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Purpose
The aim of this study was to evaluate the true incidence of cervical artery dissections (CeADs) in trauma patients with an Injury Severity Score (ISS) of ≥16, since head-and-neck computed tomography angiogram (CTA) is not a compulsory component of whole-body trauma computed tomography (CT) protocols.
Patients and methods
A total of 230 con...
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Purpose:
Spontaneous cervicocephalic dissection (SCAD) is an important cause of stroke and shows various lesion locations and clinical features. The purpose of this study was to analyze the location of SCAD and its clinical and radiologic patterns in Korean patients.
Materials and methods:
Patients with SCAD who were evaluated between 2013 and 2...
Background: Headache is one of the most common symptoms that are encountered in the postpartum period. We experienced a rare case of multiple phenomena of postpartum stroke occurred at the same time.
Case: A 38-year-old woman experienced sudden onset of thunderclap headache after delivery. We diagnosed cervicocephalic arterial dissection (CAD), and...
We report a case of vertebral artery dissecting aneurysm (VADA) that developed with subarachnoid hemorrhage and was found to be occluded based on subsequent digital subtraction angiography. Few reports have been published on ruptured VADA in which ipsilateral vertebral arteries are occluded. The proper management of this type of aneurysm is controv...
Spontaneous vertebral artery dissecting aneurysm has been increasingly attributed as a major cause of focal neurological deficits due to vertebrobasilar artery ischemia or subarachnoid hemorrhage (SAH). Although the development of spontaneous vertebral artery dissecting aneurysm (VADA) is rare, de novo VADA after treatment of contralateral vertebra...
Stroke in the young is an uncommon condition resulting in significant morbidity and as result trammels the integrity of healthcare systems [1]. We present an unusual case of a 37-year-old male presenting with neurologic signs of right parietal lobe infarction with evidence of vertebral artery dissection and persistent carotid-vertebrobasilar anasto...
Citations
... У новітній лі-тературі всі травматичні артеріовенозні фістули класифіковані як V ступеня за шкалою W.L. Biffl та співавт. [34,35]. Каротидно-кавернозні фістули спеціально не включені до цієї класифікації. ...
... Лікування спрямоване переважно на запобігання або полегшення вторинної травми. Наприклад, підвищений ризик вторинного інсульту у разі закритої цереброваскулярної травми можна значно зменшити за умови швидкого лікування [34][35][36]. ...
Traumatic cerebrovascular injuries following blunt or penetrating trauma are common and carry a high risk of permanent disability or death. Proper screening, diagnosis, and treatment of these lesions is essential to improve patient outcomes. Advances in imaging continue to improve the accuracy of non-invasive diagnosis of these injuries while new clinical data provide better evidence for optimal management, whether medical or invasive. Here, we review screening, diagnosis, and treatment of traumatic cerebrovascular injuries.
... Extracranial traumatic vertebral artery injury (eTVAI) occurs in approximately 1-2% of non-penetrating head and neck traumas. [1][2][3][4] Most patients are initially asymptomatic but have an increased risk for delayed stroke and mortality. [4][5][6][7] Guidelines for eTVAI are outdated and supported predominantly by Level 3 evidence. ...
Background
Non-penetrating head and neck trauma is associated with extracranial traumatic vertebral artery injury (eTVAI) in approximately 1–2% of cases. Most patients are initially asymptomatic but have an increased risk for delayed stroke and mortality. Limited evidence is available to guide the management of asymptomatic eTVAI. As such, we sought to investigate national practice patterns regarding screening, treatment, and follow-up domains.
Methods
A cross-sectional, electronic survey was distributed to members of the Canadian Neurosurgical Society and Canadian Spine Society. We presented two cases of asymptomatic eTVAI, stratified by injury mechanism, fracture type, and angiographic findings. Screening questions were answered prior to presentation of angiographic findings. Survey responses were analyzed using descriptive statistics.
Results
One hundred-eight of 232 (46%) participants, representing 20 academic institutions, completed the survey. Case 1: 78% of respondents would screen for eTVAI with computed topography angiography (CTA) (97%), immediately (88%). The majority of respondents (97%) would treat with aspirin (89%) for 3–6 months (46%). Respondents would follow up clinically (89%) or radiographically (75%), every 1–3 months. Case 2: 73% of respondents would screen with CTA (96%), immediately (88%). Most respondents (94%) would treat with aspirin (50%) for 3–6 months (35%). Thirty-six percent of respondents would utilize endovascular therapy. Respondents would follow up clinically (97%) or radiographically (89%), every 1–3 months.
Conclusion
This survey of Canadian practice patterns highlights consistency in the approach to screening, treatment, and follow-up of asymptomatic eTVAI. These findings are relevant to neurosurgeons, spinal surgeons, stroke neurologists, and neuro-interventionalists.
... Strokes after a carotid dissection are associated with a mortality rate of 25% and morbidity of 38%. 15 The integration of CTA head and neck into polytrauma protocols is becoming more common, but there must still be a high clinical suspicion for BCVI in what appear to be minor whiplash injuries. This case supports the conditional recommendation of the recent EAST guidelines and the recent 2020 study by Leichtle et al regarding universal screening for BCVI with CTA neck in all trauma patients. ...
Introduction:
Traumatic carotid artery dissections (CAD) are rare but produce potentially devastating injuries. Most patients develop symptoms within 72 hours of traumatic injury.
Case report:
We report the case of a 33-year-old, previously healthy male who presented to the emergency department for evaluation of transient, right-sided facial droop with visual changes. His symptoms began 12 days after falling off a scooter. Imaging revealed an extracranial internal CAD.
Conclusion:
Symptoms of CAD may present weeks after blunt trauma, making clinical diagnosis difficult. Clinicians must have high suspicion for vascular injury and consider neuroimaging in cervical flexion/extension injuries.
... For example, the increased risk of secondary stroke with BCVI can be dramatically reduced with prompt management. [34][35][36] ...
Traumatic cerebrovascular injuries following blunt or penetrating trauma are common and carry a high risk of permanent disability or death. Proper screening, diagnosis, and treatment of these lesions is essential to improve patient outcomes. Advances in imaging continue to improve the accuracy of non-invasive diagnosis of these injuries while new clinical data provide better evidence for optimal management, whether medical or invasive. Here, we review screening, diagnosis, and treatment of traumatic cerebrovascular injuries.
... [1][2][3][4] With growing attention on BCVI diagnosis and increasing use of high-resolution CT imaging, more BCVIs are diagnosed, and the true incidence may even be higher than previous literature reports. [5][6][7][8][9][10][11][12][13][14] Despite the increasing incidence of BCVIs, little is known about risk factors for subsequent stroke formation. Studies have demonstrated the importance of early diagnosis and initiation of medical therapy. ...
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 (ie: Aspirin®), radiographic features, and protocolization of care.
Methods:
An EAST-sponsored, 16 center, prospective, observational trial was undertaken. Stroke risk factors were analyzed individually for vertebral artery (VA) and internal carotid artery (ICA) BCVI. BCVI were graded on the standard 1-5 scale. Data was from the initial hospitalization only.
Results:
777 BCVIs were included. Stroke rate was 8.9% for all BCVI, 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.
Conclusions:
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.Study Type/Level of EvidenceOriginal article, prognostic and epidemiological, Level III.
... Исследование обычно включает МСКТ головы и шеи без контрастирования, а также груди, живота и таза с контрастированием. Обсуждается включение в протоколы WBCT КТ-ангиографии головы и шеи для выявления относительно редко встречающихся при политравме (6,5% случаев), но опасных повреждений сонных и позвоночных артерий [22]. NICE рекомендует провести перед выполнением WBCT линейное рентгеновское сканирование от головы до стоп для диагностики повреждений конечностей [5]. ...
... Доза облучения при применении WBCT в зависимости от протокола исследования составляет 17,2-49,7 мЗв [22,37,39] и значимо (в 1,5-2 раза) выше, чем при выполнении целенаправленных рентгенологических исследований отдельных областей тела [25]. Позиционирование рук пациента над головой снижает дозу облучения при WBCT в 1,8 раза, но увеличивает длительность сканирования на 3-7 мин, поэтому рекомендуется для пациентов со стабильной гемодинамикой. ...
... Позиционирование рук пациента над головой снижает дозу облучения при WBCT в 1,8 раза, но увеличивает длительность сканирования на 3-7 мин, поэтому рекомендуется для пациентов со стабильной гемодинамикой. Исследование в положении рук вдоль тела занимает наименьшее время, но дает наибольшую дозу облучения, поэтому рекомендуется у больных с нестабильной гемодинамикой [22]. Итеративная реконструкция изображений уменьшала дозу облучения на 10-34% [39] без значимого снижения качества изображения. ...
The review considers the problem of choosing the optimal tactical approach to primary emergency radiation diagnosis of injuries during polytrauma based on data on indications for use, advantages and disadvantages of modern methods and protocols of radiation imaging. Literary sources were searched in the MedLine/ PubMed and eLibrary databases published from 2009 to 2019.
The tactics of selective radiation diagnosis of polytrauma involves performing sequential studies (sonography, X-ray, computed tomography) of body areas in which damage is suspected by the mechanism of injury and clinical data, which limits the accuracy of the diagnosis and increases the duration of the examination. Primary multi-helical “whole-body”computed tomography including head, neck, chest, abdomen and pelvis examination, reduces the percentage of missed injuries, the duration of the examination and the time before emergency surgery, which can significantly reduce mortality in polytrauma. Its use is justified in patients with severe combined trauma if a high level of emergency hospital care organization is provided. Using “whole-body” computed tomography significantly increases the dose and economic costs, but the benefits of it for the survival of patients with polytrauma can outweigh the radiation risk and economic losses. Further development of technologies and protocols for multispiral computed tomography can significantly reduce the dose of radiation and the duration of the study. Clear and well-founded criteria for the selection of patients are needed for whom the use of “whole-body” computed tomography will be an effective strategy for radiation diagnosis.
... In the transarticular approach as per Magerl's technique, the screw trajectory passes through the C1-C2 facet joint and anterior C1 arch. By comparison, in the C1 lateral mass and C2 pedicle approach as per Goel's technique, 1 screw is placed at the midpoint between the center of the C1 lateral mass and the 31 investigated prospectively the incidence of cervical artery dissections in 230 trauma patients who underwent whole-body CT and head-and-neck CT angiography. Of 230 patients, 6.5% had a cervical artery dissection, 5.2% had a carotid artery dissection, and 1.7% had a VA dissection. ...
Introduction
Intra-operative vascular injuries in the cervical spine are rare, but carry significant morbidity and mortality when they do occur. There is a need to better characterize the risk of vertebral artery injury after posterior C1-C2 fusion.
Objective
To investigate the rate of the vertebral artery injury for patients undergoing posterior C1-C2 cervical fusion.
Methods
An electronic database search was performed to identify studies that reported rates of vertebral artery injury following posterior cervical fusion at the C1-C2 level. Patient-specific risk factors, surgical indication, surgical technique and others were collected for each study. Forest plots were created to outline the pooled ratios of vertebral artery injury in the literature.
Results
A total of 11 studies with 773 patients were identified. The mean age of subjects was 48.47 years (range 6 to 78 years) and the majority of patients were females (61.7 %, n = 399). Trauma was the most frequent indication for surgery (18.8%, n = 146), followed by inflammatory processes affecting the vertebrae (13.2%, n = 102). The rate of vertebral artery injury per patient was 2% [95%CI: 1%-4%] among 773 patients, while per screw rate was 1% [95%CI: 0%- 2%] for a total of 2238 screws placed.
Conclusion
The rate of vertebral artery injury after C1-C2 posterior cervical fusion was found to be 2% for each operated patient and 1% for each screw placed.
... Euler et al. were able to show that in 25% of cases at least one diagnosis remains undiscovered in severely injured patients [1]. With a mortality rate of up to 33% and a neurological morbidity rate of up to 38%, traumatic carotid artery dissections and vertebral artery dissections are serious injuries in complex and severely injured patients [2][3][4]. The majority of these diseases remain initially asymptomatic, which might lead to a missed diagnosis [3,4] and avoidable delays in therapy such as anticoagulation, surgery, or endovascular treatment by thrombectomy or stenting. ...
... With a mortality rate of up to 33% and a neurological morbidity rate of up to 38%, traumatic carotid artery dissections and vertebral artery dissections are serious injuries in complex and severely injured patients [2][3][4]. The majority of these diseases remain initially asymptomatic, which might lead to a missed diagnosis [3,4] and avoidable delays in therapy such as anticoagulation, surgery, or endovascular treatment by thrombectomy or stenting. Traumatic cervical vessel dissections may result from rapid movement, both acceleration and deceleration, of the head in relation to the neck in any axis or blunt trauma. ...
... In November 2018, the whole-body CT scanning protocol was modified to a single-bolus split-scan approach including a dedicated contrast-enhanced head-and-neck CT-A triggered in the Aorta ascendens. The aim of this modification was to further optimize the detection rate of cervical artery dissections as we already had a non-dedicated head-and-neck angiogram as a mandatory component of our scanning protocol [4] with fixed-delay scanning. ...
Introduction:
Traumatic cervical artery dissections are associated with high mortality and morbidity in severely injured patients. After finding even higher incidences than reported before, we decided to incorporate a dedicated head-and-neck computed tomography angiogram (CT-A) in our imaging routine for patients who have been obviously severely injured or, according to trauma mechanism, are suspected to be severely injured.
Materials and methods:
A total of 134 consecutive trauma patients with an ISS ≥ 16 admitted to our level I trauma center during an 18 month period were included. All underwent standardized whole-body CT in a 256-detector row scanner with a dedicated head-and-neck CT-A realized as single-bolus split-scan routine. Incidence, mortality, patient and trauma characteristics, and concomitant injuries were recorded and analyzed in patients with carotid artery dissection (CAD) and vertebral artery dissection (VAD).
Results:
Of the 134 patients included, 7 patients had at least one cervical artery dissection (CeAD; 5.2%; 95% CI 1.5-9.0%). Six patients (85.7%) had carotid artery dissections, with one patient having a CAD of both sides and one patient having a CAD and contralateral VAD combined. Two patients (28.6%) showed a VAD. Overall mortality was 14.3%, neurologic morbidity was 28.6%. None of the patients showed any attributable neurologic symptoms on admission. The new scanning protocol led to further 5 patients with suspected CeAD during the study period, all ruled out by additional magnetic resonance imaging with angiogram (MRI/MR-A).
Conclusion:
A lack of specific neurologic symptoms on admission urges the need for a dedicated imaging pathway for severely injured patients, reliable for the detection of cervical artery dissections. Although our modified CT protocol with mandatory dedicated CT-A led to false positives requiring additional magnetic resonance imaging, it likely helped reduce possible therapeutic delays.
... Missed injuries are a major concern in the management of trauma patients; in 25% of severely injured patients, at least one diagnosis remains undetected [1]. Traumatic blunt carotid or vertebral artery injuries are associated with mortality rates of up to 33% and a neurological morbidity of up to 38%; however, initially, a high proportion of cervical artery dissections remains asymptomatic [2]. ...
... Schicho et al. investigated 230 consecutive trauma patients with an injury severity score of ≥16 admitted to our level I trauma center using head-and-neck CT angiography [2]. Of these 230 patients, 6.5% had a cervical artery dissections. ...
A 50-year-old man driving a motorcycle at 100 kph crashed at a curve on a racing course. On arrival, he had clear consciousness, and his vital signs showed mild hypertension and tachycardia. His chief complaint was general pain. The only physiological finding was a labile injury. Whole-body computed tomography only showed fluid collection at the left maxillary sinus. While waiting on the results of a blood examination in the emergency room (ER), monitoring triggered an alarm due to a reduction in the percutaneous oxygen saturation. When a nurse checked him, he lost consciousness and entered respiratory arrest, showing left conjugated deviation and a palpable radial artery. He underwent indwelling tracheal intubation with mechanical ventilation. On the second hospital day, he regained consciousness and respiration and was therefore extubated. Brain magnetic resonance imaging revealed cerebellar infarction due to occlusion of a right vertebral artery, probably due to traumatic dissection. He was ultimately discharged on foot. This is a rare case of sudden-onset coma with respiratory arrest in the ER after a traffic accident due to occlusion of the right vertebral artery despite a clear consciousness on arrival. Physicians should closely monitor high-energy traffic accident victims, even when the patient has a clear consciousness and only minor physiological findings.
... 2e4 Cervical artery dissections are associated with mortality rates of up to 33% and a neurological morbidity rate of up to 38%. 5 The onset of symptoms and signs is frequently delayed, and a high proportion of ICAD remains asymptomatic with difficult diagnosis. 6 The lack of recognition of this injury is associated with delayed treatment and potentially adverse consequences. ...
Internal carotid artery dissection (ICAD) following motorcycle accidents is unusual but life-threatening if not promptly diagnosed and treated. We report the case of motorcyclist involved in a frontal collision with a car, suffering injuries due to direct blunt trauma, and to indirect trauma by sudden deceleration force. Bilateral ICAD was diagnosed by Computed tomography angiogram five days after the accident. Here in, starting from a medico legal case we emphasized some clinical criteria to make a promptly diagnosis to prevent permanent neurological deficit in this pathology whose best management is still under the debate. An unusual case of ICAD is described with regard to both forensic and promptly diagnostic therapeutic management.
