Liberalized screening for blunt carotid and vertebral artery injuries is justified.

BACKGROUND: Current literature suggests that blunt carotid injuries (BCIs) and vertebral artery injuries (BVIs) are more common than once appreciated. Screening criteria have been suggested, but only one previous study has attempted to identify factors that predict the presence of BCI/BVI. This current study was conducted for two reasons. First, we wanted to determine the incidence of BCI/BVI in our institution. Second, we wanted to determine the incidence of abnormal four-vessel cerebral angiograms ordered for injuries and signs believed to be associated with BCI/BVI and thus to determine whether the screening protocol developed was appropriate. METHODS: From August 1998, we used liberalized screening criteria for patients who were prospectively identified and suspected to be at high risk for BCI/BVI if any of the following were present: anisocoria, unexplained mono-/hemiparesis, unexplained neurologic exam, basilar skull fracture through or near the carotid canal, fracture through the foramen transversarium, cerebrovascular accident or transient ischemic attack, massive epistaxis, severe flexion or extension cervical spine fracture, massive facial fractures, or neck hematoma. Four-vessel cerebral angiograms were used for screening for BCI/BVI. RESULTS: Over the 18-month study period, 48 patients were angiographically screened, with 21 patients (44%) being identified as having a total of 19 BCIs and 10 BVIs. Nine patients had unilateral carotid artery injuries and three patients had bilateral carotid artery injuries. Vertebral artery injuries were unilateral in six patients. One patient had bilateral carotid artery injuries and a unilateral vertebral artery injury. One patient had a unilateral carotid artery injury and a unilateral vertebral artery injury, and one patient had a unilateral carotid artery injury and bilateral vertebral artery injuries. During the same study period, 2,331 trauma patients were admitted, with 1,941 (83%) secondary to blunt trauma. The overall incidence of BCI/BVI was 1.1%. The frequency of abnormal angiograms ordered for cerebrovascular accident or transient ischemic attack, massive epistaxis, or severe cervical spine fractures was 100%. The frequency of abnormal angiograms ordered for the other indications was as follows: fracture through foramen transversarium, 60%; unexplained mono- or hemiparesis, 44%; basilar skull fracture, 42%; unexplained neurologic examination, 38%; anisocoria, 33%; and severe facial fractures, 0%. CONCLUSION: The liberalized screening criteria used in this study were appropriate to identify patients with BCI/BVI. This study suggests BCI/BVI to be more common than previously believed and justifies that screening should be liberalized.

Spontaneous renal artery dissection in a healthy man.

We have presented a unique case of isolated renal artery dissection in an otherwise healthy young man, whose diagnosis was demonstrated by renal angiography. He was anticoagulated with warfarin for one year with resolution of the false channel in his renal artery as demonstrated by magnetic resonance angiography. Duplex ultrasonography of his renal artery was important in monitoring his renal artery flow velocities.

Predilection of brain metastasis in gray and white matter junction and vascular border zones.

BACKGROUND: The purpose of this study was to asses the importance of the vascular border zone and the gray and white matter junction on the distribution of brain metastases. METHODS: We reviewed the medical records, computed tomography (CT) of magnetic resonance imaging (MRI) of 105 patients with secondary brain tumors. The metastatic lesions noted on CT scans of MRI ere matched with a predetermined standard sheet containing axial images with shading on the border zones. To be included in the border zones, the center on more than 50% of the lesion had to be situated within these zones. RESULTS: Among 100 evaluable patients, there were 302 metastatic brain lesions. Of the 302 lesions, 210 lesions were 2 cm or smaller in greatest dimension and located in the cerebral and cerebellar hemispheres. The major vascular border zones were the site of predilection for 103 lesions (62%) although the border zones constitute only 29% of the area. Gray and white matter junction was the preferred site for 135 lesions (64%). CONCLUSION: The results demonstrated that brain metastasis occurs in the vascular border zone regions and the gray and white matter junction more frequently than previously recognized, and also supported the notion that metastatic emboli tend to lodge in an area of sudden reduction of vascular caliber (gray/white matter junction) and in the area most distal vascular field (border zone).

Rare presentation of anastomotic iliac artery false aneurysm: rupture with formation of ilio-iliac arteriovenous fistula.

A rare complication of aortoiliac bypass procedure resulting in the formation of an acute ilio-iliac arteriovenous fistula was presented. The latter was a first manifestation of anastomotic iliac pseudoaneurysm. This is only the second such case reported in the English literature. Iliac anastomotic pseudoaneurysm although rarely detected, is a potentially lethal complication that has to be repaired close to the time of its detection.

Complications of nonoperative management of blunt hepatic injuries.

Few, if any, complications have been reported with the nonoperative management of selected hepatic injuries diagnosed by computed tomographic (CT) scan in hemodynamically stable patients. This retrospective study was designed to evaluate complications associated with this form of management. Twenty-six patients (21%) of 128 patients with blunt hepatic injuries were treated nonoperatively over a 3-year period. All patients were hemodynamically stable at the time of admission and had hepatic injuries identified by CT scans of the abdomen. Five patients (19%) developed complications associated with nonoperative therapy. Of these, two patients had minor hepatic injuries (grades 1-2) and three had major (grades 3-5) hepatic injuries. Two patients (one with minor and one with major hepatic injury), developed free intraperitoneal biliary leaks and required operative repair. Three patients (one with minor and two with major hepatic injuries) developed large subcapsular bilomas with resultant hepatic dysfunction. These patients were successfully managed with percutaneous CT-guided drainage. There were no deaths in our study population with nonoperative therapy. The complications of hepatic injuries initially managed by expectant observation were treated operatively or by percutaneous CT-guided drainage. Repeated CT evaluation to follow the progress of liver fracture and the occasional use of hepatobiliary scans for the identification of biliary leaks have proven useful in our experience.