Neck CTA: When? How? The Innsbruck Experience Marius C. Wick, M.D. Department of Radiology Karolinska University Hospital Solna Stockholm, Sweden

Transcription

1 Neck CTA: When? How? The Innsbruck Experience Marius C. Wick, M.D. Department of Radiology Karolinska University Hospital Solna Stockholm, Sweden No financial or non-financial competing interests to declare

2 Innsbruck

3 Innsbruck Emergency Algorithm Prehospital Diagnosis Polytrauma 1 st ER-Phase admission first glance relocation immediate measures stabilisation / monitoring basis-diagnostics and therapy haemodynamically stable instable acute surgery or embolisation ICU Wick MC et al. AOTS 2010

4 Innsbruck Emergency Algorithm Quality management Fractures (%) Injuries of cervical spine: n= 21/ Discrepancy between conventional X-ray and CT 1 no discrepancy 2 Injury/fracture not diagnosed with X- ray 3 additional information by CTexamination Rieger M et al. Radiologe 2002

5 Innsbruck Emergency Algorithm Prehospital Diagnosis Polytrauma 1 st ER-Phase admission first glance relocation immediate measures stabilisation / monitoring basis-diagnostics and therapy haemodynamically stable instable acute surgery or embolisation ICU CT-Phase picture acquisition picture reformation picture evaluation acute surgery or embolisation ICU 2 nd ER-Phase finishing diagnostics and therapy ICU embolisation primary surgery Wick MC et al. AOTS 2010

6 Multiple contusions Vertebralis dissection Female patient, 43 years : Skiing accident, Stubai glacier Skull- and thorax contusions Clinical examination, initially only thoracic pain, neurologically unapparent Glacier treatment room: GCS 10 Transfer to Emergency Room Innsbruck: Tight but light-reactive pupils

7 Multiple contusions Vertebralis dissection

8 Headache and cervical pain Carotis dissection Male patient, 70 years : Skiing accident, head against rock Headache and pain cranial cervical spine Transfer to Emergency Room Innsbruck: neurologically unapparent; GCS 15 OC- & HWK 1 (Jefferson) fracture

9 Headache and cervical pain Carotis dissection

10 Blunt cervical vascular injury BCVI carotid lumen Wouter I et al. N Engl J Med 2001 Castaner E et al. Radiographics 2003

11 Dissection of cervical vessels Causes and symptoms Causes for posttraumatic dissection: Hyperextension with concomitant rotation of the skull stretching of the vessel over the transverse processes Chiropractic manipulation Strangulation Cerebral angiography

12 Dissection of cervical vessels Causes and symptoms Symptoms of spontaneous dissection: Ipsilateral headache in area of the orbita Carotidynie Incomplete Horner-syndrom Noise of blood-flow Symptoms of (post)traumatic dissection: initially often no symptoms ischemic symptoms TIA s (transient or permanent) impaired vision loss of strength hearing loss lalopathy

13 Dissection of cervical vessels Complications Stroke: Permanent neurologic deficit: 40% Pseudoaneurysm: Mortality: 5-30%

14 Diagnostic challenge BCVI from alpine sports accidents bear an incerased risk for being undersiagnosed during initial radiological evaluation Patients with the highest potential benefit from a therapy of their injury are asymptomatic at the timepoint of diagnosis Screening Asymtomatic patients with BCVI untreated: Cerebral insult 33 51% treated: Cerebral insult 2 4% Biffl WL et al. J Trauma 2006

15 36 Number of patients BCVI Fractures Unspecific contusions (except brain) Head injury (incl. concussion) Parenchymatous organlesion Injuries of ligaments, tendons or muscles Wick MC et al. AOTS 2010

16 Demographic characteristics* Number of patients 36 Mean (SD) age (yrs) 53 (18) Gender (male/female) 24/12 Injuries* Obviously injured with blunt trauma $ 21 Obviously uninjured $ 15 Death in the emergency room 1 Conscious at hospital admission 29 Mean Injury Severity Score (ISS) 15 (8) Mean (SD) number of injuries per patient #ß 4.6 (2.1) Victims with fracture/s ß 25 Victims with injury of a parenchymatous organ (incl. contusions) ß 7 Immediate hospitalization after admission ß 33 Mean (SD) time of hospitalization (days) ß 15.8 (16.5) Radiology* Mean (SD) number of initial Radiology modalities per patient at admission & 2.2 (0.7) Victims with computed tomography as an initial Radiology modality 36 Clinically reported uninjured but radiologically found injured $& 15 Mean (SD) number of only radiologically detectable injuries per patient # 3.5 (2.3) Victims with detectable cerebral damage at follow-up examinations 11 *All victims from skiing and mountain-biking accidents admitted to the Innsbruck Medical University Hospital between 2003 and 2009 who were diagnosed with blunt cervical vascular injury (BCVI); $ according to the primary physician on-site; ß not including the victim who died in the emergency room; # injuries were registered according to the 10 th revision of the International Classification of Diseases (ICD-10); & including plain x-ray, sonography,magnetic resonance tomography, angiography, or computed tomography. Wick MC et al. AOTS 2010

17 CT angiography CT parenchymatous phase Wick MC et al. AOTS 2010

18 Wick MC et al. AOTS 2013

19 Cervical spine fracture Optimal work-up of patients with severe spinal trauma MSCT shows all bony abnormalities (fractures, dislocations etc.) with highest precision Conventional X-ray assessment is insufficient and provides, e.g. in the cervical spine, up to 57% false negative results Imhof H et al. Eur Radiol 2002.

20 Dissection of cervical vessels Patients with BCVI initially often asymptomatic No reliable diagnostic indicator Underdiagnosed dissection Glasgow Outcome Score Indication for vascular diagnostics should be set liberally Screening for BCVI using MSCTA in every polytrauma patient in Innsbruck We recommend a carotid and vertebral CTA in all trauma-patients who are referred for CT of the cervical spine Mutze S et al. Radiology 2005 In Innsbruck, all patients referred as polytrauma are investigated following a protocol that includes neck CTA

21 Thank you! Contact: Marius C. Wick, M.D. Department of Radiology Karolinska University Hospital Solna Stockholm, Sweden