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.

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Age and traumatic brain injury as prognostic factors for late-phase mortality in patients defined as polytrauma according to the New Berlin Definition: experiences from a level I trauma center

Archives of Orthopaedic and Trauma Surgery ◽

10.1007/s00402-020-03626-w ◽

2020 ◽

Author(s):

V. Weihs ◽

V. Heel ◽

M. Dedeyan ◽

N. W. Lang ◽

S. Frenzel ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Prognostic Factors ◽

Trauma Center ◽

Late Phase ◽

Severely Injured ◽

Severely Injured Patients ◽

Berlin Definition ◽

Severe Tbi ◽

Level I ◽

Injured Patients

Abstract Background The rationale of this study was to identify independent prognostic factors influencing the late-phase survival of polytraumatized patients defined according to the New Berlin Definition. Methods Retrospective data analysis on 173 consecutively polytraumatized patients treated at a level I trauma center between January 2012 and December 2015. Patients were classified into two groups: severely injured patients (ISS > 16) and polytraumatized patients (patients who met the diagnostic criteria for the New Berlin Definition). Results Polytraumatized patients showed significantly lower late-phase and overall survival rates. The presence of traumatic brain injury (TBI) and age > 55 years had a significant influence on the late-phase survival in polytraumatized patients but not in severely injured patients. Despite the percentage of severe TBI being nearly identical in both groups, severe TBI was identified as main cause of death in polytraumatized patients. Furthermore, severe TBI remains the main cause of death in polytraumatized patients > 55 years of age, whereas younger polytraumatized patients (< 55 years of age) tend to die more often due to the acute trauma. Conclusion Our results suggest that age beyond 55 years and concomitant (severe) TBI remain as most important influencing risk factor for the late-phase survival of polytraumatized patients but not in severely injured patients. Level of evidence Prognostic study, level III.

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Magnetic Resonance Imaging after Closed Head Injury in Children

Neurosurgery ◽

10.1227/00006123-198902000-00011 ◽

1989 ◽

Vol 24 (2) ◽

pp. 223-227 ◽

Cited By ~ 32

Author(s):

Harvey S. Levin ◽

Eugenio G. Amparo ◽

Howard M. Eisenberg ◽

Michael E. Miner ◽

Walter M. High ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Head Injuries ◽

Diffuse Axonal Injury ◽

Closed Head Injury ◽

Severely Injured ◽

Resonance Imaging ◽

Severely Injured Patients ◽

Closed Head ◽

Injured Patients

Abstract Magnetic resonance imaging (MRI) was performed in a series of 21 children and adolescents who had been hospitalized after sustaining closed head injuries of varying severity at least 6 months previously. Areas of high intensity in the parenchyma were present in 8 of the 11 severely injured patients, whereas MRI findings were normal in all 10 patients with mild-to-moderate head injuries. Lesions involving the subcortical white matter were confined to severely injured patients whose clinical features were compatible with diffuse axonal injury. Neuropsychological assessment disclosed deficits primarily in the severely injured patients; these deficits were significantly associated with persistent lesions visualized by MRI. Serial MRI and neurobehavioral assessment following early injury may be useful in documenting cognitive impairment in relation to structural alterations of the young brain.

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TELEMEDICINE CONSULTATION REDUCES TIME TO TRANSFER SEVERELY INJURED PATIENTS TO A RURAL LEVEL I TRAUMA CENTER

Journal of Trauma and Acute Care Surgery ◽

10.1097/00005373-200508000-00098 ◽

2005 ◽

Vol 59 (2) ◽

pp. 529

Author(s):

William E. Charash ◽

Frederick B. Rogers ◽

Michael P. Caputo ◽

Bruce A. Crookes ◽

Peter W. Callas ◽

...

Keyword(s):

Trauma Center ◽

Severely Injured ◽

Severely Injured Patients ◽

Telemedicine Consultation ◽

Level I ◽

Injured Patients

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Magnetic Resonance Imaging and Clinical Factors Associated With Ischemic Stroke in Patients Suspected of Cervical Artery Dissection

Stroke ◽

10.1161/strokeaha.118.021868 ◽

2018 ◽

Vol 49 (10) ◽

pp. 2337-2344 ◽

Cited By ~ 5

Author(s):

J. Scott McNally ◽

Peter J. Hinckley ◽

Akihiko Sakata ◽

Laura B. Eisenmenger ◽

Seong-Eun Kim ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Ischemic Stroke ◽

Magnetic Resonance ◽

Artery Dissection ◽

Cervical Artery Dissection ◽

Resonance Imaging ◽

Clinical Factors ◽

Factors Associated ◽

Cervical Artery

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Initial Approach to the Management of Multisystem Trauma

Mayo Clinic Critical and Neurocritical Care Board Review ◽

10.1093/med/9780190862923.003.0062 ◽

2019 ◽

pp. 397-401

Author(s):

David S. Morris

Keyword(s):

Trauma Center ◽

Injury Severity ◽

Hospital Admissions ◽

The United States ◽

Emergency Department Visits ◽

Severely Injured ◽

Level Ii ◽

Level I ◽

Nonfatal Injuries ◽

Injured Patients

Nearly 200,000 people die of injury-related causes in the United States each year, and injury is the leading cause of death for all patients aged 1 to 44 years. Approximately 30 million people sustain nonfatal injuries each year, which results in about 29 million emergency department visits and 3 million hospital admissions. Management of severely injured patients, typically defined as having an Injury Severity Score greater than 15 is best managed in a level I or level II trauma center. Any physician who provides care for critically ill patients should have a basic familiarity with the fundamentals of trauma care.

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Delays in Transfer of Elderly Less-injured Trauma Patients Can Have Deadly Consequences

The American Surgeon ◽

10.1177/000313481408001130 ◽

2014 ◽

Vol 80 (11) ◽

pp. 1132-1135 ◽

Cited By ~ 4

Author(s):

Peter E. Fischer ◽

Paul D. Colavita ◽

Gregory P. Fleming ◽

Toan T. Huynh ◽

A. Britton Christmas ◽

...

Keyword(s):

Trauma Center ◽

Injury Severity ◽

Trauma Patients ◽

Severely Injured ◽

Severely Injured Patients ◽

Local Trauma ◽

Level 1 ◽

Poor Outcomes ◽

Injured Patients ◽

Level 1 Trauma Center

Transfer of severely injured patients to regional trauma centers is often expedited; however, transfer of less-injured, older patients may not evoke the same urgency. We examined referring hospitals’ length of stay (LOS) and compared the subsequent outcomes in less-injured transfer patients (TP) with patients presenting directly (DP) to the trauma center. We reviewed the medical records of less-injured (Injury Severity Score [ISS] 9 or less), older (age older than 60 years) patients transferred to a regional Level 1 trauma center to determine the referring facility LOS, demographics, and injury information. Outcomes of the TP were then compared with similarly injured DP using local trauma registry data. In 2011, there were 1657 transfers; the referring facility LOS averaged greater than 3 hours. In the less-injured patients (ISS 9 or less), the average referring facility LOS was 3 hours 20 minutes compared with 2 hours 24 minutes in more severely injured patients (ISS 25 or greater, P < 0.05). The mortality was significantly lower in the DP patients (5.8% TP vs 2.6% DP, P = 0.035). Delays in transfer of less-injured, older trauma patients can result in poor outcomes including increased mortality. Geographic challenges do not allow for every patient to be transported directly to a trauma center. As a result, we propose further outreach efforts to identify potential causes for delay and to promote compliance with regional referral guidelines.

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Biomarkers and antithrombotic treatment in cervical artery dissection – Design of the TREAT-CAD randomised trial

European Stroke Journal ◽

10.1177/2396987320921151 ◽

2020 ◽

Vol 5 (3) ◽

pp. 309-319

Author(s):

Christopher Traenka ◽

Henrik Gensicke ◽

Sabine Schaedelin ◽

Andreas Luft ◽

Marcel Arnold ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Vitamin K ◽

Vitamin K Antagonists ◽

Artery Dissection ◽

Cervical Artery Dissection ◽

Resonance Imaging ◽

Antithrombotic Treatment ◽

Data Set ◽

Cervical Artery

Introduction The type of antithrombotic treatment in cervical artery dissection patients is still a matter of debate. Most physicians prefer anticoagulants over antiplatelet agents for stroke prevention. However, this approach is not evidence-based and antiplatelets might be as safe and as effective. The ‘Biomarkers and Antithrombotic Treatment in Cervical Artery Dissection’ (‘TREAT-CAD’) trial (clinicaltrials.gov: NCT02046460) compares Aspirin to oral anticoagulants (vitamin K antagonists) with regard to efficacy and safety by using both clinical and imaging surrogate outcome measures. TREAT-CAD tests the hypothesis, that aspirin is as safe and effective as vitamin K antagonists. Patients and methods TREAD-CAD is a Prospective, Randomised controlled, Open-labelled, multicentre, non-inferiority trial with Blinded assessment of outcome Events (PROBE-design). Key eligibility criteria are (i) clinical symptoms attributable to cervical artery dissection and (ii) verification of the cervical artery dissection diagnosis by established magnetic resonance imaging criteria. Patients are randomised to receive either Aspirin 300 mg daily or vitamin K antagonists for 90 days. Results Primary outcomes are assessed at 14 ± 10 days (magnetic resonance imaging and clinical examination) and at 90 ± 30 days (clinical examinations). The primary endpoint is a composite outcome measure – labelled Cerebrovascular Ischemia, major Hemorrhagic events or Death (CIHD) – and includes (i) occurrence of any stroke (including retinal infarction), (ii) new ischaemic lesions on diffusion-weighted magnetic resonance imaging, (iii) any major extracranial haemorrhage, (iv) any symptomatic intracranial haemorrhage, (v) any new haemorrhagic lesion visible on paramagnetic-susceptible sequences and (vi) death. Discussion After database closure, (i) central verification of cervical artery dissection diagnosis will be done by two experienced raters, (ii) adjudication of outcome events will be performed by independent adjudication committees, separately for clinical and imaging outcomes. The primary analysis will be done on the per protocol data set. The targeted sample size consists of 169 evaluable patients in the per protocol data set. Conclusion TREAT-CAD is testing the non-inferiority of Aspirin versus vitamin K antagonists treatment in patients with symptomatic cervical artery dissection by combined clinical and magnetic resonance imaging outcomes.

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