Traumatic Dissection Research Articles

Cerebral Infarct due to Traumatic Carotid Artery Dissection

A patient aged 48 years was admitted to our emergency department with right motor deficit and speech disorder. On neurologic examination, dysarthria, right hemiparesis, and rightside Babinski reflex were found. The patient’s brain computerized tomography (CT) was normal. During hospitalization, he complained of neck pain spreading to the head and was questioned about trauma for the differential diagnosis of dissection. He had been attacked on the left side of his neck during a fight the day before. Twelve hours later, the patient’s symptoms continued to increase and dizziness developed. Diffusion-weighted images revealed a hyper-intensity in the region of the left middle cerebral artery, accompanied by low apparent diffusion coefficient signals (Figure 1). Duplex ultrasound was performed and acute thrombosis and stenosis of the left carotid artery was demonstrated. CT angiography revealed thrombus and dissection of the left carotid artery in the neck (Figure 2A, B, C). Treatment was started with low-molecular-weight heparin followed by warfarin. The patient was prescribed warfarin, an oral anticoagulant, for at least 6 months because the radiologic and duplex ultrasound findings did not change or worsen. Although conventional digital subtraction angiography is still the gold standard procedure, noninvasive methods are preferred to decrease the risk of stroke. Duplex ultrasound has limited ability and is the procedure of choice to follow-up the progression of dissection. CT and magnetic resonance angiography with a similar sensitivity and specificity can be used in the diagnosis of dissection (1,2). In conclusion, internal carotid artery dissection is a potentially life-threatening condition and serious cause of stroke in young patients; therefore, early diagnosis is important.

Stroke prevention by endovascular treatment of carotid and vertebral artery dissections

IntroductionEndovascular intervention for cervical carotid artery dissection (CAD) and vertebral artery dissection (VAD) may be indicated in specific circumstances.ObjectiveTo review our institutional experience with endovascular treatment of cervical dissections over...

Traumatic Dissections of Bilateral Internal carotid Artery with Aneurysms Formation

Carotid artery dissection is an unusual complication of blunt neck trauma with high mortality and severe neurological deficits. Traumatic bilateral dissections and dissecting aneurysms are extremely rare. A 17‐year‐old male presented to our emergency department with sudden onset of right hemiparesis and aphasia. Initial computed tomography scan of head and neck showed no remarkable finding. On the second day, a magnetic resonance angiography of head and neck demonstrated bilateral extracranial internal carotid artery dissections. The diagnosis of traumatic carotid artery dissection for emergency physicians is difficult because of the absence or delayed onset in symptomatology. Magnetic resonance angiography is currently considered as an appropriate initial diagnostic tool for carotid artery injury. In clinical practice, early diagnosis by keeping a high index of suspicions is required by emergency physicians.

Blunt traumatic dissection of right coronary artery presenting with acute inferior wall myocardial infarction: Dilemma in management

Thirty-nine year male had a history of road traffic accident with polytrauma. At emergency room he started having chest pain with ventricular tachycardia. He was subsequentially diagnosed with right coronary artery dissection secondary to blunt trauma which is an extremely rare cause of inferior wall myocardial infarction. After some dilemmas, he was ultimately treated with intravascular ultrasound guided coronary angioplasty with stenting and had an uneventful recovery.

Delayed subarachnoid hemorrhage 7 years after cerebellar infarction from traumatic vertebral artery dissection

Vertebral artery dissection (VAD) is an important cause of ischemic stroke and subarachnoid hemorrhage (SAH). Dissections presenting with ischemia rarely cause SAH after more than a few hours, especially without...

Malignant Middle Cerebral Artery Infarction Secondary to Traumatic Bilateral Internal Carotid Artery Dissection. A Case Report

Traumatic bilateral dissection of the carotid arteries is a rare condition with potentially life-threatening complications. The case of a 57-year-old male patient with acute onset left sided hemiparesis, twelve hours after a blunt head injury, caused by a horse kick, is reported. A cerebral CT scan revealed right middle cerebral artery (MCA) territory infarction. Based on Duplex ultrasound and Angio CT scan findings, a diagnosis of bilateral ICA dissection was established. Despite antithrombotic treatment, the patient presented with a progressive worsening of his neurological status. The control CT scan evidenced malignant right MCA territory infarction that required decompressive craniotomy. The patient was discharged with significant neurological deficits. Together with this case, the aetiologies, clinical manifestations, diagnostic and therapeutical options and outcome of carotid artery dissection are discussed.

Trends in the Diagnosis and Outcomes of Traumatic Carotid and Vertebral Artery Dissections among Medicare Beneficiaries

Early identification of carotid and vertebral artery dissections has been advocated to reduce stroke among trauma patients. We sought to characterize trends in the diagnosis of traumatic carotid and vertebral artery dissections and association changes in stroke rate among Medicare beneficiaries. Using Medicare claims, we created a cohort of 5,961 beneficiaries admitted with a new traumatic carotid or vertebral artery dissection from 2001 to 2012. We calculated rates of stroke during hospitalization and 90 days of discharge. We calculated rates of carotid imaging using computed tomography-angiography, carotid duplex, and plain angiography index hospitalization. To study concurrent secular trends, we created a secondary cohort of patients admitted after any traumatic injury from 2001 to 2012 and determined rates of stroke and carotid imaging within this cohort. From 2001 to 2012, incidence of traumatic carotid dissection increased 72% among Medicare beneficiaries (1.1-1.76 per 100,000 patients; rate ratio [RR], 1.72; 95% CI, 1.6-1.9, P<0.001). Among patients diagnosed with traumatic carotid or vertebral artery dissections, the combined in-hospital and 90-day stroke rate did not change significantly (4.9% in 2001; 5.2% in 2012; RR, 1.06; 95% CI, 0.93-1.20; P=0.094). Likewise, there was little change in mortality (10.3%; RR, 1.01; 95% CI, 0.95-1.06; P=0.88). Among all trauma patients, the use of computed tomography angiography has increased 16-fold (2-35 per 100,000 patients; RR, 16.7; 95% CI, 13-19; P<0.0001). Despite increased diagnosis of carotid or vertebral artery dissection, there has been little change in stroke risk among trauma patients. Efforts to more effectively target imaging and treatment for these patients are necessary.

Experience of endovascular repair of thoracic aortic dissection after blunt trauma injury in a district general hospital.

Traumatic thoracic aortic dissection is uncommon in clinical practice; however, it is associated with high morbidity and mortality. Thoracic aortic dissection is usually caused by sudden deceleration resulting from a traffic accident or fall. Aortic injury after blunt trauma is a critical condition. This study reported the outcomes of endovascular repair of acute traumatic aortic dissection in patients at a district general hospital. In this study, we retrospectively reviewed the clinical data of eight patients with acute traumatic aortic dissection after a blunt trauma who had undergone thoracic endovascular aortic repair (TEVAR) between January 2012 and December 2015 at a district general hospital in Taiwan. The median age of the patients was 49±22 years (range, 20-77 years), and 6 of the 8 (75%) patients were men. Five patients were involved in traffic accidents, and 3 patients had fallen from heights. The injury severity score (ISS) of the patients ranged from 17 to 66. In all patients, the aortic injury was located near the origin of the left subclavian artery (LSA). Four patients had seal ostium of subclavian artery, left. None of the patients developed paraplegia or lower extremity ischemia. Moreover, all patients had concomitant injuries, and no patients died postoperatively. Endovascular repair is a rapid and minimally invasive therapy for patients with traumatic aortic injury and is associated with favorable technical results.

Neck Pain in a Performing Arts Student

HISTORY: 24-year old female operatic student at a performing arts school with history of C5-6 left paracentral disc protrusion presented with worsening left-sided neck pain that began 1 day after a low impact motor vehicle accident (MVA). At the visit she denied any upper extremity tingling, numbness or weakness. She denied headaches, head injury or symptoms of concussion. PHYSICAL EXAM: She had full active range of motion of her cervical spine but some left-sided neck discomfort with right lateral flexion and rightward rotation. Her C-spine was tender in the midline at C7. Spurling’s was negative and upper and lower extremity neurological exams were normal. DIFFERENTIAL DIAGNOSIS: 1. Cervical disk pathology (worsened from previous) 2. Cervical muscle strain/soft tissue sprain 3. Bony injury TESTS AND RESULTS: Cervical spine AP, lateral flexion and extension views: Normal MRI Cervical spine 1. Concentric T1 hyperintense signal involving the left vertebral artery at the C5-6 level suspicious for focal dissection with intramural hematoma 2. Small left paracentral disc protrusion, largely unchanged from prior study MRA: Vertebral artery dissection at the V2 level with intramural hematoma and <33% artery narrowing MRI Brain obtained to evaluate for occult stroke: normal FINAL WORKING DIAGNOSIS: Traumatic left vertebral artery dissection TREATMENT AND OUTCOME: 1. Started on oral aspirin, discharged to outpatient follow up 2. At follow up 1 week later, MRA showed worsening vertebral artery dissection with concern for complete occlusion 3. CTA ordered to further assess artery lumen, confirmed that artery was not completely occluded 4. Admitted and started on IV anticoagulation; discharged on rivaroxaban 5. Currently restricted from dance and any vigorous activities or exercise, will reassess activity level at 3mo follow up with Neurology

Open Fracture of the Cervical Spine Due to a Peculiar Injury Mechanism

Introduction Scarce literature is available regarding traumatic open injuries of the cervical spine. In the majority of the reported cases, the injury was caused by a penetrating trauma due to a gunshot. We present the case of a patient with an open fracture of the cervical spine due to a peculiar injury mechanism. Material and Methods Case report of a healthy 29-year-old male who suffered an accident while riding a bicycle on his way to work. Characteristics of the injury mechanism, reported lesions, their treatment and follow-up are described. Results This 29-year-old male crushed his bicycle against the inside of the door of a parked car, which was suddenly opened while he was riding by it. As a result, he was expelled from the bicycle and hit the right side of the anterior aspect of his neck against the posterior superior corner of the car's door, causing a small stab wound-like injury. The patient had no head injury, dysphagia or dysphonia and was neurologically intact, but presented subcutaneous emphysema of the neck. He was initially assessed with cervical spine X-rays and a neck computed tomography (CT) scan, which revealed a marginal fracture of the anterior inferior border of the C4 vertebral body with extension to the inferior platform of the same level, but with normal sagittal alignment of the cervical spine. A cervical spine magnetic resonance imaging study was also obtained, which demonstrated hyper intensity at the anterior longitudinal ligament, the C4-C5 disc and the C4 vertebral body on T2-weighted images. He also presented a traumatic dissection of the right common carotid artery, detected on a CT-angiogram, but no injury of both the airway and the esophagus was identified. Due to the lack of clinical guides for the treatment of open spine fractures, this patient received empiric IV antibiotic treatment with ceftriaxone and clindamycin for one week follow by another week of PO amoxicillin with clavulanic acid. The wound was cleaned and closed with 2 interrupted stitches. The C4 fracture was initially treated with a hard collar, but retro listhesis at the C4-C5 level was detected on follow-up X-Rays 6 days after the accident, probably due to anterior longitudinal ligament and/or disc disruption, so an anterior discectomy and instrumented fusion of the C4-C5 level was performed. The carotid artery dissection was treated non-surgically with anti-coagulants (initially subcutaneous followed by PO treatment). C4-C5 anterior fusion was confirmed with a CT scan performed 2 months after the surgery. The patient presented no complications due to his injuries or their treatment, returned to work 3 months after the accident and evolved with no neck pain during follow-up. Conclusion Open fractures of the cervical spine present particular characteristics that must be considered during their initial work-up and treatment, usually involving a multidisciplinary approach to assess and treat associated injuries. Injury of the anterior longitudinal ligament and/or intervertebral disc disruption due to penetrating trauma may cause segmental instability requiring surgical treatment.

Traumatic Carotid Artery Dissection: A Different Entity without Specific Guidelines.

According to literature data, there are no distinct guidelines regarding the proper diagnostic and therapeutic management of traumatic carotid artery dissection (TCAD). Although most of cases evaluated in research studies refer to spontaneous carotid artery dissection, traumatic cases demand special considerations as far as diagnosis and treatment are concerned. Although both types of dissection share some common characteristics, a patient with TCAD usually presents with several concomitant injuries as well as a higher bleeding risk, thus complicating decision making in such patients. Therefore, aim of this review is to present available data regarding epidemiology, clinical presentation, diagnostics and treatment strategy in cases with TCAD in order to produce useful conclusions for everyday clinical practice.

Arterial Tortuosity: An Imaging Biomarker of Childhood Stroke Pathogenesis?

Arteriopathy is the leading cause of childhood arterial ischemic stroke. Mechanisms are poorly understood but may include inherent abnormalities of arterial structure. Extracranial dissection is associated with connective tissue disorders in adult stroke. Focal cerebral arteriopathy is a common syndrome where pathophysiology is unknown but may include intracranial dissection or transient cerebral arteriopathy. We aimed to quantify cerebral arterial tortuosity in childhood arterial ischemic stroke, hypothesizing increased tortuosity in dissection. Children (1 month to 18 years) with arterial ischemic stroke were recruited within the Vascular Effects of Infection in Pediatric Stroke (VIPS) study with controls from the Calgary Pediatric Stroke Program. Objective, multi-investigator review defined diagnostic categories. A validated imaging software method calculated the mean arterial tortuosity of the major cerebral arteries using 3-dimensional time-of-flight magnetic resonance angiographic source images. Tortuosity of unaffected vessels was compared between children with dissection, transient cerebral arteriopathy, meningitis, moyamoya, cardioembolic strokes, and controls (ANOVA and post hoc Tukey). Trauma-related versus spontaneous dissection was compared (Student t test). One hundred fifteen children were studied (median, 6.8 years; 43% women). Age and sex were similar across groups. Tortuosity means and variances were consistent with validation studies. Tortuosity in controls (1.346±0.074; n=15) was comparable with moyamoya (1.324±0.038; n=15; P=0.998), meningitis (1.348±0.052; n=11; P=0.989), and cardioembolic (1.379±0.056; n=27; P=0.190) cases. Tortuosity was higher in both extracranial dissection (1.404±0.084; n=22; P=0.021) and transient cerebral arteriopathy (1.390±0.040; n=27; P=0.001) children. Tortuosity was not different between traumatic versus spontaneous dissections (P=0.70). In children with dissection and transient cerebral arteriopathy, cerebral arteries demonstrate increased tortuosity. Quantified arterial tortuosity may represent a clinically relevant imaging biomarker of vascular biology in pediatric stroke.

致死的多発外傷に対しハイブリッド手術室を活用した治療経験(Treatment experience using hybrid operating room for fatal multiple trauma)

要旨我々は，致死的多発外傷に対しハイブリッド手術室を用いて治療し救命に至った1例を経験したので報告する。症例は日常生活の自立した81歳の女性。歩行中に40km/hr程度の軽トラックと衝突し受傷した。当院搬送時は血圧低下，意識障害を呈しておりtrauma pan scanで右急性硬膜下血腫，外傷性胸部大動脈解離，腹腔内出血を伴う脾損傷，extravasationを伴う骨盤骨折などの損傷を認めた。ハイブリッド手術室でinterventional radiology，開頭手術を行う方針とした。手技は胸部大動脈損傷に対するステントグラフト挿入術から開始し，続いて脾損傷及び骨盤骨折に対する塞栓術，開頭血腫除去術を行った。術後は脾臓仮性動脈瘤など合併症の治療を行った後，療養目的に転院となった。ハイブリッド手術室は近年国内外で広く普及しつつあるが，多発外傷の治療についての報告例は少ない。本症例のような止血術，開頭手術を要する致死的損傷を複数有する症例では，患者搬送のリスクや搬送先の判断に悩むことなく外科手術と血管内治療を同一の部屋で実施できるハイブリッド手術室が治療戦略に与える恩恵は非常に大きい。外傷への応用を想定した準備を行うことで，より迅速な治療の開始や手技完遂が期待でき今後の症例蓄積が期待される。

Management of traumatic carotid artery dissection: initial experience of a single center.

Traumatic carotid artery dissection (tCAD) bears the risk of hypoperfusion inducing delayed cerebral ischemia. The lack of consensus on standard treatment of tCAD remains a great challenge. Here, we present our successes on a series of patients with delayed tCAD diagnosis and treatment using multimodality treatment strategies. We retrospectively reviewed 21 patients with tCAD treated with carotid artery stent placement or anticoagulation therapy. There were 14 dissection locations (66.67%) which involved extracranial internal carotid artery (ICA) and seven locations (33.33%) which involved both extracranial and intracranial ICA. Stenosis severity was 70-99% in 16 cases (76.19%) and <70% in 5 cases (23.81%). Endovascular stents were administrated to 17 patients with hypoperfusion as evaluated by radiological methods, while anticoagulation therapy was administrated to the other four patients. Carotid revascularization was performed with one (9/17 patients) or multiple (8/17 patients) stents. None of the patients experienced a procedure-related complication. At discharge, the mean modified Rankin Scale (mRS) score of patients was 1.08 ± 0.76. Neither additional neurological deficient nor restenosis happened during the follow-up period. More vigilance is required to assure timely diagnosis of patients with delayed tCAD. Assessment of cerebral perfusion is an effective approach in tCAD treatment in our experience.

Abstract WP201: Ischemic Stroke Risk After Traumatic Head or Neck Injury

Introduction: Traumatic arterial dissection is an important cause of ischemic stroke in the young, but data are needed to guide selection of trauma patients to screen with cerebrovascular imaging. Hypothesis: Ischemic stroke risk after head or neck trauma can be stratified by demographic and clinical factors. Methods: In a Northern California integrated health care system, we identified people (age &lt; 50) with head or neck trauma from 1997-2011 by ICD-9 searches (800-806, 850-854; 873, 874, 900, 920, 925, 950-953; excluding fifth digit codes for injury below the neck). Ischemic strokes within 4 weeks were identified by ICD-9 (433-438) and confirmed by chart review. We randomly selected 3 controls per case from the remaining cohort. Characteristics potentially associated with stroke were abstracted and examined using logistic regression. Stroke incidence rates were calculated using survival analysis, right censoring at death or 4 weeks post-trauma. Results: From 120,494 trauma encounters in the emergency department or for hospital admission, we confirmed 45 ischemic strokes related to head or neck trauma. The 4-week stroke incidence was 0.04% (95% CI 0.03-0.05%) (Figure: Kaplan-Meier stroke failure function and 95% CI). The majority of ischemic strokes occurred early after trauma, with 40% on the day of the trauma. Stroke risk was not associated with gender or race/ethnicity, but was age-related: for each decade older, stroke risk increased 70% (OR 1.7, 95% CI 1.4-2.2%, P&lt;0.001). Any neck trauma (OR 14, 95% CI 4.9-42, P&lt;0.0001 compared to those with isolated head trauma) and altered mental status on exam (OR 18, 95% CI 6.7-46, P &lt; 0.0001) were also associated with increased risk of ischemic stroke. Neck trauma and altered mental status remained independently associated with ischemic stroke even after age-adjustment. Conclusions: Trauma patients with neck injuries or altered mental status have elevated stroke risk and should be considered for cerebrovascular imaging.

What does Doppler Ultrasonography Brings to the Diagnosis of Traumatic Vertebral Artery Dissection

Here we describe the case of a young woman with a late diagnosis of vertebral artery dissection and midbrain ischemic lesion after minor post traumatic injury. Doppler ultrasonography was used as the first diagnostic examination to evaluate the dissection. We present this unusual but not rare case related to the frequent events of cervical distraction after car accident in order to better understand the clinical approach the sensitivity Doppler ultrasonography in post-traumatic cervical distorsion.

Bilateral iliac and popliteal arterial thrombosis in a child with focal segmental glomerulosclerosis.

Thromboembolic complications (TECs) are clinically important sequelae of nephrotic syndrome (NS). The incidence of TECs in children is approximately 2%–5%. The veins are the most commonly affected sites, particularly the deep veins in the legs, the inferior vena cava, the superior vena cava, and the renal veins. Arterial thrombosis, which is less common, typically occurs in the cerebral, pulmonary, and femoral arteries, and is associated with the use of steroids and diuretics. Popliteal artery thrombosis in children has been described in cases of traumatic dissection, osteochondroma, Mycoplasma pneumoniae infection, and fibromuscular dysplasia. We report of a 33-month-old girl with bilateral iliac and popliteal arterial thrombosis associated with steroid-resistant NS due to focal segmental glomerulosclerosis. Her treatment involved thrombectomy and intravenous heparinization, followed by oral warfarin for 8 months. Herein, we report a rare case of spontaneous iliac and popliteal arterial thrombosis in a young child with NS.

Computed Tomography Perfusion Can Guide Endovascular Therapy in Bilateral Carotid Artery Dissection.

INTRODUCTIONCarotid artery dissection (CAD) is a major cause of stroke in those under age 45, accounting for around 20% of ischaemic events[1,2]. In the absence of known connective tissue disorders, most dissections are traumatic[2]. First-line management is comprised of antiplatelet or anticoagulation therapy, but many traumatic dissections progress despite this and carry the risk of long-term complications from embolism or stenosis[3].We report a case of traumatic bilateral carotid dissection leading to progressive neurological symptoms and hypoperfusion on computed tomography perfusion (CTP), despite escalation in anticoagulation, which led to emergency carotid stenting.LEARNING POINTSCarotid artery dissection should always be considered in young patients presenting with stroke.Most strokes are caused by emboli from the injured vessel but hypoperfusion, especially from bilateral dissections, can also cause stroke.Anticoagulation or antiplatelets are used as first-line therapy, though there are no randomised control trials to guide management.Failure of medical therapy can be common and endovascular therapy should be considered in these cases.Computed tomography perfusion (CTP) scanning can be useful because it highlights areas of ischaemic penumbra that may be salvageable through such intervention.

Traumatic Subclavian Artery Dissection in Clavicle Fracture Due to Blunt Injury: Surgery or Stent in Long Segment Occlusion?

Traumatic Subclavian Artery Dissection in Clavicle Fracture Due to Blunt Injury: Surgery or Stent in Long Segment Occlusion?

Fatal case of cervical blunt vascular injury with cervical vertebral fracture: a case report.

Blunt cerebrovascular injury (BCVI) is usually caused by neck trauma that predominantly occurs in high-impact injuries. BCVI may occur due to damage to both the vertebral and carotid arteries, and may be fatal in the absence of appropriate treatment and early diagnosis. Here, we describe a case of cerebral infarction caused by a combination of a lower cervical spinal fracture and traumatic injury to the carotid artery by a direct blunt external force in a 52-year-old man. Initially, there was no effect on consciousness, but 6 hours later loss of consciousness occurred due to traumatic dissection of the carotid artery that resulted in a cerebral infarction. Brain edema was so extensive that decompression by emergency craniectomy and internal decompression were performed by a neurosurgeon, but with no effect, and the patient died on day 7. This is a rare case of cerebral infarction caused by a combination of a lower cervical spinal fracture and traumatic injury to the carotid artery. The case suggests that cervical vascular injury should be considered in a patient with a blunt neck trauma and that additional imaging should be performed.