Prognostic factors associated with risk of stroke following blunt cerebrovascular injury: A systematic review and meta-analysis.

BACKGROUND & OBJECTIVES: Blunt cerebrovascular injury (BCVI) includes carotid and/or vertebral artery injury following trauma, and conveys an increased stroke risk. We conducted a systematic review and meta-analysis to provide a comprehensive summary of prognostic factors associated with risk of stroke following BCVI. METHODS: We searched the EMBASE and MEDLINE databases from January 1946 to June 2023. We identified studies reporting associations between patient or injury factors and risk of stroke following BCVI. We performed meta-analyses of odds ratios (ORs) using the random effects method and assessed individual study risk of bias using the QUIPS tool. We separately pooled adjusted and unadjusted analyses, highlighting the estimate with the higher certainty. RESULTS: We included 26 cohort studies, involving 20,458 patients with blunt trauma. The overall incidence of stroke following BCVI was 7.7 %. Studies were predominantly retrospective cohorts from North America and included both carotid and vertebral artery injuries. Diagnosis of BCVI was most commonly confirmed with CT angiography. We demonstrated with moderate to high certainty that factors associated with increased risk of stroke included carotid artery injury (as compared to vertebral artery injury, unadjusted odds ratio [uOR] 1.94, 95 % CI 1.62 to 2.32), Grade III Injury (as compared to grade I or II) (uOR 2.45, 95 % CI 1.88 to 3.20), Grade IV injury (uOR 3.09, 95 % CI 2.20 to 4.35), polyarterial injury (uOR 3.11 (95 % CI 2.05 to 4.72), occurrence of hypotension at the time of hospital admission (adjusted odds ratio [aOR] 1.32, 95 % CI 0.87 to 2.03) and higher total body injury severity (aOR 5.91, 95 % CI 1.90 to 18.39). CONCLUSION: Local anatomical injury pattern, overall burden of injury and flow dynamics contribute to BCVI-related stroke risk. These findings provide the foundational evidence base for risk stratification to support clinical decision making and further research.

Pediatric Blunt Cerebrovascular Injuries: Approach and Management.

ABSTRACT: The low incidence of blunt cerebrovascular injury (BCVI) reported in pediatric studies (<1%) might be related to an underreporting due to both the absence of current screening guidelines and the use of inadequate imaging techniques. This research is a review of the literature limited to the last 5 years (2017-2022) about the approach and management of BCVI in pediatrics. The strongest predictors for BCVI were the presence of basal skull fracture, cervical spine fracture, intracranial hemorrhage, Glasgow Coma Scale score less than 8, mandible fracture, and injury severity score more than 15. Vertebral artery injuries had the highest associated stroke rate of any injury type at 27.6% (vs 20.1% in carotid injury). The sensitivity of the well-established screening guidelines of BCVI varies when applied to the pediatric population (Utah score - 36%, 17%, Eastern Association for the Surgery of Trauma (EAST) guideline - 17%, and Denver criteria - 2%). A recent metaanalysis of 8 studies comparing early computed tomographic angiogram (CTA) to digital subtraction angiography for BCVI detection in adult trauma patients demonstrated high variability in the sensitivity and specificity of CTA across centers. Overall, CTA was found to have a high specificity but low sensitivity for BCVI. The role of antithrombotic as well as the type and duration of therapy remain controversial. Studies suggest that systemic heparinization and antiplatelet therapy are equally effective.

Trauma mechanisms and patterns of blunt cervical vascular injury: A descriptive study using a nationwide trauma registry.

OBJECTIVE: Blunt cervical vascular injury (BCVI) is a non-penetrating trauma to the carotid and/or vertebral vessels following a direct injury to the neck or by the shearing of the cervical vessels. Despite its potentially life-threatening nature, important clinical features of BCVI such as typical patterns of co-occurring injuries for each trauma mechanism are not well known. To address this knowledge gap, we described the characteristics of patients with BCVI to identify the pattern of co-occurring injuries by common trauma mechanisms. METHODS: This is a descriptive study using a Japanese nationwide trauma registry from 2004 through 2019. We included patients aged ≥13 years presenting to the emergency department (ED) with BCVI, defined as a blunt trauma to any of the following vessels: common/internal carotid artery, external carotid artery, vertebral artery, external jugular vein, and internal jugular vein. We delineated characteristics of each BCVI classified according to three damaged vessels (common/internal carotid artery, vertebral artery, and others). In addition, we applied network analysis to unravel patterns of co-occurring injuries among patients with BCVI by four common trauma mechanisms (car accident, motorcycle/bicycle accident, simple fall, and fall from a height). RESULTS: Among 311,692 patients who visited the ED for blunt trauma, 454 (0.1%) patients had BCVI. Patients with common/internal carotid artery injuries presented to the ED with severe symptoms (e.g., the median Glasgow Coma Scale was 7) and had high in-hospital mortality (45%), while patients with vertebral artery injuries presented with relatively stable vital signs. Network analysis showed that head-vertebral-cervical spine injuries were common across four trauma mechanisms (car accident, motorcycle/bicycle accident, simple fall, and fall from a height), with co-occurring injuries of the cervical spine and vertebral artery being the most common injuries due to falls. In addition, common/internal carotid artery injuries were associated with thoracic and abdominal injuries in patients with car accidents. CONCLUSIONS: Based on analyses of a nationwide trauma registry, we found that patients with BCVI had distinct patterns of co-occurring injuries by four trauma mechanisms. Our observations provide an important basis for the initial assessment of blunt trauma and could support the management of BCVI.

Epidemiology, repair technique, and predictors of stroke and mortality in penetrating carotid artery injuries.

OBJECTIVE: Penetrating carotid artery injuries (PCAI) are significantly morbid and deadly, often presenting in extremis with associated injuries and central nervous system deficit. Repair may be challenging with arterial reconstruction vs ligation role poorly defined. This study evaluated contemporary outcomes and management of PCAI. METHODS: PCAI patients in the National Trauma Data Bank from 2007 to 2018 were analyzed. Outcomes were compared between repair and ligation groups after additionally excluding external carotid injuries, concomitant jugular vein injuries, and head/spine Abbreviated Injury Severity score of ≥3. Primary end points were in-hospital mortality and stroke. Secondary end points were associated injury frequency and operative management. RESULTS: There were 4723 PCAI (55.7% gunshot wounds, 44.1% stab wounds). Gunshot wounds more frequently had associated brain (73.8% vs 19.7%; P < .001) and spinal cord (7.6% vs 1.2%; P < .001) injuries; stab wounds more frequently had jugular vein injuries (19.7% vs 29.3%; P < .001). The overall in-hospital mortality was 21.9% and the stroke rate was 6.2%. After exclusion criteria, 239 patients underwent ligation and 483 surgical repair. Ligation patients had lower presenting Glasgow Coma Scale (GCS) than repair patients (13 vs 15; P = .010). Stroke rates were equivalent (10.9% vs 9.3%; P = .507); however, in-hospital mortality was higher after ligation (19.7% vs 8.7%; P < .001). In-hospital mortality was higher in ligated common carotid artery injuries (21.3% vs 11.6%; P = .028) and internal carotid artery injuries (24.5% vs 7.3%; P = .005) compared with repair. On multivariable analysis, ligation was associated with in-hospital mortality, but not with stroke. A history of neurological deficit before injury lower GCS, and higher Injury Severity Score (ISS) were associated with stroke; ligation, hypotension, higher ISS, lower GCS, and cardiac arrest were associated with in-hospital mortality. CONCLUSIONS: PCAI are associated with a 22% rate of in-hospital mortality and a 6% rate of stroke. In this study, carotid repair was not associated with a decreased stroke rate, but did have improved mortality outcomes compared with ligation. The only factors associated with postoperative stroke were low GCS, high ISS, and a history of neurological deficit before injury. Beside ligation, low GCS, high ISS, and postoperative cardiac arrest were associated with in-hospital mortality.

Internal carotid artery injury during endoscopic endonasal surgery for skull base pathologies: an institutional incidence, management, and outcome.

BACKGROUND: Endoscopic endonasal surgery (EES) has become a popular approach to deal with skull base pathologies. The most catastrophic intra-operative complication of EES is internal carotid artery (ICA) injury. We aim to discuss and introduce our institutional experience with ICA injury during EES. METHODS: A retrospective review of patients who underwent EES from 2013 to 2022 was performed to determine the incidence and outcomes of intraoperative ICA injuries. RESULTS: There were six patients (0.56%) with intraoperative ICA injury in our institution during the last 10 years. Fortunately, there was no morbidity or mortality in our patients with intraoperative ICA injuries. The sites of injury were equally in paraclival, cavernous sinus, and preclinoidal segments of ICA. CONCLUSION: Primary prevention is the best solution for this condition. Regarding our institutional experience, the best option for primary management just after an injury is packing the surgical site. In cases where packing is not enough for temporary control of bleeding, common carotid artery occlusion should be considered. We have presented our experience and reviewed previous studies regarding different treatments and suggested our intra and post-operative management algorithm.

Blunt Traumatic Vertebral Artery Injuries: Incidence, Therapeutic Management, and Outcomes.

BACKGROUND: Blunt cerebrovascular injury (BCVI) is a term for injuries to the carotid and vertebral arteries (blunt vertebral artery injury [BVAI]) caused by blunt trauma. Computed tomographic angiography is currently the best screening test for BCVI. The subsequent management of any identified vessel injury, however, is not clearly defined. OBJECTIVE: To describe one of the largest cohorts of isolated vertebral artery injuries and report the evolution of treated and untreated lesions and clinical outcomes of treatment regimens used to reduce the risk of injury-related stroke. METHODS: The list included patients who presented to or were transferred to a level 1 trauma center and found to have an isolated BVAI. Patients were included if imaging was performed within 24 hours of presentation. Data collected included location and grade of injury, timing and type of initial therapy, follow-up imaging, evolution of the disease, and associated strokes. RESULTS: A total of 156 patients were included in the analysis. Most patients (135/156) were treated with aspirin alone, 3 with anticoagulation therapy, and 18 did not receive treatment. Three strokes were detected within 24 hours of admission and before treatment initiation. No strokes were detected during the length of the hospitalization for any other patient. CONCLUSION: Our data demonstrate that the risk of stroke after cervical vertebral artery injury is low, and aspirin as a prophylactic is efficacious in grade I and IV injuries. There are limited data regarding grade II and grade III injuries. The benefit of early interval imaging follow-up is unclear and warrants investigation.

A multicenter retrospective cohort study of blunt traumatic injury to the common or internal carotid arteries.

OBJECTIVE: Current EAST guidelines recommend against routine carotid intervention for patients with blunt carotid artery injury (BCI), but offer limited information on its role for BCI patients presenting with neurological deficit. Our goal was to describe the contemporary management and outcomes of patients presenting with BCI and neurological deficit unrelated to head injury. METHODS: We identified all adults who sustained a BCI between 2010 and 2017 in the American College of Surgeons Trauma Quality Improvement Program. We extracted patient demographics, injury characteristics (carotid and non-carotid), as well as the frequency, timing and approach of carotid intervention. Presence of neurological deficit unrelated to head injury at presentation was determined using Abbreviated Injury Scale codes. The main outcomes were in-hospital mortality and home discharge. Patients with and without neurological deficit at presentation were compared through multivariable logistic regression modeling. Among those with neurological deficit at presentation, the associations between carotid intervention (open or endovascular) and the outcomes were also assessed through multivariable logistic regression. RESULTS: We identified 5,788 patients with BCI of whom 383 (7%) presented with neurological deficit unrelated to head injury. Among the 296 patients (5%) who underwent carotid intervention, 36 (12%) had presented with neurological deficit unrelated to head injury. Interventions were most often endovascular (68% [200/296]) and within a median time of 32 h (IQR 5-203). In-hospital mortality was 16% (918/5,788), and in-hospital stroke prevalence was 6% (336/5,788). When comparing patients with and without neurological deficit at presentation, those with deficits were more frequently managed with an intervention. After adjustment, the likelihood of mortality was higher (OR [95% CI] = 2.16 [1.63-2.85]) and the likelihood of home discharge lower (OR [95% CI] = 0.29 [0.21-0.40]) among patients presenting with neurological deficit. Among those with neurological deficit, carotid intervention was positively associated with home discharge (OR [95% CI] = 2.96 [1.21-7.23]), but not with in-hospital mortality (OR [95% CI] = 0.87 [0.36-2.10]). Results were similar in the subgroup of patients with isolated BCI (2,971/5,788). CONCLUSIONS: Intervention in BCI patients presenting with neurological deficit may contribute to a greater likelihood of home discharge but not reduced in-hospital mortality.

A multi-registry analysis of military and civilian penetrating cervical carotid artery injury.

INTRODUCTION: Penetrating cervical carotid artery injury is an uncommon but high-stake scenario associated with stroke and death. The objective of this study was to characterize and compare penetrating carotid injury in the military and civilian setting, as well as provide considerations for management. METHODS: Cohorts with penetrating cervical carotid artery injury from the Department of Defense Trauma Registry (2002-2015) and the American Association for the Surgery of Trauma Prospective Observation Vascular Injury Treatment Registry (2012-2018) were analyzed. A least absolute shrinkage and selection operator multivariate analysis using random forest-based imputation was performed to identify risk factors affecting stroke and mortality. RESULTS: There were a total of 157 patients included in the study, of which 56 (35.7%) were military and 101 (64.3%) were civilian. The military cohort was more likely to have been managed with open surgery (87.5% vs. 44.6%, p < 0.001) and to have had any procedure to restore or maintain flow to the brain (71.4% vs. 35.6%, p < 0.001), while the civilian cohort was more likely to undergo nonoperative management (45.5% vs. 12.5%, p < 0.001). Stroke rate was higher within the military cohort (41.1% vs. 13.9%, p < 0.001); however, mortality did not differ between the groups (12.5% vs. 17.8%, p = 0.52). On multivariate analysis, predictors for stroke were presence of a battle injury (log odds, 2.1; p < 0.001) and internal or common carotid artery ligation (log odds 1.5, p = 0.009). For mortality outcome, protective factors included a high Glasgow Coma Scale on admission (log odds, -0.21 per point; p < 0.001). Increased admission Injury Severity Score was a predictor of mortality (log odds, 0.05 per point; p = 0.005). CONCLUSION: The stroke rate was higher in the military cohort, possibly reflecting complexity of injury; however, there was no difference in mortality between military and civilian patients. For significant injuries, concerted efforts should be made at carotid reconstruction to reduce the occurrence of stroke. LEVEL OF EVIDENCE: Retrospective cohort analysis, level III.

Early Experience of Endoscopic Endonasal Transphenoidal Surgery for Pituitary Adenoma: Preliminary Report of 56 Cases Operated in a West African Institution.

BACKGROUND: Although endoscopic endonasal approach (EEA) has been popularized worldwide for pituitary adenoma surgery, in sub-Saharan Africa, neurosurgeons are still only starting their experience with it. This study was designed to assess the early results of EEA for pituitary adenoma from an under-equipped environment, namely, the Department of Neurosurgery of the Teaching Hospital of Yopougon Abidjan and Bouaké in Ivory Coast. METHODS: The data of 56 cases of EEA for pituitary adenoma surgery performed between 2016 and March 2019 at the Teaching Hospital of Yopougon-Abidjan and Bouaké were retrospectively assessed. Pre- and postoperative neuro-ophthalmologic and hormonal status were analyzed. Moreover, the quality of tumor removal, and pre- and postoperative complications were also evaluated. RESULTS: In this study, there were nonfunctional adenomas (20), prolactinoma (18), Cushing disease (9), and acromegaly (3). A reduced visual acuity and/or visual field defect was observed in 49 cases. The mean operation time was 225 ± 94.7 minutes. The tumor removals were complete in 57.14%, subtotal in 35.71%, and partial in 7.14%. These led to a visual improvement in 69.64%. Postoperative complications were cerebrospinal fluid leaks (19.64%), diabetes insipidus (12.50%), visual worsening (7.14%), meningitis (3.57%), and carotid injury (3.57%) that led to death. CONCLUSIONS: This study represents the early surgical experience using EEA for treating pituitary adenoma in an under-equipped environment. Although the postoperative complication rate was relatively high, refinements of local surgeons' technique would lead to a better patient outcome.

Utility of Routine Computed Tomography Angiogram Screening for Blunt Carotid Injury in Isolated Mandible Fractures.

PURPOSE: Determine the incidence of blunt carotid injury (BCAI) in the blunt trauma induced isolated mandible fracture population and determine the utility of computed tomographic angiography (CTA) screening for BCAI in this population. METHODS: A retrospective data review was performed on patients presenting to Boston Medical Center from January 2008 to January 2019 with a diagnosis of mandible fracture. Population selected utilizing ICD-9 and ICD-10 diagnosis codes for mandible fracture and BCAI. Excluded populations were pediatric (less than 18 years) and penetrating carotid injuries. RESULTS: A total of 1,508 mandible fractures were identified, with 73% (n = 1,103) being isolated injuries. Five BCAIs were identified, and of these, 1 was associated with an isolated mandible fracture (incidence <0.01%). One of 110 isolated mandible fractures screened for BCAI with the use of CTA was positive (incidence 0.9%). CONCLUSIONS: BCAI is a rare finding in isolated mandible fractures. The inclusion of this population as an independent risk factor for BCAI should be questioned. Routine screening with CTA is not warranted.

Anomalous innominate artery complicating tracheal surgical procedures.

OBJECTIVE: To highlight the importance of imaging in reducing an accidental injury to the anomalous brachiocephalic trunk and its branches during tracheal surgery. CASE REPORT: This paper reports two cases of accidental injury to the great vessels in the neck during tracheal surgery. The first incident occurred during a repeat tracheostomy, when the right common carotid artery was injured. On reviewing the computed tomography images, the bifurcation of the brachiocephalic artery was seen to the left of the midline, and the right common carotid artery was adherent just below the tracheostomy site. The second incident happened during surgery for tracheal stenosis, when there was an inadvertent injury to the main brachiocephalic trunk, which was adherent to the trachea in the lower neck region. CONCLUSION: For airway surgeons, radiological assessment of vascular structures in relation to the trachea prior to surgery is as important as the endoluminal airway assessment for the best outcome.

Risk Factors and Outcomes Associated with Blunt Cerebrovascular Injury in Patients with Mild or Moderate Traumatic Brain Injury.

BACKGROUND: Blunt cerebrovascular injury (BCVI) represents a spectrum of traumatic injuries to the carotid and vertebral arteries that is an often-overlooked source of morbidity and mortality. Its incidence, risk factors, and effect on outcomes in patients with mild or moderate traumatic brain injury (mTBI) have not been studied independently. METHODS: The National Trauma Data Bank from 2013 to 2017 was queried to identify patients with mTBI who suffered blunt injuries. BCVI was identified using abbreviated injury scores and included blunt carotid artery injury (BCAI) and blunt vertebral artery injury (BVAI). A binary logistic regression was used to identify patient-related and injury-related factors associated with BCVI. Binary logistic regressions were also performed to evaluate the effect of BCVI on stroke, in-hospital mortality, nonroutine discharge disposition, total length of stay (LOS), intensive care unit LOS, and number of days mechanically ventilated. RESULTS: Of 485,880 patients with mTBI, there were 4,382 (0.9%) with BCVI. Cervical spine fracture was the strongest factor associated with BCAI (odds ratio [OR], 1.97; 95% confidence interval [95% CI], 1.77-2.19), followed by mandible fracture and basilar skull fracture. Cervical spine fracture also had the strongest association with BVAI (OR, 18.28; 95% CI, 16.47-20.28), followed by spinal cord injury and neck contusion. Stroke was more common in patients with BCAI (OR, 5.50; 95% CI, 4.19-7.21) and BVAI (OR, 7.238; 95% CI, 5.929-8.836). BVAI increased the odds of mortality, but BCAI did not. Both were associated with nonroutine discharge and increased LOS, intensive care unit LOS, and number of days mechanically ventilated. CONCLUSIONS: The incidence of BCVI in patients with mTBI is low, and it usually does not require invasive treatment. However, it is associated with greater odds of stroke and negative outcomes. Knowledge of risk factors for BCVI may tailor further investigation to aid prompt diagnosis.

Traumatic Cerebrovascular Injuries Associated with Gunshot Wounds to the Head: A Single-Institution Ten-Year Experience.

BACKGROUND: Cerebrovascular injury (CVI) is a potentially devastating complication of gunshot wounds to the head (GSWH), with yet unclear incidence and prognostic implications. Few studies have also attempted to define CVI risk factors and their role in patient outcomes. We aimed to describe 10 years of CVI from GSWH and characterize these injury patterns. METHODS: Single-institution data from 2009 to 2019 were queried to identify patients presenting with dural-penetrating GSWH. Patient records were reviewed for GSWH characteristics, CVI patterns, management, and follow-up. RESULTS: Overall, 63 of 297 patients with GSWH underwent computed tomography angiography (CTA) with 44.4% showing CVI. The middle cerebral artery (22.2%), dural venous sinuses (15.9%), and internal carotid artery (14.3%) were most frequently injured. Arterial occlusion was the most prominent injury type (22.2%) followed by sinus thrombosis (15.9%). One fifth of patients underwent delayed repeat CTA, with 20.1% showing new/previously unrecognized CVI. Bihemispheric bullet tracts were associated with CVI occurrence (P = 0.001) and mortality (P = 0.034). Dissection injuries (P = 0.013), injuries to the vertebrobasilar system (P = 0.036), or the presence of ≥2 concurrent CVIs (P = 0.024) were associated with increased risk of mortality. Of patients with CVI on initial CTA, 30% died within the first 24 hours. CONCLUSIONS: CVI was found in 44.4% of patients who underwent CTA. Dissection and vertebrobasilar injuries are associated with the highest mortality. CTA should be considered in any potentially survivable GSWH. Longitudinal study with consistent CTA use is necessary to determine the true prevalence of CVI and optimize the use of imaging modalities.

Expanded transnasal approaches to the skull base in the Middle East: Where do we stand?

BACKGROUND: Endoscopic transnasal surgery has gained rapid global acceptance over the last two decades. The growing literature and understanding of anterior skull base endoscopic anatomy, in addition to new dedicated endoscopic instruments and tools, have helped to expand the use of the transnasal route in skull base surgery. OBJECTIVE: Report our early experience in expanded endoscopic transnasal surgery (EETS) and approach to skull base neoplasms. DESIGN: Descriptive, retrospective case series. SETTING: Major tertiary care center. PATIENTS AND METHODS: A retrospective case review was conducted at King Saud University Medical City between December 2014 and August 2019. Cases with skull base neoplasms that underwent EETS were included. EETS was defined as endoscopic surgical exposure that extended beyond the sellar margins (prechiasmatic sulcus superiorly, clival recess inferiorly, cavernous carotid lines laterally). Routine transsphenoidal pituitary neoplasms, neoplasms of sinonasal origin and meningoencephaloceles were excluded. MAIN OUTCOME MEASURES: Preoperative clinical assessment, imaging results, surgical approach, and hospital course were all retrieved from the patient electronic charts. Clinical follow-up, perioperative complications, and gross residual tumor rates were documented and reviewed. SAMPLE SIZE AND CHARACTERISTICS: 45 cases of EETS, 13 males and 32 females with mean age of 39.0 (17.7) years (range 2-70 years). RESULTS: The series comprised a wide range of pathologies, including giant pituitary adenoma (8 cases), meningioma (23 cases), craniopharyngioma (4 cases), chordoma (4 cases), optic pathway glioma (2 cases), epidermoid neoplasms (2 cases), astrocytoma (1 case), and teratoma (1 case). For the entire series, gross total resection was achieved in 25/45 operations (55.5%). Postoperative cerebrospinal fluid leak was the most common complication observed in 9 patients (20%) which were all managed endoscopically. Major vascular complications occurred in 2 patients (4.4%) and are described. Other complications are outlined as well. No mortality was observed. CONCLUSIONS: EETS to the skull base can be done with results comparable to traditional approaches. More work is needed to expand our experience, improve outcomes, and educate the public and medical community in our region about the usefulness of this approach. LIMITATIONS: Sample size and study design. CONFLICT OF INTEREST: None.

Pediatric blunt cerebrovascular injuries: A national trauma database study.

BACKGROUND: The incidence of blunt cerebrovascular injuries (BCVIs) in children is unknown. We aimed to determine the rate and consequences of BCVIs in pediatric blunt trauma patients. METHODS: We queried the National Trauma Data Bank (NTDB) for all blunt trauma patients between 2007 and 2014. BCVI patients were identified by ICD-9 codes. Demographic, emergency room, and concomitant injury data were analyzed. RESULTS: There were 732,702 blunt trauma patients, and 1682 BCVIs were identified (0.23%). 791 (47%) sustained carotid artery injuries (CAIs), 957 (57%) had vertebral artery injuries (VAIs), and 4% of patients sustained both. A majority of the injuries occurred in white patients (61%) and in motor vehicle accidents (53%). The average age was 12.1 ±â€¯5.4 years. CAIs had more skull base fractures (55% vs 35%, p < 0.0001), and cervical spine fractures were more common in VAIs (26 vs 11%, p < 0.0001). Intensive care length of stay was longer in the CAI patients (9.2 vs 7.9 days, p = 0.03), as was length of stay (12.5 vs 9.7 days, p = 0.0002). 5% of CAI patients were coded for stroke, versus 2% of VAIs (p = 0.002). CONCLUSIONS: BCVIs are rare in children. Vertebral injuries are more common. Carotid injuries are associated with a longer length of stay and higher stroke rates. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: III.

Proximal penholding method - A variant to enhance safety of ultrasoundguided central venous cannulation: A prospective pilot study.

Aims: A significant incidence of Posterior Vessel Wall Puncture (PVWP) was reported during ultrasound guidance (USG) for internal jugular vein (IJV) catheterization. We studied a new technique of USGIJV cannulation to minimize or avoid PVWP, thereby decreasing overall complication rate, irrespective of the operators' experience level. Materials and Methods: After ethical approval, a prospective study was conducted on adult patients of either gender between 18-65 years of age, belonging to the American Society of Anesthesiologists Physical Status I-III, undergoing general anesthesia and requiring USG-guided IJV cannulation. After induction of general anesthesia and intubation, USG-guided IJV cannulation was done using technique of "proximal pen-holding method" in patients placed in supine position with neck rotated in 15° rotation to the opposite side. The primary outcome was defined as success rate of USG-guided IJV cannulation and incidence of PVWP. The secondary outcome was the incidences of complications such as arterial puncture, adjacent tissue damage, and performer's ease of the procedure (0-10 scale; 0 denoting no ease and extreme difficulty and 10 denoting extreme ease and no difficulty). Results: In 135 patients, right IJV puncture, guidewire, and central line insertion were achieved in single attempt without any PVWP by nine operators which included two anesthesia consultants and seven senior registrars. No complications were reported and ease of procedure were rated as median (interquartile range) of 10 (10). Conclusions: The "proximal pen-holding method" for real-time USG-IJV cannulation helped in avoiding PVWP with lesser complication rate and greater performer's ease.

Beyond the Learning Curve: Comparison of Microscopic and Endoscopic Incidences of Internal Carotid Injury in a Series of Highly Experienced Operators.

BACKGROUND: As the endoscopic endonasal approach (EEA) has gained popularity as an alternative to microsurgery (MS) for transsphenoidal resection (TSR), numerous studies have attempted to assess the differential risk of internal carotid artery (ICA) injury between the techniques, yet results have been equivocal and contradictory. The aim of this study was to evaluate ICA injury in MS versus EEA among highly experienced neurosurgeons. METHODS: We performed a systematic literature review of publications from 2002-2017 reporting ICA injury outcomes in ≥250 cases using MS or EEA. RESULTS: Seventeen series reporting 11,149 patients were included: 3 MS series, 13 EEA series, and 1 series with adequate samples for each. ICA injury incidences were 0.0%-1.6% in cohorts of 275-3000. MS series documented 5 ICA injuries in 2672 operations, for an overall incidence of 0.2% (range, 0.0%-0.4%), and EEA series reported 30 ICA injuries in 8477 operations, for a 0.4% injury rate (range, 0.0%-1.6%); the difference was nonsignificant (P = 0.25). Increased operative experience was associated with decreased incidence of ICA injury, a finding preserved in the overall study cohort and within discretely examined MS and EEA subgroups (overall r2 = 0.08, MS r2 = 0.23, EEA r2 = 0.07). CONCLUSIONS: ICA injury is the most serious complication of TSR of pituitary neoplasms. Operator inexperience may be a more important risk factor than choice of surgical technique, given the comparably low rates of injury obtained by highly experienced surgeons independent of technique. This emphasizes the need for consolidated care in pituitary centers of excellence, improvement of high-fidelity simulators, and skull base mentorship between senior and junior staff.

Penetrating Neck Injury in Two Dutch Level 1 Trauma Centres: the Non-Existent Problem.

OBJECTIVES: Penetrating neck injuries (PNIs) have a low incidence in European trauma populations. Selective non-operative management of PNI has been suggested as a safe alternative to standard surgical neck exploration, but evidence is lacking. This clinical scenario evaluates institutional PNI management, specifically the associated carotid artery injury, and compares it with current guidelines. METHODS: Retrospectively, PNI patients presenting at two Dutch level 1 trauma centres from 2007 to 2015, were identified. International guidelines on PNI management were reviewed and recommendations were assessed in relation to current institutional management, and considering an illustrative case. RESULTS: Two current guidelines on PNI management were reviewed. Both advocate a zone based approach; one recommends a prominent role for computed tomography angiography (CTA) scanning in stable patients, supplemented by endoscopy when indicated. A combined total of 43 PNI patients were identified over a nine year period. Haemodynamically unstable patients and patients with other hard signs (i.e. active bleeding, expanding haematoma, air/saliva leak, massive subcutaneous emphysema) received immediate exploration (n = 9). Haemodynamically stable patients and those responding to resuscitation (transient responders) had a CTA scan (n = 31). Three asymptomatic patients were treated conservatively, and had an uncomplicated clinical course regarding the PNI. In 10 of 14 patients who received surgical exploration, a significant vascular or aerodigestive injury was found and repaired (71%). All patients treated conservatively after CTA scanning had an uncomplicated clinical course regarding the PNI (n = 17). Six patients with penetrating carotid artery injury underwent primary arterial reconstruction, of whom five survived. CONCLUSIONS: This clinical scenario evaluates institutional management in two trauma centres for PNI and associated carotid artery injury, and compares it to current guidelines. In comparison with guideline recommendations, CTA scanning and the so called "No zone" approach appears to have assumed a more prominent role in management of PNI.

Predictors for Pediatric Blunt Cerebrovascular Injury (BCVI): An International Multicenter Analysis.

INTRODUCTION: Practice guidelines for adult BCVI patients have been implemented recently, but data for this devastating injury pattern in children are still limited. An international multicenter analysis was performed to characterize BCVI in the pediatric population. METHODS: The TraumaRegister DGU®, a prospectively maintained database, was analyzed (01/2002-12/2015). Pediatric patients (0-17 years) with major injuries [Injury Severity Score (ISS) ≥ 9 points] were included. BCVI was divided into carotid artery injury and vertebral artery injury (VAI). Data of demographics, injury, imaging, therapy, and outcome characteristics were analyzed with SPSS (Version 25, IBM Inc., Armonk, NY). RESULTS: The study cohort included 8128 pediatric trauma patients. We identified 48 BCVIs in 42 children, resulting in an overall prevalence of 0.5%. Carotid injuries were diagnosed more frequently (n = 30; 0.4%) when compared to VAIs (n = 12; 0.1%). The coincidence of head (p = 0.028), facial (p ≤ 0.001), chest (p ≤ 0.001), and spinal injuries (p ≤ 0.001) was higher in BCVI patients. The risk for thromboembolic complications (8.3% vs. 1%, p = 0.026) and in-hospital mortality (38.1% vs. 7.7%, p ≤ 0.001) was excessive in children with BCVI. We identified various predictors for pediatric BCVI and quantified the cumulative impact of these risk factors. CONCLUSION: BCVI is more uncommon in pediatric than in adult trauma patients. Due to the considerable relevance of this injury for both children and adults, special attention should be paid to this entity and associated complications in the early treatment phase after severe pediatric trauma, especially in high-risk children.

Analysis of Risk Factors for Posterior C1 Screw-Related Complication: A Retrospective Study of 358 Posterior C1 Screws.

BACKGROUND: Although C1 screw fixation is becoming popular, only a few studies have discussed about the risk factors and the patterns of C1 screw complications. OBJECTIVE: To investigate the incidence of C1 screw complications and analyze the risk factors of the C1 screw complications. METHODS: A total of 358 C1 screws in 180 consecutive patients were analyzed for C1 screw complications. Screw malposition, occipital neuralgia, major complications, and total C1 screw complications were analyzed. RESULTS: The distribution of C1 screw entry point is as follows: inferior lateral mass, 317 screws (88.5 %); posterior arch (PA), 38 screws (10.7 %); and superior lateral mass, 3 screws (0.8 %). We sacrificed the C2 root for 127 screws (35.5 %). C1 instrumentation induced 3.1 % screw malposition, 6.4 % occipital neuralgia, 0.6 % vascular injury, and 3.4 % major complications. In multivariate analysis, deformity (odds ratio [OR]: 2.10, P = .003), traumatic pathology (OR: 4.97, P = .001), and PA entry point (OR: 3.38, P = .001) are independent factors of C1 screw malposition. C2 root resection can decrease the incidence of C1 screw malposition (OR: 0.38, P = .012), but it is a risk factor of occipital neuralgia (OR: 2.62, P = .034). Advanced surgical experience (OR: 0.09, P = .020) correlated with less major complication. CONCLUSION: The incidence of C1 screw complications might not be uncommon, and deformity or traumatic pathology and PA entry point could be the risk factors to total C1 screw complications. The PA screw induces more malposition, but less occipital neuralgia. C2 root resection can reduce screw malposition, but increases occipital neuralgia.