Blunt cerebrovascular injury: an evaluation from a major trauma centre

Neurovascular trauma: Diagnosis and therapy

Traumatic cerebrovascular injuries are common in both military and civilian populations. Whether such injuries occur in the aftermath of blunt or penetrating trauma has major implications for characteristics, classification, diagnosis, and optimal management of these lesions. Advances in screening methods, including particularly the dramatic rise of high-quality CT angiography, have facilitated early detection of these lesions. Fortunately, these diagnostic advances have occurred alongside improvements in pharmacological treatment and endovascular intervention, which now play an important role alongside surgical intervention in reducing the likelihood of adverse clinical outcomes. While the management of victims of trauma remains challenging, improved understanding of and ability to appropriately manage traumatic cerebrovascular lesions promises to yield better clinical outcomes for these vulnerable patients.

Optic nerve injury-associated blunt cerebrovascular injury: Three case reports

RATIONALE

Blunt cerebrovascular injury (BCVI) is a rare complication that may occur after craniocervical trauma. The current literature is limited to extracranial carotid artery injuries; however, no reports have been published on blunt intracranial carotid injury (BICI), especially those associated with optic nerve injury.

PATIENT CONCERNS

Here we report on 3 BICI cases that demonstrated optic nerve injuries after craniofacial injuries. All 3 patients showed post-trauma vision loss on the injured side.

DIAGNOSES

Optical canal fractures can be found in these patients, and carotid sulcus was compressed by the fragments. Computed tomography angiography (CTA) and digital subtraction angiography (DSA) were performed in all 3 patients.

INTERVENTIONS

Case 1 was given no further treatment, except for symptomatic support and rehabilitation therapy. Case 2 was treated with antiplatelet therapy for 3 days, and then a stent was inserted in the injured internal carotid. Case 3 received antiplatelet therapy and a internal carotid compression test was performed simultaneously for 2 weeks, then the injured internal carotid was completely blocked.

OUTCOMES

Case 1 developed cerebral infarction that resulted in unilateral hemiplegia. Due to timely treatment, the remaining 2 patients had a better prognosis.

LESSONS

CTA should be performed primarily to exclude vascular injury and for CTA-positive patients, a further DSA should be performed to investigate pathological changes and for a definitive diagnosis. At last, the current therapeutic protocols for BCVI are not entirely applicable to intracranial vascular injury, and appropriate protocols for the treatment of BICI should be selected based on the combination of test results and the actual condition of the patient.

Increased detection of blunt carotid and vertebral artery injury after implementation of diagnostic imaging pathway in level 1 trauma centre in Western Australia

BACKGROUND

The incidence of Blunt Carotid Artery and Vertebral Artery Injury (BCVI) is relatively low in modern trauma practice. However, these injuries may be associated with severe neurological consequences. Following the introduction of a Diagnostic Imaging Pathway in Department of Health of Western Australia, we hypothesized that this injury would be less likely to be missed, and accordingly diagnosed more frequently.

METHOD

A review of all major trauma (Injury Severity Scale>15) admissions at the State Major Trauma Centre in Royal Perth Hospital was undertaken from 1995 until 2013. BCVI was identified from the hospital's trauma registry. The medical records of these patients were then reviewed.

RESULT

58 of 7451 (0.78%) major trauma patients were diagnosed of BCVI during the study period. An increased incidence, from 0.52% (20/3880) to 1.06% (38/3571), was seen after the introduction of the Diagnostic Imaging Pathway in 2007 (p=0.010). The majority of the cases were caused by motor vehicle crashes, with 66% (n=38) of the cases sustaining concomitant head or cervical spine injury. Other commonly associated injuries included chest, extremity and thoracic spine injury.

CONCLUSION

Our study reports a significant increase in the diagnosis of BCVI among major traumas after the introduction of a Diagnostic Imaging Pathway for the screening of this injury in 2007. The previously low incidence of BCVI compared with other centres' reports indicated possible previous under-screening and diagnosis of this injury.

Incidence and trends in the diagnosis of traumatic extracranial cerebrovascular injury in the nationwide inpatient sample database, 2003-2010

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.

A systematic review and meta-analysis of diagnostic screening criteria for blunt cerebrovascular injuries

BACKGROUND

Despite progress in diagnosing and managing blunt cerebrovascular injury (BCVI), controversy remains regarding the appropriate population to screen. A systematic review of published literature was conducted to summarize the overall incidence of BCVI and the various screening criteria used to detect BCVI. A meta-analysis was performed to evaluate which screening criteria may be associated with BCVI. Goals were to confirm inclusion of certain criteria in current screening protocols and possibly eliminate criteria not associated with BCVI.

STUDY DESIGN

Studies published between January 1995 and April 2011 using digital subtraction angiography or CT angiography as a diagnostic modality and reporting overall BCVI incidence or prevalence of BCVI for specific screening criteria were examined. Screening criteria were analyzed using a random effects model to determine if an association with BCVI was present.

RESULTS

The incidence range of BCVI was between 0.18% and 2.70% among approximately 122,176 blunt trauma admissions. The meta-analysis encompassed 418 BCVI and 22,568 non-BCVI patients. Of the 9 screening criteria analyzed, cervical spine (odds ratio [OR] 5.45; 95% CI 2.24 to 13.27; p < 0.0001) and thoracic (OR 1.98; 95% CI 1.35 to 2.92; p = 0.001) injuries demonstrated a significant association with BCVI.

CONCLUSIONS

Patients with cervical spine and thoracic injuries had significantly greater likelihoods of BCVI compared with patients without these injuries. All patients with either injury should be screened for BCVI. Multivariate logistic regression analysis is needed to elucidate the possible impact of the combined presence of screening criteria, but it was not possible in our study due to limitations in data presentation. Standardized reporting of BCVI data is not established and is recommended to permit future collaboration.

Blunt cerebrovascular injuries in acute trauma care: a screening protocol

INTRODUCTION

Blunt cerebrovascular injuries (BCVI) of the extra- or intracerebral vessels are frequently observed lesions which may lead to thrombembolic events with focal neurological deficits, stroke or death particularly in patients <60 years. However, a comprehensive standardised clinical algorithm for screening and management of these secondary injuries is still lacking.

MATERIALS AND METHODS

We developed a standardised screening protocol applicable for mild as well as severely injured patients. In this prospective cohort study, we evaluated the feasibility of this diagnostic algorithm in a level 1 trauma centre setting. Trauma patients who met the inclusion criteria underwent a computed tomographic angiography (CTA) as part of standard diagnostic procedure at admission. All suspicions or positive findings were reevaluated by a conventional four-vessel catheter angiography within the first 72 h after trauma. Within this period, anticoagulation with low-dose heparin was started. BCVI confirmation indicated a shift to systemic heparinisation with overlapping phenprocoumon therapy for at least 6 months. All patients were reevaluated after 6 months by another four-vessel angiography. Depending on the diagnostic findings, oral anticoagulation may be discontinued or continued for another 6 months.

RESULTS

A total of 44 patients (8 male, 6 female, age range 19-95 years) were included in the study. 20 BCVIs were detected in 16 patients (36.3%). The most common injuries identified were Biffl Type II (40%) and Type IV lesions (30%). 86.4% of the patients received a CTA upon admission, 93.2% of which were conducted within 12 h posttrauma. None of the patients had a secondary thrombembolic neurological event during the hospital stay or within 3 months postdischarge.

CONCLUSION

Our results indicate that implementation of the screening protocol can prevent strokes in patients without primary thrombembolic neurological deficits.

Blunt cerebrovascular injuries: diagnosis and management outcomes

BACKGROUND

Blunt cerebrovascular injury (BCVI) to the carotid and vertebral arteries is a potentially devastating injury in trauma patients. The optimal management for BCVI has not been standardized. At our institution, 64-slice multi-detector computed tomographic angiography (CTA) has been used as the initial screening exam for BCVI in patients who met predefined screening criteria. The purpose of this study is to review the incidence of CTA-diagnosed BCVI in at-risk patients and to evaluate the treatment and clinical outcome of patients with BCVI.

METHODS

This study included trauma patients with a positive diagnosis of BCVI on CTA during a 41-month study period. The medical records and relevant radiographic findings were retrospectively reviewed.

RESULTS

Twenty seven of 222 blunt trauma patients evaluated with CTA had a positive diagnosis of BCVI, with an occurrence rate of 12.2%. Traumatic brain injury (72.2%) and basal skull fractures (55.6%) were the most frequent associated injuries with carotid trauma while 100% of blunt vertebral injuries occurred in the setting of cervical fractures. Fourteen (51.8%) patients received medical therapy; Eleven (40.7%) patients received conservative treatment. Endovascular treatment was attempted in a single case of vertebral arteriovenous fistula. BCVI-related stroke was found in four patients (14.8%), one of whom developed an infarct while on medical treatment.

CONCLUSIONS

BCVI is found in a significant portion of blunt trauma patients with identifiable risk factors, and screening CTA has high diagnostic yield in detecting these lesions. Medical therapy is the mainstay of treatment at our institution; however, BCVI-related stroke may occur despite treatment.

Postdischarge Outcomes of Blunt Cerebrovascular Injuries

A retrospective review was conducted to assess outcomes of blunt cerebrovascular injuries (BCVIs) diagnosed in a 14-month period at a level-1 trauma center and evaluated postdischarge at a single vascular practice. Twenty-nine patients with 34 BCVIs (10 carotid; 24 vertebral) were admitted. Eleven (37.9%) patients were treated with combined anticoagulation and antiplatelet therapy, 9 (31.0%) with anticoagulation, and 4 (13.8%) with antiplatelets. Five (17.2%) patients underwent observation. Seventeen (58.6%) patients (19 injuries) returned for follow-up evaluation. At a mean follow-up of 9.2 weeks, all patients had normal neurological examinations with no complications. Sixteen (84.2%) BCVIs resolved. Anticoagulation and antiplatelet therapies were equally effective in preventing cerebral infarction. Although the majority of lesions resolve, BCVIs have the ability to progress and often require surgical intervention. Routine follow-up after discharge is warranted for all BCVIs and should include repeat computed tomography angiography (CTA) with bilateral carotid/vertebral duplex ultrasound (US) as a physiological test.

Blunt vertebral artery injuries in the era of computed tomographic angiographic screening: incidence and outcomes from 8,292 patients

INTRODUCTION

Blunt injuries to the vertebral artery (BVI) are rare. Recent improvements in the multidetector computer tomography (MDCT) technology and increased use of screening protocols have led to a greater number of these injuries identified. Well-defined treatment recommendations are still lacking, and it is unclear whether screening and treatment lead to improved outcome.

METHODS

All patients who met predefined screening criteria were screened for BVI with a MDCT angiogram (MDCT-A). All patients identified with BVI were treated based on injury grade and associated injuries. Hospital course, morbidity, mortality, and follow-up were recorded and analyzed.

RESULTS

A total of 8,292 patients were admitted for blunt injuries during this time period. Forty-four patients were found to have 47 BVI (three bilateral). Pharmacologic treatment with anticoagulants (AC)-heparin and warfarin-or an antiplatelet agent-clopidogrel and aspirin-was initiated in 37 patients (84%). Angiographic coiling was performed in eight patients (18%), and two (5%) had endovascular stents placed. Four patients developed signs of cerebral ischemia (9%), of whom three died and one recovered completely. Overall mortality rate was 16% (7/44). BVI-related mortality occurred in three patients (7%). Of these, two patients had bilateral vertebral artery occlusion or transaction, and death was considered nonpreventable. One death occurred in a patient with a unilateral vertebral dissection developed a posterior circulation infarct. Anticoagulation was felt to be contraindicated in this patient initially due to intracranial hemorrhage. This was deemed the only potentially preventable BVI-related mortality. Annual BVI-related mortality rate in the 4 years before initiating the screening protocol was 0.75 cases per year. During this study period, it was 0.57 cases per year.

CONCLUSION

Under an aggressive screening and individualized treatment protocol for BVI, we had very few potentially preventable BVI-related strokes and deaths. We are unable to conclude; however, based on historical controls that either screening or treatment improved overall outcome.

Cerebrovascular trauma

Vascular injury of the head and neck region is a rare and often life-threatening complication of head or neck trauma and is due to two major pathomechanisms: penetrating or blunt trauma. Both the arterial and the venous site of the CNS vasculature can be involved, the latter one being often overlooked. Concerning arterial lesions, depending on how many layers of the arterial vessel are affected and on the spatial relationship to adjacent structures, dissections, false aneurysms or arteriovenous fistulae may develop. On the venous side, dural tears, compressive effects on pial veins and a deranged clotting system may lead to delayed venous thrombosis. In this review we describe clinical and imaging findings, as well as diagnostic and treatment strategies in these lesions.