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Goyal K, Sunny JT, Gillespie CS, Wilby M, Clark SR, Kaiser R, Fehlings MG, Srikandarajah N. A Systematic Review and Meta-Analysis of Vertebral Artery Injury After Cervical Spine Trauma. Global Spine J 2024; 14:1356-1368. [PMID: 37924280 PMCID: PMC11289537 DOI: 10.1177/21925682231209631] [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] [Indexed: 11/06/2023] Open
Abstract
STUDY DESIGN Systematic Review and Meta-Analysis. OBJECTIVE Identify the incidence, mechanism of injury, investigations, management, and outcomes of Vertebral Artery Injury (VAI) after cervical spine trauma. METHODS A systematic review and meta-analysis were conducted in accordance with the PRISMA guidelines (PROSPERO-ID CRD42021295265). Three databases were searched (PubMed, SCOPUS, Google Scholar, CINAHL PLUS). Incidence of VAI, investigations to diagnose (Computed Tomography Angiography, Digital Subtraction Angiography, Magnetic Resonance Angiography), stroke incidence, and management paradigms (conservative, antiplatelets, anticoagulants, surgical, endovascular treatment) were delineated. Incidence was calculated using pooled proportions random effects meta-analysis. RESULTS A total of 44 studies were included (1777 patients). 20-studies (n = 503) included data on trauma type; 75.5% (n = 380) suffered blunt trauma and 24.5% (n = 123) penetrating. The overall incidence of VAI was .95% (95% CI 0.65-1.29). From the 16 studies which reported data on outcomes, 8.87% (95% CI 5.34- 12.99) of patients with VAI had a posterior stroke. Of the 33 studies with investigation data, 91.7% (2929/3629) underwent diagnostic CTA; 7.5% (242/3629) underwent MRA and 3.0% (98/3629) underwent DSA. Management data from 20 papers (n = 475) showed 17.9% (n = 85) undergoing conservative therapy, anticoagulation in 14.1% (n = 67), antiplatelets in 16.4% (n = 78), combined therapy in 25.5% (n = 121) and the rest (n = 124) managed using surgical and endovascular treatments. CONCLUSION VAI in cervical spine trauma has an approximate posterior circulation stroke risk of 9%. Optimal management paradigms for the prevention and management of VAI are yet to be standardized and require further research.
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Affiliation(s)
- Kartik Goyal
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Northern General Hospital, Sheffield Teaching Hospital Trusts, Sheffield, UK
| | - Jesvin T. Sunny
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Cambridge University Hospital NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
| | - Conor S. Gillespie
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Martin Wilby
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Simon R. Clark
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Radek Kaiser
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
| | - Michael G. Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Nisaharan Srikandarajah
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Institute of Systems, Molecular and Integrative Biology, Liverpool, UK
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Ohgaki F, Takadera M, Okano M, Tatezuki J, Mochimatsu Y. Basilar Artery Occlusion Caused by Extracranial Vertebral Artery Dissection on Its Entry into the Transverse Foramen of the C6 Vertebra: Case Report. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:225-229. [PMID: 37869484 PMCID: PMC10586882 DOI: 10.5797/jnet.cr.2023-0039] [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: 05/15/2023] [Accepted: 08/08/2023] [Indexed: 10/24/2023]
Abstract
Objective Basilar artery occlusion (BAO) is an infrequent form of acute life-threatening stroke and may occur secondary to vertebral artery dissection (VAD). VAD, which occurs spontaneously and sometimes results from mechanical stress or blunt force trauma to the neck, sometimes occurs in the V1-V2 junction, but there are not many reported cases of those. Herein, we report a pictorially illustrative and clinically informative case of VAD in the V1-V2 junction following BAO. Case Presentation The patient was a 27-year-old woman who was transferred to our hospital with abrupt severe unconsciousness. On admission, she presented with generalized convulsions and respiratory arrest, and pan-scan CT and CTA indicated BAO. We performed mechanical thrombectomy and achieved recanalization of the basilar artery, and she was diagnosed with BAO secondary to the right VAD at the entry of the C6 transverse foramen (V1-V2 junction). In hindsight, she had scapula and back pain before the onset. She recovered with a modified Rankin scale score of 3 after 90 days from the onset. Conclusion VAD sometimes occurs at its entry into the transverse foramen of the C6 vertebra. In this case, VAD may be affected by minor trauma and potentially histological fragility due to the embryonic development process. Although BAO is sometimes difficult to diagnose because it presents with various symptoms, BAO secondary to VAD should be considered in cases of abrupt severe unconsciousness preceded by neck, scapula, or back pain in young and healthy persons.
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Affiliation(s)
- Fukutaro Ohgaki
- Department of Neurosurgery, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa, Japan
| | - Mutsumi Takadera
- Department of Neurosurgery, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa, Japan
| | - Masayuki Okano
- Department of Neurosurgery, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa, Japan
| | - Junya Tatezuki
- Department of Neurosurgery, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa, Japan
| | - Yasuhiko Mochimatsu
- Department of Neurosurgery, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa, Japan
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Ishimoto Y, Iwasaki H, Sonekatsu M, Murata S, Kozaki T, Hashizume H, Tsutsui S, Takami M, Nagata K, Hira K, Kato S, Yamada H. Ultrasonography is an effective tool for the evaluation of traumatic vertebral artery injuries distal to fourth cervical vertebra in the emergency room. BMC Musculoskelet Disord 2023; 24:314. [PMID: 37087444 PMCID: PMC10122399 DOI: 10.1186/s12891-023-06426-6] [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: 06/09/2022] [Accepted: 04/12/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND This study aimed to determine the feasibility of ultrasonography in the assessment of cervical vertebral artery (VA) injury as an alternative to computed tomography angiography (CTA) in the emergency room. METHODS We analyzed 50 VAs from 25 consecutive patients with cervical spine injury that had been admitted to our emergency room. Ultrasonography and CTA were performed to assess the VA in patients with cervical spine injury. We examined the sensitivity and specificity of ultrasonography compared with CTA. RESULTS Among these VAs, six were occluded on CTA. The agreement between ultrasonography and CTA was 98% (49/50) with 0.92 Cohen's Kappa index. The sensitivity, specificity, and positive and negative predictive values of ultrasonography were 100%, 97.7%, 85.7%, and 100%, respectively. In one case with hypoplastic VA, the detection of flow in the VA by ultrasonography differed from detection by CTA. Meanwhile, there were two cases in which VAs entered at C5 transverse foramen rather than at C6 level. However, ultrasonography could detect the blood flow in these VAs. CONCLUSIONS Ultrasonography had a sensitivity of 100% compared with CTA in assessment of the VA. Ultrasonography can be used as an initial screening test for VA injury in the emergency room.
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Affiliation(s)
- Yuyu Ishimoto
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8510, Japan
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8510, Japan
| | - Hiroshi Iwasaki
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8510, Japan.
| | - Mayumi Sonekatsu
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8510, Japan
| | - Shizumasa Murata
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8510, Japan
| | - Takuhei Kozaki
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8510, Japan
| | - Hiroshi Hashizume
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8510, Japan
| | - Shunji Tsutsui
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8510, Japan
| | - Masanari Takami
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8510, Japan
| | - Keiji Nagata
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8510, Japan
| | - Kazuhiro Hira
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8510, Japan
| | - Seiya Kato
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8510, Japan
| | - Hiroshi Yamada
- Department of Orthopedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8510, Japan
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Asukai M, Ushirozako H, Suda K, Matsumoto Harmon S, Komatsu M, Minami A, Takahata M, Iwasaki N, Matsuyama Y. Safety of early posterior fusion surgery without endovascular embolization for asymptomatic vertebral artery occlusion associated with cervical spine trauma. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:3392-3401. [PMID: 35821446 DOI: 10.1007/s00586-022-07302-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/24/2022] [Accepted: 06/23/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE Vertebral artery occlusion (VAO) is an increasingly recognized complication of cervical spine trauma. However, the management strategy of VAO remains heavily debated. Therefore, the aim of this retrospective study was to investigate the safety of early fusion surgery for traumatic VAO. METHODS This study included a total of 241 patients (average age 64.7 years; 201 men) who underwent early surgical treatment for acute cervical spine injury between 2012 and 2019. The incidence of VAO, cerebral infarction rates, the recanalization rates, and cerebral thromboembolism after recanalization were retrospectively analyzed. RESULTS VAO occurred in 22 patients (9.1%). Of the 22 patients with VAO, radiographic cerebral infarction was detected in 4 patients (21.1%) at initial evaluation, including 1 symptomatic medullar infarction (4.5%) and 3 asymptomatic cerebrum infarctions. A patient who experienced right medullar infarction showed no progression of the neurologic damage. Follow-up imaging revealed that the VAOs of 9 patients (40.9%) were recanalized, and the recanalization did not correlate with clinical adverse outcomes. The arteries of the remaining 13 (59.1%) patients remained occluded and clinically silent until the final follow-up (mean final follow-up 33.0 months). CONCLUSION Despite the lack of a concurrent control group with preoperative antiplatelet therapy or endovascular embolization for VAO, our results showed low symptomatic stroke rate (4.5%), high recanalization rate (40.9%), and low mortality rate (0%). Therefore, we believe that the indication for early stabilization surgery as management strategy of asymptomatic VAO might be one of the safe and effective treatment options for prevention of symptomatic cerebral infarction.
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Affiliation(s)
- Mitsuru Asukai
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido, 072-0015, Japan.
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan.
| | - Hiroki Ushirozako
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido, 072-0015, Japan
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Kota Suda
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido, 072-0015, Japan
| | - Satoko Matsumoto Harmon
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido, 072-0015, Japan
| | - Miki Komatsu
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido, 072-0015, Japan
| | - Akio Minami
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido, 072-0015, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Yukihiro Matsuyama
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
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Meng Q, Xie X, Li L, Jiang C, Zhao K, Bai Z, Zheng Z, Yang Y, Yu Y, Zhang H, Zhao X. Assessment of neovascularization of carotid artery atherosclerotic plaques using superb microvascular imaging: a comparison with contrast-enhanced ultrasound imaging and histology. Quant Imaging Med Surg 2021; 11:1958-1969. [PMID: 33936978 DOI: 10.21037/qims-20-933] [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] [Indexed: 12/20/2022]
Abstract
Background This study aimed to investigate the usefulness of superb microvascular imaging (SMI), a novel non-contrast-enhanced ultrasound technique, in characterizing neovessels within carotid atherosclerotic plaques through comparison with contrast-enhanced ultrasound (CEUS) and histology. Methods Patients with carotid plaque were recruited and underwent SMI and CEUS ultrasound imaging of the carotid arteries. The maximum plaque thickness, length, and stenosis of each plaque were measured. Grade of the neovessels was determined by SMI and CEUS, respectively. Grade 0 was defined as no blood flow signal/microbubbles within plaques; grade 1 was defined as moderate blood flow signals/microbubbles confined to the shoulder and/or adventitial side of the plaque; and grade 2 was defined as extensive intraplaque signals/microbubbles. Patients with symptomatic carotid stenosis (stenosis ≥50%) or asymptomatic carotid stenosis (stenosis ≥70%) underwent endarterectomy, and plaque specimens were subjected to immunohistochemical analysis of CD31 expression. The neovessels were quantified by histology. The agreement of SMI with CEUS and histology in characterizing neovessels was analyzed using weighted Kappa statistic and Spearman's correlation analyses. Results Seventy-eight patients (mean age: 67.3±8.9 years old, 63 males) were recruited. Of these patients, 52 (66.7%) had a unilateral plaque and 26 (33.3%) had bilateral plaques in the carotid arteries. For the 104 carotid plaques detected, the mean plaque thickness and length were 4.3±1.1 and 18.8±6.6 mm, respectively. The prevalence of <50%, 50-69%, and ≥70% stenosis was 43.3%, 24.0%, and 32.7%, respectively. Excellent agreement was found between SMI and CEUS (κ=0.825 at the plaque level; κ=0.820 at the patient level) in evaluating the neovessel grade within the carotid plaques. Of the 25 patients who underwent carotid endarterectomy, a strong correlation (r=0.660, P<0.001) was found between SMI and histology in the evaluation of intraplaque neovessels. SMI had excellent scan-rescan (κ=0.857), intra-reader (κ=0.810), and inter-reader (κ=0.754) agreement in the assessment of intraplaque neovessels. Conclusions The SMI technique is capable of reliably characterizing neovessels within carotid atherosclerotic plaques and demonstrates good to excellent agreement with histology and CEUS.
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Affiliation(s)
- Qi Meng
- Department of Ultrasound, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Xia Xie
- Department of Ultrasound, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Li Li
- Department of Pathology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Chao Jiang
- Department of Vascular Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Keqiang Zhao
- Department of Vascular Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Zhiyong Bai
- Department of Ultrasound, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Zhuozhao Zheng
- Department of Radiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yu Yang
- Department of Vascular Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yan Yu
- Department of Pathology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Huabin Zhang
- Department of Ultrasound, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Xihai Zhao
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, China
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Mahadhipta H, Shiddieqy Pohan MA, Bakri AH. Vertebral artery injury due to air rifle: A case report. Ann Med Surg (Lond) 2021; 63:102149. [PMID: 33659055 PMCID: PMC7890135 DOI: 10.1016/j.amsu.2021.01.097] [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: 12/26/2020] [Revised: 01/27/2021] [Accepted: 01/27/2021] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION This case report presents a rare case of vertebral artery and spinal cord injury due to air rifle pellet. CASE PRESENTATION A previously healthy 19-year-old male was shot on his left neck incidentally during recreational air rifle game. He was taken to the other hospital before being referred to our hospital. CLINICAL FINDINGS AND INVESTIGATIONS The patient presented with total loss of motoric function on his left side of the body together with sensoric function on the contralateral side from the level of C5 and below. Signs of stroke were also spotted on the patient's face. The cervical plain radiograph and CT scan were carried out preoperatively to depict pellet fragments. Meanwhile, the CT angiography which was commenced postoperatively revealed the left vertebral artery injury. INTERVENTIONS Surgery comprising of pellet fragments removal, decompression and posterior stabilization of the cervical spine was carried out to retrieve the pellet fragments, which were embedded at the posterior epidural space. RELEVANCE AND IMPACT Our findings were consistent with the vertebral artery injury and Brown-Sequard syndrome. Hence, these clinical entities should be considered in the setting of penetrating cervical trauma.
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Ramamurti P, Weinreb J, Fassihi SC, Rao R, Patel S. Vertebral Artery Injury in the Cervical Spine: Anatomy, Diagnosis, and Management. JBJS Rev 2021; 9:e20.00118. [PMID: 33470592 DOI: 10.2106/jbjs.rvw.20.00118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
» Although rare, injury to the vertebral artery (VA) can occur after blunt trauma or iatrogenically during surgery. Clinicians should be aware of the anatomic variants of the VA, the presence of which may increase the risk of iatrogenic VA injury (VAI). » If VAI is suspected following blunt trauma, rapid identification via advanced imaging modalities, such as computed tomography angiography, can help clarify the site of injury and guide management. » VAI can be classified according to the Denver grading scale for blunt cerebrovascular injury, ranging from grade I to grade V, which includes intimal narrowing, pseudoaneurysm formation, complete occlusion, and arterial transection. » Treatment modalities remain controversial and include anticoagulation, endovascular interventions, surgical tamponade, ligation, and microvascular repair. The choice of treatment is influenced by the setting of the injury (iatrogenic injury in the operating room versus blunt trauma in the field) and the laterality of the dominant VA with respect to brain perfusion.
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Affiliation(s)
- Pradip Ramamurti
- George Washington School of Medicine and Health Sciences, Washington, DC
| | - Jeffrey Weinreb
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
| | - Safa C Fassihi
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
| | - Raj Rao
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
| | - Shalin Patel
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
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Jaffe TA, Harris NS, Wittels K, Wilcox SR. Found Down at Home. J Emerg Med 2020; 59:705-709. [PMID: 32828602 DOI: 10.1016/j.jemermed.2020.06.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/07/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Todd A Jaffe
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - N Stuart Harris
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kathleen Wittels
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan R Wilcox
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
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LaRiccia AK, Wolff TW, Magee DJ, Patel R, Hoenninger DW, Oxs'Mara MS, Pandya UB, Hill JH, Nguyen TV, Spalding MC. Variability of radiological grading of blunt cerebrovascular injuries in trauma patients. Int J Crit Illn Inj Sci 2020; 10:81-87. [PMID: 32904506 PMCID: PMC7456289 DOI: 10.4103/ijciis.ijciis_103_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/20/2020] [Accepted: 02/13/2020] [Indexed: 11/19/2022] Open
Abstract
Context: Blunt cerebrovascular injury (BCVI) occurs in 1%–2% of all blunt trauma patients. Computed tomographic angiography of the neck (CTAn) is commonly used for the diagnosis and grading of BCVIs. Grade of injury dictates treatment, and there remains a lack in understanding the inter-reader reliability of these interpretations. Aims: The aim of this study is to determine the extent of variability in BCVIs among specialized neuroradiologist interpretation of CTAn. Settings and Design: Retrospective review of trauma patients admitted to a level one trauma center with a BCVI from January 2012 to December 2017. Patients were randomly assigned for CTAn re-evaluation by two of three blinded, neuroradiologists. Statistical Analysis Used: The variability in BCVI grades was measured using the coefficient of unalikeability (u), and inter-reader reliability was calculated using weighted Cohen's kappa (k). Results: Two hundred and twenty-eight BCVIs were analyzed with initial grades of 71 (31%) grade one, 74 (32%) grade two, 26 (11%) grade three, 57 (25%) grade four, and 0 grade five. Variability was present in 93 (41%) of all BCVIs. Grade one injuries had the lowest occurrence of total agreement (31%) followed by grade three (61%), grade two (63%), and grade four (92%). Total variability of grade interpretations (u = 100) occurred most frequently with grade three BCVIs (21%). Weighted Cohen's k calculations had a mean of 0.07, indicating poor reader agreement. Conclusions: This novel study demonstrated the BCVI variability of radiological grade interpretation occurs in more than a third of patients. The reliability of CTAn interpretation of BCVI grades is not uniform, potentially leading to undertreatment and overtreatment.
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Affiliation(s)
- Aimee K LaRiccia
- Division of Trauma and Acute Care Surgery, Ohio Health Grant Medical Center, Athens, OH, USA.,Department of Surgery, Ohio Health Doctors Hospital, Athens, OH, USA.,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Timothy W Wolff
- Division of Trauma and Acute Care Surgery, Ohio Health Grant Medical Center, Athens, OH, USA.,Department of Surgery, Ohio Health Doctors Hospital, Athens, OH, USA.,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | | | | | | | - M Shay Oxs'Mara
- Division of Trauma and Acute Care Surgery, Ohio Health Grant Medical Center, Athens, OH, USA.,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Urmil B Pandya
- Division of Trauma and Acute Care Surgery, Ohio Health Grant Medical Center, Athens, OH, USA.,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Joshua H Hill
- Division of Trauma and Acute Care Surgery, Ohio Health Grant Medical Center, Athens, OH, USA.,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Thanh V Nguyen
- Division of Trauma and Acute Care Surgery, Ohio Health Grant Medical Center, Athens, OH, USA.,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - M Chance Spalding
- Division of Trauma and Acute Care Surgery, Ohio Health Grant Medical Center, Athens, OH, USA.,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
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Abu Mughli R, Wu T, Li J, Moghimi S, Alem Z, Nasir MU, Abdellatif W, Nicolaou S. An Update in Imaging of Blunt Vascular Neck Injury. Can Assoc Radiol J 2020; 71:281-292. [PMID: 32174162 DOI: 10.1177/0846537120909468] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Traumatic injuries of the cervical carotid and vertebral arteries, collectively referred to as blunt cerebrovascular injury (BCVI), can result in significant patient morbidity and mortality, with one of the most feared outcomes being cerebrovascular ischemia. Systematic imaging-guided screening for BCVI aims for early detection to guide timely management. In particular, accurate detection of the severity and grade of BCVI is paramount in guiding initial management. Furthermore, follow-up imaging is required to decide the duration of antithrombotic therapy. In this article, classification of the grades of BCVI and associated imaging findings will be outlined and diagnostic pitfalls and mimickers that can confound diagnosis will be described. In addition, updates to existing screening guidelines and recent efforts of criteria modification to improve detection of BCVI cases will be reviewed. The advent of postprocessing tools applied to conventional computed tomography (CT) angiograms and new diagnostic tools in dual energy CT for improved detection will also be discussed.
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Affiliation(s)
- Rawan Abu Mughli
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Tong Wu
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Jessica Li
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Saba Moghimi
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Zersenay Alem
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Muhammad Umer Nasir
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Waleed Abdellatif
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Savvas Nicolaou
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
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