Blunt cerebrovascular injury screening with 64-channel multidetector computed tomography: more slices finally cut it

A bibliometric analysis of blunt cerebrovascular injury: the top 50 most instrumental articles

OBJECTIVE

Blunt cerebrovascular injury (BCVI) is a collective term describing blunt-force trauma involving the carotid and/or vertebral arteries. As awareness, screening protocols, and diagnostic modalities have advanced over recent decades, reported incidence has risen accordingly. This bibliometric review examines the most highly cited literature on BCVI, spotlighting key academic trends, influential authors, and journals that have shaped our current understanding.

METHODS

The Scopus database was queried for BCVI-related articles published through June 2024 with titles, abstracts, and/or keywords containing the terms "BCVI" OR "blunt cerebrovascular injury" OR " blunt carotid artery injury" OR "blunt carotid artery trauma" OR "traumatic carotid artery dissection" OR "blunt vertebral artery injury" OR "blunt vertebral artery trauma" OR "traumatic vertebral artery dissection." Results were organized by descending citation count and followed by citations per year. The top 50 most-cited articles were selected for analysis. Additional data collected included document titles, publication year, authors, specialty of the first author, affiliations, country of origin, and publishing journal.

RESULTS

This study retrieved 426 BCVI-related articles published since 1974. The top 50, published between 1974 and 2018, garnered 6,760 citations, with an average of 135.2 citations per article, and a mean self-citation rate of 8.83%.

CONCLUSIONS

This bibliometric analysis maps the academic landscape of BCVI, presenting valuable insights into its evolution and the pivotal studies that have informed our knowledge and clinical practice thus far. It serves as a foundation for future research directions and clinical advancements, aimed at enhancing patient outcomes in the face of blunt cerebrovascular trauma.

CLINICAL TRIAL NUMBER

Not applicable.

Traumatic vertebral artery occlusion is associated with high rates of recanalization: insights from a systematic review and meta-analysis

BACKGROUND

Vertebral artery occlusion (VAO) is a known complication of blunt cervical injuries and can be associated with a risk of devastating strokes. VAO can spontaneously recanalize, particularly following cervical spine intervention. The aim of this study is to examine overall recanalization rates, recanalization in the context of cervical spine intervention, and the associations between VAO and stroke, spinal cord injury, and acute cervical deformity.

METHODS

We conducted a systematic review and meta-analysis of literature using Medline, EMBASE, Cochrane, and manual citation searches. Included studies reported at least 5 adult patients with traumatic VAO and delayed radiographic outcomes, unless embolization was performed for permanent occlusion during the initial admission. Cervical spine intervention was defined as open surgery or external traction. Random effects meta-analysis was used.

RESULTS

Fifteen of 755 studies were included. VAO was associated with spinal cord injury in 67% of cases (95%CI, 43-92%, n = 132, p < 0.001) and acute cervical deformity in 73% (95%CI, 62-83%, n = 91, p < 0.001). The incidence of stroke at presentation was 13% (95%CI, 6-19%, n = 269, p < 0.001). The overall rate of VAO recanalization was 36% in non-embolized patients (95%CI, 23-48%, n = 285, p < 0.001). When only studies reporting on cervical spine intervention were considered, the rate of recanalization post-intervention was 57% (95%CI, 30-85%, n = 45, p < 0.001). Follow-up periods were highly variable, ranging from 1 to 103 weeks.

CONCLUSIONS

A substantial portion of traumatic VAOs recanalized at follow-up, with more than half of patients undergoing cervical spine intervention recanalizing. The analyses revealed considerable heterogeneity, likely indicative of variability in clinical practices, established guidelines and reporting standards. These findings offer important insights into the natural history of traumatic VAO and should be considered when choosing management strategies for this patient population.

Evaluating Artificial Intelligence in Spinal Cord Injury Management: A Comparative Analysis of ChatGPT-4o and Google Gemini Against American College of Surgeons Best Practices Guidelines for Spine Injury

STUDY DESIGN

Comparative Analysis.

OBJECTIVES

The American College of Surgeons developed the 2022 Best Practice Guidelines to provide evidence-based recommendations for managing spinal injuries. This study aims to assess the concordance of ChatGPT-4o and Gemini Advanced with the 2022 ACS Best Practice Guidelines, offering the first expert evaluation of these models in managing spinal cord injuries.

METHODS

The 2022 ACS Trauma Quality Program Best Practices Guidelines for Spine Injury were used to create 52 questions based on key clinical recommendations. These were grouped into informational (8), diagnostic (14), and treatment (30) categories and posed to ChatGPT-4o and Google Gemini Advanced. Responses were graded for concordance with ACS guidelines and validated by a board-certified spine surgeon.

RESULTS

ChatGPT was concordant with ACS guidelines on 38 of 52 questions (73.07%) and Gemini on 36 (69.23%). Most non-concordant answers were due to insufficient information. The models disagreed on 8 questions, with ChatGPT concordant in 5 and Gemini in 3. Both achieved 75% concordance on clinical information; Gemini outperformed on diagnostics (78.57% vs 71.43%), while ChatGPT had higher concordance on treatment questions (73.33% vs 63.33%).

CONCLUSIONS

ChatGPT-4o and Gemini Advanced demonstrate potential as valuable assets in spinal injury management by providing responses aligned with current best practices. The marginal differences in concordance rates suggest that neither model exhibits a superior ability to deliver recommendations concordant with validated clinical guidelines. Despite LLMs increasing sophistication and utility, existing limitations currently prevent them from being clinically safe and practical in trauma-based settings.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular Trauma

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with vascular trauma with the aim of assisting physicians in selecting the optimal management strategy.

METHODS

The guidelines are based on scientific evidence completed with expert opinion. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to the ESVS evidence grading system, where the strength (class) of each recommendation is graded from I to III, and the letters A to C mark the level of evidence.

RESULTS

A total of 105 recommendations have been issued on the following topics: general principles for vascular trauma care and resuscitation including technical skill sets, bleeding control and restoration of perfusion, graft materials, and imaging; management of vascular trauma in the neck, thoracic aorta and thoracic outlet, abdomen, and upper and lower extremities; post-operative considerations after vascular trauma; and paediatric vascular trauma. In addition, unresolved vascular trauma issues and the patients' perspectives are discussed.

CONCLUSION

The ESVS clinical practice guidelines provide the most comprehensive, up to date, evidence based advice to clinicians on the management of vascular trauma.

Diagnosis and management of blunt cerebrovascular injuries: What you need to know

ABSTRACT

Blunt cerebrovascular injuries are not as rare as they were once thought to be-but they still have the same potential for disastrous outcomes. They may occur following any trauma, but more common with higher energy transfer mechanisms. If stroke occurs, prompt recognition and treatment offers the best chance for optimal outcome. Early diagnosis and provision of antithrombotic therapy may prevent strokes, so screening of asymptomatic patients is recommended. Herein we will present what you need to know to diagnose and manage blunt cerebrovascular injury.

Imaging of cerebrovascular complications from blunt skull base trauma

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.

Fractured cervical spine, dissected vertebral artery, and life-threatening stroke: A challenging case report and literature review

INTRODUCTION

Vertebral artery injury (VAI) following blunt trauma can lead to acute or delayed life-threatening posterior fossa ischemic stroke. Its management raises controversial issues and is still open to debate.

MATERIAL & METHOD

We report the case of a 48-year-old male who presented a life-threatening posterior circulation ischemic stroke, secondary to a vertebral artery dissection caused by a cervical spine fracture. This case was successfully managed through intravenous thrombolysis and endovascular thrombectomy followed by antiplatelet therapy and an anterior cervical discectomy and fusion. At the one-year follow-up, the patient had no persisting deficit and was back working as a policeman.

CONCLUSION

Rapid management of patients with dramatic clinical presentation can lead to full recovery. Implications include a systematic screening of blunt trauma VAI through computed tomography angiography when dealing with high-risk cervical spine fractures; patients harboring both a cervical spine fracture and a VAI must be transferred to a tertiary referral hospital able to deal both with strokes and cervical spine surgery to ensure responsiveness in case of stroke.

Traumatic Cervical Cerebrovascular Injury and the Role of CTA: AJR Expert Panel Narrative Review

Traumatic cerebrovascular injury (CVI) involving the cervical carotid and vertebral arteries is rare but can lead to stroke, hemodynamic compromise, and mortality in the absence of early diagnosis and treatment. The diagnosis of both blunt cerebrovascular injury (BCVI) and penetrating CVI is based on cerebrovascular imaging. The most commonly used screening criteria for BCVI include the expanded Denver criteria and the Memphis criteria, each providing varying thresholds for subsequent imaging. Neck CTA has supplanted catheter-based digital subtraction angiography as the preferred screening modality for CVI in patients with trauma. This AJR Expert Panel Narrative Review describes the current state of CTA-based cervical imaging in trauma. We review the most common screening criteria for BCVI, discuss BCVI grading scales that are based on neck CTA, describe the diagnostic performance of CTA in the context of other imaging modalities and evolving treatment strategies, and provide a practical guide for neck CTA implementation.

The effect of circle of willis anatomy and scanning practices on outcomes for blunt cerebrovascular injuries

BACKGROUND

Limited research has explored the effect of Circle of Willis (CoW) anatomy among blunt cerebrovascular injuries (BCVI) on outcomes. It remains unclear if current BCVI screening and scanning practices are sufficient in identification of concomitant COW anomalies and how they affect outcomes.

METHODS

This retrospective cohort study included adult traumatic BCVIs at 17 level I-IV trauma centers (08/01/2017-07/31/2021). The objectives were to compare screening criteria, scanning practices, and outcomes among those with and without COW anomalies.

RESULTS

Of 561 BCVIs, 65% were male and the median age was 48 y/o. 17% (n = 93) had a CoW anomaly. Compared to those with normal CoW anatomy, those with CoW anomalies had significantly higher rates of any strokes (10% vs. 4%, p = 0.04), ICHs (38% vs. 21%, p = 0.001), and clinically significant bleed (CSB) before antithrombotic initiation (14% vs. 3%, p < 0.0001), respectively. Compared to patients with a normal CoW, those with a CoW anomaly also had ischemic strokes more often after antithrombotic interruption (13% vs. 2%, p = 0.02).Patients with CoW anomalies were screened significantly more often because of some other head/neck indication not outlined in BCVI screening criteria than patients with normal CoW anatomy (27% vs. 18%, p = 0.04), respectively. Scans identifying CoW anomalies included both the head and neck significantly more often (53% vs. 29%, p = 0.0001) than scans identifying normal CoW anatomy, respectively.

CONCLUSIONS

While previous studies suggested universal scanning for BCVI detection, this study found patients with BCVI and CoW anomalies had some other head/neck injury not identified as BCVI scanning criteria significantly more than patients with normal CoW which may suggest that BCVI screening across all patients with a head/neck injury may improve the simultaneous detection of CoW and BCVIs. When screening for BCVI, scans including both the head and neck are superior to a single region in detection of concomitant CoW anomalies. Worsened outcomes (strokes, ICH, and clinically significant bleeding before antithrombotic initiation) were observed for patients with CoW anomalies when compared to those with a normal CoW. Those with a CoW anomaly experienced strokes at a higher rate than patients with normal CoW anatomy specifically when antithrombotic therapy was interrupted. This emphasizes the need for stringent antithrombotic therapy regimens among patients with CoW anomalies and may suggest that patients CoW anomalies would benefit from more varying treatment, highlighting the need to include the CoW anatomy when scanning for BCVI.

LEVEL OF EVIDENCE

Level III, Prognostic/Epidemiological.

Neurovascular Interventions for Neurotrauma: From Treatment of Injured Vessels to Treatment of the Injured Brain?

Traumatic brain injury is often associated with a direct or secondary neurovascular pathology. In this review, we present recent advancements in endovascular neurosurgery that enable accurate and effective vessel reconstruction with emphasis on its role in early diagnosis, the expanding use of flow diversion in pseudoaneurysms, and traumatic arteriovenous fistulas. In addition, future directions in which catheter-based interventions could potentially affect traumatic brain injury are described: targeting blood brain barrier integrity using the advantages of intra-arterial drug delivery of blood brain barrier stabilizers to prevent secondary brain edema, exploring the impact of endovascular venous access as a means to modulate venous outflow in an attempt to reduce intracranial pressure and augment brain perfusion, applying selective intra-arterial hypothermia as a neuroprotection method mitigating some of the risks conferred by systemic cooling, trans-vessel wall delivery of regenerative therapy agents, and shifting attention using multimodal neuromonitoring to post-traumatic vasospasm to further characterize the role it plays in secondary brain injury. Thus, we believe that the potential of endovascular tools can be expanded because they enable access to the "highways" governing perfusion and flow and call for further research focused on exploring these routes because it may contribute to novel endovascular approaches currently used for treating injured vessels, harnessing them for treatment of the injured brain.

Management Patterns and Outcomes After Traumatic Brain Injury With Associated Blunt Cerebrovascular Injury

BACKGROUND AND OBJECTIVES

Although blunt cerebrovascular injuries (BCVIs) are relatively common in patients with traumatic brain injuries (TBIs), uncertainty remains regarding optimal management strategies to prevent neurological complications, morbidity, and mortality. Our objectives were to characterize common care patterns; assess the prevalence of adverse outcomes, including stroke, functional deficits, and death, by BCVI grade; and evaluate therapeutic approaches to treatment in patients with BCVI and TBI.

METHODS

Patients with TBI and BCVI treated at our Level I trauma center from January 2016 to December 2020 were identified. Presenting characteristics, treatment, and outcomes were captured for univariate and multivariate analyses.

RESULTS

Of 323 patients with BCVI, 145 had Biffl grade I, 91 had grade II, 49 had grade III, and 38 had grade IV injuries. Lower-grade BCVIs were more frequently managed with low-dose (81 mg) aspirin ( P < .01), although all grades were predominantly treated with high-dose (150-600 mg) aspirin ( P = .10). Patients with low-grade BCVIs had significantly fewer complications ( P < .01) and strokes ( P < .01). Most strokes occurred in the acute time frame (<24 hours), including 10/11 (90.9%) grade IV-related strokes. Higher BCVI grade portended elevated risk of stroke (grade II odds ratio [OR] 5.3, grade III OR 12.2, and grade IV OR 19.6 compared with grade I; all P < .05). The use of low- or high-dose aspirin was protective against mortality (both OR 0.1, P < .05).

CONCLUSION

In patients with TBI, BCVIs impart greater risk for stroke and other associated morbidities as their severity increases. It may prove difficult to mitigate high-grade BCVI-related stroke, considering most events occur in the acute window. The paucity of late time frame strokes suggest that current management strategies do help mitigate risks.

Which Patients Receive Diagnostic Angiography? An EAST Multicenter Study Analysis of Internal Carotid Artery Blunt Cerebrovascular Injury

BACKGROUND

Digital subtraction angiography (DSA) is the gold standard radiologic modality in blunt cerebrovascular injury (BCVI). However, computerized tomography angiography (CTA) is primarily used in modern practice with CTA's widespread availability and the decreased stroke rate with CTA use. The frequency and indications for DSA in BCVI is undefined. We hypothesized that DSA use in internal carotid artery (ICA) BCVI would be infrequent and dependent on radiologic features.

METHODS

This was a post hoc analysis of an EAST multicenter, prospective, observational trial of 16 trauma centers for stroke factors in BCVI. ICA BCVI was divided into those undergoing DSA and not undergoing DSA (no-DSA). Only ICA BCVI was included.

RESULTS

332 ICA BCVI were included, 221 (66.6%) no-DSA and 111 (33.4%) DSA. Lower hospital trauma volume, non-urban environment, and non-academic status were associated with DSA use (all P ≤ .001). BCVI grade (P = .02) and presence of luminal stenosis (P = .005) were associated with DSA use while pseudoaneurysm presence was not. Median time to DSA was 1 hour. The most common indication for angiography was to determine the presence of injury in 71 (64%) ICA BCVI, followed by determining grade of injury in 16 (14.4%) and concerning imaging characteristics in 12 (10.8%). BCVI grade on initial imaging and on DSA were equivalent in 94 (84.7%) ICA BCVI.

DISCUSSION

DSA is frequently used in ICA BCVI, primarily early in the hospital course for injury diagnosis and grade determination. DSA appears primarily driven by hospital type, BCVI grade, and luminal stenosis.

Blunt Cerebrovascular Injury: Are We Overscreening Low-Mechanism Trauma?

BACKGROUND AND PURPOSE

Screening patients with trauma for blunt cerebrovascular injury with neck CTA is a common practice, but there remains disagreement regarding which patients should be screened. We reviewed adult blunt cerebrovascular injury data from a level 1 trauma center to investigate whether screening is warranted in low-mechanism trauma.

MATERIALS AND METHODS

We reviewed all neck CTAs performed on adult trauma patients in the emergency department during the 2019 calendar year. Clinical and imaging risk factors for blunt cerebrovascular injury, trauma mechanism, initial neck CTA interpretations, results from subsequent CTA and DSA studies, antiplatelet and anticoagulant treatments, and outcome data were recorded.

RESULTS

One thousand one hundred thirty-six neck CTAs met the inclusion criteria, of which 965 (85%) were interpreted as having negative findings; 125, as having indeterminate findings (11%); and 46, as having positive findings (4%). Review of subsequent imaging and clinical documentation led to classification of 40 indeterminate studies (32%) as true-positives and 85 (68%) as false-positives. Blunt cerebrovascular injury was identified in 77 (12.6%) cases meeting and in 9 (1.7%) cases not meeting the expanded Denver criteria. The subset of 204 low-mechanism trauma cases (ground-level falls, blunt assaults, and low-impact motor vehicle collisions) not meeting the expanded Denver criteria (18% of the entire data set) could have been excluded from screening with 1 questionable injury and 0 ischemic strokes missed and 12 false-positive cases prevented.

CONCLUSIONS

We advocate reservation of blunt cerebrovascular injury screening in low-mechanism trauma for patients meeting the expanded Denver criteria. Further research is needed to determine the behavior of indeterminate cases and to establish criteria for separating true-positive from false-positive findings.

Efficacy of Antithrombotic Therapy and Risk of Hemorrhagic Complication in Blunt Cerebrovascular Injury Patients with Concomitant Injury: A Systematic Review

BACKGROUND

The risk-benefit balance of antithrombotic therapy administration for blunt cerebrovascular injuries (BCVI) patients with concomitant injuries at high risk for bleeding is an ongoing therapeutic conundrum for trauma clinicians. We performed a systematic review to assess the reported efficacy and safety of treatment in this population with respect to prevention of ischemic stroke and risk of hemorrhagic complications.

STUDY DESIGN

A systematic electronic literature search of MEDLINE, EMBASE, Cochrane Library, and Web of Science databases was performed from January 1, 1996 to December 31, 2021. Studies were included if they reported treatment-stratified clinical outcomes after antithrombotic therapy in BCVI patients with concomitant injuries at high risk of bleeding into a critical site. Data were extracted from selected studies by two independent reviewers, including the main outcomes of interest were BCVI-related ischemic stroke rates and rates of hemorrhagic complications.

RESULTS

Of the 5,999 studies reviewed, 10 reported on the effects of treating BCVI patients with concurrent traumatic injuries and were included for review. In the pooled data, among patients with BCVI and concomitant injury who received any form of antithrombotic therapy, the BCVI-related stroke rate was 7.6%. The subgroup of patients who did not receive therapy had an overall BCVI-related stroke rate of 34%. The total rate of hemorrhagic complications in the treated population was 3.4%.

CONCLUSIONS

In BCVI patients with concomitant injuries at high risk for bleeding, antithrombotic use reduces the risk of ischemic strokes with a low reported risk of serious hemorrhagic complications.

Low-Dose Heparin Infusion as Venous Thromboembolism Chemoprophylaxis in Patients With Blunt Cerebrovascular Injury

INTRODUCTION

Blunt cerebrovascular injury (BCVI) can result in devastating stroke. Because of operative inaccessibility, the most common treatment for BCVI is aspirin or a low-dose systemic heparin infusion. While it is assumed that low dose heparin infusion imparts venous thromboembolism (VTE) prophylaxis, this has not been evaluated in the BCVI population. The purpose of this study was to evaluate VTE rates in patients receiving low-dose heparin infusion as treatment for BCVI.

METHODS

Patients diagnosed with BCVI between 2014 and 2018 were reviewed for initiation of low-dose systemic heparin treatment. VTE was defined as a deep vein thrombosis or pulmonary embolism. BCVI patients without systemic heparin treatment were compared to BCVI patients with heparin treatment for overall VTE rates. Comparisons were also made to injured patients without a BCVI in our Trauma Activation Protocol (TAP) database.

RESULTS

During the 5-year study period, 265 patients were identified with a BCVI. The majority (61%) were men with a median injury severity score (ISS) 22 (interquartile range [IQR]:14-33). Of these patients, 146 (55.1%) received a heparin infusion to treat BCVI. VTE was identified in eight of these patients (5.5%). Compared to TAP patients (n = 1020) who received standard dosing of VTE chemoprophylaxis, there was no difference in VTE rates compared to BCVI patients who were started on a low dose heparin infusion (3% versus 5.5%, P = 0.16). Area under the receiver operating characteristics (AUROC) was used to evaluate the predictive power of time to initiation of heparin infusion (AUC = 0.64 95% CI 0.42-0.85, P = 0.2) and time to reaching PTT goal (AUC = 0.52 95% CI 0.27-0.77, P = 0.83) as a predictor VTE events.

CONCLUSIONS

Low dose heparin infusion is frequently used as an initial treatment of BCVI. In injured patients with BCVI, a low dose heparin infusion is associated with a low rate of VTE, comparable to injured patients without BCVI that received standard VTE chemoprophylaxis.

Ultrasonography is an effective tool for the evaluation of traumatic vertebral artery injuries distal to fourth cervical vertebra in the emergency room

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.

Blunt cerebrovascular injury: contribution of Timothy C Fabian MD and investigators from the University of Tennessee at Memphis to our understanding of the injury

Our understanding of blunt cerebrovascular injury (BCVI) has evolved considerably over recent decades. It was once seen as a rare injury that was difficult or impossible to predict and had no useful prevention or treatment measures available. In the late 20th century, work by physicians caring for these injuries began to show that this was not the case. There were distinct risk factors for the injury and the often seen interval between injury and stroke provided an opportunity for stroke prevention. Timothy Fabian and the investigators at Memphis have been one of the groups at the forefront of this type of inquiry for >30 years. The contributions of this group has advanced the care of BCVI immensely. This review examines some of the work done by Dr Fabian and his colleagues and its importance in the care of injured patients.

Neurointerventional management of cerebrovascular trauma

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.

ACR Appropriateness Criteria® Cranial Neuropathy: 2022 Update

Cranial neuropathy can result from pathology affecting the nerve fibers at any point and requires imaging of the entire course of the nerve from its nucleus to the end organ in order to identify a cause. MRI with and without intravenous contrast is often the modality of choice with CT playing a complementary role. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Patterns of Head and Neck Injuries in Urban India: A Multicenter Study

Objective

The pattern of head and neck injuries has been well studied in high-income countries, but the data are limited in low- and middle-income countries, which are disproportionately affected by trauma. We examined a prospective multicenter database to describe patterns and outcomes of head and neck injuries in urban India.

Study Design

Retrospective review of trauma registry.

Setting

Four tertiary public hospitals in Mumbai, Delhi, Kolkata.

Methods

We identified patients with isolated head and neck injuries using International Classification of Diseases, 10th Revision (ICD-10) codes and excluded those with traumatic brain and/or ophthalmic injuries and injuries in other body regions.

Results

Our cohort included 171 patients. Most were males (80.7%) and adults aged 18 to 55 years (60.2%). Falls (36.8%) and road traffic accidents (36.3%) were the 2 predominant mechanisms of injury. Overall, 35.7% required intensive care unit (ICU) admission, and 11.7% died. More than 20% of patients were diagnosed with “unspecified injury of neck.” Those with the diagnosis had a higher ICU admission rate (51.4% vs 31.3%, P = .025) and mortality rate (27.0% vs 7.5%, P = .001) than those without the diagnosis.

Conclusion

Isolated head and neck injuries are not highly prevalent among Indian trauma patients admitted to urban tertiary hospitals but are associated with high mortality. Over a fifth of patients were diagnosed with “unspecified injury of neck,” which is associated with more severe clinical outcomes. Exactly what this diagnosis entails and encompasses remains unclear.

Cervical fracture patterns associated with blunt cerebrovascular injures when utilizing computed tomographic angiography: a systematic review and meta-analysis

BACKGROUND CONTEXT

Prior studies have demonstrated an association between cervical spine fractures and blunt cerebrovascular injuries (BCVI) due to the intimate anatomic relationship between the cervical spine and the vertebral arteries. Digital subtraction angiography (DSA) has historically been the gold standard, but computed tomography angiography (CTA) is commonly used to screen for BCVI in the trauma setting. However, there is no consensus regarding which fracture patterns mandate screening. Over aggressive screening may lead to increased radiation, increased false positives, and overtreatment of patients which can cause unnecessary patient harm, and increased healthcare costs.

PURPOSE

The aim of this meta-analysis is to analyze which cervical spine fracture patterns are most predictive of BCVI when utilizing CTA.

STUDY DESIGN/SETTING

Systematic review and meta-analysis.

OUTCOME MEASURES

Odds ratios for specific cervical fracture patterns and risk of developing a BCVI.

METHODS

A systematic literature review of all English language studies from 2000-2020 was conducted. The year 2000 was chosen as the cut-off because use of CTA prior to 2000 was rare. Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Scopus, Global Index Medicus, and ClinicalTrials.gov were queried. Studies were included if they met the following criteria: (1) the diagnostic imaging modality was CTA; (2) investigated blunt cervical trauma; (3) noted specific cervical spine fracture patterns associated with BCVI; (4) odds ratios for specific cervical spine fracture patterns or the odds ratio could be calculated; (5) subjects were 18 years old or older. Studies were excluded if they: (1) included DSA or magnetic resonance imaging; (2) included penetrating cervical trauma; (3) included pediatric patients less than 18 years of age; (4) were not written in English. All statistical analysis was performed using R Studio (RStudio, Boston, MA, USA).

RESULTS

The initial search, after duplicates were removed, resulted in 10,940 articles for independent review. Six studies met the criteria for inclusion in the meta-analysis. Specific fracture patterns mentioned are isolated C1, C2, C3 fractures, any C1-C3 fracture, any C4-C7 fracture, two-level fractures, subluxation/dislocations, and transverse foramen (TF) fractures. Three studies were included in the meta-analysis for C1, C2, C1-C3, subluxations/dislocations, and TF fractures. Two studies were included in the meta-analysis for C3, C4-C7, and two-level fractures. The pooled odds ratio with 95% confidence interval for: C1 fractures and BCVI is 1.3 (0.8-2.1); C2: 1.6 (0.9-2.8); C3: 1.8 (0.9-3.6); C1-C3: 2.2 (1.1-4.2); C4-C7: 0.7 (0.3-1.7); Two-level: 2.5 (1.4-4.6); Subluxation/Dislocation: 2.9 (1.8-4.5); TF: 3.6 (1.4-8.9).

DISCUSSION/CONCLUSION

This study found that when utilizing CTA for screening of BCVI only fractures in the C1-C3 region, two-level fractures, subluxations/dislocations, and transverse foramen fractures were associated with increased incidence of a BCVI. Further refinement of protocols for CTA in the setting of blunt cervical trauma may help limit unnecessary patient harm from overtreatment and reduce healthcare costs.

Emergent neurovascular imaging in patients with blunt traumatic injuries

Blunt cerebrovascular injuries (BCVIs) are commonly encountered after blunt trauma. Given the increased risk of stroke incurred after BCVI, it is crucial that they are promptly identified, characterized, and treated appropriately. Current screening practices generally consist of computed tomography angiography (CTA), with escalation to digital subtraction angiography for higher-grade injuries. Although it is quick, cost-effective, and readily available, CTA suffers from poor sensitivity and positive predictive value. A review of the current literature was conducted to examine the current state of emergent imaging for BCVI. After excluding reviews, irrelevant articles, and articles exclusively available in non-English languages, 36 articles were reviewed and included in the analysis. In general, as CTA technology has advanced, so too has detection of BCVI. Magnetic resonance imaging (MRI) with sequences such as vessel wall imaging, double-inversion recovery with black blood imaging, and magnetization prepared rapid acquisition echo have notably improved the utility for MRI in characterizing BCVIs. Finally, transcranial Doppler with emboli detection has proven to be associated with strokes in anterior circulation injuries, further allowing for the identification of high-risk lesions. Overall, imaging for BCVI has benefited from a tremendous amount of innovation, resulting in better detection and characterization of this pathology.

Imaging analysis of ischemic strokes due to blunt cerebrovascular injury

BACKGROUND

The timing of stroke onset among patients with blunt cerebrovascular injury (BCVI) is not well understood. All blunt trauma patients at our institution undergo a screening computed tomographic angiography (CTA) of the neck. Most patients with CTA evidence of BCVI are treated with aspirin, and all patients with clinical evidence of stroke are treated with aspirin and undergo magnetic resonance imaging (MRI) of the brain. We conducted a retrospective review to determine the incidence of stroke upon admission and following admission.

METHODS

All neck CTAs and head MRIs obtained in blunt trauma patients were reviewed from August 2017 to August 2019. All CTAs that were interpreted as showing BCVI were individually reviewed to confirm the diagnosis of BCVI. Stroke was defined as brain MRI evidence of new ischemic lesions, and each MRI was reviewed to identify the brain territory affected. We extracted the time to aspirin administration and the timing of stroke onset from patients' electronic health records.

RESULTS

Of the 6,849 blunt trauma patients, 479 (7.0%) had BCVIs. Twenty-four patients (5.0%) with BCVI had a stroke on admission. Twelve (2.6%) of the remaining 455 patients subsequently had a stroke during their hospitalization. The incidence of stroke among patients with BCVI was 7.5%; 2.6% were potentially preventable. Only 5 of the 12 patients received aspirin before the onset of stroke symptoms. All 36 patients with BCVI and stroke had thromboembolic lesions in the territory supplied by an injured vessel.

CONCLUSION

With universal screening, CTA evidence of BCVI is common among blunt trauma patients. Although acute stroke is also relatively common in this population, two thirds of strokes are already evident on admission. One third of BCVI-related strokes occur after admission and often relatively early, necessitating rapid commencement of preventative treatment. Further studies are required to demonstrate the value of antithrombotic administration in preventing stroke in BCVI patients.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level IV.

ACR Appropriateness Criteria® Imaging of Facial Trauma Following Primary Survey

Maxillofacial trauma patients comprise a significant subset of patients presenting to emergency departments. Before evaluating for facial trauma, an emergency or trauma physician must perform a primary survey to ensure patient stabilization. Following this primary survey, this document discusses the following clinical scenarios for facial trauma: tenderness to palpation or contusion or edema over frontal bone (suspected frontal bone injury); pain with upper jaw manipulation or pain overlying zygoma or zygomatic deformity or facial elongation or malocclusion or infraorbital nerve paresthesia (suspected midface injury); visible nasal deformity or palpable nasal deformity or tenderness to palpation of the nose or epistaxis (suspected nasal bone injury); and trismus or malocclusion or gingival hemorrhage or mucosal hemorrhage or loose teeth or fractured teeth or displaced teeth (suspected mandibular injury). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Current Concepts in Imaging Diagnosis and Screening of Blunt Cerebrovascular Injuries

Blunt cerebrovascular injury (BCVI) is an often underrecognized injury occurring in the carotid or vertebral arteries, associated with a risk of ischemic stroke and potential for poor neurological outcome or death. Computed tomographic angiography (CTA) is the most common modality for initial screening and diagnosis. Vessel wall intimal injuries, intraluminal thrombus, dissection, intramural hematoma, pseudoaneurysm, vessel transection, and arteriovenous fistula, are potential findings to be considered in approach to imaging. Identification of high-risk trauma patients based on clinical and radiological risk factors can determine patients at risk of BCVI for targeted screening.

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.

Neurointerventional management of cerebrovascular trauma

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.

Structural and Process Data on Radiological Imaging in the Treatment of Severely Injured Patients - Results of a Survey of Level I and II Trauma Centers in Germany

PURPOSE

 Systematic data collection regarding the integration of radiology as well as structural and process characteristics of radiological diagnostics of severely injured patients in Germany using a structured questionnaire.

MATERIALS AND METHODS

 Personal contact with all certified Level I and Level II Trauma Centers in Germany. Data on infrastructure, composition of the trauma room team, equipment, and data on the organization/performance of primary major trauma diagnostics were collected.

RESULTS

 With a participation rate of 46.9 % (n = 151) of all German trauma centers (N = 322), a solid database is available. There were highly significant differences in the structural characteristics incl. CT equipment between the level I and II centers: In 63.8 % of the level II centers, the CT unit was located more than 50 m away from the trauma room (34.2 % in the level I centers). A radiologist was part of the trauma room team in 59.5 % of level II centers (level I 88.1 %). Additionally, highly significant differences were found comparing 24-h provision of other radiologic examinations and interventions, such as MRI (level II 44.9 %, level I 92.8 %) and angiography (level II 69.2 %, level I 97.1 %).

CONCLUSION

 Heterogeneous structural and process characteristics of the diagnosis of severely injured patients in Germany were revealed, with highly significant differences between level I and level II centers.

KEY POINTS

  · This is the first study on the diagnostic reality of radiology in severely injured patients in Germany. Despite a high level of standardization, significant differences were observed..

CITATION FORMAT

· Ernstberger A, Reske SU, Brandl A et al. Structural and Process Data on Radiological Imaging in the Treatment of Severely Injured Patients - Results of a Survey of Level I and II Trauma Centers in Germany. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1682-7377.

Diagnostic accuracy of computed tomography angiography (CTA) for diagnosing blunt cerebrovascular injury in trauma patients: a systematic review and meta-analysis

Objectives

Previous literature showed that the diagnostic accuracy of computed tomographic angiography (CTA) is not equally comparable with that of the rarely used golden standard of digital subtraction angiography (DSA) for detecting blunt cerebrovascular injuries (BCVI) in trauma patients. However, advances in CTA technology may prove CTA to become equally accurate. This study investigated the diagnostic accuracy of CTA in detecting BCVI in comparison with DSA in trauma patients.

Methods

An electronic database search was performed in PubMed, EMBASE, and Cochrane Library. Summary estimates of sensitivity, specificity, positive and negative likelihood, diagnostic odds ratio, and 95% confidence intervals were determined using a bivariate random-effects model.

Results

Of the 3293 studies identified, 9 met the inclusion criteria. Pooled sensitivity was 64% (95% CI, 53–74%) and specificity 95% (95% CI, 87–99%) The estimated positive likelihood ratio was 11.8 (95%, 5.6–24.9), with a negative likelihood ratio of 0.38 (95%, 0.30–0.49) and a diagnostic odds ratio of 31 (95%, 17–56).

Conclusion

CTA has reasonable specificity but low sensitivity when compared to DSA in diagnosing any BCVI. An increase in channels to 64 slices did not yield better sensitivity. There is a risk for underdiagnosis of BCVI when only using DSA to confirm CTA-positive cases, especially in those patients with low-grade injuries.

Key Points

• Low sensitivity and high specificity were seen in identifying BCVI with CTA as compared to DSA.

• Increased CTA detector channels (≤ 64) did not lead to higher sensitivity when detecting BCVI.

• The use of CTA instead of DSA may lead to underdiagnosis and, consequently, undertreatment of BCVI.

Derivation and validation of a quantitative screening model for blunt cerebrovascular injury

OBJECTIVE

The objective of this study was to derive and validate a new screening model using a nomogram that allows clinicians to quantify the risk of blunt cerebrovascular injury (BCVI).

METHODS

In this study, the authors examined 258,935 patients from a prospectively collected nationwide Japanese database (January 2009-December 2018) who experienced blunt injury. Patients were randomly divided into training (n = 129,468) and validation (n = 129,467) cohorts. First, the authors investigated the prevalence of BCVI, which was defined as blunt injury to any intracranial vessel, the extracranial vertebral artery, the extracranial carotid (common, internal) artery, or the internal jugular vein. Then, a new arterial BCVI screening model using a nomogram was derived, based on multivariate logistic regression analysis through quantifying the association of potential predictive factors with BCVI in the training cohort. The model's discriminatory ability was validated using the area under the receiver operating characteristic curve (AUC) in the validation cohort.

RESULTS

Multivariate analysis in the training cohort showed that 13 factors were significantly associated with arterial BCVI and were included in our model. These factors were 1) male sex; 2) high-energy impact; 3) hypotension on hospital arrival; 4) Glasgow Coma Scale score < 9; 5) injury to the face; 6) injury to the neck; 7) injury to the spine; 8) skull base fracture; 9) cervical spine fracture or subluxation; and those with negative associations, i.e., 10) injury to the lower-extremity region; 11) supratentorial subdural hemorrhage; 12) lumbar spine fracture or subluxation; and 13) soft tissue injury of the face. In the validation cohort, the model had an AUC of 0.83 (95% CI 0.81-0.86). When the definition of BCVI was narrowed to include only carotid (common, internal) and vertebral artery injuries, the AUC of the model in predicting these injuries was 0.89 (95% CI 0.87-0.91).

CONCLUSIONS

A new screening model that incorporates an easy-to-use nomogram to quantify the risk of BCVI and assist clinicians in identifying patients who warrant additional evaluation was established.

Blunt cerebrovascular injuries: Outcomes from the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) multicenter registry

BACKGROUND

Administering antithrombotics (AT) to the multiply injured patient with blunt cerebrovascular injury (BCVI) requires a thoughtful assessment of the risk of stroke and death associated with nontreatment. Large, multicenter analysis of outcomes stratified by injury grade and vessel injured is needed to inform future recommendations.

METHODS

Nine hundred and seventy-one BCVIs were identified from the PROspective Vascular Injury Treatment registry in this retrospective analysis. Using multivariate analysis, we identified predictors of BCVI-related stroke and death. We then stratified these risks by injury grade and vessel injured. We compared the risk of adverse outcomes in the nontreatment group with those treated with antiplatelet agents and/or anticoagulants.

RESULTS

Stroke was identified in 7% of cases. Overall mortality was 12%. Both increased with increasing BCVI grade. Treatment with ATs was associated with lower mortality and was not significantly affected by the choice of agent. Withholding ATs was associated with an increased risk of stroke and/or death across all subgroups (Grade I/II: odds ratio [OR], 4.66; 95% confidence interval [CI], 2.48-8.75; Grade III: OR, 7.0; 95% CI, 2.01-24.5; Grade IV: OR, 4.43; 95% CI, 1.76-11.1) even after controlling for covariates. Predictors of death included more severe trauma, Grade IV injury, and the occurrence of stroke. Arterial occlusion, hypotension, and endovascular intervention were significant predictors of stroke. Patients that experienced a BCVI-related stroke were at a 4.2× increased risk of death. The data set lacked the granularity necessary to evaluate AT timing or dosing regimen, which limited further analysis of stroke prevention strategies.

CONCLUSION

Stroke and death remain significant risks for all BCVI grades regardless of the vessel injured. Antithrombotics represent the only management strategy that is consistently associated with a lower incidence of stroke and death in all BCVI categories. In the multi-injured BCVI patient with a high risk of bleeding on anticoagulation, antiplatelet agents are an efficacious alternative. Given the 40% mortality rate in patients who survived their initial trauma and developed a BCVI-related stroke, nontreatment may no longer be a viable option.

LEVEL OF EVIDENCE

Epidemiological III; Therapeutic IV.

Universal screening for blunt cerebrovascular injury

BACKGROUND

Blunt cerebrovascular injury (BCVI) can result in thromboembolic stroke. Many trauma centers selectively screen patients with cervical computed tomographic angiography (CTA) based on clinical criteria. In 2016, our institution adopted universal screening for BCVI for all blunt trauma patients. The aim of this study was to accurately determine the incidence of BCVI and to evaluate the diagnostic performance of the Denver criteria (DC), expanded Denver criteria (eDC), and Memphis criteria (MC) in selecting patients for screening.

METHODS

Retrospective cohort study of adult (≥16 years) blunt trauma patients who presented to the Level I trauma center at University of Alabama at Birmingham. We reviewed all CTA reports and selected CTA images to obtain the true incidence rate of BCVI. We then evaluated the diagnostic performance of the DC, eDC, and MC.

RESULTS

A total of 6,800 patients who had suffered blunt trauma were evaluated, of whom 6,287 (92.5%) had a neck CTA. Of these, 480 (7.6%) patients had CTA evidence of BCVI. The eDC identified the most BCVI cases (sensitivity 74.7%) but had the lowest positive predictive value (14.6%). The DC and MC had slightly greater positive predictive values (19.6% and 20.6%, respectively) and had the highest diagnostic ability in terms of likelihood ratio (2.8 and 2.9) but had low sensitivity (57.5% and 47.3%). Consequently, if relying on the traditional screening criteria, the DC, eDC, and MC would have respectively resulted in 42.5%, 25.3%, and 52.7% of patients with BCVI identified by universal screening not receiving a neck CTA to screen for BCVI.

CONCLUSION

Blunt cerebrovascular injury is even more common than previously thought. The diagnostic performance of selective clinical screening criteria is poor. Consideration should be given to the implementation of universal screening for BCVI using neck CTA in all blunt trauma patients.

LEVEL OF EVIDENCE

Diagnostic, level III.

Neurovascular trauma: Diagnosis and therapy

Traumatic cerebrovascular injuries are common in both military and civilian populations. Whether such injuries occur in the aftermath of blunt or penetrating trauma has major implications for characteristics, classification, diagnosis, and optimal management of these lesions. Advances in screening methods, including particularly the dramatic rise of high-quality CT angiography, have facilitated early detection of these lesions. Fortunately, these diagnostic advances have occurred alongside improvements in pharmacological treatment and endovascular intervention, which now play an important role alongside surgical intervention in reducing the likelihood of adverse clinical outcomes. While the management of victims of trauma remains challenging, improved understanding of and ability to appropriately manage traumatic cerebrovascular lesions promises to yield better clinical outcomes for these vulnerable patients.

Atypical hangman's fracture with concomitant subaxial fracture-dislocation treated with circumferential fusion of C2-C5-a case report

INTRODUCTION

Atypical hangman's fractures are coronally-oriented vertical fractures of the posterior body of C2. Though these are not uncommon injuries, there is a paucity of data investigating the management of these fractures, especially when they occur in association with subaxial fracture dislocations.

CASE PRESENTATION

A 50-year-old male suffered a cervical extension injury when he dove into a shallow swimming pool while intoxicated. Initial examination demonstrated 2/5 strength in the right deltoid and biceps and 3/5 strength in the left deltoid and biceps with no motor or sensory function distal to the C5 level. Cervical CT scan revealed a C2 atypical hangman's fracture and a C4 right-sided facet fracture with traumatic spondylolisthesis at C4/5. We performed C2-C5 anterior cervical discectomy and fusion followed by a C3-C5 posterior instrumented fusion. At the patient's two year postoperative visit, the patient has had minimal improvement in neurologic function with 4/5 strength in bilateral deltoids and biceps and 2/5 strength in right wrist extension. Radiographs show a solid arthrodesis on flexion-extension radiographs.

DISCUSSION

To our knowledge, this is the first case report discussing the operative management of an atypical hangman's fracture with a concomitant subaxial fracture-dislocation. This case report adds to our current knowledge by demonstrating a novel anterior-posterior approach for treating these complicated injuries.

Different strokes: differences in the characteristics and outcomes of BCVI and non-BCVI strokes in trauma patients

Background

Although strokes are rare in trauma patients, they are associated with worse functional and cognitive outcomes and decreased mobility. Blunt cerebrovascular injury (BCVI)–related strokes and mortality have decreased, likely due to refined screening and treatment algorithms in trauma literature; however, there is a paucity of research addressing non-BCVI strokes in trauma. The purpose of this study is to evaluate the incidence, etiology, and risk factors of stroke in our trauma population in order to identify preventive strategies.

Methods

This study was a retrospective review of all adult trauma patients admitted to a level 1 trauma hospital who suffered a stroke during trauma admission from 2010 to 2017. Data were collected from the prospectively maintained trauma and stroke databases. Stroke etiology was determined by a vascular neurologist.

Results

Of the 43 674 adult trauma patients admitted during the study period, 99 (0.2%) were diagnosed with a stroke during the index admission. Twenty-one (21%) strokes were due to BCVI. Seventy-eight (79%) strokes were due to non-BCVI etiologies. Patients with non-BCVI strokes were older, less severely injured, and had more medical comorbidities compared with patients with a BCVI stroke. While patients with a BCVI stroke were more likely to suffer multiple traumatic injuries from MVC (76% vs 28%, p<0.001), non-BCVI strokes had more isolated extremity injuries from fall mechanism (55% vs 10%, p<0.001). Over the study period, the age and incidence of stroke and BCVI (p<0.001) increased. However, the rate of BCVI strokes decreased while the rate of non-BCVI strokes increased.

Discussion

The incidence of stroke has increased despite aggressive screening and treatment of BCVI. This increase is primarily due to non-BCVI strokes which are associated with advanced age and medical comorbidities after low mechanism traumatic injury. Medical optimization of comorbid conditions during trauma hospitalization will become increasingly important for stroke prevention as the population ages.

Level of evidence: Level III

Not all in your head (and neck): Stroke after blunt cerebrovascular injury is associated with systemic hypercoagulability

BACKGROUND

Stroke secondary to blunt cerebrovascular injury (BCVI) most often occurs before initiation of antithrombotic therapy. Earlier treatment, especially in multiply injured patients with relative contraindications to antithrombotic agents, could be facilitated with improved risk stratification; furthermore, the relationship between BCVI-attributed stroke and hypercoagulability remains unknown. We hypothesized that patients who suffer BCVI-related stroke are hypercoagulable compared with those with BCVI who do not stroke.

METHODS

Rapid thromboelastography (TEG) was evaluated for patients with BCVI-attributed stroke at an urban Level I trauma center from 2011 to 2018. Contemporary controls who had BCVI but did not stroke were selected for comparison using propensity-score matching with 20% caliper that accounted for age, sex, injury severity, and BCVI location and grade.

RESULTS

During the study period, 15,347 patients were admitted following blunt trauma. Blunt cerebrovascular injury was identified in 435 (3%) patients, of whom 28 experienced associated stroke and had a TEG within 24 hours of arrival. Forty-nine patients who had BCVI but did not suffer stroke served as matched controls. Stroke patients formed clots faster as evident in their larger angle (77.5 degrees vs. 74.6 degrees, p = 0.03) and had greater clot strength as indicated by their higher maximum amplitude (MA) (66.9 mm vs. 61.9 mm, p < 0.01). Activated clotting time was shorter among stroke patients but not significantly (113 seconds vs. 121 seconds, p > 0.05). Increased angle and elevated MA were significant predictors of stroke with odds ratios of 2.97 for angle greater than 77.3 degrees and 4.30 for MA greater than 63.0 mm.

CONCLUSION

Patients who suffer BCVI-related stroke are hypercoagulable compared with those with BCVI who remain asymptomatic. Increased angle or MA should be considered when assessing the risk of thrombosis and determining the optimal time to initiate antithrombotic therapy in patients with BCVI.

LEVEL OF EVIDENCE

Prognostic, Level III.

Pediatric blunt cerebrovascular injuries: A national trauma database study

BACKGROUND

The incidence of blunt cerebrovascular injuries (BCVIs) in children is unknown. We aimed to determine the rate and consequences of BCVIs in pediatric blunt trauma patients.

METHODS

We queried the National Trauma Data Bank (NTDB) for all blunt trauma patients between 2007 and 2014. BCVI patients were identified by ICD-9 codes. Demographic, emergency room, and concomitant injury data were analyzed.

RESULTS

There were 732,702 blunt trauma patients, and 1682 BCVIs were identified (0.23%). 791 (47%) sustained carotid artery injuries (CAIs), 957 (57%) had vertebral artery injuries (VAIs), and 4% of patients sustained both. A majority of the injuries occurred in white patients (61%) and in motor vehicle accidents (53%). The average age was 12.1 ± 5.4 years. CAIs had more skull base fractures (55% vs 35%, p < 0.0001), and cervical spine fractures were more common in VAIs (26 vs 11%, p < 0.0001). Intensive care length of stay was longer in the CAI patients (9.2 vs 7.9 days, p = 0.03), as was length of stay (12.5 vs 9.7 days, p = 0.0002). 5% of CAI patients were coded for stroke, versus 2% of VAIs (p = 0.002).

CONCLUSIONS

BCVIs are rare in children. Vertebral injuries are more common. Carotid injuries are associated with a longer length of stay and higher stroke rates.

TYPE OF STUDY

Retrospective cohort study.

LEVEL OF EVIDENCE

III.

Imaging of cranio-cervical junction traumas

The craniocervical junction (CCJ) or upper cervical spine (UCS) has anatomic features and a biomechanics completely different from the other spinal segment of the spine. Several ligaments and muscles control its motion and function and ensure the maximum mobility and the visual and auditory spatial exploration. UCS traumas represent approximately one-third of all cervical spine injuries. Most of UCS traumas results from blows to the head and sudden deceleration of the body. Thanks to the improvement of the Advanced Trauma Life Support protocols dissociative injuries of CCJ have become less lethal onsite. In other less severe but unstable injuries, patients are neurologically intact at presentation, but they may deteriorate during the stay in hospital, with important clinical and medico-legal consequences. Knowing the peculiarities of UCS is fundamental for the early detection of imaging findings that influences the patient management and outcome. The classification of UCS traumas is mechanistic. More than in any other spinal segment, fractures of CCJ bones can occur without generating instability; on the contrary highly unstable injuries may not be associated with bone fractures. An early and correct diagnosis of occipito-cervical instability may prevent secondary neurological injury. The goal of imaging is to identify which patients can benefit of surgical stabilization and prevent secondary neurologic damage. Actual helical multidetector-CT (MDCT) offers high sensitivity and specificity for bone lesions and displacements in cervical spine traumas, but magnetic resonance imaging (MRI) is increasingly being used to evaluate soft tissues and ligaments, and mainly to identify possible spinal cord injury.

An Update in Imaging of Blunt Vascular Neck Injury

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.

Evaluation of Nonfatal Strangulation in Alert Adults

STUDY OBJECTIVE

There is a paucity of evidence to guide the diagnostic evaluation of emergency department (ED) patients presenting after nonfatal strangulation (manual strangulation or near hanging). We seek to define the rate of serious injuries in alert strangled patients and determine which symptoms and examination findings, if any, predict such injuries.

METHODS

Using prospectively populated databases and electronic medical record review, we performed a retrospective analysis of alert strangled patients treated in the ED of an academic Level I trauma center. Exclusions were Glasgow Coma Scale (GCS) score less than 13, younger than 16 years, and interhospital transfers. Trained researchers used structured forms to abstract demographics, symptoms, examination findings, radiology and operative findings, and final diagnoses. Injuries requiring greater than 24 hours' observation or specific treatment (surgery, procedure, specific medication) were considered clinically important. The electronic medical record was searched for 30 days after presentation to identify missed injuries.

RESULTS

Advanced imaging (computed tomography or magnetic resonance maging) was obtained in 60%. Injuries were identified in 6 patients (1.7%, 95% CI, 0.7% to 3.6%). Two injuries were clinically important (0.6%, 95% CI, 0.1% to 2.0%). Both were cervical artery dissections with no neurologic deficits, treated with aspirin. No additional injuries were identified within 30 days or at next medical contact. Of 343 uninjured patients, 291 (85%) had documented medical follow up confirming the absence of any new diagnosis of injury or stroke. The small number of injuries precluded analyses of associations.

CONCLUSION

Alert, strangled patients had a low rate of injuries. All patients with neck injuries had concerning findings besides neck pain; specifically, GCS score less than 15 or dysphagia. Our findings suggest, but do not prove, that a selective imaging strategy is safe in alert patients after strangulation findings besides neck pain.

Screening for blunt cerebrovascular injuries in pediatric trauma patients

BACKGROUND

Adult imaging for blunt cerebrovascular injuries (BCVI) is based on the Denver and Memphis screening criteria where CT angiogram (CTA) is performed for any one of the criteria being positive. These guidelines have been extrapolated to the pediatric population. We hypothesize that the current adult criteria applied to pediatrics lead to unnecessary CTA in pediatric trauma patients.

STUDY DESIGN

At our center, a 9-year retrospective study revealed that strict adherence to the Denver and Memphis criteria would have resulted in 332 unnecessary CTAs out of 2795 trauma patients with only 0.3% positive for BCVI. We also conducted a retrospective chart review of 776,355 pediatric trauma patients in the National Trauma Data Bank (NTDB) from 2007 to 2014. Data collection included children between ages 0 and 18, ICD-9 search for blunt cerebrovascular injury, and ICD-9 codes that applied to both Denver and Memphis criteria.

RESULTS

Of 776,355 pediatric trauma activations, 81,294 pediatric patients in the NTDB fit the Denver/Memphis criteria for screening CTA neck or angiography based on ICD-9 codes, while only 2136 patients suffered BCVI. Strict utilization of the Denver/Memphis criteria would have led to a negative CTA in 79,158 (97.4%) patients. Multivariate regression analysis indicates that patients with skull base fracture, cervical spine fractures, cervical spine fracture with cervical cord injury, traumatic jugular venous injury, and cranial nerve injury should be considered part of the screening criteria for BCVI.

CONCLUSION

Our study suggests the Denver and Memphis criteria are inadequate screening criteria for CTA looking for BCVI in the pediatric blunt trauma population. New criteria are needed to adequately indicate the need for CT angiography in the pediatric trauma population.

LEVEL OF EVIDENCE

IV.