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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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2
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Tuan NHN, Van Khoa L, Van Tien Bao N, Tu PD, Van Phuoc L. Endovascular management of giant post-traumatic pseudoaneurysm in cavernous sinus: A case report. Radiol Case Rep 2023; 18:2514-2518. [PMID: 37214327 PMCID: PMC10199404 DOI: 10.1016/j.radcr.2023.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 04/12/2023] [Indexed: 05/24/2023] Open
Abstract
A 20-year-old male was admitted with the history of a traumatic head injury after traffic accident. The physical examination revealed blurred vision, swelling of the right face, and minor epistaxis. CT and MRI findings revealed a giant pseudoaneurysm of cavernous carotid artery. The patient was enrolled endovascular coils embolization of the internal carotid artery. After the procedure, the patient recovered well. Endovascular treatment is an effective therapy in cavernous carotid pseudoaneurysm.
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Bai J, Kessler A, Kawakyu-O'Connor D. Development of Anterior Cranial Fossa Dural Arteriovenous Fistula and Supraclinoid Internal Carotid Artery Pseudoaneurysm Following Frontobasal Trauma: A Case Report and Literature Review. Cureus 2023; 15:e42330. [PMID: 37614272 PMCID: PMC10443888 DOI: 10.7759/cureus.42330] [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: 07/23/2023] [Indexed: 08/25/2023] Open
Abstract
Cerebrovascular injuries resulting from frontobasal head trauma represent a range of imaging and clinical presentations. Severe cerebrovascular injuries such as vessel transection commonly present with profound neurological deficits and are often easily identified with routine imaging. However, small intimal injuries and dissections may be challenging to detect and may be clinically silent or masked by additional injuries in the setting of polytrauma. The onset of symptoms and complications from cerebrovascular injuries may be delayed from the time of initial presentation, and failure to recognize and diagnose these injuries may result in devastating outcomes if management is delayed. In this case report, we present a case of frontobasal craniofacial trauma that resulted in an anterior cranial fossa dural arteriovenous fistula (ACF-dAVF) and supraclinioid segment internal carotid artery (ICA) pseudoaneurysm.
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Affiliation(s)
- James Bai
- Imaging Science, University of Rochester Medical Center, Rochester, USA
| | - Alex Kessler
- Radiology, University of Rochester Medical Center, Rochester, USA
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4
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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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5
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Fromm J, Meuwly E, Wendling-Keim D, Lehner M, Kammer B. Clival fractures in children: a challenge in the trauma room setting! Childs Nerv Syst 2021; 37:1199-1208. [PMID: 33245407 DOI: 10.1007/s00381-020-04963-2] [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: 06/13/2020] [Accepted: 11/04/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE A clival fracture is a rare but life-threatening traumatic brain injury in the adult and pediatric populations. To date, there are very few conclusive recommendations in the literature concerning the diagnosis and treatment of pediatric clival fractures. METHODS In 2014 and 2015, two pediatric patients with severe blunt head trauma and clival fractures were evaluated and treated at a level I trauma center. Both cases are documented and supplemented by an extensive review of the literature focusing on the diagnostic workup, classification, and clinical course of clival fractures in children. RESULTS The clinical course of two children (8 and 9 years old) with clival fractures in concert with other intra- and extracranial injuries was analyzed. A total of 17 papers encompassing 37 patients (age range, 1-18 years) were included for a systematic review. The literature review revealed a mortality rate of 23% in pediatric patients with a clival fracture. Over 50% of the patients presented with cranial nerve damage, and two-thirds suffered from intracranial vascular damage or intracerebral bleeding. CONCLUSIONS Clival fractures are a very rare but severe consequence of blunt head trauma in the pediatric population and may be challenging to diagnose, especially in cases with an unfused sphenooccipital synchondrosis. Vascular damage following clival fractures appears to be as common in pediatric patients as in adults. Therefore, contrast-enhanced CT of the cervical spine and head and/or magnetic resonance angiography is strongly recommended to rule out vascular injury of the extra- and intracranial brain-supplying vessels within the trauma room setting.
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Affiliation(s)
- Julian Fromm
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Eliane Meuwly
- Department of Pediatric Surgery, Children's Hospital Lucerne, Luzerner Kantonsspital, Spitalstrasse 20, 6000, Lucerne 16, Switzerland
| | - Danielle Wendling-Keim
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Markus Lehner
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337, Munich, Germany. .,Department of Pediatric Surgery, Children's Hospital Lucerne, Luzerner Kantonsspital, Spitalstrasse 20, 6000, Lucerne 16, Switzerland.
| | - Birgit Kammer
- Pediatric Radiology, Department of Clinical Radiology, Ludwig-Maximilians-University Munich, Lindwurmstr. 4, 80337, Munich, Germany
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Lee S, Oh JS, Kim DE, Kim Y. Concomitant Injury of Vagus and Hypoglossal Nerves Caused by Fracture of Skull Base: A Case Report and Literature Review. Korean J Neurotrauma 2020; 16:284-291. [PMID: 33163439 PMCID: PMC7607037 DOI: 10.13004/kjnt.2020.16.e41] [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: 08/27/2020] [Revised: 09/25/2020] [Accepted: 09/29/2020] [Indexed: 11/15/2022] Open
Abstract
Injury of lower cranial nerves (CNs) by skull base fracture after head trauma can occur sometimes. However, selectively different CN damage on either side is extremely rare. A 53-year-old man had difficulty of swallowing, phonation, and articulation after falling off his bicycle. In physical examination, a deviated tongue to the right side was shown. Brain computed tomography showed a skull base fracture involving bilateral jugular foramina and right hypoglossal canal. Left vocal cord palsy was confirmed by laryngoscopy. Electromyography confirmed injury of left superior laryngeal nerve, recurrent laryngeal nerve, and right hypoglossal nerve. Video fluoroscopic swallowing study revealed large amounts of remnant in vallecula and pyriform sinus without opening of upper esophageal sphincter due to dysfunction of cricopharyngeus muscle. After constant rehabilitation for dysphagia, he was allowed to eat a general diet with compensatory techniques at discharge and further recovery after 3 months. Injury of lower CNs after fracture of the skull base can cause severe morbidity. However, the prognosis of such injuries can be favorable with early rehabilitation treatment by identifying the injured CN. A careful and accurate examination of lower CN injury in skull base fracture is essential for planning a treatment strategy.
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Affiliation(s)
- Sanghoon Lee
- Department of Physical Medicine and Rehabilitation, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jae Sang Oh
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Doh-Eui Kim
- Department of Emergency Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Yuntae Kim
- Department of Physical Medicine and Rehabilitation, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
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Angula LN, Sun L, Fang N, Wang X. External auditory canal haemorrhage as the first sign of internal carotid artery pseudoaneurysm, a rare case: a case report. Pan Afr Med J 2020; 37:163. [PMID: 33425196 PMCID: PMC7757232 DOI: 10.11604/pamj.2020.37.163.21968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 10/06/2020] [Indexed: 12/28/2022] Open
Abstract
Assessing the cause, severity of bleeding and strategies to control bleeding is crucial. We describe a rare case of a patient who was presented with epistaxis and left ear haemorrhage, as a probable complication of a ruptured internal carotid artery pseudoaneurysm. The massive haemorrhage compelled blood transfusion and clinical intervention. The diagnosis of internal carotid artery (ICA) pseudoaneurysm measuring 2.9 cm x 3.7 cm was concluded by computed tomography. Several coils were used to embolize the internal carotid artery pseudoaneurysm and arrest the bleeding with the guidance of an angiography. Coiling the pseudoaneurysm is highly recommended. Yet, the best methods to completely treat aneurysm are still in question. After the clinical intervention, the patient remained symptom-free and no episodes of bleeding were noted.
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Affiliation(s)
| | - Le Sun
- Peking Union Medical College Hospital, Beijing, China
| | - Ning Fang
- Peking Union Medical College Hospital, Beijing, China
| | - Xin Wang
- Peking Union Medical College Hospital, Beijing, China
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8
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Moscote-Salazar L, Garcia-Ballestas E, Agrawal A. Clivus fracture and entrapment of the basilar artery. Neurochirurgie 2020; 66:63. [DOI: 10.1016/j.neuchi.2019.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/27/2019] [Accepted: 10/11/2019] [Indexed: 11/26/2022]
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9
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Bassi ST, Noronha V, Halbe S. A Time Bomb Defused, In Time! A Traumatic Optic Neuropathy To Be Wary Of. Neuroophthalmology 2019; 43:32-35. [PMID: 30723522 DOI: 10.1080/01658107.2018.1458886] [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: 11/03/2017] [Revised: 02/28/2018] [Accepted: 03/26/2018] [Indexed: 10/28/2022] Open
Abstract
Authors describe a case of traumatic pseudoaneurysm of cavernous internal carotid artery in a young male who presented with complaints of progressive decrease in vision, inability to move the eye, and delayed epistaxis 8 months after the head injury sustained during a motor vehicle accident. The presence of optic atrophy and epistaxis in the setting of head trauma alerted the authors to look for this potentially life-threatening condition. Timely intervention in the form of endovascular coil occlusion of the internal carotid artery was performed and the epistaxis stopped without any ischaemic or thromboembolic sequaelae.
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Affiliation(s)
| | - Veena Noronha
- Department of Radiology, Sankara Nethralaya, Chennai, India
| | - Swatee Halbe
- Department of Radiology and Imaging Services, Senior Interventional Radiologist Apollo Hospitals, Chennai, India
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10
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Faraji AH, Ochalski PG, Ozpinar A, Blatt JE, Pollack IF. Isolated Traumatic Diastasis of the Clival Synchondroses without Clival Fracture. Pediatr Neurosurg 2018; 53:270-274. [PMID: 29672322 DOI: 10.1159/000488058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 02/26/2018] [Indexed: 12/22/2022]
Abstract
Traumatic clival fractures in the pediatric population are associated with high mortality rates. In our previously reported series, a subset of clival fractures were associated with traumatic diastasis of the surrounding clival synchondroses. Herein, we describe a pediatric case of an isolated traumatic diastasis of the clival synchondroses without clival fracture with significant injury to neurovascular structures. To our knowledge this is the first report to describe this entity. Careful radiological attention should be made towards the clival synchondroses in crushing head injuries to best tailor screening for cerebrovascular injury even in the absence of clival fractures.
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Affiliation(s)
- Amir H Faraji
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA
| | | | - Alp Ozpinar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA
| | - Jason E Blatt
- Department of Neurological Surgery, University of Florida, Gainesville, Florida, USA
| | - Ian F Pollack
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA
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11
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Abstract
Skull base fractures extend through the floor of the anterior, middle, or posterior cranial fossa. They are frequently associated with complex facial fractures and serious complications such as cranial nerve or vascular injury, cerebrospinal fluid leak, or meningitis. Several distinct patterns of skull base fractures have been recognized, each of them associated with different complications. Recognition of, often subtle, skull base fracture is essential to prevent or allow early treatment of these serious complications.
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Affiliation(s)
- Matthew Bobinski
- Department of Radiology, University of California-Davis School of Medicine, Sacramento, California, United States
| | - Peter Y Shen
- Department of Radiology, University of California-Davis School of Medicine, Sacramento, California, United States
| | - Arthur B Dublin
- Department of Radiology, University of California-Davis School of Medicine, Sacramento, California, United States
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12
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Dahlin BC, Waldau B. Surgical and Nonsurgical Treatment of Vascular Skull Base Trauma. J Neurol Surg B Skull Base 2016; 77:396-403. [PMID: 27648396 DOI: 10.1055/s-0036-1583539] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Vascular trauma is associated with blunt skull base fractures and penetrating injuries. We review the contemporary management of cranial vascular trauma, including blunt and penetrating cerebrovascular injury as well as refractory epistaxis from facial trauma.
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Affiliation(s)
- Brian C Dahlin
- Department of Radiology, UC Davis Medical Center, Sacramento, California, United States
| | - Ben Waldau
- Department of Neurosurgery, UC Davis Medical Center, Sacramento, California, United States
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13
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Kelts G, Maturo S, Couch ME, Schmalbach CE. Blunt cerebrovascular injury following craniomaxillofacial fractures: A systematic review. Laryngoscope 2016; 127:79-86. [DOI: 10.1002/lary.26186] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2016] [Indexed: 12/13/2022]
Affiliation(s)
- Gregory Kelts
- Department of Otolaryngology; San Antonio Uniformed Services Health Education Consortium Otolaryngology; San Antonio Texas U.S.A
| | - Stephen Maturo
- Department of Otolaryngology; San Antonio Uniformed Services Health Education Consortium Otolaryngology; San Antonio Texas U.S.A
| | - Marion Everett Couch
- Department of Otolaryngology; Indiana University School of Medicine; Indianapolis Indiana U.S.A
| | - Cecelia E. Schmalbach
- Department of Otolaryngology; Indiana University School of Medicine; Indianapolis Indiana U.S.A
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14
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Yellinek S, Cohen A, Merkin V, Shelef I, Benifla M. Clinical significance of skull base fracture in patients after traumatic brain injury. J Clin Neurosci 2015; 25:111-5. [PMID: 26724846 DOI: 10.1016/j.jocn.2015.10.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 10/10/2015] [Indexed: 10/22/2022]
Abstract
About 4% of all head injuries include skull base fractures. Most of these fractures (90%) are secondary to closed head trauma; the remainder are due to penetrating trauma. We reviewed the records from January 2006 through December 2008 of all patients older than 18 years of age who arrived at Soroka Medical Center in Be'er-Sheva, Israel, with skull base fractures following a traumatic brain injury (TBI). We identified 107 patients with a mean age of 42 years at the time of TBI. Glasgow Coma score on arrival predicted the clinical outcome. We observed temporal fractures in 30% of these patients, occipital fractures in 20%, pyramidal fractures in 19%, anterior skull base fractures in 17%, and multiple fractures in 14%. Cerebrospinal fluid (CSF) leak was observed in 16 patients (15%). Of the patients experiencing CSF leaks, otorrhea occurred in 10 (62%) and rhinorrhea occurred in six (37%). Three patients required surgical intervention to repair the leak. Meningitis occurred in four patients with clinically evident CSF leak. Multiple skull base fractures are associated with poor neurological outcome. The low rate of meningitis in this patient sample implies that there is no indication to administer prophylactic antibiotics to patients with skull base fractures.
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Affiliation(s)
- Shlomi Yellinek
- Neurosurgery Department, Soroka Medical Center and Ben-Gurion University, Be'er-Sheva, Israel
| | - Avi Cohen
- Neurosurgery Department, Soroka Medical Center and Ben-Gurion University, Be'er-Sheva, Israel
| | - Vladimir Merkin
- Neurosurgery Department, Soroka Medical Center and Ben-Gurion University, Be'er-Sheva, Israel
| | - Ilan Shelef
- Neuroradiology Division, Soroka Medical Center and Ben-Gurion University, Be'er-Sheva, Israel
| | - Mony Benifla
- Neurosurgery Department, Hadassah Medical Center, Jerusalem, Israel.
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15
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Buch K, Nguyen T, Mahoney E, Libby B, Calner P, Burke P, Norbash A, Mian A. Association between cervical spine and skull-base fractures and blunt cerebrovascular injury. Eur Radiol 2015; 26:524-31. [DOI: 10.1007/s00330-015-3858-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 05/07/2015] [Accepted: 05/20/2015] [Indexed: 11/29/2022]
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16
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Harrison DA, Griggs KA, Prabhu G, Gomes M, Lecky FE, Hutchinson PJA, Menon DK, Rowan KM. External Validation and Recalibration of Risk Prediction Models for Acute Traumatic Brain Injury among Critically Ill Adult Patients in the United Kingdom. J Neurotrauma 2015; 32:1522-37. [PMID: 25898072 DOI: 10.1089/neu.2014.3628] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
This study validates risk prediction models for acute traumatic brain injury (TBI) in critical care units in the United Kingdom and recalibrates the models to this population. The Risk Adjustment In Neurocritical care (RAIN) Study was a prospective, observational cohort study in 67 adult critical care units. Adult patients admitted to critical care following acute TBI with a last pre-sedation Glasgow Coma Scale score of less than 15 were recruited. The primary outcomes were mortality and unfavorable outcome (death or severe disability, assessed using the Extended Glasgow Outcome Scale) at six months following TBI. Of 3626 critical care unit admissions, 2975 were analyzed. Following imputation of missing outcomes, mortality at six months was 25.7% and unfavorable outcome 57.4%. Ten risk prediction models were validated from Hukkelhoven and colleagues, the Medical Research Council (MRC) Corticosteroid Randomisation After Significant Head Injury (CRASH) Trial Collaborators, and the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) group. The model with the best discrimination was the IMPACT "Lab" model (C index, 0.779 for mortality and 0.713 for unfavorable outcome). This model was well calibrated for mortality at six months but substantially under-predicted the risk of unfavorable outcome. Recalibration of the models resulted in small improvements in discrimination and excellent calibration for all models. The risk prediction models demonstrated sufficient statistical performance to support their use in research and audit but fell below the level required to guide individual patient decision-making. The published models for unfavorable outcome at six months had poor calibration in the UK critical care setting and the models recalibrated to this setting should be used in future research.
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Affiliation(s)
- David A Harrison
- 1 Clinical Trials Unit, Intensive Care National Audit and Research Centre , Napier House, London, United Kingdom
| | - Kathryn A Griggs
- 1 Clinical Trials Unit, Intensive Care National Audit and Research Centre , Napier House, London, United Kingdom
| | - Gita Prabhu
- 1 Clinical Trials Unit, Intensive Care National Audit and Research Centre , Napier House, London, United Kingdom
| | - Manuel Gomes
- 2 Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine , London, United Kingdom
| | - Fiona E Lecky
- 3 School of Health and Related Research, University of Sheffield , Regent Court, Sheffield, United Kingdom
| | - Peter J A Hutchinson
- 4 Department of Clinical Neurosciences, University of Cambridge , Cambridge, United Kingdom
| | - David K Menon
- 5 Division of Anaesthesia, University of Cambridge , Cambridge, United Kingdom
| | - Kathryn M Rowan
- 1 Clinical Trials Unit, Intensive Care National Audit and Research Centre , Napier House, London, United Kingdom
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18
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Abstract
Fractures of the orbitozygomatic complex are one of the most common facial fractures encountered by plastic surgeons. Many would consider this to be primarily a cosmetic deformity; however, these injuries can be associated with acute life-threatening complications. Intracranial pseudoaneurysm, although rare, is a well-documented complication of blunt facial trauma, which most plastic surgeons are unaware of. We present the case of a 20-year-old woman who developed an intracranial pseudoaneurysm after blunt facial trauma to illustrate the importance of (1) understanding this rare but highly morbid complication, (2) assessing high-risk patients for pseudoaneurysm, and (3) delaying reconstruction in high-risk patients.
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19
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Agrawal A, Singh SP. Acute subdural and intracerebral hematoma in the vicinity of the sylvian fissure. INDIAN JOURNAL OF NEUROTRAUMA 2013. [DOI: 10.1016/j.ijnt.2013.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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20
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Sung EK, Nadgir RN, Sakai O. Computed tomographic imaging in head and neck trauma: what the radiologist needs to know. Semin Roentgenol 2013; 47:320-9. [PMID: 22929691 DOI: 10.1053/j.ro.2012.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Edward K Sung
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, MA 02118, USA
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Chittiboina P, Banerjee AD, Nanda A. Do concomitant cranium and axis injuries predict worse outcome? A trauma database quantitative analysis. Skull Base 2012; 21:249-54. [PMID: 22470268 DOI: 10.1055/s-0031-1280679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
We performed a trauma database analysis to identify the effect of concomitant cranial injuries on outcome in patients with fractures of the axis. We identified patients with axis fractures over a 14-year period. A binary outcome measure was used. Univariate and multiple logistic regression analysis were performed. There were 259 cases with axis fractures. Closed head injury was noted in 57% and skull base trauma in 14%. Death occurred in 17 cases (6%). Seventy-two percent had good outcome. Presence of abnormal computed tomography head findings, skull base fractures, and visceral injury was significantly associated with poor outcome. Skull base injury in association with fractures of the axis is a significant independent predictor of worse outcomes, irrespective of the severity of the head injury. We propose that presence of concomitant cranial and upper vertebral injuries require careful evaluation in view of the associated poor prognosis.
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Affiliation(s)
- Prashant Chittiboina
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana
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Abstract
OBJECTIVES Determine the prevalence of carotid artery injury (CAI) in patients with basilar skull fractures and describe significant demographic and radiographic risk factors for CAI. STUDY DESIGN From January 2004 to December 2008, medical records of 1,279 consecutive adult patients treated for basilar skull fractures at a tertiary care academic hospital were retrospectively reviewed. Diagnostic angiography was performed in 112 patients because of concern for CAI. Computed tomographic studies of the head and cranial base were reviewed for evidence of pneumocephalus, petrous carotid canal fractures, and sphenoid bone fractures. RESULTS Mean age of patients undergoing angiography was 38.7 years, and 85 patients (75.9%) were male subjects. Thirty-five (50%) of 70 discrete cerebrovascular injuries on angiography involved the carotid canal. The prevalence of CAI in patients with basilar skull trauma was 2.0%. CAI was associated with female sex (p = 0.001), whereas lower Glasgow Coma Scale score approached statistical significance (p = 0.07). Sensitivity and specificity of the 3 computed tomographic findings individually were 44% to 68% and 41% to 67%, respectively. With all 3 findings concurrently, 85% specificity and 80% negative predictive value for CAI were obtained, although sensitivity declined. CONCLUSION The frequency of CAI in patients with basilar skull fractures was higher than that in those without basilar skull involvement. Female sex was strongly associated with CAI. The intimate anatomic relationship between the carotid artery and the cranial base posit substantial diagnostic and therapeutic challenges for the contemporary cranial base surgeon, and thus, understanding the epidemiology and risk factors for CAI is of paramount importance.
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Ochalski PG, Adamo MA, Adelson PD, Okonkwo DO, Pollack IF. Fractures of the clivus and traumatic diastasis of the central skull base in the pediatric population. J Neurosurg Pediatr 2011; 7:261-7. [PMID: 21361764 DOI: 10.3171/2010.12.peds10190] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Fractures of the clivus and traumatic diastases of the clival synchondroses are rare in the pediatric population. The incidence, outcome, and biomechanics associated with these fractures have been difficult to ascertain secondary to the lack of literature pertaining to their occurrence. METHODS A Boolean search of the electronic medical record database at the Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, was performed to identify patients with fractures of the clivus that were diagnosed using CT of the head. A retrospective review of the chart and radiographic imaging was then performed to assess data regarding patient demographics, mechanism of injury, and skull and brain parenchymal injuries, as well as outcomes. RESULTS Between May 2002 and November 2007, 16 patients with fractures of the clivus were identified. The mean age of these patients was 9 years (range 1-16 years). Eleven (68.8%) of the 16 patients had an associated traumatic diastasis of the central skull base. Five (31.3%) of the 16 patients died. However, of the 11 patients who survived, all had a good outcome with a Glasgow Outcome Scale score of 4 or 5 at the time of discharge. The incidence of clival fractures among patients with head injuries was 0.33%. CONCLUSIONS Clival fractures occur with a similar incidence in both the pediatric and adult trauma population. Outcome is not correlated directly with the extent of clival fracture, but rather with the presenting Glasgow Coma Scale score and concomitant brain parenchymal injuries. The identification of traumatic diastases in patients with clival fractures suggests that static loading forces are a significant factor in the biomechanics producing these types of fractures.
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Affiliation(s)
- Pawel G Ochalski
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Abstract
BACKGROUND Blunt cerebrovascular injury (BCVI) to the carotid and vertebral arteries is a potentially devastating injury in trauma patients. The optimal management for BCVI has not been standardized. At our institution, 64-slice multi-detector computed tomographic angiography (CTA) has been used as the initial screening exam for BCVI in patients who met predefined screening criteria. The purpose of this study is to review the incidence of CTA-diagnosed BCVI in at-risk patients and to evaluate the treatment and clinical outcome of patients with BCVI. METHODS This study included trauma patients with a positive diagnosis of BCVI on CTA during a 41-month study period. The medical records and relevant radiographic findings were retrospectively reviewed. RESULTS Twenty seven of 222 blunt trauma patients evaluated with CTA had a positive diagnosis of BCVI, with an occurrence rate of 12.2%. Traumatic brain injury (72.2%) and basal skull fractures (55.6%) were the most frequent associated injuries with carotid trauma while 100% of blunt vertebral injuries occurred in the setting of cervical fractures. Fourteen (51.8%) patients received medical therapy; Eleven (40.7%) patients received conservative treatment. Endovascular treatment was attempted in a single case of vertebral arteriovenous fistula. BCVI-related stroke was found in four patients (14.8%), one of whom developed an infarct while on medical treatment. CONCLUSIONS BCVI is found in a significant portion of blunt trauma patients with identifiable risk factors, and screening CTA has high diagnostic yield in detecting these lesions. Medical therapy is the mainstay of treatment at our institution; however, BCVI-related stroke may occur despite treatment.
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Zhang CW, Xie XD, You C, Mao BY, Wang CH, He M, Sun H. Endovascular treatment of traumatic pseudoaneurysm presenting as intractable epistaxis. Korean J Radiol 2010; 11:603-11. [PMID: 21076585 PMCID: PMC2974221 DOI: 10.3348/kjr.2010.11.6.603] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2010] [Accepted: 07/07/2010] [Indexed: 02/05/2023] Open
Abstract
Objective To investigate the clinical efficacy of individual endovascular management for the treatment of different traumatic pseudoaneurysms presenting as intractable epistaxis. Materials and Methods For 14 consecutive patients with traumatic pseudoaneurysm presenting as refractory epistaxes, 15 endovascular procedures were performed. Digital subtraction angiography revealed that the pseudoaneurysms originated from the internal maxillary artery in eight patients; and all were treated with occlusion of the feeding artery. In six cases, they originated from the internal carotid artery (ICA); out of which, two were managed with detachable balloons, two with covered stents, one by means of cavity embolization, and the remaining one with parent artery occlusion. All of these cases were followed up clinically from six to 18 months, with a mean follow up time of ten months; moreover, three cases were also followed with angiography. Results Complete cessation of bleeding was achieved in all the 15 instances (100%) immediately after the endovascular therapies. Of the six patients who suffered from ICA pseudoaneurysms, one presented with a permanent stroke and one had an episode of rebleeding requiring intervention. Conclusion In patients presenting with a history of craniocerebral trauma, traumatic pseudoaneurysm must be considered as a differential diagnosis. Individual endovascular treatment is a relatively safe, plausible, and reliable means of managing traumatic pseudoaneurysms.
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Affiliation(s)
- Chang wei Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
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Ochalski PG, Spiro RM, Fabio A, Kassam AB, Okonkwo DO. FRACTURES OF THE CLIVUS. Neurosurgery 2009; 65:1063-9; discussion 1069. [DOI: 10.1227/01.neu.0000360154.18604.28] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
We report the morbidity and mortality associated with fractures of the clivus and discuss management approaches specific to this unique diagnostic entity.
METHODS
We performed a boolean search of our electronic medical record database to identify patients with fractures of the clivus that were diagnosed using computed tomography of the head. A retrospective imaging and chart analysis was completed to further characterize the fractures and to analyze outcomes.
RESULTS
Between January 1999 and December 2007, 41 patients were identified with fractures of the clivus. We found a 0.21% overall incidence among all head-injured patients presenting to our institution and a 2.3% incidence among those patients with a cranial fracture. Ten of 41 patients (24.4%) died, and neurological and vascular complications associated with central cranial base fractures were observed in 19 of 41 patients (46%). Furthermore, associated cranial fractures remote from the central cranial base and associated intracranial hemorrhages were observed in 40 of 41 (97.6%) and 33 of 41 (80.5%) patients, respectively. In terms of outcomes, 26 of 41 patients (63.5%) had a Glasgow Coma Scale score of 12 or greater at the time of discharge from the hospital.
CONCLUSION
We demonstrate a lower than previously reported mortality rate in patients with clival fractures. Nevertheless, as a result of location, fractures of the clivus were frequently associated with a high rate of complications and neurological sequelae.
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Affiliation(s)
- Pawel G. Ochalski
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Richard M. Spiro
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Anthony Fabio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amin B. Kassam
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Jamshidi S, Kandiah PA, Singhal AB, Resnick JB, Furie KL, Borczuk P, Parry BA, Lev M, Koroshetz WJ, Chang Y, Nagurney JT. Clinical predictors of significant findings on head computed tomographic angiography. J Emerg Med 2009; 40:469-75. [PMID: 19854018 DOI: 10.1016/j.jemermed.2009.08.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Revised: 05/31/2009] [Accepted: 08/29/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Although head computed tomographic angiography (CTA) is a sensitive tool for the evaluation of neurological symptoms in the emergency department (ED), little is known about which clinical signs predict significant CTA findings. OBJECTIVES To identify clinical factors that predict significant findings on head CTA in patients presenting to the ED with neurological complaints. METHODS Retrospective chart review of consecutive adult patients undergoing head CTA over a 6-month period in an urban, tertiary care ED with an annual volume of 76,000. Significant head CTA findings were defined as clinically significant neurological abnormalities undetected by previous imaging studies. Demographics, chief complaint, results of the neurological examinations (NE), and head non-contrast computed tomography (CT) results were used as predictors of significant head CTA. All predictors with a univariate p < 0.2 using Pearson's chi-squared were entered stepwise into a multivariable logistic regression including odds ratios (OR), with inclusion restricted to p < 0.05. RESULTS Chart review yielded 456 cases; 215 (47%) were male. Mean age was 62 (SD 20) years. There were 189 patients (41%) with abnormal CTAs. Multivariable logistic regression indicated five variables that predicted a clinically significant CTA: abnormal CT (OR 3.72), chief complaint of subarachnoid hemorrhage-type headache (OR 2.30), and motor deficit (OR 2.23), visual deficit (OR 2.23), and other focal deficit (OR 2.18) on NE. A chief complaint of trauma (OR 0.23) predicted a normal CTA. CONCLUSIONS Specific historical and focal neurological findings are useful for predicting clinically significant findings on head CTA.
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Affiliation(s)
- Soheil Jamshidi
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Sliker CW. Blunt Cerebrovascular Injuries: Imaging with Multidetector CT Angiography. Radiographics 2008; 28:1689-708; discussion 1709-10. [DOI: 10.1148/rg.286085521] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Zanini MA, Tahara A, Santos GSD, Freitas CCMD, Jory M, Caldas JGMP, Pereira VM. Pseudoaneurysm of the internal carotid artery presenting with massive (recurrent) epistaxes: a life-threatening complication of craniofacial trauma. ARQUIVOS DE NEURO-PSIQUIATRIA 2008; 66:268-71. [DOI: 10.1590/s0004-282x2008000200029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Cerebrovascular trauma. Eur Radiol 2008; 18:1531-45. [PMID: 18392832 DOI: 10.1007/s00330-008-0915-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2007] [Revised: 12/24/2007] [Accepted: 01/11/2008] [Indexed: 10/22/2022]
Abstract
Vascular injury of the head and neck region is a rare and often life-threatening complication of head or neck trauma and is due to two major pathomechanisms: penetrating or blunt trauma. Both the arterial and the venous site of the CNS vasculature can be involved, the latter one being often overlooked. Concerning arterial lesions, depending on how many layers of the arterial vessel are affected and on the spatial relationship to adjacent structures, dissections, false aneurysms or arteriovenous fistulae may develop. On the venous side, dural tears, compressive effects on pial veins and a deranged clotting system may lead to delayed venous thrombosis. In this review we describe clinical and imaging findings, as well as diagnostic and treatment strategies in these lesions.
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