motorcycle/bicycle accident, simple fall, and fall from a height). RESULTS Among 311,692 patients who visited the ED for blunt trauma, 454 (0.1%) patients had BCVI. Patients with common/internal carotid artery injuries presented to the ED with severe symptoms (e.g., the median Glasgow Coma Scale was 7) and had high in-hospital mortality (45%), while patients with vertebral artery injuries presented with relatively stable vital signs. Network analysis showed that head-vertebral-cervical spine injuries were common across four trauma mechanisms (car accident, motorcycle/bicycle accident, simple fall, and fall from a height), with co-occurring injuries of the cervical spine and vertebral artery being the most common injuries due to falls. In addition, common/internal carotid artery injuries were associated with thoracic and abdominal injuries in patients with car accidents. CONCLUSIONS Based on analyses of a nationwide trauma registry, we found that patients with BCVI had distinct patterns of co-occurring injuries by four trauma mechanisms. Our observations provide an important basis for the initial assessment of blunt trauma and could support the management of BCVI.
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Affiliation(s)
- Junichiro Shibata
- Faculty of Medicine, The University of Tokyo, Tokyo, Japan; TXP Medical Co. Ltd., Tokyo, Japan
| | - Yohei Okada
- TXP Medical Co. Ltd., Tokyo, Japan; Preventive Services, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Health Services and Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore.
| | - Itsuki Osawa
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
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16
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Tran NA, Pawar JP, Tobert D, Harris MB, Khurana B. Upper cervical spine fracture patterns and blunt cerebrovascular injuries. Emerg Radiol 2023; 30:315-323. [PMID: 37043145 DOI: 10.1007/s10140-023-02129-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/27/2023] [Indexed: 04/13/2023]
Abstract
PURPOSE To determine patterns of C1 and C2 vertebral fractures that are associated with blunt cerebrovascular injury (BCVI). METHODS Retrospective chart review of clinical and imaging reports at a level 1 trauma center over 10 consecutive years was conducted in patients with C1 and C2 fractures. Student t-test and chi-squared analyses were used to determine associations between fracture levels and fracture types with the presence of BCVI on CTA and/or MRI or stroke on CT and/or MRI. RESULTS Multilevel fractures were associated with higher incidence of BCVI compared to isolated C1 or C2 fractures (p < 0.01), but not with stroke (p = 0.16). There was no difference in incidence of BCVI or stroke between isolated C1 and isolated C2 fractures (p = 0.46, p = 0.25). Involvement of the transverse foramen (TF) alone was not associated with BCVI or stroke (p = 0.10-0.40, p = 0.34-0.43). However, TF fractures that were comminuted or contained fracture fragment(s) were associated with increased BCVI (p < 0.01, p = 0.02), though not with stroke (p = 0.11, p = 0.09). In addition, high-energy mechanism of injury was also associated with BCVI (p < 0.01) and stroke (p < 0.01). CONCLUSION C1 and C2 fractures are associated with BCVI in the presence of high-energy mechanism of injury, concomitant fractures of other cervical vertebral body levels, comminuted TF fractures, or TF fractures with internal fragments. Attention to these fracture parameters is important in evaluating C1 and C2 fractures for BCVI.
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Affiliation(s)
- Ngoc-Anh Tran
- Department of Radiology, Brigham & Women's Hospital, Boston, USA.
| | - Jayashri P Pawar
- Center for Clinical Data Science, Massachusetts General Hospital & Brigham & Women's Hospital, Boston, USA
| | - Daniel Tobert
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, USA
| | - Mitchel B Harris
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, USA
| | - Bharti Khurana
- Trauma Imaging Research and Innovation Center, Brigham & Women's Hospital, Boston, USA
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17
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Curry SD, Christensen DN, Varman PM, Harp KA, Jones DT. Systematic Review of CT Angiography in Guiding Management in Pediatric Oropharyngeal Trauma. Laryngoscope 2023; 133:457-466. [PMID: 35561004 DOI: 10.1002/lary.30179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/25/2022] [Accepted: 04/29/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Pediatric oropharyngeal trauma is common. Although most cases resolve uneventfully, there have been reports of internal carotid artery injury leading to devastating neurovascular sequelae. There is significant controversy regarding the utility of CT angiography (CTA) in children with seemingly minor oropharyngeal trauma. The goal of this study was to appraise changes in diagnosis and treatment based on CTA results. METHODS A comprehensive search of PubMed, Embase, CINAHL, Scopus, the Cochrane Ear, Nose and Throat Disorders Group Trials Register, and the ClinicalTrials.gov database was performed following PRISMA guidelines. RESULTS The search yielded 5,078 unique abstracts, of which 8 articles were included. A total of 662 patients were included, with 293 having any CT head/neck imaging, and 255 with CTA. Eleven injuries/abnormalities of the carotid were found on CTAs, comprising edema around the carotid (n = 8), potential intimal tear (n = 1), carotid spasm (n = 1), and carotid compression (n = 1). The pooled proportion of imaging findings on CTA that could lead to changes in clinical management was 0.00 (95% CI 0.00-0.43). Angiography was obtained in 10 patients, in 6 cases due to abnormal CTA. Angiography identified 1 patient with vessel spasm and two patients with carotid intima disruption without thrombus. No patient underwent vascular repair or suffered cerebrovascular injury. CONCLUSION Imaging with CTA yielded radiological abnormalities in a few instances. These results do not support the routine use of CTA in screening pediatric oropharyngeal trauma when balanced against the risk of radiation, as it rarely resulted in management changes and was not shown to improve outcomes. LEVEL OF EVIDENCE N/A Laryngoscope, 133:457-466, 2023.
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Affiliation(s)
- Steven D Curry
- Department of Otolaryngology - Head and Neck Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Dallin N Christensen
- Department of Otolaryngology - Head and Neck Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Pooja M Varman
- Creighton University School of Medicine, Creighton University, Omaha, Nebraska, USA
| | - Kimberly A Harp
- McGoogan Heath Sciences Library, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Dwight T Jones
- Department of Otolaryngology - Head and Neck Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
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18
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Filiberto DM, Kerwin AJ. Blunt Cerebrovascular Injury. CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00350-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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19
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Azad TD, Raj D, Ahmed K, Ran K, Materi J, Dardick J, Olexa J, Musharbash F, Lubelski D, Witham T, Bydon A, Theodore N, Byrne JP, Haut E. Predictors of Blunt Cerebrovascular Injury, Stroke, and Mortality in Patients with Cervical Spine Trauma. World Neurosurg 2023; 169:e251-e259. [PMID: 36334717 DOI: 10.1016/j.wneu.2022.10.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 10/28/2022] [Accepted: 10/29/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Blunt cerebrovascular injury (BCVI), defined as blunt traumatic injury to the carotid or vertebral arteries, is associated with significant risk of stroke and mortality. Cervical spine trauma is a recognized risk factor for BCVI. OBJECTIVE The objective of this study was to identify significant predictors of BCVI and its sequelae in patients with known cervical spine injury. METHODS Patients from 2007 to 2018 with blunt cervical spine injury diagnoses were identified in the National Trauma Data Bank. Multivariable logistic regression models were used to identify patient baseline and injury characteristics associated with BCVI, stroke, and mortality. RESULTS We identified 229,254 patients with cervical spine injury due to blunt trauma. The overall rate of BCVI was 1.6%. Factors associated with BCVI in patients with cervical spine injury included lower Glasgow Coma Scale, motor vehicle crash, higher Injury Severity Score, concomitant traumatic brain or spinal cord injury, and current smoking status. BCVI was a strong predictor of stroke (odds ratio, 8.2; 95% confidence interval, 5.7-12.0) and was associated with mortality (odds ratio, 1.7; 95% confidence interval, 1.3-2.2). Stroke occurred in 3.3% of patients with BCVI versus 0.02% for patients without BCVI. CONCLUSIONS While BCVI is rare following cervical spine injury due to blunt trauma, it is a significant predictor of stroke and mortality. The risk factors associated with BCVI, stroke, and mortality identified here should be used in the development of more effective predictive tools to improve care.
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Affiliation(s)
- Tej D Azad
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Divyaansh Raj
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kowsar Ahmed
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kathleen Ran
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joshua Materi
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joseph Dardick
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joshua Olexa
- Department of Neurosurgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Farah Musharbash
- Department of Orthopedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Timothy Witham
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ali Bydon
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - James P Byrne
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Elliott Haut
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA.
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20
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Färkkilä EM, Kaban LB, Boos-Lima FBDJ, Peacock ZS. Association of craniomaxillofacial fractures and blunt cerebrovascular injuries. Int J Oral Maxillofac Surg 2022:S0901-5027(22)00485-4. [PMID: 36564270 DOI: 10.1016/j.ijom.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/29/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022]
Abstract
High energy trauma has been considered a risk factor for blunt cerebrovascular injuries (BCVI). The purpose of this study was to determine the incidence and risk factors for BCVI specifically in patients with maxillofacial fractures in an urban level I trauma center. A retrospective cohort study of patients aged ≥ 18 years, admitted to Massachusetts General Hospital (MGH) between 2007 and 2017, was implemented. There were 23,394 patients treated and entered into the MGH Trauma Registry: 22,287 sustained blunt trauma. Of the total blunt trauma patients, 68 (0.3%) had BCVI. There were 2421 patients with CMF fractures from blunt trauma (mean ± standard deviation age, 53 ± 22 years; 29.9% female included as study subjects, of whom 24 (1.0%) had BCVI). In a multivariate model, all mandible fracture (odds ratio (OR) 4.3, 95% confidence interval (CI) 1.6-11.6, P = 0.004), crush injury, defined as blunt compression injury (OR 11.1, 95% CI 2.1-58.1, P = 0.004), and cervical spine injury (OR 10.1, 95 CI 3.7-27.5, P < 0.001) were independent risk factors for BCVI. Mortality was 4.3 times higher in craniomaxillofacial fracture patients with BCVI versus those without BCVI; complications of BCVI (stroke) contributed to the majority of deaths. Appropriate screening and treatment of BCVI in patients with maxillofacial fractures is important.
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Affiliation(s)
- E M Färkkilä
- Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Boston, Massachusetts, USA; Department of Oral and Maxillofacial Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - L B Kaban
- Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Boston, Massachusetts, USA
| | - F B D J Boos-Lima
- Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Boston, Massachusetts, USA
| | - Z S Peacock
- Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Boston, Massachusetts, USA.
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21
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Temperley HC, McDonnell JM, O'Sullivan NJ, Waters C, Cunniffe G, Darwish S, Butler JS. The Incidence, Characteristics and Outcomes of Vertebral Artery Injury Associated with Cervical Spine Trauma: A Systematic Review. Global Spine J 2022; 13:1134-1152. [PMID: 36341773 DOI: 10.1177/21925682221137823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
STUDY DESIGN Systematic Review. OBJECTIVES Vertebral Artery Injury (VAI) is a potentially serious complication of cervical spine fractures. As many patients can be asymptomatic at the time of injury, the identification and diagnosis of VAI can often prove difficult. Due to the high rates of morbidity and mortality associated with VAI, high clinical suspicion is paramount. The purpose of this review is to elucidate incidence, diagnosis, treatment and outcomes of VAI associated with cervical spine injuries. METHODS A systematic search of electronic databases was performed using 'PUBMED', 'EMBASE','Medline (OVID)', and 'Web of Science, for articles pertaining to traumatic cervical fractures with associated VAI. RESULTS 24 studies were included in this systematic review. Data was included from 48 744 patients. In regards to the demographics of the focus groups that highlighted information on VAI, the mean average age was 46.6 (32.1-62.6). 75.1% (169/225) were male and 24.9% (56/225) were female. Overall incidence of VAI was 596/11 479 (5.19%). 190/420 (45.2%) of patients with VAI had fractures involving the transverse foramina. The right vertebral artery was the most commonly injured 114/234 (48.7%). V3 was the most common section injured (16/36 (44.4%)). Grade I was the most common (103/218 (47.2%)) injury noted. Collective acute hospital mortality rate was 32/226 (14.2%), ranging from 0-26.2% across studies. CONCLUSION VAI secondary to cervical spine trauma has a notable incidence and high associated mortality rates. The current available literature is limited by a low quality of evidence. In order to optimise diagnostic protocols and treatment strategies, in addition to reducing mortality rates associated with VAI, robust quantitative and qualitative studies are needed.
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Affiliation(s)
| | - Jake M McDonnell
- 8881The Mater Misericordiae University Hospital, Dublin, Ireland
| | | | | | - Gráinne Cunniffe
- 8881The Mater Misericordiae University Hospital, Dublin, Ireland
| | | | - Joseph S Butler
- 8881The Mater Misericordiae University Hospital, Dublin, Ireland
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Maiese A, Frati P, Manetti AC, De Matteis A, Di Paolo M, La Russa R, Turillazzi E, Frati A, Fineschi V. Traumatic Internal Carotid Artery Injuries: Do We Need a Screening Strategy? Literature Review, Case Report, and Forensic Evaluation. Curr Neuropharmacol 2022; 20:1752-1773. [PMID: 34254918 PMCID: PMC9881067 DOI: 10.2174/1570159x19666210712125929] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/05/2021] [Accepted: 06/01/2021] [Indexed: 11/22/2022] Open
Abstract
Internal carotid artery dissection (ICAD) represents the cause of ictus cerebri in about 20% of all cases of cerebral infarction among the young adult population. ICAD could involve the extracranial and intracranial internal carotid artery (ICA). It could be spontaneous (SICAD) or traumatic (TICAD). It has been estimated that carotid injuries could complicate the 0,32% of cases of general blunt trauma and the percentage seems to be higher in cases of severe multiple traumas. TICAD is diagnosed when neurological symptoms have already occurred, and it could have devastating consequences, from permanent neurological impairment to death. Thus, even if it is a rare condition, a prompt diagnosis is essential. There are no specific guidelines regarding TICAD screening. Nevertheless, TICAD should be taken into consideration when a young adult or middle-aged patient presents after severe blunt trauma. Understanding which kind of traumatic event is most associated with TICAD could help clinicians to direct their diagnostic process. Herein, a review of the literature concerning TICAD has been carried out to highlight its correlation with specific traumatic events. TICAD is mostly correlated to motor vehicle accidents (94/227), specifically to car accidents (39/94), and to direct or indirect head and cervical trauma (76/227). As well, a case report is presented to discuss TICAD forensic implications.
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Affiliation(s)
- Aniello Maiese
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126Pisa (PI), Italy; ,IRCSS Neuromed Mediterranean Neurological Institute, Via Atinense 18, 86077 Pozzilli (IS), Italy;
| | - Paola Frati
- IRCSS Neuromed Mediterranean Neurological Institute, Via Atinense 18, 86077 Pozzilli (IS), Italy; ,Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome (RM), Italy;
| | - Alice Chiara Manetti
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126Pisa (PI), Italy;
| | - Alessandra De Matteis
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome (RM), Italy;
| | - Marco Di Paolo
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126Pisa (PI), Italy;
| | - Raffaele La Russa
- IRCSS Neuromed Mediterranean Neurological Institute, Via Atinense 18, 86077 Pozzilli (IS), Italy; ,Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome (RM), Italy;
| | - Emanuela Turillazzi
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126Pisa (PI), Italy;
| | - Alessandro Frati
- IRCSS Neuromed Mediterranean Neurological Institute, Via Atinense 18, 86077 Pozzilli (IS), Italy; ,Neurosurgery Division, Human Neurosciences Department, Sapienza University of Rome, Rome, Italy
| | - Vittorio Fineschi
- IRCSS Neuromed Mediterranean Neurological Institute, Via Atinense 18, 86077 Pozzilli (IS), Italy; ,Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome (RM), Italy; ,Address correspondence to this author at the Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome (RM), Italy; E-mail:
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Harper PR, Jacobson LE, Sheff Z, Williams JM, Rodgers RB. Routine CTA screening identifies blunt cerebrovascular injuries missed by clinical risk factors. Trauma Surg Acute Care Open 2022; 7:e000924. [PMID: 36101794 PMCID: PMC9422891 DOI: 10.1136/tsaco-2022-000924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 08/05/2022] [Indexed: 11/28/2022] Open
Abstract
Objectives Current guidelines for screening for blunt cerebrovascular injury (BCVI) are commonly based on the expanded Denver criteria, a set of risk factors that identifies patients who require CT-angiographic (CTA) screening for these injuries. Based on previously published data from our center, we have adopted a more liberal screening guideline than those outlined in the expanded Denver criteria. This entails routine CTA of the neck for all blunt trauma patients already undergoing CT of the cervical spine and/or CTA of the chest. The aim of this study was to analyze the incidence of patients with BCVI who did not meet any of the risk factors included in the expanded Denver criteria. Methods A retrospective review of all patients diagnosed with BCVI between June 2014 and December 2019 at a Level I Trauma Center were identified from the trauma registry. Medical records were reviewed for the presence or absence of risk factors as outlined in the expanded Denver criteria. Demographic data, time to CTA and treatment, BCVI grade, Glasgow Coma Scale and Injury Severity Score were collected. Results During the study period, 17 054 blunt trauma patients were evaluated, and 29% (4923) underwent CTA of the neck to screen for BCVI. 191 BCVIs were identified in 160 patients (0.94% of all blunt trauma patients, 3.25% of patients screened with CTA). 16% (25 of 160) of patients with BCVI had none of the risk factors outlined in the Denver criteria. Conclusion Our findings indicate that reliance on the expanded Denver criteria alone for BCVI screening will result in missed injuries. We recommend CTA screening in all patients with blunt trauma undergoing CT of the cervical spine and/or CTA of the chest to minimize this risk. Level of evidence Level III, therapeutic/care management.
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Affiliation(s)
- Paul R Harper
- Department of Trauma, Ascension St Vincent Hospital—Indianapolis, Indianapolis, Indiana, USA
| | - Lewis E Jacobson
- Department of Trauma, Ascension St Vincent Hospital—Indianapolis, Indianapolis, Indiana, USA
| | - Zachary Sheff
- Department of Trauma, Ascension St Vincent Hospital—Indianapolis, Indianapolis, Indiana, USA
| | - Jamie M Williams
- Department of Trauma, Ascension St Vincent Hospital—Indianapolis, Indianapolis, Indiana, USA
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24
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Esposito EC, Kufera JA, Wolff TW, Spalding MC, Simpson J, Dunn JA, Zier L, Burruss S, Kim P, Jacobson LE, Williams J, Nahmias J, Grigorian A, Harmon L, Gergen A, Chatoor M, Rattan R, Young AJ, Pascual JL, Murry J, Ong AW, Muller A, Sandhu RS, Appelbaum R, Bugaev N, Tatar A, Zreik K, Hustad L, Lieser MJ, Stein DM, Scalea TM, Lauerman MH. Factors associated with stroke formation in blunt cerebrovascular injury: An EAST multicenter study. J Trauma Acute Care Surg 2022; 92:347-354. [PMID: 34739003 DOI: 10.1097/ta.0000000000003455] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Stroke risk factors after blunt cerebrovascular injury (BCVI) are ill-defined. We hypothesized that factors associated with stroke for BCVI would include medical therapy (i.e., Aspirin), radiographic features, and protocolization of care. METHODS An Eastern Association for the Surgery of Trauma-sponsored, 16-center, prospective, observational trial was undertaken. Stroke risk factors were analyzed individually for vertebral artery (VA) and internal carotid artery (ICA) BCVI. Blunt cerebrovascular injuries were graded on the standard 1 to 5 scale. Data were from the initial hospitalization only. RESULTS Seven hundred seventy-seven BCVIs were included. Stroke rate was 8.9% for all BCVIs, with an 11.7% rate of stroke for ICA BCVI and a 6.7% rate for VA BCVI. Use of a management protocol (p = 0.01), management by the trauma service (p = 0.04), antiplatelet therapy over the hospital stay (p < 0.001), and Aspirin therapy specifically over the hospital stay (p < 0.001) were more common in ICA BCVI without stroke compared with those with stroke. Antiplatelet therapy over the hospital stay (p < 0.001) and Aspirin therapy over the hospital stay (p < 0.001) were more common in VA BCVI without stroke than with stroke. Percentage luminal stenosis was higher in both ICA BCVI (p = 0.002) and VA BCVI (p < 0.001) with stroke. Decrease in percentage luminal stenosis (p < 0.001), resolution of intraluminal thrombus (p = 0.003), and new intraluminal thrombus (p = 0.001) were more common in ICA BCVI with stroke than without, while resolution of intraluminal thrombus (p = 0.03) and new intraluminal thrombus (p = 0.01) were more common in VA BCVI with stroke than without. CONCLUSION Protocol-driven management by the trauma service, antiplatelet therapy (specifically Aspirin), and lower percentage luminal stenosis were associated with lower stroke rates, while resolution and development of intraluminal thrombus were associated with higher stroke rates. Further research will be needed to incorporate these risk factors into lesion specific BCVI management. LEVEL OF EVIDENCE Prognostic and Epidemiologic, Level IV.
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Affiliation(s)
- Emily C Esposito
- From the University of Maryland School of Medicine (E.E., J.A.K., T.M.S., M.H.L.), Baltimore, Maryland; Ohio State University Wexner Medical Center (T.W.W., M.C.S., A.J.Y.), Columbus, Ohio; Greenville Health System (J.S.), Greenville, South Carolina; University of Colorado (J.A.D., L.Z., La.H., An.G.), Boulder, Colorado; Loma Linda University (S.B., P.K.)., Loma Linda, California; Ascension Health (L.E.J., J.W.), St. Louis, Missouri; University of California (J.N., Ar.G.), Oakland, California; University of Miami (M.C., R.R.), Miami, Florida; Perelman School of Medicine at the University of Pennsylvania (J.L.P.), Philadelphia, Pennsylvania; UT Health Tyler (J.M.), Tyler, Texas; Towerhealth (A.W.O., A.M.), West Reading, Pennsylvania; Lehigh Valley Health Network (R.S.S., R.A.), Allentown, Pennsylvania; Tufts University School of Medicine (N.B., A.T.), Boston, Massachusetts; Sanford Health (K.Z., Le.H.), Sioux Falls, South Dakota; Research Medical Center (M.J.L.), Kansas City, Missouri; University of California San Francisco (D.M.S.), San Francisco, California
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25
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Jacob-Brassard J, Al-Omran M, Haas B, Nathens AB, Gomez D, Dueck AD, Forbes TL, de Mestral C. A multicenter retrospective cohort study of blunt traumatic injury to the common or internal carotid arteries. Injury 2022; 53:152-159. [PMID: 34376278 DOI: 10.1016/j.injury.2021.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 07/19/2021] [Accepted: 07/26/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Current EAST guidelines recommend against routine carotid intervention for patients with blunt carotid artery injury (BCI), but offer limited information on its role for BCI patients presenting with neurological deficit. Our goal was to describe the contemporary management and outcomes of patients presenting with BCI and neurological deficit unrelated to head injury. METHODS We identified all adults who sustained a BCI between 2010 and 2017 in the American College of Surgeons Trauma Quality Improvement Program. We extracted patient demographics, injury characteristics (carotid and non-carotid), as well as the frequency, timing and approach of carotid intervention. Presence of neurological deficit unrelated to head injury at presentation was determined using Abbreviated Injury Scale codes. The main outcomes were in-hospital mortality and home discharge. Patients with and without neurological deficit at presentation were compared through multivariable logistic regression modeling. Among those with neurological deficit at presentation, the associations between carotid intervention (open or endovascular) and the outcomes were also assessed through multivariable logistic regression. RESULTS We identified 5,788 patients with BCI of whom 383 (7%) presented with neurological deficit unrelated to head injury. Among the 296 patients (5%) who underwent carotid intervention, 36 (12%) had presented with neurological deficit unrelated to head injury. Interventions were most often endovascular (68% [200/296]) and within a median time of 32 h (IQR 5-203). In-hospital mortality was 16% (918/5,788), and in-hospital stroke prevalence was 6% (336/5,788). When comparing patients with and without neurological deficit at presentation, those with deficits were more frequently managed with an intervention. After adjustment, the likelihood of mortality was higher (OR [95% CI] = 2.16 [1.63-2.85]) and the likelihood of home discharge lower (OR [95% CI] = 0.29 [0.21-0.40]) among patients presenting with neurological deficit. Among those with neurological deficit, carotid intervention was positively associated with home discharge (OR [95% CI] = 2.96 [1.21-7.23]), but not with in-hospital mortality (OR [95% CI] = 0.87 [0.36-2.10]). Results were similar in the subgroup of patients with isolated BCI (2,971/5,788). CONCLUSIONS Intervention in BCI patients presenting with neurological deficit may contribute to a greater likelihood of home discharge but not reduced in-hospital mortality.
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Affiliation(s)
| | - Mohammed Al-Omran
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
| | - Barbara Haas
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
| | - Avery B Nathens
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
| | - David Gomez
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
| | - Andrew D Dueck
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
| | - Thomas L Forbes
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.
| | - Charles de Mestral
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
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26
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Wolf B, Czajkowska M, Dorobisz A. Intraoperative Carotid Artery Injuries. Review of the
literature, analysis of the material of one centre. POLISH JOURNAL OF SURGERY 2021. [DOI: 10.5604/01.3001.0015.6102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
<br><b>Introduction:</b> Injuries of the carotid artery constitute a rare group of injuries. This study presents results of the treatment of 44 patients with iatrogenic carotid artery injuries for over 20 years. The patients were treated by the team of doctors of the Department of Vascular, General and Transplant Surgery in Wroclaw in the years 1997–2017 (Head of the Department Prof. Klemens Skóra, MD, and Prof. Piotr Szyber, MD, PhD – material used with permission).</br>
<br><b>Aim:</b> Aims of the analysis are: to estimate the frequency of different forms of iatrogenic injuries to the common and internal carotid artery, to evaluate the results of treatment, to assess the most effective surgical method depending on the type of injury, and develop an effective preoperative, intraoperative and postoperative regimen.</br>
<br><b>Discussion and results:</b> The frequency of various carotid artery injuries (blunt, acute, traffic) was constant between years, but the number of iatrogenic injuries definitely increased over time. The prognosis for patients with carotid artery injury, especially when combined with multi-organ trauma, is the gravest. Significantly better treatment results were achieved with both acute and iatrogenic injuries. This is mainly due to easier and quicker diagnosis and better conditions for assisting patients.</br>
<br><b>Conclusions:</b> In iatrogenic injuries, a well-designed surgical scheme, i.e. primarily the administration of UTH and placing a temporary suction drain by the first operating team, reduces the risk of neurological complications.</br>
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Affiliation(s)
- Barbara Wolf
- The Silesian Piasts’ Medical University, Wroclaw
| | - Magda Czajkowska
- The Department of Pharmacy of the Regional Blood Donation Centre in Wroclaw, Poland
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27
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Blunt Cerebrovascular Injury-Like Injury Observed in Patients With Craniofacial Self-Inflicted Gunshot Wounds. J Craniofac Surg 2021; 33:1046-1050. [PMID: 34873101 DOI: 10.1097/scs.0000000000008384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Although blunt cerebrovascular injury (BCVI) is recognized as a risk factor for trauma morbidity and mortality, little is described regarding similar cerebrovascular injury (CVI) in patients with penetrating wounds. The authors aim to characterize these injuries in the craniofacial self-inflicted gunshot wound (SIGSW) population. METHODS An institutional review board (IRB)-approved retrospective nstudy was conducted on patients presenting to the R Adams Cowley Shock Trauma Center with SIGSWs between 2007 and 2016. All CVIs were categorized by location, type, and associated neurologic deficits. Demographic data, patient characteristics, additional studies, and long-term outcomes were collected. A multivariate analysis determining independent predictors of CVI in the SIGSW population was performed. RESULTS Of the 73 patients with SIGSWs, 5 (6.8%) had CVIs separate from the bullet/cavitation tract (distant CVIs) and 9 had CVIs along the bullet/cavitation tract (in-tract CVIs). A total of 55.6% of in-tract and 40% of distant injuries were missed on initial radiology read. One distant CVI patient suffered a stroke during admission. The anterior to posterior gunshot wound trajectory was positively associated with distant CVIs when compared with no CVIs (P = 0.01). Vessel dissection was more prevalent in patients with distant CVIs, when compared against patients with in-tract CVIs (P = 0.02). CONCLUSIONS Nearly 20% of craniofacial SIGSW patients have CVIs and 6.8% have BCVI-like injuries, which is 2-to-6-fold times higher than traditional BCVIs. Craniofacial SIGSWs serve as an independent screening criterion with comparable screening yields; the authors recommend radiographic screening for these patients with particular scrutiny for CVIs as they are frequently missed on initial radiographic interpretations.
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28
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Vogt K, Kaminsky M, Joos E, Ball CG. Universal screening for blunt cerebrovascular injury: A critical appraisal. Evidence-based reviews in surgery. J Trauma Acute Care Surg 2021; 91:e142-e145. [PMID: 34538824 DOI: 10.1097/ta.0000000000003403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Kelly Vogt
- From the Department of Surgery (K.V.), Western University, London, Ontario, Canada; Department of Surgery, Cook County Hospital (M.K.), Chicago, Illinois; Department of Surgery, University of British Columbia (E.J.), Vancouver, BC; and Department of Surgery, University of Calgary (C.G.B.), Calgary, Alberta, Canada
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29
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Williamson F, Collins S, Dehn A, Doig S. Vascular injury is an infrequent finding following non-fatal strangulation in two Australian trauma centres. Emerg Med Australas 2021; 34:223-229. [PMID: 34505351 DOI: 10.1111/1742-6723.13863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 08/02/2021] [Accepted: 08/23/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Non-fatal strangulation assessment is challenging for clinicians as clear guidelines for evaluation are limited. The prevalence of non-fatal strangulation events, clinical findings, frequency of injury on computed tomography angiogram (CTA) and outcomes across two trauma centres will be used to improve this assessment process. METHODS This is a retrospective observational study of adult presentations during 2-year period to two major-trauma referral hospitals and subsequent 12 months to identify delayed vascular injury. Patients included using standardised search terms. Demographic data, clinical findings, radiological reports and outcomes were included for review. RESULTS A total of 425 patients were included for analysis. Self-inflicted injury comprised 62.1%, with domestic violence (28.5%) and assault (9.4%) the remainder. Manual strangulation events 36.7% of overall presentations and 63.3% following ligature strangulation (ligature strangulation, incomplete and complete hanging). On examination soft signs present in 133 (31.2%) cases, commonly neck tenderness in isolation. No hard signs suggesting vascular damage. Vascular injury was demonstrated in three cases (0.7% of the total cohort and 1.5% of CTA scans completed), and all occurred in ligature strangulation events as a result of hanging. No patients had delayed vascular injury in the 12-month period post-initial presentation. CONCLUSIONS In non-fatal strangulation presentations, the majority have subtle signs of neck injury on examination with inconsistent documentation of findings. Low rate of vascular injury overall (0.7%), and entirely in hanging events. No longer-term vascular sequalae identified. Improving documentation focusing on hypoxic insult and evidence of airway trauma is warranted, rather than a reliance on computed tomography imaging to delineate a traumatic event in non-fatal strangulation.
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Affiliation(s)
- Frances Williamson
- Emergency and Trauma Centre and Trauma Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Jamieson Trauma Institute, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - Sarah Collins
- Emergency Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Anja Dehn
- Emergency Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Shaela Doig
- Emergency and Trauma Centre and Trauma Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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Srivastava S, Raj A, Bhosale S, Marathe N, Gaddikeri M. A Rare Case Report of Flexion Teardrop Cervical Fracture with Blunt Vertebral Artery Injury Leading to Stroke. Asian J Neurosurg 2021; 16:187-190. [PMID: 34211892 PMCID: PMC8202375 DOI: 10.4103/ajns.ajns_31_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 06/14/2020] [Accepted: 10/15/2020] [Indexed: 11/27/2022] Open
Abstract
Non penetrating trauma to vertebral artery is a known complication in craniovertebral trauma. They are mainly reported with facet dislocations or injuries involving the foramen transversarium. Such a type of injury is rarely seen with flexion injuries. We report such a case leading to cerebellar stroke in a young male presenting to us with hemiparesis. A 43-year-old male presented to us 1 month post trauma after a motor vehicular accident with complaint of weakness of right half of the body since the trauma. He suffered blunt trauma to head and neck and complained of a flail right upper limb since trauma and weakness of the right lower limb which had partly improved. He was conservatively managed elsewhere. Radiographic investigations revealed complete occlusion of the right vertebral injury above the level of 6th cervical vertebra and flexion teardrop fracture of 5th cervical vertebra. He was managed conservatively for the vertebral artery injury (VAI) and corpectomy of C5 vertebra with anterior cervical plating and fusion. Such a rare type of injury can present with unexplained neurodeficit which needs appropriate radiological investigations for diagnosis before ascribing the cause to cord trauma. Hence, all high velocity motor vehicular accidents with associated fractures and neurodeficit should be screened for blunt VAIs.
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Affiliation(s)
- Sudhir Srivastava
- Department of Orthopedics, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Aditya Raj
- Department of Orthopedics, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Sunil Bhosale
- Department of Orthopedics, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Nandan Marathe
- Department of Orthopedics, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Manojkumar Gaddikeri
- Department of Orthopedics, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
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31
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Ku JC, Priola SM, Mathieu F, Taslimi S, Pasarikovski CR, Zeiler FA, Machnowska M, Nathens A, Yang VXD, da Costa L. Antithrombotic choice in blunt cerebrovascular injuries: Experience at a tertiary trauma center, systematic review, and meta-analysis. J Trauma Acute Care Surg 2021; 91:e1-e12. [PMID: 34144568 DOI: 10.1097/ta.0000000000003194] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Blunt cerebrovascular injuries (BCVIs) may occur following trauma and lead to ischemic stroke if untreated. Antithrombotic therapy decreases this risk; however, the optimal agent has yet to be determined in this population. The aim of this study was to compare the risk-benefit profile of antiplatelet (AP) versus anticoagulant (AC) therapy in rates of ischemic stroke and hemorrhagic complications in BCVI patients. METHODS We performed a retrospective review of BCVI patients at our tertiary care Trauma hospital from 2010 to 2015, and a systematic review and meta-analysis of the literature. The OVID Medline, Embase, Web of Science, and Cochrane Library databases were searched from inception to September 16, 2019. References of included publications were searched manually for other relevant articles. The search was limited to articles in humans, in patients 18 years or older, and in English. Studies that reported treatment-stratified clinical outcomes following AP or AC treatment in BCVI patients were included. Exclusion criteria included case reports, case series with n < 5, review articles, conference abstracts, animal studies, and non-peer-reviewed publications. Data were extracted from each study independently by two reviewers, including study design, country of origin, sex and age of patients, Injury Severity Score, Biffl grade, type of treatment, ischemic stroke rate, and hemorrhage rate. Pooled estimates using odds ratio (OR) were combined using a random-effects model using a Mantel-Hanzel weighting. The main outcome of interest was rate of ischemic stroke due to BCVI, and the secondary outcome was hemorrhage rate based on AC or AP treatment. RESULTS In total, there were 2044 BCVI patients, as reported in the 22 studies in combination with our institutional data. The stroke rate was not significantly different between the two treatment groups (OR, 1.27; 95% confidence interval, 0.40-3.99); however, the hemorrhage rate was decreased in AP versus AC treated groups (OR, 0.38; 95% confidence interval, 0.15-1.00). CONCLUSION Based on this meta-analysis, both AC and AP seem similarly effective in preventing ischemic stroke, but AP is better tolerated in the trauma population. This suggests that AP therapy may be preferred, but this should be further assessed with prospective randomized trials. LEVEL OF EVIDENCE Review article, level II.
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Affiliation(s)
- Jerry C Ku
- From the Division of Neurosurgery (J.C.K., S.M.P., F.M., S.T., C.R.P., V.X.D.Y., L.d.C.), Sunnybrook Health Sciences Centre, University of Toronto, Toronto; Health Sciences North, Division of Neurosurgery (S.M.P.), Northern Ontario School of Medicine, Sudbury, ON; Biomedical Engineering, Faculty of Engineering (F.A.Z.), Department of Anatomy and Cell Science, Rady Faculty of Health Sciences (F.A.Z.), and Centre on Aging (F.A.Z.), University of Manitoba, Winnipeg, MA, Canada; Division of Anaesthesia, Department of Medicine (F.A.Z.), Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom; and Sunnybrook Health Sciences Centre, Department of Medical Imaging (M.M.), Sunnybrook Health Sciences Centre, Department of Surgery (A.N.), and Department of Medical Imaging, Sunnybrook Health Sciences Centre (L.d.C.), University of Toronto, Toronto, ON, Canada
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32
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Vellimana AK, Lavie J, Chatterjee AR. Endovascular Considerations in Traumatic Injury of the Carotid and Vertebral Arteries. Semin Intervent Radiol 2021; 38:53-63. [PMID: 33883802 DOI: 10.1055/s-0041-1724008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cervical carotid and vertebral artery traumatic injuries can have a devastating natural history. This article reviews the epidemiology, mechanisms of injury, clinical presentation, and classification systems pertinent to consideration of endovascular treatment. The growing role of modern endovascular techniques for the treatment of these diseases is presented to equip endovascular surgeons with a framework for critically assessing patients presenting with traumatic cervical cerebrovascular injury.
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Affiliation(s)
- Ananth K Vellimana
- Department of Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Jayson Lavie
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Arindam Rano Chatterjee
- Department of Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
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Kansagra AP, Balasetti V, Huang MC. Neurovascular trauma: Diagnosis and therapy. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:325-344. [PMID: 33272402 DOI: 10.1016/b978-0-444-64034-5.00012-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Traumatic cerebrovascular injuries are common in both military and civilian populations. Whether such injuries occur in the aftermath of blunt or penetrating trauma has major implications for characteristics, classification, diagnosis, and optimal management of these lesions. Advances in screening methods, including particularly the dramatic rise of high-quality CT angiography, have facilitated early detection of these lesions. Fortunately, these diagnostic advances have occurred alongside improvements in pharmacological treatment and endovascular intervention, which now play an important role alongside surgical intervention in reducing the likelihood of adverse clinical outcomes. While the management of victims of trauma remains challenging, improved understanding of and ability to appropriately manage traumatic cerebrovascular lesions promises to yield better clinical outcomes for these vulnerable patients.
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Affiliation(s)
- Akash P Kansagra
- Departments of Radiology, Neurological Surgery, and Neurology, Washington University School of Medicine, St. Louis, MO, United States.
| | - Vamshi Balasetti
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, United States
| | - Michael C Huang
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States
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The Utility of a Screening Neck Computed Tomographic Angiogram in Blunt Trauma Patients Presenting With a Seat Belt Sign in the Absence of Associated Risk Factors. J Comput Assist Tomogr 2020; 44:941-946. [PMID: 33196601 DOI: 10.1097/rct.0000000000001098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Blunt cerebrovascular injuries (BCVI) of the neck are a common cause for concern after blunt trauma. The purpose of this article is to demonstrate whether patients with a cervical seat belt sign in the absence of associated high-risk injuries or neurological symptoms are at an increased risk for developing a clinically significant vascular injury and therefore require a screening neck computed tomographic angiography (CTA). METHODS A retrospective review was performed of patients who presented after motor vehicle collision and received a neck CTA for an indication of "seat belt sign." Imaging was reviewed to determine the vascular injury grade, associated injuries, and, if available, follow-up imaging was reviewed to assess for interval change or resolution. The patients were split into 2 groups. Group 1 included patients without high-risk injuries, and group 2 included patients with high-risk injuries. RESULTS In group 1, 6 (2.9%) of 208 patients had BCVI. In group 2, 7 (18.9%) of 37 patients had BCVI. Patients in group 2 were 6.5 times more likely to suffer BCVI compared with group 1 (P < 0.001). No patient in group 1 was ever symptomatic, and only 1 (0.5%) patient underwent interventional treatment. CONCLUSIONS Patients presenting after blunt trauma with a seat belt sign and no other high-risk injuries as laid out by screening criteria demonstrate a low probability of BCVI and an even lower likelihood of adverse outcome.
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Pini R, Faggioli G, Fenelli C, Vacirca A, Gallitto E, Mascoli C, Abualhin M, Gargiulo M. Cervical artery dissection: presentation and treatment. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.23736/s1824-4777.20.01459-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Treatment of blunt cerebrovascular injuries: Anticoagulants or antiplatelet agents? J Trauma Acute Care Surg 2020; 89:74-79. [PMID: 32251264 DOI: 10.1097/ta.0000000000002704] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Blunt cerebrovascular injury (BCVI) is associated with cerebrovascular accidents (CVA). Early therapy with antiplatelet agents or anticoagulants is recommended. There are limited data comparing the effectiveness of these treatments. The aim of our study was to compare outcomes between BCVI patients who received anticoagulants versus those who received antiplatelet agents. METHODS We performed an (2011-2015) analysis of the Nationwide Readmission Database and included all adult trauma patients 18 years or older who had an isolated BCVI (other body regions Abbreviated Injury Scale [AIS] < 3). Head injury patients or those who developed a CVA during the index admission were excluded. Patients were stratified into anticoagulants and antiplatelet agents. Propensity score matching was performed (1:1 ratio) to control for demographics, comorbidities, BCVI grade, distribution, and severity of injuries. Outcomes were readmission with CVA and mortality within 6 months. RESULTS A total of 725 BCVI patients were identified. A matched cohort of 370 patients (antiplatelet agents, 185; anticoagulants, 185) was obtained. Mean age was 50 ± 15 years, neck AIS was 3 (3,4), and Injury Severity Score was 12 (9-17). The majority of the patients (69%) had high-grade BCVI (AIS ≥ 3). Overall, 3.7% were readmitted with CVA and 3% died within 6 months. Patients who received anticoagulants had a lower rate of readmission with CVA (1.8% vs. 5.72%; p = 0.03), and a lower rate of 6-month mortality (1.3% vs. 4.9%; p = 0.03). There was no significant difference between the two groups reading the median time to stroke (9 days vs. 6 days; p = 0.12). CONCLUSION The BCVI patients on CVA prophylaxis for BCVI have a 3.7% rate of stroke after discharge. Compared with antiplatelet agents, anticoagulants are associated with lower rates of CVA in the first 6-month postdischarge. Further studies are required to identify the optimal agent to prevent CVA in this high-risk subset of trauma patients. LEVEL OF EVIDENCE Therapeutic, level IV.
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Wu L, Christensen D, Call L, Vranic J, Colip C, Hippe DS, Witt C, Bonow RH, Mossa-Basha M. Natural History of Blunt Cerebrovascular Injury: Experience Over a 10-year Period at a Level I Trauma Center. Radiology 2020; 297:428-435. [PMID: 32897159 DOI: 10.1148/radiol.2020192866] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background Blunt cerebrovascular injury (BCVI) is associated with increased stroke and mortality risk. However, the most appropriate follow-up strategy remains uncertain. Purpose To better understand the natural history of BCVI and help define the most optimal timing and length of follow-up imaging. Materials and Methods In this retrospective HIPAA-compliant study, data from all patients treated for BCVI at a level I trauma center between April 1, 2005, and June 30, 2015, were reviewed. For patients with at least one follow-up study, time-to-event analysis was performed to assess the trend in injury evolution. Association of injury grade and injury evolution was also assessed. The Fisher exact test and multivariable logistic regression were used to evaluate association of the number of injured vessels, vessel grade, and vessel type (internal carotid artery, vertebral artery) with BCVI-associated stroke. Results A total of 1204 patients (800 men; mean age ± standard deviation, 45 years ± 22) with 1604 vessel injuries were evaluated. High-grade (grades 3-5) injuries were less likely to resolve (hazard ratio [HR], 0.2; P < .001) than low-grade injuries. High-grade injuries were more likely to progress than low-grade injuries (HR, 3.3; P = .005). Of the injuries that improved or resolved (343 of 419 [81.9%]), 76% (259 of 343) changed within 30 days after the initial injury, and the remaining 24% (84 of 343) changed between 30 and 90 days. Of the injuries that progressed (46 of 419 [11.0%]), 87% (40 of 46) changed within 90 days. Beyond 90 days, no improvement or resolution occurred, and only 1.4% (six of 419) of injuries progressed. Higher injury grade (adjusted odds ratio, 2.0 per one-grade increase [95% confidence interval {CI}: 1.6, 2.4]; P < .001), carotid injuries versus vertebral artery injuries (49 of 420 [11.7%] vs 35 of 667 [5.2%]; P < .001), and increasing number of vessels injured per patient (adjusted odds ratio, 1.6 per one-vessel increase [95% CI: 1.3, 2.2]; P < .001) were associated with increased risk for BCVI-related stroke. Conclusion Most blunt cerebrovascular injury-related changes occurred within 30 days; changes rarely occurred beyond 90 days. Follow-up imaging is therefore unlikely to be helpful beyond 90 days. © RSNA, 2020 See also the editorial by Talbott in this issue.
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Affiliation(s)
- Lei Wu
- From the Departments of Radiology (L.W., D.C., L.C., J.V., C.C., D.S.H., M.M.B.) and Neurologic Surgery (C.W., R.H.B.), University of Washington, 1959 NE Pacific St, Seattle, WA 98195-0005; and Department of Surgery, University of Colorado, Denver, Colo (C.W.)
| | - Diana Christensen
- From the Departments of Radiology (L.W., D.C., L.C., J.V., C.C., D.S.H., M.M.B.) and Neurologic Surgery (C.W., R.H.B.), University of Washington, 1959 NE Pacific St, Seattle, WA 98195-0005; and Department of Surgery, University of Colorado, Denver, Colo (C.W.)
| | - Lindsey Call
- From the Departments of Radiology (L.W., D.C., L.C., J.V., C.C., D.S.H., M.M.B.) and Neurologic Surgery (C.W., R.H.B.), University of Washington, 1959 NE Pacific St, Seattle, WA 98195-0005; and Department of Surgery, University of Colorado, Denver, Colo (C.W.)
| | - Justin Vranic
- From the Departments of Radiology (L.W., D.C., L.C., J.V., C.C., D.S.H., M.M.B.) and Neurologic Surgery (C.W., R.H.B.), University of Washington, 1959 NE Pacific St, Seattle, WA 98195-0005; and Department of Surgery, University of Colorado, Denver, Colo (C.W.)
| | - Charles Colip
- From the Departments of Radiology (L.W., D.C., L.C., J.V., C.C., D.S.H., M.M.B.) and Neurologic Surgery (C.W., R.H.B.), University of Washington, 1959 NE Pacific St, Seattle, WA 98195-0005; and Department of Surgery, University of Colorado, Denver, Colo (C.W.)
| | - Daniel S Hippe
- From the Departments of Radiology (L.W., D.C., L.C., J.V., C.C., D.S.H., M.M.B.) and Neurologic Surgery (C.W., R.H.B.), University of Washington, 1959 NE Pacific St, Seattle, WA 98195-0005; and Department of Surgery, University of Colorado, Denver, Colo (C.W.)
| | - Cordelie Witt
- From the Departments of Radiology (L.W., D.C., L.C., J.V., C.C., D.S.H., M.M.B.) and Neurologic Surgery (C.W., R.H.B.), University of Washington, 1959 NE Pacific St, Seattle, WA 98195-0005; and Department of Surgery, University of Colorado, Denver, Colo (C.W.)
| | - Robert H Bonow
- From the Departments of Radiology (L.W., D.C., L.C., J.V., C.C., D.S.H., M.M.B.) and Neurologic Surgery (C.W., R.H.B.), University of Washington, 1959 NE Pacific St, Seattle, WA 98195-0005; and Department of Surgery, University of Colorado, Denver, Colo (C.W.)
| | - Mahmud Mossa-Basha
- From the Departments of Radiology (L.W., D.C., L.C., J.V., C.C., D.S.H., M.M.B.) and Neurologic Surgery (C.W., R.H.B.), University of Washington, 1959 NE Pacific St, Seattle, WA 98195-0005; and Department of Surgery, University of Colorado, Denver, Colo (C.W.)
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Modified Split-Scan Computed Tomography (CT) Diagnostics of Severely Injured Patients: First Results from a Level I Trauma Center Using a Dedicated Head-and-Neck CT-Angiogram for the Detection of Cervical Artery Dissections. J Clin Med 2020; 9:jcm9082568. [PMID: 32784360 PMCID: PMC7464925 DOI: 10.3390/jcm9082568] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/06/2020] [Accepted: 08/06/2020] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Traumatic cervical artery dissections are associated with high mortality and morbidity in severely injured patients. After finding even higher incidences than reported before, we decided to incorporate a dedicated head-and-neck computed tomography angiogram (CT-A) in our imaging routine for patients who have been obviously severely injured or, according to trauma mechanism, are suspected to be severely injured. MATERIALS AND METHODS A total of 134 consecutive trauma patients with an ISS ≥ 16 admitted to our level I trauma center during an 18 month period were included. All underwent standardized whole-body CT in a 256-detector row scanner with a dedicated head-and-neck CT-A realized as single-bolus split-scan routine. Incidence, mortality, patient and trauma characteristics, and concomitant injuries were recorded and analyzed in patients with carotid artery dissection (CAD) and vertebral artery dissection (VAD). RESULTS Of the 134 patients included, 7 patients had at least one cervical artery dissection (CeAD; 5.2%; 95% CI 1.5-9.0%). Six patients (85.7%) had carotid artery dissections, with one patient having a CAD of both sides and one patient having a CAD and contralateral VAD combined. Two patients (28.6%) showed a VAD. Overall mortality was 14.3%, neurologic morbidity was 28.6%. None of the patients showed any attributable neurologic symptoms on admission. The new scanning protocol led to further 5 patients with suspected CeAD during the study period, all ruled out by additional magnetic resonance imaging with angiogram (MRI/MR-A). CONCLUSION A lack of specific neurologic symptoms on admission urges the need for a dedicated imaging pathway for severely injured patients, reliable for the detection of cervical artery dissections. Although our modified CT protocol with mandatory dedicated CT-A led to false positives requiring additional magnetic resonance imaging, it likely helped reduce possible therapeutic delays.
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Dhillon RS, Barrios C, Lau C, Pham J, Bernal N, Kong A, Lekawa M, Dolich M. Seatbelt Sign as an Indication for Four-vessel Computed Tomography Angiogram of the Neck to Diagnose Blunt Carotid Artery and Other Cervical Vascular Injuries. Am Surg 2020. [DOI: 10.1177/000313481307901009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Computed tomography angiography (CTA) of the neck has become the most common modality for diagnosing blunt carotid artery injury (BCAI). The protocol at our institution includes CTA on trauma patients with a seatbelt sign. The purpose of this study is to evaluate whether a solitary seatbelt sign is an indication for CTA of the neck to diagnose BCAI. We conducted a retrospective review of patients from 2000 to 2010 who received CTAs as a result of a seatbelt sign performed at our Level I trauma center. Four hundred eighteen patients received CTAs based on the presence of a seatbelt sign. Two hundred twenty-six had skeletal injuries, obvious soft tissue injuries, and/or positive findings on imaging, including 11 positive vascular findings with two BCAIs found. Patients with noncarotid vascular injuries on CTA had a higher Injury Severity Score than patients with solitary seatbelt signs (11.4 ± 7.6 vs 3.4 ± 4.2, P < 0.01). The correlation between seatbelt sign and positive finding on CTA was weak ( r = 0.007). Patients with vascular findings on CTA also had obvious hard/soft tissue injuries and/or positive findings on standard trauma imaging. This suggests that a protocol for CTA of the neck for patients with a seatbelt sign can be reserved for those with associated injuries on physical examination and/or findings on standard trauma imaging.
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Affiliation(s)
- Ramandeep Singh Dhillon
- Division of Trauma, Critical Care, Burn and Acute Care Surgery, Department of Surgery, University of California Irvine Medical Center, Irvine, California
| | - Cristobal Barrios
- Division of Trauma, Critical Care, Burn and Acute Care Surgery, Department of Surgery, University of California Irvine Medical Center, Irvine, California
| | - Cecilia Lau
- Division of Trauma, Critical Care, Burn and Acute Care Surgery, Department of Surgery, University of California Irvine Medical Center, Irvine, California
| | - Jacqueline Pham
- Division of Trauma, Critical Care, Burn and Acute Care Surgery, Department of Surgery, University of California Irvine Medical Center, Irvine, California
| | - Nicole Bernal
- Division of Trauma, Critical Care, Burn and Acute Care Surgery, Department of Surgery, University of California Irvine Medical Center, Irvine, California
| | - Allen Kong
- Division of Trauma, Critical Care, Burn and Acute Care Surgery, Department of Surgery, University of California Irvine Medical Center, Irvine, California
| | - Michael Lekawa
- Division of Trauma, Critical Care, Burn and Acute Care Surgery, Department of Surgery, University of California Irvine Medical Center, Irvine, California
| | - Matthew Dolich
- Division of Trauma, Critical Care, Burn and Acute Care Surgery, Department of Surgery, University of California Irvine Medical Center, Irvine, California
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LaRiccia AK, Wolff TW, Magee DJ, Patel R, Hoenninger DW, Oxs'Mara MS, Pandya UB, Hill JH, Nguyen TV, Spalding MC. Variability of radiological grading of blunt cerebrovascular injuries in trauma patients. Int J Crit Illn Inj Sci 2020; 10:81-87. [PMID: 32904506 PMCID: PMC7456289 DOI: 10.4103/ijciis.ijciis_103_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/20/2020] [Accepted: 02/13/2020] [Indexed: 11/19/2022] Open
Abstract
Context: Blunt cerebrovascular injury (BCVI) occurs in 1%–2% of all blunt trauma patients. Computed tomographic angiography of the neck (CTAn) is commonly used for the diagnosis and grading of BCVIs. Grade of injury dictates treatment, and there remains a lack in understanding the inter-reader reliability of these interpretations. Aims: The aim of this study is to determine the extent of variability in BCVIs among specialized neuroradiologist interpretation of CTAn. Settings and Design: Retrospective review of trauma patients admitted to a level one trauma center with a BCVI from January 2012 to December 2017. Patients were randomly assigned for CTAn re-evaluation by two of three blinded, neuroradiologists. Statistical Analysis Used: The variability in BCVI grades was measured using the coefficient of unalikeability (u), and inter-reader reliability was calculated using weighted Cohen's kappa (k). Results: Two hundred and twenty-eight BCVIs were analyzed with initial grades of 71 (31%) grade one, 74 (32%) grade two, 26 (11%) grade three, 57 (25%) grade four, and 0 grade five. Variability was present in 93 (41%) of all BCVIs. Grade one injuries had the lowest occurrence of total agreement (31%) followed by grade three (61%), grade two (63%), and grade four (92%). Total variability of grade interpretations (u = 100) occurred most frequently with grade three BCVIs (21%). Weighted Cohen's k calculations had a mean of 0.07, indicating poor reader agreement. Conclusions: This novel study demonstrated the BCVI variability of radiological grade interpretation occurs in more than a third of patients. The reliability of CTAn interpretation of BCVI grades is not uniform, potentially leading to undertreatment and overtreatment.
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Affiliation(s)
- Aimee K LaRiccia
- Division of Trauma and Acute Care Surgery, Ohio Health Grant Medical Center, Athens, OH, USA.,Department of Surgery, Ohio Health Doctors Hospital, Athens, OH, USA.,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Timothy W Wolff
- Division of Trauma and Acute Care Surgery, Ohio Health Grant Medical Center, Athens, OH, USA.,Department of Surgery, Ohio Health Doctors Hospital, Athens, OH, USA.,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | | | | | | | - M Shay Oxs'Mara
- Division of Trauma and Acute Care Surgery, Ohio Health Grant Medical Center, Athens, OH, USA.,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Urmil B Pandya
- Division of Trauma and Acute Care Surgery, Ohio Health Grant Medical Center, Athens, OH, USA.,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Joshua H Hill
- Division of Trauma and Acute Care Surgery, Ohio Health Grant Medical Center, Athens, OH, USA.,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Thanh V Nguyen
- Division of Trauma and Acute Care Surgery, Ohio Health Grant Medical Center, Athens, OH, USA.,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - M Chance Spalding
- Division of Trauma and Acute Care Surgery, Ohio Health Grant Medical Center, Athens, OH, USA.,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
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Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2020; 88:875-887. [DOI: 10.1097/ta.0000000000002668] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Barrera D, Sercy E, Orlando A, Mains CW, Madayag R, Carrick MM, Tanner A, Lieser M, Acuna D, Yon J, Bar-Or D. Associations of Antithrombotic Timing and Regimen with Ischemic Stroke and Bleeding Complications in Blunt Cerebrovascular Injury. J Stroke Cerebrovasc Dis 2020; 29:104804. [PMID: 32305279 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104804] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/15/2020] [Accepted: 03/03/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Blunt cerebrovascular injuries (BCVIs) are associated with long-term neurological effects. The first-line treatment for BCVIs is antithrombotics, but consensus on the optimal choice and timing of treatment is lacking. METHODS This was a retrospective study on patients aged at least 18 years admitted to 6 level 1 trauma centers between 1/1/2014 and 12/31/2017 with grade 1-4 BCVI and treated with antithrombotics. Differences in treatment practices were examined across the 6 centers. The primary outcome was ischemic stroke, and secondary outcomes were related to bleeding complications: blood transfusion and intracranial hemorrhage (ICH). Treatment characteristics examined were time to diagnosis and first computerized tomography angiography, time of total treatment course, time on each antithrombotic (anticoagulants, antiplatelets, combination), time from hospital arrival to antithrombotic initiation, and treatment interruption, i.e., treatment halted for a surgical procedure and restarted postoperatively. Chi-square, Fisher exact, Spearman's rank-order correlation, Wilcoxon rank-sum, Kruskal-Wallis, and Cox proportional hazards models with time-varying covariates were used to evaluate associations with the outcomes. RESULTS A total of 189 patients with BCVI were included. The median (IQR) time from arrival to antithrombotic initiation was 27 (8-61) hours, and 28% of patients had treatment interrupted. The ischemic stroke rate was 7.5% (n = 14), with most strokes (64%, n = 9) occurring between arrival and treatment initiation. Treatment interruption was associated with ischemic stroke (75% of patients with stroke had an interruption versus 24% of patients with no stroke; P < .01). Time on anticoagulants was not associated with ischemic stroke (P = .78), transfusion (P = .43), or ICH (P = .96). Similarly, time on antiplatelets (P = .54, P = .65, P = .60) and time on combination therapy (P = .96, P = .38, P = .57) were not associated with these outcomes. CONCLUSIONS The timing and consistency of antithrombotic administration are critical in preventing adverse outcomes in patients with BCVI. Most ischemic strokes in this study population occurred between arrival and antithrombotic initiation, representing events that may potentially be intervened upon by earlier treatment. Future studies should examine the safety of continuing treatment through surgical procedures.
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MESH Headings
- Adult
- Blood Transfusion
- Brain Injuries, Traumatic/diagnostic imaging
- Brain Injuries, Traumatic/drug therapy
- Brain Injuries, Traumatic/etiology
- Brain Ischemia/diagnostic imaging
- Brain Ischemia/etiology
- Brain Ischemia/therapy
- Cerebral Hemorrhage, Traumatic/diagnostic imaging
- Cerebral Hemorrhage, Traumatic/etiology
- Cerebral Hemorrhage, Traumatic/therapy
- Drug Administration Schedule
- Female
- Fibrinolytic Agents/administration & dosage
- Fibrinolytic Agents/adverse effects
- Humans
- Male
- Middle Aged
- Practice Patterns, Physicians'
- Retrospective Studies
- Risk Factors
- Stroke/diagnostic imaging
- Stroke/etiology
- Stroke/therapy
- Time Factors
- Time-to-Treatment
- Treatment Outcome
- United States
- Wounds, Nonpenetrating/diagnostic imaging
- Wounds, Nonpenetrating/drug therapy
- Wounds, Nonpenetrating/etiology
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Affiliation(s)
- Daniel Barrera
- Trauma Services Department, St. Anthony Hospital, Lakewood, Colorado
| | - Erica Sercy
- Trauma Research Department, St. Anthony Hospital, Lakewood, Colorado; Trauma Research Department, Swedish Medical Center, Englewood, Colorado; Trauma Research Department, Penrose Hospital, Colorado Springs, Colorado; Trauma Research Department, Medical City Plano, Plano, Texas; Trauma Research Department, Research Medical Center, Kansas City, Missouri; Trauma Research Department, Wesley Medical Center, Wichita, Kansas
| | - Alessandro Orlando
- Trauma Research Department, St. Anthony Hospital, Lakewood, Colorado; Trauma Research Department, Swedish Medical Center, Englewood, Colorado; Trauma Research Department, Penrose Hospital, Colorado Springs, Colorado; Trauma Research Department, Medical City Plano, Plano, Texas; Trauma Research Department, Research Medical Center, Kansas City, Missouri; Trauma Research Department, Wesley Medical Center, Wichita, Kansas
| | | | - Robert Madayag
- Trauma Services Department, St. Anthony Hospital, Lakewood, Colorado
| | | | - Allen Tanner
- Trauma Services Department, Penrose Hospital, Colorado Springs, Colorado
| | - Mark Lieser
- Trauma Services Department, Research Medical Center, Kansas City, Missouri
| | - David Acuna
- Trauma Services Department, Wesley Medical Center, Wichita, Kansas
| | - James Yon
- Trauma Services Department, Swedish Medical Center, Englewood, Colorado
| | - David Bar-Or
- Trauma Research Department, St. Anthony Hospital, Lakewood, Colorado; Trauma Research Department, Swedish Medical Center, Englewood, Colorado; Trauma Research Department, Penrose Hospital, Colorado Springs, Colorado; Trauma Research Department, Medical City Plano, Plano, Texas; Trauma Research Department, Research Medical Center, Kansas City, Missouri; Trauma Research Department, Wesley Medical Center, Wichita, Kansas.
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Merrill S, Clifton W, Valero-Moreno F, Damon A, Rahmathulla G. Vertebral Artery Injury with Coinciding Unstable Cervical Spine Trauma: Mechanisms, Evidence-based Management, and Treatment Options. Cureus 2020; 12:e7225. [PMID: 32274283 PMCID: PMC7141798 DOI: 10.7759/cureus.7225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Unstable traumatic cervical spine fracture is a commonly encountered neurosurgical issue. Concomitant vertebral artery injuries present a challenge in surgical decision-making regarding the timing and order of surgical intervention with respect to endovascular intervention and internal fixation of the unstable fracture. Currently, there are no studies that have specifically examined stroke rate or outcomes for patients who have vertebral artery injuries and unstable cervical spine fractures with respect to temporal treatment course. The purpose of this paper is to review the current evidence for the standards of diagnosis and management of vertebral artery injuries with coinciding unstable cervical spine injuries and propose an evidence-based algorithm for workup and treatment.
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Affiliation(s)
- Sarah Merrill
- Neurological Surgery, Mayo Clinic Alix School of Medicine, Scottsdale, USA
| | | | | | - Aaron Damon
- Neurological Surgery, Mayo Clinic, Jacksonville, USA
| | - Gazanfar Rahmathulla
- Neurological Surgery, University of Florida College of Medicine, Gainesville, USA
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Kuo LW, Hsu CP, Kang SC, Cheng CT, Liao CH, Yang CHO, Fu CY, Hsieh CH, Kuo IM. Early brain computed tomographic angiography to screen for blunt cerebrovascular injuries in patients with polytrauma: Is it necessary? Am J Emerg Med 2020; 39:121-124. [PMID: 32005409 DOI: 10.1016/j.ajem.2020.01.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/31/2019] [Accepted: 01/18/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Early diagnosis of blunt cerebrovascular injury (BCVI) is among the most difficult challenges in trauma treatment. This study aimed to determine the optimal timing of computed tomographic angiography (CTA) screening for suspicious BCVI in patients with polytrauma. METHODS We reviewed the trauma registry and medical records of patients with head and neck injuries from a Level I trauma center between January 2012 and December 2016. Those receiving CTA within 24 h of presentation at the emergency department were the primary CTA group; those who received CTA after 24 h were the delayed CTA group. The basic demographics, indications for CTA, CTA severity grading, and outcomes were compared. RESULTS In all, 228 patients received brain CTA. Most were male (75%); the mean age was around 40 years. The 38 patients with positive BCVI had a significantly higher ratio of severe chest trauma (52.6% vs 25.8%, p = 0.001); 26 of them received primary CTA and 12 received delayed CTA. Patients with polytrauma predominated in the delayed CTA group (66.7% vs 30.8%, p = 0.037). Of the patients in the primary CTA group, 26.9% received CTA due to symptomatic presentation (p = 0.047). Patients in the delayed group had better neurological outcomes (83% neurologically intact, vs 38.5%, p = 0.01) and lower mortality (0% vs 26.9%, p = 0.047). The only independent positive prognostic factor was initial motor response ≥M5 (Odds Ratio 21.46, 95% Confidence Interval 2.01-228.71). CONCLUSIONS For patients with polytrauma, performing brain CTA for BCVI screening in the first 24-h or after may not affect clinical outcome. Initial motor response is the sole indicator for outcome. Delaying the study for to the next 24-hour can be considered in such patients, when regarding hemodynamic stability, the dose of contrast medium, and the radiation exposure.
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Affiliation(s)
- Ling-Wei Kuo
- Department of Surgery, Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
| | - Chih-Po Hsu
- Department of Surgery, Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
| | - Shih-Ching Kang
- Department of Surgery, Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
| | - Chi-Tung Cheng
- Department of Surgery, Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
| | - Chien-Hung Liao
- Department of Surgery, Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
| | - Chun-Hsiang Ou Yang
- Department of Surgery, Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
| | - Chih-Yuan Fu
- Department of Surgery, Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
| | - Chi-Hsun Hsieh
- Department of Surgery, Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
| | - I-Ming Kuo
- Department of Surgery, Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan.
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Rattan A, Kataria R, Kumar A, Azam Q. Blunt carotid injury with thrombotic occlusion: Is an intervention always required for best outcome? Trauma Case Rep 2019; 24:100263. [PMID: 31872027 PMCID: PMC6911937 DOI: 10.1016/j.tcr.2019.100263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2019] [Indexed: 01/26/2023] Open
Abstract
Blunt cerebrovascular injuries are rare, comprises of 0.08 to 0.33% of all traumatic blunt injuries. Depending on the grade of severity, they may heal with minimal consequences or may lead to debilitating and devastating stroke. Surgically accessible lesions are infrequent and hence endovascular management is preferred modality for high-grade lesions. We hereby present a case of complete thrombosis of the common carotid artery, which couldn't receive either surgical or endovascular treatment due to low resource settings. The patient developed a stroke after 18 h of trauma, which, however, recovered completely and dramatically within 96 h. To the best of our knowledge, such rapid and complete recovery from stroke secondary to blunt carotid injury managed non-operatively hasn't been reported in literature so far. Our report adds to the scarce but growing body of evidence recommending conservative management in BCVI in absence of enlarging pseudoaneurysm and dissection with near-complete stenosis.
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Affiliation(s)
- Amulya Rattan
- Department of Trauma Surgery & Critical Care, Trauma Center, AIIMS Rishikesh, India
| | - Ruby Kataria
- Department of Trauma Surgery & Critical Care, Trauma Center, AIIMS Rishikesh, India
| | - Ajay Kumar
- Department of Trauma Surgery & Critical Care, Trauma Center, AIIMS Rishikesh, India
| | - Quamar Azam
- Department of Trauma Surgery & Critical Care, Trauma Center, AIIMS Rishikesh, India
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48
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Abstract
Anthropogenic disasters may be defined as any disaster caused by human action or inaction. Natural disasters occur without human interference. Injuries caused by terrorists and related criminal activities may be broadly grouped into 3 categories: blunt, blast, and penetrating trauma. Most terrorist and criminal activities that create a mass-casualty situation are performed using the weapons most readily available, such as firearms or explosives. A consistent pattern, comparing terrorism with interpersonal violence, is the greater severity of impact on the victim.
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Leraas HJ, Kuchibhatla M, Nag UP, Kim J, Ezekian B, Reed CR, Rice HE, Tracy ET, Adibe OO. Cervical seatbelt sign is not associated with blunt cerebrovascular injury in children: A review of the national trauma databank. Am J Surg 2019; 218:100-105. [DOI: 10.1016/j.amjsurg.2018.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 09/20/2018] [Accepted: 10/05/2018] [Indexed: 12/31/2022]
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50
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Blunt cerebrovascular injury: incidence and long-term follow-up. Eur J Trauma Emerg Surg 2019; 47:161-170. [PMID: 31197394 PMCID: PMC7851103 DOI: 10.1007/s00068-019-01171-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 06/04/2019] [Indexed: 12/23/2022]
Abstract
PURPOSE Blunt cerebrovascular injuries (BCVI), which can result in ischemic stroke, are identified in 1-2% of all blunt trauma patients. Computed tomography angiography (CTA) scanning has improved and is the diagnostic modality of choice in BCVI suspected patients. Data about long-term functional outcomes and the incidence of ischemic stroke after BCVI are limited. The aim of this study was to determine BCVI incidence in relation to imaging modality improvements and to determine long-term functional outcomes. METHODS All consecutive trauma patients from 2007 to 2016 with BCVI were identified from the level 1 trauma center prospective trauma database. Three periods were identified where CTA diagnostic modalities for trauma patients were improved. Long-term functional outcomes using the EuroQol six-dimensional (EQ-6D™) were determined. RESULTS Seventy-one BCVI patients were identified among the 12.122 (0.59%) blunt trauma patients. In the first period BCVI incidence among the overall study cohort, polytrauma, basilar skull fracture and cervical trauma subgroups was found to be 0.3%, 0.9%, 1.2%, 4.6%, respectively, which more than doubled towards the third period (0.8, 2.4, 1.9 and 8.5% respectively). Ischemic stroke as a result of BCVI was found in 20 patients (28%). In-hospital stroke rate was lower in patients receiving antiplatelet therapy (p < 0.01). Six in-hospital deaths were BCVI related. Long-term follow-up (follow-up rate of 83%) demonstrated lower functional outcomes compared to Dutch reference populations (p < 0.01). Ischemic stroke was identified as a major cause of functional impairment at long-term follow-up. CONCLUSIONS Improved CTA diagnostic modalities have increased BCVI incidence. Furthermore, BCVI patients reported significant functional impairment at long-term follow-up. Antiplatelet therapy showed a significant effect on in-hospital stroke rate reduction.
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