State of the art: noninvasive imaging and management of neurovascular trauma

Role of imaging in penetrating vascular injuries of the craniocervical region

Penetrating vascular injury has become the topic of interest with increased gun violence in the United States. The radiologist plays a crucial role in establishing and systemizing the signs of vascular injury such as intimal flap, dissection, pseudoaneurysm, rupture, and arteriovenous fistula. Various imaging techniques such as ultrasound Doppler, computed tomographic angiography (CTA), magnetic resonance angiography, and conventional angiography are being employed based on clinical recommendations. Of all the techniques, CTA has been shown to embrace a promising role in identifying vascular injuries with superior sensitivity, specificity, and accuracy. An acquaintance of the imaging features has been shown to improve the approach to trauma patients in clinical settings. This article details the imaging modalities and the features of the head-and-neck penetrating vascular injury.

Vertebral Artery Injury with Coinciding Unstable Cervical Spine Trauma: Mechanisms, Evidence-based Management, and Treatment Options

Unstable traumatic cervical spine fracture is a commonly encountered neurosurgical issue. Concomitant vertebral artery injuries present a challenge in surgical decision-making regarding the timing and order of surgical intervention with respect to endovascular intervention and internal fixation of the unstable fracture. Currently, there are no studies that have specifically examined stroke rate or outcomes for patients who have vertebral artery injuries and unstable cervical spine fractures with respect to temporal treatment course. The purpose of this paper is to review the current evidence for the standards of diagnosis and management of vertebral artery injuries with coinciding unstable cervical spine injuries and propose an evidence-based algorithm for workup and treatment.

Assessing the risk: Scoring systems for outcome prediction in emergency laparotomies

Emergency laparotomy is the commonest emergency surgical procedure in most hospitals and includes over 400 diverse surgical procedures. Despite the evolution of medicine and surgical practices, the mortality in patients needing emergency laparotomy remains abnormally high. Although surgical risk assessment first started with the ASA Physical Status score in 1941, efforts to find an ideal scoring system that accurately estimates the risk of mortality, continues till today. While many scoring systems have been developed, no single scoring system has been validated across multiple centers and geographical locations. While some scoring systems can predict the risk merely based upon preoperative findings and parameters, some rely on intra-operative assessment and histopathology reports to accurately stratify the risk of mortality. Although most scoring systems can potentially be used to compare risk-adjusted mortality across hospitals and amongst surgeons, only those which are based on preoperative findings can be used for risk prognostication and identify high-risk patients before surgery for an aggressive treatment. The recognition of the fact, that in the absence of outcome data in these patients, it would be impossible to evaluate the impact of quality improvement initiatives on risk-adjusted mortality, hospital groups and surgical societies have got together and started to pool data and analyze it. Appropriate scoring systems for emergency laparotomies would help in risk prognostication, risk-adjusted audit and assess the impact of quality improvement initiative in patient care across hospitals. Large multi-centric studies across varied geographic locations and surgical practices need to assess and validate the ideal and most apt scoring system for emergency laparotomies. While APACHE-II and P-POSSUM continue to be the most commonly used scoring system in emergency laparotomies,studies need to compare them in their ability to predict mortality and explore if either has a higher sensitivity and specificity than the other.

Imaging of blunt vascular neck injuries: a clinical perspective

OBJECTIVE

We will review the common injuries and anatomic distributions of blunt cerebrovascular injuries (BCVIs) of the neck, explain the grading criteria, and discuss the corresponding management. Artifacts associated with BCVI on CT will also be examined.

CONCLUSION

Identifying common injury patterns and anatomic distributions associated with BCVI can help decide the grade and management earlier and reduce the risk for potential complications. Recognizing the common artifacts associated with BCVI helps the reader successfully recognize a true BCVI.

Endovascular therapy for acute trauma: a pictorial review

The traditional role of radiology in the multidisciplinary approach to modern trauma care has been primarily diagnostic and noninvasive. With the advent of more sophisticated and faster imaging equipment, computed tomography has further entrenched its role as the workhorse of trauma imaging. However, the specialty has evolved over the years with various therapeutic techniques now part of the interventional radiology armamentarium. Several of these techniques have become essential for the management of critically ill trauma patients. This article provides an overview of the common imaging findings of vascular and solid organ trauma from head to toe and subsequent endovascular interventions in these critically ill trauma patients.

Endovascular management of neurovascular arterial injuries in the face and neck

The diagnosis and treatment of traumatic vascular injuries continues to improve as new tools and techniques are developed. In addition to locoregional hemorrhagic complications, injuries to blood vessels in the neck and face can result in ischemic injuries to the brain and cervical spinal cord. Surgical access to these lesions may be difficult, and endovascular techniques, including stenting and embolization, now serve as definitive treatments in many instances. This article reviews the endovascular management of patients with arterial injuries in the neck and face.

Interventional neuroimaging

Interventional neuroimaging procedures are becoming more effective and safer. This article discusses the therapeutic benefits of endovascular procedures for commonly encountered clinical situations in cerebrovascular disease and brain tumors and then briefly discusses the advances in interventional neuroimaging modalities. Each topic is subdivided into prevalence/natural course, techniques/interventions, summary of clinical trials, and current guidelines/recommendations from professional organizations, whenever applicable.

Bilateral carotid artery dissection after high impact road traffic accident

A 58 year old man was involved in a high impact road traffic incident and was admitted for observation. Asymptomatic for the first 24 hours, he collapsed with symptoms and signs consistent with a cerebrovascular accident. Computed tomography angiogram (CTA) and Magnetic resonance angiogram (MRA) demonstrated bilateral internal carotid artery dissections and a left middle cerebral artery infarct. It was not considered appropriate to attempt stenting or other revascularistation. The patient was treated with heparin prior to starting warfarin. He made a partial recovery and was discharged to a rehabilitation facility. This case is a reminder of carotid dissection as an uncommon but serious complication of high speed motor vehicle accident, which may be silent initially. Literature Review suggests risk stratification before relevant radiological screening at risk patients. Significant advances in CTA have made it the diagnostic tool of choice, but ultrasound is an important screening tool.