Functional outcomes following blunt cerebrovascular injury.

BACKGROUND: There has been much debate on whom to screen, how to screen, and how to treat blunt cerebrovascular injury (BCVI), but there has been little published on long-term functional outcomes following diagnosis and treatment of BCVI. This study was conducted to address those long-term outcomes. METHODS: Patients with BCVI during a 53-month period ending June 2009 were identified. Charts were reviewed for demographics, associated injuries, treatments, strokes, and in-hospital mortality. Posthospital discharge follow-up was conducted. A structured telephone interview was performed using a functional independence measurement-functional activity measurement questionnaire consisting of 30 questions in seven categories (self-care, sphincter control, mobility, locomotion, communication, psychosocial, and cognitive). Each question was scored from 1 (requires full assistance) to 7 (fully independent). Outcomes were compared by type of BCVI, associated injuries, and stroke. RESULTS: Two hundred twenty-two patients with BCVI were identified. Twenty-four patients died during their initial hospitalization, and an additional 11 patient died after hospital discharge. The 68 patients who completed the interview constituted our study population. Mean follow-up was 35 months. Of a possible 210 points, the mean total score on functional independence measurement and functional activity measurement was 186, 185, and 188 for all patients, carotid artery injuries, and vertebral arteries injuries, respectively. A significant difference was seen when comparing patients with and without strokes (173 and 189, respectively). CONCLUSION: This is the first report of functional outcomes following BCVI. We found that carotid and vertebral artery injuries have similar functional outcomes. As would be expected, the development of stroke led to worse outcomes. This underscores the importance of early diagnosis and initiation of therapy. Prevention of stroke in patients with BCVI leads to near-normal functional outcomes. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Components separation for abdominal wall reconstruction: the Memphis modification.

Since the advent of damage control surgery, more patients are left with an open abdomen. Surgeons are then left with the challenge of how to restore continuity of the abdominal wall. Many different techniques have been utilized for reconstruction with widely variable recurrence rates, mainly depending on the length of follow-up. A modification of the components separation technique was developed in Memphis, Tennessee at the Presley Memorial Trauma Center. This modification greatly increased the length gained in the midline. Additionally, many patients can be reconstructed without the use of prosthetics, reducing the infectious complications. The purpose of this manuscript is to describe in detail how to perform a modification of the components separation technique that has been shown to have one of the lowest recurrence rates in the literature.

Improving the screening criteria for blunt cerebrovascular injury: the appropriate role for computed tomography angiography.

BACKGROUND: Screening criteria and diagnostic methods for blunt cerebrovascular injury (BCVI) are evolving. Using current screening guidelines, up to 20% of injuries are not recognized until symptoms occur, and thus missing the therapeutic window. All patients who meet screening criteria at our institution undergo angiography due to conflicting sensitivity data reported for computed tomographic angiography (CTA). We sought to refine screening criteria for BCVI to optimize patient care. METHODS: All trauma admissions screened for BCVI over a 29-month period ending May 2009 were analyzed. Thirty-two channel CTA was obtained during initial radiologic evaluation. Patients underwent angiography for conventional screening criteria or abnormal CTA. Demographics, criteria for BCVI screening, fracture patterns, associated injuries, and results of CTA and angiography were analyzed. RESULTS: A total of 748 patients were screened, 143 injuries (78 carotid and 65 vertebral) were diagnosed in 117 patients (16%). Nineteen of the 117 patients (16%) with BCVI had no conventional criteria and were only screened for CTA abnormalities. One patient developed neurologic symptoms subsequent to initial evaluation with no conventional screening criteria or CTA findings. CONCLUSIONS: The conventional screening criteria identify most patients with BCVI (84%). CTA as a screening criterion captures nearly all remaining patients before symptoms developing. This allows for detection and treatment of injuries in patients that otherwise would be missed until symptomatic. CTA should be part of the radiologic evaluation for potential head, neck, and facial injuries. Unfortunately, CTA is not sensitive enough to reliably detect injuries, but should be added as a screening criterion. Angiography remains the gold standard for BCVI diagnosis.

Optimal outcomes for patients with blunt cerebrovascular injury (BCVI): tailoring treatment to the lesion.

BACKGROUND: Blunt cerebrovascular injuries (BCVI) once went unrecognized until cerebral ischemia or death occurred. We previously demonstrated that screening of high-risk asymptomatic patients and early treatment improved outcomes. However, major dissections, pseudoaneurysms, and fistulas rarely heal with antithrombotic therapy alone. Endovascular therapy in these lesions has increased without reports of outcomes. We sought to determine ischemic stroke and death rates after BCVI with and without endovascular treatment. STUDY DESIGN: Patients with BCVI during a 53-month period ending May 2009 were identified. Antithrombotic therapy with heparin (goal partial thromboplastin time 40-60 s) or antiplatelets (aspirin and/or clopidogrel) was instituted after diagnosis of BCVI. Endovascular treatment was performed in patients with pseudoaneurysms, major dissections, and fistulas, whereas minor dissections and occluded vessels were treated with medical therapy alone. Outcomes evaluated were ischemic stroke and mortality, both in hospital and long term. RESULTS: A total of 222 patients had 263 BCVI (115 carotid, 148 vertebral injuries); 22 patients had ischemic strokes before their angiographic diagnosis (17 present on arrival, 5 before angiography); 41% of patients underwent endovascular treatment for their BCVI, 50% were placed on heparin drips, and 76% and 52% were given aspirin and clopidogrel, respectively. Seven patients developed infarcts after BCVI diagnosis for a postdiagnosis rate of 4%. Follow-up was achieved in 85% of patients at a mean of 22 months. In-hospital mortality was 11%, and overall mortality rate was 16% at last follow-up. CONCLUSIONS: Endovascular therapy of appropriate lesions in conjunction with medical therapy leads to the lowest ischemic stroke rates reported. Despite being used for more severe lesions with higher potential for ischemia, endovascular therapy had outcomes similar to medical therapy. Aggressive screening and treatment of BCVI leads to the lowest reported mortality and stroke rates.

Quality of life after abdominal wall reconstruction following open abdomen.

BACKGROUND: Management of intra-abdominal hypertension with an open abdomen and planned ventral hernia results in decreased mortality. But, delayed abdominal wall reconstruction (DAWR) is necessary. Results after DAWR demonstrate acceptable recurrence, morbidity, and mortality rates. However, little is known about quality of life (QOL) after DAWR. The purpose of this study was to analyze QOL after DAWR. METHODS: Patients who had DAWR>15 years were identified from operative logs of a trauma center. Patients were contacted, and a QOL assessment was administered in person or via telephone. The QOL assessment contained the Short-Form 36-Item Health Survey 1.0, the Posttraumatic Stress Disorder (PTSD) Checklist-Civilian Version, and the Centers for Epidemiologic Studies Depression Scale. RESULTS: The QOL assessment was completed by 41 of 152 patients. The indication for open abdomen was injury in 37 (90%) and emergency operation in 4 (10%). Time to follow-up ranged from 9 months to 14.6 years after DAWR. Of 31 patients working before DAWR, 23% had not returned to work secondary to DAWR. Also, 65% screened positive for depression and 23% screened positive for PTSD. Compared with population norms Physical Component Scores were significantly lower for the study population (41.1±13.2, p<0.05). CONCLUSION: Patients who undergo DAWR have decreased physical functioning and have a high prevalence of PTSD and depression. Consideration should be given to screening for depression and PTSD in this patient population.

Blunt cerebrovascular injury screening with 32-channel multidetector computed tomography: more slices still don't cut it.

OBJECTIVE: We sought to determine the diagnostic accuracy of computed tomographic angiography (CTA) using 32-channel multidetector computed tomography for blunt cerebrovascular injuries (BCVIs). BACKGROUND: Unrecognized BCVI is a cause of stroke in young trauma patients. Digital subtraction angiography (DSA), the reference standard, is invasive, expensive, and time-consuming. Computed tomographic angiography has been rapidly adopted by many institutions because of its availability, less resource intensive, and noninvasive nature. However, conflicting results comparing CTA and DSA have been reported. Studies with 16-channel CTA report a wide range of sensitivities for BCVI diagnosis. METHODS: From January 2007 through May 2009, patients with risk factors for BCVI underwent both CTA and DSA. All CTAs were performed using a 32-channel multidetector CT scanner. Using DSA as the reference standard, the diagnostic accuracy of CTA for determination of BCVI was calculated. RESULTS: There were 684 patients who met the inclusion criteria. Ninety patients (13%) had 109 injuries identified; 52 carotid and 57 vertebral injuries were diagnosed. CTA failed to detect 53 confirmed BCVI, yielding a sensitivity of 51%. CONCLUSION: Given the devastation of stroke, and high mortality from missed injuries, this study demonstrates that even with more advanced technology (32 vs 16 channel), CTA is inadequate for BCVI screening. Digital subtraction angiography remains the gold standard for the diagnosis of BCVI.

Long-term follow-up of abdominal wall reconstruction after planned ventral hernia: a 15-year experience.

BACKGROUND: Although damage control strategies and the open abdomen have improved survival, they present their own unique set of challenges in caring for the multiply injured trauma patient. We previously reported the technique of staged abdominal wall closure for the management of the open abdomen. The purpose of this study was to evaluate the efficacy of various techniques of abdominal wall reconstruction (final stage of management) on long-term outcomes after planned ventral hernia, and to better define risk factors for recurrence. STUDY DESIGN: Patients undergoing abdominal wall reconstruction over a 15-year period were identified and stratified by gender, age, severity of shock, injury severity, and method of repair: secondary fascial closure +/- prosthetic, standard components separation (SCS) +/- prosthetic and modified components separation (MCS) +/- prosthetic. Long-term outcomes (recurrence) were determined using hospital records, telephone interview, and physical examination. Multivariable logistic regression analysis was performed to determine independent predictors of recurrence. RESULTS: One hundred fifty-two patients were identified. Fourteen (9%) patients underwent secondary fascial closure +/- prosthetic, 47 (31%) underwent SCS +/- prosthetic, and 91 (60%) underwent MCS +/- prosthetic. Long-term follow-up (up to 14.6 years, mean 5.3 years) was obtained in 114 (75%) patients. Sixteen patients (14%) had a recurrence. Prosthetic use increased recurrence 4-fold. There were 2 known recurrences (5%) in patients with MCS without prosthetic. Logistic regression identified both female gender and body mass index as independent predictors of recurrence. CONCLUSIONS: The MCS technique is the procedure of choice for repair of giant abdominal wall defects. This approach can avoid the need for prosthetics. In fact, MCS without prosthetic resulted in an acceptably low hernia recurrence rate (5%).

Ventilator-associated pneumonia: an overview.

Despite aggressive efforts to reduce nosocomial infections, many intubated patients develop ventilator-associated pneumonia (VAP). VAP has been an area of intense research; however, there is still little consensus in the literature on how to accurately diagnose or treat VAP. VAP complicates the course of 8 - 28% of mechanically ventilated patients and mortality varies greatly from 8 to 76%, depending on the specific population being studied. Once pneumonia is suspected, bacteriologic confirmation should be obtained and empiric therapy must be instituted as soon as possible, as a delay in therapy or inappropriate therapy greatly increases mortality. Initial antibiotic therapy should be based on the most common organisms in each hospital or unit, and the most likely pathogens for that specific patient. Constant surveillance of the responsible pathogens through the use of antibiograms allows clinicians to make educated choices for antibiotics. When final cultures and sensitivities are available, de-escalation to less broad spectrum antibiotics should be performed. If cultures show no bacterial growth, antibiotics should be discontinued so that patients are not exposed to unnecessary antibiotics. Following these practices will help to decrease multi-resistant strains of bacteria and can improve the morbidity and mortality of VAP.

A transgene carrying an A2G missense mutation in the SMN gene modulates phenotypic severity in mice with severe (type I) spinal muscular atrophy.

5q spinal muscular atrophy (SMA) is a common autosomal recessive disorder in humans and the leading genetic cause of infantile death. Patients lack a functional survival of motor neurons (SMN1) gene, but carry one or more copies of the highly homologous SMN2 gene. A homozygous knockout of the single murine Smn gene is embryonic lethal. Here we report that in the absence of the SMN2 gene, a mutant SMN A2G transgene is unable to rescue the embryonic lethality. In its presence, the A2G transgene delays the onset of motor neuron loss, resulting in mice with mild SMA. We suggest that only in the presence of low levels of full-length SMN is the A2G transgene able to form partially functional higher order SMN complexes essential for its functions. Mild SMA mice exhibit motor neuron degeneration, muscle atrophy, and abnormal EMGs. Animals homozygous for the mutant transgene are less severely affected than heterozygotes. This demonstrates the importance of SMN levels in SMA even if the protein is expressed from a mutant allele. Our mild SMA mice will be useful in (a) determining the effect of missense mutations in vivo and in motor neurons and (b) testing potential therapies in SMA.