Traumatic Dissection Research Articles

Abstract 1122‐000200: Chiropractor Manipulation Leading to Bilateral Vertebral Artery Dissection and Acute Ischemic Stroke

Introduction : Traumatic cervical artery dissection is one of the leading causes of stroke in patients under the age of 45. Recent chiropractic neck manipulation is associated with risk of vertebral artery dissection (VAD). The V3 segment of the vertebral artery is highly susceptible to the bending forces during forced manipulation leading to intimal damage. Methods : N/A Results : This is a case presentation of a 44 year old male who was transferred from another emergency department for left homonymous inferior quadrantanopia noted on an optometrist visit. He reported sudden onset left homonymous hemianopia after receiving a high velocity cervical spine adjustment at a chiropractor appointment for chronic neck pain a few days prior. CT angiogram of the head and neck revealed bilateral vertebral artery dissection at left V2 and right V3 segments. MRI brain confirmed an acute infract in the right medial occipital lobe. His right PCA stroke was likely embolic from the injured right V3 but possibly from the left V2 as well. As the patient reported progression from a homonymous hemianopia to a quadrantanopia, he likely had a migrating embolus. Conclusions : Arterial dissection accounts for about 2% of all ischemic strokes, but may be between 8–25% in patients less than 45 years old. VAD can result from trauma of varying severities ‐ from sports, motor vehicle accidents, and chiropractor neck manipulations to violent coughing/sneezing. It is estimated that 1 in 20,000 spinal manipulation results in vertebral artery aneurysm/dissection. In the United States, patients who have multiple chronic conditions are reporting higher use of complementary or alternative medicine, including chiropractic manipulation. Education about the association of VAD and chiropractor maneuvers can be beneficial to the public as these are preventable acute ischemic strokes. In addition, vertebral artery dissection symptoms can be subtle and patients presenting to chiropractors may have distracting pain masking their deficits. Evaluating for appropriateness of cervical manipulation in high‐risk patients and detecting early clinical signs of VAD by chiropractors can be beneficial in preventing acute ischemic strokes in young patients.

Renal Parenchyma Trauma and General Trauma Recommandations

Among trauma emergencies, kidney damage is uncommon. The urologist is frequently on the second line in the management of patients with multiple traumatic lesions. Knowledge of treatment is necessary to be able to integrate the different teams involved in an approach that is both vital in the context of damage control and functional with a concern for parenchymal preservation. A systematic review of the literature was carried out using the Medline database in order to identify the most relevant articles in English and French. Kidney trauma occurs either by direct shock or by a deceleration mechanism. They are classified by severity according to the AAST classification. Management is mostly conservative by avoiding surgery and controlling bleeding by arterial embolization. Surveillance checks for complications occurrence in high-grade trauma. Traumatic dissection of the renal artery, with a poor functional prognosis requires a short delay before treatment. The prognosis for trauma to the kidney, regardless of the grade, is currently good, with improvements of effective resuscitation and embolization in the event of bleeding.

Endovascular Transcarotid Artery Revascularization Using the Walrus Balloon Guide Catheter: Preliminary Experience

The Walrus Balloon Guided System Catheter is a new generation of balloon guide catheter (BGC) designed to bypass some technical limitations of conventional BGC devices. Their utility in cervical carotid disease treatment has not been reported. We report our preliminary experience in cervical carotid treatment using the Walrus BGC to perform a modified endovascular transcarotid artery revascularization technique. Patients with cervical carotid disease undergoing endovascular treatment using the Walrus BGC at our institution were identified. The pertinent baseline demographics and procedural outcomes were collected and analyzed. Twelve patients were included (median age, 70; 58.3% females). All patients had an imaging-confirmed cervical carotid disease that indicated intervention: 6 with high-grade cervical arteriosclerotic carotid stenosis, 2 with intraluminal thrombi, 1 with traumatic carotid dissection, and 3 patients with cervical carotid tandem occlusion along with acute ischemic stroke secondary to large vessel occlusion that required mechanical thrombectomy. Carotid artery stenting was performed in all cases, except 2 of the 3 mechanical thrombectomy cases (angioplasty only). All patients had at least periprocedural follow-up of 30 days, with no stroke, myocardial infarction, or death encountered. We describe a modified endovascular transcarotid artery revascularization technique. We used a standard femoral access to navigate the Walrus catheter in the common carotid artery, followed by balloon inflation for proximal flow arrest or flow reversal (when connected to the aspiration pump) to deploy the carotid stent across the stenosis, while avoiding distal external carotid artery balloon occlusion. Successful treatment was achieved inall cases, with no periprocedural complications encountered.

Endoprosthesis replacement of the thoracic aorta for traumatic dissection and pseudoaneurysm

Aortic injury in closed chest trauma takes the second place in the structure of mortality in closed injuries. The type of aortic injury is a crucial factor in determining the optimal timing of the operation. For many years, the treatment strategy was reduced to immediate surgical intervention. The mortality rate in open operations is still high. The widespread introduction of endovascular technologies and aortic endoprosthetics has significantly reduced mortality and reduced the number of severe postoperative complications. With the advent of new endoprostheses, the possibilities of treatment have increased even more and its results have improved for various aortic injuries. A case of successful treatment of a patient with traumatic dissection and pseudoaneurysm of the thoracic aorta by endoprosthetics is presented.

Traumatic coronary artery dissection with total occlusion of left descending coronary artery: to stent or not to stent.

Traumatic coronary artery dissection with total occlusion of left descending coronary artery: to stent or not to stent.

Traumatic intracranial internal carotid artery dissection and pseudoaneurysm presenting as oculomotor nerve palsy

Traumatic intracranial internal carotid artery dissection and pseudoaneurysm presenting as oculomotor nerve palsy

Isolated basilar artery dissection following blunt trauma challenging the Glasgow coma score: A case report

Blunt cerebrovascular injury is a very rare complication of blunt trauma and a diagnostic challenge. A 14year old male fell 10m sustaining multi system trauma. The atypical Glasgow Coma Score was six with a fully preserved eye component. Initial whole-body CT scanning demonstrated multiple injuries but no obvious brain injury. Trauma management involved non-operative resuscitation and was successful, however profound coma occurred and brain stem reflexes disappeared on day two. Repeat brain CT scan demonstrated multiple cerebral and cerebellar ischemic lesions and no opacification of the vertebral or basilar arteries. Secondary analysis of the first CT scan demonstrated a small focal basilar artery dissection not initially reported. Our case report highlights an unusual cause of coma after traumatic brain injury where the clinical scenario mimics locked in syndrome. In such circumstances cerebrovascular injury, and in particular traumatic basilar artery dissection, must be actively excluded.

Traumatic Aortic Dissection Complicating Retrieval of an Embolised Atrial Septal Defect Closure Device

A 65 year old man presented with embolisation of an atrial septal defect closure device (Flex II, Occlutech, Helsingborg, Sweden) to the abdominal aorta. Endovascular attempts failed to recapture it within a 9Fr introducer. Despite significant friction in the aorta, the device was pulled to the right common iliac artery. Arteriography (A) and computed tomography scan (B) showed aortic dissection complicated by right external iliac artery occlusion. The device was removed surgically, and retroperitoneal iliofemoral bypass was performed. Pulling a non-covered device may cause vessel injuries; inability to recapture the device indicates the need for a larger sheath or open surgery.Image 1

Traumatic right coronary artery dissection

A 61-year-old woman presented with two days history of intermittent left-sided chest pain, she is a smoker with a long history of poorly controlled high blood pressure. Clinical examination was...

Persistent Trigeminal Artery as Collateral Circulation in Ischemic Stroke

The persistent trigeminal artery is the most frequent of the persistent embryonic carotid-basilar artery anastomoses. In the literature, it has most often been described in relation to cerebrovascular pathologies such as aneurysms, vascular nerve compression, trigeminal cavernous fistulas, and thromboembolic ischemia. Its role as collateral circulation, thus supplying brain perfusion during main arterial trunk occlusion, has seldom been described. We describe the case of a patient who presented with a stroke due to a traumatic dissection of the internal carotid artery at the neck, in which the infarction may have been limited by a persistent trigeminal artery.

Traumatic Aortic Dissection (Stanford Type A, DeBakey Type II) Caused by Blunt Chest Trauma

症例は55歳男性．来院4時間前，仕事中に前胸部を打撲し，前胸部痛が持続するため前医を受診した．胸腹部CTで胸骨横骨折および外傷性急性大動脈解離（Stanford A型，DeBakeyII型）を認め，他の出血性合併損傷を認めなかったため緊急で上行置換術を施行した．経過は良好で術後19日目に独歩退院した．病理組織所見では嚢状中膜壊死を認めず，外傷性大動脈解離の所見であった．高度の粥状動脈硬化性変化を有する場合，高エネルギー外傷でない場合においても大動脈損傷の可能性を念頭に置くべきである．外傷性大動脈損傷では，合併損傷を考慮して症例ごとに治療介入の至適時期を見極めることが重要である.

Endovascular repair of traumatic aortic dissection: a single-center experience.

The data on endovascular aortic repair (EVAR) for traumatic aortic dissection (TAD) are lacking. Hence, this study aimed to evaluate the efficacy of EVAR for TAD and report our experience based on patients from our medical center with a relatively long follow-up. A total of 25 consecutive patients with TAD underwent EVAR from October 2015 to October 2020. The demographics, imaging characteristics, clinical features, treatment details, and follow-up results were reviewed. Urgent EVAR was performed in 3 patients (12%), while the remaining 22 patients (88%) underwent delayed EVAR. Systematic heparinization was used in all patients during the endovascular procedure. The EVAR was technically successful in all patients, with no cases converted into open surgery. No death occurred during the perioperative period. One patient presented with a type II endoleak on postoperative 1-month CT images during a mean follow-up of 42.3 ± 17.7 months (5-67.5 months) and showed spontaneous regression of the endoleak without any intervention during the subsequent follow-up. All the patients survived until the time of writing, and none of them showed late endoleak, stent migration, paraplegia, and reintervention. The patients with left subclavian artery covered (n = 8) had no obvious ischemia of the arm and brain. The study results demonstrated that EVAR for TAD proved to be safe and effective, and most patients could undergo delayed EVAR. Systematically heparinization during EVAR under the setting of multi-trauma was safe.

CT-fusion-guided thoracic endovascular aortic repair: Case report and literature review

Interventional and hybrid methods of treatment, combining open surgical and endovascular repairs, are the most promising areas in the surgery of the thoracoabdominal aorta. Recent studies, however, have demonstrated that complex thoracic endovascular aneurysm repair (TEVAR) is one of the most high-dose endovascular interventions. In addition, TEVAR is associated with the use of a significant volume of contrast media (CM), which can lead to contrast-induced acute kidney injury (CI-AKI). The use of advanced imaging techniques and computed tomographic fusion (CT-fusion) in routine practice can potentially reduce operation duration, radiation exposure and CM volume usage. We analyzed the literature on CTfusion in endovascular aortic repair and present a clinical case of a 50-year-old male with a history of concomitant blunt chest trauma. CT of the chest revealed an aneurysm of the arch and descending aorta after traumatic dissection of the aorta (IIIa DeBakey, type B Stanford), post-traumatic diaphragmatic hernia of the left dome of the diaphragm with stomach and intestinal loops prolapse. The patient underwent a staged hybrid intervention — subtotal aortic arch debranching followed by CT-fusion-guided semi-arch TEVAR. CT-fusion is a dynamically developing technology, may reduce the CM volume, the duration of the procedure and radiation exposure and requires further research.

Clinical analysis of 30 cases of traumatic aortic injury

Objective: To examine the clinical treatment methods and short- and mid-term results of traumatic aortic injury (TAI). Methods: The clinical data of 30 patients suffering from TAI who were admitted to Department of Cardiothoracic Surgery, General Hospital of Eastern Theater Command from January 2010 to December 2018 were summarized and analyzed retrospectively. All patients were diagnosed as TAI by aortic CT angiography. There were 20 males and 10 females, aging (46.4±15.2) years (range: 17 to 76 years). One patient was diagnosed as extensive intramural hematoma (IMH). The other 29 cases had aortic intimal injury, and the primary intimal tear of all these patients was located in the isthmus of descending aorta. There were 2 cases of ulcer-like changes combined with IMH, and 27 cases of traumatic aortic dissection (TAD) including 23 cases of localized TAD and 4 cases of extensive TAD. Endovascular repair, artificial vascular replacement or conservative treatment were performed according to the patient's specific condition. The patients were followed up in outpatient or by telephone. The clinical data of all the patients of the in-hospital treatment and during follow-up period was analyzed retrospectively. Results: One patient with IMH was treated conservatively. Surgical intervention was performed in 29 cases with intimal injury, of which 14 cases underwent emergency surgery on the day of admission or the next day, and 15 cases underwent elective surgery. Twenty-seven cases underwent thoracic endovascular aortic repair (TEVAR), and 2 cases underwent artificial vascular replacement. Nine cases suffered combined operations in early or late stage. All patients were cured and discharged with in-hospital stay of (13.2±5.4) days (range: 7 to 30 days). There was no in-hospital death. Two patients underwent tracheotomy, and the rest had no serious complications. Up to the last follow-up in June 2019, 4 patients were lost to follow-up, and the remaining 26 patients were followed up for (50.6±34.1) months (range: 6 to 112 months) and survived healthily without new aortic events. Conclusions: Most of TAD cases are ascribed to Stanford type B aortic dissection, and a satisfactory short-term and mid-term result can be achieved by emergency TEVAR in most patients. Some patients can achieve good long-term results by open surgery with artificial vascular replacement.

Traumatic Dissection of Arterial Cervical Vessels: Report of Two Cases and Literature Review

AbstractEven though traumatic dissection of cervical arterial vessels is the major cause of stroke among adults, it is still an underdiagnosed disease in neurosurgical emergencies, since most patients do not have or present subtle clinical signs in the acute phase. The authors report two interesting cases of cervical artery dissection with different traumatic mechanisms and present a broad literature review about this subject.

Cerebral infarct secondary to traumatic internal carotid artery dissection.

BACKGROUNDTraumatic internal carotid artery dissection (TICAD) is rare and can result in severe neurological disability and even death. No consensus regarding its diagnostic screening and management has been established.AIMTo investigate the clinical presentation, imaging features, diagnostic workup, and treatment of TICAD.METHODSIn this retrospective case series, emergency admissions for TICAD due to closed head injury were analyzed. The demographic, clinical, and radiographic data were retrieved from patient charts and the picture archiving and communication system.RESULTSSix patients (five males and one female, age range of 43-62 years, mean age of 52.67 years) presented with TICAD. Traffic accidents (4/6) were the most frequent cause of TICAD. The clinical presentation was always related to brain hypoperfusion. Imaging examination revealed dissection of the affected artery and corresponding brain infarction. All the patients were definitively diagnosed with TICAD. One patient was treated conservatively, one patient underwent anticoagulant therapy, two patients were given both antiplatelet and anticoagulant drugs, and two patients underwent decompressive craniectomy. One patient fully recovered, while three patients were disabled at follow-up. Two patients died of refractory brain infarction.CONCLUSIONTICAD can cause catastrophic outcomes and even refractory brain hernia. Early and efficient diagnosis of TICAD is essential for initiating appropriate treatment. The treatment of TICAD is challenging and variable and is based on clinician discretion on a case-by-case basis.

Modified Split-Scan Computed Tomography (CT) Diagnostics of Severely Injured Patients: First Results from a Level I Trauma Center Using a Dedicated Head-and-Neck CT-Angiogram for the Detection of Cervical Artery Dissections.

Introduction: Traumatic cervical artery dissections are associated with high mortality and morbidity in severely injured patients. After finding even higher incidences than reported before, we decided to incorporate a dedicated head-and-neck computed tomography angiogram (CT-A) in our imaging routine for patients who have been obviously severely injured or, according to trauma mechanism, are suspected to be severely injured. Materials and Methods: A total of 134 consecutive trauma patients with an ISS ≥ 16 admitted to our level I trauma center during an 18 month period were included. All underwent standardized whole-body CT in a 256-detector row scanner with a dedicated head-and-neck CT-A realized as single-bolus split-scan routine. Incidence, mortality, patient and trauma characteristics, and concomitant injuries were recorded and analyzed in patients with carotid artery dissection (CAD) and vertebral artery dissection (VAD). Results: Of the 134 patients included, 7 patients had at least one cervical artery dissection (CeAD; 5.2%; 95% CI 1.5–9.0%). Six patients (85.7%) had carotid artery dissections, with one patient having a CAD of both sides and one patient having a CAD and contralateral VAD combined. Two patients (28.6%) showed a VAD. Overall mortality was 14.3%, neurologic morbidity was 28.6%. None of the patients showed any attributable neurologic symptoms on admission. The new scanning protocol led to further 5 patients with suspected CeAD during the study period, all ruled out by additional magnetic resonance imaging with angiogram (MRI/MR-A). Conclusion: A lack of specific neurologic symptoms on admission urges the need for a dedicated imaging pathway for severely injured patients, reliable for the detection of cervical artery dissections. Although our modified CT protocol with mandatory dedicated CT-A led to false positives requiring additional magnetic resonance imaging, it likely helped reduce possible therapeutic delays.

The first case of traumatic internal carotid arterial dissection? Verneuil's case report from 1872.

Dissecting aneurysms of the internal carotid artery were considered as very rare disorders before the seventies. Undiagnosed carotid-artery dissections, however, may have gone hidden behind earlier reports of delayed "apoplexy" due to "traumatic carotid thrombosis". Here, we present a case report of delayed stroke after trauma, published by Aristide Verneuil in 1872 in the Bulletin de l'Académie de Médecine and cited under the heading of vascular rupture and dissecting aneurysm by Heinrich Quincke in 1876. Verneuil's case report represents, to our knowledge, the first detailed clinical description of a patient with a traumatic carotid dissection confirmed at autopsy. The author highlighted the diagnostic challenges of this case, head injury followed by delayed hemiplegia suggesting an intracranial bleeding.

Successful stent graft placement in the patient with acute spinal cord circulatory impairment due to traumatic descending thoracic aortic dissection: a case report

The article presents a clinical case of the successful stent graft placement in the descending aorta of the patient with acute spinal cord circulatory impairment due to traumatic aortic dissection after a traffic collision.

The Need to Look for Visual Deficit After Stroke in Children.

Purpose: To evaluate the role of the ophthalmologist in the management of children with arterial stroke, at presentation and during follow-up.Methods: This retrospective case series comprised children with arterial stroke who were followed for at least 12 months in a tertiary pediatric medical center in 2005–2016. Demographic data and findings on radiological neuroimaging and ophthalmological and neurological examination were retrieved from the medical files.Results: The cohort included 26 children with stroke. Underlying disorders included metabolic syndrome (n = 5, 19.2%), cardiac anomaly or Fontan repair (n = 3 each, 11.5%), vascular anomaly (n = 3, 11.5%), head trauma with traumatic dissection (n = 3, 11.5%), and hypercoagulability (n = 1, 3.8%); in eight patients (30.8%), no apparent cause was found. Eleven patients (42.3%) had a non-ophthalmological neurological deficit as a result of the stroke. Eye examination was performed in nine patients (34.6%) during follow-up. Ophthalmological manifestations included hemianopic visual field defect in seven patients (7.7%) and complete blindness and poor visual acuity in one patient each (3.8%). At the last visit, no change in visual function was detected.Conclusion: The variable etiology and presentation of pediatric stroke may mask specific visual signs. Children with arterial stroke should be referred for early ophthalmological evaluation and visual rehabilitation.