Cervical Artery Injury Research Articles

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

BackgroundThis 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.MethodsWe 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.ResultsAmong 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.ConclusionsUltrasonography 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.

The value of performing cerebrovascular CT angiography in major trauma patients: a 5-year retrospective review

To assess whether routine cerebrovascular imaging is required in all major trauma (MT) patients. All MT patients with cerebrovascular imaging between January 2015 and December 2020 were included in the study. Data were collated regarding the type of indication for computed tomography (CT) angiography imaging, time interval from the initial trauma, relevant trauma diagnoses on initial trauma imaging, and CT angiography. Findings, such as aneurysms, vascular malformations, luminal thrombus, venous sinus thrombosis, or vascular injury, were collated. Subsequent treatment with anti-coagulants/anti-platelets or surgical/radiological intervention was noted. Follow-up imaging was assessed for residual injury or complications. Two hundred and fifty of the 6,251 MT patients underwent dedicated cerebrovascular imaging and were included in the study. Of these 41 (16.4%) had cervical artery or venous sinus injury. Further positive vascular findings were identified in 25/250 patients who presented with an incidental stroke or a vascular abnormality and were mislabelled as MT patients at presentation. One patient with a carotid injury subsequently died following a large infarction. Another patient with vertebral artery injury suffered a non-lethal stroke. No patients underwent surgery or intervention. The present study showed that the overall incidence of detected blunt cerebrovascular injuries was very low (0.6%) and even lower for symptomatic vascular injury (0.03%). Routine cerebrovascular imaging is not recommended in all MT trauma patients, but instead, a continued case-by-case basis should be considered.

Blunt traumatic aortic injury to the brachiocephalic and left carotid arteries

BackgroundBlunt traumatic aortic injury (BTAI) is a life-threatening pathology that most commonly occurs after traffic accidents or a fall from a considerable height. We report a rare case of traumatic double transection which included the brachiocephalic artery (BCA) and left carotid artery (LCA) following a motorcycle accident.Case presentationA 52-year-old man was brought to our emergency room for blunt trauma. Urgent computed tomography (CT) indicated BCA and LCA transection. Two weeks after the BTAI, CT indicated an increase in the size of the BCA pseudoaneurysm, a newly developed LCA pseudoaneurysm, and a spread of hematoma. An emergency partial aortic arch replacement including BCA and LCA reconstruction was performed 17 days after the BTAI. The postoperative course was good, and he was discharged 12 days later.ConclusionsAn open aortic repair appeared to be more suited in the present case because the aortic injury occurred in a branched lesion of the aortic arch. It was thought that complete stent graft coverage of the transection lesion would be difficult. Although coexisting multiple system injuries complicate aortic repair, there was a rapid enlargement of the BCA and LCA pseudoaneurysms. Therefore, strict management is needed even in the case of cervical artery injury.

Blunt Traumatic Vertebral Artery Injuries: Incidence, Therapeutic Management, and Outcomes

A single-center, retrospective review between 2011 and 2018. A total of 156 patients were treated for isolated blunt vertebral artery injuries (16 bilateral) and underwent computed tomography angiography within 24 hours of presentation. Injury location was classified as: V1 = subclavian artery origin to the entrance into the C-6 transverse foramen; V2 = within the C2-C6 transverse foramen; V3 = from the C2 foramen to the foramen magnum dura; V4 = intradural. There were 79 grade I (≤25% luminal stenosis), 39 grade II (>25% luminal stenosis), 5 grade III (pseudoaneurysm), 49 grade IV (occlusion), and 0 grade V (extravasation or arteriovenous fistula) injuries. Three strokes were detected before treatment initiation. Most patients (135) were treated with aspirin alone, 2 with heparin, and 1 with Plavix, and 18 did not receive treatment (grade I injuries or required multiple surgeries for other problems). Only two patients were switched from aspirin to anticoagulation for injury progression. No strokes were detected during hospitalization for any other patient. The risk of stroke after blunt cervical vertebral artery injury is low. Aspirin is efficacious in grade I and IV injuries, but there are limited data regarding grade II and III injuries.

Blunt Traumatic Vertebral Artery Injuries: Incidence, Therapeutic Management, and Outcomes.

Blunt cerebrovascular injury (BCVI) is a term for injuries to the carotid and vertebral arteries (blunt vertebral artery injury [BVAI]) caused by blunt trauma. Computed tomographic angiography is currently the best screening test for BCVI. The subsequent management of any identified vessel injury, however, is not clearly defined. To describe one of the largest cohorts of isolated vertebral artery injuries and report the evolution of treated and untreated lesions and clinical outcomes of treatment regimens used to reduce the risk of injury-related stroke. The list included patients who presented to or were transferred to a level 1 trauma center and found to have an isolated BVAI. Patients were included if imaging was performed within 24 hours of presentation. Data collected included location and grade of injury, timing and type of initial therapy, follow-up imaging, evolution of the disease, and associated strokes. A total of 156 patients were included in the analysis. Most patients (135/156) were treated with aspirin alone, 3 with anticoagulation therapy, and 18 did not receive treatment. Three strokes were detected within 24 hours of admission and before treatment initiation. No strokes were detected during the length of the hospitalization for any other patient. Our data demonstrate that the risk of stroke after cervical vertebral artery injury is low, and aspirin as a prophylactic is efficacious in grade I and IV injuries. There are limited data regarding grade II and grade III injuries. The benefit of early interval imaging follow-up is unclear and warrants investigation.

A multi-registry analysis of military and civilian penetrating cervical carotid artery injury.

Penetrating cervical carotid artery injury is an uncommon but high-stake scenario associated with stroke and death. The objective of this study was to characterize and compare penetrating carotid injury in the military and civilian setting, as well as provide considerations for management. Cohorts with penetrating cervical carotid artery injury from the Department of Defense Trauma Registry (2002-2015) and the American Association for the Surgery of Trauma Prospective Observation Vascular Injury Treatment Registry (2012-2018) were analyzed. A least absolute shrinkage and selection operator multivariate analysis using random forest-based imputation was performed to identify risk factors affecting stroke and mortality. There were a total of 157 patients included in the study, of which 56 (35.7%) were military and 101 (64.3%) were civilian. The military cohort was more likely to have been managed with open surgery (87.5% vs. 44.6%, p < 0.001) and to have had any procedure to restore or maintain flow to the brain (71.4% vs. 35.6%, p < 0.001), while the civilian cohort was more likely to undergo nonoperative management (45.5% vs. 12.5%, p < 0.001). Stroke rate was higher within the military cohort (41.1% vs. 13.9%, p < 0.001); however, mortality did not differ between the groups (12.5% vs. 17.8%, p = 0.52). On multivariate analysis, predictors for stroke were presence of a battle injury (log odds, 2.1; p < 0.001) and internal or common carotid artery ligation (log odds 1.5, p = 0.009). For mortality outcome, protective factors included a high Glasgow Coma Scale on admission (log odds, -0.21 per point; p < 0.001). Increased admission Injury Severity Score was a predictor of mortality (log odds, 0.05 per point; p = 0.005). The stroke rate was higher in the military cohort, possibly reflecting complexity of injury; however, there was no difference in mortality between military and civilian patients. For significant injuries, concerted efforts should be made at carotid reconstruction to reduce the occurrence of stroke. Retrospective cohort analysis, level III.

Pediatric hanging and strangulation: is vascular injury a true risk?

Acute screening of pediatric strangulation and hanging injuries has evolved at many institutions to include cervical arterial vascular imaging. As current standards in pediatric imaging support less radiation exposure and increased imaging appropriateness, it is questionable whether vascular arterial injury is a true risk in this population. To determine the role of cervical vascular arterial imaging in the evaluation of pediatric hanging and strangulation injuries. This is a retrospective study of patients who present at a Level 1 pediatric trauma center with a history of hanging and strangulation injuries. All relevant studies, including computed tomography (CT) angiography of the neck, contrast-enhanced neck CT, cervical magnetic resonance (MR) angiography, magnetic resonance imaging (MRI) and/or CT of the brain and cervical spine and associated clinical records, were reviewed. Sixty-six patients were identified, 60 with vascular arterial imaging studies. No vascular injury was identified. Soft-tissue injury was noted in 20/66 (30%) patients and craniocervical injury was suspected in 2/66 (3%), but no cervical spine fracture was identified. Only 49 patients had brain imaging, with 7/49 (14%) demonstrating changes consistent with cerebral edema, which correlated negatively with survival (P<0.01). Vascular arterial imaging, particularly with CT angiography, performed in the pediatric population after hanging and strangulation injury resulted in no positive studies for cervical arterial injury. This study supports the need to reevaluate routine screening CT angiography in this study population.

Management and outcomes of wartime cervical carotid artery injury.

Cervical carotid artery injuries entail high morbidity and mortality and are technically challenging to repair. This retrospective study describes the management and outcomes of cervical carotid injuries sustained during the recent wars in Iraq and Afghanistan. The Department of Defense Trauma Registry was queried to identify US military personnel who sustained battle-related cervical carotid injury between January 2002 and December 2015. Retrospective chart reviews of the military Electronic Health Record were performed on patients identified. Demographics, injury characteristics, surgical management, and outcomes were reviewed. Statistical analysis was performed to identify associations between injury and management factors, as well as stroke and mortality. In total, 67 patients (100% male; age, 25 ± 7 years) were identified with cervical carotid artery injuries. Fifty-six patients (84%) sustained a common carotid artery (CCA) or internal carotid artery (ICA) injury, and 11 patients (16%) had an isolated external carotid artery (ECA) injury. The anatomic distribution of injury was as follows: CCA, 26 (38.8%); ICA, 24 (35.8%); CCA and ICA 2 (3%); ICA and ECA 3 (4.5%); and CCA, ICA, and ECA 1 (1.5%). Of the 56 CCA or ICA injuries, 39 underwent vascular repair, 9 (16%) were managed with ligation, 1 was treated with a temporary vascular shunt but succumbed to injuries before vascular repair, and 7 (13%) were treated nonoperatively. Seven (23%) of 30 ICA injuries were ligated compared with 2 (7.7%) of 26 injuries isolated to the CCA (p = 0.02). Compared with repair, ligation of the CCA/ICA was associated with a higher rate of stroke (89% vs. 33%, p = 0.003) and increased mortality without statistical significance (22% vs. 10%, p = 0.3). Every patient who underwent ICA ligation had a stroke (7/7). There was no difference in Injury Severity Score between the ligation and repair groups (23.8 ± 10.6 vs. 24.7 ± 13.4, p = 0.9). At a mean follow-up of 34.5 months, 10 of 17 stroke survivors had permanent neurologic deficits. In modern combat, penetrating injuries involving the cervical carotid arteries are relatively infrequent. In this experience, isolated ICA injuries were three times more likely to be ligated than those involving the CCA. As a surgical maneuver, ICA ligation resulted in stroke in all cases. Retrospective cohort analysis, level III.

Occurrence and prognostic effect of cervical spine injuries and cervical artery injuries with concomitant severe head injury

BackgroundBlunt cerebrovascular injuries (BCVIs) and cervical spinal injuries (CSIs) are not uncommon injuries in patients with severe head injury and may affect patient recovery. We aimed to assess the independent relationship between BCVI, CSI, and outcome in patients with severe head injury.MethodsWe identified patients with severe head injury from the Helsinki Trauma Registry treated during 2015–2017 in a large level 1 trauma hospital. We assessed the association between BCVI and SCI using multivariable logistic regression, adjusting for injury severity. Our primary outcome was functional outcome at 6 months, and our secondary outcome was 6-month mortality.ResultsOf 255 patients with a cervical spine CT, 26 patients (10%) had a CSI, and of 194 patients with cervical CT angiography, 16 patients (8%) had a BCVI. Four of the 16 BCVI patients had a BCVI-related brain infarction, and four of the CSI patients had some form of spinal cord injury. After adjusting for injury severity in multivariable logistic regression analysis, BCVI associated with poor functional outcome (odds ratio [OR] = 6.0, 95% CI [confidence intervals] = 1.4–26.5) and mortality (OR = 7.9, 95% CI 2.0–31.4). We did not find any association between CSI and outcome.ConclusionsWe found that BCVI with concomitant head injury was an independent predictor of poor outcome in patients with severe head injury, but we found no association between CSI and outcome after severe head injury. Whether the association between BCVI and poor outcome is an indirect marker of a more severe injury or a result of treatment needs further investigations.

Evaluation of Novel Stereotactic Cannula for Stem Cell Transplantation against Central Nervous System Disease.

Cell therapy for central nervous system (CNS) disorders is beginning to prove its safety and efficiency. Intraparenchymal transplantation can be an option for cell delivery; however, one concern regarding this method is that the transplantation cannula may cause additional brain injuries. These include vessel damage, which results in brain hemorrhage, and clogging of the cannula by brain debris and/or cell clusters, which requires replacement of the cannula or forced injection causing jet flow of the cell suspension. We compared cannulas for cell delivery used in clinical trials, the Pittsburg and Mizuho cannulas, to a newly designed one, MK01, to assess their usability. MK01 has a spherical-shaped tip with a fan-like open orifice on the side of the cannula, which prevents vessel damage, clogging of brain debris, and jet flow phenomenon. We compared the extent of rat cervical and abdominal arterial damage with the cannula, the amount of debris in the cannula, the force needed to cause jet flow, and cell viability. While the viability of cells passed through the cannulas was almost the same among cannulas (approximately 95%), the Pittsburg cannula caused cervical arterial injury and subsequent hemorrhage, as it required a significantly smaller force to penetrate the arterial wall. Moreover, the Pittsburg cannula, but not the Mizuho and MK01 cannulas, showed high frequency of brain debris in the needle tip (approximately 80%) after brain puncture. While jet flow of the injection liquid was observed even when using smaller forces in the Pittsburg and Mizuho cannulas, MK01 constantly showed low jet flow occurrence. Thus, MK01 seems to be safer than the previously reported cannulas, although further investigation is necessary to validate its safety for clinical use.

Predictors of Cervical Vertebral and Carotid Artery Dissection During Blunt Trauma: Experience From a Level 1 Trauma Center

The current data available to identify the factors associated with vertebral and carotid artery dissection in the trauma setting are conflicting, and further research is needed to accurately assess these predictors. The data from 950 patients who had undergone neck computed tomography angiography (CTA) at a level 1 trauma center were analyzed. Of the 950 patients, 435 were included who had undergone neck CTA for blunt traumatic injuries. The mechanism of injury was classified as high or low impact according to the hospital criteria for trauma. Positive neurological signs included altered mental status (Glasgow coma scale score ≤15 than baseline) or focal neurological deficits. Fractures and dissections were radiologically confirmed. Multivariable logistic regression software was used to analyze the data. Of the 435 patients, 236 (54.25%) had experienced high-impact injuries, 124 (28.51%) had vertebral fractures (including 63 displaced fractures [50.81%]), and 180 (41.38%) had had positive neurological signs on presentation. Of the 435 patients, cervical carotid artery injury had been diagnosed in 9 (2.07%), and 18 patients (4.14%) had had a cervical vertebral artery injury (VAI). Carotid artery injuries did not have significant associations with positive neurological signs, age, sex, mechanism of injury, or vertebral fracture (P > 0.05 for all). Positive neurological signs and vertebral fractures were significant predictors for VAI (odds ratio, 3.19; P < 0.05; odds ratio, 9.81; P < 0.001, respectively). Age, sex, mechanism of injury, and displacement of the vertebral fracture were not significant predictors for VAI (P > 0.05 for all). Positive neurological signs and the presence of cervical vertebral fractures are significant predictors for VAI. All trauma patients with cervical spine fractures and/or positive neurological findings should be considered for surveillance imaging with neck CTA and/or magnetic resonance angiography for vascular injury screening.

Successful Endovascular Treatment of Bilateral Carotid Dissection in a Near-Hanging Victim

Introduction - Blunt cervical carotid artery injury has been reported in 0.1% to 1.55% of all trauma patients1. Improved understanding of the injury mechanism and the availability of noninvasive imaging techniques have led to more comprehensive screening of trauma patients and an increase in diagnosis.

Disaster Scenarios in Spine Surgery: A Survey Analysis.

Survey analysis among spine surgeons. To identify current consensus and discrepancies in managing adverse intraoperative events among spine surgeons. Major intraoperative events are not commonly the subject of formal medical training, in part due to the relative paucity of their occurrence and in part due to an insufficient evidence base. Given the clinical impact of appropriate complication management, it is important to identify where surgeons may be able to improve decision making when choosing interventions. A survey was created including five hypothetical unpredicted scenarios affecting different organ systems to assess the respondents' preferred reactions. The five clinical vignettes that were selected by the researchers involved: 1) loss of spinal signals in neuro-monitoring, 2) prone position cardiac arrest, 3) prone position hypoxia during thoracic corpectomy and instrumentation, 4) supine cervical vertebral artery injury, and 5) sudden onset hypotension in major prone position reconstructive spine surgery. Twenty-eight surveys (Spine Fellows n = 11; Spine surgeon Faculty n = 17) were completed and returned to the investigators. Results were sorted and ranked according to the frequency each action was identified as a top five choice. Following formal statistical evaluation loss of signals in neuro-monitoring had the statistically significantly most uniform response while the scenario involving cardiac compromise had the most heterogeneous. Many "best" responses had near or complete consensus while some "distractor" possibilities that could harm a patient were also selected by the respondents. The heterogeneity of responses in the face of "disaster scenario" intraoperative events shows there is room for more thorough and directed education of spine surgeons during training. As surgical teaching moves toward increased use of patient simulation and situational learning, these vignettes hopefully serve to provide direction for training future spine surgeons on how best to approach difficult situations. 4.

Penetrating Pharyngoesophageal Injury: Practice Patterns in the Era of Nonoperative Management – A National Trauma Data Bank Review from 2007 to 2011

Introduction: Selective nonoperative management of neck injuries from penetrating mechanism has become an acceptable management strategy. We herein characterize current management strategies of cervical pharyngoesophageal injuries implemented by trauma surgeons in the United States. Methods: The National Trauma Data Bank datasets 2007–2011 were queried for penetrating pharyngeal and/or cervical esophageal injuries. Subjects surviving 24 hours or more were analyzed based on whether a surgical exploration was pursued and by gunshot versus stabbing mechanism. Results: In all, 1,256 patients were identified, representing 6% of all penetrating neck injuries during the study period. The majority (84%) were male, with a median age of 27 years. Injury severity was high (median score of 14). Compared to stabbing victims, gunshot patients were more likely to have associated cervical spine (24% vs. 1%, p < .01) and carotid artery injury (14% vs. 9%, p < .01). Neck exploration was performed in 49% of patients who survived at least 24 hours, with 90% occurring within the first day of admission. Of patients who underwent a delayed neck exploration, 35% required a tracheostomy and 41% required a feeding tube placement. The overall mortality was 4%. Nonoperative management was not associated with increased odds for death (adjusted odds ratio (AOR) 0.55, p = .17). Conclusions: Nonoperative management of penetrating pharyngoesophageal injuries is commonly utilized with no effect on mortality.

Cervical vertebral artery injury caused by cervical blunt injury in a traffic accident, a case report

Cervical vertebral artery injury caused by cervical blunt injury in a traffic accident, a case report

Wednesday, September 26, 2018 10:35 AM – 12:00 PM Cervical Spine Trauma: 26. The clinical implications of adding computed tomography angiography in the evaluation of cervical spine fractures: a propensity matched analysis

BACKGROUND CONTEXT Screening asymptomatic blunt trauma patients for cervical arterial injury is controversial. Vertebral artery injury (VAI) is most commonly associated with cervical spine fracture and some guidelines advocate indiscriminate screening of all cervical spine fractures. PURPOSE To determine whether the addition of computed tomography angiography (CT-A) resulted in a change in management for patients with cervical spine fractures. STUDY DESIGN/SETTING Propensity score matching cohort study. Participants of this study originated from two large academic trauma centers located in a single city. PATIENT SAMPLE Adult patients with acute cervical spine fractures sustained after blunt trauma between 2000 and 2015 were included. Patients with penetrating trauma, neoplasm and prior cervical spine surgery were excluded. There were 3,943 patients screened for inclusion and 2,831 patients eligible. OUTCOME MEASURES Recommendation for a change in management with antithrombosis was the primary outcome measure. Detection of stroke and vertebral artery injury were secondary outcomes. METHODS Demographic data, cervical spine fracture characteristics, utilization of CT-A, presence of vertebral artery injury and outcome were extracted from the medical record. Logistic regression identified factors associated with obtaining a CT-A. Propensity score matching was performed to negate the significant baseline characteristic differences including age, race, medical comorbidities, injury burden, mechanism of injury, upper cervical spine fracture, foramen transversarium involvement, multilevel involvement and associated facet dislocation. This resulted in one cohort receiving CT-A and one cohort that did not, both with 644 patients and equivalent demographic and clinical characteristics. The score matched patients who obtained CT-A with those who obtained CT alone to create two statistically equivalent cohorts. RESULTS In the matched cohorts, average age was 59 years and 57% of each cohort was male. CT-A identified definite or indeterminate VAI in 113 patients and 62 patients had antithrombosis recommended. In the cohort without CT-A, VAI was discovered in 11 patients incidentally through other imaging and eight were recommended antithrombosis. Two patients in the CT-A group had major adverse bleeding events as a result of antithrombosis initiation. There were no preventable strokes in either group. CONCLUSIONS The addition of CT-A increased the detection of VAI and antithrombosis recommendation. There was a high incidence of indeterminate CT-A findings. There were no preventable strokes in either cohort and two major adverse bleeding events as a result of recommended pharmacologic antithrombosis. Non-selective screening is not warranted and should be limited to a high-risk subset of patients. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Anchoring Pipeline Flow Diverter Construct in the Treatment of Traumatic Distal Cervical Carotid Artery Injury

Background: Traumatic extracranial internal carotid artery (ICA) dissections are uncommon and can be difficult to treat. Thinning of adventitia and dilatation may occur following arterial dissection, thus resulting in a fusiform pseudoaneurysm, which can subsequently cause bleeding, expanding, or pulsatile hematoma. Currently, medical management with anticoagulation remains the first line of treatment and yields good outcomes in 75% of cases with a mortality rate of 3-4%. Endovascular intervention is indicated with failure of medical therapy, progressive enlargement of a traumatic pseudoaneurysm, acute flow-related infarcts due to vessel occlusion, or when anticoagulation is contraindicated due to risk of pseudoaneurysm rupture and hemorrhage. Recognized interventional treatments include parent artery occlusion with or without revascularization, endovascular coil embolization, and covered stenting. Summary: A wide variety of endovascular stents are available that are capable of opening a stenosed vessel while obliterating the associated false lumen and providing a scaffold for embolization of the pseudoaneurysm. The use of the Pipeline Embolization Device (PED) in the management of traumatic intracranial pseudoaneurysms has been described. However, there are few reports on the usage of the PED for treating traumatic extracranial ICA dissection and/or pseudoaneurysms. However, a potential complication of the use of PED in the extracranial ICA is a hypothetical tendency to migrate in a mobile vessel. Thus, the risk of migration of the PED has encouraged practitioners to adopt strategies to limit this risk. Key Messages: We describe different techniques employed to anchor the flow-diverting construct within tortuous, mobile vessels.

A Histopathological Study of Carotid Artery Injuries in Vehicular Accidents

The study was conducted in the Department of Forensic Medicine and Toxicology, Indira Gandhi Government Medical College, Nagpur. Total 100 cases were examined to study various patterns, anatomical location and histological extent of the cervical carotid artery injuries. Traumatic vascular injury to the extra cranial circulation appears relatively underdiagnosed in part because of frequent co-existence of traumatic brain injury. In this study, intimal tears were present in 15(57.69%) and compound intimo-medial tears were found in 15(57.69%) subjects of the 26 subjects with positive findings. Medial tears were noted in 12(46.15%) subjectsand total 8 complete wall transections were present. It seems, the intimal tear is the basic and most common injury which leads to further thrombosis and occlusion.

A Study of Injuries to Carotid Arteries in Vehicular Accidents

The study was conducted in the Department of Forensic Medicine and Toxicology, Indira Gandhi Government Medical College, Nagpur. Total 100 cases were examined to study various patterns, anatomical location of the cervical carotid artery injuries. Traumatic vascular injury to the extra cranial circulation appears relatively underdiagnosed in part because of frequent co-existence of traumatic brain injury. The blunt injuries to the carotid arteries usually present late with devastating stroke. As per this study, the maximum number of cases belonged to the age group 21-30 years (27%) and 82% of the victims were male. In only 42.3% of the cases with carotid artery injuries, there were surface injuries to the neck. The most common vessel involved was left common carotid artery (45.9%) followed by right common carotid artery (35.1%). In maximum number of cases, the cause of death was head injury (65%) which usually masks the presentation of the carotid artery injury. The multiple i.e. dual vessel involvement was found in the 42.31% of the positive cases suggesting possible mechanism of hyperextension of the neck rather than direct trauma. Language: en

Misplaced Central venous Catheter in the Vertebral Artery: Endovascular Treatment of Foreseen Hemorrhage during Catheter Withdrawal

We report on the endovascular management of hemorrhage with stent-graft due to a misplaced central venous catheter in the vertebral artery (VA) during percutaneous internal jugular vein catheterization in a child. A 16-year-old female was presented with the diagnosis of familial Mediterranean fever related chronic renal insufficiency. An attempt was made to place a central venous catheter via the right internal jugular vein without image guidance and the patient experienced dyspnea and pain at the catheter insertion site. Computerized tomography (CT) showed hemorrhage in the cervical region and upper mediastinum, also reformatted images showed that the catheter was passing through the proximal part of the VA and terminating in the right mediastinum. The catheter was removed during manual compression under angio-flouroscopic monitoring and ongoing extravasation was observed. A stent-graft was placed to the bleeding site of the VA. Angiography immediately after the stent-graft placement revealed complete disappearance of extravasation and patency of vertebral and subclavian arteries. Central venous catheterization (CVC) is not a risk-free procedure and arterial injuries are in a wide spectrum from a simple puncture to rupture of the artery. Inadvertent VA cannulation is a rare and serious complication necessitating prompt diagnosis and early treatment. If an arterial injury with a large-caliber catheter occurs, endovascular treatment with stent-graft seems to be a safe and effective option in terms of achieving hemostasis and preserving arterial patency. Recent findings suggest that endovascular management of inadvertent cervical arterial injury secondary to CVC seems to be the safest strategy.