Blunt vertebral artery injury in occipital condyle fractures

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.

A Systematic Review and Meta-Analysis of Vertebral Artery Injury After Cervical Spine Trauma

STUDY DESIGN

Systematic Review and Meta-Analysis.

OBJECTIVE

Identify the incidence, mechanism of injury, investigations, management, and outcomes of Vertebral Artery Injury (VAI) after cervical spine trauma.

METHODS

A systematic review and meta-analysis were conducted in accordance with the PRISMA guidelines (PROSPERO-ID CRD42021295265). Three databases were searched (PubMed, SCOPUS, Google Scholar, CINAHL PLUS). Incidence of VAI, investigations to diagnose (Computed Tomography Angiography, Digital Subtraction Angiography, Magnetic Resonance Angiography), stroke incidence, and management paradigms (conservative, antiplatelets, anticoagulants, surgical, endovascular treatment) were delineated. Incidence was calculated using pooled proportions random effects meta-analysis.

RESULTS

A total of 44 studies were included (1777 patients). 20-studies (n = 503) included data on trauma type; 75.5% (n = 380) suffered blunt trauma and 24.5% (n = 123) penetrating. The overall incidence of VAI was .95% (95% CI 0.65-1.29). From the 16 studies which reported data on outcomes, 8.87% (95% CI 5.34- 12.99) of patients with VAI had a posterior stroke. Of the 33 studies with investigation data, 91.7% (2929/3629) underwent diagnostic CTA; 7.5% (242/3629) underwent MRA and 3.0% (98/3629) underwent DSA. Management data from 20 papers (n = 475) showed 17.9% (n = 85) undergoing conservative therapy, anticoagulation in 14.1% (n = 67), antiplatelets in 16.4% (n = 78), combined therapy in 25.5% (n = 121) and the rest (n = 124) managed using surgical and endovascular treatments.

CONCLUSION

VAI in cervical spine trauma has an approximate posterior circulation stroke risk of 9%. Optimal management paradigms for the prevention and management of VAI are yet to be standardized and require further research.

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.

Treatment of Unstable Occipital Condylar Fractures in Children-A STROBE-Compliant Investigation

Background and objectives: Occipital condyle fractures (OCF) occur rarely in children. The choice of treatment is based on the Anderson-Montesano and Tuli classification systems. We evaluated the outcome of unstable OCF in children and adolescents after halo-vest therapy. Materials and Methods: We treated 6 pediatric patients for OCF, including 3 patients (2 girls, 1 boy) with unstable OCF. Among the 3 patients with unstable OCF, 2 patients presented with an Anderson-Montesano type III and Tuli type IIB injury, while 1 patient had an Anderson-Montesano type I fracture (Tuli type IIB) accompanied by a C1 fracture. On admission, the children underwent computed tomography (CT) of the head and cervical spine as well as magnetic resonance imaging (MRI) of the cervical spine. We treated the children diagnosed with unstable OCF with halo-vest immobilization. Before removing the halo vest at the end of therapy, we applied the CT and MRI to confirm OCF consolidation. At follow-up, we rated functionality of the craniocervical junction (CCJ) based on the Neck Disability Index (NDI) and Questionnaire Short Form 36 Health Survey (SF-36). Results: All children achieved OCF consolidation after halo-vest therapy for a median of 13.0 weeks (range: 12.5-14.0 weeks). CT and MRI at the end of halo-vest therapy showed no signs of C0/C1 subluxation and confirmed the correct consolidation of OCF. The only complication associated with halo-vest therapy was a superficial infection caused by a halo-vest pin. At follow-up, all children exhibited favorable functionality of the CCJ as documented by the NDI score (median: 3 points; range: 3-11 points) and SF-36 score (median: 91 points; range: 64-96 points). Conclusions: In our small case series, halo-vest therapy resulted in good mid-term outcome in terms of OCF consolidation and CCJ functionality. In pediatric patients with suspected cervical spine injuries, we recommend CT and MRI of the CCJ to establish the diagnosis of OCF and confirm stable fracture consolidation before removing the halo vest.

Occipital condyle fracture-A rare but severe injury in cranial fracture patients

We clarified occurrence, severity, and associated injuries of occipital condyle fractures (OCFs) in a cranial fracture population. Retrospective data of cranial fracture patients were analyzed. The outcome variable was presence of OCF in cranial fracture patients. Predictor variables were type of associated injury, Glasgow Coma Scale (GCS) value under 6, and death during hospital care. In addition, occurrence of OCF was assessed according to cranial fracture subtypes. Explanatory variables were age, sex, injury mechanism, involvement of alcohol, and high-energy injury. Treatment and outcome of OCFs were analyzed. Of 637 cranial fracture patients, 19 (3.0%) sustained an OCF, eight of whom had no other cranial fractures. In the multivariate adjusted model, increased risk for OCF was detected in patients with cervical injuries (OR 18.66, 95% CI 5.52, 63.12; p < 0.001) and facial fractures (OR 5.99, 95% CI 1.01, 35.45; p = 0.049). Patients with fractures not extending to the skull base were less likely to have OCF (OR 0.01, 95% CI 0.001, 0.25; p = 0.004), and fractures localized solely to the base of the skull offered a protective effect for OCF (OR 0.19, 95% CI 0.06, 0.58; p = 0.003). All OCFs were treated non-operatively with a cervical collar without complications. OCF patients typically sustain other severe injuries, particularly cervical injuries and facial fractures. Careful screening for associated injuries is therefore crucial when examining a patient with OCF. The classification scheme of Mueller et al. seems to be useful in guiding the treatment of OCFs, at least type 1 and 2 fractures.

Isolated condylar fractures diagnosed by post mortem computed tomography

Due to their anatomical location, occipital condylar fractures (OCFs) are usually not observed during traditional autopsies and are therefore considered a rare injury. The aim of this study was to determine the true frequency of OCFs using post-mortem computed tomography (PMCT) in traumatic casualties. We retrospectively analyzed 438 PMCT studies of victims of traffic accidents, falls from height, violence, and low-energy head injuries (324 males and 114 females). OCFs were present in 22.6% of cases (n = 99), mostly in victims of railway accidents (48.5%, n = 17), falls from height (26.6%, n = 29), cyclists (24%, n = 6), and pedestrians hit by cars (22.5%, n = 29). Isolated OCFs were found in 5.5% of cases (n = 24), most often in cyclists (12%, n = 3) and pedestrians (9.3%, n = 12) hit by cars. There were no OCFs in the cases of fatalities caused by violence or accidental low-energy head injury. PMCT scans revealed that OCFs are common in high-energy injury fatalities and can be useful for determining the mechanism of trauma more precisely.