Post traumatic vascular injuries in the neck, do current imaging protocols suffice?

Transcription

1 Post traumatic vascular injuries in the neck, do current imaging protocols suffice? Poster No.: C-2398 Congress: ECR 2015 Type: Educational Exhibit Authors: J. Kumaraguru, A. Shah, R. Balachandar, D. Lewis, N. Kandasamy; London/UK Keywords: DOI: Trauma, Dissection, Complications, CT-Angiography, CT, Head and neck, Cardiovascular system /ecr2015/C-2398 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 12

2 Learning objectives Post contrast acquisitions through the neck are now a standard protocol when whole body CT is performed as part of the trauma protocol. Whilst the neck images are not always performed in the arterial phase (in non-penetrating trauma), optimal arterial opacification would be ideal to identify important vascular injuries (eg post traumatic dissection). The current evidence pertaining to imaging post traumatic neck injuries, particularly in blunt or non-penetrating injuries has also been reviewed. Page 2 of 12

3 Background Vascular neck injuries are a diverse group of lesions which may be arterial, venous,or a combination of both. Nature of the trauma could be blunt or penetrating and understanding their mechanisms is of utmost importance in the emergency setting because un- or mis- diagnosed traumas may have disastrous life- long consequences or may even lead to death. Blunt cerebrovascular injury (BCVI) encompasses injuries to the carotid and vertebral arteries. Although BCVIs have previously been believed to be rare, recent studies reported a significantly higher incidence of these injuries[1]. These injuries can occur in the setting of polytrauma or injury to the craniocervical region. Indications for screening the patients rely on presenting signs and symptoms and the mechanism of injury. The collective set of signs, symptoms and risk factors are commonly known as ''Modified Denver Risk criteria'' and is used to aid in imaging for early detection and management of BCVIs. Modified Denver Screening Criteria for Blunt Cerebrovascular Injuries (BCVIs): (If any of these signs, symptoms, or risk factors is present, an urgent CT angiography examination should be performed to look for a potential BCVI.) Signs and Symptoms of BCVIs Arterial hemorrhage Cervical bruit Expanding cervical hematoma Focal neurologic deficit Neurologic examination findings unexplained by neurologic imaging Ischemic stroke on secondary head CT Risk Factors for BCVIs Cervical spine fracture especially subluxation, extension into the foramen transversarium, or upper C1 to C3 fractures.[2] Diffuse axonal injury with Glasgow coma scale < 6 Page 3 of 12

4 LeFort II or III fracture Basal skull fracture with carotid canal involvement Near hanging with anoxic brain injury. The management of these BCVI's are predominantly medical with anticoagulation especially after the recent intracranial stenting trial, and endovascular stenting is rarely necessary, except when the patient presents with symptomatology or markedly enlarging pseudoaneurysm[3].early identification of the vascular injuries and understanding the mechanisms of vascular injury in the neck is of utmost importance in the emergency setting un- or mis- diagnosed traumas may have disastrous life- long consequences or may even lead to death[4]. Page 4 of 12

5 Findings and procedure details We describe a case of post traumatic arterial dissection of the vertebral artery following a blunt neck injury who subsequently had an occipital infarct. We routinely perform split bolus single phase contrast technique for the major trauma patients with blunt injuries to aid adequate opcification of the arterial system and biphasic (arterial and venous dual phase) scans for patients with penetrating injuries. Page 5 of 12

6 Images for this section: Fig. 1: Axial contrast enhanced (single phase - split bolus) cervical spine image showing a normal calibre left vertebral artery (red arrow) Department of Radiology, Kings College Hospital, London 2015 Page 6 of 12

7 Fig. 2: Axial Cervical spine image showing a comminuted fracture involving the left lateral mass of the cervical vertebra (red arrow). Note a normally opacified vertebral artery on the contralateral side. Department of Radiology, Kings College Hospital, London 2015 Page 7 of 12

8 Fig. 3: Axial CT image at the level of the skull base showing a normally opacified right vertebral artery and non-opacification of the intramural segment of the left vertebral artery (red arrow) Department of Radiology, Kings College Hospital, London 2015 Page 8 of 12

9 Fig. 4: Axial brain CT examination performed 5 days later shows an established left occipital infarct (red arrow). Department of Radiology, Kings College Hospital, London 2015 Page 9 of 12

10 Conclusion Attention to excluding vascular injuries in the context of blunt trauma has important clinical implications. Whilst images are not routinely obtained in the arterial phase in this setting the use of the split bolus single phase technique is extremely valuable in interpreting subtle arterial injuries. But the arterial phase imaging can be easily integrated into routine trauma protocol for major trauma patients and this avoids the need for performing separate screening CT angiograms and the patients presenting later with strokes and incidence of death due to complications can be reduced. Page 10 of 12

11 Personal information Dr. Janani Kumaraguru MBBS BA FRCR, Specialty Registrar in Radiology (Musculoskeletal and trauma), Kings College Hospital, London UK Dr Asad Shah MBBS MRCS FRCR, Musculoskeletal fellow in Radiology, Kings College Hospital, London UK Dr Ramya Balachandar MBBS Dr Dylan Lewis MBBCh(Hons) FRCR, Consultant Trauma and intervention Radiologist, Kings College Hospital, London UK Dr Nagachandar Kandasamy MBBS DMRD FRCR, Consultant Neurovascular Radiologist (Interventional), Kings College Hospital, London UK Page 11 of 12

12 References 1. Imaging of Blunt Vascular Neck Injuries: A Review of Screening and Imaging Modalities. Teresa Liang, David K. Tso, Rita Y. W. Chiu and Savvakis Nicolaou S. Am J Roentgenol Oct;201(4): Cervical spine fracture patterns mandating screening to rule out blunt cerebrovascular injury. Cothren CC, Moore EE, Ray CE Jr, Johnson JL, Moore JB, Burch JM. Surgery 2007; 141: Endovascular stenting is rarely necessary for the management of bluntcerebrovascular injuries. Burlew CC, Biffl WL, Moore EE, Pieracci FM, Beauchamp KM, Stovall R, Wagenaar AE, Jurkovich GJ. J Am Coll Surg May;218(5): CT and MR Angiography Features of Traumatic Vascular Injuries of the Neck. Romain Kohler,Maria Isabel Vargas,Karen Masterson,Karl Olof Lovblad,Vitor Mendes Pereira, Minerva Becker. Am J Roentgenol Jun;196(6) 5. Multi-detector row CT angiography of the neck in blunt trauma. Munera F, Foley M, Chokshi FH.Radiol Clin North Am Jan;50(1): Whole-body CT trauma imaging with adapted and optimized CT angiography of the craniocervical vessels: do we need an extra screening examination?langner S, Fleck S, Kirsch M, Petrik M, Hosten N.AJNR Am J Neuroradiol Nov;29(10): Blunt vascular neck injuries: diagnosis and outcomes of extracranial vessel injury. McKevitt EC, Kirkpatrick AW, Vertesi L, Granger R, Simons RK. J Trauma Sep;53(3): Review of multidetector computed tomography angiography as a screening modality in the assessment of blunt vascular neck injuries. Liang T, McLaughlin PD, Louis L, Nicolaou S. Can Assoc Radiol J May;64(2): Page 12 of 12