Diagnosis and Treatment of Traumatic Cerebrovascular Injury: Pitfalls in the Management of Neurotrauma

Self-inflicted very-low-velocity penetrating head injury: A CARE-compliant case report

RATIONALE

Low-velocity penetrating head injury (PHI) is rare, comprising 0.2% to 0.4% of head traumas, but can be devastating and is associated with significant morbidity and mortality. No previous case of very-low-velocity PHI due to self-inflicted stabbing with a gimlet has been reported.

PATIENT CONCERNS

A 62-year-old man was admitted to the hospital with bleeding head and abdominal wounds after stabbing his abdomen with a gimlet, and then hammering the same gimlet into his forehead and removing the gimlet himself.

DIAGNOSES

Upon examination at admission, stab wounds were present on the forehead and the right upper quadrant. Computed tomography (CT) of the head revealed a bone defect in the left frontal bone and showed the intracranial path of the gimlet surrounded by mild hemorrhage and pneumocephalus. Magnetic resonance imaging (MRI) confirmed a small amount of hemorrhage with pneumocephalus but no vascular injury.

INTERVENTIONS

Conservative treatment without surgery.

OUTCOMES

Follow-up MRI on hospital day 58 showed no abscess or traumatic intracranial aneurysm. The patient achieved full recovery of motor and mental functions with conservative treatment and was discharged on hospital day 69.

LESSONS

Very-low-velocity PHI might be successfully treated with conservative treatment.

Role of imaging in penetrating vascular injuries of the craniocervical region

Penetrating vascular injury has become the topic of interest with increased gun violence in the United States. The radiologist plays a crucial role in establishing and systemizing the signs of vascular injury such as intimal flap, dissection, pseudoaneurysm, rupture, and arteriovenous fistula. Various imaging techniques such as ultrasound Doppler, computed tomographic angiography (CTA), magnetic resonance angiography, and conventional angiography are being employed based on clinical recommendations. Of all the techniques, CTA has been shown to embrace a promising role in identifying vascular injuries with superior sensitivity, specificity, and accuracy. An acquaintance of the imaging features has been shown to improve the approach to trauma patients in clinical settings. This article details the imaging modalities and the features of the head-and-neck penetrating vascular injury.

Transorbital Intracranial Penetrating Injury from a Homemade Gun: A Case Report

A transorbital intracranial penetrating injury (TOPI) is an unusual traumatic brain injury that requires multidisciplinary management. TOPI may cause traumatic cerebrovascular injury (TCVI) and fatal brain damage with a high mortality rate. Herein, the authors described an 8-year-old male patient who was injured from a handmade gun; a projectile (marble) had penetrated the left frontal base via the left orbit. TOPI caused left anterior cerebral artery compression. A transorbital approach with an intraoperative transcranial approach on standby was performed to remove the foreign body. Postoperative intensive broad-spectrum antibiotics were administrated, and the patient made an uneventful recovery. In summary, TOPI is an uncommon TBI that risks TCVI. Intracranial vascular investigation should be performed before surgical management, and postoperative complications, such as meningitis, brain abscess, and delayed pseudoaneurysm, should be monitored.

Reverse shock index multiplied by Glasgow coma scale as a predictor of massive transfusion in trauma

BACKGROUND AND PURPOSE

Previous studies have identified that the reverse shock index multiplied by the Glasgow Coma Scale score (rSIG) is a good predictor of mortality in trauma patients. However, it is unknown if rSIG has utility as a predictor for massive transfusion (MT) in trauma patients. The present study evaluated the ability of rSIG to predict MT in trauma patients.

METHODS

This was a retrospective, observational study performed at a level 1 trauma center. Consecutive patients who presented to the trauma center emergency department between January 2016 and December 2018 were included. The predictive ability of rSIG for MT was assessed as our primary outcome measure. Our secondary outcome measures were the predictive ability of rSIG for coagulopathy, in-hospital mortality, and 24-h mortality. We compared the prognostic performance of rSIG with the shock index, age shock index, and quick Sequential Organ Failure Assessment.

RESULTS

In total, 1627 patients were included and 117 (7.2%) patients received MT. rSIG showed the highest area under the receiver operating characteristic (AUROC) curve (0.842; 95% confidence interval [CI], 0.806--0.878) for predicting MT. rSIG also showed the highest AUROC for predicting coagulopathy (0.769; 95% CI, 0.728-0.809), in-hospital mortality (AUROC 0.812; 95% CI, 0.772-0.852), and 24-h mortality (AUROC 0.826; 95% CI, 0.789-0.864). The sensitivity of rSIG for MT was 0.79, and the specificity of rSIG for MT was 0.77. All tools had a high negative predictive value and low positive predictive value.

CONCLUSION

rSIG is a useful, rapid, and accurate predictor for MT, coagulopathy, in-hospital mortality, and 24- h mortality in trauma patients.

Cerebral vasospasm and hypoperfusion after traumatic brain injury: Combined CT angiography and CT perfusion imaging study

Background:

Timely identification of the cerebral perfusion abnormalities after traumatic brain injury (TBI) is highly important. The objective of this study was the evaluation of the post traumatic vasospasm and cerebral hypoperfusion with the serial combined CT angiography (CTA) and CT perfusion (CTP) imaging examinations.

Methods:

The case series comprised 25 adult patients with closed TBI accompanied by various types of intracranial hematoma. Emergency surgery was done in 15 cases (60%). Combined CTA and CTP were performed on days 0 (D0) and 7 ± 1 (D7) after trauma.

Results:

CTA on D0 did not demonstrate vasospasm in any case but revealed it on D7 in 9 patients (36%). In the multivariate analysis, only the presence of subarachnoid hemorrhage (SAH) on D7 had confirmed a significant association with the development of vasospasm (P = 0.0201). Cerebral hypoperfusion at least in one evaluated brain region was noted on D0 and D7 in 76% and 60% of patients, respectively, and showed highly variable spatial distribution and temporal development. Treatment results were not associated with the presence of vasospasm (P = 0.7337) or the number of brain regions affected by hypoperfusion on D0 (P = 0.2285), but the number of brain regions affected by hypoperfusion on D7 was significantly greater in cases of unfavorable outcome (P = 0.0187).

Conclusion:

Vasospasm is merely related to SAH sustained at the subacute stage of TBI, but its spatial and temporary interrelationships with the post traumatic cerebral hypoperfusion are complex. Serial combined CTA and CTP examinations may facilitate monitoring of perfusion abnormalities and treatment guidance.

The epidemiology and outcomes of vascular trauma in Gold Coast, Australia: Institutional experience at a level 1 trauma centre

BACKGROUND

Vascular trauma is a complex and evolving area. Unlike internationally, the epidemiology of vascular trauma is not well documented in Australia; the most recent study was published in 2013. Gold Coast University Hospital (GCUH) is a level 1 trauma centre in Queensland, Australia. The aim of this study was to describe the epidemiology and outcomes of vascular trauma at a level 1 trauma centre, and compare these with the Australian and international literature.

METHODS

All individuals who presented to GCUH between January 2014 and December 2019 with vascular injury were retrieved from the GCUH prospective trauma database. A descriptive analysis was undertaken on this cohort.

RESULTS

The incidence of vascular trauma as a percentage of total trauma remained stable over the study period. The study included 5454 trauma admissions to GCUH, of which 213 sustained vascular injuries. Males were more likely to be injured and blunt trauma was more common than penetrating. Blunt trauma was associated with increased injury complexity. The mortality rate was 8.5% and 10 patients required amputation.

CONCLUSIONS

The proportion of vascular injuries as a percentage of total trauma in Australia is higher than in previous studies. Vascular trauma causes significant injuries and has a higher mortality rate than general trauma.

Traumatic cerebrovascular injury: clinical characteristics and illustrative cases

OBJECTIVE

Traumatic cerebrovascular injury (TCVI) is a rare and serious complication of traumatic brain injury (TBI). Various forms of TCVIs have been reported, including occlusions, arteriovenous fistulas, pseudoaneurysms, and transections. They can present at a variety of intervals after TBI and may manifest as sudden episodes, progressive symptoms, and even delayed fatal events. The purpose of this study was to analyze cases of TCVI identified at a single institution and further explore types and characteristics of these complications of TBI in order to improve recognition and treatment of these injuries.

METHODS

The authors performed a retrospective review of cases of TCVI identified at their institution between 2013 and 2016. A total of 5178 patients presented with TBI during this time period, and 42 of these patients qualified for a diagnosis of TCVI and had adequate medical and imaging records for analysis. Data from their cases were analyzed, and 3 illustrative cases are presented in detail.

RESULTS

The most common type of TCVI was arteriovenous fistula (86.4%), followed by pseudoaneurysm (11.9%), occlusion (2.4%), and transection (2.4%). The mortality rate of patients with TCVI was 7.1%.

CONCLUSIONS

The authors describe the clinical characteristics of patients with TCVI and provide data from a series of 42 cases. It is important to recognize TCVI in order to facilitate early diagnosis and treatment.

Risk Factors and Outcomes Associated with Blunt Cerebrovascular Injury in Patients with Mild or Moderate Traumatic Brain Injury

BACKGROUND

Blunt cerebrovascular injury (BCVI) represents a spectrum of traumatic injuries to the carotid and vertebral arteries that is an often-overlooked source of morbidity and mortality. Its incidence, risk factors, and effect on outcomes in patients with mild or moderate traumatic brain injury (mTBI) have not been studied independently.

METHODS

The National Trauma Data Bank from 2013 to 2017 was queried to identify patients with mTBI who suffered blunt injuries. BCVI was identified using abbreviated injury scores and included blunt carotid artery injury (BCAI) and blunt vertebral artery injury (BVAI). A binary logistic regression was used to identify patient-related and injury-related factors associated with BCVI. Binary logistic regressions were also performed to evaluate the effect of BCVI on stroke, in-hospital mortality, nonroutine discharge disposition, total length of stay (LOS), intensive care unit LOS, and number of days mechanically ventilated.

RESULTS

Of 485,880 patients with mTBI, there were 4,382 (0.9%) with BCVI. Cervical spine fracture was the strongest factor associated with BCAI (odds ratio [OR], 1.97; 95% confidence interval [95% CI], 1.77-2.19), followed by mandible fracture and basilar skull fracture. Cervical spine fracture also had the strongest association with BVAI (OR, 18.28; 95% CI, 16.47-20.28), followed by spinal cord injury and neck contusion. Stroke was more common in patients with BCAI (OR, 5.50; 95% CI, 4.19-7.21) and BVAI (OR, 7.238; 95% CI, 5.929-8.836). BVAI increased the odds of mortality, but BCAI did not. Both were associated with nonroutine discharge and increased LOS, intensive care unit LOS, and number of days mechanically ventilated.

CONCLUSIONS

The incidence of BCVI in patients with mTBI is low, and it usually does not require invasive treatment. However, it is associated with greater odds of stroke and negative outcomes. Knowledge of risk factors for BCVI may tailor further investigation to aid prompt diagnosis.

Time-dependent hemeoxygenase-1, lipocalin-2 and ferritin induction after non-contusion traumatic brain injury

Traumatic brain injury (TBI) often presents with focal contusion and parenchymal bleeds, activating heme oxygenase (HO) to degrade released hemoglobin. Here we show that diffuse, midline fluid percussion injury causes time-dependent induction of HO-1 and iron binding proteins within both hemorrhagic neocortex and non-hemorrhagic hippocampus. Rats subjected to midline fluid percussion injury (FPI) survived 1-15d postinjury and tissue was collected for Western blot and immunohistochemical assays. HO-1 was elevated 1d after FPI, peaked at 3d, and returned to control baseline 7-15d. Iron management proteins lipocalin 2 (LCN2) and ferritin (FTL) exhibited distinct postinjury time courses, where peak LCN2 response preceded, and FTL followed that of HO-1. LCN2 elevation supported not only its role in iron transport, but also mediation of matrix metalloproteinase 9 (MMP9) activity. Upregulation of FTL for intracellular iron sequestration was delayed relative to both HO-1 and LCN2 induction. In the neocortex IBA-1+ microglia around the injury core expressed HO-1, but astrocytes co-localized with HO-1 in perilesional parenchyma. Non-hemorrhagic dentate gyrus showed predominant HO-1 labeling in hilar microglia and in molecular layer astrocytes. At 1d postinjury, LCN2 and HO-1 co-localized in a subpopulation of reactive glia within both brain regions. Notably, FTL was distributed within cells around injured vessels, damaged subcortical white matter, and along vessels of the hippocampal fissure. Together these results confirm that even the moderate, non-contusional insult of diffuse midline FPI can significantly activate postinjury HO-1 heme processing pathways and iron management proteins. Moreover, this activation is time-dependent and occurs in the absence of overt hemorrhage.

Diagnosis, management and treatment of neck trauma

Trauma injuries to the neck account for 5-10% of all trauma injuries and carry a high rate of morbidity and mortality, as several vital structures can be damaged. Currently, there are several treatment approaches based on initial management by zones, initial management not based on zones and conservative management of selected patients. The objective of this systematic review is to describe the management of neck trauma.

Imaging of Brain Trauma

Conventional imaging in the acute setting of brain trauma, relevant pathophysiology of injury, and advanced imaging techniques that may provide value in understanding the immediate management and long-term sequela of traumatic brain injury are reviewed. Key imaging findings that can guide clinical management related to such injuries as concussions, hematomas, dissections, dural atrioventricular fistula, and diffuse axonal injury are discussed. The role and accuracy of computed tomography, dual-energy computed tomography, computed tomography angiography, and magnetic resonance angiography in the acute setting are evaluated. In addition, caveats related to imaging the elderly and pediatric population are addressed.

Traumatic cerebrovascular injury: Prevalence and risk factors

BACKGROUND

Traumatic cerebrovascular injury (TCVI) is uncommon in traumatic brain injury (TBI). Although TCVI is a rare condition, this complication is serious. A missed or delayed diagnosis may lead to an unexpected life-threatening hemorrhagic event or persistent neurological deficit. The object of this study was to determine the prevalence and risk factors associated with TCVI.

METHODS

The authors retrospectively reviewed medical records and neuroimaging studies of 5178 patients with TBI. The association of various factors was investigated using time-to-event statistical analysis. A TCVI which resulted in an occlusion, arteriovenous fistula, pseudoaneurysm or cerebral artery transection was defined as an event.

RESULTS

Forty-two patients developed a TCVI after injuries with an overall prevalence of 0.8%. The risk factors for an intracranial arterial injury based on univariate analysis using the Cox proportional hazard regression were penetrating injury, severe head injury, orbitofacial injury, basilar skull fracture, subdural hematoma, and cerebral contusion. In multivariable analysis, the two variables that were independently associated with TCVI were basilar skull fracture (odds ratio [OR] 22.1, 95% confidence interval [CI] 11.5-42.2) followed by orbitofacial fracture (OR 13.6, 95% CI 6.8-27.3).

CONCLUSIONS

Although TCVI is a rare complication of TBI, early investigation in high-risk patients may be necessary for early treatment before an unexpected fatal event occurs.

Blunt Traumatic Cervical Vascular Injury Without any Modified Denver Criteria

Blunt traumatic cervical vascular injury (BCVI) is challenging to recognize, but it is a potentially devastating entity that warrants attention from emergency physicians. Injury to the vertebral or carotid artery can result in a delayed manifestation of neurologic injury that may be preventable if promptly recognized and treated. The modified Denver Criteria are frequently used to guide imaging decisions for BCVI; however, injuries can still be missed. We present a case of BCVI in a trauma patient whose initial presentation evaded standard screening criteria, illustrating the need for a high index of suspicion for BCVI in blunt trauma.

Bilateral Carotid and Vertebral Artery Dissection from Blunt Trauma

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).