Factors associated with stroke formation in blunt cerebrovascular injury: An EAST multicenter study

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.

The association of ABO blood groups and trauma outcomes: A retrospective analysis of 3779 patients

Background:

There is currently a lack of understanding regarding the link between ABO blood types with outcomes of traumatically injured patients. The purpose of this study was to determine the association of ABO blood types with outcomes in traumatically injured patients separated by injury type.

Methods:

This retrospective study evaluated trauma patients at an urban, Level 1 trauma center from January 1, 2017, through December 31, 2017. Patients were excluded if they were pregnant or <16 years old. Recorded outcomes included: ABO blood group, mortality, Injury Severity Score (ISS), race, injury type, mechanism of injury, and complications. Data analysis was performed using descriptive statistics including Chi-squared, Kruskal–Wallis, and F-test calculations.

Results:

A total of 3779 patients were included in this study. No significant differences were present in mean age or ISS between blood types. In patients with penetrating injuries, blood type O was associated with a significant increase in mortality (P = 0.017), red blood cell transfusion (P = 0.027), and massive transfusion protocol (MTP) (P = 0.026) compared to non-O blood types. In patients with blunt injuries, blood type AB was associated with a significant increase in mortality rate compared to non-AB blood types (P = 0.03).

Conclusion:

ABO blood type is connected with an underlying process which affects trauma outcomes, including mortality. Blood type O is associated with increased blood transfusion, MTP, and mortality during the initial hospitalization following a traumatic penetrating injury, while blood type AB is associated with increased mortality during the initial hospitalization following a blunt traumatic injury.

Variability of radiological grading of blunt cerebrovascular injuries in trauma patients

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.

Incidence of intraoperative hypotension in acute traumatic spinal cord injury and associated factors

OBJECTIVE

The importance of maintaining mean arterial pressure (MAP) > 85 mm Hg for patients with acute spinal cord injury (SCI) is well documented, because systemic hypotension greatly increases the risk of secondary SCI. Current literature focuses on the ICU setting; however, there is a paucity of data describing the changes in MAP in the operating room (OR). In the present study, the authors investigated the incidence of intraoperative hypotension for patients with acute traumatic SCI as well as any associated factors that may have impacted these findings.

METHODS

This retrospective study was performed at a level 1 trauma center from 2015 to 2016. All patients with American Spinal Injury Association (ASIA) score A-D acute traumatic SCIs from C1 to L1 were identified. Those included underwent spinal instrumentation and/or laminectomy decompression. Associated factors investigated include the following: age, body mass index, trauma mechanism of injury, Injury Severity Score, level of SCI, ASIA score, hospital day of surgery, total OR time, need for laminectomy decompression, use of spinal fixation, surgical positioning, blood loss, use of blood products, length of hospital stay, length of ICU stay, and discharge disposition. Intraoperative minute-by-minute MAP recordings were used to determine time spent in various MAP ranges.

RESULTS

Thirty-two patients underwent a total of 33 operations. Relative to the total OR time, patients spent an average of 51.9% of their cumulative time with an MAP < 85 mm Hg. Furthermore, 100% of the study population recorded at least one MAP measurement < 85 mm Hg. These hypotensive episodes lasted a mean of 103 cumulative minutes per operative case. Analysis of associated factors demonstrated that fall mechanisms of injury led to a statistically significant increase in intraoperative hypotension compared to motor vehicle collisions/motorcycle collisions (p = 0.033). There were no significant differences in MAP recordings when analyzed according to all other associated factors studied.

CONCLUSIONS

This is the first study reporting the incidence of intraoperative hypotension for patients with acute traumatic SCIs, and the results demonstrated higher proportions of relative hypotension than previously reported in the ICU setting. Furthermore, the authors identified that every patient experienced at least one MAP below the target value, which was much greater than the initial hypothesis of 50%. Given the findings of this study, adherence to the MAP protocol intraoperatively needs to be improved to minimize the risk of secondary SCI and associated deleterious neurological outcomes.

Silicone block interposition for traumatic bone loss

In situations where bone is lost secondary to trauma, the use of a hand-carved silicone block provides good results. When bone grafting is undertaken, a well-defined membrane will have enveloped the implant. Incising the membrane allows easy block removal, and after freshening the bone ends, a cavity awaits the bone graft. This technique offers simplicity and adequate stability for therapy, and secondary bone grafting is facilitated by the created space.

Synchronous subungual glomus tumours in adjacent digits

In the hand, glomus tumours usually present as a single lesion comprising one or more discrete masses affecting the subungual area of one digit. We report a case in which typical glomus tumours occurred simultaneously in the subungual area of two adjacent digits.

Ulnar nerve compression in Guyon's canal caused by calcinosis in scleroderma

Calcium deposits in Guyon's canal secondary to scleroderma caused low ulnar nerve paralysis in a 70-year-old white woman. Excision of calcium deposits resulted in rapid alleviation of pain. After nerve regeneration, the patient's clawing disappeared, and she was able to abduct and adduct all digits.

Guillain-Barré syndrome during childhood

Guillain-Barré syndrome is an acquired disease of the peripheral nervous system. The etiology appears to be autoimmune in nature. The major clinical features are progressive weakness and loss of reflexes, with respiratory failure being a serious complication. The prognosis for Guillain-Barré syndrome in children is good with proper intensive care and early detection of the disease.

A case of neurofibroma of the palmar cutaneous branch of the median nerve

This case report describes a previously unreported entity, a neurofibroma of the palmar cutaneous branch of the median nerve. The lesion presented as a palmar mass with an overlying abnormality of the skin. Treatment consisted of excision of the lesion. Infiltration of the terminal branches of the nerve by the tumour prevented nerve reconstruction but provided a previously unknown diagnostic clue: fibrosis of an area of skin innervated by the involved nerve, which had the appearance of a callosity.

Haemangioma of the digital nerve: a case report

An intra-neural haemangioma of the digital nerve of the left index finger is described, the first report of such a lesion in a digit. Treatment consisted of excision of the tumour and the affected portion of the nerve, followed by direct coaptation of the nerve ends.

Transfer of the trapezius for flail shoulder after brachial plexus injury

Shoulder arthrodesis is often used to treat flail shoulder after a brachial plexus injury, but has a high complication rate and entails loss of passive mobility. We have reviewed 27 patients with brachial plexus injury treated by transfer of the trapezius to the proximal humerus at an average time from injury of 31.3 months. Pre-operatively, all 27 shoulders were subluxated, with an average abduction of 3.5 degrees. Postoperatively, shoulder abduction averaged 45.4 degrees, and subluxation was abolished. All patients were satisfied with their improvement in function. Trapezius transfer is recommended as a simple procedure that requires only a brief period in hospital, allows early rehabilitation, and gives a satisfactory outcome, while retaining passive mobility of the shoulder.

Ring avulsion injuries: classification and prognosis

Fifty-five cases of ring avulsion injury were reviewed to examine how extent of injury and surgical management correlated with results. After injury, three patients had adequate circulation. Of 52 patients with inadequate circulation, 8 had primary amputation; salvage was attempted in 44. Of these 44, 9 fingers were amputated secondarily, 19 were successfully revascularized, and 16 were successfully replanted. Return-to-work time averaged between 4.5 and 10.3 weeks. Cold symptoms occurred in 65% of salvaged fingers. Range of motion was usually normal at the metacarpophalangeal joint; most patients had 90 degrees or better combined arc of motion at the proximal and distal interphalangeal joints. Two-point discrimination of less than 10 mm returned in 47% of patients with injured nerves. Most patients whose fingers were successfully salvaged were glad they had had the procedure. We conclude that amputated digits are salvageable and propose a classification system that includes skeletal injury.

The lateral arm free flap in releasing severe contracture of the first web space

To permanently release severe contracture of the first web space, suitable additional skin must be provided. Local skin is often insufficient and is unable to fill the depths of the space. Pedicle flaps are bulky, require a second operation for division, and frequently demand further procedures for revision. A precisely tailored lateral arm free flap allows unparalleled correction to be achieved with one surgical intervention. The operation can be performed under regional anaesthesia with morbidity restricted to one extremity.

Delayed rupture of the extensor pollicis longus tendon after nonunion of a fracture of the dorsal radial tubercle

Several apparently conflicting mechanisms have been proposed to explain the seemingly spontaneous delayed rupture of the extensor pollicis longus tendon (EPL). The following case, the first of its kind of which we are aware, may help to clarify the relationships between these mechanisms. Traumatic hyperextension of a patient's wrist brought the styloid process of the third metacarpal into contact with Lister's tubercle, fracturing it. Chronic chafing of the EPL on the nonunited fracture's jagged surface seemed to cause its spontaneous rupture 18 months later. The long period between accident and rupture is evidence that rupture was not caused by crush injury. Because a fracture of Lister's tubercle will not normally be visible on radiographs, after accidents in which this may have occurred or when the EPL ruptures more than 3 months after injury, we recommend that special radiographs of Lister's tubercle be taken to determine if such a fracture exists.

Transmetacarpal amputations and replantation: the importance of the normal vascular anatomy

Three transmetacarpal injuries are described in which the patency of one common digital vessel alone provided blood flow to all fingers. Transverse commissural vessels connect the digital vessels proximal to the proximal and distal interphalangeal joints. Retrograde flow to the adjacent common digital vessels revascularises the other digits. The volar metacarpal vessels, if not ligated, may allow continued bleeding into the palm following reattachment of a transmetacarpal amputation. These vessels may have been responsible for failure of the replantation in one case.

The Lateral Arm Free Flap in Releasing Severe Contracture of the First Web Space

To permanently release severe contracture of the first web space, suitable additional skin must be provided. Local skin is often insufficient and is unable to fill the depths of the space. Pedicle flaps are bulky, require a second operation for division, and frequently demand further procedures for revision. A precisely tailored lateral arm free flap allows unparalleled correction to be achieved with one surgical intervention. The operation can be performed under regional anaesthesia with morbidity restricted to one extremity.

Transmetacarpal Amputations and Replantation: The Importance of the Normal Vascular Anatomy

Three transmetacarpal injuries are described in which the patency of one common digital vessel alone provided blood flow to all fingers. Transverse commissural vessels connect the digital vessels proximal to the proximal and distal interphalangeal joints. Retrograde flow to the adjacent common digital vessels revascularises the other digits.

The volar metacarpal vessels, if not ligated, may allow continued bleeding into the palm following reattachment of a transmetacarpal amputation. These vessels may have been responsible for failure of the replantation in one case.

Perichondrial resurfacing arthroplasty in the hand

A retrospective study of 36 perichondrial resurfacing arthroplasties, 16 metacarpophalangeal (MP) joints, and 20 proximal interphalangeal (PIP) joints with a minimum follow-up of 3 years was conducted to further define indication and contraindication of this procedure. The overall results for MP joints were 56% good, 25% fair, and 19% revision, and for PIP joints, 55% good, 15% fair, and 30% revision. All arthroplasties for healed pyarthrosis failed. Concomitant tendon repair was a cofactor in the high failure rate. Patient age had a direct influence on the outcome of the arthroplasty. In MP joint arthroplasties, 100% of patients in their 20s had good results and 75% in their 30s had good results. In PIP joint arthroplasties, 75% of patients in their teens and 66% in their 20s had good results. Good results were not recorded in MP or PIP joints for patients older than 40 years of age. Perichondrial resurfacing arthroplasty should be considered contraindicated in the treatment of arthropathies resulting from healed pyarthrosis, systemic diseases with joint involvement, concomitant tendon reconstruction, and age over 40 years. The procedure is indicated and can be utilized in the treatment of traumatic arthritis of the MP and PIP joints of the hand in young individuals.

Primary microsurgical repair of ring avulsion amputation injuries

Patients with ring avulsion injuries of the fourth and fifth digits often demand attempts at reconstruction rather than completion of the amputation. In the past, this has led to reconstruction involving a staged series of operations with results that were often less than desirable. Seven patients with ring avulsion amputation injuries that were reconstructed by use of microsurgical reanastomoses are reported. All were classified as either Carroll type IV or Urbaniak type III. Six patients (85%) had a successful replantation leading to a useful finger. The operating time averaged 5.5 hours. On average, 1.9 arteries (range 1 to 2) and 3.3 veins (range 2 to 5) were repaired for each digit. Average hospital stay was 6.7 days (range 4 to 15). Average range of motion was 0(2)/84(2) for metacarpophalangeal joint and 15(2)/90(2) for proximal interphalangeal joint (PIP) with distal interphalangeal joint ankylosis at between 0(2) and 15(2) of flexion. Sensibility was protective in all cases and good in three. If the PIP joint was damaged, completion of amputation was the treatment of choice. If the amputation is distal to the PIP with a functional superficialis tendon, primary microsurgical repair is the treatment of choice in complex ring avulsion injuries.

Reconstruction of severe transmetacarpal mutilating hand injuries by combined second and third toe transfer

This paper reports on nine instances of combined second and third toe-to-hand transfers in eight patients for severe transmetacarpal mutilating hand injuries. In four cases, the transfer included an innervated flap from the fibular side of the great toe to provide sensibility to a previously constructed osteoplastic thumb. Prehensile function was significantly improved by providing chuck or tripod pinch as well as improved pulp-to-pulp and lateral pinch. At a mean follow-up of 20.3 months, there was only one failure.