1
|
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.
Collapse
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
| | | | | | | | | |
Collapse
|
2
|
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.
Collapse
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
| | | |
Collapse
|
3
|
Morris L, Lawless A, McDonnell JM, Wilson KV, Marland H, Darwish S, Butler JS. Retrospective case series of vertebral artery injuries associated with cervical spine trauma. Surgeon 2024:S1479-666X(24)00079-9. [PMID: 39084923 DOI: 10.1016/j.surge.2024.07.007] [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: 11/30/2023] [Revised: 07/20/2024] [Accepted: 07/22/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Vertebral artery injuries (VAI) can occur due to cervical spine trauma. VAI can prove a serious complication and potentially compromise vascular supply to the posterior aspect of the brain. Currently, there is a paucity of evidence with regards to incidence, management, and outcomes for these patients. The purpose of this study is to investigate and elucidate the incidence of VAI associated with cervical trauma at a national tertiary referral centre for spinal pathology, their respective management, and associated outcomes. METHODS A retrospective review was conducted from 2012 to 2021 to identify patients with VAI secondary to cervical spine trauma. Demographic, clinical, and radiological data was collected to identify common traits in injury characteristics and management. RESULTS 1013 spine patients presented to our institution across the 10-year period. 739/1013 (72.9 %) were trauma patients. 42/739 (5.7 %) were imaged for suspected VAI secondary to trauma. There were 14/739 (1.9 %) confirmed VAI. All patients had CT-angiography for diagnosis. Four of the confirmed VAI patients (28.6 %) had additional MR-angiography imaging. Right-side was the most common side of VAI injury (7/14; 50 %), followed by left (5/14; 35.7 %) and bilateral (2/14; 14.3 %) injuries. 8/14 (57.1 %) patients were prescribed anti-thrombotic therapy. Acute mortality within 3-months was noted to be 2/14 (14.3 %) and occurred at 49 days and 57 days respectively. CONCLUSION VAI associated with cervical spine injury is rare in occurrence. However, it can be associated with high morbidity and mortality. As such, a multi-disciplinary approach to care is integral to ensuring good outcomes in these patients.
Collapse
Affiliation(s)
- Leah Morris
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland; School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Anna Lawless
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
| | - Jake M McDonnell
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland; Trinity Centre of Biomedical Engineering, Trinity College Dublin, Dublin, Ireland
| | - Kielan V Wilson
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland.
| | - Harry Marland
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland; School of Medicine, University of Galway, Galway, Ireland
| | - Stacey Darwish
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland; Department of Orthopaedics, St. Vincent's University Hospital, Dublin, Ireland
| | - Joseph S Butler
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
| |
Collapse
|
4
|
Meng Y, Zhang C, Song T, Gao R, Zhou X. Vertebral artery injury following combination Jefferson fracture of C1 and Type II odontoid fracture: A case report. Clin Case Rep 2024; 12:e9173. [PMID: 39035121 PMCID: PMC11258472 DOI: 10.1002/ccr3.9173] [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: 04/08/2024] [Revised: 06/06/2024] [Accepted: 06/22/2024] [Indexed: 07/23/2024] Open
Abstract
Traumatic posterior atlantoaxial dislocation combined with Jefferson fracture and odontoid process fracture with vertebral artery injury is rare. The management of such injury raises controversial issues and is still open to debate. A 74-year-old Chinese male presented with sustained neck pain and stiffness after falling from height. The patient was neurologically intact. Preoperative radiographs demonstrated a Jefferson burst fracture with a posterior dislocation of the atlantoaxial joints and odontoid process Anderson and D'alonzo type II fracture. A computed tomography angiography (CTA) showed an occluded left vertebral artery. Coil embolization in the proximal portion of the occluded vertebral artery was performed to prevent further cerebral infarction due to distal embolization of the thrombus. Then a second stage occipito-cervical fusion was performed to reconstruct cervical spine stability. A systematic screening of blunt trauma vertebral artery injuries through CTA is required when dealing with upper cervical fracture. For cases with vertebral artery occlusion secondary to cervical spine injury, endovascular treatment preceding cervical spine surgery is a feasible and a safe treatment.
Collapse
Affiliation(s)
- Yichen Meng
- Department of OrthopedicsShanghai Changzheng HospitalShanghaiPeople's Republic of China
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic DiseasesRuijin Hospital, Shanghai Jiao Tong University School of MedicineShanghaiPeople's Republic of China
- Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Shanghai National Clinical Research Center for Metabolic DiseasesRuijin Hospital, Shanghai Jiao Tong University School of MedicineShanghaiPeople's Republic of China
| | - Chenglin Zhang
- Department of OrthopedicsShanghai Changzheng HospitalShanghaiPeople's Republic of China
| | - Tengfei Song
- Department of OrthopedicsShanghai Changzheng HospitalShanghaiPeople's Republic of China
| | - Rui Gao
- Department of OrthopedicsShanghai Changzheng HospitalShanghaiPeople's Republic of China
| | - Xuhui Zhou
- Department of OrthopedicsShanghai Changzheng HospitalShanghaiPeople's Republic of China
| |
Collapse
|
5
|
Zygogiannis K, Benetos IS, Evangelopoulos DS, Koulalis D, Pneumaticos SG. Blunt Traumatic Vertebral Artery Injury After Cervical Fracture Dislocation: A Systematic Review of the Literature. Cureus 2024; 16:e65250. [PMID: 39184777 PMCID: PMC11342292 DOI: 10.7759/cureus.65250] [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: 07/24/2024] [Indexed: 08/27/2024] Open
Abstract
Certain high-energy blunt forces may produce unstable cervical fractures with or without dislocation. In rare cases where the superior facets are dislocated, however showing a significant increase within the last decade, these types of injuries may include vertebral artery entrapment at the involvement level leading to artery dissection or occlusion. This phenomenon is usually seen at the C4-C5 and C5-C6 levels of injury. A systematic review of the literature was performed by examining online databases such as PubMed - NCBI, Web of Science, Cochrane Library, Scopus, and Embase to identify relevant scientific articles. Keywords (MeSH terms) used in the search included cervical spine injuries, cervical spine dislocation, cerebrovascular injury, vertebral artery injury, vertebral artery injury management, and incidence of vertebral artery injury. Initially, 1516 studies were identified as a primary search for screening. After excluding papers that did not fulfill the inclusion criteria, 34 studies were included in this review. Vertebral artery injury consists of a severe complication that could compromise a surgical intervention since the patient's clinical image may be unrevealing at first. Early diagnosis and correct timing constitute the golden standard for adequate treatment. This systematic review aims to summarize the current evidence for the diagnosis, management, and treatment of blunt traumatic vertebral artery injuries.
Collapse
Affiliation(s)
| | - Ioannis S Benetos
- Orthopaedics Department, KAT Hospital, University of Athens, Athens, GRC
| | | | - Dimitrios Koulalis
- Orthopaedics and Traumatology Department, Attikon University Hospital, Athens, GRC
| | | |
Collapse
|
6
|
Choucha A, Barraque T, Meyer M, Dufour H, Farah K, Fuentes S. Fractured cervical spine, dissected vertebral artery, and life-threatening stroke: A challenging case report and literature review. Neurochirurgie 2024; 70:101561. [PMID: 38621474 DOI: 10.1016/j.neuchi.2024.101561] [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: 01/20/2024] [Revised: 04/02/2024] [Accepted: 04/09/2024] [Indexed: 04/17/2024]
Abstract
INTRODUCTION Vertebral artery injury (VAI) following blunt trauma can lead to acute or delayed life-threatening posterior fossa ischemic stroke. Its management raises controversial issues and is still open to debate. MATERIAL & METHOD We report the case of a 48-year-old male who presented a life-threatening posterior circulation ischemic stroke, secondary to a vertebral artery dissection caused by a cervical spine fracture. This case was successfully managed through intravenous thrombolysis and endovascular thrombectomy followed by antiplatelet therapy and an anterior cervical discectomy and fusion. At the one-year follow-up, the patient had no persisting deficit and was back working as a policeman. CONCLUSION Rapid management of patients with dramatic clinical presentation can lead to full recovery. Implications include a systematic screening of blunt trauma VAI through computed tomography angiography when dealing with high-risk cervical spine fractures; patients harboring both a cervical spine fracture and a VAI must be transferred to a tertiary referral hospital able to deal both with strokes and cervical spine surgery to ensure responsiveness in case of stroke.
Collapse
Affiliation(s)
- Anis Choucha
- Aix Marseille Univ, APM, UH Timone, Department of Neurosurgery, Marseille, France; Laboratory of Biomechanics and Application, UMRT24, Gustave Eiffel University, Aix Marseille University, Marseille, France.
| | - Thomas Barraque
- Aix Marseille Univ, APHM, UH Timone, Department of Emergency Medicine, Marseille, France
| | - Mikael Meyer
- Aix Marseille Univ, APM, UH Timone, Department of Neurosurgery, Marseille, France
| | - Henry Dufour
- Aix Marseille Univ, APM, UH Timone, Department of Neurosurgery, Marseille, France
| | - Kaissar Farah
- Aix Marseille Univ, APM, UH Timone, Department of Neurosurgery, Marseille, France
| | - Stephane Fuentes
- Aix Marseille Univ, APM, UH Timone, Department of Neurosurgery, Marseille, France
| |
Collapse
|
7
|
Namikawa H, Ogata A, Furukawa T, Masuoka J, Abe T. Traumatic Vertebral Artery Dissection Without Cervical Spine Injury Treated by Mechanical Thrombectomy. Cureus 2024; 16:e60287. [PMID: 38872668 PMCID: PMC11175024 DOI: 10.7759/cureus.60287] [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: 05/13/2024] [Indexed: 06/15/2024] Open
Abstract
A 59-year-old female injured in a motor vehicle accident presented with progressively impaired consciousness, and emergent magnetic resonance imaging (MRI) revealed basilar artery occlusion (BAO). Mechanical thrombectomy (MT) was performed immediately and achieved complete recanalization. Contrast-enhanced MRI also indicated right vertebral artery dissection (VAD), and the patient was subsequently diagnosed with artery-to-artery embolism caused by traumatic VAD. Anticoagulation therapy was initiated postoperatively, and there was no VAD or BAO recurrence during the three-month follow-up. This is the first reported case of BAO caused by traumatic VAD in an adult without accompanying cervical vertebral fracture treated using MT.
Collapse
Affiliation(s)
| | - Atsushi Ogata
- Department of Neurosurgery, Saga University, Saga, JPN
| | | | - Jun Masuoka
- Department of Neurosurgery, Saga University, Saga, JPN
| | - Tatsuya Abe
- Department of Neurosurgery, Saga University, Saga, JPN
| |
Collapse
|
8
|
Godil J, Smith S, Wright C, Yoo JU. Risk Factors, Incidence and Mortality of Vertebral Artery Injury in Patients Undergoing Anterior Cervical Corpectomy: A Retrospective Large National Data Base Study. Global Spine J 2024; 14:889-893. [PMID: 36052427 PMCID: PMC11192100 DOI: 10.1177/21925682221125127] [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: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective Cohort Study. OBJECTIVE To determine the incidence of vertebral artery injury (VAI), risk factors, intervention, associated complications, and mortality in patients undergoing anterior cervical corpectomy. METHODS We performed a retrospective review of the incidence of VAI during anterior cervical corpectomy using the PearlDiver database from 2010-2017. The CPT code 63 081 to identify corpectomy patients. Patient data extracted included, incidence of VAI, demographic factors, intervention, and future complications of death and stroke. The risk were calculated compared with those patients who did not have VAI. RESULTS 26 126 patients were identified to have undergone cervical corpectomy. Multivariate analysis of risk factors showed that younger age and male sex were associate with higher rate of injury (t = -11.5; P < .0001 and t = 3.8; P = .0001, respectively). Vertebral artery injuries occurred in 78 patients at an incidence of .3%. 11 (14%) VAI patients had a cerebral infarction compared with 1705 (7%) for non-VAI patients (OR = 2.13; 95% CI = [1.18 - 3.85; P = .0179]) during the follow up period. 1-year mortality rates were higher in patients who suffered a VAI (14%) compared to those who did not suffer a VAI (4%; OR = 3.85; CI = [2.04 - 7.14]; P < .0001). CONCLUSION Consequence of VAI may not be known for months following the injury. Although the same admission mortality is rare with this injury, there is a significant increase in post-discharge complications. This study suggests that further investigations into long term health risk of VAI is needed.
Collapse
Affiliation(s)
- Jamila Godil
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Spencer Smith
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Christina Wright
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Jung U. Yoo
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| |
Collapse
|
9
|
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.
Collapse
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.
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Boggs HK, Kiang SC, Tran Z, Mukherjee K, Tomihama RT. Analysis of Extracranial Cerebrovascular Injuries: Clinical Predictors of Management and Outcomes. Ann Vasc Surg 2024; 100:53-59. [PMID: 38110079 DOI: 10.1016/j.avsg.2023.10.022] [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: 12/07/2021] [Revised: 09/23/2023] [Accepted: 10/21/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Optimal management of traumatic extracranial cerebrovascular injuries (ECVIs) remains undefined. We sought to evaluate the factors that influence management and neurologic outcomes (stroke and brain death) following traumatic ECVI. METHODS A retrospective review of a single level 1 trauma center's prospectively maintained data registry of patients older than 18 years of age with a diagnosis of ECVI was performed from 2013 to 2019. Injuries limited to the external carotid artery were excluded. Patient demographics, type of injury, timing of presentation, Biffl Classification of Cerebrovascular Injury Grade, Injury Severity Score (ISS), and Abbreviated Injury Scale were documented. Ultimate treatments (medical management and procedural interventions) and brain-related outcomes (stroke and brain death) were recorded. RESULTS ECVIs were identified in 96 patients. The primary mechanism of injury was blunt trauma (89.5% vs. 10.5%, blunt versus penetrating), with 70 cases (66%) of vertebral artery injury and 37 cases of carotid artery injury. Treatments included vascular intervention (6.5%) and medical management (93.5%). Overall outcomes included ipsilateral ischemic stroke (29%) and brain death (6.5%). In the carotid group, vascular intervention was associated with higher Biffl grades (mean Biffl 3.17 vs. 2.23; P = 0.087) and decreased incidence of brain death (0% vs. 19%, P = 0.006), with no difference seen in ISS scores. Brain death was associated with higher ISS scores (40.29 vs. 24.17, P = 0.01), lower glascow coma score on arrival (3.57 vs. 10.63, P < 0.001), and increased rates of ischemic stroke (71% vs. 30%, P = 0.025). In the vertebral group, neither Biffl grade nor ISS were associated with treatment or outcomes. Regarding the timing of stroke in ECVI, there was no significant difference in the time from presentation to cerebral infarction between the carotid and vertebral artery groups (24.7 hr vs. 21.20 hr, P = 0.739). After this window, 98% of the ECVI cases demonstrated no further aneurysmal degeneration or new neurological deficits beyond the early time period (mean follow-up 9.7 months). CONCLUSIONS Blunt cerebrovascular injuries should be viewed distinctly in the carotid and vertebral territories. In cases of injury to the carotid artery, Biffl grade and ISS score are associated with surgical intervention and neurologic events, respectively; vertebral artery injuries did not share this association. Neurologic deficits were detected in a similar time frame between the carotid artery and the vertebral artery injury groups and both groups had rare late neurologic events.
Collapse
Affiliation(s)
- Hans K Boggs
- Division of Vascular Surgery, Department of Surgery, Linda University School of Medicine, Loma Linda, CA; Department of Radiology, Section of Vascular and Interventional Radiology, Linda University School of Medicine, Loma Linda, CA
| | - Sharon C Kiang
- Division of Vascular Surgery, Department of Surgery, Linda University School of Medicine, Loma Linda, CA; Division of Vascular Surgery, Department of Surgery, VA Loma Linda Healthcare System, Loma Linda, CA.
| | - Zachary Tran
- Division of Trauma Surgery/Critical Care, Department of Surgery, Linda University School of Medicine, Loma Linda, CA
| | - Kaushik Mukherjee
- Division of Trauma Surgery/Critical Care, Department of Surgery, Linda University School of Medicine, Loma Linda, CA
| | - Roger T Tomihama
- Department of Radiology, Section of Vascular and Interventional Radiology, Linda University School of Medicine, Loma Linda, CA
| |
Collapse
|
12
|
Tran A, Fernando SM, Rochwerg B, Hawes H, Hameed MS, Dawe P, Garraway N, Evans DC, Kim D, Biffl WL, Inaba K, Engels PT, Vogt K, Kubelik D, Petrosoniak A, Joos E. Prognostic factors associated with risk of stroke following blunt cerebrovascular injury: A systematic review and meta-analysis. Injury 2024; 55:111319. [PMID: 38277875 DOI: 10.1016/j.injury.2024.111319] [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: 11/23/2023] [Revised: 12/23/2023] [Accepted: 01/08/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND & OBJECTIVES Blunt cerebrovascular injury (BCVI) includes carotid and/or vertebral artery injury following trauma, and conveys an increased stroke risk. We conducted a systematic review and meta-analysis to provide a comprehensive summary of prognostic factors associated with risk of stroke following BCVI. METHODS We searched the EMBASE and MEDLINE databases from January 1946 to June 2023. We identified studies reporting associations between patient or injury factors and risk of stroke following BCVI. We performed meta-analyses of odds ratios (ORs) using the random effects method and assessed individual study risk of bias using the QUIPS tool. We separately pooled adjusted and unadjusted analyses, highlighting the estimate with the higher certainty. RESULTS We included 26 cohort studies, involving 20,458 patients with blunt trauma. The overall incidence of stroke following BCVI was 7.7 %. Studies were predominantly retrospective cohorts from North America and included both carotid and vertebral artery injuries. Diagnosis of BCVI was most commonly confirmed with CT angiography. We demonstrated with moderate to high certainty that factors associated with increased risk of stroke included carotid artery injury (as compared to vertebral artery injury, unadjusted odds ratio [uOR] 1.94, 95 % CI 1.62 to 2.32), Grade III Injury (as compared to grade I or II) (uOR 2.45, 95 % CI 1.88 to 3.20), Grade IV injury (uOR 3.09, 95 % CI 2.20 to 4.35), polyarterial injury (uOR 3.11 (95 % CI 2.05 to 4.72), occurrence of hypotension at the time of hospital admission (adjusted odds ratio [aOR] 1.32, 95 % CI 0.87 to 2.03) and higher total body injury severity (aOR 5.91, 95 % CI 1.90 to 18.39). CONCLUSION Local anatomical injury pattern, overall burden of injury and flow dynamics contribute to BCVI-related stroke risk. These findings provide the foundational evidence base for risk stratification to support clinical decision making and further research.
Collapse
Affiliation(s)
- Alexandre Tran
- Division of Critical Care, The Ottawa Hospital, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Shannon M Fernando
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Harvey Hawes
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Morad S Hameed
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Phillip Dawe
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Naisan Garraway
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - David C Evans
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Dennis Kim
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Walter L Biffl
- Department of Surgery, Scripps Medical Group, La Jolla, CA, USA
| | - Kenji Inaba
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Paul T Engels
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Canada; Department of Surgery, McMaster University, Hamilton, Canada
| | - Kelly Vogt
- Department of Surgery, University of Western Ontario, London, Canada
| | - Dalibor Kubelik
- Division of Critical Care, The Ottawa Hospital, Ottawa, Canada; Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Andrew Petrosoniak
- Department of Emergency Medicine, University of Toronto, Toronto, Canada
| | - Emilie Joos
- Department of Surgery, University of British Columbia, Vancouver, Canada
| |
Collapse
|
13
|
Du PZ, Christopher ND, Ganapathy V. Association between cervical fracture patterns and blunt cerebrovascular injury when screened with computed tomographic angiography. Spine J 2024; 24:310-316. [PMID: 37734494 DOI: 10.1016/j.spinee.2023.09.010] [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: 06/26/2023] [Revised: 09/07/2023] [Accepted: 09/16/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND CONTEXT Prior studies have demonstrated a close association between cervical spine fractures and blunt cerebrovascular injuries (BCVI). Undiagnosed BCVI is a feared complication because of the potentially catastrophic outcomes in a missed posterior circulation stroke. Computed tomography angiography (CTA) is commonly used to screen BCVI in the trauma setting. However, determining which cervical fracture patterns mandate screening is still not clearly known. PURPOSE The aim of this retrospective review is to further elucidate which fracture patterns are associated with BCVI when using CTA and may mandate screening. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE All patients that presented to our trauma and emergency departments with a blunt cervical spine fracture from January 2018 to December 2021. Inclusion criteria included blunt cervical trauma and the use of CTA for BCVI screening. Exclusion criteria included patients under the age of 18, penetrating cervical trauma, and use any imaging modality besides CTA for BCVI screening. OUTCOME MEASURES Patient demographics (age, gender, Glasgow coma scale, hospital length of stay (LOS), intensive care unit LOS, mechanism of energy of injury, polytrauma status), fracture location, fracture pattern (anterior arch, dens, dislocations/subluxations, facet, hangman, Jefferson, lamina, lateral mass, occipital condyle dissociation, occipital condyle, pedicle, posterior arch, spinous process, transverse process, transverse foramen, and vertebral body), and whether the patient sustained a BCVI or CVA. METHODS If a patient had multiple fracture levels or fracture patterns, each level and pattern was counted as a separate BCVI. Multilevel fractures were defined as any patient with fractures at two distinct cervical levels. Differences between the patients who had a BCVI and those who did not were analyzed using independent sample t-tests for continuous variables and the chi-square or Fisher exact test for categorical variables. Odds ratios and 95% confidence intervals were calculated to assess likelihood between patient characteristics/fracture characteristics and BCVI. RESULTS A total of 690 patients were identified as having a blunt cervical spine injury. A total of 453 patients (66%) underwent screening for BCVI with CTA. Among patients who underwent CTA, BCVI was diagnosed in 138 patients (30%), VAI in 119 patients (26%), CAI in 30 patients (7%), and 11 patients were diagnosed with both a VAI and CAI (2%). Overall, among all patients there were 9 strokes, all in patients identified with a BCVI (1%). No individual cervical level was associated with increased risk of BCVI, but when combined, OC-C3 fractures were associated with an increased risk (OR: 1.4, 95% CI: 1.0-1.9, p-value: .006). Multilevel fractures were also associated with an increased risk (OR: 1.7, 95% CI: 1.1-2.3, p-value: .01). The only fracture pattern associated with increased risk of BCVI were fractures associated with a dislocation/subluxation (OR: 3.8, 95% CI: 1.9-7.8, p-value = .0001). CONCLUSIONS The only fracture pattern associated with an increased risk of BCVI were fractures associated with dislocation/subluxation. The only fracture levels associated with BCVI were combined OC-C3 and multilevel fractures. We recommend that any upper cervical fracture (OC-C3), multilevel fracture, or fracture with dislocation/subluxation undergo screening for BCVI.
Collapse
Affiliation(s)
- Peter Z Du
- Department of Orthopaedic Surgery, University of Arizona, 1501 N Campbell Ave, 8th Floor Room 8401, Tucson, AZ, 85724, USA.
| | - Nicholas D Christopher
- College of Medicine, University of Arizona, 1501 N Campbell Ave, PO Box 245017, Tucson, AZ, 85724, USA
| | - Venkat Ganapathy
- Department of Orthopaedic Surgery, University of Arizona, 1501 N Campbell Ave, 8th Floor Room 8401, Tucson, AZ, 85724, USA
| |
Collapse
|
14
|
Zagorac S, Vasic M, Novakovic U, Mladenovic M, Tulic I, Teodosic V, Vracevic D. Extreme dislocation of the cervical spine-case report. J Surg Case Rep 2024; 2024:rjae039. [PMID: 38328451 PMCID: PMC10847399 DOI: 10.1093/jscr/rjae039] [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] [Received: 11/12/2023] [Accepted: 01/10/2024] [Indexed: 02/09/2024] Open
Abstract
We present the case of rare extreme dislocation of subaxial cervical spine, which was challenging regarding type and time of surgery. A 22-year-old patient was injured in a traffic accident, from very beginning with signs of spinal shock. Severe traumatic C6/C7 dislocation with resulting transection of the spinal cord was diagnosed with MDCT imaging. The main dilemmas regarding the surgical treatment of this injury referred to the timing of surgery and the choice of surgical approach. We decided to perform posterior surgery at first stage. Postoperative her condition get worsening and on the 16th postoperative day came to the fatal outcome. Despite all the available protocols, in our case, the decision had to be made on the basis of individual multidisciplinary assessment, bearing in mind the mechanism of the injury and the clinical presentation of the injured patient.
Collapse
Affiliation(s)
- Slavisa Zagorac
- Faculty of Medicine, University of Belgrade, dr Subotica starijeg 8, Belgrade 11000, Serbia
- Clinic for Orthopedic Surgery and Traumatology, University Clinical Center of Serbia, Pasterova 2, Belgrade 11000, Serbia
| | - Milos Vasic
- Clinic for Orthopedic Surgery and Traumatology, University Clinical Center of Serbia, Pasterova 2, Belgrade 11000, Serbia
| | - Uros Novakovic
- Clinic for Orthopedic Surgery and Traumatology, University Clinical Center of Serbia, Pasterova 2, Belgrade 11000, Serbia
| | - Milos Mladenovic
- Clinic for Orthopedic Surgery and Traumatology, University Clinical Center of Serbia, Pasterova 2, Belgrade 11000, Serbia
| | - Ivan Tulic
- Clinic for Orthopedic Surgery and Traumatology, University Clinical Center of Serbia, Pasterova 2, Belgrade 11000, Serbia
| | - Valerija Teodosic
- Clinic for Orthopedic Surgery and Traumatology, University Clinical Center of Serbia, Pasterova 2, Belgrade 11000, Serbia
| | - Dragana Vracevic
- Clinic for Orthopedic Surgery and Traumatology, University Clinical Center of Serbia, Pasterova 2, Belgrade 11000, Serbia
- Department of Anesthesiology, Reanimation and Intensive Care, Clinic for Orthopedic Surgery and Traumatology, University Clinical Center of Serbia, Pasterova 2, Belgrade 11000, Serbia
| |
Collapse
|
15
|
Isaji T, Yukiue T, Amano T. Coil Embolization for Asymptomatic Low-grade Vertebral Artery Injury which Worsened after Cervical Decompression Surgery: A Case Report. J Orthop Case Rep 2024; 14:63-67. [PMID: 38292093 PMCID: PMC10823830 DOI: 10.13107/jocr.2024.v14.i01.4160] [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: 10/06/2023] [Revised: 11/22/2023] [Indexed: 02/01/2024] Open
Abstract
Introduction Blunt cervical injuries rarely cause vertebral artery injuries (VAIs), such as vertebral artery (VA) dissection or occlusion. To prevent subsequent embolic infarction, embolization of the injured VA is needed before surgical fixation of the cervical spine. However, evidence on endovascular treatment for asymptomatic low-grade VAIs with blunt traumatic cervical injury is insufficient. Case Report In the present case, a 79-year-old Japanese man presented tetraparesis after falling while walking. Digital subtraction angiography showed no intimal flap and only slight stenosis of the right VA. Embolization was not performed before spinal decompression surgery for this low-grade injury. However, on the 3rd day after surgery, diffuse-weighted imaging showed dot-like high signal intensity in the right thalamus and right posterior lobe, and magnetic resonance angiography (MRA) showed near occlusion of the right VA. 8 days after surgery, MRA showed recanalization of the right VA flow. We performed VA embolization to prevent emboli scattering to the distal region during recanalization of the intracranial blood flow. Conclusion According to the relevant literature, prophylactic embolization may be indicated to prevent the embolic infarction not only in cases of VA occlusion requiring fixation of the cervical spine but also in cases of low-grade VAIs in which fixation is not required. Embolization of the VA before spinal surgery might be an aggressive treatment strategy that avoids serious embolic infarction disorder after VAIs.
Collapse
Affiliation(s)
- Taiki Isaji
- Department of Neurosurgery, Nagoya Tokushukai General Hospital, 2-52 Kozojikita, Kasugai, Aichi, Japan
| | - Tadato Yukiue
- Department of Neurosurgery, Nagoya Tokushukai General Hospital, 2-52 Kozojikita, Kasugai, Aichi, Japan
| | - Takayuki Amano
- Department of Neurosurgery, Nagoya Tokushukai General Hospital, 2-52 Kozojikita, Kasugai, Aichi, Japan
| |
Collapse
|
16
|
Biffl WL, Castelo M, Dandan IS, Lu N, Rivera P, Bayat D. Exploring the role of endovascular interventions in blunt carotid and vertebral artery trauma. Am J Surg 2023; 226:688-691. [PMID: 37604750 DOI: 10.1016/j.amjsurg.2023.07.030] [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: 03/24/2023] [Revised: 07/20/2023] [Accepted: 07/22/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND The role of endovascular interventions (EI) for blunt carotid and vertebral artery injuries (BCI and BVI) is poorly defined. The purpose of this study was to assess the efficacy of EI compared with antithrombotic therapy (AT) to inform future prospective study. METHODS Retrospective review (2017-2022) of records at a Level I trauma center to determine injury, treatment, and outcome information. Primary outcome was stroke. RESULTS 96 patients suffered 106 injuries (74 BVI, 32 BCI). 12 patients underwent 13 EI- 4 therapeutic, 9 prophylactic. Stroke occurred in 12 patients- 6 who had EI. In grade IV BVI, stroke rates are low with both EI and AT. Thrombectomy after stroke improved neurologic function in 4 (100%) of 4 patients. CONCLUSIONS Most strokes occur prior to preventive therapy. Neither AT nor EI is 100% effective in preventing stroke. Thrombectomy may improve neurologic outcomes after stroke. Prospective multicenter study is imperative.
Collapse
Affiliation(s)
- Walter L Biffl
- Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA.
| | - Matthew Castelo
- Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA.
| | - Imad S Dandan
- Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA.
| | - Ning Lu
- Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA.
| | - Patricia Rivera
- Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA.
| | - Dunya Bayat
- Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA.
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Kinosada M, Ikeda H, Uezato M, Yokochi Y, Kaneko R, Kurosaki Y, Chin M. Parent artery occlusion for cerebral infarction after spontaneous recanalization in traumatic vertebral artery: A case report. Surg Neurol Int 2023; 14:278. [PMID: 37680919 PMCID: PMC10481815 DOI: 10.25259/sni_462_2023] [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: 06/02/2023] [Accepted: 07/26/2023] [Indexed: 09/09/2023] Open
Abstract
Background There is no established treatment strategy for traumatic vertebral artery occlusion that does not require cervical spine repair surgery. Case Description A 49-year-old man was brought to our hospital with traffic trauma. Fractures were observed in the left lateral mass and transverse process of Atlas and the left vertebral artery was occluded at the level of the foramen transversum of Atlas. No acute cerebral infarction was observed. Because the cervical spinal cord was not compressed by the fracture, no repair surgery was performed. Continuous intravenous heparin and oral aspirin were started for traumatic vertebral artery occlusion. Thereafter, the left vertebral artery spontaneously recanalized, but no cerebral infarction was observed. The patient was discharged home on day 16 of injury. Four days later, however, he was brought to our hospital with nausea and lightheadedness. Acute cerebral infarction was observed in the left posterior inferior cerebellar artery territory and a thrombus in the left vertebral artery V4 segment. Parent artery occlusion was performed to prevent further cerebral infarction due to distal embolization of the thrombus. No further cerebral infarction occurred after the operation and the patient was discharged home with a modified Rankin scale score of 1. Conclusion In cases of traumatic vertebral artery occlusion without an occlusive mechanism, parent artery occlusion may be considered in terms of recanalization risk, regardless of the need for repair surgery.
Collapse
Affiliation(s)
- Masanori Kinosada
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | | | | | | | | | | | | |
Collapse
|
19
|
Tudose RC, Rusu MC, Hostiuc S. The Vertebral Artery: A Systematic Review and a Meta-Analysis of the Current Literature. Diagnostics (Basel) 2023; 13:2036. [PMID: 37370931 DOI: 10.3390/diagnostics13122036] [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: 05/09/2023] [Revised: 06/01/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
(1) Background. The anatomical variations of the vertebral arteries (VAs) have a significant impact both in neurosurgery and forensic pathology. The purpose of this study was to evaluate the variational anatomy of the vertebral artery. We evaluated anatomical aspects regarding the V1 and V2 segments of the VA: origin, course, tortuosity, hypoplasia, and dominance, and established the prevalence of each variation. (2) Methods. We conducted a systematic search in PubMed and Google Scholar databases, up to December 2022. Sixty-two studies, comprising 32,153 vessels, were included in the current meta-analysis. We used a random-effects model with a DerSimonian-Laird estimator. The confidence intervals were set at 95%. The heterogeneity between studies was assessed using I2. The funnel plot and Egger's regression test for plot asymmetry were used for the evaluation of publication bias. Statistical significance was considered at p < 0.05. (3) Results. The most common site for the origin of both VAs was the subclavian artery. The aortic arch origin of the left VA had a prevalence of 4.81%. Other origins of the right VAs were noted: aortic arch (0.1%), right common carotid artery (0.1%), and brachiocephalic trunk (0.5%). Ninety-two percent of the VAs entered the transverse foramen (TF) of the C6 vertebra, followed by C5, C7, C4, and least frequently, C3 (0.1%). Roughly one out of four (25.9%) VAs presented a sort of tortuosity, the transversal one representing the most common variant. Hypoplasia occurred in 7.94% of the vessels. Left VA dominance (36.1%) is more common, compared to right VA dominance (25.3%). (4) Conclusions. The anatomy of the VA is highly irregular, and eventual intraoperative complications may be life-threatening. The prevalence of VA origin from the subclavian artery is 94.1%, 92.0% of the VAs entered the TF at C6, 26.6% were tortuous, and 7.94% were hypoplastic.
Collapse
Affiliation(s)
- Răzvan Costin Tudose
- Division of Anatomy, Faculty of Dentistry, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Mugurel Constantin Rusu
- Division of Anatomy, Faculty of Dentistry, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Sorin Hostiuc
- Division of Legal Medicine and Bioethics, Faculty of Dentistry, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
| |
Collapse
|
20
|
Moskopp ML, Sannwald LW, Burbelko M, Moskopp D. Operative V2 decompression for traumatic vertebrobasilar insufficiency: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2023; 5:CASE2358. [PMID: 37096815 PMCID: PMC10550676 DOI: 10.3171/case2358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 02/27/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND Blunt vertebral artery injuries after cervical trauma due to the close anatomical relationship of the vertebral artery to the cervical spine may have fatal consequences because of posterior circulation ischemia and vertebrobasilar insufficiency. While the standard of care remains medical treatment by anticoagulation or antiplatelet therapy, surgical decompression of the vertebral artery is rarely indicated. OBSERVATIONS The authors present a case of selective decompression of a traumatically constricted vertebral artery within the transverse foramen of C2 presenting with vertebrobasilar insufficiency due to bilateral aplasia of the posterior communicating arteries and contralateral hypoplasia of the vertebral artery. LESSONS Because of their close relationship to the cervical spine, the vertebral arteries are at risk for blunt injury, which may present asymptomatically or with symptoms of posterior circulation ischemia or vertebrobasilar insufficiency either immediately or after a latency phase. The anatomical variability of (1) the vertebral arteries, (2) collateral brainstem perfusion, and (3) the individual injury pattern demands individualized treatment strategies. If endovascular treatment of hemodynamically relevant stenosis of the V2 segment of the vertebral artery poses too high a risk for vessel injury, decompression of the transverse foramen can be performed safely and without risk to the biomechanical stability of the cervical spine.
Collapse
Affiliation(s)
- Mats L. Moskopp
- Department of Neurosurgery, Vivantes Friedrichshain Hospital, Charité Academic Teaching Hospital, Berlin, Germany
- Institute of Physiology, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; and
| | - Lennart W. Sannwald
- Department of Neurosurgery, Vivantes Friedrichshain Hospital, Charité Academic Teaching Hospital, Berlin, Germany
| | - Michael Burbelko
- Institute for Radiology and Interventional Therapy, Vivantes Friedrichshain Hospital, Charité Academic Teaching Hospital, Berlin, Germany
| | - Dag Moskopp
- Department of Neurosurgery, Vivantes Friedrichshain Hospital, Charité Academic Teaching Hospital, Berlin, Germany
| |
Collapse
|
21
|
Matsuzaki R, Nakada C, Kondo K, Mikai M, Sakaeyama Y, Fuchinoue Y, Uchino K, Terazono S, Harada N, Sugo N. Diagnosis and treatment of vertebral artery injuries due to blunt trauma: A case series. Trauma Case Rep 2023; 44:100780. [PMID: 36817073 PMCID: PMC9929849 DOI: 10.1016/j.tcr.2023.100780] [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] [Accepted: 02/04/2023] [Indexed: 02/09/2023] Open
Abstract
Blunt traumatic vertebral artery injuries are rare, but they cause rapid secondary strokes with worsening prognoses. We report four blunt traumatic vertebral artery injury cases that were diagnosed before developing stroke and successfully treated with coil embolization. All four patients were male, aged between 45 and 71 years (mean 57 years). The injuries were caused by road accidents in 2 cases and falls in 2 cases. The GCS at initial examination was 15, except for one case of hypoxic encephalopathy associated with pulmonary contusion (11 points). The vertebral arteries were completely occluded (Denver grade IV). Before treatment, only one patient had a mild right cerebellar hemispheric stroke, but three patients were asymptomatic. All patients underwent coil embolization (2 on 0 days, 1 on 7 days, and 1 on 17 days), and the postoperative course was uneventful. The neuroradiological imaging studies should be performed as early as possible in vertebral artery injuries due to blunt neck trauma. Moreover, endovascular coil embolization is a safe, effective treatment for blunt traumatic vertebral artery injuries.
Collapse
Affiliation(s)
- Ryo Matsuzaki
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, Japan,Corresponding author at: Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, 6-11-1, Omori-nishi, Ota-Ku, Tokyo 143-8541, Japan.
| | - Chie Nakada
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, Japan
| | - Kosuke Kondo
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, Japan
| | - Masataka Mikai
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, Japan
| | - Yuki Sakaeyama
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, Japan
| | - Yutaka Fuchinoue
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, Japan
| | - Kei Uchino
- Department of Neurosurgery (Sakura), School of Medicine, Faculty of Medicine, Toho University, Japan
| | - Sayaka Terazono
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, Japan
| | - Naoyuki Harada
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, Japan
| | - Nobuo Sugo
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, Japan
| |
Collapse
|
22
|
Cerebrovascular injuries in traumatic brain injury. Clin Neurol Neurosurg 2022; 223:107479. [DOI: 10.1016/j.clineuro.2022.107479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/22/2022] [Accepted: 10/13/2022] [Indexed: 11/19/2022]
|
23
|
Asukai M, Ushirozako H, Suda K, Matsumoto Harmon S, Komatsu M, Minami A, Takahata M, Iwasaki N, Matsuyama Y. Safety of early posterior fusion surgery without endovascular embolization for asymptomatic vertebral artery occlusion associated with cervical spine trauma. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:3392-3401. [PMID: 35821446 DOI: 10.1007/s00586-022-07302-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/24/2022] [Accepted: 06/23/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE Vertebral artery occlusion (VAO) is an increasingly recognized complication of cervical spine trauma. However, the management strategy of VAO remains heavily debated. Therefore, the aim of this retrospective study was to investigate the safety of early fusion surgery for traumatic VAO. METHODS This study included a total of 241 patients (average age 64.7 years; 201 men) who underwent early surgical treatment for acute cervical spine injury between 2012 and 2019. The incidence of VAO, cerebral infarction rates, the recanalization rates, and cerebral thromboembolism after recanalization were retrospectively analyzed. RESULTS VAO occurred in 22 patients (9.1%). Of the 22 patients with VAO, radiographic cerebral infarction was detected in 4 patients (21.1%) at initial evaluation, including 1 symptomatic medullar infarction (4.5%) and 3 asymptomatic cerebrum infarctions. A patient who experienced right medullar infarction showed no progression of the neurologic damage. Follow-up imaging revealed that the VAOs of 9 patients (40.9%) were recanalized, and the recanalization did not correlate with clinical adverse outcomes. The arteries of the remaining 13 (59.1%) patients remained occluded and clinically silent until the final follow-up (mean final follow-up 33.0 months). CONCLUSION Despite the lack of a concurrent control group with preoperative antiplatelet therapy or endovascular embolization for VAO, our results showed low symptomatic stroke rate (4.5%), high recanalization rate (40.9%), and low mortality rate (0%). Therefore, we believe that the indication for early stabilization surgery as management strategy of asymptomatic VAO might be one of the safe and effective treatment options for prevention of symptomatic cerebral infarction.
Collapse
Affiliation(s)
- Mitsuru Asukai
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido, 072-0015, Japan.
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan.
| | - Hiroki Ushirozako
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido, 072-0015, Japan
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Kota Suda
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido, 072-0015, Japan
| | - Satoko Matsumoto Harmon
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido, 072-0015, Japan
| | - Miki Komatsu
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido, 072-0015, Japan
| | - Akio Minami
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido, 072-0015, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Yukihiro Matsuyama
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| |
Collapse
|
24
|
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.
Collapse
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
| |
Collapse
|
25
|
Son JI, An TY, Ko MJ, Park SW, Lee YS. Occlusion of Both Vertebral Arteries With Development of Collateral Circulation From the Deep Cervical Artery After Cervical Spine Trauma. Korean J Neurotrauma 2022; 18:374-379. [PMID: 36381429 PMCID: PMC9634321 DOI: 10.13004/kjnt.2022.18.e57] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/31/2022] [Accepted: 09/07/2022] [Indexed: 10/07/2023] Open
Abstract
Careful evaluation of vertebral artery injuries is important after cervical translation injuries or transverse foramen fractures. Treatment of trauma can be complicated in cases of concomitant vertebral artery injuries. A 76-year-old woman was admitted to our hospital with left hemiparesis (Motor grade 3) after a motorcycle accident. Cervical spine magnetic resonance imaging (MRI) and computed tomography (CT) revealed a C3 burst fracture and a left C3 lateral mass and lamina fracture. CT angiography revealed fracture fragments that predisposed the vertebral artery to injury throughout its course in the area. CT angiography confirmed that both vertebral arteries were occluded at the C3 fracture site. Subsequent brain MRI revealed acute infarction in the right occipital area. Although both vertebral arteries were occluded, the infarction site did not correspond to the territory supplied by these vessels; therefore, we performed transfemoral cerebral angiography, which revealed collateralization of the bilateral vertebral arteries by the deep cervical artery.. The deep cervical arteries are located between the posterior muscles; therefore, a fixation operation performed using the posterior approach may have affected the collateral circulation and led to exacerbation of the infarction site. Therefore, surgery was performed using an anterior approach and it was possible to minimize the risk of cerebral infarction through preservation of collateral circulation.
Collapse
Affiliation(s)
- Jun-Ik Son
- Department of Neurosurgery, College of Medicine, Chung-Ang University, Seoul, Korea
- Department of Neurosurgery, College of Medicine, Chung-Ang University Hospital, Seoul, Korea
| | - Tae Yong An
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Myeong Jin Ko
- Department of Neurosurgery, College of Medicine, Chung-Ang University, Seoul, Korea
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Seung Won Park
- Department of Neurosurgery, College of Medicine, Chung-Ang University, Seoul, Korea
- Department of Neurosurgery, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea
| | - Young-Seok Lee
- Department of Neurosurgery, College of Medicine, Chung-Ang University, Seoul, Korea
- Department of Neurosurgery, College of Medicine, Chung-Ang University Hospital, Seoul, Korea
| |
Collapse
|
26
|
Du PZ, Barton D, Bridge N, Ganapathy V. Cervical fracture patterns associated with blunt cerebrovascular injures when utilizing computed tomographic angiography: a systematic review and meta-analysis. Spine J 2022; 22:1716-1725. [PMID: 35671944 DOI: 10.1016/j.spinee.2022.05.009] [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: 03/07/2022] [Revised: 05/04/2022] [Accepted: 05/26/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Prior studies have demonstrated an association between cervical spine fractures and blunt cerebrovascular injuries (BCVI) due to the intimate anatomic relationship between the cervical spine and the vertebral arteries. Digital subtraction angiography (DSA) has historically been the gold standard, but computed tomography angiography (CTA) is commonly used to screen for BCVI in the trauma setting. However, there is no consensus regarding which fracture patterns mandate screening. Over aggressive screening may lead to increased radiation, increased false positives, and overtreatment of patients which can cause unnecessary patient harm, and increased healthcare costs. PURPOSE The aim of this meta-analysis is to analyze which cervical spine fracture patterns are most predictive of BCVI when utilizing CTA. STUDY DESIGN/SETTING Systematic review and meta-analysis. OUTCOME MEASURES Odds ratios for specific cervical fracture patterns and risk of developing a BCVI. METHODS A systematic literature review of all English language studies from 2000-2020 was conducted. The year 2000 was chosen as the cut-off because use of CTA prior to 2000 was rare. Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Scopus, Global Index Medicus, and ClinicalTrials.gov were queried. Studies were included if they met the following criteria: (1) the diagnostic imaging modality was CTA; (2) investigated blunt cervical trauma; (3) noted specific cervical spine fracture patterns associated with BCVI; (4) odds ratios for specific cervical spine fracture patterns or the odds ratio could be calculated; (5) subjects were 18 years old or older. Studies were excluded if they: (1) included DSA or magnetic resonance imaging; (2) included penetrating cervical trauma; (3) included pediatric patients less than 18 years of age; (4) were not written in English. All statistical analysis was performed using R Studio (RStudio, Boston, MA, USA). RESULTS The initial search, after duplicates were removed, resulted in 10,940 articles for independent review. Six studies met the criteria for inclusion in the meta-analysis. Specific fracture patterns mentioned are isolated C1, C2, C3 fractures, any C1-C3 fracture, any C4-C7 fracture, two-level fractures, subluxation/dislocations, and transverse foramen (TF) fractures. Three studies were included in the meta-analysis for C1, C2, C1-C3, subluxations/dislocations, and TF fractures. Two studies were included in the meta-analysis for C3, C4-C7, and two-level fractures. The pooled odds ratio with 95% confidence interval for: C1 fractures and BCVI is 1.3 (0.8-2.1); C2: 1.6 (0.9-2.8); C3: 1.8 (0.9-3.6); C1-C3: 2.2 (1.1-4.2); C4-C7: 0.7 (0.3-1.7); Two-level: 2.5 (1.4-4.6); Subluxation/Dislocation: 2.9 (1.8-4.5); TF: 3.6 (1.4-8.9). DISCUSSION/CONCLUSION This study found that when utilizing CTA for screening of BCVI only fractures in the C1-C3 region, two-level fractures, subluxations/dislocations, and transverse foramen fractures were associated with increased incidence of a BCVI. Further refinement of protocols for CTA in the setting of blunt cervical trauma may help limit unnecessary patient harm from overtreatment and reduce healthcare costs.
Collapse
Affiliation(s)
- Peter Z Du
- University of Arizona - Department of Orthopaedic Surgery, 1501 N Campbell Avenue, 8th Floor Room 8401, Tucson, AZ 85724, USA.
| | - Dane Barton
- University of Arizona - Department of Orthopaedic Surgery, 1501 N Campbell Avenue, 8th Floor Room 8401, Tucson, AZ 85724, USA
| | - Nathaniel Bridge
- University of Arizona - College of Medicine, 1501 N Campbell Avenue, PO Box 245017, Tucson, AZ 85724, USA
| | - Venkat Ganapathy
- University of Arizona - Department of Orthopaedic Surgery, 1501 N Campbell Avenue, 8th Floor Room 8401, Tucson, AZ 85724, USA
| |
Collapse
|
27
|
Indication of imaging to identify cerebral infarction due to vertebral artery damage associated with blunt cervical spine injury. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
28
|
Vierunen RM, Haapamäki VV, Koivikko MP, Bensch FV. Ankylosis of the cervical spine increases the incidence of blunt cerebrovascular injury (BCVI) in CTA screening after blunt trauma. Emerg Radiol 2022; 29:507-517. [PMID: 35296926 PMCID: PMC9123032 DOI: 10.1007/s10140-022-02022-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 01/10/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE To examine the incidence, location, and grade of blunt cerebrovascular injury (BCVI), as well as associated strokes in patients with ankylosis of the cervical spine, imaged with CT angiography (CTA) after blunt trauma. The related etiologies of ankylosis had an additional focus. MATERIALS AND METHODS Altogether of 5867 CTAs of the craniocervical arteries imaged after blunt trauma between October 2011 and March 2020 were manually reviewed for a threshold value of ankylosis of at least three consecutive cervical vertebrae. BCVI was the primary outcome and associated stroke as the secondary outcome. Variables were craniofacial and cervical spine fractures, etiology and levels of ankylosis, traumatic brain injury, spinal hematoma, spinal cord injury, and spinal cord impingement, for which correlations with BCVI were examined. RESULTS Of the 153 patients with ankylosis and blunt trauma of the cervical spine, 29 had a total of 36 BCVIs, of whom two had anterior and 4 posterior circulation strokes. Most of the BCVIs (n = 32) were in the vertebral arteries. Injuries were graded according to the Biffl scale: 17 grade II, 4 grade III, 14 grade IV, and 1 grade V. A ground-level fall was the most common trauma mechanism. Cervical spine fracture was the only statistically significant predictor for BCVI (OR 7.44). Degenerative spondylosis was the most prevalent etiology for ankylosis. CONCLUSION Ankylosis of the cervical spine increases the incidence of BCVI up to sevenfold compared to general blunt trauma populations, affecting especially the vertebral arteries.
Collapse
Affiliation(s)
- Riku M Vierunen
- Department of Radiology, Helsinki University and Helsinki University Hospital, Töölö Hospital, Topeliuksenkatu 5, FIN-00029, Helsinki, Finland.
| | - Ville V Haapamäki
- Department of Radiology, Helsinki University and Helsinki University Hospital, Töölö Hospital, Topeliuksenkatu 5, FIN-00029, Helsinki, Finland
| | - Mika P Koivikko
- Department of Radiology, Helsinki University and Helsinki University Hospital, Töölö Hospital, Topeliuksenkatu 5, FIN-00029, Helsinki, Finland
| | - Frank V Bensch
- Department of Radiology, Helsinki University and Helsinki University Hospital, Töölö Hospital, Topeliuksenkatu 5, FIN-00029, Helsinki, Finland
| |
Collapse
|
29
|
Endovascular and Antithrombotic Treatment in Blunt Cerebrovascular Injuries: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2022; 31:106456. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 11/22/2022] Open
|
30
|
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.
Collapse
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
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Pinter ZW, Wagner S, Sebastian AS, Roach WB. Is Anticoagulation Necessary for Asymptomatic Unilateral Vertebral Artery Injury? Clin Spine Surg 2022; 35:E65-E67. [PMID: 33086254 DOI: 10.1097/bsd.0000000000001085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 06/02/2020] [Indexed: 11/26/2022]
Affiliation(s)
| | - Scott Wagner
- Walter Reed National Military Medical Center, Bethesda, MD
| | | | - William B Roach
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
32
|
Zeineddine HA, King N, Lewis CT, Kole MJ, Kitagawa R, Dannenbaum M, Chen PR, Day AL, Blackburn S. Blunt Traumatic Vertebral Artery Injuries: Incidence, Therapeutic Management, and Outcomes. Neurosurgery 2022; 90:399-406. [PMID: 35064660 DOI: 10.1227/neu.0000000000001843] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 10/25/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Blunt cerebrovascular injury (BCVI) is a term for injuries to the carotid and vertebral arteries (blunt vertebral artery injury [BVAI]) caused by blunt trauma. Computed tomographic angiography is currently the best screening test for BCVI. The subsequent management of any identified vessel injury, however, is not clearly defined. OBJECTIVE To describe one of the largest cohorts of isolated vertebral artery injuries and report the evolution of treated and untreated lesions and clinical outcomes of treatment regimens used to reduce the risk of injury-related stroke. METHODS The list included patients who presented to or were transferred to a level 1 trauma center and found to have an isolated BVAI. Patients were included if imaging was performed within 24 hours of presentation. Data collected included location and grade of injury, timing and type of initial therapy, follow-up imaging, evolution of the disease, and associated strokes. RESULTS A total of 156 patients were included in the analysis. Most patients (135/156) were treated with aspirin alone, 3 with anticoagulation therapy, and 18 did not receive treatment. Three strokes were detected within 24 hours of admission and before treatment initiation. No strokes were detected during the length of the hospitalization for any other patient. CONCLUSION Our data demonstrate that the risk of stroke after cervical vertebral artery injury is low, and aspirin as a prophylactic is efficacious in grade I and IV injuries. There are limited data regarding grade II and grade III injuries. The benefit of early interval imaging follow-up is unclear and warrants investigation.
Collapse
Affiliation(s)
- Hussein A Zeineddine
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Devi B, Gupta R, Siroya H, Bhat D, Shukla D, Pruthi N. Vertebral artery dissection in acute cervical spine trauma. J Craniovertebr Junction Spine 2022; 13:27-37. [PMID: 35386245 PMCID: PMC8978858 DOI: 10.4103/jcvjs.jcvjs_3_22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/09/2022] [Indexed: 12/05/2022] Open
Abstract
Objective: The aim of this study was to study mechanism, risk factors, and prognosis of patients with vertebral artery dissection (VAD) from acute cervical spine trauma (CST). Methods: A total of 149 consecutive patients were chosen from 2014 to 2019 from our institute data base, and their records were retrospectively studied. Morphology of fracture and subluxation were studied in detail with respect to the presence or absence of VAD. Results: Patients were divided in subsets of axial spine injury and subaxial spine injury. Subgroup and group analysis was performed and computerized tomography angiogram, MR angiogram and T1/T2 axial scans were studied to identify VAD, an incidence of 14.1% was found. Patients having infarcts in posterior circulation were also identified. Conclusion: There is a significant contribution of biomechanics of CST and evolution of VAD. This is an important consideration to prevent significant morbidity and mortality. Hence, a diagnostic algorithm which can be applied in any hospital setup is the need of the hour.
Collapse
|
34
|
Wynn MS, Kesler KK, Bertroche E, Pugely AJ, Igram C. Patient specific predictive factors of vertebral artery injury following blunt cervical spine trauma. Clin Neurol Neurosurg 2021; 210:106988. [PMID: 34678555 DOI: 10.1016/j.clineuro.2021.106988] [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: 08/24/2021] [Revised: 10/04/2021] [Accepted: 10/08/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Determine patient and injury characteristics predictive of vascular injury (VAI) in blunt cervical spine (BCS) trauma to identify high-risk patients and propose an alternative screening protocol. METHODS Patients presenting between 2014 and 2018 with BCS injury and cervical spine CT imaging were included. Demographics and injury characteristics of BCS injuries were collected. Univariate and multivariate analyses to determine risk factors for VAI were performed. Once factors associated with greater odds of VAI were identified, this information was used to create an alternative protocol for indicating CTA in patients who sustained BCS injury. RESULTS A total of 475 patients were included. CTA of the neck was performed in 55.5% patients. In patients who received CTA, 18.2% had a contraindication to receiving anti-platelet therapy, and 25% were already receiving anti-coagulation therapy as an outpatient medication. VAI was found in 13.2% patients. In patients with VAI, 48.5% were already receiving anti-coagulation as outpatient medication. Acute kidney injury was found in 10.5% patients who had received CTA. Factors associated with greater odds of having VAI included transverse foramen involvement(p = 0.0001), subluxation/displacement/dislocation of fracture(p = 0.03), high energy mechanism(p = 0.02), SLIC score > 4(p = 0.04), and concomitant lumbar spine injury(p = 0.03). Using Modified Hawkeye Protocol, 40.2% of patients were indicated to receive a CTA, and 17 VAI were identified. Compared to Denver Criteria, CTAs were performed in 73 less patients(p = 0.04). CONCLUSIONS Updated protocols utilizing evidence-based clinical parameters to predict chance of VAI may avoid unnecessary advanced imaging and contrast load to patients in the setting of BCS trauma.
Collapse
Affiliation(s)
- Malynda S Wynn
- University of Iowa Hospital & Clinics, Department of Orthopedics & Rehabilitation, Iowa City, IA, United States.
| | - Kyle K Kesler
- University of Iowa Hospital & Clinics, Department of Orthopedics & Rehabilitation, Iowa City, IA, United States
| | - Eric Bertroche
- University of Iowa Hospital & Clinics, Department of Orthopedics & Rehabilitation, Iowa City, IA, United States
| | - Andrew J Pugely
- University of Iowa Hospital & Clinics, Department of Orthopedics & Rehabilitation, Iowa City, IA, United States
| | - Cassim Igram
- University of Iowa Hospital & Clinics, Department of Orthopedics & Rehabilitation, Iowa City, IA, United States
| |
Collapse
|
35
|
Extensive brain infarctions from bilateral vertebral artery injury because of cervical hyperextension injury: A case report. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
36
|
Nakamura Y, Kusakabe K, Nakao S, Hagihara Y, Matsuoka T. Vertebral artery occlusion associated with blunt traumatic cervical spine injury. Acute Med Surg 2021; 8:e670. [PMID: 34408881 PMCID: PMC8359820 DOI: 10.1002/ams2.670] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/06/2021] [Accepted: 06/02/2021] [Indexed: 11/10/2022] Open
Abstract
Aim Vertebral artery injury associated with blunt traumatic cervical spine injury sometimes causes severe cerebellar and brain stem infarction. No treatment guidelines for vertebral artery injury aimed at preventing stroke have been decided. We have conducted endovascular embolization in patients with up to Denver grade IV cerebrovascular injury complicated by unstable cervical spine injury before open reduction and fixation surgery. The purpose of this study was to validate the clinical course of vertebral artery injury and especially endovascular treatment for grade IV patients in our hospital. Methods Participants comprised of patients diagnosed as having traumatic cervical spine injury in our hospital between January 2015 and April 2018. Among these patients, we selected those with vertebral artery injury and retrospectively examined the background characteristics of the patients, details of treatment, and complications with or without stroke. Results Traumatic cervical spine injury was diagnosed in 89 patients. Among these patients, 15 (16.7%) showed a complicating vertebral artery injury. Mean age was 62.6 years, and almost 50% of the patients were injured in falls. Three types of cervical spine injury caused vertebral artery injury: subluxation, Jefferson fracture, and fracture involving the foramen transversarium. Vertebral artery injury was classified as grade IV in 12 patients, of whom nine required spinal surgery. All patients who needed spinal surgery underwent endovascular therapy before surgery, and none experienced a stroke. Conclusion Endovascular embolization of the vertebral artery occlusion in patients with unstable cervical spine injury before open reduction and fixation surgery can be a treatment option to prevent stroke.
Collapse
Affiliation(s)
- Youhei Nakamura
- Department of Neurosurgery Rinku General Medical Center Osaka Japan and
| | - Kenji Kusakabe
- Senshu Trauma and Critical Care Center/Department of Trauma & Critical Care Rinku General Medical Center Osaka Japan
| | - Shota Nakao
- Senshu Trauma and Critical Care Center/Department of Trauma & Critical Care Rinku General Medical Center Osaka Japan
| | - Yasushi Hagihara
- Department of Neurosurgery Rinku General Medical Center Osaka Japan and.,Senshu Trauma and Critical Care Center/Department of Trauma & Critical Care Rinku General Medical Center Osaka Japan
| | - Tetsuya Matsuoka
- Senshu Trauma and Critical Care Center/Department of Trauma & Critical Care Rinku General Medical Center Osaka Japan
| |
Collapse
|
37
|
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.
Collapse
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
| |
Collapse
|
38
|
Russo RM, Davidson AJ, Alam HB, DuBose JJ, Galante JM, Fabian TC, Savage S, Holcomb JB, Scalea TM, Rasmussen TE. Blunt cerebrovascular injuries: Outcomes from the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) multicenter registry. J Trauma Acute Care Surg 2021; 90:987-995. [PMID: 34016922 DOI: 10.1097/ta.0000000000003127] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Administering antithrombotics (AT) to the multiply injured patient with blunt cerebrovascular injury (BCVI) requires a thoughtful assessment of the risk of stroke and death associated with nontreatment. Large, multicenter analysis of outcomes stratified by injury grade and vessel injured is needed to inform future recommendations. METHODS Nine hundred and seventy-one BCVIs were identified from the PROspective Vascular Injury Treatment registry in this retrospective analysis. Using multivariate analysis, we identified predictors of BCVI-related stroke and death. We then stratified these risks by injury grade and vessel injured. We compared the risk of adverse outcomes in the nontreatment group with those treated with antiplatelet agents and/or anticoagulants. RESULTS Stroke was identified in 7% of cases. Overall mortality was 12%. Both increased with increasing BCVI grade. Treatment with ATs was associated with lower mortality and was not significantly affected by the choice of agent. Withholding ATs was associated with an increased risk of stroke and/or death across all subgroups (Grade I/II: odds ratio [OR], 4.66; 95% confidence interval [CI], 2.48-8.75; Grade III: OR, 7.0; 95% CI, 2.01-24.5; Grade IV: OR, 4.43; 95% CI, 1.76-11.1) even after controlling for covariates. Predictors of death included more severe trauma, Grade IV injury, and the occurrence of stroke. Arterial occlusion, hypotension, and endovascular intervention were significant predictors of stroke. Patients that experienced a BCVI-related stroke were at a 4.2× increased risk of death. The data set lacked the granularity necessary to evaluate AT timing or dosing regimen, which limited further analysis of stroke prevention strategies. CONCLUSION Stroke and death remain significant risks for all BCVI grades regardless of the vessel injured. Antithrombotics represent the only management strategy that is consistently associated with a lower incidence of stroke and death in all BCVI categories. In the multi-injured BCVI patient with a high risk of bleeding on anticoagulation, antiplatelet agents are an efficacious alternative. Given the 40% mortality rate in patients who survived their initial trauma and developed a BCVI-related stroke, nontreatment may no longer be a viable option. LEVEL OF EVIDENCE Epidemiological III; Therapeutic IV.
Collapse
Affiliation(s)
- Rachel M Russo
- From the University of California Davis Medical Center, Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care (R.R., J.G.), Sacramento; David Grant Medical Center, Department of Surgery (R.R.), Travis AFB, Fairfield, California; University of Michigan, Department of Surgery, Division of Vascular Surgery (A.D.), Ann Arbor, Michigan; Northwestern University, Feinberg School of Medicine, Department of Surgery (H.A.), Chicago, Illinois; University of Maryland R Adams Cowley Shock Trauma Center (J.D., T.S.), Baltimore, Maryland; University of Tennessee Health Sciences Center, Department of Surgery (T.F.), Memphis, Tennessee; University of Wisconsin Madison Medical Center, Department of Surgery (S.S.), Madison, Wisconsin; Uniformed Services University of the Health Sciences, Department of Surgery, Division of Trauma and Acute Care Surgery (J.H., R.R.), Bethesda, Maryland; and Uniformed Services University of the Health Sciences, Department of Surgery, Division of Vascular Surgery (T.R.), Bethesda, Maryland
| | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Murphy PB, Severance S, Holler E, Menard L, Savage S, Zarzaur BL. Treatment of asymptomatic blunt cerebrovascular injury (BCVI): a systematic review. Trauma Surg Acute Care Open 2021; 6:e000668. [PMID: 33981860 PMCID: PMC8076921 DOI: 10.1136/tsaco-2020-000668] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 03/11/2021] [Accepted: 03/16/2021] [Indexed: 11/24/2022] Open
Abstract
Background The management of asymptomatic blunt cerebrovascular injury (BCVI) with respect to stroke prevention and vessel healing is challenging. Objectives The aim of this systematic review was to determine if a specific treatment results in lower stroke rates and/or improved vessel healing in asymptomatic BCVI. Data sources An electronic literature search of MEDLINE, EMBASE, Cochrane Library, CINAHL, SCOPUS, Web of Science, and ClinicalTrials.gov performed from inception to March 2020. Study eligibility criteria Studies were included if they reported on a comparison of any treatment for BCVI and stroke and/or vessel healing rates. Participants and interventions Adult patients diagnosed with asymptomatic BCVI(s) who were treated with any preventive medication or procedure. Study appraisal and synthesis methods All studies were systematically reviewed and bias was evaluated by the Newcastle-Ottawa Scale. No meta-analysis was performed secondary to significant heterogeneity across studies in patient population, screening protocols, and treatment selection. The main outcomes were stroke and healing rate. Results Of 8781 studies reviewed, 19 reported on treatment effects for asymptomatic BCVI and were included for review. Any choice of medical management was better than no treatment, but no specific differences between choice of medical management and stroke outcomes were found. Vessel healing was rare and the majority of healed vessels were following low-grade injuries. Limitations Majority of the included studies were retrospective and at high risk of bias. Conclusions or implications of key findings Asymptomatic BCVI should be treated medically using a consistent, local protocol. High-quality studies on the effect of individual antithrombotic agents on stroke rates and vessel healing for asymptomatic BCVI are required.
Collapse
Affiliation(s)
| | - Sarah Severance
- Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Emma Holler
- Surgery, Eskenazi Health, Indianapolis, Indiana, USA
| | - Laura Menard
- Medical Education and Access Services, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Stephanie Savage
- Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ben L Zarzaur
- Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| |
Collapse
|
40
|
Matsumoto S, Tagawa M, Inoue A, Takeba J, Watanabe H, Kunieda T. Interventional Distal Embolization before Corrective Cervical Spinal Surgery for Posttraumatic Vertebral Artery Occlusion: A Case Report and Review of the Literature. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 15:719-724. [PMID: 37502271 PMCID: PMC10370999 DOI: 10.5797/jnet.cr.2020-0204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 01/18/2021] [Indexed: 07/29/2023]
Abstract
Objective A traumatic vertebral artery (VA) injury may result in serious cerebral infarction in the vertebrobasilar area. However, the approach to its diagnosis and the optimal treatment have not yet been established. We present a patient with traumatic occlusion of a unilateral VA due to the multiple cervical spine fractures who required decompression and fixation, in whom the injured VA was coil embolized distal to the occlusion prior to the cervical spine surgery. Case Presentation A 47-year-old woman was injured in a car accident and, presented with C6-C7 superior articular process fractures and C2-C3 ossification of the posterior longitudinal ligament (OPLL) with sensory hypoesthesia and motor palsy of the left upper limb. MRA showed left VA occlusion and patent contralateral VA. DSA showed left VA occlusion from the origin to C5/6 and its antegrade flow by collateral orthodromic circulation from the muscular branches. To prevent vertebrobasilar infarction due to migration of the thrombus from the occluded VA which was recanalized by surgical fixation, distal coil embolization of the injured VA by navigating a microcatheter through the contralateral VA across the vertebrobasilar junction was performed. Neither ischemic events nor new neurologic symptoms occurred during follow-up. Conclusion Preoperative coil embolization to a traumatic VA occlusion can be one of the therapeutic choices to prevent thromboembolic stroke after cervical spine surgery. When the proximal segment of the VA was injured and VA occluded from origin, this treatment strategy is feasible, safe, and effective.
Collapse
Affiliation(s)
- Shirabe Matsumoto
- Department of Neurosurgery, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Masahiko Tagawa
- Department of Neurosurgery, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Akihiro Inoue
- Department of Neurosurgery, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Jun Takeba
- Emergency Medicine and Critical Care, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Hideaki Watanabe
- Department of Neurosurgery, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Takeharu Kunieda
- Department of Neurosurgery, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| |
Collapse
|
41
|
Ramamurti P, Weinreb J, Fassihi SC, Rao R, Patel S. Vertebral Artery Injury in the Cervical Spine: Anatomy, Diagnosis, and Management. JBJS Rev 2021; 9:e20.00118. [PMID: 33470592 DOI: 10.2106/jbjs.rvw.20.00118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
» Although rare, injury to the vertebral artery (VA) can occur after blunt trauma or iatrogenically during surgery. Clinicians should be aware of the anatomic variants of the VA, the presence of which may increase the risk of iatrogenic VA injury (VAI). » If VAI is suspected following blunt trauma, rapid identification via advanced imaging modalities, such as computed tomography angiography, can help clarify the site of injury and guide management. » VAI can be classified according to the Denver grading scale for blunt cerebrovascular injury, ranging from grade I to grade V, which includes intimal narrowing, pseudoaneurysm formation, complete occlusion, and arterial transection. » Treatment modalities remain controversial and include anticoagulation, endovascular interventions, surgical tamponade, ligation, and microvascular repair. The choice of treatment is influenced by the setting of the injury (iatrogenic injury in the operating room versus blunt trauma in the field) and the laterality of the dominant VA with respect to brain perfusion.
Collapse
Affiliation(s)
- Pradip Ramamurti
- George Washington School of Medicine and Health Sciences, Washington, DC
| | - Jeffrey Weinreb
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
| | - Safa C Fassihi
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
| | - Raj Rao
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
| | - Shalin Patel
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
| |
Collapse
|
42
|
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.
Collapse
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
| |
Collapse
|
43
|
Pinter ZW, Lawson BK, Freedman BA, Sebastian AS. Atypical hangman's fracture with concomitant subaxial fracture-dislocation treated with circumferential fusion of C2-C5-a case report. Spinal Cord Ser Cases 2020; 6:108. [PMID: 33268764 DOI: 10.1038/s41394-020-00365-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 11/14/2020] [Accepted: 11/14/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Atypical hangman's fractures are coronally-oriented vertical fractures of the posterior body of C2. Though these are not uncommon injuries, there is a paucity of data investigating the management of these fractures, especially when they occur in association with subaxial fracture dislocations. CASE PRESENTATION A 50-year-old male suffered a cervical extension injury when he dove into a shallow swimming pool while intoxicated. Initial examination demonstrated 2/5 strength in the right deltoid and biceps and 3/5 strength in the left deltoid and biceps with no motor or sensory function distal to the C5 level. Cervical CT scan revealed a C2 atypical hangman's fracture and a C4 right-sided facet fracture with traumatic spondylolisthesis at C4/5. We performed C2-C5 anterior cervical discectomy and fusion followed by a C3-C5 posterior instrumented fusion. At the patient's two year postoperative visit, the patient has had minimal improvement in neurologic function with 4/5 strength in bilateral deltoids and biceps and 2/5 strength in right wrist extension. Radiographs show a solid arthrodesis on flexion-extension radiographs. DISCUSSION To our knowledge, this is the first case report discussing the operative management of an atypical hangman's fracture with a concomitant subaxial fracture-dislocation. This case report adds to our current knowledge by demonstrating a novel anterior-posterior approach for treating these complicated injuries.
Collapse
Affiliation(s)
| | - Bryan K Lawson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Brett A Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | |
Collapse
|
44
|
Maruiwa R, Watanabe K, Suzuki S, Nori S, Tsuji O, Nagoshi N, Okada E, Yagi M, Fujita N, Nakamura M, Matsumoto M. Chin on Chest Deformity Caused by Upper Cervical Kyphosis Associated With Ankylosing Spondylitis: A Case Report. Neurospine 2020; 17:666-671. [PMID: 33022171 PMCID: PMC7538344 DOI: 10.14245/ns.2040502.251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 09/09/2020] [Indexed: 11/19/2022] Open
Abstract
Chin on chest deformity caused by upper cervical kyphosis associated with ankylosing spondylitis is rare. A 66-year-old woman presented at our institute with chief complaints of difficulty in horizontal gaze and opening her mouth. Cervical radiographs showed a C0–2 angle of 1° on flexion and 7° on extension, and her chin-brow vertical angle was 49°. We planned fixation surgery at C0–5 posteriorly to prevent the progression of kyphosis, with slight correction of the kyphosis at C0–2. The correction was performed by pushing down the over lordotically contoured titanium rods connected to an occipital plate onto the C3–5 lateral mass screws, just like cantilever technique. No palpable cracking or loss of resistance was noticed during the correction. However, intraoperative radiographs revealed apparent anterior separation of the vertebral bodies between C3 and C4. Postoperative computed tomography images at the C3/4 level suggested hemorrhage from the fracture site. Tracheostomy was performed because of massive edema around the pharynx. To secure solid bone fusion, staged surgery to extend the fusion to T3 and to graft an additional iliac bone was performed. Fortunately, the C2–7 angle was corrected to 40°, and her chin-brow vertical angle was restored to 17° without any catastrophic complications. Although the patient finally obtained an ideal sagittal alignment, the surgeon should be aware that the technique had a higher perioperative risk for iatrogenic fracture, resulting in neurological and vascular injuries.
Collapse
Affiliation(s)
- Ryosuke Maruiwa
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kota Watanabe
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Suzuki
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Nori
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Osahiko Tsuji
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Narihito Nagoshi
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Eijiro Okada
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Mitsuru Yagi
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Nobuyuki Fujita
- Department of Orthopedic Surgery, Fujita Medical University, Aichi, Japan
| | - Masaya Nakamura
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| |
Collapse
|
45
|
Chowdhury S, Almubarak SH, Binsaad KH, Mitra B, Fitzgerald M. Vertebral artery injury in major trauma patients in Saudi Arabia: A retrospective cohort study. Sci Rep 2020; 10:16199. [PMID: 33004855 PMCID: PMC7530664 DOI: 10.1038/s41598-020-73238-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/15/2020] [Indexed: 12/04/2022] Open
Abstract
Blunt vertebral artery injury (VAI) is associated with severe cervicocephalic trauma and may have devastating consequences. This study aimed to determine the incidence and nature of VAI in polytrauma patients. The secondary objective was to assess the association of VAI with previously suggested risk factors. It was a retrospective observational study of all polytrauma patients admitted to the trauma unit between April 2018 and July 2019, who had CT neck angiography to diagnose blunt VAI according to modified Denver criteria. Out of 1084 admitted polytrauma patients, 1025 (94.6%) sustained blunt trauma. Of these, 120 (11.7%) underwent screening CT neck angiography. VAI was detected in 10 (8.3%; 95% CI 4.1–14.8) patients. There were three patients with Grade I injury, two with Grade II, and five with Grade IV injury. Among all trauma admissions, the incidence of diagnosed VAI was 0.9% (95% CI 0.5–1.8). Among patients suspected of VAI, there was no univariable association of VAI with C-Spine fracture: OR 4.2 (95% CI 0.51–34.4; p = 0.18). There were two (20%) deaths related to VAI. Traumatic VAI was uncommonly detected in this major trauma service in Saudi Arabia. High suspicion and liberal screening by CT angiography in cases where VAI is possible should be considered to avoid missed injuries.
Collapse
Affiliation(s)
| | | | | | - Biswadev Mitra
- National Trauma Research Institute, 89 Commercial Road, Melbourne, VIC, 3004, Australia.,Alfred Health, The Alfred Hospital, 55 Commercial Road, Melbourne, VIC, 3004, Australia.,Critical Care Division, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Mark Fitzgerald
- National Trauma Research Institute, 89 Commercial Road, Melbourne, VIC, 3004, Australia.,Alfred Health, The Alfred Hospital, 55 Commercial Road, Melbourne, VIC, 3004, Australia
| |
Collapse
|
46
|
R S, Gem K, A N, E AM, N D. Vertebral Artery Injury in Cervical Spine Fractures: A Cohort Study and Review of the Literature. THE ULSTER MEDICAL JOURNAL 2020; 89:89-94. [PMID: 33093693 PMCID: PMC7576392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 02/17/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The risk of vertebral artery injury (VAI) secondary to cervical spine fracture is increasingly recognised in the literature. The aim of this study was to determine the incidence of VAI amongst patients presenting to the Royal Victoria Hospital (Northern Ireland's regional trauma centre with emergency surgical spinal services) with acute cervical spine fractures, and to identify fracture patterns associated with the highest risk of VAI. METHODS A retrospective review of 1,894 computed tomography (CT) reports of patients who underwent imaging of their cervical spine and/or vertebral arteries over a 12-month period, from June 2018 to June 2019, was conducted. RESULTS Sixty-eight patients (3.59%) with a confirmed cervical spine fracture were identified. These patients had an age range of 18-97 years and included 39 males (57.4%) and 29 females (42.6%). The fractures were then classified according to the AOSpine Cervical Spine Fracture Classification. Of the 68 patients with a confirmed cervical spine fracture, five (7.35%) were diagnosed with VAI, all involving fractures of their upper cervical spine. Two involved fractures extending into the transverse foramen, two involved subluxation of the vertebrae and one involved both. In all five cases, these fractures resulted from high- energy injuries. Regarding management, the patients with VAI in this study were either monitored and given no specific treatment or treated medically with antiplatelet therapy. None underwent surgical intervention. CONCLUSIONS Fracture patterns associated with increased risk of VAI are fractures involving the upper cervical spine, fractures with associated subluxation, and fractures of the transverse process extending into the transverse foramen - urgent CT-angiography in these cases is recommended. Further work should develop a targeted set of criteria for screening for VAI in cervical spine fractures, with consideration of high-risk fracture patterns.
Collapse
Affiliation(s)
- Sheppard R
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL
| | - Kennedy Gem
- Royal Victoria Hospital, Belfast Health and Social Care Trust, 274 Grosvenor Road, Belfast, BT12 6BA
| | - Nelson A
- Royal Victoria Hospital, Belfast Health and Social Care Trust, 274 Grosvenor Road, Belfast, BT12 6BA
| | - Abdel Meguid E
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL
| | - Darwish N
- Royal Victoria Hospital, Belfast Health and Social Care Trust, 274 Grosvenor Road, Belfast, BT12 6BA
| |
Collapse
|
47
|
Rathod T, Garje V, Marathe N, Mohanty S, Shende C, Jogani A, Srivastava AK. Incidence and Outcome Analysis of Vertebral Artery Injury in Posttraumatic Cervical Spine. Asian J Neurosurg 2020; 15:644-647. [PMID: 33145220 PMCID: PMC7591224 DOI: 10.4103/ajns.ajns_45_20] [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: 03/17/2020] [Revised: 03/02/2020] [Accepted: 04/14/2020] [Indexed: 12/01/2022] Open
Abstract
Objective: Vertebral artery injury (VAI) after cervical spine trauma often remains undiagnosed. Despite various clinical studies suggesting simultaneous occurrence of VAI with cervical spine trauma, guidelines regarding screening and management of posttraumatic VAI are yet to be formulated. The primary objective of the current study was to formulate a low-cost screening protocol for posttraumatic VAI, thereby reducing the incidence of missed VAI in developing countries. Materials and Methods: This was a single-center prospective study performed on 61 patients using plain magnetic resonance imaging (MRI) as a screening tool to assess the frequency of VAI and routine X-ray to detect morphological fracture patterns associated with the VAI in posttraumatic cervical spine cases. If the MRI study showed any evidence of vascular disruption, then further investigation in the form of computed tomography angiography was done to confirm the diagnosis. Results: This study showed the incidence of VAI was 14.75% (9/61). Of 61 patients, 16 had supraaxial, and 45 patients sustained subaxial cervical spine fractures. In the cohort of nine cases of VAI, eight patients had subaxial cervical spine injuries, of which seven were due to flexion-distraction injury. C5–C6 flexion-distraction injury was most commonly associated with VAI (4 cases). Of the nine cases, five succumbed to injury (mortality 55.55%), and 19 patients from the non-VAI group succumbed to injury (mortality 36.53%). From surviving four cases with VAI, two had improvement in the American Spinal Injury Association scale by Grade 1. Conclusion: VAI in cervical spine trauma is an underrecognized phenomenon. Plain MRI axial imaging sequence can be an instrumental low-cost screening tool in resource-deficient parts of the world. VAI has tendency to occur with high-velocity trauma like bi-facetal dislocation, which has a high mortality and poor neurological recovery.
Collapse
Affiliation(s)
- Tushar Rathod
- Department of Orthopaedics, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Vinayak Garje
- Department of Orthopaedics, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Nandan Marathe
- Department of Spine Services, Indian Spinal Injuries Centre, New Delhi, India
| | - Shubranshu Mohanty
- Department of Orthopaedics, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Chetan Shende
- Department of Orthopaedics, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Abhinav Jogani
- Department of Orthopaedics, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Abhinav Kumar Srivastava
- Department of Orthopaedics, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| |
Collapse
|
48
|
Hoffman H, Bunch KM, Protas M, Chin LS. Risk Factors and Outcomes Associated with Blunt Cerebrovascular Injury in Patients with Mild or Moderate Traumatic Brain Injury. Ann Vasc Surg 2020; 71:157-166. [PMID: 32768544 DOI: 10.1016/j.avsg.2020.07.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Blunt cerebrovascular injury (BCVI) represents a spectrum of traumatic injuries to the carotid and vertebral arteries that is an often-overlooked source of morbidity and mortality. Its incidence, risk factors, and effect on outcomes in patients with mild or moderate traumatic brain injury (mTBI) have not been studied independently. METHODS The National Trauma Data Bank from 2013 to 2017 was queried to identify patients with mTBI who suffered blunt injuries. BCVI was identified using abbreviated injury scores and included blunt carotid artery injury (BCAI) and blunt vertebral artery injury (BVAI). A binary logistic regression was used to identify patient-related and injury-related factors associated with BCVI. Binary logistic regressions were also performed to evaluate the effect of BCVI on stroke, in-hospital mortality, nonroutine discharge disposition, total length of stay (LOS), intensive care unit LOS, and number of days mechanically ventilated. RESULTS Of 485,880 patients with mTBI, there were 4,382 (0.9%) with BCVI. Cervical spine fracture was the strongest factor associated with BCAI (odds ratio [OR], 1.97; 95% confidence interval [95% CI], 1.77-2.19), followed by mandible fracture and basilar skull fracture. Cervical spine fracture also had the strongest association with BVAI (OR, 18.28; 95% CI, 16.47-20.28), followed by spinal cord injury and neck contusion. Stroke was more common in patients with BCAI (OR, 5.50; 95% CI, 4.19-7.21) and BVAI (OR, 7.238; 95% CI, 5.929-8.836). BVAI increased the odds of mortality, but BCAI did not. Both were associated with nonroutine discharge and increased LOS, intensive care unit LOS, and number of days mechanically ventilated. CONCLUSIONS The incidence of BCVI in patients with mTBI is low, and it usually does not require invasive treatment. However, it is associated with greater odds of stroke and negative outcomes. Knowledge of risk factors for BCVI may tailor further investigation to aid prompt diagnosis.
Collapse
Affiliation(s)
- Haydn Hoffman
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, NY.
| | - Katherine M Bunch
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, NY
| | - Matthew Protas
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, NY
| | - Lawrence S Chin
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, NY
| |
Collapse
|
49
|
Asensio JA, Dabestani PJ, Wenzl FA, Miljkovic SS, Kessler JJ, Fernandez CA, Becker T, Cornell D, Siu M, Voigt C, Agrawal DK. A systematic review of penetrating extracranial vertebral artery injuries. J Vasc Surg 2020; 71:2161-2169. [DOI: 10.1016/j.jvs.2019.10.084] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 10/19/2019] [Indexed: 11/25/2022]
|
50
|
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]
|