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Teli P, Islam N, Petzold A. Headache management in traumatic brain injury. J Neurol Sci 2024; 463:123002. [PMID: 39047510 DOI: 10.1016/j.jns.2024.123002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 04/07/2024] [Indexed: 07/27/2024]
Abstract
Traumatic brain injury (TBI) is estimated to rank as the third most important disease burden worldwide. About 60% of the survivors develop chronic headaches and visual symptoms, and the long-term management of headaches in these patients is controversial. Importantly, the care pathway of most patients is fragmented, complicating conclusive headache management. Here we review the epidemiology and aetiology of post traumatic headaches (PTH), discuss the diagnostic work up and summarise the acute and long-term management.
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Affiliation(s)
- Parisa Teli
- Queen Square Institute of Neurology, UCL, UK
| | - Niaz Islam
- Moorfields Eye Hospital, City Road, London, UK
| | - Axel Petzold
- Queen Square Institute of Neurology, UCL, UK; The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Moorfields Eye Hospital, City Road, London, UK; Amsterdam University Medical Centre, Departments of Neurology and Ophthalmology, Amsterdam, NL
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Goyal K, Sunny JT, Gillespie CS, Wilby M, Clark SR, Kaiser R, Fehlings MG, Srikandarajah N. A Systematic Review and Meta-Analysis of Vertebral Artery Injury After Cervical Spine Trauma. Global Spine J 2024; 14:1356-1368. [PMID: 37924280 PMCID: PMC11289537 DOI: 10.1177/21925682231209631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2023] Open
Abstract
STUDY DESIGN Systematic Review and Meta-Analysis. OBJECTIVE Identify the incidence, mechanism of injury, investigations, management, and outcomes of Vertebral Artery Injury (VAI) after cervical spine trauma. METHODS A systematic review and meta-analysis were conducted in accordance with the PRISMA guidelines (PROSPERO-ID CRD42021295265). Three databases were searched (PubMed, SCOPUS, Google Scholar, CINAHL PLUS). Incidence of VAI, investigations to diagnose (Computed Tomography Angiography, Digital Subtraction Angiography, Magnetic Resonance Angiography), stroke incidence, and management paradigms (conservative, antiplatelets, anticoagulants, surgical, endovascular treatment) were delineated. Incidence was calculated using pooled proportions random effects meta-analysis. RESULTS A total of 44 studies were included (1777 patients). 20-studies (n = 503) included data on trauma type; 75.5% (n = 380) suffered blunt trauma and 24.5% (n = 123) penetrating. The overall incidence of VAI was .95% (95% CI 0.65-1.29). From the 16 studies which reported data on outcomes, 8.87% (95% CI 5.34- 12.99) of patients with VAI had a posterior stroke. Of the 33 studies with investigation data, 91.7% (2929/3629) underwent diagnostic CTA; 7.5% (242/3629) underwent MRA and 3.0% (98/3629) underwent DSA. Management data from 20 papers (n = 475) showed 17.9% (n = 85) undergoing conservative therapy, anticoagulation in 14.1% (n = 67), antiplatelets in 16.4% (n = 78), combined therapy in 25.5% (n = 121) and the rest (n = 124) managed using surgical and endovascular treatments. CONCLUSION VAI in cervical spine trauma has an approximate posterior circulation stroke risk of 9%. Optimal management paradigms for the prevention and management of VAI are yet to be standardized and require further research.
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Affiliation(s)
- Kartik Goyal
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Northern General Hospital, Sheffield Teaching Hospital Trusts, Sheffield, UK
| | - Jesvin T. Sunny
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Cambridge University Hospital NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
| | - Conor S. Gillespie
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Martin Wilby
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Simon R. Clark
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Radek Kaiser
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
| | - Michael G. Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Nisaharan Srikandarajah
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Institute of Systems, Molecular and Integrative Biology, Liverpool, UK
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Ivanov I, Cataldo M, Cocchiara A, Nguyen R. Vertebral Artery Dissection. BMJ Case Rep 2024; 17:e255923. [PMID: 38195187 PMCID: PMC10806942 DOI: 10.1136/bcr-2023-255923] [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: 01/11/2024] Open
Abstract
Vertebral artery dissections are a rare pathology that carries a high risk of stroke in a younger population. They may be caused by minor mechanisms and the index of suspicion should be high. Treatment with anticoagulation or antiplatelets should follow if no surgical management is indicated.We describe a case of a female in her 30s who fell backward off a swing and rolled over her head and complained of continued posterior neck pain. The patient was found to have a vertebral artery dissection on MRI. The patient was then anticoagulated with high-dose apixaban and low-dose aspirin.The emergency medicine provider should be aware of possible low-impact mechanisms that can cause vertebral artery dissection and should have a high index of suspicion. If surgical management is not indicated, anticoagulation should be initiated.
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Affiliation(s)
- Ivan Ivanov
- Emergency Department, New York City Health and Hospitals Coney Island, Brooklyn, New York, USA
| | - Michael Cataldo
- Emergency Department, New York City Health and Hospitals Coney Island, Brooklyn, New York, USA
| | - Alyssa Cocchiara
- Emergency Department, New York City Health and Hospitals Coney Island, Brooklyn, New York, USA
| | - Rosalee Nguyen
- Emergency Department, New York City Health and Hospitals Coney Island, Brooklyn, New York, USA
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Bodiguel E, Naggara O, Mas JL. Dissecazione delle arterie carotidee e vertebrali extracraniche. Neurologia 2021. [DOI: 10.1016/s1634-7072(21)45783-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Al Babtain I, Abdullah M Alsahly M, A Aba Alkhail AB, Almutib JT, Al Otaibi RAF, Alsalamah ASH, Asseri YM, Ahmed AO. The Relationship Between Cerebrovascular Injuries and Craniomaxillofacial Fractures: Findings From a Tertiary Hospital in Saudi Arabia. Cureus 2021; 13:e17959. [PMID: 34660147 PMCID: PMC8515776 DOI: 10.7759/cureus.17959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2021] [Indexed: 11/08/2022] Open
Abstract
Background and objective Blunt cerebrovascular injuries (BCVIs) can lead to serious outcomes, particularly because they are difficult to detect in the acute phase. There are studies that have described the association between cerebrovascular injuries and craniomaxillofacial (CMF) fractures; however, no such study has been conducted among a Saudi population. In light of this, we conducted this study to evaluate the correlation between BCVI and CMF fractures among the local population in Saudi Arabia. In addition, the most common types of fractures associated with BCVI were identified. Methods This retrospective cohort study was conducted at the King Abdulaziz Medical City, a tertiary hospital in Riyadh, Saudi Arabia. All eligible patients with CMF fractures who were hospitalized at the King Abdulaziz Medical City were included. Consecutive patients were screened; no sampling or randomization was required. Patients with penetrating or avulsive mechanisms of injury were excluded. Results Out of a total of 1,560 patients included in the study, 1,537 (98.5%) had CMF fractures, while 23 (1.5%) had BCVIs. None of the patients with CMF fractures had BCVIs. Among the patients with BCVIs, 12 (52.2%) were men and 11 (47.8%) were women. The mean age of these patients was 46.91 ± 17.04 years. Among patients with CMF fractures, 1,071 (69.7%) were men and 466 (30.3%) were women. Their mean age was 23.93 ± 17.36 years. Conclusion The study did not identify any correlation between BCVI and CMF fractures; however, further studies with larger samples across multiple centers are needed to validate our findings and gain deeper insight into the relationship between BCVI and CMF fractures.
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Affiliation(s)
| | | | | | - Jehad T Almutib
- Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Rakan Ahmed F Al Otaibi
- Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
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New ischemic lesions on brain magnetic resonance imaging in patients with blunt traumatic cerebrovascular injury. J Trauma Acute Care Surg 2020; 88:796-802. [PMID: 32176175 DOI: 10.1097/ta.0000000000002660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with blunt cerebrovascular injuries are at risk of thromboembolic stroke. Although primary prevention with antithrombotic therapy is widely used in this setting, its effectiveness is not well defined and requires further investigation. The aim of this study was to evaluate the utility of magnetic resonance imaging (MRI)-detected ischemic brain lesions as a possible future outcome for randomized clinical trials in this patient population. METHODS This prospective observational study included 20 adult blunt trauma patients admitted to a level I trauma center with a screening neck CTA showing extracranial carotid or vertebral artery injury. All subjects lacked initial evidence of an ischemic stroke and were managed with antithrombotic therapy and observation and then underwent brain MRI within 30 days of the injury to assess for ischemic lesions. The MRI scans included diffusion, susceptibility, and Fluid-attenuated Inversion Recovery (FLAIR) sequences, and were reviewed by two neuroradiologists blinded to the computed tomography angiography (CTA) findings. RESULTS Eleven CTAs were done in the emergency department upon admission. There were 12 carotid artery dissections and 11 unilateral or bilateral vertebral artery injuries. Median interval between injury and MRI scan was 4 days (range, 0.1-14; interquartile range, 3-7 days). Diffusion-weighted imaging evidence of new ischemic lesions was present in 10 (43%) of 23 of the injured artery territories. In those injuries with ischemic lesions, the median number was 8 (range, 2-25; interquartile range, 5-8). None of the lesions were symptomatic. Blunt cerebrovascular injury was associated with a higher mean ischemic lesion count (mean count of 3.17 vs. 0.14, p < 0.0001), with the association remaining after adjusting for injury severity score (p < 0.0001). CONCLUSION In asymptomatic blunt trauma patients with CTA evidence of extracranial cerebrovascular injury and treated with antithrombotic therapy, nearly half of arterial injuries are associated with ischemic lesions on MRI. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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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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Bilateral Carotid and Vertebral Artery Dissection from Blunt Trauma. Case Rep Emerg Med 2018; 2018:1919034. [PMID: 29721341 PMCID: PMC5867688 DOI: 10.1155/2018/1919034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 02/11/2018] [Indexed: 12/03/2022] Open
Abstract
Carotid and vertebral artery injuries are rare following blunt trauma. They can, however, lead to severe consequences with a significant associated rate of stroke and intracranial hemorrhage, particularly if the diagnosis and treatment are delayed. We report a case of a 23-year-old female who presented to the Emergency Department with bilateral carotid and vertebral artery dissection following a motor vehicle collision (MVC).
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Foreman PM, Harrigan MR. Blunt Traumatic Extracranial Cerebrovascular Injury and Ischemic Stroke. Cerebrovasc Dis Extra 2017; 7:72-83. [PMID: 28399527 PMCID: PMC5425764 DOI: 10.1159/000455391] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 12/19/2016] [Indexed: 12/11/2022] Open
Abstract
Background Ischemic stroke occurs in a significant subset of patients with blunt traumatic cerebrovascular injury (TCVI). The patients are victims of motor vehicle crashes, assaults or other high-energy collisions, and suffer ischemic stroke due to injury to the extracranial carotid or vertebral arteries. Summary An increasing number of patients with TCVI are being identified, largely because of the expanding use of computed tomography angiography for screening patients with blunt trauma. Patients with TCVI are particularly challenging to manage because they often suffer polytrauma, that is, numerous additional injuries including orthopedic, chest, abdominal, and head injuries. Presently, there is no consensus about optimal management. Key Messages Most literature about TCVI and stroke has been published in trauma, general surgery, and neurosurgery journals; because of this, and because these patients are managed primarily by trauma surgeons, patients with stroke due to TCVI have been essentially hidden from view of neurologists. This review is intended to bring this clinical entity to the attention of clinicians and investigators with specific expertise in neurology and stroke.
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Affiliation(s)
| | - Mark R. Harrigan
- *Mark R. Harrigan, MD, FOT 1005, 1720 2nd Ave South, Birmingham, AL 35294-3410 (USA), E-Mail
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Kelts G, Maturo S, Couch ME, Schmalbach CE. Blunt cerebrovascular injury following craniomaxillofacial fractures: A systematic review. Laryngoscope 2016; 127:79-86. [DOI: 10.1002/lary.26186] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2016] [Indexed: 12/13/2022]
Affiliation(s)
- Gregory Kelts
- Department of Otolaryngology; San Antonio Uniformed Services Health Education Consortium Otolaryngology; San Antonio Texas U.S.A
| | - Stephen Maturo
- Department of Otolaryngology; San Antonio Uniformed Services Health Education Consortium Otolaryngology; San Antonio Texas U.S.A
| | - Marion Everett Couch
- Department of Otolaryngology; Indiana University School of Medicine; Indianapolis Indiana U.S.A
| | - Cecelia E. Schmalbach
- Department of Otolaryngology; Indiana University School of Medicine; Indianapolis Indiana U.S.A
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Motomura A, Inokuchi G, Yajima D, Hayakawa M, Makino Y, Chiba F, Torimitsu S, Sato K, Otsuka K, Kobayashi K, Odo Y, Iwase H. Observation of vertebral artery damage using angioscopy in autopsy cases. Int J Legal Med 2014; 128:979-85. [PMID: 25030189 DOI: 10.1007/s00414-014-1039-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Accepted: 06/16/2014] [Indexed: 10/25/2022]
Abstract
The vertebral arteries are important blood vessels that supply the cerebral circulation in conjunction with the internal carotid arteries. In cases of subarachnoid hemorrhage, it is necessary to examine the vertebral arteries as potential sources of bleeding due to blunt trauma (head and neck) or of cerebral embolism that originated on the surface of the damaged intima as a result of hyperflexion or hyperextension. However, a considerable part of the vertebral arterial surface is surrounded by bone, resulting in challenges during examination in a routine autopsy. In this study, angioscopy was used to inspect the vertebral artery intima for damage in cases of neck injury, head injury, or neck strangulation. Intimal damage was detected in 34 out of the total 75 cases. Of the 28 cases with cervical discopathy or fracture, 61% had intimal damage. In addition, postmortem application of computed tomography angiography was performed to identify the injured vessel in a case with traumatic subarachnoid hemorrhage, and a perforated hole was detected using angioscopy, which did not introduce autopsy-related artifacts. Therefore, angioscopy may be a useful and nondestructive method to identify intimal damage in the vertebral arteries during an autopsy.
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Affiliation(s)
- Ayumi Motomura
- Department of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo, Chiba City, Chiba, 260-8670, Japan,
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Blunt-Mechanism Facial Fracture Patterns Associated With Internal Carotid Artery Injuries: Recommendations for Additional Screening Criteria Based on Analysis of 4,398 Patients. J Oral Maxillofac Surg 2013; 71:2092-100. [DOI: 10.1016/j.joms.2013.07.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 06/30/2013] [Accepted: 07/05/2013] [Indexed: 11/19/2022]
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Mitha AP, Kalb S, Ribas-Nijkerk JC, Solano J, McDougall CG, Albuquerque FC, Spetzler RF, Theodore N. Clinical Outcome After Vertebral Artery Injury Following Blunt Cervical Spine Trauma. World Neurosurg 2013; 80:399-404. [DOI: 10.1016/j.wneu.2012.04.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Revised: 01/12/2012] [Accepted: 04/11/2012] [Indexed: 11/26/2022]
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Vertebral artery injury associated with blunt cervical spine trauma: a multivariate regression analysis. Spine (Phila Pa 1976) 2013; 38:1352-61. [PMID: 23574813 DOI: 10.1097/brs.0b013e318294bacb] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis of prospective registry data. OBJECTIVE To determine the patient characteristics, risk factors, and fracture patterns associated with vertebral artery injury (VAI) in patients with blunt cervical spine injury. SUMMARY OF BACKGROUND DATA VAI associated with cervical spine trauma has the potential for catastrophical clinical sequelae. The patterns of cervical spine injury and patient characteristics associated with VAI remain to be determined. METHODS A retrospective review of prospectively collected data from the American College of Surgeons trauma registries at 3 level-1 trauma centers identified all patients with a cervical spine injury on multidetector computed tomographic scan during a 3-year period (January 1, 2007, to January 1, 2010). Fracture pattern and patient characteristics were recorded. Logistic multivariate regression analysis of independent predictors for VAI and subgroup analysis of neurological events related to VAI was performed. RESULTS Twenty-one percent of 1204 patients with cervical injuries (n = 253) underwent screening for VAI by multidetector computed tomography angiogram. VAI was diagnosed in 17% (42 of 253), unilateral in 15% (38 of 253), and bilateral in 1.6% (4 of 253) and was associated with a lower Glasgow coma scale (P < 0.001), a higher injury severity score (P < 0.01), and a higher mortality (P < 0.001). VAI was associated with ankylosing spondylitis/diffuse idiopathic skeletal hyperosteosis (crude odds ratio [OR] = 8.04; 95% confidence interval [CI], 1.30-49.68; P = 0.034), and occipitocervical dissociation (P < 0.001) by univariate analysis and fracture displacement into the transverse foramen 1 mm or more (adjusted OR = 3.29; 95% CI, 1.15-9.41; P = 0.026), and basilar skull fracture (adjusted OR = 4.25; 95% CI, 1.25-14.47; P= 0.021), by multivariate regression model. Subgroup analyses of neurological events secondary to VAI occurred in 14% (6 of 42) and the stroke-related mortality rate was 4.8% (2 of 42). Neurological events were associated with male sex (P = 0.024), facet subluxation/dislocation (crude OR = 9.00; 95% CI, 1.51-53.74; P = 0.004) and the diagnosis of ankylosing spondylitis/diffuse idiopathic skeletal hyperosteosis (OR = 40.67; 95% CI, 5.27-313.96; P < 0.001). CONCLUSION VAI associated with blunt cervical spine injury is a marker for more severely injured patients. High-risk patients with basilar skull fractures, occipitocervical dissociation, fracture displacement into the transverse foramen more than 1 mm, ankylosing spondylitis/diffuse idiopathic skeletal hyperosteosis, and facet subluxation/dislocation deserve focused consideration for VAI screening.
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Rao VY, Shah KB, Bollo RJ, Mawad ME, Whitehead WE, Curry DJ, Dauser RC, Luerssen TG, Jea A. Management of ruptured dissecting intracranial aneurysms in infants: report of four cases and review of the literature. Childs Nerv Syst 2013; 29:685-91. [PMID: 23014950 DOI: 10.1007/s00381-012-1924-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 09/05/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND Intracranial cerebral aneurysms in the pediatric population are infrequent, and those occurring in infants less than 1 year old are extremely rare. Of intracranial aneurysms in children, dissecting aneurysms are the most common type seen. While spontaneous dissecting aneurysms usually present with ischemia, hemorrhage can also occur. METHODS A retrospective review of our patients revealed that from July 1, 2007 to June 30, 2012, four infants were treated for ruptured distal dissecting intracranial aneurysms at Texas Children's Hospital. Mycotic aneurysms and collagen vascular disorder were excluded in all four cases. All patients presented in our series presented with subarachnoid hemorrhage, and three had intraventricular hemorrhage. All patients underwent conventional catheter angiography for diagnosis. All patients in this series were managed in the acute or subacute period with surgical or endovascular trapping without distal bypass procedures. All four patients tolerated sacrifice of the parent vessels feeding these distal aneurysms well. CASE REPORT AND REVIEW OF LITERATURE We describe the presentation and management of these rare cases and then review the current literature on the management of these dissecting aneurysms in infants.
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Affiliation(s)
- Vikas Y Rao
- Division of Pediatric Neurosurgery, Texas Children's Hospital, 6621 Fannin Street, CCC 1230.01, 12th Floor, Houston, TX 77030, USA
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Mohan IV. Current optimal assessment and management of carotid and vertebral spontaneous and traumatic dissection. Angiology 2013; 65:274-83. [PMID: 23401625 DOI: 10.1177/0003319712475154] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Dissection of the internal carotid or vertebral artery has been recognized as a cause of stroke in young patients. It is disproportionate in its representation as a cause of stroke in this age group. Intimal tears, intramural hematomas, and dissection aneurysms may be the result of trauma or may occur spontaneously. Spontaneous dissection may be the result of inherent arterial weakness or in association with other predisposing factors. Clinical diagnosis is often difficult, but increased awareness and a range of modern investigations such as computerized tomography or magnetic resonance imaging may aid in diagnosis. Management options include antiplatelet therapy, anticoagulation, thrombolysis, and surgical or endovascular procedures. Prognosis is variable, and dissection may be asymptomatic but may lead to profound neurological deficit and death.
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Affiliation(s)
- Irwin V Mohan
- 1Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
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Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE To evaluate the clinical indications for acquiring arterial imaging in cervical trauma. SUMMARY OF BACKGROUND DATA Cervical spine injuries are very common in high-energy trauma and are frequently seen at Level I trauma centers across the country. A clinical standard of care does not exist to indicate when further evaluation of the cervical vasculature is warranted after a documented cervical spine injury. METHODS After institutional review board approval, a retrospective study combining the data from 2 Level I trauma centers was undertaken. An evaluation of every arterial imaging procedure (computed tomography and magnetic resonance angiography) of the cervical spine was collected to further delineate indications and outcomes of these imaging modalities. RESULTS From 2005 to 2009, there were a total of 159 patients who underwent cervical arterial imaging at the 2 participating institutions for the indication of cervical trauma with concern for arterial injury. Thirty-six (22.64%) were found to have an injury after arterial imaging. There was a statistically significant correlation with displaced cervical injuries (P < 0.0153), which were defined as cervical dissociations or perched and/or jumped facets. The other statistically significant correlation was the presence of a neurological deficit (P < 0.001), defined as any presenting deficit on sensory or motor examination. Level of injury defined as axial (O-C2) versus subaxial (C3-C7), age, body mass index, and history of cigarette smoking were not statistically related to vascular injury. CONCLUSION Our retrospective evaluation indicates that there should be a lower threshold for obtaining arterial imaging with cervical injury patterns historically known to compromise the vasculature, which also have concomitant displaced cervical spine injuries and/or a neurological deficit.
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Fusco MR, Harrigan MR. Cerebrovascular dissections: a review. Part II: blunt cerebrovascular injury. Neurosurgery 2011; 68:517-30; discussion 530. [PMID: 21135751 DOI: 10.1227/neu.0b013e3181fe2fda] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Traumatic cerebrovascular injury (TCVI) is present in approximately 1% of all blunt force trauma patients and is associated with injuries such as head and cervical spine injuries and thoracic trauma. Increased recognition of patients with TCVI in the past quarter century has been because of aggressive screening protocols and noninvasive imaging with computed tomography angiography. Extracranial carotid and vertebral artery injuries demonstrate a spectrum of severity, from intimal disruption to traumatic aneurysm formation or vessel occlusion. The most common intracranial arterial injuries are carotid-cavernous fistulae and traumatic aneurysms. Data on the long-term natural history of TCVI are limited, and management of patients with TCVI is controversial. Although antithrombotic medical therapy is associated with improved neurological outcomes, the optimal medication regimen is not yet established. Endovascular techniques have become more popular than surgery for the treatment of TCVI; endovascular options include stenting of dissections, intra-arterial thrombolysis for acute ischemic stroke caused by trauma, and embolization of traumatic aneurysms.
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Affiliation(s)
- Matthew R Fusco
- Department of Surgery, Division of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Desouza RM, Crocker MJ, Haliasos N, Rennie A, Saxena A. Blunt traumatic vertebral artery injury: a clinical review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 20:1405-16. [PMID: 21674212 DOI: 10.1007/s00586-011-1862-y] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Revised: 05/22/2011] [Accepted: 05/22/2011] [Indexed: 11/25/2022]
Abstract
Blunt traumatic vertebral injury (TVAI) is frequently associated with head and neck injury and is being detected with increasing frequency due to improved imaging of the trauma patient. In a few cases, it can lead to potentially fatal posterior circulation ischaemia There is debate in the literature regarding whether TVAI should be actively screened for and, if so, how. Management of TVAI may be conservative, medical (antiplatelet agents or anticoagulation), endovascular or open surgery. We review the literature concerning the mechanisms and presentation of TVAI following blunt injury and the current screening recommendations. Management strategies proposed are based on the radiological grade and clinical severity of TVAI, where high-grade symptomatic injuries and high-grade injuries in patients where anticoagulation is contraindicated are treated endovascularly and asymptomatic or low-grade injuries are managed with anticoagulation where it is not contraindicated. Follow-up is via CT angiography to assess for resolution of the injury.
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Affiliation(s)
- R M Desouza
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK.
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Harrigan MR, Weinberg JA, Peaks YS, Taylor SM, Cava LP, Richman J, Walters BC. Management of blunt extracranial traumatic cerebrovascular injury: a multidisciplinary survey of current practice. World J Emerg Surg 2011; 6:11. [PMID: 21477304 PMCID: PMC3097147 DOI: 10.1186/1749-7922-6-11] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Accepted: 04/08/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Extracranial traumatic cerebrovascular injury (TCVI) is present in 1-3% of all blunt force trauma patients. Although options for the management of patients with these lesions include anticoagulation, antiplatelet agents, and endovascular treatment, the optimal management strategy for patients with these lesions is not yet established. OBJECTIVE Multidisciplinary survey of clinicians about current management of TCVI. METHODS A six-item multiple-choice survey was sent by electronic mail to a total of 11,784 neurosurgeons, trauma surgeons, stroke neurologists, and interventional radiologists. The survey included questions about their choice of imaging, medical management, and the use of endovascular techniques. Survey responses were analyzed according to stated specialty. RESULTS Seven hundred eighty-five (6.7%) responses were received. Overall, a total of 325 (42.8%) respondents favored anticoagulation (heparin and/or warfarin), 247 (32.5%) favored antiplatelet drugs, 130 (17.1%) preferred both anticoagulation and antiplatelet drugs, and 57 (7.5%) preferred stenting and/or embolization. Anticoagulation was the most commonly preferred treatment among vascular surgeons (56.9%), neurologists (50.2%) and neurosurgeons (40.7%), whereas antiplatelet agents were the most common preferred treatment among trauma surgeons (41.5%). Overall, 158 (20.7%) of respondents recommended treatment of asymptomatic dissections and traumatic aneurysms, 211 (27.7%) did not recommend it, and 39.4% recommended endovascular treatment only if there is worsening of the lesion on follow-up imaging. CONCLUSIONS These data demonstrate the wide variability of physicians' management of traumatic cerebrovascular injury, both on an individual basis, and between specialties. These findings underscore the need for multicenter, randomized trials in this field.
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Affiliation(s)
- Mark R Harrigan
- Division of Neurosurgery, University of Alabama, Birmingham, Birmingham, Alabama, USA.
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Fusco MR, Harrigan MR. Cerebrovascular Dissections—A Review Part I: Spontaneous Dissections. Neurosurgery 2011; 68:242-57; discussion 257. [DOI: 10.1227/neu.0b013e3182012323] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
abstract
Spontaneous cerebrovascular dissections are subintimal or subadventitial cervical carotid and vertebral artery wall injuries and are the cause of as many as 2% of all ischemic strokes. Spontaneous dissections are the leading cause of stroke in patients younger than 45 years of age, accounting for almost one fourth of strokes in this population. A history of some degree of trivial trauma is present in nearly one fourth of cases. Subsequent mortality or neurological morbidity is usually the result of distal ischemia produced by emboli released from the injury site, although local mass effect produced by arterial dilation or aneurysm formation also can occur. The gold standard for diagnosis remains digital subtraction angiography. Computed tomography angiography, magnetic resonance angiography, and ultrasonography are complementary means o evaluation, particularly for injury screening or treatment follow-up. The annual rate of stroke after injury is approximately 1% or less per year. The currently accepted method of therapy remains antithrombotic medication, either in the form of anticoagulation or antiplatelet agents; however, no class I medical evidence exists to guide therapy. Other options for treatment include thrombolysis and endovascular therapy, although the efficacy and indications for these methods remain unclear.
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Affiliation(s)
- Matthew R. Fusco
- Department of Surgery, Division of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mark R. Harrigan
- Department of Surgery, Division of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
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Chamoun RB, Jea A. Traumatic Intracranial and Extracranial Vascular Injuries in Children. Neurosurg Clin N Am 2010; 21:529-42. [DOI: 10.1016/j.nec.2010.03.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Aries MJH, De Jong BM, Uyttenboogaart M, Regtien JG, van der Naalt J. Traumatic cervical artery dissection in head injury: the value of follow-up brain imaging. Clin Neurol Neurosurg 2010; 112:691-4. [PMID: 20580486 DOI: 10.1016/j.clineuro.2010.05.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2009] [Revised: 05/18/2010] [Accepted: 05/30/2010] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Traumatic cervical artery dissection (TCAD) is a relative infrequent complication of traumatic brain injury (TBI). Since TCAD is associated with morbidity in a considerable percentage of patients, it is important to obtain clues for recognising TCAD in this category of patients. METHODS Retrospective case-cohort study in severe TBI patients. RESULTS Five patients with traumatic cervical artery dissection after severe TBI, leading to ischemic strokes, are described. Secondary deterioration to coma was present in four out of five patients during admission. The diagnosis of TCAD was delayed in most cases because the secondary deterioration was often attributed to multisystem problems related to trauma patients, i.e. shock or hypoxia or medication effects. Local clinical symptoms and signs suggestive of TCAD are difficult to detect in this patient group. In all patients, the CT-scan on admission demonstrated no abnormalities. A follow-up scan at day 2 revealed that in all patients abnormalities in the vascular territories had evolved. CONCLUSION With this case-cohort study we underline the importance of considering TCAD in severe TBI patients and emphasise the role for standard follow-up brain imaging. Also possible treatment consequences are discussed.
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Affiliation(s)
- M J H Aries
- Department of Neurology and Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands.
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