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Ardeshna S, Esposito E, Spalding C, Dunn J, Nahmias J, Grigorian A, Harmon L, Gergen A, Young A, Pascual J, Murry J, Ong A, Appelbaum R, Bugaev N, Tatar A, Zreik K, Scalea TM, Stein D, Lauerman M. Which Patients Receive Diagnostic Angiography? An EAST Multicenter Study Analysis of Internal Carotid Artery Blunt Cerebrovascular Injury. Am Surg 2023; 89:5183-5190. [PMID: 36417771 DOI: 10.1177/00031348221138083] [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: 12/22/2023]
Abstract
BACKGROUND Digital subtraction angiography (DSA) is the gold standard radiologic modality in blunt cerebrovascular injury (BCVI). However, computerized tomography angiography (CTA) is primarily used in modern practice with CTA's widespread availability and the decreased stroke rate with CTA use. The frequency and indications for DSA in BCVI is undefined. We hypothesized that DSA use in internal carotid artery (ICA) BCVI would be infrequent and dependent on radiologic features. METHODS This was a post hoc analysis of an EAST multicenter, prospective, observational trial of 16 trauma centers for stroke factors in BCVI. ICA BCVI was divided into those undergoing DSA and not undergoing DSA (no-DSA). Only ICA BCVI was included. RESULTS 332 ICA BCVI were included, 221 (66.6%) no-DSA and 111 (33.4%) DSA. Lower hospital trauma volume, non-urban environment, and non-academic status were associated with DSA use (all P ≤ .001). BCVI grade (P = .02) and presence of luminal stenosis (P = .005) were associated with DSA use while pseudoaneurysm presence was not. Median time to DSA was 1 hour. The most common indication for angiography was to determine the presence of injury in 71 (64%) ICA BCVI, followed by determining grade of injury in 16 (14.4%) and concerning imaging characteristics in 12 (10.8%). BCVI grade on initial imaging and on DSA were equivalent in 94 (84.7%) ICA BCVI. DISCUSSION DSA is frequently used in ICA BCVI, primarily early in the hospital course for injury diagnosis and grade determination. DSA appears primarily driven by hospital type, BCVI grade, and luminal stenosis.
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Affiliation(s)
| | | | | | - Julie Dunn
- University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | | | | | | | - Anna Gergen
- University of Colorado Denver, Denver, CO, USA
| | - Andrew Young
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jose Pascual
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | | | - Rachel Appelbaum
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Antony Tatar
- Tufts University School of Medicine, Boston, MA, USA
| | | | | | - Deborah Stein
- R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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2
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Majumdar R, Gautam P, Ghozy S, Saha R. Bilateral spontaneous vertebral artery dissection complicated by bilateral posterior cerebral artery occlusion in a migraine patient: a case report with systematic review. Int J Neurosci 2023:1-8. [PMID: 38009304 DOI: 10.1080/00207454.2023.2286919] [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: 07/27/2023] [Accepted: 11/19/2023] [Indexed: 11/28/2023]
Abstract
Migraines being a possible risk factor for spontaneous multivessel cervical artery dissection has been previously introduced but rarely discussed in literature. We present the case of a 32-year-old man with a history of migraines and a 2-week history of bilateral neck pain who was found to have bilateral Vertebral Artery dissection by CT angiography. The patient's stroke's etiology was spontaneous dissection followed by thromboembolism caused by bilateral Posterior Cerebral Artery (P1) occlusion. Due to an inability to protect his airway, he was scheduled to have a tracheostomy and percutaneous endoscopic gastrostomy (PEG). Over the following weeks, the patient continued to be unresponsive to stimuli, unable to follow commands, and unable to exhibit active/purposeful movement. As a result, the patient was transitioned to inpatient palliative care with total parenteral nutrition. We conducted a systematic literature review querying four databases: MEDLINE, Embase, CINAHL, and Academic Search Complete. Eligibility criteria were applied based on article type, title, abstract, and full text screening. Four case reports and three case-control studies discussing patients with a past medical history of migraines presenting with unilateral or bilateral vertebral artery dissection were identified and included in this review. We describe the possibility of the patient's migraine history and potentially associated vasculopathy as a predisposing factor in the development of Vertebral Artery Dissection. Further research is needed to fully understand the exact mechanism occurring that predisposes migraine patients to spontaneous arterial wall injury.
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Affiliation(s)
- Rahul Majumdar
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Purvika Gautam
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Sherief Ghozy
- Department of Radiology, Mayo Foundation for Medical Education and Research, Rochester, Minnesota, USA
| | - Ram Saha
- Department of Neurology, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
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Maclean MA, Touchette CJ, Duda T, Almojuela A, Bergeron D, Kameda-Smith M, Persad ARL, Sader N, Alant J, Christie SD. Work-up and Management of Asymptomatic Extracranial Traumatic Vertebral Artery Injury. Can J Neurol Sci 2023; 50:662-672. [PMID: 36017734 DOI: 10.1017/cjn.2022.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Non-penetrating head and neck trauma is associated with extracranial traumatic vertebral artery injury (eTVAI) in approximately 1-2% of cases. Most patients are initially asymptomatic but have an increased risk for delayed stroke and mortality. Limited evidence is available to guide the management of asymptomatic eTVAI. As such, we sought to investigate national practice patterns regarding screening, treatment, and follow-up domains. METHODS A cross-sectional, electronic survey was distributed to members of the Canadian Neurosurgical Society and Canadian Spine Society. We presented two cases of asymptomatic eTVAI, stratified by injury mechanism, fracture type, and angiographic findings. Screening questions were answered prior to presentation of angiographic findings. Survey responses were analyzed using descriptive statistics. RESULTS One hundred-eight of 232 (46%) participants, representing 20 academic institutions, completed the survey. Case 1: 78% of respondents would screen for eTVAI with computed topography angiography (CTA) (97%), immediately (88%). The majority of respondents (97%) would treat with aspirin (89%) for 3-6 months (46%). Respondents would follow up clinically (89%) or radiographically (75%), every 1-3 months. Case 2: 73% of respondents would screen with CTA (96%), immediately (88%). Most respondents (94%) would treat with aspirin (50%) for 3-6 months (35%). Thirty-six percent of respondents would utilize endovascular therapy. Respondents would follow up clinically (97%) or radiographically (89%), every 1-3 months. CONCLUSION This survey of Canadian practice patterns highlights consistency in the approach to screening, treatment, and follow-up of asymptomatic eTVAI. These findings are relevant to neurosurgeons, spinal surgeons, stroke neurologists, and neuro-interventionalists.
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Affiliation(s)
- Mark A Maclean
- Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Charles J Touchette
- Division of Neurosurgery, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Taylor Duda
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Alysa Almojuela
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Bergeron
- Division of Neurosurgery, Universite de Montreal, Montreal, Quebec, Canada
| | - Michelle Kameda-Smith
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Amit R L Persad
- Division of Neurosurgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Nicholas Sader
- Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | - Jacob Alant
- Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sean D Christie
- Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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Shibata J, Okada Y, Osawa I, Shiraishi A, Goto T. Trauma mechanisms and patterns of blunt cervical vascular injury: A descriptive study using a nationwide trauma registry. Am J Emerg Med 2023; 71:117-122. [PMID: 37379619 DOI: 10.1016/j.ajem.2023.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/05/2023] [Accepted: 06/15/2023] [Indexed: 06/30/2023] Open
Abstract
OBJECTIVE Blunt cervical vascular injury (BCVI) is a non-penetrating trauma to the carotid and/or vertebral vessels following a direct injury to the neck or by the shearing of the cervical vessels. Despite its potentially life-threatening nature, important clinical features of BCVI such as typical patterns of co-occurring injuries for each trauma mechanism are not well known. To address this knowledge gap, we described the characteristics of patients with BCVI to identify the pattern of co-occurring injuries by common trauma mechanisms. METHODS This is a descriptive study using a Japanese nationwide trauma registry from 2004 through 2019. We included patients aged ≥13 years presenting to the emergency department (ED) with BCVI, defined as a blunt trauma to any of the following vessels: common/internal carotid artery, external carotid artery, vertebral artery, external jugular vein, and internal jugular vein. We delineated characteristics of each BCVI classified according to three damaged vessels (common/internal carotid artery, vertebral artery, and others). In addition, we applied network analysis to unravel patterns of co-occurring injuries among patients with BCVI by four common trauma mechanisms (car accident, motorcycle/bicycle accident, simple fall, and fall from a height). RESULTS Among 311,692 patients who visited the ED for blunt trauma, 454 (0.1%) patients had BCVI. Patients with common/internal carotid artery injuries presented to the ED with severe symptoms (e.g., the median Glasgow Coma Scale was 7) and had high in-hospital mortality (45%), while patients with vertebral artery injuries presented with relatively stable vital signs. Network analysis showed that head-vertebral-cervical spine injuries were common across four trauma mechanisms (car accident, motorcycle/bicycle accident, simple fall, and fall from a height), with co-occurring injuries of the cervical spine and vertebral artery being the most common injuries due to falls. In addition, common/internal carotid artery injuries were associated with thoracic and abdominal injuries in patients with car accidents. CONCLUSIONS Based on analyses of a nationwide trauma registry, we found that patients with BCVI had distinct patterns of co-occurring injuries by four trauma mechanisms. Our observations provide an important basis for the initial assessment of blunt trauma and could support the management of BCVI.
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Affiliation(s)
- Junichiro Shibata
- Faculty of Medicine, The University of Tokyo, Tokyo, Japan; TXP Medical Co. Ltd., Tokyo, Japan
| | - Yohei Okada
- TXP Medical Co. Ltd., Tokyo, Japan; Preventive Services, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Health Services and Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore.
| | - Itsuki Osawa
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
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Abstract
Blunt and penetrating vascular injuries of the head and neck can represent life-threatening emergencies that require accurate detection to prevent devastating and long-lasting consequences. Implementing appropriate screening criteria to indicate imaging studies is crucial as there is a variable latent time before the onset of clinical manifestations. Computed tomography angiography, MR imaging, and digital subtraction angiography represent the imaging modalities of choice to evaluate vascular injuries. The aim of this review is to provide a description of the different types of vascular injuries, describe the importance of each imaging modality, and recognize the imaging appearance of traumatic vessel injury.
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Affiliation(s)
- Andres Rodriguez
- Department of Diagnostic and Interventional Imaging, Neuroradiology Section, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Luis Nunez
- Department of Diagnostic and Interventional Imaging, Neuroradiology Section, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Roy Riascos
- Department of Diagnostic and Interventional Imaging, Neuroradiology Section, The University of Texas Health Science Center at Houston, Houston, TX, USA.
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Ossaba Vélez S, Sanz Canalejas L, Martínez-Checa Guiote J, Díez Tascón A, Martí de Gracia M. Cervical spine trauma. RADIOLOGIA 2023; 65 Suppl 1:S21-S31. [PMID: 37024227 DOI: 10.1016/j.rxeng.2022.10.012] [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: 07/15/2022] [Accepted: 10/22/2022] [Indexed: 04/08/2023]
Abstract
Cervical spine trauma encompasses a wide of injuries, ranging from stable, minor lesions to unstable, complex lesions that can lead to neurologic sequelae or vascular involvement. The Canadian C-Spine Rule and the NEXUS criteria aim to identify individuals with a low risk of cervical spine trauma who can safely forgo imaging tests. In high-risk patients, an imaging test is indicated. In adult patients the imaging test of choice is multidetector computed tomography. Complementary imaging tests such as CT angiography of the supra-aortic vessels and/or magnetic resonance imaging are occasionally necessary. It can be challenging for radiologists to diagnose and classify these lesions, because some of them can be subtle and difficult to detect. This paper aims to describe the most important imaging findings and the most widely used classification systems.
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Affiliation(s)
- S Ossaba Vélez
- Sección de Radiología de Urgencias, Servicio de Radiodiagnóstico, Hospital Universitario La Paz, Madrid, Spain.
| | - L Sanz Canalejas
- Sección de Radiología de Urgencias, Servicio de Radiodiagnóstico, Hospital Universitario La Paz, Madrid, Spain
| | - J Martínez-Checa Guiote
- Sección de Radiología de Urgencias, Servicio de Radiodiagnóstico, Hospital Universitario La Paz, Madrid, Spain
| | - A Díez Tascón
- Sección de Radiología de Urgencias, Servicio de Radiodiagnóstico, Hospital Universitario La Paz, Madrid, Spain
| | - M Martí de Gracia
- Sección de Radiología de Urgencias, Servicio de Radiodiagnóstico, Hospital Universitario La Paz, Madrid, Spain
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Ossaba Vélez S, Sanz Canalejas L, Martínez-Checa Guiote J, Díez Tascón A, Martí de Gracia M. Traumatismo de la columna vertebral cervical. RADIOLOGIA 2022. [DOI: 10.1016/j.rx.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Current Concepts in Imaging Diagnosis and Screening of Blunt Cerebrovascular Injuries. Tomography 2022; 8:402-413. [PMID: 35202198 PMCID: PMC8877014 DOI: 10.3390/tomography8010033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/16/2022] [Accepted: 01/29/2022] [Indexed: 11/21/2022] Open
Abstract
Blunt cerebrovascular injury (BCVI) is an often underrecognized injury occurring in the carotid or vertebral arteries, associated with a risk of ischemic stroke and potential for poor neurological outcome or death. Computed tomographic angiography (CTA) is the most common modality for initial screening and diagnosis. Vessel wall intimal injuries, intraluminal thrombus, dissection, intramural hematoma, pseudoaneurysm, vessel transection, and arteriovenous fistula, are potential findings to be considered in approach to imaging. Identification of high-risk trauma patients based on clinical and radiological risk factors can determine patients at risk of BCVI for targeted screening.
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9
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Sheng K. Radiological investigation of acute mandibular injury. Natl J Maxillofac Surg 2022; 13:165-171. [PMID: 36051802 PMCID: PMC9426694 DOI: 10.4103/njms.njms_27_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 07/15/2019] [Accepted: 01/09/2020] [Indexed: 12/04/2022] Open
Abstract
This article focuses on the different imaging modalities used to evaluate acute mandibular fractures and explores important concepts relating to their diagnosis, investigation, and treatment. Significant focus will be given to exploring general management principles, considerations regarding first-line imaging, and recent technological advancement. Computed tomography (CT) is the preferred method when attempting to identify acute mandibular fractures, particularly in trauma patients, and has very high specificity and sensitivity. Multidetector CT now represents the standard of care, enabling fast scan times, reduced artifact, accurate reconstructed views, and three-dimensional (3D) reconstructions. Cone-beam CT is a newer advanced imaging modality that is increasingly being used worldwide, particularly in the ambulatory and intraoperative setting. It produces high-resolution images with submillimeter isotropic voxels, 3D and multiplanar reconstruction, and low radiation dose, however is less widely available and more expensive. Ultrasound is a valuable method in identifying a fracture in unstable patients, but is limited in its ability to detect nondisplaced fractures. Magnetic resonance imaging is useful in determining the presence of soft-tissue injury. CT angiography is invaluable in the assessment of potential vascular injury in condylar fracture dislocations.
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Alfanek Z, Herzog A, Taylor N, Jensen H, Bhavaraju A, Meek M, Kalkwarf K, Radvany MG. Evaluating the Routine Use of Head Computed Tomography Angiography in Blunt Cerebrovascular Trauma. J Surg Res 2021; 269:129-133. [PMID: 34560313 DOI: 10.1016/j.jss.2021.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/28/2021] [Accepted: 08/11/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND The aim of this study was to evaluate a protocol change that mandated routine incorporation of head computed tomography angiography (CTA) for the work-up of suspected blunt cerebrovascular injury (BCVI) at an academic Level I trauma center. METHODS The BCVI screening guidelines at our institution changed in 2018 to include the addition of a head CTA for all patients receiving a neck CTA as part of our BCVI screening guidelines. We performed a retrospective chart review of patients between 2018 and 2019 who were 18 years or older and met screening criteria for BCVI based on our institutional guidelines. The head CTAs of this cohort were assessed for findings that could potentially alter the course of the patients' treatment. RESULTS A total of 319 patients fit this criterion and had a head CTA as part of their trauma workup. Findings that could potentially alter a patient's clinical course were identified in 6.6% (n = 21) of the head CTA's. These included decreased arterial perfusion (n = 9), active bleeds (n = 6), vessel occlusions (n = 1), aneurysms (n = 1), and vasospasms (n = 2). Of these 21 patients, 8 had clinically significant findings that affected their course of management (2.5% of total sample). They also had a higher mortality rate and ISS compared to the rest of the cohort. CONCLUSIONS In patients with clinically suspected BCVI, the addition of head CTA to the existing BCVI screening guideline identified clinically significant vascular abnormalities that affected management in 2.5% of cases.
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Affiliation(s)
- Zain Alfanek
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Abigail Herzog
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Nathan Taylor
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Hanna Jensen
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Avi Bhavaraju
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Mary Meek
- Department of Radiology, Division of Interventional Radiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Kyle Kalkwarf
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Martin G Radvany
- Department of Radiology, Division of Interventional Neuroradiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
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Prasad N, Mitra A, Shlobin NA, Azad HA, Cloney MB, Hopkins BS, Jahromi BS, Potts MB, Dahdaleh NS. Traumatic and Spontaneous Vertebral Artery Dissections: An Analysis of Tertiary-Center 310 Patient Cohort. Oper Neurosurg (Hagerstown) 2021; 21:343-350. [PMID: 34392360 DOI: 10.1093/ons/opab277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 06/06/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Vertebral artery dissections (VADs) are rare yet potentially devastating events. While the etiology of these events is either traumatic or spontaneous, there is a paucity of quantitative literature comparing the two. OBJECTIVE To identify differences in predisposing factors, event characteristics, and clinical outcomes between traumatic VADs (tVADs) and spontaneous VADs (sVADs). METHODS We retrospectively identified patients with VADs presenting to our institution at VAD onset with at least a 3-mo follow-up. Demographics, event characteristics, treatment details, and neurological outcomes as modified Rankin scale (mRS) scores were collected. RESULTS Of the 310 patients sustaining 366 VADs total, 187 (60.3%) patients experienced a total of 221 (60.4%) sVADs and 123 (39.7%) patients experienced a total of 145 (39.6%) tVADs. sVADs were more likely to occur in the intracranial course of the artery (P = .042) and have a lower mRS at discharge, 3-month, and last clinical follow-up (P = 003, .002, and .001, respectively). tVADs were more likely associated with concomitant fractures (P < .001). CONCLUSION Despite similar patient populations, tVADs are associated with higher mRS scores at all time points. Although further study is needed, this may suggest other concomitant trauma rather than the VAD itself is contributing to worse neurological status in patients with tVADs.
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Affiliation(s)
- Nikil Prasad
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Akash Mitra
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nathan A Shlobin
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Hooman A Azad
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Michael B Cloney
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Benjamin S Hopkins
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Babak S Jahromi
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Matthew B Potts
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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12
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The Utility of a Screening Neck Computed Tomographic Angiogram in Blunt Trauma Patients Presenting With a Seat Belt Sign in the Absence of Associated Risk Factors. J Comput Assist Tomogr 2020; 44:941-946. [PMID: 33196601 DOI: 10.1097/rct.0000000000001098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Blunt cerebrovascular injuries (BCVI) of the neck are a common cause for concern after blunt trauma. The purpose of this article is to demonstrate whether patients with a cervical seat belt sign in the absence of associated high-risk injuries or neurological symptoms are at an increased risk for developing a clinically significant vascular injury and therefore require a screening neck computed tomographic angiography (CTA). METHODS A retrospective review was performed of patients who presented after motor vehicle collision and received a neck CTA for an indication of "seat belt sign." Imaging was reviewed to determine the vascular injury grade, associated injuries, and, if available, follow-up imaging was reviewed to assess for interval change or resolution. The patients were split into 2 groups. Group 1 included patients without high-risk injuries, and group 2 included patients with high-risk injuries. RESULTS In group 1, 6 (2.9%) of 208 patients had BCVI. In group 2, 7 (18.9%) of 37 patients had BCVI. Patients in group 2 were 6.5 times more likely to suffer BCVI compared with group 1 (P < 0.001). No patient in group 1 was ever symptomatic, and only 1 (0.5%) patient underwent interventional treatment. CONCLUSIONS Patients presenting after blunt trauma with a seat belt sign and no other high-risk injuries as laid out by screening criteria demonstrate a low probability of BCVI and an even lower likelihood of adverse outcome.
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13
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Abstract
BACKGROUND Near hangings are an infrequent cause of trauma, and the optimal workup for these patients is unclear. The study objectives were to define the epidemiology, injury patterns, and use of investigations, including computed tomographic angiography (CTA) neck, after near hangings. METHODS All patients presenting to LAC+USC Medical Center (2008-2015) after near hanging (International Classification of Diseases, Ninth Revision, code of E913.8, E953.0, E963, or E983.0) were screened for inclusion. Transferred patients were excluded. Patient demographics, clinical data, injury data, investigations performed, and outcomes were collected. RESULTS Over the study period, 71 patients were identified. Median age was 32 years (interquartile range [IQR], 24-44), and 85% (n=64) were male. Median Glasgow Coma Scale was 12 [IQR 5-15], and median Injury Severity Score was 1 [IQR 1-2]. Mortality rate was 14% (n = 10). The most common finding on physical examination was a ligature mark (n = 38, 54%). Cervical injuries after near hangings occurred infrequently (five injuries in four patients [6%]: 3 [4%] arterial injuries and 2 [3%] laryngotracheal injuries). Only one patient (1%) required surgical and/or endovascular intervention. Two (3%) arrived in cardiac arrest, underwent resuscitative thoracotomy, and were pronounced dead. All others (n = 69, 97%) underwent CTA of the neck. No patient in this series manifested signs or symptoms of cervical injury during hospitalization after a normal CTA neck on presentation. CONCLUSION Near hangings infrequently result in cervical injury, and intervention is rarely needed. When injuries are sustained, they occur to critical structures such as the larynx, trachea, and cervical vasculature. Therefore, effective injury screening is important. We recommend CTA of the neck as the optimal initial imaging investigation after near hangings. LEVEL OF EVIDENCE Epidemiologic, level IV; therapeutic/care management, level IV.
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Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2020; 88:875-887. [DOI: 10.1097/ta.0000000000002668] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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15
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Izzo R, Popolizio T, Balzano RF, Simeone A, Gasparotti R, Scarabino T, Muto M. Imaging of cranio-cervical junction traumas. Eur J Radiol 2020; 127:108960. [PMID: 32298957 DOI: 10.1016/j.ejrad.2020.108960] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/14/2020] [Indexed: 11/19/2022]
Abstract
The craniocervical junction (CCJ) or upper cervical spine (UCS) has anatomic features and a biomechanics completely different from the other spinal segment of the spine. Several ligaments and muscles control its motion and function and ensure the maximum mobility and the visual and auditory spatial exploration. UCS traumas represent approximately one-third of all cervical spine injuries. Most of UCS traumas results from blows to the head and sudden deceleration of the body. Thanks to the improvement of the Advanced Trauma Life Support protocols dissociative injuries of CCJ have become less lethal onsite. In other less severe but unstable injuries, patients are neurologically intact at presentation, but they may deteriorate during the stay in hospital, with important clinical and medico-legal consequences. Knowing the peculiarities of UCS is fundamental for the early detection of imaging findings that influences the patient management and outcome. The classification of UCS traumas is mechanistic. More than in any other spinal segment, fractures of CCJ bones can occur without generating instability; on the contrary highly unstable injuries may not be associated with bone fractures. An early and correct diagnosis of occipito-cervical instability may prevent secondary neurological injury. The goal of imaging is to identify which patients can benefit of surgical stabilization and prevent secondary neurologic damage. Actual helical multidetector-CT (MDCT) offers high sensitivity and specificity for bone lesions and displacements in cervical spine traumas, but magnetic resonance imaging (MRI) is increasingly being used to evaluate soft tissues and ligaments, and mainly to identify possible spinal cord injury.
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Affiliation(s)
- Roberto Izzo
- Radiology Department, Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy.
| | - Teresa Popolizio
- Radiology Department, Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy.
| | | | - Anna Simeone
- Radiology Department, Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | | | | | - Mario Muto
- Neuroradiology Department, A. Cardarelli Hospital, Napoli, Italy
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16
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Abu Mughli R, Wu T, Li J, Moghimi S, Alem Z, Nasir MU, Abdellatif W, Nicolaou S. An Update in Imaging of Blunt Vascular Neck Injury. Can Assoc Radiol J 2020; 71:281-292. [PMID: 32174162 DOI: 10.1177/0846537120909468] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Traumatic injuries of the cervical carotid and vertebral arteries, collectively referred to as blunt cerebrovascular injury (BCVI), can result in significant patient morbidity and mortality, with one of the most feared outcomes being cerebrovascular ischemia. Systematic imaging-guided screening for BCVI aims for early detection to guide timely management. In particular, accurate detection of the severity and grade of BCVI is paramount in guiding initial management. Furthermore, follow-up imaging is required to decide the duration of antithrombotic therapy. In this article, classification of the grades of BCVI and associated imaging findings will be outlined and diagnostic pitfalls and mimickers that can confound diagnosis will be described. In addition, updates to existing screening guidelines and recent efforts of criteria modification to improve detection of BCVI cases will be reviewed. The advent of postprocessing tools applied to conventional computed tomography (CT) angiograms and new diagnostic tools in dual energy CT for improved detection will also be discussed.
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Affiliation(s)
- Rawan Abu Mughli
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Tong Wu
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Jessica Li
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Saba Moghimi
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Zersenay Alem
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Muhammad Umer Nasir
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Waleed Abdellatif
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Savvas Nicolaou
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
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17
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Blunt Cerebrovascular Injuries: Screening and Diagnosis. CURRENT TRAUMA REPORTS 2019. [DOI: 10.1007/s40719-019-0153-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Crilly SM, McElroy E, Ryan J, O'Donohue M, Lawler LP. "Mixed" trauma to the carotid artery in a mixed martial arts injury - A case report and review of the literature. J Radiol Case Rep 2019; 12:1-11. [PMID: 30651908 DOI: 10.3941/jrcr.v12i5.3234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We present the case of a mixed martial arts (MMA) cage fighter who presented to the emergency department with a right sided common carotid artery pseudoaneurysm as a result of a neck trauma at an MMA event. We discuss the management of blunt force neck trauma, differential diagnosis, imaging findings and review the literature on blunt cerebrovascular injury following blunt force injury to the neck.
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Affiliation(s)
- Shane M Crilly
- Department of Surgery, Royal Perth Hospital, Perth, WA, Australia
| | - Eileen McElroy
- Department of Medicine, Fiona Stanley Hospital, Murdoch, Perth, WA, Australia
| | - Jonathan Ryan
- Department of Diagnostic Radiology, Sligo University Hospital, Sligo, Republic of Ireland
| | - Martin O'Donohue
- Department of Vascular Surgery, Mater Misericordiae University Hospital, Dublin, Republic of Ireland
| | - Leo P Lawler
- Department of Diagnostic Radiology, Mater Misericordiae University Hospital, Dublin, Republic of Ireland
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Brommeland T, Helseth E, Aarhus M, Moen KG, Dyrskog S, Bergholt B, Olivecrona Z, Jeppesen E. Best practice guidelines for blunt cerebrovascular injury (BCVI). Scand J Trauma Resusc Emerg Med 2018; 26:90. [PMID: 30373641 PMCID: PMC6206718 DOI: 10.1186/s13049-018-0559-1] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 10/10/2018] [Indexed: 01/12/2023] Open
Abstract
Blunt cerebrovascular injury (BCVI) is a non-penetrating injury to the carotid and/or vertebral artery that may cause stroke in trauma patients. Historically BCVI has been considered rare but more recent publications indicate an overall incidence of 1-2% in the in-hospital trauma population and as high as 9% in patients with severe head injury. The indications for screening, treatment and follow-up of these patients have been controversial for years with few clear recommendations. In an attempt to provide a clinically oriented guideline for the handling of BCVI patients a working committee was created. The current guideline is the end result of this committees work. It is based on a systematic literature search and critical review of all available publications in addition to a standardized consensus process. We recommend using the expanded Denver screening criteria and CT angiography (CTA) for the detection of BCVI. Early antithrombotic treatment should be commenced as soon as considered safe and continued for at least 3 months. A CTA at 7 days to confirm or discard the diagnosis as well as a final imaging control at 3 months should be performed.
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Affiliation(s)
- Tor Brommeland
- Department of Neurosurgery, Oslo University Hospital Ullevål, Kirkeveien 166, 0450 Oslo, Norway
| | - Eirik Helseth
- Department of Neurosurgery, Oslo University Hospital Ullevål, Kirkeveien 166, 0450 Oslo, Norway
- Faculty of Medicine, University of Oslo, Problemveien 7, 0315 Oslo, Norway
| | - Mads Aarhus
- Department of Neurosurgery, Oslo University Hospital Ullevål, Kirkeveien 166, 0450 Oslo, Norway
| | - Kent Gøran Moen
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Medical Imaging, Nord-Trondelag Health Trust, Levanger, Norway
| | - Stig Dyrskog
- Department of Neurointensive care, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus, C, Denmark
| | - Bo Bergholt
- Department of Neurosurgery, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus, C, Denmark
| | - Zandra Olivecrona
- Department of Anestesia and Intensive care, Section for Neurosurgery, Faculty of Health and Medicine, Department for Medical Sciences, Södre Grev Rosengatan, 70185 Örebro, Sweden
| | - Elisabeth Jeppesen
- National Trauma Registry, Department of Research and Development, Division of Orthopedics, Oslo University Hospital, NO-0424 Oslo, Norway
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20
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Stone DK, Viswanathan VT, Wilson CA. Management of Blunt Cerebrovascular Injury. Curr Neurol Neurosci Rep 2018; 18:98. [DOI: 10.1007/s11910-018-0906-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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21
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Abstract
Blunt cerebrovascular injury (BCVI) is a relatively rare but potentially devastating finding in patients with high-energy blunt force trauma or direct cervical and/or craniofacial injury. The radiologist plays an essential role in identifying and grading the various types of vascular injury, including minimal intimal injury, dissection with raised intimal flap or intraluminal thrombus, intramural hematoma, pseudoaneurysm, occlusion, transection, and arteriovenous fistula. Early identification of BCVI is important, as treatment with antithrombotic therapy has been shown to reduce the incidence of postinjury ischemic stroke. Patients with specific mechanisms of injury, particular imaging findings, or certain clinical signs and symptoms have been identified as appropriate and cost-effective for BCVI screening. Although digital subtraction angiography was previously considered the standard examination for screening, technologic improvements have led to its replacement with computed tomographic angiography. Of note, although not appropriate for screening, improvements in magnetic resonance angiography with vessel wall imaging hold promise as supplemental imaging studies that may improve diagnostic specificity for vessel wall injuries. Understanding the screening criteria, imaging modalities of choice, imaging appearances, and grading of BCVI is essential for the radiologist to ensure fast and appropriate diagnosis and treatment. This article details the imaging evaluation of BCVI and discusses the clinical and follow-up imaging implications of specific injury findings. ©RSNA, 2018.
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Affiliation(s)
- Aaron M Rutman
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Box 357115, Seattle, WA 98195
| | - Justin E Vranic
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Box 357115, Seattle, WA 98195
| | - Mahmud Mossa-Basha
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Box 357115, Seattle, WA 98195
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22
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George E, Khandelwal A, Potter C, Sodickson A, Mukundan S, Nunez D, Khurana B. Blunt traumatic vascular injuries of the head and neck in the ED. Emerg Radiol 2018; 26:75-85. [DOI: 10.1007/s10140-018-1630-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 07/31/2018] [Indexed: 12/29/2022]
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Abstract
STUDY DESIGN Retrospective. OBJECTIVE The purpose of this project is to identify factors that predict vertebral artery injury (VAI) in an effort to assess risks and benefits of computed tomography angiography (CT-A) of the neck in the trauma setting. We seek to develop guidelines for practitioners to stratify patients at medium/high risk of VAI from those who are at low risk. SUMMARY OF BACKGROUND DATA VAI and blunt carotid injury (BCI) together comprise blunt cerebrovascular injury (BCVI). More is known about risk factors for BCI than for VAI, but the neurovascular complications associated with VAI are similarly disastrous. With increasing frequency, trauma providers are using CT-A to screen for BCVI; this test carries risks that include radiation exposure and nephrotoxicity, in addition to higher cost of treatment and longer hospital stay. METHODS Trauma patients seen over 4 months at an urban, level 1 trauma were analyzed. BCVI screening was conducted in 144/1854 (7.77%) patients. Presence of VAI and several clinical characteristics were recorded. Univariate analysis and binomial logistic regression analysis were conducted at a 95% significance level. RESULTS VAI was diagnosed in 0.49% of the study population. Univariate analysis determined six factors associated with positive VAI screening. Regression analysis showed four factors that independently predicted VAI: female sex, decreased Glasgow Coma Scale, cervical spine (c-spine) fracture, and concurrent BCI. A positive c-spine physical examination trended toward predicting VAI without achieving significance. CONCLUSION Several independent predictors of VAI were identified. This study highlights the importance of identifying patients at a higher risk for VAI and indicating CT-A of the neck versus those who are at low risk and can be evaluated without undergoing advanced imaging, as CT-A appears unnecessary for most trauma patients. LEVEL OF EVIDENCE 3.
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24
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Fox CK, Hills NK, Vinson DR, Numis AL, Dicker RA, Sidney S, Fullerton HJ. Population-based study of ischemic stroke risk after trauma in children and young adults. Neurology 2017; 89:2310-2316. [PMID: 29117963 PMCID: PMC5719927 DOI: 10.1212/wnl.0000000000004708] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 08/16/2017] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To quantify the incidence, timing, and risk of ischemic stroke after trauma in a population-based young cohort. METHODS We electronically identified trauma patients (<50 years old) from a population enrolled in a Northern Californian integrated health care delivery system (1997-2011). Within this cohort, we identified cases of arterial ischemic stroke within 4 weeks of trauma and 3 controls per case. A physician panel reviewed medical records, confirmed cases, and adjudicated whether the stroke was related to trauma. We calculated the 4-week stroke incidence and estimated stroke odds ratios (OR) by injury location using logistic regression. RESULTS From 1,308,009 trauma encounters, we confirmed 52 trauma-related ischemic strokes. The 4-week stroke incidence was 4.0 per 100,000 encounters (95% confidence interval [CI] 3.0-5.2). Trauma was multisystem in 26 (50%). In 19 (37%), the stroke occurred on the day of trauma, and all occurred within 15 days. In 7/28 cases with cerebrovascular angiography at the time of trauma, no abnormalities were detected. In unadjusted analyses, head, neck, chest, back, and abdominal injuries increased stroke risk. Only head (OR 4.1, CI 1.1-14.9) and neck (OR 5.6, CI 1.03-30.9) injuries remained associated with stroke after adjusting for demographics and trauma severity markers (multisystem trauma, motor vehicle collision, arrival by ambulance, intubation). CONCLUSIONS Stroke risk is elevated for 2 weeks after trauma. Onset is frequently delayed, providing an opportunity for stroke prevention during this period. However, in one-quarter of stroke cases with cerebrovascular angiography at the time of trauma, no vascular abnormality was detected.
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Affiliation(s)
- Christine K Fox
- From the Departments of Neurology (C.K.F., A.L.N., H.J.F.), Pediatrics (C.K.F., A.L.N., H.J.F.), Epidemiology and Biostatistics (N.K.H.), and Surgery (R.A.D.), University of California, San Francisco; the Division of Research (D.R.V., S.S.), Kaiser Permanente Northern California, Oakland; and the Department of Emergency Medicine (D.R.V.), Kaiser Permanente Sacramento Medical Center, Sacramento, CA.
| | - Nancy K Hills
- From the Departments of Neurology (C.K.F., A.L.N., H.J.F.), Pediatrics (C.K.F., A.L.N., H.J.F.), Epidemiology and Biostatistics (N.K.H.), and Surgery (R.A.D.), University of California, San Francisco; the Division of Research (D.R.V., S.S.), Kaiser Permanente Northern California, Oakland; and the Department of Emergency Medicine (D.R.V.), Kaiser Permanente Sacramento Medical Center, Sacramento, CA
| | - David R Vinson
- From the Departments of Neurology (C.K.F., A.L.N., H.J.F.), Pediatrics (C.K.F., A.L.N., H.J.F.), Epidemiology and Biostatistics (N.K.H.), and Surgery (R.A.D.), University of California, San Francisco; the Division of Research (D.R.V., S.S.), Kaiser Permanente Northern California, Oakland; and the Department of Emergency Medicine (D.R.V.), Kaiser Permanente Sacramento Medical Center, Sacramento, CA
| | - Adam L Numis
- From the Departments of Neurology (C.K.F., A.L.N., H.J.F.), Pediatrics (C.K.F., A.L.N., H.J.F.), Epidemiology and Biostatistics (N.K.H.), and Surgery (R.A.D.), University of California, San Francisco; the Division of Research (D.R.V., S.S.), Kaiser Permanente Northern California, Oakland; and the Department of Emergency Medicine (D.R.V.), Kaiser Permanente Sacramento Medical Center, Sacramento, CA
| | - Rochelle A Dicker
- From the Departments of Neurology (C.K.F., A.L.N., H.J.F.), Pediatrics (C.K.F., A.L.N., H.J.F.), Epidemiology and Biostatistics (N.K.H.), and Surgery (R.A.D.), University of California, San Francisco; the Division of Research (D.R.V., S.S.), Kaiser Permanente Northern California, Oakland; and the Department of Emergency Medicine (D.R.V.), Kaiser Permanente Sacramento Medical Center, Sacramento, CA
| | - Stephen Sidney
- From the Departments of Neurology (C.K.F., A.L.N., H.J.F.), Pediatrics (C.K.F., A.L.N., H.J.F.), Epidemiology and Biostatistics (N.K.H.), and Surgery (R.A.D.), University of California, San Francisco; the Division of Research (D.R.V., S.S.), Kaiser Permanente Northern California, Oakland; and the Department of Emergency Medicine (D.R.V.), Kaiser Permanente Sacramento Medical Center, Sacramento, CA
| | - Heather J Fullerton
- From the Departments of Neurology (C.K.F., A.L.N., H.J.F.), Pediatrics (C.K.F., A.L.N., H.J.F.), Epidemiology and Biostatistics (N.K.H.), and Surgery (R.A.D.), University of California, San Francisco; the Division of Research (D.R.V., S.S.), Kaiser Permanente Northern California, Oakland; and the Department of Emergency Medicine (D.R.V.), Kaiser Permanente Sacramento Medical Center, Sacramento, CA
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Rossidis AC, Tharakan SJ, Bose SK, Shekdar KV, Nance ML, Blinman TA. Predictors of pediatric blunt cerebrovascular injury. J Pediatr Surg 2017; 53:S0022-3468(17)30659-0. [PMID: 29108846 DOI: 10.1016/j.jpedsurg.2017.10.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 10/05/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND/PURPOSE Blunt cerebrovascular injury (BCVI) is clinically challenging because these injuries are hard to detect and can have serious neurological consequences, and optimal screening criteria have not been established for children. This study aims to determine risk factors for BCVI in pediatric patients and to evaluate screening practices in a single institutional series. METHODS A retrospective review of all pediatric blunt trauma patients evaluated over a 10-year period was performed. Demographic, clinical, and radiographic data were reviewed, including the presence of adult risk factors for BCVI. Logistic regression analyses were performed with statistical significance established at p<0.05. RESULTS Of the 11,596 patients evaluated during the study period, 1018 (8.8%) had at least one adult risk factor for BCVI, but only 62 (6.1% of those with risk factors) underwent angiographic evaluation. Overall, 11 BCVIs were observed, resulting in an incidence of 0.095%. All 11 patients with BCVI had at least one risk factor. Multivariate logistic regression analysis identified cervical spine fracture (OR 36.88 [8.36, 169.95]), GCS score ≤ 8 (OR 16.42 [2.16, 102.33]), male gender (OR 10.52 [1.33, 363.30]), Le Fort II or III facial fracture (OR 63.71 [2.16, 1124.68]), and ISS (unit OR 1.10 [1.04, 1.17]) as independent risk factors for BCVI. CONCLUSION Adult screening criteria for BCVI appear appropriate for pediatric patients, but most at-risk children are not being screened. LEVEL OF EVIDENCE Level III (retrospective case-control study).
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Affiliation(s)
- Avery C Rossidis
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Sasha J Tharakan
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Sourav K Bose
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Karuna V Shekdar
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Michael L Nance
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Thane A Blinman
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA.
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Nagpal P, Policeni BA, Bathla G, Khandelwal A, Derdeyn C, Skeete D. Blunt Cerebrovascular Injuries: Advances in Screening, Imaging, and Management Trends. AJNR Am J Neuroradiol 2017; 39:ajnr.A5412. [PMID: 29025722 PMCID: PMC7655313 DOI: 10.3174/ajnr.a5412] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Blunt cerebrovascular injury is a relatively uncommon but sometimes life-threatening injury, particularly in patients presenting with ischemic symptoms in that vascular territory. The decision to pursue vascular imaging (generally CT angiography) is based on clinical and imaging findings. Several grading scales or screening criteria have been developed to guide the decision to pursue vascular imaging, as well as to recommend different treatment options for various injuries. The data supporting many of these guidelines and options are limited however. The purpose of this article is to review and compare these scales and criteria and the data supporting clinical efficacy and to make recommendations for future research in this area.
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Affiliation(s)
- P Nagpal
- From the Department of Radiology (P.N., B.A.P., G.B., C.D.)
| | - B A Policeni
- From the Department of Radiology (P.N., B.A.P., G.B., C.D.)
| | - G Bathla
- From the Department of Radiology (P.N., B.A.P., G.B., C.D.)
| | - A Khandelwal
- Department of Radiology (A.K.), Mayo Clinic, Rochester, Minnesota
| | - C Derdeyn
- From the Department of Radiology (P.N., B.A.P., G.B., C.D.)
| | - D Skeete
- Trauma Services (D.S.), Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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27
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Tveita IA, Madsen MRS, Nielsen EW. Dissection of the internal carotid artery and stroke after mandibular fractures: a case report and review of the literature. J Med Case Rep 2017; 11:148. [PMID: 28576125 PMCID: PMC5455209 DOI: 10.1186/s13256-017-1316-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 05/09/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND We present a report of a patient with blunt trauma and mandibular fractures who developed a significant cerebral infarction due to an initially unrecognized injury of her left internal carotid artery. We believe that increased knowledge of this association will facilitate early recognition and hence prevention of a devastating outcome. CASE PRESENTATION A 41-year-old ethnic Norwegian woman presented to our Emergency Room after a bicycle accident that had caused a direct blow to her chin. At admittance, her Glasgow Coma Scale was 15. Initial trauma computed tomography showed triple fractures of her mandible, but no further pathology. She was placed in our Intensive Care Unit awaiting open reduction of her mandibular fractures. During the following 9 hours, she showed recurrent episodes of confusion and a progressive right-sided hemiparesis. Repeated cerebral computed tomography revealed no further pathology compared to the initial scan. She had magnetic resonance angiography 17 hours after admittance, which showed dissection and thrombus formation in her left internal carotid artery, total occlusion of her left medial cerebral artery, and left middle cerebral artery infarction was detected. CONCLUSIONS Carotid artery dissection is a rare but life-threatening condition that can develop after trauma to the head and neck. There should be a high index of suspicion in patients with a mechanism of injury that places the internal carotid artery at risk because blunt vascular injury may show delayed onset with no initial symptoms of vascular damage. By implementing an algorithm for early detection and treatment of these injuries, serious brain damage may be avoided.
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MESH Headings
- Accidents, Traffic
- Adult
- Anticoagulants/therapeutic use
- Aphasia/etiology
- Aphasia/physiopathology
- Bicycling/injuries
- Carotid Artery, Internal, Dissection/etiology
- Carotid Artery, Internal, Dissection/physiopathology
- Carotid Artery, Internal, Dissection/therapy
- Cerebral Angiography
- Critical Care
- Delayed Diagnosis
- Female
- Humans
- Infarction, Middle Cerebral Artery/complications
- Infarction, Middle Cerebral Artery/diagnostic imaging
- Infarction, Middle Cerebral Artery/physiopathology
- Infarction, Middle Cerebral Artery/therapy
- Mandibular Fractures/complications
- Mandibular Fractures/diagnostic imaging
- Mandibular Fractures/physiopathology
- Paresis/etiology
- Paresis/physiopathology
- Stroke/etiology
- Stroke/physiopathology
- Stroke/therapy
- Wounds, Nonpenetrating/complications
- Wounds, Nonpenetrating/diagnostic imaging
- Wounds, Nonpenetrating/physiopathology
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Affiliation(s)
- Ingrid Aune Tveita
- Department of Ear Nose and Throat Surgery, Nordland Hospital, Bodø, Norway
| | | | - Erik Waage Nielsen
- Department of Anesthesiology and Intensive Care, Nordland Hospital, Bodø, Norway
- Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
- Faculty of Professional Studies, Nord University, Bodø, Norway
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28
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Wu X, Malhotra A, Forman HP, Nunez D, Sanelli P. The Use of High-Risk Criteria in Screening Patients for Blunt Cerebrovascular Injury: A Survey. Acad Radiol 2017; 24:456-461. [PMID: 27979639 DOI: 10.1016/j.acra.2016.11.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 11/01/2016] [Accepted: 11/02/2016] [Indexed: 11/17/2022]
Abstract
RATIONALE AND OBJECTIVES Blunt cerebrovascular injury (BCVI) is uncommon, but delayed detection can have disastrous consequences. The Denver criteria are the most commonly used screening criteria. We aim to examine the utilization of screening criteria in the emergency department (ED) of our institution and assess whether patients with risk factors were imaged. MATERIALS AND METHODS A survey questionnaire was sent out to radiologists in a large academic institution. A search was performed in the database on the use of CT angiography (CTA) and MR angiography (MRA) among patients with risk factors in the last 11 years. RESULTS The survey was sent to 173 radiologists, with 41 responses (35 complete). Most of the physicians (30 out of 35) surveyed selected CTA as their preferred modality to screen for BCVI, whereas the remaining physicians selected MRA. None of the respondents reported routine use of Denver screening criteria or grading scale in their readouts. Only five respondents selected risk factors in the Denver criteria correctly. In the institution search, among the 1331 patients with blunt trauma and risk factors for BCVI, 537 underwent at least one angiographic study (40.3%). There was an increase in the screening rate after February 2010 in all risk factors, but only statistically significant among patients with foramen transversarium fractures and C1-C3 fractures. CONCLUSIONS Both the Denver screening criteria and grading scale of vascular injury have been underutilized in the ED for patients with risk factors. Greater awareness and utilization of imaging can potentially result in decreased incidence of subsequent stroke in patients with blunt injury.
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Affiliation(s)
- Xiao Wu
- Yale School of Medicine, New Haven, Connecticut
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Box 208042, Tompkins East 2, 333 Cedar St, New Haven, CT 06520-8042.
| | - Howard P Forman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut; Department of Economics, Yale School of Medicine, New Haven, Connecticut; Department of Management, Yale School of Medicine, New Haven, Connecticut; Department of Public Health, Yale School of Medicine, New Haven, Connecticut
| | - Diego Nunez
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Pina Sanelli
- Department of Radiology, Northwell Health, Great Neck, New York
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Jambhekar A, Maselli A, Lindborg R, Bobka T, Fahoum B, Rucinski J. Blunt traumatic transection of the right common carotid artery. TRAUMA-ENGLAND 2017. [DOI: 10.1177/1460408616675642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Carotid injuries are infrequent following blunt traumatic injury but can have potentially devastating neurologic consequences. We present a case of a 31-year-old male with right common carotid transection after blunt trauma to the neck. Case report A 31-year-old male with no notable medical history presented as a trauma level one activation after riding his bicycle into an open car door causing a Zone II laceration of his right anterior neck. The patient was hemodynamically normal, had an intact airway and had no neurologic deficits on evaluation in the trauma bay. He underwent a computed tomography angiogram of his neck which revealed a focal dissection of the right common carotid artery causing a 70%–80% luminal narrowing suspicious for a grade II injury. The patient was taken to the operating room for exploration of his neck laceration. He was found to have a grade V injury with complete transection of the right common carotid artery through the intima and media with intact adventitia. The arterial injury was repaired with polytetrafluoroethylene interposition graft. Perioperatively, the patient was started on dual antiplatelet therapy. He recovered uneventfully without neurologic deficits. Conclusion Complete transection of the common carotid artery following blunt trauma is rarely reported. Based on a review of the literature regarding blunt carotid injuries, it is reasonable to repair such injuries with prosthetic graft followed by either systemic anticoagulation or dual antiplatelet therapy.
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Affiliation(s)
- Amani Jambhekar
- Department of Surgery, New York Methodist Hospital, Brooklyn, NY, USA
| | - Amy Maselli
- Department of Surgery, New York Methodist Hospital, Brooklyn, NY, USA
| | - Ryan Lindborg
- Department of Surgery, New York Methodist Hospital, Brooklyn, NY, USA
| | - Thomas Bobka
- Department of Surgery, New York Methodist Hospital, Brooklyn, NY, USA
| | - Bashar Fahoum
- Department of Surgery, New York Methodist Hospital, Brooklyn, NY, USA
| | - James Rucinski
- Department of Surgery, New York Methodist Hospital, Brooklyn, NY, USA
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Tso MK, Lee MM, Ball CG, Morrish WF, Mitha AP, Kirkpatrick AW, Wong JH. Clinical utility of a screening protocol for blunt cerebrovascular injury using computed tomography angiography. J Neurosurg 2017; 126:1033-1041. [DOI: 10.3171/2016.1.jns151545] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Blunt cerebrovascular injury (BCVI) occurs in approximately 1% of the blunt trauma population and may lead to stroke and death. Early vascular imaging in asymptomatic patients at high risk of having BCVI may lead to earlier diagnosis and possible stroke prevention. The objective of this study was to determine if the implementation of a formalized asymptomatic BCVI screening protocol with CT angiography (CTA) would lead to improved BCVI detection and stroke prevention.
METHODS
Patients with vascular imaging studies were identified from a prospective trauma registry at a single Level 1 trauma center between 2002 and 2008. Detection of BCVI and stroke rates were compared during the 3-year periods before and after implementation of a consensus-based asymptomatic BCVI screening protocol using CTA in 2005.
RESULTS
A total of 5480 patients with trauma were identified. The overall BCVI detection rate remained unchanged postprotocol compared with preprotocol (0.8% [24 of 3049 patients] vs 0.9% [23 of 2431 patients]; p = 0.53). However, postprotocol there was a trend toward a decreased risk of stroke secondary to BCVI on a trauma population basis (0.23% [7 of 3049 patients] vs 0.53% [13 of 2431 patients]; p = 0.06). Overall, 75% (35 of 47) of patients with BCVI were treated with antiplatelet agents, but no patient developed new or progressive intracranial hemorrhage despite 70% of these patients having concomitant traumatic brain injury.
CONCLUSIONS
The results of this study suggest that a CTA screening protocol for BCVI may be of clinical benefit with possible reduction in ischemic complications. The treatment of BCVI with antiplatelet agents appears to be safe.
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Affiliation(s)
- Michael K. Tso
- 1Division of Neurosurgery, Department of Clinical Neurosciences,
| | - Myunghyun M. Lee
- 2Division of Cardiac Surgery, University of Toronto, Ontario, Canada
| | | | - William F. Morrish
- 4Division of Neuroradiology, Department of Diagnostic Imaging, University of Calgary, Foothills Medical Centre, Calgary, Alberta; and
| | - Alim P. Mitha
- 1Division of Neurosurgery, Department of Clinical Neurosciences,
- 4Division of Neuroradiology, Department of Diagnostic Imaging, University of Calgary, Foothills Medical Centre, Calgary, Alberta; and
| | | | - John H. Wong
- 1Division of Neurosurgery, Department of Clinical Neurosciences,
- 4Division of Neuroradiology, Department of Diagnostic Imaging, University of Calgary, Foothills Medical Centre, Calgary, Alberta; and
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Early antithrombotic therapy is safe and effective in patients with blunt cerebrovascular injury and solid organ injury or traumatic brain injury. J Trauma Acute Care Surg 2016; 81:173-7. [DOI: 10.1097/ta.0000000000001058] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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32
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Grissom TE, Pierce B. Radiographic Imaging and Ultrasound in Early Trauma Management: Damage Control Radiology for the Anesthesiologist. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0147-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Lolli V, Pezzullo M, Delpierre I, Sadeghi N. MDCT imaging of traumatic brain injury. Br J Radiol 2016; 89:20150849. [PMID: 26607650 PMCID: PMC4985461 DOI: 10.1259/bjr.20150849] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 11/18/2015] [Accepted: 11/23/2015] [Indexed: 01/24/2023] Open
Abstract
The aim of emergency imaging is to detect treatable lesions before secondary neurological damage occurs. CT plays a primary role in the acute setting of head trauma, allowing accurate detection of lesions requiring immediate neurosurgical treatment. CT is also accurate in detecting secondary injuries and is therefore essential in follow-up. This review discusses the main characteristics of primary and secondary brain injuries.
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Affiliation(s)
- Valentina Lolli
- Radiology Department, Erasmus University Hospital, Brussels, Belgium
| | - Martina Pezzullo
- Radiology Department, Erasmus University Hospital, Brussels, Belgium
| | | | - Niloufar Sadeghi
- Radiology Department, Erasmus University Hospital, Brussels, Belgium
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Malhotra A, Wu X, Kalra VB, Schindler J, Matouk CC, Forman HP. Evaluation for Blunt Cerebrovascular Injury: Review of the Literature and a Cost-Effectiveness Analysis. AJNR Am J Neuroradiol 2015; 37:330-5. [PMID: 26450540 DOI: 10.3174/ajnr.a4515] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 06/26/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Evaluation for blunt cerebrovascular injury has generated immense controversy with wide variations in recommendations regarding the need for evaluation and the optimal imaging technique. We review the literature and determine the most cost-effective strategy for evaluating blunt cerebrovascular injury in trauma patients. MATERIALS AND METHODS A comprehensive literature review was performed with data extracted to create a decision-tree analysis for 5 different strategies: anticoagulation for high-risk (based on the Denver screening criteria) patients, selective DSA or CTA (only high-risk patients), and DSA or CTA for all trauma patients. The economic evaluation was based on a health care payer perspective during a 1-year horizon. Statistical analyses were performed. The cost-effectiveness was compared through 2 main indicators: the incremental cost-effectiveness ratio and net monetary benefit. RESULTS Selective anticoagulation in high-risk patients was shown to be the most cost-effective strategy, with the lowest cost and greatest effectiveness (an average cost of $21.08 and average quality-adjusted life year of 0.7231). Selective CTA has comparable utility and only a slightly higher cost (an average cost of $48.84 and average quality-adjusted life year of 0.7229). DSA, whether performed selectively or for all patients, was not optimal from both the cost and utility perspectives. Sensitivity analyses demonstrated these results to be robust for a wide range of parameter values. CONCLUSIONS Selective CTA in high-risk patients is the optimal and cost-effective imaging strategy. It remains the dominant strategy over DSA, even assuming a low CTA sensitivity and irrespective of the proportion of patients at high-risk and the incidence of blunt cerebrovascular injury in high-risk patients.
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Affiliation(s)
- A Malhotra
- From the Departments of Diagnostic Radiology (A.M., X.W., V.B.K., C.C.M., H.P.F.) ajay.malhotra@yale
| | - X Wu
- From the Departments of Diagnostic Radiology (A.M., X.W., V.B.K., C.C.M., H.P.F.)
| | - V B Kalra
- From the Departments of Diagnostic Radiology (A.M., X.W., V.B.K., C.C.M., H.P.F.)
| | - J Schindler
- Neurology (J.S.) Neurosurgery (J.S., C.C.M.), Yale School of Medicine, New Haven, Connecticut
| | - C C Matouk
- From the Departments of Diagnostic Radiology (A.M., X.W., V.B.K., C.C.M., H.P.F.) Neurosurgery (J.S., C.C.M.), Yale School of Medicine, New Haven, Connecticut
| | - H P Forman
- From the Departments of Diagnostic Radiology (A.M., X.W., V.B.K., C.C.M., H.P.F.)
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35
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Buch K, Nguyen T, Mahoney E, Libby B, Calner P, Burke P, Norbash A, Mian A. Association between cervical spine and skull-base fractures and blunt cerebrovascular injury. Eur Radiol 2015; 26:524-31. [DOI: 10.1007/s00330-015-3858-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 05/07/2015] [Accepted: 05/20/2015] [Indexed: 11/29/2022]
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Vertebral Artery Transection in Nonpenetrating Trauma: A Series of 4 Patients. Ann Vasc Surg 2015; 29:1450.e11-6. [PMID: 26122415 DOI: 10.1016/j.avsg.2015.03.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 03/16/2015] [Accepted: 03/19/2015] [Indexed: 01/11/2023]
Abstract
Blunt cerebrovascular injury is a common and potentially devastating consequence of nonpenetrating trauma to the head and neck. The degree of injury ranges from minimal intimal disruption to complete transection with free extravasation. Although blunt carotid transection has been well characterized in clinical reports and radiologic studies, the computed tomographic angiography (CTA) features of blunt vertebral artery transection have not been well described. We report a series of 4 patients presenting to our level I trauma center with blunt vertebral artery transection, with an emphasis on their CTA imaging findings at presentation and their respective clinical courses. A brief review of the pertinent literature is provided.
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Treatment of a high large extracranial carotid artery pseudoaneurysm from trauma using a Viabahn graft. Ann Vasc Surg 2015; 29:837.e1-7. [PMID: 25596404 DOI: 10.1016/j.avsg.2014.10.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Revised: 10/05/2014] [Accepted: 10/12/2014] [Indexed: 11/21/2022]
Abstract
Blunt cerebrovascular injury has received much attention over the recent years; however, there is still considerable variability in terms of adequate criteria and treatment strategies. A case report was conducted to discuss the available literature in this disease process relative to the current practices at a level 1 urban trauma center. Screening and treatment methods were discussed. A patient with a high cervical extracranial pseudoaneurysm of the internal carotid artery was treated successfully with endovascular techniques without future neurologic sequalae.
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Abstract
Dissection of the extracranial carotid and vertebral arteries is increasingly recognized as a cause of transient ischemic attacks and stroke. The annual incidence of spontaneous carotid artery dissection is 2.5 to 3 per 100,000, while the annual incidence of spontaneous vertebral artery dissection is 1 to 1.5 per 100,000. Traumatic dissection occurs in approximately 1% of all patients with blunt injury mechanisms, and is frequently initially unrecognized. Overall, dissections are estimated to account for only 2% of all ischemic strokes, but they are an important factor in the young, and account for approximately 20% of strokes in patients less than 45 years of age. Arterial dissection can cause ischemic stroke either by thromboemboli forming at the site of injury or as a result of hemodynamic insufficiency due to severe stenosis or occlusion. Available evidence strongly favors embolism as the most common cause. Both anticoagulation and antiplatelet agents have been advocated as treatment methods, but there is limited evidence on which to base these recommendations. A Cochrane review on the topic of antithrombotic drugs for carotid dissection did not identify any randomized trials, and did not find that anticoagulants were superior to antiplatelet agents for the primary outcomes of death and disability. Healing of arterial dissections occurs within three to six months, with resolution of stenosis seen in 90%, and recanalization of occlusions in as many as 50%. Dissecting aneurysms resolve on follow-up imaging in 5- 40%, decrease in size in 15-30%, and remain unchanged in 50-65%. Resolution is more common in vertebral dissections than in carotid dissections. Aneurysm enlargement occurs rarely. The uncommon patient presenting with acute hemodynamic insufficiency should be managed with measures to increase cerebral blood flow, and in this setting emergency stent placement to restore cerebral perfusion may be considered, provided that irreversible infarction has not already occurred.
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Dreizin D, Letzing M, Sliker CW, Chokshi FH, Bodanapally U, Mirvis SE, Quencer RM, Munera F. Multidetector CT of Blunt Cervical Spine Trauma in Adults. Radiographics 2014; 34:1842-65. [DOI: 10.1148/rg.347130094] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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40
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Lee TS, Ducic Y, Gordin E, Stroman D. Management of carotid artery trauma. Craniomaxillofac Trauma Reconstr 2014; 7:175-89. [PMID: 25136406 DOI: 10.1055/s-0034-1372521] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
With increased awareness and liberal screening of trauma patients with identified risk factors, recent case series demonstrate improved early diagnosis of carotid artery trauma before they become problematio. There remains a need for unified screening criteria for both intracranial and extracranial carotid trauma. In the absence of contraindications, antithrombotic agents should be considered in blunt carotid artery injuries, as there is a significant risk of progression of vessel injury with observation alone. Despite CTA being used as a common screening modality, it appears to lack sufficient sensitivity. DSA remains to be the gold standard in screening. Endovascular techniques are becoming more widely accepted as the primary surgical modality in the treatment of blunt extracranial carotid injuries and penetrating/blunt intracranial carotid lessions. Nonetheless, open surgical approaches are still needed for the treatment of penetrating extracranial carotid injuries and in patients with unfavorable lesions for endovascular intervention.
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Affiliation(s)
- Thomas S Lee
- Department of Otolaryngology-Head and Neck Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Yadranko Ducic
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas ; Department of Otolaryngology-Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Eli Gordin
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| | - David Stroman
- Division of Vascular Surgery, John Peter Smith Hospital, Fort Worth, Texas
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41
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Cuellar TA, Lottenberg L, Moore FA. Blunt cerebrovascular injury in rugby and other contact sports: case report and review of the literature. World J Emerg Surg 2014; 9:36. [PMID: 24872841 PMCID: PMC4036724 DOI: 10.1186/1749-7922-9-36] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 04/15/2014] [Indexed: 11/10/2022] Open
Abstract
Contact sports have long been a part of human existence. The two earliest recorded organized contact games, both of which still exist, include Royal Shrovetide Football played since the 12(th) century in England and Caid played since 1308 AD in Ireland. Rugby is the premier contact sport played throughout the world with the very popular derivative American football being the premier contact sport of the North American continent. American football in the USA has on average 1,205,037 players at the high school and collegiate level per year while rugby in the USA boasts a playing enrollment of 457,983 at all levels. Recent media have highlighted injury in the context of competitive contact sports including their long-term sequelae such as chronic traumatic encephalopathy (CTE) that had previously been underappreciated. Blunt cerebrovascular injury (BCVI) has become a recognized injury pattern for trauma; however, a paucity of data regarding this injury can be found in the sports trauma literature. We present a case of an international level scrum-half playing Rugby Union at club level for a local non-professional team, in which a player sustained a fatal BCVI followed by a discussion of the literature surrounding sport related BCVI.
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Affiliation(s)
- Trajan A Cuellar
- Division of Acute Care Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Lawrence Lottenberg
- Division of Acute Care Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Frederick A Moore
- Division of Acute Care Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
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Harrigan MR, Falola MI, Shannon CN, Westrick AC, Walters BC. Incidence and trends in the diagnosis of traumatic extracranial cerebrovascular injury in the nationwide inpatient sample database, 2003-2010. J Neurotrauma 2014; 31:1056-62. [PMID: 24494787 DOI: 10.1089/neu.2013.3309] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Patients with traumatic extracranial cerebrovascular injury (TCVI) comprise about 1% of all blunt trauma admissions according to numerous single-center studies. However, previous studies have used aggressive screening protocols; these studies may not reflect common practice and the overall incidence of TCVI. The annual incidence of the diagnosis of TCVI from 2003 to 2010 was estimated using the Nationwide Inpatient Sample (NIS). For comparison, a systematic review of previous studies of the incidence of the diagnosis of TCVI was conducted. The estimated total number of admissions with TCVI ranged from 1283 to 2652; these admissions represented 0.46-0.95% of all blunt trauma admissions. There was a significant increase in the incidence of TCVI during the study period. A total of 49 studies of TCVI reported incidences of diagnosis ranging from 0.03% to 4.8%. In conclusion, the annual nationwide incidence of the diagnosis of TCVI is increasing. Although NIS incidences of the diagnosis of TCVI are at the low end of the range of previous reports, the increasing incidence in the NIS data likely reflects increasing use of aggressive screening protocols.
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Affiliation(s)
- Mark R Harrigan
- 1 Department of Neurosurgery, University of Alabama at Birmingham , Birmingham, Alabama
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43
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Payabvash S, McKinney AM, McKinney ZJ, Palmer CS, Truwit CL. Screening and detection of blunt vertebral artery injury in patients with upper cervical fractures: The role of cervical CT and CT angiography. Eur J Radiol 2014; 83:571-7. [DOI: 10.1016/j.ejrad.2013.11.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 11/18/2013] [Accepted: 11/26/2013] [Indexed: 11/30/2022]
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44
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Endovascular stent repair of traumatic cervical internal carotid artery injuries. J Trauma Acute Care Surg 2014; 75:896-903. [PMID: 24158213 DOI: 10.1097/ta.0b013e3182a686be] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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45
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Imaging of Blunt Vascular Neck Injuries: A Review of Screening and Imaging Modalities. AJR Am J Roentgenol 2013; 201:884-92. [DOI: 10.2214/ajr.12.9664] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
PURPOSE OF REVIEW Blunt cerebrovascular injuries (BCVI) are a rare but potentially devastating injury with stroke rates up to 50%. Over the past decade, the recognition and subsequent management of these injuries has undergone a marked evolution. This review will focus on the rationale for BCVI screening, imaging options, and treatment modalities. RECENT FINDINGS There are no prospective randomized controlled trials evaluating the management of BCVI. Available studies support screening a high-risk patient population based upon injury mechanism and constellation of associated injuries using multidetector-row (16-slice or greater) computed tomographic angiography (CTA). Although the ideal regimen of antithrombotic therapy has yet to be determined, treatment with either anticoagulation or antiplatelet agents has been shown to reduce BCVI-related stroke rate. SUMMARY Cerebrovascular injuries (CVI) are now diagnosed in approximately 1% of blunt trauma patients. The recognition of a clinically silent period allows for injury screening based upon mechanism of trauma and the patient's injury pattern. Following identification of injuries in asymptomatic patients, prompt initiation of antithrombotic therapy reduces the incidence of stroke.
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47
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Purvis D, Aldaghlas T, Trickey AW, Rizzo A, Sikdar S. A novel decision tree approach based on transcranial Doppler sonography to screen for blunt cervical vascular injuries. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2013; 32:1023-1031. [PMID: 23716524 DOI: 10.7863/ultra.32.6.1023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVES Early detection and treatment of blunt cervical vascular injuries prevent adverse neurologic sequelae. Current screening criteria can miss up to 22% of these injuries. The study objective was to investigate bedside transcranial Doppler sonography for detecting blunt cervical vascular injuries in trauma patients using a novel decision tree approach. METHODS This prospective pilot study was conducted at a level I trauma center. Patients undergoing computed tomographic angiography for suspected blunt cervical vascular injuries were studied with transcranial Doppler sonography. Extracranial and intracranial vasculatures were examined with a portable power M-mode transcranial Doppler unit. The middle cerebral artery mean flow velocity, pulsatility index, and their asymmetries were used to quantify flow patterns and develop an injury decision tree screening protocol. Student t tests validated associations between injuries and transcranial Doppler predictive measures. RESULTS We evaluated 27 trauma patients with 13 injuries. Single vertebral artery injuries were most common (38.5%), followed by single internal carotid artery injuries (30%). Compared to patients without injuries, mean flow velocity asymmetry was higher for single internal carotid artery (P = .003) and single vertebral artery (P = .004) injuries. Similarly, pulsatility index asymmetry was higher in single internal carotid artery (P = .015) and single vertebral artery (P = .042) injuries, whereas the lowest pulsatility index was elevated for bilateral vertebral artery injuries (P = .006). The decision tree yielded 92% specificity, 93% sensitivity, and 93% correct classifications. CONCLUSIONS In this pilot feasibility study, transcranial Doppler measures were significantly associated with the blunt cervical vascular injury status, suggesting that transcranial Doppler sonography might be a viable bedside screening tool for trauma. Patient-specific hemodynamic information from transcranial Doppler assessment has the potential to alter patient care pathways to improve outcomes.
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Affiliation(s)
- Dianna Purvis
- Department of Neuroscience, George Mason University, Fairfax, VA 22030, USA
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48
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Abbo M, Hussain K, Ali MBM. Blunt traumatic internal carotid artery dissection with delayed stroke in a young skydiver. BMJ Case Rep 2013; 2013:bcr-2012-008412. [PMID: 23559649 DOI: 10.1136/bcr-2012-008412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We describe a case of a 33-year-old skydiver who presented to the emergency department after a traumatic landing following a parachuting episode. He initially presented with right knee pain secondary to a tibial plateau fracture. There were no neurological symptoms or signs at the initial assessment. While he was still in the emergency department, he suddenly developed headache and left-sided hemiplegia. An urgent work-up showed right middle cerebral artery thrombosis with right internal carotid thrombosis and dissection. We have discussed some possible mechanism of injury in skydiving that may have predisposed to the occurrence of cervical dissection in our patient.
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Affiliation(s)
- Michael Abbo
- Department of Emergency Medicine, Rashid Hospital Trauma Center, Dubai Health Authority, Dubai, UAE
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49
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Liang T, McLaughlin PD, Louis L, Nicolaou S. Review of multidetector computed tomography angiography as a screening modality in the assessment of blunt vascular neck injuries. Can Assoc Radiol J 2013; 64:130-9. [PMID: 23541829 DOI: 10.1016/j.carj.2013.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 02/14/2013] [Indexed: 01/20/2023] Open
Abstract
Blunt vascular neck injuries (BVNI), previously thought to be rare, have demonstrated increasing incidence rates in recent literature and are associated with significant mortality and morbidity. A radiologist needs to efficiently recognize these injuries on preliminary screening to enable initiation of early management. When initiation of accurate management is started promptly, decreased rates of postinjury complications, for example, stroke, have been demonstrated. This article reviews the incidence, pathophysiology, and rationale for screening for these BVNI injuries. The utility of computed tomography angiography (CTA) as the potential new criterion standard as the screening and follow-up imaging modality for BVNI will be discussed. The application of new multidetector CTA techniques available, such as dual-energy CT and iterative reconstruction, are also reviewed. In addition, the characteristic imaging findings on CTA and the associated Denver Grading scale for BVNI will be reviewed to allow readers to become familiar with the injury patterns and to understand the prognostic and clinical implications, respectively. Examples of the spectrum of injuries, potential injury mimics, and different artifacts on multidetector CTA are shown to help familiarize readers and allow them to successfully and confidently recognize a true BVNI.
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Affiliation(s)
- Teresa Liang
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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50
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Bonatti M, Vezzali N, Ferro F, Manfredi R, Oberhofer N, Bonatti G. Blunt cerebrovascular injury: diagnosis at whole-body MDCT for multi-trauma. Insights Imaging 2013; 4:347-55. [PMID: 23512271 PMCID: PMC3675247 DOI: 10.1007/s13244-013-0235-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Revised: 02/10/2013] [Accepted: 02/12/2013] [Indexed: 11/25/2022] Open
Abstract
Purpose To analyse the prevalence of blunt cerebrovascular injuries (BCVIs) in multi-trauma patients by means of a post-contrast acquisition of neck vessels included into the whole-body multi-detector computed tomography (MDCT) protocol performed at admission and to correlate it with the presence of risk factors (Memphis approach). Materials and methods A retrospective study was undertaken for the period January 2005 to November 2011, involving 976 multi-trauma patients. Post-contrast images of neck vessels in MDCT scan were evaluated by two experienced radiologists; carotid, vertebral and basilar arteries were rated according to the Biffl classification. The presence of clinical and/or CT risk factors for BCVI was assessed. Results BCVI were present in 32/976 (3.3 %) multi-trauma patients. Risk factors for BCVI were present in 247/976 (25.3 %) patients. The group of patients presenting risk factors showed a significantly higher prevalence of cerebrovascular injuries (8.1 %) compared with the group of patients without risk factors (1.6 %) (p = 0.009); however, 12/32 (37.5 %) patients presenting BCVI did not show any of the risk factors proposed by the Memphis group. Conclusion An investigation for the presence of BCVI should be performed on all multi-trauma patients despite the absence of clinical-radiological risk factors. Key Points BCVIs are present in 3.3 % of multi-trauma patients. BCVIs are significantly associated to the Memphis risk factors. Of the multi-trauma patients affected by BCVIs, 37.5 % do not show clinical-radiological risk factors. A screening for BCVI should be performed on all multi-trauma patients.
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Affiliation(s)
- Matteo Bonatti
- Department of Radiology, San Maurizio Hospital, 5 Boehler Street, 39100, Bolzano, Italy,
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