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Chatterjee AR, Malhotra A, Curl P, Andre JB, Perez-Carrillo GJG, Smith EB. Traumatic Cervical Cerebrovascular Injury and the Role of CTA: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2024:1-13. [PMID: 37791730 DOI: 10.2214/ajr.23.29783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Traumatic cerebrovascular injury (CVI) involving the cervical carotid and vertebral arteries is rare but can lead to stroke, hemodynamic compromise, and mortality in the absence of early diagnosis and treatment. The diagnosis of both blunt cerebrovascular injury (BCVI) and penetrating CVI is based on cerebrovascular imaging. The most commonly used screening criteria for BCVI include the expanded Denver criteria and the Memphis criteria, each providing varying thresholds for subsequent imaging. Neck CTA has supplanted catheter-based digital subtraction angiography as the preferred screening modality for CVI in patients with trauma. This AJR Expert Panel Narrative Review describes the current state of CTA-based cervical imaging in trauma. We review the most common screening criteria for BCVI, discuss BCVI grading scales that are based on neck CTA, describe the diagnostic performance of CTA in the context of other imaging modalities and evolving treatment strategies, and provide a practical guide for neck CTA implementation.
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Affiliation(s)
- Arindam Rano Chatterjee
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, 510 S Kingshighway, Box 8131, St. Louis, MO 63110
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT
| | - Patti Curl
- Department of Radiology, Neuroradiology Section, University of Washington School of Medicine, Seattle, WA
| | - Jalal B Andre
- Department of Radiology, Neuroradiology Section, University of Washington School of Medicine, Seattle, WA
| | - Gloria J Guzman Perez-Carrillo
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, 510 S Kingshighway, Box 8131, St. Louis, MO 63110
| | - Elana B Smith
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD
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Bar-Or D, Jarvis S, Lensing F, Bassa D, Carrick M, Palacio Lascano C, Busch M, Hamilton D, Acuna D, Greenseid S, Ojala D. The effect of circle of willis anatomy and scanning practices on outcomes for blunt cerebrovascular injuries. Scand J Trauma Resusc Emerg Med 2024; 32:57. [PMID: 38886775 PMCID: PMC11181559 DOI: 10.1186/s13049-024-01225-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 05/27/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Limited research has explored the effect of Circle of Willis (CoW) anatomy among blunt cerebrovascular injuries (BCVI) on outcomes. It remains unclear if current BCVI screening and scanning practices are sufficient in identification of concomitant COW anomalies and how they affect outcomes. METHODS This retrospective cohort study included adult traumatic BCVIs at 17 level I-IV trauma centers (08/01/2017-07/31/2021). The objectives were to compare screening criteria, scanning practices, and outcomes among those with and without COW anomalies. RESULTS Of 561 BCVIs, 65% were male and the median age was 48 y/o. 17% (n = 93) had a CoW anomaly. Compared to those with normal CoW anatomy, those with CoW anomalies had significantly higher rates of any strokes (10% vs. 4%, p = 0.04), ICHs (38% vs. 21%, p = 0.001), and clinically significant bleed (CSB) before antithrombotic initiation (14% vs. 3%, p < 0.0001), respectively. Compared to patients with a normal CoW, those with a CoW anomaly also had ischemic strokes more often after antithrombotic interruption (13% vs. 2%, p = 0.02).Patients with CoW anomalies were screened significantly more often because of some other head/neck indication not outlined in BCVI screening criteria than patients with normal CoW anatomy (27% vs. 18%, p = 0.04), respectively. Scans identifying CoW anomalies included both the head and neck significantly more often (53% vs. 29%, p = 0.0001) than scans identifying normal CoW anatomy, respectively. CONCLUSIONS While previous studies suggested universal scanning for BCVI detection, this study found patients with BCVI and CoW anomalies had some other head/neck injury not identified as BCVI scanning criteria significantly more than patients with normal CoW which may suggest that BCVI screening across all patients with a head/neck injury may improve the simultaneous detection of CoW and BCVIs. When screening for BCVI, scans including both the head and neck are superior to a single region in detection of concomitant CoW anomalies. Worsened outcomes (strokes, ICH, and clinically significant bleeding before antithrombotic initiation) were observed for patients with CoW anomalies when compared to those with a normal CoW. Those with a CoW anomaly experienced strokes at a higher rate than patients with normal CoW anatomy specifically when antithrombotic therapy was interrupted. This emphasizes the need for stringent antithrombotic therapy regimens among patients with CoW anomalies and may suggest that patients CoW anomalies would benefit from more varying treatment, highlighting the need to include the CoW anatomy when scanning for BCVI. LEVEL OF EVIDENCE Level III, Prognostic/Epidemiological.
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Affiliation(s)
- David Bar-Or
- Swedish Medical Center, Englewood, CO, USA.
- Injury Outcomes Network, Colorado, , Englewood, United States.
| | - Stephanie Jarvis
- Swedish Medical Center, Englewood, CO, USA
- Injury Outcomes Network, Colorado, , Englewood, United States
| | | | - David Bassa
- Medical City Plano, Texas, , Plano, United States
| | | | | | | | | | - David Acuna
- Wesley Medical Center, Kansas, , Wichita, United States
| | | | - Daniel Ojala
- Saint Anthony Hospital, Colorado, , Lakewood, United States
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Khormi YH, Darraj AI, Arishy A, Abuzahirah SO, Atteya M. Bilateral Blunt Traumatic Dissections of the Extracranial Internal Carotid Artery: A Case Report and Literature Review. Cureus 2024; 16:e53630. [PMID: 38449976 PMCID: PMC10917072 DOI: 10.7759/cureus.53630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2024] [Indexed: 03/08/2024] Open
Abstract
Bilateral traumatic dissections of the cervical internal carotid artery (ICA) are rare complications of polytrauma. A thorough literature review was performed, and data from selected studies were analyzed to assess the trends in clinical presentation, modes of trauma, management protocols, and clinical outcomes. The reported outcomes were categorized and graded into optimal, intermediate, and poor outcomes. We describe a rare case of bilateral dissection of ICA in a 31-year-old woman who was involved in a motor vehicle accident. She had a Glasgow Coma Scale score of 9 and right-sided hemiparesis. Radiological findings revealed left upper ICA dissection, arterial intramural thrombus, and stenosis of the upper segment of the right ICA. She improved on conservative management and had a good clinical outcome at a three-month follow-up. Emergency physicians must be knowledgeable about such cases, as more than half of these trauma victims are initially asymptomatic on initial presentation. Specific diagnostic and therapeutic modalities should be implemented based on low threshold clinical suspicion to avoid missing these potentially disabling injuries and reduce morbidity and mortality. Computed tomographic angiography is recommended in cases with atypical clinical presentations, unexplained neurological deficits, or delayed-onset clinical deterioration. While antiplatelet and anticoagulant therapies are the mainstays of conservative management, endovascular and surgical management are only used in severe cases when medical treatment has failed, the artery has been completely transected, or there is active bleeding. Generally, good outcomes were reported in about two-thirds of those patients.
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Affiliation(s)
| | | | | | - Seham O Abuzahirah
- Medicine and Life Sciences, Maastricht University, Netherlands, NLD
- Neurosurgery, King Fahad Hospital, Jeddah, SAU
| | - Mostafa Atteya
- Neurological Surgery, King Fahad General Hospital, Jazan, SAU
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Rodriguez A, Nunez L, Riascos R. Vascular Injuries in Head and Neck Trauma. Radiol Clin North Am 2023; 61:467-477. [PMID: 36931763 DOI: 10.1016/j.rcl.2023.01.012] [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: 02/21/2023]
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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Ntola VC, Hardcastle TC. Diagnostic Approaches to Vascular Injury in Polytrauma-A Literature Review. Diagnostics (Basel) 2023; 13:diagnostics13061019. [PMID: 36980328 PMCID: PMC10046960 DOI: 10.3390/diagnostics13061019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/04/2023] [Accepted: 03/06/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Polytrauma is understood as significant injuries, occurring at the same time, to two or more anatomical regions (the ISS regions) or organ systems, with at least one of the injuries considered as posing a threat to life. Trauma is the main cause of unexpected demise in individuals below the age of 44 years and represents a huge burden on society. Vascular injury is highly morbid; it can lead to rapid exsanguination and death, posing a threat to both life and the limb. Independent predictors of outcome include mechanism of injury, associated injuries, and time from injury to definitive care. The mechanisms of vascular injury in the setting of polytrauma are either blunt, penetrating or a combination of the two. METHODS Comprehensive literature review of current diagnostic approaches to traumatic vascular injury in the context of polytrauma. The factors influencing the diagnostic approach are highlighted. The focus is the epidemiology of vascular injury and diagnostic approaches to it in the context of polytrauma. RESULTS Traumatic vascular injuries are associated with limb loss or even death. They are characterised by multiple injuries, the dilemma of the diagnostic approach, timing of intervention and higher risk of limb loss or death. The systematic approach in terms of clinical diagnosis and imaging is crucial in order save life and preserve the limb. The various diagnostic tools to individualise the investigation are discussed. CONCLUSION This paper highlights the significance of timely and appropriate use of diagnostic tools for traumatic vascular trauma to save life and to preserve the limb. The associated injury also plays a crucial role in deciding the imaging modalities. At times, more than one investigation may be required.
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Affiliation(s)
- Vuyolwethu C Ntola
- Department of Surgical Sciences, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban 4058, South Africa
| | - Timothy C Hardcastle
- Department of Surgical Sciences, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban 4058, South Africa
- Trauma and Burns Service, Inkosi Albert Luthuli Central Hospital, Durban 4058, South Africa
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Bounajem MT, McNally JS, Baker C, Colby S, Grandhi R. Emergent neurovascular imaging in patients with blunt traumatic injuries. FRONTIERS IN RADIOLOGY 2022; 2:1001114. [PMID: 37492683 PMCID: PMC10365007 DOI: 10.3389/fradi.2022.1001114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 08/25/2022] [Indexed: 07/27/2023]
Abstract
Blunt cerebrovascular injuries (BCVIs) are commonly encountered after blunt trauma. Given the increased risk of stroke incurred after BCVI, it is crucial that they are promptly identified, characterized, and treated appropriately. Current screening practices generally consist of computed tomography angiography (CTA), with escalation to digital subtraction angiography for higher-grade injuries. Although it is quick, cost-effective, and readily available, CTA suffers from poor sensitivity and positive predictive value. A review of the current literature was conducted to examine the current state of emergent imaging for BCVI. After excluding reviews, irrelevant articles, and articles exclusively available in non-English languages, 36 articles were reviewed and included in the analysis. In general, as CTA technology has advanced, so too has detection of BCVI. Magnetic resonance imaging (MRI) with sequences such as vessel wall imaging, double-inversion recovery with black blood imaging, and magnetization prepared rapid acquisition echo have notably improved the utility for MRI in characterizing BCVIs. Finally, transcranial Doppler with emboli detection has proven to be associated with strokes in anterior circulation injuries, further allowing for the identification of high-risk lesions. Overall, imaging for BCVI has benefited from a tremendous amount of innovation, resulting in better detection and characterization of this pathology.
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Affiliation(s)
- Michael T. Bounajem
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - J. Scott McNally
- Department of Radiology, University of Utah, Salt Lake City, UT, United States
| | - Cordell Baker
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Samantha Colby
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
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Davies J, Johnson R, Kashef E, Khan M, Dick E. How to deliver an effective primary survey report for the trauma CT: A radiological and surgical perspective. TRAUMA-ENGLAND 2021. [DOI: 10.1177/1460408621995144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Whole body contrast-enhanced multidetector CT (WB-CE MDCT) is integral to the assessment of the severely injured patient with stable haemodynamic parameters or in those who respond to resuscitation with blood products. WB-CE MDCT is able to identify the number and severity of injuries sustained by the patient and enable time critical intervention. In this narrative review article we discuss how communication within the trauma team, including the radiologists and appropriate clinicians is crucial in optimizing the effectiveness of WB-CE MDCT. We review the time critical imaging findings and their clinical relevance, which should be included in a succinct CT primary survey report. We also discuss the process through which the effectiveness of the trauma report may be maximised and how non technical factors including teamwork may be optimised to facilitate decision making in this high pressure environment.
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Affiliation(s)
- Joseph Davies
- Maidstone & Tunbridge Wells NHS Trust, Maidstone, UK
| | - Rowena Johnson
- Nuffield Orthopaedic Centre, Oxford NHS Foundation Trust, Oxford, UK
| | - Elika Kashef
- St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mansoor Khan
- Digestive Diseases Department, Brighton and Sussex University Hospitals, Brighton, UK
| | - Elizabeth Dick
- St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
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Wang G, Li C, Piao J, Xu B, Yu J. Endovascular treatment of blunt injury of the extracranial internal carotid artery: the prospect and dilemma. Int J Med Sci 2021; 18:944-952. [PMID: 33456352 PMCID: PMC7807178 DOI: 10.7150/ijms.50275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 12/18/2020] [Indexed: 11/15/2022] Open
Abstract
The extracranial internal carotid artery (ICA) refers to the anatomic location that reaches from the common carotid artery proximally to the skull base distally. The extracranial ICA belongs to the C1 segment of the Bouthillier classification and is at considerable risk for injury. Currently, the understanding of endovascular treatment (EVT) for blunt injury of the extracranial ICA is limited, and a comprehensive review is therefore important. In this review, we found that extracranial ICA blunt injury should be identified in patients presenting after blunt trauma, including classical dissection, pseudoaneurysm, and stenosis/occlusion. Computed tomography angiography (CTA) is the first-line method for screening for extracranial ICA blunt injury, although digital subtraction angiography (DSA) remains the "gold standard" in imaging. Antithrombotic treatment is effective for stroke prevention. However, routine EVT in the form of stenting should be reserved for patients with prolonged neurological symptoms from arterial stenosis or considerably enlarged pseudoaneurysm. Endovascular repair is now emerging as a favored therapeutic option given its demonstrated safety and positive clinical and radiographic outcomes.
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Affiliation(s)
- Guangming Wang
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
| | - Chao Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, 130021, China
| | - Jianmin Piao
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
| | - Baofeng Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
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