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Lau KW, Chen CT, Chen CC, Lin TC, Yeap MC, Hsieh PC, Chuang CC, Wang YC, Yang ST, Liu ZH. Clinical outcomes among patients with concurrent blunt cerebrovascular injury and traumatic intracranial hemorrhage. J Neurol Sci 2024; 466:123216. [PMID: 39255590 DOI: 10.1016/j.jns.2024.123216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 07/28/2024] [Accepted: 09/02/2024] [Indexed: 09/12/2024]
Abstract
BACKGROUND Blunt cerebrovascular injury (BCVI) accounts for 1-3 % of patients with blunt trauma, which should be promptly diagnosed and managed due to risk of cerebral infarction and death. Antithrombotic therapy had been proven to reduce risk of stroke and mortality. However, due to concern of hematoma progression, treatment suggestion is still inconclusive for patients with concurrent traumatic intracranial hemorrhage. MATERIALS AND METHODS We performed a retrospective, observational study from 2002 to 2020 at a Level I trauma center, all patients with BCVI and concurrent traumatic intracranial hemorrhage were recruited. Patients' demographics, initial CT findings, severity of BCVI, treatment and outcomes were documented and analyzed to define possible risk factors of death and stroke. RESULTS Among all 57 patients, 49 (86.0 %) patients had injury at ICA, 6 (10.5 %) had VA injury, and 2 (3.5 %) suffered from both. Targeted treatments for BCVI were provided to 33 (57.9 %) patient, mostly endovascular intervention (78.8 %), antithrombotic treatment was given to 11 (19.3 %) patients. At 3-month follow-up, 17 (29.8 %) patients expired, and 18 (31.6 %) patients had cerebral infarction due to BCVI. We identified more severe initial CT findings (p = 0.016), higher head Abbreviated Injury Scale (p = 0.049) and initial life-threatening events (p = 0.047) as risk factors of death, and traumatic basal cistern subarachnoid hemorrhage(SAH) (p = 0.040) as single risk factor of cerebral infarction. CONCLUSIONS Around one-thirds of patients with concurrent BCVI and traumatic intracranial hemorrhage were death or suffered from cerebral infarction within 3 months, with severity of initial head injury and SAH at basal cistern as risk factors, respectively.
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Affiliation(s)
- Ka-Wei Lau
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Chun-Ting Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Ching-Chang Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Tzu-Chin Lin
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Mun-Chun Yeap
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Po-Chuan Hsieh
- Department of Neurosurgery, New Taipei Municipal Tucheng Hospital (Built and Operated by Chang Gung Medical Foundation), New Taipei, Taiwan
| | - Chi-Cheng Chuang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Yu-Chi Wang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Shun-Tai Yang
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan; Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Zhuo-Hao Liu
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan; School of Medicine, National Tsing Hua University, Hsinchu, Taiwan.
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Bai J, Ismail R, Kessler A, Kawakyu-O'Connor D. Imaging of cerebrovascular complications from blunt skull base trauma. Emerg Radiol 2024; 31:529-542. [PMID: 38806851 PMCID: PMC11289000 DOI: 10.1007/s10140-024-02243-z] [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: 04/16/2024] [Accepted: 05/13/2024] [Indexed: 05/30/2024]
Abstract
Cerebrovascular complications from blunt trauma to the skull base, though rare, can lead to potentially devastating outcomes, emphasizing the importance of timely diagnosis and management. Due to the insidious clinical presentation, subtle nature of imaging findings, and complex anatomy of the skull base, diagnosing cerebrovascular injuries and their complications poses considerable challenges. This article offers a comprehensive review of skull base anatomy and pathophysiology pertinent to recognizing cerebrovascular injuries and their complications, up-to-date screening criteria and imaging techniques for assessing these injuries, and a case-based review of the spectrum of cerebrovascular complications arising from skull base trauma. This review will enhance understanding of cerebrovascular injuries and their complications from blunt skull base trauma to facilitate diagnosis and timely treatment.
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Affiliation(s)
- James Bai
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA.
- School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 648, 14642, Rochester, NY, USA.
| | - Rahim Ismail
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Alex Kessler
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
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3
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Kelley W, Zreik K, Gergen A, Williams J, Jacobson LE, Nahmias J, Tatar A, Murry J, Grigorian A, Ong A, Stein DM, Scalea TM, Lauerman MH. Early Pharmacologic Therapy in Patients With Blunt Cerebrovascular Injury and TBI: Is it Safe and Effective? An EAST Multicenter Study. Am Surg 2024; 90:1330-1337. [PMID: 38253324 DOI: 10.1177/00031348241230094] [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: 01/24/2024]
Abstract
BACKGROUND Blunt cerebrovascular injury (BCVI) with concurrent traumatic brain injury (TBI) presents increased risk of both ischemic stroke and bleeding. This study investigated the safety and survival benefit of BCVI treatment (antithrombotic and/or anticoagulant therapy) in this population. We hypothesized that treatment would be associated with fewer and later strokes in patients with BCVI and TBI without increasing bleeding complications. METHODS Patients with head AIS >0 were selected from a database of BCVI patients previously obtained for an observational trial. A Kaplan-Meier analysis compared stroke survival in patients who received BCVI treatment to those who did not. Logistic regression was used to evaluate for confounding variables. RESULTS Of 488 patients, 347 (71.1%) received BCVI treatment and 141 (28.9%) did not. BCVI treatment was given at a median of 31 h post-admission. BCVI treatment was associated with lower stroke rate (4.9% vs 24.1%, P < .001 and longer stroke-free survival (P < .001), but also less severe systemic injury. Logistic regression identified motor GCS and BCVI treatment as the only predictors of stroke. No patients experienced worsening TBI because of treatment. DISCUSSION Patients with BCVI and TBI who did not receive BCVI treatment had an increased rate of stroke early in their hospital stay, though this effect may be confounded by worse motor deficits and systemic injuries. BCVI treatment within 2-3 days of admission may be safe for patients with mean head AIS of 2.6. Future prospective trials are needed to confirm these findings and determine optimal timing of BCVI treatment in TBI patients with BCVI.
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Affiliation(s)
- William Kelley
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Khaled Zreik
- Department of Surgery, Sanford Health, Sioux Falls, SD, USA
| | - Anna Gergen
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA
| | - Jamie Williams
- Department of Surgery, Ascension St. Vincent Hospital, Indianapolis, IN, USA
| | - Lewis E Jacobson
- Department of Surgery, Ascension St. Vincent Hospital, Indianapolis, IN, USA
| | - Jeffry Nahmias
- Department of Surgery, University of California - Irvine, Irvine, CA, USA
| | - Anthony Tatar
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jason Murry
- Department of Surgery, UT Health Tyler, Tyler, TX, USA
| | - Areg Grigorian
- Department of Surgery, University of California - Irvine, Irvine, CA, USA
| | - Adrian Ong
- Department of Surgery, Towerhealth, West Reading, PA, USA
| | - Deborah M Stein
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas M Scalea
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Margaret H Lauerman
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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Cutts L, Gray C, Gill N, Horner D. Best Evidence Topic report: Antithrombotic therapy and endovascular intervention for blunt cerebrovascular injury. Emerg Med J 2024; 41:337-339. [PMID: 38360063 DOI: 10.1136/emermed-2023-213815] [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: 02/17/2024]
Abstract
A short cut review of the literature was carried out to examine the evidence supporting antithrombotic treatment and/or endovascular therapy to reduce mortality and/or prevent future stroke following blunt cerebrovascular injury (BCVI). Five papers were identified as suitable for inclusion using the reported search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. It is concluded that in patients with BCVI confirmed by CT angiography, there is limited evidence to support screening for, or treating BCVI. In confirmed BCVI where the risk of stroke is felt to outweigh the risk of bleeding, antiplatelet therapy appears to be as effective as therapeutic anticoagulation.
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Affiliation(s)
- Luke Cutts
- Critical Care Department, Northern Care Alliance NHS Foundation Trust, Salford, Manchester, UK
| | - Chris Gray
- Emergency Department, Manchester University NHS Foundation Trust, Manchester, UK
| | - Navdeep Gill
- Critical Care Department, Northern Care Alliance NHS Foundation Trust, Salford, Manchester, UK
| | - Daniel Horner
- Critical Care Department, Northern Care Alliance NHS Foundation Trust, Salford, Manchester, UK
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
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Findlay MC, Sarriera-Valentin G, Earl ER, Cole KL, Hamrick FA, Baradaran H, Cortez J, Lombardo S, Nunez J, Kilburg C, Grandhi R, Menacho ST. Management Patterns and Outcomes After Traumatic Brain Injury With Associated Blunt Cerebrovascular Injury. Neurosurgery 2024; 94:340-349. [PMID: 37721436 DOI: 10.1227/neu.0000000000002688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/27/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Although blunt cerebrovascular injuries (BCVIs) are relatively common in patients with traumatic brain injuries (TBIs), uncertainty remains regarding optimal management strategies to prevent neurological complications, morbidity, and mortality. Our objectives were to characterize common care patterns; assess the prevalence of adverse outcomes, including stroke, functional deficits, and death, by BCVI grade; and evaluate therapeutic approaches to treatment in patients with BCVI and TBI. METHODS Patients with TBI and BCVI treated at our Level I trauma center from January 2016 to December 2020 were identified. Presenting characteristics, treatment, and outcomes were captured for univariate and multivariate analyses. RESULTS Of 323 patients with BCVI, 145 had Biffl grade I, 91 had grade II, 49 had grade III, and 38 had grade IV injuries. Lower-grade BCVIs were more frequently managed with low-dose (81 mg) aspirin ( P < .01), although all grades were predominantly treated with high-dose (150-600 mg) aspirin ( P = .10). Patients with low-grade BCVIs had significantly fewer complications ( P < .01) and strokes ( P < .01). Most strokes occurred in the acute time frame (<24 hours), including 10/11 (90.9%) grade IV-related strokes. Higher BCVI grade portended elevated risk of stroke (grade II odds ratio [OR] 5.3, grade III OR 12.2, and grade IV OR 19.6 compared with grade I; all P < .05). The use of low- or high-dose aspirin was protective against mortality (both OR 0.1, P < .05). CONCLUSION In patients with TBI, BCVIs impart greater risk for stroke and other associated morbidities as their severity increases. It may prove difficult to mitigate high-grade BCVI-related stroke, considering most events occur in the acute window. The paucity of late time frame strokes suggest that current management strategies do help mitigate risks.
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Affiliation(s)
| | | | - Emma R Earl
- School of Medicine, University of Utah, Salt Lake City , Utah , USA
| | - Kyril L Cole
- School of Medicine, University of Utah, Salt Lake City , Utah , USA
| | - Forrest A Hamrick
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Hediyeh Baradaran
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City , Utah , USA
| | - Janet Cortez
- Department of Surgery, University of Utah, Salt Lake City , Utah , USA
| | - Sarah Lombardo
- Department of Surgery, University of Utah, Salt Lake City , Utah , USA
| | - Jade Nunez
- Department of Surgery, University of Utah, Salt Lake City , Utah , USA
| | - Craig Kilburg
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Sarah T Menacho
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
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Mäkitie RE, Nyman K, Ilmarinen T, Tapiovaara L. Changes in occurrence and management of laryngeal fractures at the Helsinki University Hospital during 25 years. Eur Arch Otorhinolaryngol 2024; 281:915-924. [PMID: 37923860 PMCID: PMC10796824 DOI: 10.1007/s00405-023-08298-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/17/2023] [Indexed: 11/06/2023]
Abstract
PURPOSE Laryngeal fracture is a rare but potentially life-threatening trauma. Fractures vary from mild to dislocated and extensive with risk of severe complications. This study investigated the occurrence, clinical characteristics and management of laryngeal fractures in the last 15 years. MATERIAL AND METHODS A retrospective population-based cohort study reviewing all laryngeal fractures at the Helsinki University Hospital in 2005-2019. Patient records and imaging studies were systematically reviewed for mode of injury, fracture type, secondary complications, treatment modality, possible airway management, length of stay, and mortality. Results were compared with corresponding data from 1995 to 2004. RESULTS Overall 80 fracture patients were recorded (5.3/year); 79% were men and mean age was 42 years (range 18-78). Altogether 91% were closed and 9% open. While unintentional traumas were most common (54%), an increasing proportion were from intentional injury (10%) or Schaefer Gr IV in severity (35%). Altogether 46% had compromised airway and 21% needed airway intervention; airway narrowing was more common with cricoid (p = 0.042) and multiple fractures (p = 0.07) and correlated positively with amount of dislocation (p = 0.001) and number of fracture lines (p = 0.006). Surgery was performed for 33%, of which 46% were Schaefer Gr IV and 62% from intentional trauma. Mortality was 1.4%. CONCLUSIONS Deliberate and violence-related laryngeal fractures have increased. These often result in more extensive injuries predisposing to compromised airway and requiring surgical intervention and longer treatment. Most fractures are still treated conservatively with good long-term outcomes. An observation period of 24 h is recommended to detect any delayed complications. Mortality remains low.
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Affiliation(s)
- Riikka E Mäkitie
- Department of Otorhinolaryngology-Head and Neck Surgery, Head and Neck Center, Helsinki University Hospital and University of Helsinki, Kasarmikatu 11-13, FI-00029, Helsinki, Finland.
- Clinicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland.
| | - Kristofer Nyman
- Radiology, HUS Diagnostic Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Taru Ilmarinen
- Department of Otorhinolaryngology-Head and Neck Surgery, Head and Neck Center, Helsinki University Hospital and University of Helsinki, Kasarmikatu 11-13, FI-00029, Helsinki, Finland
| | - Laura Tapiovaara
- Department of Otorhinolaryngology-Head and Neck Surgery, Head and Neck Center, Helsinki University Hospital and University of Helsinki, Kasarmikatu 11-13, FI-00029, Helsinki, Finland
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Ardeshna S, Esposito E, Spalding C, Dunn J, Nahmias J, Grigorian A, Harmon L, Gergen A, Young A, Pascual J, Murry J, Ong A, Appelbaum R, Bugaev N, Tatar A, Zreik K, Scalea TM, Stein D, Lauerman M. Which Patients Receive Diagnostic Angiography? An EAST Multicenter Study Analysis of Internal Carotid Artery Blunt Cerebrovascular Injury. Am Surg 2023; 89:5183-5190. [PMID: 36417771 DOI: 10.1177/00031348221138083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Digital subtraction angiography (DSA) is the gold standard radiologic modality in blunt cerebrovascular injury (BCVI). However, computerized tomography angiography (CTA) is primarily used in modern practice with CTA's widespread availability and the decreased stroke rate with CTA use. The frequency and indications for DSA in BCVI is undefined. We hypothesized that DSA use in internal carotid artery (ICA) BCVI would be infrequent and dependent on radiologic features. METHODS This was a post hoc analysis of an EAST multicenter, prospective, observational trial of 16 trauma centers for stroke factors in BCVI. ICA BCVI was divided into those undergoing DSA and not undergoing DSA (no-DSA). Only ICA BCVI was included. RESULTS 332 ICA BCVI were included, 221 (66.6%) no-DSA and 111 (33.4%) DSA. Lower hospital trauma volume, non-urban environment, and non-academic status were associated with DSA use (all P ≤ .001). BCVI grade (P = .02) and presence of luminal stenosis (P = .005) were associated with DSA use while pseudoaneurysm presence was not. Median time to DSA was 1 hour. The most common indication for angiography was to determine the presence of injury in 71 (64%) ICA BCVI, followed by determining grade of injury in 16 (14.4%) and concerning imaging characteristics in 12 (10.8%). BCVI grade on initial imaging and on DSA were equivalent in 94 (84.7%) ICA BCVI. DISCUSSION DSA is frequently used in ICA BCVI, primarily early in the hospital course for injury diagnosis and grade determination. DSA appears primarily driven by hospital type, BCVI grade, and luminal stenosis.
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Affiliation(s)
| | | | | | - Julie Dunn
- University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | | | | | | | - Anna Gergen
- University of Colorado Denver, Denver, CO, USA
| | - Andrew Young
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jose Pascual
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | | | - Rachel Appelbaum
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Antony Tatar
- Tufts University School of Medicine, Boston, MA, USA
| | | | | | - Deborah Stein
- R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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Ucaroglu ER, Tahtabasi M. Surgical Treatment of Extracranial Internal Carotid Artery Pseudoaneurysm in an Infant Due to Falling from Height: An Unusual Case. Int Med Case Rep J 2023; 16:667-672. [PMID: 37840971 PMCID: PMC10576563 DOI: 10.2147/imcrj.s433360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/04/2023] [Indexed: 10/17/2023] Open
Abstract
Pseudoaneurysms of the internal carotid artery (ICA) caused by non-penetrating trauma are extremely rare. Patients with ICA pseudoaneurysms may present with cerebral ischemia, cervical masses, neck swelling, hematoma, rupture, pain, or cranial nerve dysfunction. We present a case of a left ICA pseudoaneurysm that developed in a 7-month-old infant because of a fall from height. The patient developed left-sided neck swelling that caused severe airway obstruction and respiratory arrest. The patient was urgently intubated and underwent emergency surgery under general anesthesia to repair the defect in the left ICA. Primary repair was performed to treat the pseudoaneurysms. The pseudoaneurysm sac was not removed because it was complicated and had extended into the respiratory tract. The patient was extubated on the 2nd day and discharged on the 7th day without complications. Follow-up of the patient after two weeks was unremarkable. Extracranial ICA pseudoaneurysms should be identified in patients presenting with blunt trauma. Emergency surgery should be considered for patients with progressive pseudoaneurysms.
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Affiliation(s)
- Erhan Renan Ucaroglu
- Department of Cardiovascular Surgery, University of Health Sciences- Somalia Turkey Recep Tayyip Erdogan Education and Research Hospital, Mogadishu, Somalia
| | - Mehmet Tahtabasi
- Department of Radiology, University of Health Sciences- Somalia Turkey Recep Tayyip Erdogan Education and Research Hospital, Mogadishu, Somalia
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Tanburoglu A, Andic C. Endovascular Treatment of Vascular Injuries in the Craniocervical Region With a Graft Stent: A Single-Center Experience. Cureus 2023; 15:e47323. [PMID: 37869052 PMCID: PMC10586528 DOI: 10.7759/cureus.47323] [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: 10/19/2023] [Indexed: 10/24/2023] Open
Abstract
AIM We aimed to evaluate the efficacy and safety of graft stent implantation in the endovascular treatment of vascular injuries in the craniocervical area. MATERIALS AND METHODS This study was carried out through the retrospective screening of eight (two females and six males) patients' records. Patients who used graft stents as an endovascular method were included in the study. The mean age of the patients was 43.6 years (with a range of 15-69 years). Due to different mechanisms, the patients had vascular injuries in the craniocervical region, and graft stent implantation was performed between 2010 and 2022. We evaluated patient demographics, admission symptoms, trauma mechanisms, angiographic findings, treatment modalities and materials, patient outcomes, and follow-up periods. RESULTS Due to iatrogenesis for four patients, penetrating trauma for three patients, and blunt trauma for one patient, injuries were present in the right internal carotid artery {ICA} (n=1), left ICA (n=1), left common carotid artery {CCA} (n=3), right CCA (n=1), right vertebral artery (n=1), and left vertebral artery (n=1). Angiographically, pseudoaneurysm was detected in seven patients, and vascular rupture was detected in one patient using contrast agent extravasation. All patients who underwent the endovascular method had technical success. Since bleeding from the external carotid artery branches was seen in two patients, these branches were embolized with coils. No radiologically or neurologically pathological findings were recorded during the follow-up period (with a range of one week to 12 years). CONCLUSION Graft stent use in the endovascular treatment of craniocervical vascular injuries is an operable, safe, and promising option, especially in patients with pseudoaneurysms and active bleeding.
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Affiliation(s)
| | - Cagatay Andic
- Interventional Radiology, Faculty of Medicine, Baskent University, Adana, TUR
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10
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D'Souza K, Norman M, Rebchuk AD, Samarasinghe N, Hounjet CD, Griesdale DE, Joos E, Field TS. Efficacy of Antithrombotic Therapy and Risk of Hemorrhagic Complication in Blunt Cerebrovascular Injury Patients with Concomitant Injury: A Systematic Review. J Am Coll Surg 2023; 237:663-672. [PMID: 37222430 DOI: 10.1097/xcs.0000000000000771] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND The risk-benefit balance of antithrombotic therapy administration for blunt cerebrovascular injuries (BCVI) patients with concomitant injuries at high risk for bleeding is an ongoing therapeutic conundrum for trauma clinicians. We performed a systematic review to assess the reported efficacy and safety of treatment in this population with respect to prevention of ischemic stroke and risk of hemorrhagic complications. STUDY DESIGN A systematic electronic literature search of MEDLINE, EMBASE, Cochrane Library, and Web of Science databases was performed from January 1, 1996 to December 31, 2021. Studies were included if they reported treatment-stratified clinical outcomes after antithrombotic therapy in BCVI patients with concomitant injuries at high risk of bleeding into a critical site. Data were extracted from selected studies by two independent reviewers, including the main outcomes of interest were BCVI-related ischemic stroke rates and rates of hemorrhagic complications. RESULTS Of the 5,999 studies reviewed, 10 reported on the effects of treating BCVI patients with concurrent traumatic injuries and were included for review. In the pooled data, among patients with BCVI and concomitant injury who received any form of antithrombotic therapy, the BCVI-related stroke rate was 7.6%. The subgroup of patients who did not receive therapy had an overall BCVI-related stroke rate of 34%. The total rate of hemorrhagic complications in the treated population was 3.4%. CONCLUSIONS In BCVI patients with concomitant injuries at high risk for bleeding, antithrombotic use reduces the risk of ischemic strokes with a low reported risk of serious hemorrhagic complications.
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Affiliation(s)
- Karan D'Souza
- From the Section of Acute Care Surgery and Trauma, Division of General Surgery (D'Souza, Samarasinghe, Joos), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mathew Norman
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Alexander D Rebchuk
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Neurosurgery, Department of Surgery (Rebchuk, Hounjet), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nadeesha Samarasinghe
- From the Section of Acute Care Surgery and Trauma, Division of General Surgery (D'Souza, Samarasinghe, Joos), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Celine D Hounjet
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Neurosurgery, Department of Surgery (Rebchuk, Hounjet), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Donald Eg Griesdale
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Critical Care Medicine (Griesdale), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Emilie Joos
- From the Section of Acute Care Surgery and Trauma, Division of General Surgery (D'Souza, Samarasinghe, Joos), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Thalia S Field
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Vancouver Stroke Program, Division of Neurology (Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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Hirota S, Takahashi S, Yoshimura M, Hirai S, Takei T, Orihara A, Sagawa H, Wakabayashi H, Fuji S, Yamamoto S, Sumita K. Mechanical Thrombectomy and Parent Artery Occlusion for Acute Basilar Artery Occlusion Due to Vertebral Fracture and Artery Dissection: A Case Report. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:286-292. [PMID: 38125961 PMCID: PMC10730297 DOI: 10.5797/jnet.cr.2023-0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/13/2023] [Indexed: 12/23/2023]
Abstract
Objective Basilar artery occlusion (BAO) secondary to traumatic vertebral artery (VA) dissection caused by vertebral fracture is a rare cause of acute ischemic stroke, and optimal management, such as antithrombotic agents, surgical fixation, and parent artery occlusion (PAO), has been controversial. We report a case in which mechanical thrombectomy and PAO were performed for a BAO due to right VA dissection caused by a transverse foramen fracture of the axis vertebra. Case Presentation A patient in her 80s suffered from a backward fall, and a neck CT revealed a fracture and dislocation of the right lateral mass of the axis and a compressed transverse foramen. The patient was instructed to admit and to remain in bed rest; however, she suddenly lost consciousness the following day. The CTA revealed right VA occlusion and BAO; therefore, the patient underwent mechanical thrombectomy and the BAO was successfully reperfused but the VA stenotic dissection remained. PAO of the right VA was performed on the fifth day after the accident to prevent BAO recurrence. Conclusion Mechanical thrombectomy is an effective treatment for BAO caused by VA dissection, and PAO may contribute to the prevention of stroke recurrence.
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Affiliation(s)
- Shin Hirota
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Satoru Takahashi
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masataka Yoshimura
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Sakyo Hirai
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takamaro Takei
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Asumi Orihara
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Hirotaka Sagawa
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hikaru Wakabayashi
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shoko Fuji
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Shinji Yamamoto
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Kazutaka Sumita
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
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12
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Ferrete-Araujo AM, Godoy DA, Murillo-Cabezas F. Vascular injury of the supra-aortic trunks in patients with traumatic brain injury. Med Intensiva 2023:S2173-5727(23)00015-2. [PMID: 36966042 DOI: 10.1016/j.medine.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2023]
Affiliation(s)
- Ana María Ferrete-Araujo
- Unidad de Neurocríticos, Servicio de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Seville, Spain; Departamento de Medicina, Facultad de Medicina, Instituto de Biomedicina de Sevilla (IBiS)/Centro de Investigaciones Científicas (CSIC)/Universidad de Sevilla, Seville, Spain.
| | - Daniel A Godoy
- Unidad de Cuidados Neurointensivos, Sanatorio Pasteur, San Fernando del Valle de Catamarca, Catamarca, Argentina; Unidad de Terapia Intensiva, Hospital San Juan Bautista, San Fernando del Valle de Catamarca, Catamarca, Argentina
| | - Francisco Murillo-Cabezas
- Departamento de Medicina, Facultad de Medicina, Instituto de Biomedicina de Sevilla (IBiS)/Centro de Investigaciones Científicas (CSIC)/Universidad de Sevilla, Seville, Spain
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13
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Lesión vascular de los troncos supraaórticos en pacientes con traumatismo craneoencefálico. Med Intensiva 2023. [DOI: 10.1016/j.medin.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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14
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Lauzier D, Chatterjee A, Kansagra A. Neurointerventional management of cerebrovascular trauma. UKRAINIAN INTERVENTIONAL NEURORADIOLOGY AND SURGERY 2022. [DOI: 10.26683/2786-4855-2022-2(40)-41-54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Traumatic cerebrovascular injuries following blunt or penetrating trauma are common and carry a high risk of permanent disability or death. Proper screening, diagnosis, and treatment of these lesions is essential to improve patient outcomes. Advances in imaging continue to improve the accuracy of non-invasive diagnosis of these injuries while new clinical data provide better evidence for optimal management, whether medical or invasive. Here, we review screening, diagnosis, and treatment of traumatic cerebrovascular injuries.
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15
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Cerebrovascular injuries in traumatic brain injury. Clin Neurol Neurosurg 2022; 223:107479. [DOI: 10.1016/j.clineuro.2022.107479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/22/2022] [Accepted: 10/13/2022] [Indexed: 11/19/2022]
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16
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Appelbaum RD, Esposito E, Spaulding MC, Simpson JP, Dunn J, Zier LB, Burruss S, Kim PP, Jacobson LE, Williams JM, Nahmias J, Grigorian A, Harmon L, Gergen AK, Chatoor M, Rattan R, Young AJ, Pascual JL, Murry J, Ong AW, Muller A, Sandhu RS, Bugaev N, Tatar A, Zreik K, Lieser MJ, Stein DM, Scalea TM, Lauerman MH. Does treatment delay for blunt cerebrovascular injury affect stroke rate?: An EAST multicenter study. Injury 2022; 53:3702-3708. [PMID: 36085175 DOI: 10.1016/j.injury.2022.08.043] [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] [Received: 03/02/2022] [Revised: 08/13/2022] [Accepted: 08/16/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this study was to analyze injury characteristics and stroke rates between blunt cerebrovascular injury (BCVI) with delayed vs non-delayed medical therapy. We hypothesized there would be increased stroke formation with delayed medical therapy. METHODS This is a sub-analysis of a 16 center, prospective, observational trial on BCVI. Delayed medial therapy was defined as initiation >24 hours after admission. BCVI which did not receive medical therapy were excluded. Subgroups for injury presence were created using Abbreviated Injury Scale (AIS) score >0 for AIS categories. RESULTS 636 BCVI were included. Median time to first medical therapy was 62 hours in the delayed group and 11 hours in the non-delayed group (p < 0.001). The injury severity score (ISS) was greater in the delayed group (24.0 vs the non-delayed group 22.0, p < 0.001) as was the median AIS head score (2.0 vs 1.0, p < 0.001). The overall stroke rate was not different between the delayed vs non-delayed groups respectively (9.7% vs 9.5%, p = 1.00). Further evaluation of carotid vs vertebral artery injury showed no difference in stroke rate, 13.6% and 13.2%, p = 1.00 vs 7.3% and 6.5%, p = 0.84. Additionally, within all AIS categories there was no difference in stroke rate between delayed and non-delayed medical therapy (all N.S.), with AIS head >0 13.8% vs 9.2%, p = 0.20 and AIS spine >0 11.0% vs 9.3%, p = 0.63 respectively. CONCLUSIONS Modern BCVI therapy is administered early. BCVI with delayed therapy were more severely injured. However, a higher stroke rate was not seen with delayed therapy, even for BCVI with head or spine injuries. This data suggests with competing injuries or other clinical concerns there is not an increased stroke rate with necessary delays of medical treatment for BCVI.
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Affiliation(s)
| | - Emily Esposito
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Deborah M Stein
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine
| | - Margaret H Lauerman
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine
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17
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Zheng B, Luo X, Zhou J, Huang X, Li M, Zheng H, Yuan Y, Wang J. Case report: Acute ischemic stroke caused by intracranial artery dissection in a patient with skull fractures. Front Neurol 2022; 13:963396. [DOI: 10.3389/fneur.2022.963396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
Abstract
The intracranial artery dissection (IAD) is an uncommon but life-threatening disease. The IAD would develop a significant cerebral infarction due to unrecognized contrecoup brain injury. We report a 53-year-old man fell to develop blunt cerebrovascular injuries (BCVIs) more than 2 months ago. During his rehabilitation, he often had a transient left headache and underwent short-term right limb weakness twice, but he did not care. He was hospitalized again because of suffering right limb weakness for more than 4 h. The brain computed tomography angiography (CTA) showed subtotal occlusion of the left middle cerebral artery M1 segment, and the vascular morphology displayed the IAD. The patient was then treated with balloon dilation and a self-expanding stent. This case highlights that IAD may show delayed onset with no initial typical symptom. By early detecting of abnormal signs and symptoms, serious traumatic brain injury may be avoided.
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18
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Nursing Method of Patients with Severe Traumatic Brain Injury and Fracture in the Ambulance. BIOMED RESEARCH INTERNATIONAL 2022; 2022:2652916. [PMID: 36119922 PMCID: PMC9473891 DOI: 10.1155/2022/2652916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/08/2022] [Accepted: 08/20/2022] [Indexed: 11/17/2022]
Abstract
Craniocerebral injury accounts for 9%-21% of the injuries in all parts of the body, and the incidence rate ranks first in all types of trauma or only lower than limb fractures. This study mainly discusses the nursing methods of patients with severe traumatic brain injury and fractures in ambulances. This study is based on risk factors with moderate-to-higher association strength from retrospective studies. According to the regression coefficients of the logistic regression model, the risk factors were assigned, and the early warning score table of craniocerebral injury complicated with hyponatremia was established. The energy efficiency of the early warning score table was evaluated by case diagnostic test and ROC analysis. At the same time, risk grading is carried out, and the chi-square test is used to test the reliability of the grading standard, so as to identify the risk of hyponatremia in patients with craniocerebral injury early and screen out high-risk patients as the key observation objects of nurses. Based on the early warning score table of craniocerebral injury complicated with hyponatremia, different systematic nursing intervention measures were taken for low-risk patients and high-risk patients, and their application effects were evaluated. The clinical application effect of the systematic nursing intervention program was evaluated by the historical control research method, which provided a reference for the nursing in the ambulance to prevent other complications of patients with craniocerebral injury. The positive rate of prehospital operation can reach 64.44%, and the specific rate can reach 84.44%. 60% of the sample sought better metastatic care in terms of the purpose of using an ambulance. The systematic nursing intervention program has a certain effect on reducing the incidence of hyponatremia in patients with craniocerebral injury and shortening the hospitalization time of patients with craniocerebral injury. The early warning score of craniocerebral injury complicated with hyponatremia developed in this study is concise and practical and can provide a basis for clinical assessment of the risk of hyponatremia in patients with craniocerebral injury.
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19
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Vierunen RM, Haapamäki VV, Koivikko MP, Bensch FV. Ankylosis of the cervical spine increases the incidence of blunt cerebrovascular injury (BCVI) in CTA screening after blunt trauma. Emerg Radiol 2022; 29:507-517. [PMID: 35296926 PMCID: PMC9123032 DOI: 10.1007/s10140-022-02022-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 01/10/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE To examine the incidence, location, and grade of blunt cerebrovascular injury (BCVI), as well as associated strokes in patients with ankylosis of the cervical spine, imaged with CT angiography (CTA) after blunt trauma. The related etiologies of ankylosis had an additional focus. MATERIALS AND METHODS Altogether of 5867 CTAs of the craniocervical arteries imaged after blunt trauma between October 2011 and March 2020 were manually reviewed for a threshold value of ankylosis of at least three consecutive cervical vertebrae. BCVI was the primary outcome and associated stroke as the secondary outcome. Variables were craniofacial and cervical spine fractures, etiology and levels of ankylosis, traumatic brain injury, spinal hematoma, spinal cord injury, and spinal cord impingement, for which correlations with BCVI were examined. RESULTS Of the 153 patients with ankylosis and blunt trauma of the cervical spine, 29 had a total of 36 BCVIs, of whom two had anterior and 4 posterior circulation strokes. Most of the BCVIs (n = 32) were in the vertebral arteries. Injuries were graded according to the Biffl scale: 17 grade II, 4 grade III, 14 grade IV, and 1 grade V. A ground-level fall was the most common trauma mechanism. Cervical spine fracture was the only statistically significant predictor for BCVI (OR 7.44). Degenerative spondylosis was the most prevalent etiology for ankylosis. CONCLUSION Ankylosis of the cervical spine increases the incidence of BCVI up to sevenfold compared to general blunt trauma populations, affecting especially the vertebral arteries.
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Affiliation(s)
- Riku M Vierunen
- Department of Radiology, Helsinki University and Helsinki University Hospital, Töölö Hospital, Topeliuksenkatu 5, FIN-00029, Helsinki, Finland.
| | - Ville V Haapamäki
- Department of Radiology, Helsinki University and Helsinki University Hospital, Töölö Hospital, Topeliuksenkatu 5, FIN-00029, Helsinki, Finland
| | - Mika P Koivikko
- Department of Radiology, Helsinki University and Helsinki University Hospital, Töölö Hospital, Topeliuksenkatu 5, FIN-00029, Helsinki, Finland
| | - Frank V Bensch
- Department of Radiology, Helsinki University and Helsinki University Hospital, Töölö Hospital, Topeliuksenkatu 5, FIN-00029, Helsinki, Finland
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20
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Endovascular and Antithrombotic Treatment in Blunt Cerebrovascular Injuries: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2022; 31:106456. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 11/22/2022] Open
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21
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Current Concepts in Imaging Diagnosis and Screening of Blunt Cerebrovascular Injuries. Tomography 2022; 8:402-413. [PMID: 35202198 PMCID: PMC8877014 DOI: 10.3390/tomography8010033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/16/2022] [Accepted: 01/29/2022] [Indexed: 11/21/2022] Open
Abstract
Blunt cerebrovascular injury (BCVI) is an often underrecognized injury occurring in the carotid or vertebral arteries, associated with a risk of ischemic stroke and potential for poor neurological outcome or death. Computed tomographic angiography (CTA) is the most common modality for initial screening and diagnosis. Vessel wall intimal injuries, intraluminal thrombus, dissection, intramural hematoma, pseudoaneurysm, vessel transection, and arteriovenous fistula, are potential findings to be considered in approach to imaging. Identification of high-risk trauma patients based on clinical and radiological risk factors can determine patients at risk of BCVI for targeted screening.
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22
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Esposito EC, Kufera JA, Wolff TW, Spalding MC, Simpson J, Dunn JA, Zier L, Burruss S, Kim P, Jacobson LE, Williams J, Nahmias J, Grigorian A, Harmon L, Gergen A, Chatoor M, Rattan R, Young AJ, Pascual JL, Murry J, Ong AW, Muller A, Sandhu RS, Appelbaum R, Bugaev N, Tatar A, Zreik K, Hustad L, Lieser MJ, Stein DM, Scalea TM, Lauerman MH. Factors associated with stroke formation in blunt cerebrovascular injury: An EAST multicenter study. J Trauma Acute Care Surg 2022; 92:347-354. [PMID: 34739003 DOI: 10.1097/ta.0000000000003455] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Stroke risk factors after blunt cerebrovascular injury (BCVI) are ill-defined. We hypothesized that factors associated with stroke for BCVI would include medical therapy (i.e., Aspirin), radiographic features, and protocolization of care. METHODS An Eastern Association for the Surgery of Trauma-sponsored, 16-center, prospective, observational trial was undertaken. Stroke risk factors were analyzed individually for vertebral artery (VA) and internal carotid artery (ICA) BCVI. Blunt cerebrovascular injuries were graded on the standard 1 to 5 scale. Data were from the initial hospitalization only. RESULTS Seven hundred seventy-seven BCVIs were included. Stroke rate was 8.9% for all BCVIs, with an 11.7% rate of stroke for ICA BCVI and a 6.7% rate for VA BCVI. Use of a management protocol (p = 0.01), management by the trauma service (p = 0.04), antiplatelet therapy over the hospital stay (p < 0.001), and Aspirin therapy specifically over the hospital stay (p < 0.001) were more common in ICA BCVI without stroke compared with those with stroke. Antiplatelet therapy over the hospital stay (p < 0.001) and Aspirin therapy over the hospital stay (p < 0.001) were more common in VA BCVI without stroke than with stroke. Percentage luminal stenosis was higher in both ICA BCVI (p = 0.002) and VA BCVI (p < 0.001) with stroke. Decrease in percentage luminal stenosis (p < 0.001), resolution of intraluminal thrombus (p = 0.003), and new intraluminal thrombus (p = 0.001) were more common in ICA BCVI with stroke than without, while resolution of intraluminal thrombus (p = 0.03) and new intraluminal thrombus (p = 0.01) were more common in VA BCVI with stroke than without. CONCLUSION Protocol-driven management by the trauma service, antiplatelet therapy (specifically Aspirin), and lower percentage luminal stenosis were associated with lower stroke rates, while resolution and development of intraluminal thrombus were associated with higher stroke rates. Further research will be needed to incorporate these risk factors into lesion specific BCVI management. LEVEL OF EVIDENCE Prognostic and Epidemiologic, Level IV.
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Affiliation(s)
- Emily C Esposito
- From the University of Maryland School of Medicine (E.E., J.A.K., T.M.S., M.H.L.), Baltimore, Maryland; Ohio State University Wexner Medical Center (T.W.W., M.C.S., A.J.Y.), Columbus, Ohio; Greenville Health System (J.S.), Greenville, South Carolina; University of Colorado (J.A.D., L.Z., La.H., An.G.), Boulder, Colorado; Loma Linda University (S.B., P.K.)., Loma Linda, California; Ascension Health (L.E.J., J.W.), St. Louis, Missouri; University of California (J.N., Ar.G.), Oakland, California; University of Miami (M.C., R.R.), Miami, Florida; Perelman School of Medicine at the University of Pennsylvania (J.L.P.), Philadelphia, Pennsylvania; UT Health Tyler (J.M.), Tyler, Texas; Towerhealth (A.W.O., A.M.), West Reading, Pennsylvania; Lehigh Valley Health Network (R.S.S., R.A.), Allentown, Pennsylvania; Tufts University School of Medicine (N.B., A.T.), Boston, Massachusetts; Sanford Health (K.Z., Le.H.), Sioux Falls, South Dakota; Research Medical Center (M.J.L.), Kansas City, Missouri; University of California San Francisco (D.M.S.), San Francisco, California
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23
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Zeineddine HA, King N, Lewis CT, Kole MJ, Kitagawa R, Dannenbaum M, Chen PR, Day AL, Blackburn S. Blunt Traumatic Vertebral Artery Injuries: Incidence, Therapeutic Management, and Outcomes. Neurosurgery 2022; 90:399-406. [PMID: 35064660 DOI: 10.1227/neu.0000000000001843] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 10/25/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Blunt cerebrovascular injury (BCVI) is a term for injuries to the carotid and vertebral arteries (blunt vertebral artery injury [BVAI]) caused by blunt trauma. Computed tomographic angiography is currently the best screening test for BCVI. The subsequent management of any identified vessel injury, however, is not clearly defined. OBJECTIVE To describe one of the largest cohorts of isolated vertebral artery injuries and report the evolution of treated and untreated lesions and clinical outcomes of treatment regimens used to reduce the risk of injury-related stroke. METHODS The list included patients who presented to or were transferred to a level 1 trauma center and found to have an isolated BVAI. Patients were included if imaging was performed within 24 hours of presentation. Data collected included location and grade of injury, timing and type of initial therapy, follow-up imaging, evolution of the disease, and associated strokes. RESULTS A total of 156 patients were included in the analysis. Most patients (135/156) were treated with aspirin alone, 3 with anticoagulation therapy, and 18 did not receive treatment. Three strokes were detected within 24 hours of admission and before treatment initiation. No strokes were detected during the length of the hospitalization for any other patient. CONCLUSION Our data demonstrate that the risk of stroke after cervical vertebral artery injury is low, and aspirin as a prophylactic is efficacious in grade I and IV injuries. There are limited data regarding grade II and grade III injuries. The benefit of early interval imaging follow-up is unclear and warrants investigation.
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Affiliation(s)
- Hussein A Zeineddine
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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24
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Hego C, Rousseau G, Abback PS, Pommier R, Hamada SR, Bergis B, Jurcisin I, Diallo A, Paugam-Burtz C, Sigaut S, Gauss T, Moyer JD. Long-term outcome following blunt cerebrovascular injuries: occurrence of ischemic complications, treatment, and outcome. Eur J Trauma Emerg Surg 2022; 48:3131-3140. [DOI: 10.1007/s00068-021-01860-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 12/11/2021] [Indexed: 11/03/2022]
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25
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Lauzier DC, Chatterjee AR, Kansagra AP. Neurointerventional management of cerebrovascular trauma. J Neurointerv Surg 2021; 14:718-722. [PMID: 34949708 DOI: 10.1136/neurintsurg-2021-017923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/04/2021] [Indexed: 11/03/2022]
Abstract
Traumatic cerebrovascular injuries following blunt or penetrating trauma are common and carry a high risk of permanent disability or death. Proper screening, diagnosis, and treatment of these lesions is essential to improve patient outcomes. Advances in imaging continue to improve the accuracy of non-invasive diagnosis of these injuries while new clinical data provide better evidence for optimal management, whether medical or invasive. Here, we review screening, diagnosis, and treatment of traumatic cerebrovascular injuries.
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Affiliation(s)
- David C Lauzier
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Arindam R Chatterjee
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA.,Department of Neurological Surgery, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA .,Department of Neurological Surgery, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA
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26
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Diagnostic accuracy of computed tomography angiography (CTA) for diagnosing blunt cerebrovascular injury in trauma patients: a systematic review and meta-analysis. Eur Radiol 2021; 32:2727-2738. [PMID: 34854931 PMCID: PMC8921112 DOI: 10.1007/s00330-021-08379-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/08/2021] [Accepted: 10/02/2021] [Indexed: 11/06/2022]
Abstract
Objectives Previous literature showed that the diagnostic accuracy of computed tomographic angiography (CTA) is not equally comparable with that of the rarely used golden standard of digital subtraction angiography (DSA) for detecting blunt cerebrovascular injuries (BCVI) in trauma patients. However, advances in CTA technology may prove CTA to become equally accurate. This study investigated the diagnostic accuracy of CTA in detecting BCVI in comparison with DSA in trauma patients. Methods An electronic database search was performed in PubMed, EMBASE, and Cochrane Library. Summary estimates of sensitivity, specificity, positive and negative likelihood, diagnostic odds ratio, and 95% confidence intervals were determined using a bivariate random-effects model. Results Of the 3293 studies identified, 9 met the inclusion criteria. Pooled sensitivity was 64% (95% CI, 53–74%) and specificity 95% (95% CI, 87–99%) The estimated positive likelihood ratio was 11.8 (95%, 5.6–24.9), with a negative likelihood ratio of 0.38 (95%, 0.30–0.49) and a diagnostic odds ratio of 31 (95%, 17–56). Conclusion CTA has reasonable specificity but low sensitivity when compared to DSA in diagnosing any BCVI. An increase in channels to 64 slices did not yield better sensitivity. There is a risk for underdiagnosis of BCVI when only using DSA to confirm CTA-positive cases, especially in those patients with low-grade injuries. Key Points • Low sensitivity and high specificity were seen in identifying BCVI with CTA as compared to DSA. • Increased CTA detector channels (≤ 64) did not lead to higher sensitivity when detecting BCVI. • The use of CTA instead of DSA may lead to underdiagnosis and, consequently, undertreatment of BCVI.
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Abstract
PURPOSE OF REVIEW Traumatic brain injury (TBI) encompasses a group of heterogeneous manifestations of a disease process with high neurologic morbidity and, for severe TBI, high probability of mortality and poor neurologic outcomes. This article reviews TBI in neurocritical care, hence focusing on moderate and severe TBI, and includes an up-to-date review of the many variables to be considered in clinical care. RECENT FINDINGS With advances in medicine and biotechnology, understanding of the impact of TBI has substantially elucidated the distinction between primary and secondary brain injury. Consequently, care of TBI is evolving, with intervention-based modalities targeting multiple physiologic variables. Multimodality monitoring to assess intracranial pressure, cerebral oxygenation, cerebral metabolism, cerebral blood flow, and autoregulation is at the forefront of such advances. SUMMARY Understanding the anatomic and physiologic principles of acute brain injury is necessary in managing moderate to severe TBI. Management is based on the prevention of secondary brain injury from resultant trauma. Care of patients with TBI should occur in a dedicated critical care unit with subspecialty expertise. With the advent of multimodality monitoring and targeted biomarkers in TBI, patient outcomes have a higher probability of improving in the future.
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Shibahashi K, Hoda H, Ishida T, Motoshima T, Sugiyama K, Hamabe Y. Derivation and validation of a quantitative screening model for blunt cerebrovascular injury. J Neurosurg 2021; 135:1129-1138. [PMID: 33578388 DOI: 10.3171/2020.8.jns202589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 08/24/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to derive and validate a new screening model using a nomogram that allows clinicians to quantify the risk of blunt cerebrovascular injury (BCVI). METHODS In this study, the authors examined 258,935 patients from a prospectively collected nationwide Japanese database (January 2009-December 2018) who experienced blunt injury. Patients were randomly divided into training (n = 129,468) and validation (n = 129,467) cohorts. First, the authors investigated the prevalence of BCVI, which was defined as blunt injury to any intracranial vessel, the extracranial vertebral artery, the extracranial carotid (common, internal) artery, or the internal jugular vein. Then, a new arterial BCVI screening model using a nomogram was derived, based on multivariate logistic regression analysis through quantifying the association of potential predictive factors with BCVI in the training cohort. The model's discriminatory ability was validated using the area under the receiver operating characteristic curve (AUC) in the validation cohort. RESULTS Multivariate analysis in the training cohort showed that 13 factors were significantly associated with arterial BCVI and were included in our model. These factors were 1) male sex; 2) high-energy impact; 3) hypotension on hospital arrival; 4) Glasgow Coma Scale score < 9; 5) injury to the face; 6) injury to the neck; 7) injury to the spine; 8) skull base fracture; 9) cervical spine fracture or subluxation; and those with negative associations, i.e., 10) injury to the lower-extremity region; 11) supratentorial subdural hemorrhage; 12) lumbar spine fracture or subluxation; and 13) soft tissue injury of the face. In the validation cohort, the model had an AUC of 0.83 (95% CI 0.81-0.86). When the definition of BCVI was narrowed to include only carotid (common, internal) and vertebral artery injuries, the AUC of the model in predicting these injuries was 0.89 (95% CI 0.87-0.91). CONCLUSIONS A new screening model that incorporates an easy-to-use nomogram to quantify the risk of BCVI and assist clinicians in identifying patients who warrant additional evaluation was established.
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Affiliation(s)
- Keita Shibahashi
- 1Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo; and
| | - Hidenori Hoda
- 1Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo; and
| | - Takuto Ishida
- 1Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo; and
| | - Takayuki Motoshima
- 2Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kazuhiro Sugiyama
- 1Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo; and
| | - Yuichi Hamabe
- 1Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo; and
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Murphy PB, Severance S, Holler E, Menard L, Savage S, Zarzaur BL. Treatment of asymptomatic blunt cerebrovascular injury (BCVI): a systematic review. Trauma Surg Acute Care Open 2021; 6:e000668. [PMID: 33981860 PMCID: PMC8076921 DOI: 10.1136/tsaco-2020-000668] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 03/11/2021] [Accepted: 03/16/2021] [Indexed: 11/24/2022] Open
Abstract
Background The management of asymptomatic blunt cerebrovascular injury (BCVI) with respect to stroke prevention and vessel healing is challenging. Objectives The aim of this systematic review was to determine if a specific treatment results in lower stroke rates and/or improved vessel healing in asymptomatic BCVI. Data sources An electronic literature search of MEDLINE, EMBASE, Cochrane Library, CINAHL, SCOPUS, Web of Science, and ClinicalTrials.gov performed from inception to March 2020. Study eligibility criteria Studies were included if they reported on a comparison of any treatment for BCVI and stroke and/or vessel healing rates. Participants and interventions Adult patients diagnosed with asymptomatic BCVI(s) who were treated with any preventive medication or procedure. Study appraisal and synthesis methods All studies were systematically reviewed and bias was evaluated by the Newcastle-Ottawa Scale. No meta-analysis was performed secondary to significant heterogeneity across studies in patient population, screening protocols, and treatment selection. The main outcomes were stroke and healing rate. Results Of 8781 studies reviewed, 19 reported on treatment effects for asymptomatic BCVI and were included for review. Any choice of medical management was better than no treatment, but no specific differences between choice of medical management and stroke outcomes were found. Vessel healing was rare and the majority of healed vessels were following low-grade injuries. Limitations Majority of the included studies were retrospective and at high risk of bias. Conclusions or implications of key findings Asymptomatic BCVI should be treated medically using a consistent, local protocol. High-quality studies on the effect of individual antithrombotic agents on stroke rates and vessel healing for asymptomatic BCVI are required.
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Affiliation(s)
| | - Sarah Severance
- Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Emma Holler
- Surgery, Eskenazi Health, Indianapolis, Indiana, USA
| | - Laura Menard
- Medical Education and Access Services, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Stephanie Savage
- Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ben L Zarzaur
- Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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Figueroa JM, Berry K, Boddu J, Kader M, Silva M, Luther E, Ayala V, Starke RM, Jagid J, Benveniste R. Treatment strategies for patients with concurrent blunt cerebrovascular and traumatic brain injury. J Clin Neurosci 2021; 88:243-250. [PMID: 33992192 DOI: 10.1016/j.jocn.2021.03.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 03/20/2021] [Accepted: 03/31/2021] [Indexed: 01/17/2023]
Abstract
Patients who present with traumatic brain injury (TBI) combined with blunt cerebrovascular injuries (BCVI) are difficult to manage, in part because treatment for each entity may exacerbate the other. It is necessary to develop a treatment paradigm that ensures maximum benefit while mitigating the opposing risks. A cohort of 150 patients from 2015 to present, with either internal carotid artery (ICA) and/or vertebral artery (VA) dissections or pseudoaneurysms, was cross-referenced with those who had sustained TBI. Of the 38 patients identified with both TBI and BCVI, 25 suffered ICA injuries, 10 had VA injuries and 3 had combined ICA/VA injuries. Unilateral BCVI occurred in 30 patients, while 8 had bilateral BCVI. Two patients required surgical intervention for TBI, and 5 patients required endovascular intervention for BCVI. Positive emboli detection studies (EDS) on transcranial dopplers (TCD) were demonstrated in 19 patients, with 9 patients having radiographic evidence of stroke. Anti-platelet therapy was initiated in 32 patients, and anti-coagulation in 10 patients, without new or worsening intracranial hemorrhages (ICH). Overall, 76% of patients were able to be discharged home or to rehabilitation, with good recovery demonstrated in 73% of the patients who had appropriate follow-up. In the setting of concurrent TBI and BCVI, use of anti-platelet/coagulation to prevent stroke can be safe if monitored closely. Here we describe a treatment paradigm which weighs the risk and benefits of therapies based on severity of ICH and stroke prevention, which tended to result in good disposition and recovery.
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Affiliation(s)
- Javier M Figueroa
- University of Miami Miller School of Medicine, Department of Neurosurgery, USA.
| | - Katherine Berry
- University of Miami Miller School of Medicine, Department of Neurosurgery, USA
| | - James Boddu
- University of Miami Miller School of Medicine, Department of Neurosurgery, USA
| | - Michael Kader
- University of Miami Miller School of Medicine, Department of Neurosurgery, USA
| | - Michael Silva
- University of Miami Miller School of Medicine, Department of Neurosurgery, USA
| | - Evan Luther
- University of Miami Miller School of Medicine, Department of Neurosurgery, USA
| | - Veronica Ayala
- University of Miami Miller School of Medicine, Department of Neurosurgery, USA
| | - Robert M Starke
- University of Miami Miller School of Medicine, Department of Neurosurgery, USA
| | - Jonathan Jagid
- University of Miami Miller School of Medicine, Department of Neurosurgery, USA
| | - Ronald Benveniste
- University of Miami Miller School of Medicine, Department of Neurosurgery, USA
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Vellimana AK, Lavie J, Chatterjee AR. Endovascular Considerations in Traumatic Injury of the Carotid and Vertebral Arteries. Semin Intervent Radiol 2021; 38:53-63. [PMID: 33883802 DOI: 10.1055/s-0041-1724008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cervical carotid and vertebral artery traumatic injuries can have a devastating natural history. This article reviews the epidemiology, mechanisms of injury, clinical presentation, and classification systems pertinent to consideration of endovascular treatment. The growing role of modern endovascular techniques for the treatment of these diseases is presented to equip endovascular surgeons with a framework for critically assessing patients presenting with traumatic cervical cerebrovascular injury.
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Affiliation(s)
- Ananth K Vellimana
- Department of Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Jayson Lavie
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Arindam Rano Chatterjee
- Department of Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
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Chin DL, Zeber JE. Mental Health Outcomes Among Military Service Members After Severe Injury in Combat and TBI. Mil Med 2021; 185:e711-e718. [PMID: 31889174 DOI: 10.1093/milmed/usz440] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 10/25/2019] [Accepted: 11/06/2019] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Studies examining the mental health outcomes of military personnel deployed into combat zones have focused on the risk of developing post-traumatic stress disorder conferred by mild or moderate traumatic brain injury (TBI). However, other mental health outcomes among veterans who sustained critical combat injuries have not been described. MATERIALS AND METHOD We examined the associations of moderate and severe TBI and combat injury with the risk for anxiety and mood disorders, adjustment reactions, schizophrenia and other psychotic disorders, cognitive disorders, and post-traumatic stress disorder. We conducted a retrospective cohort study of U.S. military service members critically injured in combat during military operations in Iraq and Afghanistan from February 1, 2002, to February 1, 2011. Health care encounters from (1) the Department of Defense (DoD) Trauma Registry (TR), (2) acute and ambulatory care in military facilities, and (3) civilian facilities are reimbursed by Tricare. Service members who sustained severe combat injury require critical care. We estimated the risk of mental health outcomes using risk-adjusted logit models for demographic and clinical factors. We explored the relationship between TBI and the total number of mental health diagnoses. RESULTS Of the 4,980 subjects who met inclusion criteria, most injuries occurred among members of the Army (72%) or Marines (25%), with mean (SD) age of 25.5(6.1) years. The prevalence of moderate or severe TBI was 31.6% with explosion as the most common mechanism of injury (78%). We found 71% of the cohort was diagnosed with at least one poor mental health condition, and the adjusted risk conferred by TBI ranged from a modest increase for anxiety disorder (odds ratio, 1.27; 95% confidence interval [CI], 1.11-1.45) to a large increase for cognitive disorder (odds ratio, 3.24; 95% CI, 2.78-3.77). We found TBI was associated with an increased number of mental health diagnoses (incidence rate ratio, 1.52; 95% CI, 1.42-1.63). CONCLUSIONS Combat-associated TBI may have a broad effect on several mental health conditions among critically injured combat casualties. Early recognition and treatment for trauma-associated mental health are crucial to improving outcomes among service personnel as they transition to post-deployment care in the DoD, Department of Veterans Affairs, or community health systems.
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Affiliation(s)
- David L Chin
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, 715 N. Pleasant Street, Amherst, MA 01003
| | - John E Zeber
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, 715 N. Pleasant Street, Amherst, MA 01003.,Central Texas Veterans Health Care System, Temple TX 76504
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Sherbaf FG, Chen B, Pomeranz T, Shahriari M, Adin ME, Mirbagheri S, Beheshtian E, Jalilianhasanpour R, Pakpoor J, Lazor JW, Kamali A, Yousem DM. Value of Emergent Neurovascular Imaging for "Seat Belt Injury": A Multi-institutional Study. AJNR Am J Neuroradiol 2021; 42:743-748. [PMID: 33541893 PMCID: PMC8041015 DOI: 10.3174/ajnr.a6992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/09/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Screening for blunt cerebrovascular injury in patients after motor vehicle collision (MVC) solely based on the presence of cervical seat belt sign has been debated in the literature without consensus. Our aim was to assess the value of emergent neurovascular imaging in patients after an MVC who present with a seat belt sign through a large-scale multi-institutional study. MATERIALS AND METHODS The electronic medical records of patients admitted to the emergency department with CTA/MRAs performed with an indication of seat belt injury of the neck were retrospectively reviewed at 5 participating institutions. Logistic regression analysis was used to determine the association among age, sex, and additional trauma-related findings with blunt cerebrovascular injury. RESULTS Five hundred thirty-five adult and 32 pediatric patients from June 2003 until March 2020 were identified. CTA findings were positive in 12/567 (2.1%) patients for the presence of blunt cerebrovascular injury of the vertebral (n = 8) or internal carotid artery (n = 4) in the setting of acute trauma with the seat belt sign. Nine of 12 patients had symptoms, signs, or risk factors for cervical blunt cerebrovascular injury other than the seat belt sign. The remaining 3 patients (3/567, 0.5%) had Biffl grades I-II vascular injury with no neurologic sequelae. The presence of at least 1 additional traumatic finding or the development of a new neurologic deficit was significantly associated with the presence of blunt cerebrovascular injury among adult patients, with a risk ratio of 11.7 (P = .001). No children had blunt cerebrovascular injury. CONCLUSIONS The risk of vascular injury in the presence of the cervical seat belt sign is small, and most patients diagnosed with blunt cerebrovascular injury have other associated findings. Therefore, CTA based solely on this sign has limited value (3/567 = a 0.5% positivity rate). We suggest that in the absence of other clinical findings, the seat belt sign does not independently justify neck CTA in patients after trauma.
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Affiliation(s)
- F G Sherbaf
- From the Division of Neuroradiology (F.G.S., E.B., R.J., D.M.Y.), Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - B Chen
- Department of Diagnostic and Interventional Imaging (B.C., A.K.), Division of Neuroradiology, University of Texas Health Science Center at Houston, Houston, Texas
| | - T Pomeranz
- Department of Radiology (T.P., J.P., J.W.L.), University of Pennsylvania, Philadelphia, Pennsylvania
| | - M Shahriari
- Department of Radiology (M.S.), Christiana Care Health System, Newark, Delaware
| | - M E Adin
- Department of Radiology and Biomedical Imaging (M.E.A.), Yale University School of Medicine, New Haven, Connecticut
| | - S Mirbagheri
- Department of Diagnostic Radiology (S.M.), Mount Sinai Beth Israel, New York, New York
| | - E Beheshtian
- From the Division of Neuroradiology (F.G.S., E.B., R.J., D.M.Y.), Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - R Jalilianhasanpour
- From the Division of Neuroradiology (F.G.S., E.B., R.J., D.M.Y.), Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - J Pakpoor
- Department of Radiology (T.P., J.P., J.W.L.), University of Pennsylvania, Philadelphia, Pennsylvania
| | - J W Lazor
- Department of Radiology (T.P., J.P., J.W.L.), University of Pennsylvania, Philadelphia, Pennsylvania
| | - A Kamali
- Department of Diagnostic and Interventional Imaging (B.C., A.K.), Division of Neuroradiology, University of Texas Health Science Center at Houston, Houston, Texas
| | - D M Yousem
- From the Division of Neuroradiology (F.G.S., E.B., R.J., D.M.Y.), Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Moyer JD, Dioguardi Burgio M, Abback PS, Gauss T. Isolated basilar artery dissection following blunt trauma challenging the Glasgow coma score: A case report. Am J Emerg Med 2021; 47:347.e1-347.e3. [PMID: 33745773 DOI: 10.1016/j.ajem.2021.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/25/2021] [Accepted: 03/02/2021] [Indexed: 11/16/2022] Open
Abstract
Blunt cerebrovascular injury is a very rare complication of blunt trauma and a diagnostic challenge. A 14 year old male fell 10 m sustaining multi system trauma. The atypical Glasgow Coma Score was six with a fully preserved eye component. Initial whole-body CT scanning demonstrated multiple injuries but no obvious brain injury. Trauma management involved non-operative resuscitation and was successful, however profound coma occurred and brain stem reflexes disappeared on day two. Repeat brain CT scan demonstrated multiple cerebral and cerebellar ischemic lesions and no opacification of the vertebral or basilar arteries. Secondary analysis of the first CT scan demonstrated a small focal basilar artery dissection not initially reported. Our case report highlights an unusual cause of coma after traumatic brain injury where the clinical scenario mimics locked in syndrome. In such circumstances cerebrovascular injury, and in particular traumatic basilar artery dissection, must be actively excluded.
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Affiliation(s)
- J D Moyer
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Paris, France.
| | - M Dioguardi Burgio
- Departement of Radiology, Beaujon Hospital, AP-HP.Nord, Paris, France; Inserm UMR S1149, Inserm et Université de Paris, Paris, France
| | - P S Abback
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Paris, France
| | - T Gauss
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Paris, France
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Tien L, Giurgiutiu DV, Switzer EF, Switzer JA. Characterizing Blunt Cerebrovascular Injuries and Stroke: A Single Center Retrospective Study. J Stroke Cerebrovasc Dis 2021; 30:105563. [PMID: 33482568 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/04/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE To highlight the occurrence of ischemic stroke after blunt cerebrovascular injuries and discuss the neurologist's role in preventing and managing ischemic strokes in this trauma population. METHODS A retrospective chart review was performed and included data from 2016 to 2019 from a Level I trauma center. Demographics, injury mechanism, ischemic stroke occurrence, interventions, and neurology consultations were examined and descriptive statistics were utilized to characterize the nature of ischemic strokes and their management. RESULTS A total of forty patients (81% male, average age 44) presented with blunt cerebrovascular injury, nine of whom later developed ischemic stroke. Eighteen patients had a carotid artery injury with six developing ischemic stroke. Twenty-seven patients had a vertebral artery injury with three developing ischemic stroke. Six of the nine ischemic strokes occurred on hospital day two, whereas neurology was generally consulted on hospital day four. CONCLUSIONS A considerable portion of patients may go on to develop ischemic stroke following blunt cerebrovascular injuries. Polytrauma may interfere with prompt diagnosis which may contribute to delayed anti-thrombotic therapy for ischemic stroke prevention. Neurologists have the opportunity to reduce ischemic stroke burden in this trauma population and patients may benefit from earlier neurology consultation.
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Affiliation(s)
- Lillie Tien
- Medical College of Georgia at Augusta University.
| | | | - Erin F Switzer
- Department of Surgery at Augusta University Medical Center.
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Predictors of swallowing outcomes in patients with combat-injury related dysphagia. J Trauma Acute Care Surg 2021; 89:S192-S199. [PMID: 32068719 DOI: 10.1097/ta.0000000000002623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Traumatic injuries, such as those from combat-related activities, can lead to complicated clinical presentations that may include dysphagia. METHODS This retrospective observational database study captured dysphagia-related information for 215 US military service members admitted to the first stateside military treatment facility after sustaining combat-related or combat-like traumatic injuries. A multidimensional relational database was developed to document the nature, course, and management for dysphagia in this unique population and to explore variables predictive of swallowing recovery using Bayesian statistical modeling and inferential statistical methods. RESULTS Bayesian statistical modeling revealed the importance of maxillofacial fractures and soft tissue loss as primary predictors of poor swallowing outcomes. The presence of traumatic brain injury (TBI), though common, did not further complicate dysphagia outcomes. A more detailed examination and rating of videofluoroscopic swallow studies from a subset of 161 participants supported greater impairment for participants with maxillofacial trauma and no apparent relationship between having sustained a TBI and swallow functioning. CONCLUSION These analyses revealed that maxillofacial trauma is a stronger indicator than TBI of dysphagia severity and slower or incomplete recovery following combat-related injuries. LEVEL OF EVIDENCE Therapeutic/Care Management study, level IV.
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Kansagra AP, Balasetti V, Huang MC. Neurovascular trauma: Diagnosis and therapy. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:325-344. [PMID: 33272402 DOI: 10.1016/b978-0-444-64034-5.00012-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Akash P Kansagra
- Departments of Radiology, Neurological Surgery, and Neurology, Washington University School of Medicine, St. Louis, MO, United States.
| | - Vamshi Balasetti
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, United States
| | - Michael C Huang
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States
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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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Wang GM, Xue H, Guo ZJ, Yu JL. Cerebral infarct secondary to traumatic internal carotid artery dissection. World J Clin Cases 2020; 8:4773-4784. [PMID: 33195645 PMCID: PMC7642541 DOI: 10.12998/wjcc.v8.i20.4773] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/20/2020] [Accepted: 09/03/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Traumatic internal carotid artery dissection (TICAD) is rare and can result in severe neurological disability and even death. No consensus regarding its diagnostic screening and management has been established.
AIM To investigate the clinical presentation, imaging features, diagnostic workup, and treatment of TICAD.
METHODS In this retrospective case series, emergency admissions for TICAD due to closed head injury were analyzed. The demographic, clinical, and radiographic data were retrieved from patient charts and the picture archiving and communication system.
RESULTS Six patients (five males and one female, age range of 43-62 years, mean age of 52.67 years) presented with TICAD. Traffic accidents (4/6) were the most frequent cause of TICAD. The clinical presentation was always related to brain hypoperfusion. Imaging examination revealed dissection of the affected artery and corresponding brain infarction. All the patients were definitively diagnosed with TICAD. One patient was treated conservatively, one patient underwent anticoagulant therapy, two patients were given both antiplatelet and anticoagulant drugs, and two patients underwent decompressive craniectomy. One patient fully recovered, while three patients were disabled at follow-up. Two patients died of refractory brain infarction.
CONCLUSION TICAD can cause catastrophic outcomes and even refractory brain hernia. Early and efficient diagnosis of TICAD is essential for initiating appropriate treatment. The treatment of TICAD is challenging and variable and is based on clinician discretion on a case-by-case basis.
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Affiliation(s)
- Guang-Ming Wang
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Hang Xue
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Zhen-Jie Guo
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Jin-Lu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
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Le DT, Barhorst KA, Castiglione J, Yang GL, Shah SJ, Harlan SS, Keegan SP, Jandarov RA, Ngwenya LB, Prestigiacomo CJ. Blunt cerebrovascular injury in the geriatric population. Neurosurg Focus 2020; 49:E10. [PMID: 33002862 DOI: 10.3171/2020.7.focus20499] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Blunt cerebrovascular injury (BCVI) is associated with high rates of neurological morbidity and mortality. The detection and management of BCVI has improved with advances in imaging and sensitive screening protocols. Few studies have explored how these injuries specifically affect the geriatric population. The purpose of this retrospective analysis was to investigate the presentation and prognosis of BCVI in the elderly population and to assess its clinical implications in the management of these patients. METHODS All patients presenting to the University of Cincinnati (UC) level I trauma center between February 2017 and December 2019 were screened for BCVI and entered into the prospectively maintained UC Neurotrauma Registry. Patients with BCVI confirmed by CT angiography underwent retrospective chart reviews to collect information regarding demographics, positive screening criteria, cause of injury, antithrombotic agent, injury location, Denver Grading Scale, hospital and ICU length of stay, and discharge disposition. Patients were divided into geriatric (age ≥ 65 years) and adult (age < 65 years) subgroups. Continuous variables were analyzed using the Student t-test and categorical variables with the Pearson chi-square test. RESULTS Of 124 patients with BCVI, stratification by age yielded 23 geriatric and 101 adult patients. Injury in the geriatric group was associated with significantly higher mortality (p = 0.0194). The most common cause of injury in the elderly was falls (74%, 17/23; p < 0.0001), whereas motor vehicle accidents were most common in the adult group (38%, 38/100; p = 0.0642). With respect to the location of injury, carotid (p = 0.1171) and vertebral artery (p = 0.6981) injuries did not differ significantly for the geriatric group. The adult population presented more often with Denver grade I injuries (p < 0.0001), whereas the geriatric population presented with grade IV injuries (p = 0.0247). Elderly patients were more likely to be discharged to skilled nursing facilities (p = 0.0403) and adults to home or self-care (p = 0.0148). CONCLUSIONS This study is the first to characterize BCVI to all cervical and intracranial vessels in the geriatric population. Older age at presentation is significantly associated with greater severity, morbidity, and mortality from injury, with no preference for the particular artery injured. These findings carry important clinical implications for adapting practice in an aging population.
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Affiliation(s)
- Diana T Le
- 1University of Cincinnati College of Medicine
| | | | | | - George L Yang
- 2Department of Neurological Surgery, University of Cincinnati College of Medicine
| | - Sanjit J Shah
- 2Department of Neurological Surgery, University of Cincinnati College of Medicine
| | - Sarah S Harlan
- 3Division of Pharmaceutical Sciences, James L. Winkle College of Pharmacy, University of Cincinnati; and
| | - Shaun P Keegan
- 3Division of Pharmaceutical Sciences, James L. Winkle College of Pharmacy, University of Cincinnati; and
| | - Roman A Jandarov
- 4Division of Biostatistics and Bioinformatics, Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Laura B Ngwenya
- 2Department of Neurological Surgery, University of Cincinnati College of Medicine
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Puolakkainen T, Vähäsilta L, Bensch F, Narjus-Sterba M, Wilson ML, Thorén H, Snäll J. Blunt cerebrovascular injuries in the craniofacial fracture population-Are we screening the right patients? Int J Oral Maxillofac Surg 2020; 50:463-470. [PMID: 32994036 DOI: 10.1016/j.ijom.2020.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/16/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
Current knowledge of blunt cerebrovascular injuries (BCVIs) in craniomaxillofacial fracture (CMF) patients is limited. The purpose of this study was to determine the occurrence of BCVIs in patients with all types of CMF. This retrospective study included CMF patients in a level 1 trauma centre during a 3-year period. Patients who were not imaged with computed tomography angiography and patients with mechanisms other than blunt injury were excluded. The primary outcome variable was BCVI. A total of 753 patients were included in the analysis. A BCVI was detected in 4.4% of the patients screened. BCVIs occurred in 8.7% of cranial fracture patients, 7.1% of combined craniofacial fracture patients, and 3.1% of facial fracture patients. The risk of BCVI was significantly increased in patients with isolated cranial fractures (odds ratio (OR) 2.55, 95% confidence interval (CI) 1.18-5.50; P=0.017), those involved in motor vehicle accidents (OR 3.42, 95% CI 1.63-7.17; P=0.001), and those sustaining high-energy injuries (OR 3.17, 95% CI 1.57-6.40; P=0.001). BCVIs in CMF patients are relatively common in high-energy injuries. However, these injuries also occur in minor traumas. Imaging thresholds should be kept low in this patient population when BCVIs are suspected.
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Affiliation(s)
- T Puolakkainen
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - L Vähäsilta
- Department of Oral and Maxillofacial Surgery, Institute of Dentistry, University of Turku, Turku, Finland; Department of Oral and Maxillofacial Diseases, Turku University Hospital, Turku, Finland
| | - F Bensch
- Department of Radiology, HUS Medical Imaging Centre, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - M Narjus-Sterba
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - M L Wilson
- Injury Epidemiology and Prevention (IEP), Turku Brain Injury Centre, Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland; Injury Epidemiology and Prevention Unit, Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
| | - H Thorén
- Department of Oral and Maxillofacial Surgery, Institute of Dentistry, University of Turku, Turku, Finland; Department of Oral and Maxillofacial Diseases, Turku University Hospital, Turku, Finland
| | - J Snäll
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Treatment of blunt cerebrovascular injuries: Anticoagulants or antiplatelet agents? J Trauma Acute Care Surg 2020; 89:74-79. [PMID: 32251264 DOI: 10.1097/ta.0000000000002704] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Blunt cerebrovascular injury (BCVI) is associated with cerebrovascular accidents (CVA). Early therapy with antiplatelet agents or anticoagulants is recommended. There are limited data comparing the effectiveness of these treatments. The aim of our study was to compare outcomes between BCVI patients who received anticoagulants versus those who received antiplatelet agents. METHODS We performed an (2011-2015) analysis of the Nationwide Readmission Database and included all adult trauma patients 18 years or older who had an isolated BCVI (other body regions Abbreviated Injury Scale [AIS] < 3). Head injury patients or those who developed a CVA during the index admission were excluded. Patients were stratified into anticoagulants and antiplatelet agents. Propensity score matching was performed (1:1 ratio) to control for demographics, comorbidities, BCVI grade, distribution, and severity of injuries. Outcomes were readmission with CVA and mortality within 6 months. RESULTS A total of 725 BCVI patients were identified. A matched cohort of 370 patients (antiplatelet agents, 185; anticoagulants, 185) was obtained. Mean age was 50 ± 15 years, neck AIS was 3 (3,4), and Injury Severity Score was 12 (9-17). The majority of the patients (69%) had high-grade BCVI (AIS ≥ 3). Overall, 3.7% were readmitted with CVA and 3% died within 6 months. Patients who received anticoagulants had a lower rate of readmission with CVA (1.8% vs. 5.72%; p = 0.03), and a lower rate of 6-month mortality (1.3% vs. 4.9%; p = 0.03). There was no significant difference between the two groups reading the median time to stroke (9 days vs. 6 days; p = 0.12). CONCLUSION The BCVI patients on CVA prophylaxis for BCVI have a 3.7% rate of stroke after discharge. Compared with antiplatelet agents, anticoagulants are associated with lower rates of CVA in the first 6-month postdischarge. Further studies are required to identify the optimal agent to prevent CVA in this high-risk subset of trauma patients. LEVEL OF EVIDENCE Therapeutic, level IV.
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Hoffman H, Bunch KM, Protas M, Chin LS. Risk Factors and Outcomes Associated with Blunt Cerebrovascular Injury in Patients with Mild or Moderate Traumatic Brain Injury. Ann Vasc Surg 2020; 71:157-166. [PMID: 32768544 DOI: 10.1016/j.avsg.2020.07.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Haydn Hoffman
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, NY.
| | - Katherine M Bunch
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, NY
| | - Matthew Protas
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, NY
| | - Lawrence S Chin
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, NY
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Vehviläinen J, Brinck T, Lindfors M, Numminen J, Siironen J, Raj R. Occurrence and prognostic effect of cervical spine injuries and cervical artery injuries with concomitant severe head injury. Acta Neurochir (Wien) 2020; 162:1445-1453. [PMID: 32157398 PMCID: PMC7235059 DOI: 10.1007/s00701-020-04279-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/27/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Blunt cerebrovascular injuries (BCVIs) and cervical spinal injuries (CSIs) are not uncommon injuries in patients with severe head injury and may affect patient recovery. We aimed to assess the independent relationship between BCVI, CSI, and outcome in patients with severe head injury. METHODS We identified patients with severe head injury from the Helsinki Trauma Registry treated during 2015-2017 in a large level 1 trauma hospital. We assessed the association between BCVI and SCI using multivariable logistic regression, adjusting for injury severity. Our primary outcome was functional outcome at 6 months, and our secondary outcome was 6-month mortality. RESULTS Of 255 patients with a cervical spine CT, 26 patients (10%) had a CSI, and of 194 patients with cervical CT angiography, 16 patients (8%) had a BCVI. Four of the 16 BCVI patients had a BCVI-related brain infarction, and four of the CSI patients had some form of spinal cord injury. After adjusting for injury severity in multivariable logistic regression analysis, BCVI associated with poor functional outcome (odds ratio [OR] = 6.0, 95% CI [confidence intervals] = 1.4-26.5) and mortality (OR = 7.9, 95% CI 2.0-31.4). We did not find any association between CSI and outcome. CONCLUSIONS We found that BCVI with concomitant head injury was an independent predictor of poor outcome in patients with severe head injury, but we found no association between CSI and outcome after severe head injury. Whether the association between BCVI and poor outcome is an indirect marker of a more severe injury or a result of treatment needs further investigations.
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Affiliation(s)
- Juho Vehviläinen
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PO. Box 266, 00029, Helsinki, Finland
| | - Tuomas Brinck
- Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Matias Lindfors
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PO. Box 266, 00029, Helsinki, Finland
| | - Jussi Numminen
- Department of Radiology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jari Siironen
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PO. Box 266, 00029, Helsinki, Finland
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PO. Box 266, 00029, Helsinki, Finland.
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Razaghi R, Biglari H, Karimi A. A patient-specific fluid–structure interaction model of the cerebrovascular damage in relation to traumatic brain injury. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408620921729] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background There is a lack of knowledge on the magnitudes of the biomechanical stresses and deformations occurring in the cerebral arterial wall after traumatic brain injury (TBI). Experimental techniques are unable to calculate the stresses and deformations in the cerebral arterial wall after TBI; therefore, the application of numerical simulations, such as finite element modeling, is preferred. Methods This study was aimed to calculate the stresses and deformations as well as the alteration in the pressure and velocity of the blood in the cerebrovascular artery using a fluid–structure interaction model. Results The results revealed considerable increase in the pressure and velocity of the blood which might lead to cerebrovascular damage followed by hemorrhage. The arterial wall showed the highest deformation of 0.047 mm in the X direction which was higher than that in the Y (0.035–0.050 mm) and Z (0.019–0.030 mm) directions. Conclusions These results have implications not only for the understanding of the stresses and deformations in the cerebral artery because of TBI, but also for providing a comprehensive knowledge for biomechanical and medical experts in regard to thresholds of cerebrovascular damage for use in establishing preventive and/or treatment methods.
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Affiliation(s)
- Reza Razaghi
- Department of Mechanical Engineering, University of Tabriz, Tabriz, Iran
| | - Hasan Biglari
- Department of Mechanical Engineering, University of Tabriz, Tabriz, Iran
| | - Alireza Karimi
- Department of Mechanical Engineering, Kyushu University, Fukuoka, Japan
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Wang K, Peng XX, Liu AF, Zhang YY, Lv J, Xiang L, Liu YE, Jiang WJ. Covered Stenting Is an Effective Option for Traumatic Carotid Pseudoaneurysm with Promising Long-Term Outcome. J Korean Neurosurg Soc 2020; 63:590-597. [PMID: 32272508 PMCID: PMC7477158 DOI: 10.3340/jkns.2019.0202] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 02/14/2020] [Indexed: 11/27/2022] Open
Abstract
Objective Covered stenting is an optional strategy for traumatic carotid pseudoaneurysm, especially in malignant conditions of potential rupture, but the long-term outcomes are not clear. Our aim was to determine if covered stenting is an effective option for traumatic carotid pseudoaneurysm with promising long-term outcomes.
Methods Self-expanding Viabahn and balloon-expandable Willis covered stents were separately implanted for extra- and intracranial traumatic carotid pseudoaneurysm. The covered stent was placed across the distal and proximal pseudoaneurysm leakage under roadmap guidance. Procedural success was defined as technical success (complete exclusion of the pseudoaneurysm and patency of the parent artery) without a primary end point (any stroke or death within 30 days after the procedure). Long-term outcomes were evaluated as ischemic stroke in the territory of the qualifying artery by clinical follow-up through outpatient or telephone consultation and as the exclusion of the pseudoaneurysm and patency of the parent artery by imaging follow-up through angiography.
Results Five patients with traumatic carotid pseudoaneurysm who underwent covered stenting were enrolled. The procedural success rate was 100%. No ischemic stroke in the territory of the qualifying artery was recorded in any of the five patients during a mean clinical follow-up of 44±16 months. Complete exclusion of the pseudoaneurysm and patency of the parent artery were maintained in all five patients during a mean imaging follow-up of 39±16 months.
Conclusion Satisfactory procedural and long-term outcomes were obtained, suggesting that covered stenting is an effective option for traumatic carotid pseudoaneurysm.
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Affiliation(s)
- Kai Wang
- New Era Stroke Care and Research Institute, The PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Xiao-Xin Peng
- Department of Radiology, Beijing Jishuitan Hospital, Beijing, China
| | - Ao-Fei Liu
- New Era Stroke Care and Research Institute, The PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Ying-Ying Zhang
- New Era Stroke Care and Research Institute, The PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Jin Lv
- New Era Stroke Care and Research Institute, The PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Li Xiang
- New Era Stroke Care and Research Institute, The PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Yun-E Liu
- New Era Stroke Care and Research Institute, The PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Wei-Jian Jiang
- New Era Stroke Care and Research Institute, The PLA Rocket Force Characteristic Medical Center, Beijing, China
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Boot E, Ekker MS, Putaala J, Kittner S, De Leeuw FE, Tuladhar AM. Ischaemic stroke in young adults: a global perspective. J Neurol Neurosurg Psychiatry 2020; 91:411-417. [PMID: 32015089 DOI: 10.1136/jnnp-2019-322424] [Citation(s) in RCA: 118] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 11/04/2022]
Abstract
Ischaemic stroke at young age is an increasing problem in both developing and developed countries due to rising incidence, high morbidity and mortality and long-term psychological, physical and social consequences. Compared with stroke in older adults, stroke in young adults is more heterogeneous due to the wide variety of possible underlying risk factors and aetiologies. In this review, we will provide an overview of the global variation in the epidemiology of stroke in young adults, with special attention to differences in geography, ethnicity/race and sex, as well as traditional and novel risk factors for early-onset ischaemic stroke, such as air pollution. Understanding global differences is an important prerequisite for better region-specific prevention and treatment of this devastating condition.
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Affiliation(s)
- Esther Boot
- Department of Neurology, Radboud Univerisity Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, Nijmegen, The Netherlands
| | - Merel Sanne Ekker
- Department of Neurology, Radboud Univerisity Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, Nijmegen, The Netherlands
| | - Jukka Putaala
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Steven Kittner
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Frank-Erik De Leeuw
- Department of Neurology, Radboud Univerisity Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, Nijmegen, The Netherlands
| | - Anil M Tuladhar
- Department of Neurology, Radboud Univerisity Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, Nijmegen, The Netherlands
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Camillo FX, Mitchell SM. Cervical Spine Decompression and Fusion Outcomes in Trauma Patients Actively Receiving Anticoagulation Treatment for Cerebrovascular Injury: A Retrospective Comparative Study. Int J Spine Surg 2020; 14:66-71. [PMID: 32128305 DOI: 10.14444/7009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Cervical spine blunt trauma patients with the presence of a cerebrovascular injury may be given initiation of heparin anticoagulation treatment prior to necessary surgical stabilization. Literature regarding the safety and efficacy of these procedures while a patient is on active anticoagulation is limited, requiring further investigation. The primary research question for this study is: Can cervical spine decompression and fusion in the context of a blunt cerebrovascular injury and anticoagulation therapy be completed safely? To accomplish this a comparison of outcomes and perioperative complications was made to a control group. Methods A total of 63 trauma patients requiring cervical spine decompression and fusion from 2013 to 2015 were identified at our North American level 1 trauma center. Evaluation of patient injury data, bleeding events, postoperative infections, and neurologic outcomes was collected from chart review. The American Spinal Injury Association (ASIA) grading system was used to measure change in postoperative neurologic outcomes. Results Of 63 patients, 14 had a concomitant cerebrovascular injury that required perioperative anticoagulation treatment. In the 14 patients receiving anticoagulation, 11 had anterior and 3 had posterior stabilization. A total of 2 patients experienced a complication (pneumonia and hardware failure), but neither was related to anticoagulation. An elevated prothrombin time value was noted postoperatively in 1 patient, but with no adverse outcome. No bleeding or thrombotic events, surgical site infection, or neurologic deterioration occurred. The difference in postoperative ASIA grades between groups was not significantly different (P = .57). Conclusions The operative cohort receiving anticoagulation therapy did not demonstrate an increase affinity for perioperative complications or a decline in ASIA scores postoperatively when compared to a control cohort. Clinical Relevance Patients with a cerebrovascular injury receiving anticoagulation treatment can undergo safe and successful cervical spine stabilization procedures. Level of Evidence Therapeutic level III.
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Tsuchiya R, Kamide T, Nakajima H, Torio T, Nemoto M, Suzuki K, Kikkawa Y, Kurita H. The distance of cervical vertebral dislocation could be a risk factor for blunt vertebral artery injury after traumatic cervical spine injury. Acta Neurochir (Wien) 2019; 161:2359-2363. [PMID: 31455995 DOI: 10.1007/s00701-019-04041-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 08/11/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Blunt vertebral artery injury (BVAI) is a well-known potentially fatal complication of cervical spine injury. The condition is reported to be associated with vertebral fractures and cervical hyperextension. However, appropriate patient screening methods remain to be elucidated. This study aimed to identify the risk factors associated with BVAI in patients with cervical spine injury. METHODS We conducted a retrospective, observational, single-centered study, including 137 patients with cervical spine injury transferred to our center from April 2007 to December 2016. Evaluation for BVAI was available in 62 patients based on magnetic resonance angiography or multi-detector computed tomography angiography. BVAI was classified using the Biffl grade. RESULTS Among the 62 patients evaluated, 13 (21%) were diagnosed with BVAI. All injuries were classified as Biffl grade 2 (50%) or 4 (50%). Univariate analysis of patients with and without BVAI showed that cervical dislocation (p = 0.041) and low average hemoglobin level (p = 0.032) were associated with BVAI. On multivariate logistic regression analysis, cervical dislocation (odds ratio 1.189; 95% confidence interval 1.011-1.399, p = 0.036) remained a significant predictor of BVAI. Based on receiver operating characteristic (ROC) analysis, a dislocation > 6.7 mm was selected as the optimal cutoff value for prediction of BVAI (sensitivity and specificity, 87.5% and 71.4%, respectively). CONCLUSIONS BVAI frequently occurred in combination with cervical spine dislocation, and the distance of the cervical dislocation was identified as a useful predictor of BVAI.
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Affiliation(s)
- Ryosuke Tsuchiya
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Tomoya Kamide
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan.
| | - Hiroyuki Nakajima
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Tetsuya Torio
- Department of Critical Care and Emergency, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Manabu Nemoto
- Department of Critical Care and Emergency, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Kaima Suzuki
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Yuichiro Kikkawa
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Hiroki Kurita
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
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ARIYADA K, SHIBAHASHI K, HODA H, WATANABE S, NISHIDA M, HANAKAWA K, MURAO M. Bilateral Internal Carotid and Left Vertebral Artery Dissection after Blunt Trauma: A Case Report and Literature Review. Neurol Med Chir (Tokyo) 2019; 59:154-161. [PMID: 30880295 PMCID: PMC6465530 DOI: 10.2176/nmc.cr.2018-0239] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 12/28/2018] [Indexed: 11/30/2022] Open
Abstract
Multi-vessel cervical arterial injury after blunt trauma is rare, and its pathophysiology is unclear. Although blunt cerebrovascular injury is a common cause of cerebral ischemia, its management is still controversial. We describe a 23-year-old man in previously good health who developed three-vessel cervical arterial dissections due to blunt trauma. He was admitted to our emergency and critical care center after a motor vehicle crash. Computed tomography showed a thin, acute subdural hematoma in the right hemisphere and fractures of the odontoid process (Anderson type III), pelvis, and extremities. He was treated conservatively, and about 1 month later, he developed bleariness. Computed tomography angiography showed bilateral internal carotid and left vertebral artery dissection. Aspirin therapy was started immediately, and then clopidogrel was added to the regimen. Two weeks later, magnetic resonance angiography (MRA) showed improved blood flow of the vessels. Only aspirin therapy was continued. About 3 months after discharge, MRA demonstrated further improvement of the blood flow of both internal carotid arteries, but the dissection flap on the right side remained. Therefore, we extended the duration of antiplatelet therapy. On the basis of our experience with this case, we think that antithrombotic therapy is crucial for the management of multi-vessel cervical arterial injury, and agents should be used properly according to the injury grade and phase; however, further study is needed to confirm this recommendation.
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MESH Headings
- Angiography, Digital Subtraction
- Carotid Artery, Internal, Dissection/diagnosis
- Carotid Artery, Internal, Dissection/etiology
- Carotid Artery, Internal, Dissection/therapy
- Humans
- Magnetic Resonance Angiography
- Male
- Vertebral Artery Dissection/diagnosis
- Vertebral Artery Dissection/etiology
- Vertebral Artery Dissection/therapy
- Wounds, Nonpenetrating/complications
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/therapy
- Young Adult
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Affiliation(s)
- Kenichi ARIYADA
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Keita SHIBAHASHI
- Department of Emergency and Critical Care Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Hidenori HODA
- Department of Emergency and Critical Care Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Shinta WATANABE
- Department of Emergency and Critical Care Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Masahiro NISHIDA
- Department of Emergency and Critical Care Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Kazuo HANAKAWA
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Masahiko MURAO
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
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