The management of traumatic aortic tear in the multiply-injured patient

Patients with traumatic aortic tears and severe life-threatening associated injuries require early and expeditious evaluation and treatment in order to improve survival. Diagnostic and treatment priorities, however, are not clearly established in this subset of patients. The purpose of this retrospective analysis was to help identify successful diagnostic and treatment priorities in this group of patients. Between 1979–1989 the medical records of all patients sustaining blunt chest trauma resulting in a traumatic aortic tear were reviewed. There were 11 patients with multiple injuries and this diagnosis was treated at Boston University Medical Center. Five patients had diagnostic peritoneal lavage or an exploratory laparotomy prior to a thoracotomy. Four patients had only a thoracotomy. Two patients in this series had a thoracotomy prior to treatment of suspected intraabdominal injuries. One of these two patients died. Our overall survival rate was 82%. This series suggests that the management sequence in patients with coexistent injuries should include treatment of severe associated injuries prior to treatment of the aortic injury and that initial treatment of traumatic aortic tears is appropriate if there is no evidence of severe life-threatening trauma.     

Anterior dural laceration caused by thoracolumbar and lumbar burst fractures

A retrospective review of the records of 60 patients with thoracolumbar and lumbar burst fractures was undertaken to document the incidence and evaluate the sequelae of dural injuries found during anterior procedures. In the entire series, six (10%) patients each had a preexisting vertically oriented dural tear. All patients with anterior dural lacerations were male and had associated neurologic deficits. In all six patients, preoperative computed tomography showed an asymmetrically retropulsed bone fragment. Dural tears were repaired primarily. A postoperative cerebrospinal fluid leak developed into the chest cavity of one patient, who was treated successfully with subarachnoid drainage. In patients with anterior dural laceration, primary repair is warranted and can be performed more easily after intraoperative correction of kyphosis. Subarachnoid drainage may be effective in cases of continued postoperative anterior cerebrospinal fluid leakage before repeated operation is considered.     

Pseudoaneurysm of the proximal facial artery presenting as oropharyngeal hemorrhage.

BACKGROUND: Penetrating trauma to the neck traversing zones II and III may cause considerable damage to soft tissues and neurovascular structures. Delayed sequelae of vascular injuries, such as pseudoaneurysm (PA), may present weeks to months after the initial injury. METHODS: We report an unusual case of a traumatic PA of the proximal facial artery that ruptured into the oropharynx. RESULTS: A 30-year-old man presented with oropharyngeal hemorrhage one month after a gunshot wound to the neck. Angiography revealed a PA of the proximal facial artery, which was treated with embolization. The arterial injury leading to the pseudoaneurysm had not been detected by arteriography at the time. CONCLUSIONS: PAs are rare complications of penetrating neck trauma. To our knowledge, this is only the second report of PA involving the proximal facial artery, and the first of a facial PA rupture into the pharynx.     

Traumatic aneurysm of the posterior inferior cerebellar artery: case report

We report a case of a traumatic aneurysm of the posterior inferior cerebellar artery caused by an occipital fracture. The necessity to suspect a vascular traumatic lesion when an unusual subarachnoid hemorrhage is seen on the computed tomographic scan in a case of trauma is stressed.     

Multidisciplinary management of a traumatic posterior meningeal artery pseudoaneurysm: A case report and review of the literature

BackgroundMeningeal arterial injuries represent <1% of all blunt traumatic brain injuries (TBIs). Middle meningeal artery (MMA) lesions comprise the majority. However, there is little clinical data on posterior meningeal artery (PMA) injuries.Case reportA 69-year-old man was brought to our trauma center after sustaining a fall inside a warehouse. He was GCS (Glasgow Coma Scale) 3 on arrival. Non-contrast CT (computed tomography) brain showed subarachnoid hemorrhage with diffuse cerebral edema and a basilar skull fracture. The patient subsequently underwent emergency ventriculostomy. Immediately after the procedure, further imaging with CTA (computed tomography angiography) head identified a hyperintense posterior cranial fossa lesion, prompting cerebral angiography with identification and embolization of a traumatic PMA pseudoaneurysm. The patient improved and was discharged to a long-term acute care facility. At 3 months post-discharge, the patient was eating, talking with family, and working aggressively with physical therapy.DiscussionThis case represents a functional neurologic outcome from a rare subset of TBI. Early CTA head imaging is not supported by limited literature, but allowed for expedient identification and definitive management of this PMA pseudoaneurysm. In the critical care setting, hyperosmolar therapy, CSF (cerebrospinal fluid) drainage, prompt enteral nutritional support, and early tracheostomy all represent evolving evidence-based strategies to optimize care for severe TBI.ConclusionsThe initial evaluation and management of severe TBI can be nuanced. Future research may refine indications for CTA head to the diagnostic evaluation of patients with both severe TBI and skull fractures.     

Percutaneous endovascular repair of blunt thoracic aortic transection

BACKGROUND: Untreated traumatic aortic transection carries a mortality rate higher than 85%. Standard therapy has been open repair via a left thoracotomy with systemic heparin and is associated with a high risk of paralysis. We reviewed our experience of endoluminal stent-graft repair for treatment of acute traumatic thoracic aortic transection. METHODS: Between February 2001 and February 2005, 11 patients sustaining severe blunt trauma with multiple injuries underwent acute endovascular repair for thoracic aortic transection with 'off-the-shelf' commercially available proximal aortic cuffs. No systemic heparin was used. Access to the aorta was obtained either through a femoral/iliac cutdown (n = 4) or percutaneously through the femoral artery (n = 7). Mean follow-up was 21 months (range, 3-49 months). RESULTS: Technically successful repair was achieved in 100% of patients, as determined by completion angiography demonstrating apposition of the stent-grafts to the aortic wall, normal perfusion of the aortic branches, and exclusion of the aortic transection without evidence of extravasation. None of the patients required secondary interventions, and there were no instances of death or paralysis. Patient follow-up, using computed tomography angiography, demonstrated durability of endovascular repair without evidence of endoleak, stent migration, or late pseudoaneurysm formation. CONCLUSION: Adaptation and use of commercially available abdominal devices in the thoracic aorta has proven to be technically feasible. Urgent repair of thoracic aortic transection in the setting of blunt trauma can be transformed into a well-tolerated surgical intervention using endovascular techniques. Long-term durability of endovascular repair of traumatic thoracic transections remains unknown, but early and midterm results are promising.     

Is the Grading of Liver Injuries a Useful Clinical Tool in the Initial Management of Blunt Trauma Patients?

Abstract Background:   Computed tomography (CT) has become the preferred method for evaluation of the abdomen for victims of blunt trauma. Grading of liver injuries, primarily by CT, has been advocated as a measure of severity and, by implication, the likelihood for intervention or complications. We have sought to determine if grading of liver injuries, as a clinical tool, affects immediate or extended management of patients. Methods:   We have retrospectively reviewed all patients sustaining blunt liver injuries as diagnosed by CT over a five-year period at a Level I trauma center to determine if grading of injury influenced management. The AAST organ scaling system was utilized (major grade 4–5, minor grade 1–3), as well as the ISS, AIS, mortality, morbidity, and treatment. There were 133 patients available for review. The patients were grouped into major (n = 20) and minor (n = 113) liver injuries and operative (n = 12) and nonoperative (n = 121) management. Results:   Major liver injuries had a higher ISS (39 + 13 vs. 27 + 15, p = 0.001) and were more likely to require operative intervention (5/20 vs. 7/113, p = 0.02). Mortality in this group was not different (major vs. minor), and there were no differences in the incidence of complications. Twelve patients (9%) required operation, all for hemodynamic instability, all within 24 h, and 11/12 within 6 h. At operation 8/12 patients had other sources of bleeding beside the liver injury, and 7/12 had minor hepatic injuries. The operative patients had higher ISS and AIS scores (head/neck, chest, abdomen, extremities) than those managed nonoperatively. More patients died in the operative group (6/12 vs. 8/121, p = 0.0003). There were more pulmonary (6/12 vs. 16/121, p = 0.005), cardiovascular (6/12 vs. 19/121, p = 0.01), and infectious (5/12 vs. 20/121, p = 0.049) complications in the operative group. There were 14 deaths overall; 13/14 were due to traumatic brain injury, and 8/14 required urgent operation for hemorrhage. Conclusions:   In conclusion, grading of liver injuries does not seem to influence immediate management. Physiologic behavior dictated management and need for operative intervention, as well as prognosis. However, both major hepatic injuries and need for early operation reflected overall severity and the possibility of associated injuries.     

Myelographic and enhanced computed tomographic appearance of acute traumatic spinal cord avulsion.

The neuroradiological findings that revealed spinal cord transection/laceration in 6 patients with acute, blunt spinal trauma are described. Four patients suffered cervical spine injuries, and two had thoracic injuries. Initially, all patients had complete neurological deficit at the level of injury. The deficit improved in only 1 patient. On the basis of clinical history and spinal radiographs, spinal hyperflexion with distraction was the predominant mechanism of injury in our patients. Computed tomography with intrathecal contrast was performed on all patients and was always diagnostic. Visualization of intrathecal contrast material accumulating within the cord or the absence of cord shadow within the contrast column established the diagnosis in all cases. A dural tear was noted in 3 patients. Thoracic myelography was performed in 2 patients and, in both, demonstrated contrast pooling within the spinal cord at the level of the laceration. Magnetic resonance imaging was obtained in 1 patient and revealed an irregular, low-signal-intensity, intramedullary region extending to the cord surface on T1-weighted axial images. The myelographic and enhanced computed tomographic appearances of acute, traumatic spinal cord avulsion/laceration, which have been infrequently reported in the literature, are described.     

Whiplash injury determination with conventional spine imaging and cryomicrotomy.

STUDY DESIGN: Soft tissue-related injuries to the cervical spine structures were produced by use of intact entire human cadavers undergoing rear-end impacts. Radiography, computed tomography, and cryomicrotomy techniques were used to evaluate the injury. OBJECTIVES: To replicate soft tissue injuries resulting from single input of whiplash acceleration to whole human cadavers simulating vehicular rear impacts, and to assess the ability of different modes of imaging to visualize soft tissue cervical lesions. SUMMARY OF BACKGROUND DATA: Whiplash-associated disorders such as headache and neck pain are implicated with soft tissue abnormalities to structures of the cervical spine. To the authors' best knowledge, no previous studies have been conducted to determine whether single cycle whiplash acceleration input to intact entire human cadavers can result in these soft tissue alterations. There is also a scarcity of data on the efficacy of radiography and computed tomography in assessing these injuries. METHODS: Four intact entire human cadavers underwent single whiplash acceleration (3.3 g or 4.5 g) loading by use of a whole-body sled. Pretest and posttest radiographs, computed tomography images, and sequential anatomic sections using a cryomicrotome were obtained to determine the extent of trauma to the cervical spine structures. RESULTS: Routine radiography identified the least number of lesions (one lesion in two specimens). Although computed tomography was more effective (three lesions in two specimens), trauma was not readily apparent to all soft tissues of the cervical spine. Cryomicrotome sections identified structural alterations in all four specimens to lower cervical spine components that included stretch and tear of the ligamentum flavum, anulus disruption, anterior longitudinal ligament rupture, and zygopophysial joint compromise with tear of the capsular ligaments. CONCLUSIONS: These results clearly indicate that a single application of whiplash acceleration pulse can induce soft tissue-related and ligament-related alterations to cervical spine structures. The pathologic changes identified in this study support previous observations from human volunteers observations with regard to the location of whiplash injury and may assist in the explanation of pain arising from this injury. Although computed tomography is a better imaging modality than radiography, subtle but clinically relevant injuries may be left undiagnosed with this technique. The cryomicrotome technique offers a unique procedure to understand and compare soft tissue-related injuries to the cervical anatomy caused by whiplash loading. Recognition of these injuries may advance the general knowledge of the whiplash disorder.     

Cranio-cervical junction dural arteriovenous malformation presenting with subarachnoid hemorrhage: report of two cases

Most spinal dural arteriovenous malformations (AVMs) affect the thoracic and lumbar regions. The clinical features of dural AVMs are, usually, gradually progressing myelopathy, while hemorrhage is a rare occurrence. We have recently encountered two cases of cranio-cervical junction dural AVM which caused subarachnoid hemorrhage. Both patients, a 61-year-old and a 37-year-old man were admitted to our hospital due to sudden onset of severe headache. Left vertebral angiography demonstrated a dural AVM at the cranio-cervical junction. A left suboccipital craniotomy and left hemilaminectomy of the atlas were performed. Dural opening disclosed tortuous dilated abnormal vessels. The dural AVM was fed by multiple small dural branches of the left vertebral artery and drained into an intracranial pial vein. The dura where the left vertebral artery penetrated was coagulated and divided from the left vertebral artery. Postoperative courses of these patients were uneventful. The pathophysiology and surgical treatment of dural AVMs in the cranio-cervical junction are discussed.     

Cerebrovascular dissections: a review. Part II: blunt cerebrovascular injury

Traumatic cerebrovascular injury (TCVI) is present in approximately 1% of all blunt force trauma patients and is associated with injuries such as head and cervical spine injuries and thoracic trauma. Increased recognition of patients with TCVI in the past quarter century has been because of aggressive screening protocols and noninvasive imaging with computed tomography angiography. Extracranial carotid and vertebral artery injuries demonstrate a spectrum of severity, from intimal disruption to traumatic aneurysm formation or vessel occlusion. The most common intracranial arterial injuries are carotid-cavernous fistulae and traumatic aneurysms. Data on the long-term natural history of TCVI are limited, and management of patients with TCVI is controversial. Although antithrombotic medical therapy is associated with improved neurological outcomes, the optimal medication regimen is not yet established. Endovascular techniques have become more popular than surgery for the treatment of TCVI; endovascular options include stenting of dissections, intra-arterial thrombolysis for acute ischemic stroke caused by trauma, and embolization of traumatic aneurysms.     

Isolated Gallbladder Injury after Blunt Abdominal Trauma: a Case Report and Review

Abstract  We describe a case of isolated gallbladder contusion after deceleration trauma. On admission, no evident signs of intra-abdominal injury were present. However, after 24 h observation an explorative laparotomy was performed because of persistent abdominal complaints. A contusion of the gallbladder wall was found with intraluminal haematoma and a cholecystectomy was performed. Isolated injury of the gallbladder after blunt trauma is extremely rare. Risk factors are distention of the gallbladder, deceleration trauma and the presence of a relatively mobile gallbladder. Clinical signs often are very subtle. Delayed presentation is common with signs of hemobilia or obstruction due to intraluminal clots. Ultrasound and computed tomography are suitable diagnostic tools. However, the diagnosis is often missed if no other injuries are present. Signs pointing to gallbladder injury are a collapsed gallbladder with pericholecystic fluid or a hydroptic gallbladder with intraluminal hematoma. Hepatobiliary scintigraphy or angiography might be necessary if additional injuries are suspected. The choice of treatment depends on the kind of injury. Contusion of the gallbladder allows conservative treatment, but in case of a rupture, surgery will be necessary. Accompanying bile duct injuries can be treated by endoscopic stenting. If active arterial bleeding is present, selective embolization can be performed. There was an error in the authors' name: Please note the correct authors' list: Vera Tudyka, Susan Toebosch, Wietse Zuidema     

Conservative Management of Major Blunt Renal Trauma with Extravasation: A Viable Option?

Abstract Objectives:   To evaluate our experience in the management of patients with major blunt renal trauma treated at a major urban trauma center during the last ten years. Patients and Methods:   The medical records of 72 patients with major blunt renal lacerations treated from 1998 to 2008 were reviewed retrospectively. Patients were broken down into two groups based on whether they were managed conservatively (group 1) or surgically (group 2). Each group was compared with respect to the initial evaluation, computerized tomography findings, associated injuries, hospital stay, transfusion requirements, nephrectomy rate, complications and follow-up imaging. Results:   There were 57 patients with grade IV and 15 patients with grade V renal injuries. Of these, 51 (70.8%) patients were managed conservatively (48 with grade IV and 3 with grade V) and 21 (29.2%) patients were managed surgically (9 with grade IV and 12 with grade V). Patients in group 1 had significantly lower transfusion requirements (3.1 vs. 7.5 units, p < 0.0001), shorter hospital stays (11.8 vs. 15.9 days p < 0.003) and fewer complications (21.6 vs. 76.1%, p < 0.001). No death was observed in group 1, while three in group 2 died of major associated injuries. All surviving patients had significant resolution of the extravasation before hospital discharge. Conclusions:   Our data supports the conservative management of grade IV blunt renal parenchymal injuries in the absence of hemodynamic instability of renal origin. Even select patients with grade V parenchymal injuries can undergo a trial of conservative management.     

Delayed revascularization following complete transection of left anterior descending artery after a stab wound

IntroductionPenetrating heart injury as a consequence of a stab wound is usually considered fatal. Nevertheless, there are rare lucky cases with mild symptoms which deserve clinical suspicion and proper management.Presentation of caseWe report a penetrating cardiac trauma with left anterior descending coronary artery transection after a stab wound. Successful revascularization without cardiopulmonary bypass support was performed.DiscussionCoronary artery injuries after penetrating cardiac trauma are mostly fatal. The standard approach has traditionally been coronary artery ligation with serious morbidity. We report a case of complete coronary artery transection with delayed revascularization validating the safety of off-pump approach. We add a short literature review of the management of traumatic coronary artery injury.ConclusionThis adds to the world literature on coronary artery trauma with successful off-pump revascularization. Coronary artery transection stab-wound victims can have only mild symptoms. Slightest intimation of heart injury should provoke proper clinical examination and management.     

Blunt trauma to the high cervical carotid artery.

Closed injuries to the neck, occasionally associated with mandibular fractures, can result in trauma to the internal carotid artery at the high cervical level opposite the uppermost cervical vertebrae. Such arterial injuries range from spasm to intimal tear with thrombus formation, medial tear, and aneurysm formation. These types of lesions may overlap. Ten patients are presented, five with traumatic carotid occlusions and five with traumatic aneurysms. The clinical diagnosis of traumatic cervical carotid occlusion may be difficult because of the absence of physical trauma to the neck. The diagnosis of aneurysm poses fewer problems. Oculopneumoplethysmography, computerized tomographic head scanning, and carotid arteriography with cross compression are the most useful diagnostic techniques. Thrombectomy should be carried out early, particularly in the presence of fluctuating neurological signs. Aneurysms that cannot be approached directly may necessitate carotid ligation.     

Rupture of a large ophthalmic segment saccular aneurysm associated with closed head injury: case report

OBJECTIVE AND IMPORTANCE: Although each year approximately 30,000 to 50,000 cases of subarachnoid hemorrhage in the United States are caused by the rupture of intracranial saccular aneurysms, there is little information in the literature documenting the association of aneurysmal rupture with closed head injury. CLINICAL PRESENTATION: A 61-year-old woman presented after a motor vehicle accident with multiple injuries, including a severe closed head injury. Computed tomography revealed a diffuse basal subarachnoid hemorrhage. Angiography revealed the source as a large aneurysm arising from the ophthalmic segment of the left carotid artery. INTERVENTION: After the patient was stabilized for her multiple injuries, she underwent craniotomy and clipping of the aneurysm. She recovered without developing new neurological deficits. CONCLUSION: Although the association of head trauma and aneurysmal subarachnoid hemorrhage is rare, the presence of significant basal subarachnoid blood on a computed tomographic scan should alert the physician to the possibility of a ruptured aneurysm.     

Chylothorax Resulting from a Penetrating Injury of the Neck: a Case Report

Abstract  Chylothorax is characterized by an accumulation of lymphatic fluid in the pleural cavity due to compression or loss of integrity of the thoracic duct for any reason. It is frequently secondary to intrathoracic malignancies and iatrogenic trauma. Thoracic duct injury and resulting chylothorax, due to penetrating injuries of the neck, are very rare. This report presents a patient with chylothorax associated with penetrating neck trauma, who was successfully treated, and provides discussion on this very rare case in the light of the available literature.     

Prehospital and Emergency Department Ultrasound in Blunt Abdominal Trauma

Abstract   Blunt abdominal trauma is a challenging aspect of trauma management. Early detection has a major impact on patient outcome. In contrast to physical examination, computed tomography is known to be a sensitive and specific test for blunt abdominal injuries. However, it is time-consuming and thus contraindicated in hemodynamically unstable patients. Therefore, focused assessment with sonography for trauma (FAST) offers a fast and easily applicable screening method to identify patients for urgent laparotomy without any further diagnostics. FAST detects, with high sensitivity, intraperitoneal fluid that accumulates in dependent areas indicating blunt abdominal trauma. FAST has been established as a gold standard early screening method for blunt abdominal trauma when performing trauma management in the emergency department (ED) based on the Advanced Trauma Life Support^? algorithm. The development of hand-held ultrasound devices facilitated the introduction of FAST into prehospital trauma management. It was demonstrated that prehospital FAST (p-FAST) can be performed with high sensitivity and specificity, and can lead to significant changes in prehospital trauma therapy and management. Standardized training with both theoretical and hands-on modules is mandatory in order to gain the skills required to perform FAST or p-FAST well. M. Ruesseler, R. Breitkreutz, T. Kirschning, and F. Walcher belong to the Working Group of Emergency Ultrasound.