Blunt cerebrovascular injuries: Outcomes from the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) multicenter registry.

BACKGROUND: Administering antithrombotics (AT) to the multiply injured patient with blunt cerebrovascular injury (BCVI) requires a thoughtful assessment of the risk of stroke and death associated with nontreatment. Large, multicenter analysis of outcomes stratified by injury grade and vessel injured is needed to inform future recommendations. METHODS: Nine hundred and seventy-one BCVIs were identified from the PROspective Vascular Injury Treatment registry in this retrospective analysis. Using multivariate analysis, we identified predictors of BCVI-related stroke and death. We then stratified these risks by injury grade and vessel injured. We compared the risk of adverse outcomes in the nontreatment group with those treated with antiplatelet agents and/or anticoagulants. RESULTS: Stroke was identified in 7% of cases. Overall mortality was 12%. Both increased with increasing BCVI grade. Treatment with ATs was associated with lower mortality and was not significantly affected by the choice of agent. Withholding ATs was associated with an increased risk of stroke and/or death across all subgroups (Grade I/II: odds ratio [OR], 4.66; 95% confidence interval [CI], 2.48-8.75; Grade III: OR, 7.0; 95% CI, 2.01-24.5; Grade IV: OR, 4.43; 95% CI, 1.76-11.1) even after controlling for covariates. Predictors of death included more severe trauma, Grade IV injury, and the occurrence of stroke. Arterial occlusion, hypotension, and endovascular intervention were significant predictors of stroke. Patients that experienced a BCVI-related stroke were at a 4.2× increased risk of death. The data set lacked the granularity necessary to evaluate AT timing or dosing regimen, which limited further analysis of stroke prevention strategies. CONCLUSION: Stroke and death remain significant risks for all BCVI grades regardless of the vessel injured. Antithrombotics represent the only management strategy that is consistently associated with a lower incidence of stroke and death in all BCVI categories. In the multi-injured BCVI patient with a high risk of bleeding on anticoagulation, antiplatelet agents are an efficacious alternative. Given the 40% mortality rate in patients who survived their initial trauma and developed a BCVI-related stroke, nontreatment may no longer be a viable option. LEVEL OF EVIDENCE: Epidemiological III; Therapeutic IV.

Big problems in little patients: Nationwide blunt cerebrovascular injury outcomes in the pediatric population.

BACKGROUND: Blunt cerebrovascular injuries (BCVI) are uncommon but potentially devastating. The epidemiology, outcomes, and screening criteria are well described in adults, but data in pediatric patients are extremely limited. The purpose of this study was to characterize pediatric BCVI in a large nationwide sample. We hypothesized that outcomes of BCVI in the pediatric blunt trauma population will vary by age. METHODS: We conducted a retrospective cohort study of the Kids' Inpatient Database for pediatric BCVI from 2000 to 2012. Epidemiology, associated injuries, outcomes (including stroke and mortality), and the utility of standard screening criteria were analyzed. RESULTS: There were 1,182 cases of BCVI identified, yielding an incidence of 0.21%. Patients were predominately male (69%; mean age, 15 ± 5 years). Injuries were 59% carotid, 13% vertebral, and 28% unspecified, with 15% having bilateral or multivessel BCVI. Although younger patients (<11 years) had significantly lower ISS and decreased severe associated injuries (all p < 0.01), they had a similar mortality rate (10%) versus the older cohort. Additionally, the stroke rate was significantly higher among the younger patients versus their older peers (29% mortality for <11 years vs. 15% for ≥11 years, p < 0.01). Only four of seven commonly utilized risk factors were associated with BCVI overall, but none were significantly associated with BCVI in younger children (<11 years). CONCLUSION: This represents the first nationwide assessment of BCVI in the pediatric population. Pediatric BCVI carry considerable mortality and stroke risk. Despite being less severely injured, younger children (<11 years) had similar a mortality rate and a significantly higher stroke rate compared with older pediatric patients. Furthermore, commonly utilized adult screening criteria had limited utility in the younger cohorts. These findings suggest pediatric BCVI may require screening and treatment protocols that are significantly different than currently utilized adult-based programs. LEVEL OF EVIDENCE: Prognostic/Epidemiological Study, level III.

Long-Term Functional Outcomes after Blunt Cerebrovascular Injury: A 20-Year Experience.

Since blunt cerebrovascular injury (BCVI) became increasingly recognized more than 20 years ago, significant improvements have been made in both diagnosis and treatment. Little is known regarding long-term functional outcomes in BCVI. The purpose of this study was to evaluate the impact of BCVI on those long-term outcomes. All patients with BCVI from 1996 to 2014 were identified from the trauma registry. Functional outcome was measured using the Boston University Activity Measure for Post-Acute Care. Multiple regression analysis was performed to identify potential predictors of outcomes. A total of 509 patients were identified. Overall mortality was 18 per cent (BCVI-related = 1%). Of the 415 survivors, follow-up was obtained in 77 (19%). Mean follow-up was five years, with a maximum of 19 years. Mean age and injury severity score were 47 and 25, respectively. Six (8%) patients suffered strokes. Mean Activity Measure for Post-Acute Care scores were 59 (mobility), 58 (activity), and 44 (cognitive function), each indicating significant impairment compared with normal. Multiple regression models identified 1) age as a predictor of decreased mobility, 2) injury severity score as a predictor of decreased mobility, activity, and cognitive function, and 3) stroke as a predictor of decreased activity, cognitive function, and likely mobility. Development of stroke and increased injury severity resulted in worse long-term functional outcomes after BCVI. Thus, stroke prevention with optimal diagnostic and treatment algorithms remains critical in the successful treatment of BCVI because it has significant impact on long-term functional outcomes and is the only modifiable predictor of outcomes in patients after BCVI.

Impact of Continuous Evaluation of Technology and Therapy: 30 Years of Research Reduces Stroke and Mortality from Blunt Cerebrovascular Injury.

BACKGROUND: Blunt cerebrovascular injury (BCVI) was underdiagnosed until the 1990s when blunt carotid injuries were found to be more common than historically described. Technological advancements and regionalization of trauma care have resulted in increased screening and improved diagnosis of BCVI. The aim of this study was to demonstrate that systematic evaluation of the screening and diagnosis of BCVI, combined with early and aggressive treatment, have led to reductions in BCVI-related stroke and mortality. STUDY DESIGN: Patients with BCVI from 1985 to 2015 were identified and stratified by age, sex, and Injury Severity Score. BCVI-related stroke and mortality rates were then calculated and compared. Patients were divided into 5 eras based on changes in technology, screening, or treatment algorithms at our institution. RESULTS: Five hundred and sixty-four patients were diagnosed with BCVI: 508 carotid artery and 267 vertebral artery injuries. Sixty-five percent of patients were male, mean age was 41 years, and mean Injury Severity Score was 27. Incidence of BCVI diagnosis increased from 0.33% to approximately 2% of all blunt trauma (p < 0.001) during the study period. Ninety (14%) patients suffered BCVI-related stroke, with the incidence of stroke significantly decreasing over time from 37% to 5% (p < 0.001). Twenty-eight (5%) patients died as a direct result of BCVI, and BCVI-related mortality also decreased significantly over time from 24% to 0% (p < 0.001). CONCLUSIONS: Although increased screening has resulted in a higher incidence of injuries over time, BCVI-related stroke and mortality have decreased significantly. Continuous critical evaluation of evolving technology and diagnostic and treatment algorithms has contributed substantially to those improved outcomes. Appraisals of technological advances, preferably through prospective multi-institutional studies, should advance our understanding of these injuries and lead to even lower stroke rates.

Blunt cerebrovascular injury following craniomaxillofacial fractures: A systematic review.

OBJECTIVES: Blunt cerebrovascular injury (BCVI) is a known sequela of high-energy craniomaxillofacial (CMF) trauma and can result in stroke or death. The objective of this systematic review is to 1) identify CMF trauma patients who may benefit from BCVI screening and 2) describe the optimal diagnostic and treatment modalities. STUDY DESIGN: Systematic review of the literature (1946-2013). METHODS: An a priori study protocol was created using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. The authors conducted a search of Ovid/Medline, PubMed, and Cochrane databases for articles related to BCVI and CMF fractures. All abstracts were reviewed, and data was extracted to determine the incidence of BCVI in the setting of CMF trauma. Individual fracture patterns were analyzed using descriptive statistics. RESULTS: Twenty-one studies met inclusion criteria. The overall incidence of CMF fracture-associated BCVI was 0.45%. The majority of patients (86.6%) sustained BCVI in the setting of high-energy trauma. The distribution of CMF fractures among BCVI patients was the mandible (12.5%), followed by the maxilla (11.8%). Computed tomographic angiography (CTA) was the most common diagnostic modality. A total of 63.1% of patients with BCVI were managed medically. The mortality among CMF patients with BCVI was 23.9%, and stroke rate was 47.1%. CONCLUSION: Blunt cerebrovascular injury is a rare but devastating complication of blunt trauma. The recommended screening modality is CTA, and the most common treatment is antiplatelet/anticoagulant medication. Mandibular and LeFort fractures were the most common isolated CMF injury associated with BCVI, highlighting the need for prospective trials to expand current screening criteria. LEVEL OF EVIDENCE: N/A. Laryngoscope, 127:79-86, 2017.

The Natural History of Indeterminate Blunt Cerebrovascular Injury.

IMPORTANCE: The Denver criteria grade blunt cerebrovascular injuries (BCVIs) but fail to capture many patients with indeterminate findings on initial imaging. OBJECTIVE: To evaluate outcomes and clinical significance of indeterminate BCVIs (iBCVIs). DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of all patients treated for BCVIs at our institution from January 1, 2007, through July 31, 2014, was completed. Patients were divided into 2 groups: those with true BCVIs as defined by the Denver criteria and those with iBCVIs, which was any initial imaging suggestive of a cerebrovascular arterial injury not classifiable by the Denver criteria. MAIN OUTCOMES AND MEASURES: Primary outcomes were rate of resolution of iBCVIs, freedom from cerebrovascular accident (CVA) or transient ischemic attack (TIA), and 30-day mortality. RESULTS: We identified 100 patients with 138 BCVIs: 79 with true BCVIs and 59 with iBCVIs. With serial imaging, 23 iBCVIs (39.0%) resolved and 21 (35.6%) remained indeterminate, whereas 15 (25.4%) progressed to true BCVI. The rate of CVA or TIA in the iBCVI group was 5.1% compared with 15.2% in the true BCVI group (P = .06). Of the 15 total CVAs or TIAs, 11 (73.3%) resulted from carotid injury and 4 (26.7%) from vertebral artery occlusion (P = .03). By Kaplan-Meier analysis, there was no difference in freedom from CVA or TIA for the 2 groups (P = .07). Median clinical follow-up was 91 days. Overall and 30-day mortality for the entire series were 17.4% and 15.2%, respectively. There was no difference in long-term or 30-day mortality between true BCVI and iBCVI groups. CONCLUSIONS AND RELEVANCE: Detection of iBCVI has become a common clinical conundrum with improved and routine imaging. Indeterminate BCVI is not completely benign, with 25.4% demonstrating anatomical progression to true BCVI and 5.1% developing cerebrovascular symptoms. We therefore recommend serial imaging and antiplatelet therapy for iBCVI.

Lethal now or lethal later: The natural history of Grade 4 blunt cerebrovascular injury.

BACKGROUND: Grade 4 blunt cerebrovascular injury (BCVI4) has a known, significant rate of stroke. However, little is known about the natural history of BCVI4 and the pathophysiology of subsequent stroke formation. METHODS: A 4-year review of patients with BCVI4 at the R Adams Cowley Shock Trauma Center was performed. Rates of BCVI4-related stroke, stroke-related mortality, and overall mortality were calculated. The relationship of change in vessel characteristics and BCVI4-related stroke was examined, as was the mechanism of stroke formation. RESULTS: There were 82 BCVI4s identified, with 13 carotid artery (ICA) and 69 vertebral artery BCVI4s. BCVI4-related stroke rate was 2.9% in vertebral artery BCVI4 and 70% in ICA BCVI4 patients surviving to reimaging. Stroke mechanisms included embolic strokes, thrombotic strokes, and combined embolic and thrombotic strokes. Peristroke vessel recanalization and an embolic stroke mechanism were seen in 100% of ICA BCVI4-related strokes developing after admission. BCVI4-related stroke occurred within 10 hours of hospital admission in 67% of the patients with strokes. Contraindications to anticoagulation were present in most patients with BCVI4-related stroke developing after admission. CONCLUSION: Multiple etiologies of stroke formation exist in BCVI4. Early risk-benefit analysis for initiation of anticoagulation or antiplatelet agents should be performed in all patients with BCVI4, and the use of endovascular vessel occlusion should be considered in those with true contraindications to anticoagulation. However, more aggressive medical therapy may be needed to lessen BCVI4-related stroke development. LEVEL OF EVIDENCE: Prognostic study, level IV; therapeutic study, level V.

Proyecto de intervención para prevenir enfermedades cerebrovasculares en adultos mayores vinculados a una casa de abuelos / Project Intervention to Prevent Stroke in Older Adults Attending to a Senior Care Home

Introducción: en el municipio de Sagua la Grande se produjo durante el último quinquenio un incremento de la morbilidad y mortalidad en adultos mayores por enfermedades cerebrovasculares, problema de salud que preocupa por el grado de incapacidad funcional permanente que provoca cuando se logra que el paciente sobreviva. Objetivos: caracterizar y determinar los factores de riesgos de las enfermedades cerebrovasculares en los adultos mayores; identificar el nivel de conocimientos en relación con las enfermedades cerebrovasculares y su prevención; y elaborar alternativas de solución que permitan minimizar o atenuar el problema de salud que dio origen a esta investigación. Métodos: se realizó una investigación cuanticualitativa de tipo descriptivo transversal, en adultos mayores vinculados a la casa de abuelos del Consejo Popular “Villa Alegre” perteneciente al Policlínico “Idalberto Revuelta”, municipio de Sagua la Grande, provincia Villa Clara, en el periodo comprendido entre los meses de enero de 2012 a junio de 2013. El universo estuvo constituido por 30 adultos mayores y la muestra quedó integrada por 25, seleccionados por el método de muestreo no probabilístico intencional por criterios. Resultados: los adultos mayores con factores de riesgo de enfermedades cerebrovasculares se caracterizaron por el predomino del sexo femenino, raza blanca y edad mayor de 75 años. Se identificó que la mayoría tienen hábitos tóxicos y presentan al menos, uno o dos factores de riesgo, entre los más frecuentes: la hipertensión arterial, la cardiopatía isquémica y la diabetes mellitus. La mayoría no poseen adecuados conocimientos sobre las enfermedades cerebrovasculares.Conclusiones: debido a que los adultos mayores con factores de riesgo de enfermedades cerebrovasculares vinculados a la casa de abuelos presentaron en su mayoría, uno o dos factores de riesgos y poseen inadecuados conocimientos sobre las enfermedades...(AU)

Introduction: in the municipality of Sagua the Big one took place during the last five year period an increment of the morbilidad and the mortality in bigger adults for illnesses cerebrovasculares, problem of health that worries for the grade of functional permanent inability that provokes when it is achieved the patient to survive.Objetive: he/she was carried out an investigation cuanticualitativa of descriptive traverse type, in bigger adults linked to the house of grandparents, of the Popular Council Cheerful" "Villa belonging to Policlínico Revolved" "Idalberto, of the municipality of Sagua the Big one, county Villa Clara, in the period understood among the months of January from 2012 to June of 2013. The universe was constituted by bigger 30 adults and the sample was integrated by 25, selected by the non probabilistic intentional sampling method by approaches. Results: that the biggest adults with factors of risk of illnesses cerebrovasculares were characterized for the I prevail of the feminine sex, the white race and the age bigger than 75 years. It was identified that most has toxic habits and they present one or two factors of risk at least, among the most frequent the arterial Hypertension; ischemic Cardiopatía and the Diabetes Mellitus. Most possesses inadequate knowledge on the illnesses cerebrovasculares. Conclusions: because older adults with risk factors for cerebrovascular diseases linked to the grandparents' house had mostly one or two risk factors and have inadequate knowledge about cerebrovascular diseases, specialists consider relevant and feasible project for prevention of these(AU)

Tromboembolismo venoso asociadoa cirugía ortognática: revisión de laliteratura y reporte de caso clínico / Venous tromboembolism after orthognathic surgery: literature review and case report

Antecedentes: El tromboembolismo venoso (TEV) es una complicación clínico-patológicacomún en pacientes quirúrgicos, que es potencialmente mortal. La trombosis venosa profunda(TVP) y el tromboembolismo pulmonar (TEP) están relacionados entre sí; aproximadamenteel 50 % de los pacientes con TVP desarrolla TEP la cual, en la mayoría de los casos,es asintomática. Es la tercera causa de morbilidad cardiovascular y es precedida por lacardiopatía isquémica y la enfermedad cerebrovascular. La incidencia del TEP en cirugía oraly maxilofacial ha sido poco reportada. Objetivos: Se presenta una revisión de la literaturasobre los procedimientos de cirugía maxilofacial y el riesgo para desarrollar TEP y se reportael caso de una seria complicación posterior a cirugía ortognática bimaxilar. Resultados:Más del 90 % de los casos de TEP se origina en el sistema venoso profundo de las piernas.En cirugía ortognática el riesgo es excepcionalmente bajo; se estima una tasa del 0,15 % al1,6 % en relación con cirugía abdominal y pélvica, donde se reporta con mayor frecuencia...

Background: Venous thromboembolism (VTE) is a common clinical pathological complicationthat is life threatening in patients undergoing surgery. Deep vein thrombosis (DVT) andpulmonary embolism (PE) are interrelated; about 50 % patients with DVT develop PE that isasymptomatic in most cases. It is the third leading cause of cardiovascular morbidity andis preceded by ischemic heart disease and cerebrovascular disease. The incidence of PEin oral and maxillofacial surgery has been barely reported. Objective: This article presentsa literature review on maxillofacial surgery and the risk to develop and reports a case of aserious complication after bimaxilar surgery. Results: Over 90 % PE cases originate in thedeep venous system of the legs. The risk is exceptionally low in orthognathic surgery; it isestimated that ranges from 0.15 % to 1.6 % when compared to abdominal and pelvic surgery,which are more frequently reported...

Long-term clinical and angiographic outcomes in patients with cervico-cranial dissections treated with stent placement: a meta-analysis of case series.

Limited clinical and angiographic data exists for patients with spontaneous or traumatic cervico-cranial dissections treated with stent placement. We reviewed clinical and angiographic data on consecutive patients admitted to our hospital with spontaneous, traumatic, and iatrogenic cervico-cranial dissections treated with stent placement to study immediate and long-term clinical and angiographic outcomes. Additional patients were identified using pertinent studies published between 1980 and 2009, using a search of the PubMed, Cochrane, and Ovid libraries. Post-procedure complications and clinical outcomes were documented. Angiographic abnormalities collected at follow-up included presence of in-stent restenosis or pseudoaneurysm. After applying our strict search criteria, four studies including our series were used in the meta-analysis, representing 46 patients (mean age [standard deviation] 47 ± 14 years; 24 [52%] male) treated with stent placement for dissection. Overall, 72 stents were placed to treat 28 spontaneous, 11 traumatic, and 7 iatrogenic dissection patients with 51 dissections, involving 51 vessels; with a mean pre-stent stenosis of 71 ± 26% and mean post-stent stenosis of 6 ± 15%. The immediate and follow-up post-procedure complication rates per stent placed was 8 (11%) and 8 (11%), respectively. Among the 36 patients who underwent follow-up angiography, in-stent restenosis or pseudoaneurysms were present in 3 (8%) and 2 (6%) patients, respectively. A high rate of sustained resolution of angiographic abnormalities during long-term follow-up was noted, with a low rate of new transient ischemic attack, ischemic stroke, or death, supporting the feasibility, safety, and effectiveness of endovascular stent reconstruction.

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.

Association of MRI markers of vascular brain injury with incident stroke, mild cognitive impairment, dementia, and mortality: the Framingham Offspring Study.

BACKGROUND AND PURPOSE: White matter hyperintensities and MRI-defined brain infarcts (BIs) have individually been related to stroke, dementia, and mortality in population-based studies, mainly in older people. Their significance in middle-aged community-dwelling persons and the relative importance of these associations remain unclear. We simultaneously assessed the relation of white matter hyperintensities and BI with incident stroke, mild cognitive impairment, dementia, and mortality in a middle-aged community-based cohort. METHODS: A total of 2229 Framingham Offspring Study participants aged 62+/-9 years underwent volumetric brain MRI and neuropsychological testing (1999 to 2005). Incident stroke, dementia, and mortality were prospectively ascertained and for 1694 participants in whom a second neuropsychological assessment was performed (2005 to 2007), incident mild cognitive impairment was evaluated. All outcomes were related to white matter hyperintensities volume (WMHV), age-specific extensive WMHV and BI adjusting for age and gender. RESULTS: Extensive WMHV and BI were associated with an increased risk of stroke (hazard ratio [HR]=2.28, 95% CI: 1.02 to 5.13; HR=2.84, 95% CI: 1.32 to 6.10). WMHV, extensive WMHV, and BI were associated with an increased risk of dementia (HR=2.22, 95% CI: 1.32 to 3.72; HR=3.97, 95% CI: 1.10 to 14.30; HR=6.12, 95% CI: 1.82 to 20.54) independently of vascular risk factors and interim stroke. WMHV and extensive WMHV were associated with incident amnestic mild cognitive impairment in participants aged > or = 60 years only (OR=2.47, 95% CI: 1.31 to 4.66 and OR=1.49, 95% CI: 1.14 to 1.97). WMHV and extensive WMHV were associated with an increased risk of death (HR=1.38, 95% CI: 1.13 to 1.69; HR=2.27, 95% CI: 1.41 to 3.65) independent of vascular risk factors and of interim stroke and dementia. CONCLUSIONS: In a large community-based sample of middle-aged adults, BI predicted an increased risk of stroke and dementia independent of vascular risk factors. White matter hyperintensities portended an increased risk of stroke, amnestic mild cognitive impairment, dementia, and death independent of vascular risk factors and interim vascular events.

Influence of early antioxidant supplements on clinical evolution and organ function in critically ill cardiac surgery, major trauma, and subarachnoid hemorrhage patients.

INTRODUCTION: Oxidative stress is involved in the development of secondary tissue damage and organ failure. Micronutrients contributing to the antioxidant (AOX) defense exhibit low plasma levels during critical illness. The aim of this study was to investigate the impact of early AOX micronutrients on clinical outcome in intensive care unit (ICU) patients with conditions characterized by oxidative stress. METHODS: We conducted a prospective, randomized, double-blind, placebo-controlled, single-center trial in patients admitted to a university hospital ICU with organ failure after complicated cardiac surgery, major trauma, or subarachnoid hemorrhage. Stratification by diagnosis was performed before randomization. The intervention was intravenous supplements for 5 days (selenium 270 microg, zinc 30 mg, vitamin C 1.1 g, and vitamin B1 100 mg) with a double-loading dose on days 1 and 2 or placebo. RESULTS: Two hundred patients were included (102 AOX and 98 placebo). While age and gender did not differ, brain injury was more severe in the AOX trauma group (P = 0.019). Organ function endpoints did not differ: incidence of acute kidney failure and sequential organ failure assessment score decrease were similar (-3.2 +/- 3.2 versus -4.2 +/- 2.3 over the course of 5 days). Plasma concentrations of selenium, zinc, and glutathione peroxidase, low on admission, increased significantly to within normal values in the AOX group. C-reactive protein decreased faster in the AOX group (P = 0.039). Infectious complications did not differ. Length of hospital stay did not differ (16.5 versus 20 days), being shorter only in surviving AOX trauma patients (-10 days; P = 0.045). CONCLUSION: The AOX intervention did not reduce early organ dysfunction but significantly reduced the inflammatory response in cardiac surgery and trauma patients, which may prove beneficial in conditions with an intense inflammation. TRIALS REGISTRATION: Clinical Trials.gov RCT Register: NCT00515736.

Estudio microanatómico de la Arteria Calloso Marginal en cerebros humanos / Micro-anatomical study of the Callosomarginal Artery in human brains

En la actualidad existe una elevada incidencia de enfermedades cerebrovasculares en las edades medias y avanzadas de la vida, con una significativa tendencia al desplazamiento de la mortalidad hacia edades más tempranas de la vida. El Sistema de la Arteria Calloso Marginal constituye un complejo multivariable por origen, trayecto, ramificaciones y territorios de irrigación; lo que implica grandes dificultades para el cirujano, puesto que obstaculiza el diagnóstico y proceder quirúrgico frente a innumerables entidades neurovasculares. Para describirlo desde el punto de vista microanatómico se realizó un estudio descriptivo en cincuenta cerebros humanos, disecándose cada hemisferio cerebral con su sistema arterial correspondiente, donde se obtuvo que la arteria Calloso Marginal es un vaso variable por origen y trayecto. Se identificaron ramas constantes e inconstantes, generalmente únicas o dobles, con origen en diferentes segmentos y con una gran prevalencia de troncos comunes para dos o más arterias. El calibre externo de la Calloso Marginal fue mayor en el tronco principal, mientras que las ramas secundarias tuvieron un menor diámetro. Se constató además una arteria Calloso Marginal accesoria.

An elevated incidence of cerebrovascular diseases in middle and advanced ages of life occurs nowadays, with a significant tendency to decrease the death rate in early ages of life. The system of the Callosomarginal Artery constitutes a multivariable complex because of its origin, trajectory, ramifications and territories of irrigation; involving great difficulties to surgeon because it hinders the surgical diagnosis and procedures opposite innumerable neurovascular entities. A descriptive study was done to fifty human brains to describe it from the micro anatomic viewpoint, stuffing each cerebral hemisphere with it correspondent arterial system. It was then checked that the Callosomarginal artery is a variable vessel because of its origin and trajectory. Constant and inconstant branches were identified, being generally unique and double, with origin in different segments and with a great prevalence of common trunks for two or more arteries. The external size of the Callosomarginal artery was larger in the main trunk, while the secondary branches had a smaller diameter. A Callosomarginal accessorial artery was also noted.

Estudio microanatómico de la Arteria Calloso Marginal en cerebros humanos / Micro-anatomical study of the Callosomarginal Artery in human brains

En la actualidad existe una elevada incidencia de enfermedades cerebrovasculares en las edades medias y avanzadas de la vida, con una significativa tendencia al desplazamiento de la mortalidad hacia edades más tempranas de la vida. El Sistema de la Arteria Calloso Marginal constituye un complejo multivariable por origen, trayecto, ramificaciones y territorios de irrigación; lo que implica grandes dificultades para el cirujano, puesto que obstaculiza el diagnóstico y proceder quirúrgico frente a innumerables entidades neurovasculares. Para describirlo desde el punto de vista microanatómico se realizó un estudio descriptivo en cincuenta cerebros humanos, disecándose cada hemisferio cerebral con su sistema arterial correspondiente, donde se obtuvo que la arteria Calloso Marginal es un vaso variable por origen y trayecto. Se identificaron ramas constantes e inconstantes, generalmente únicas o dobles, con origen en diferentes segmentos y con una gran prevalencia de troncos comunes para dos o más arterias. El calibre externo de la Calloso Marginal fue mayor en el tronco principal, mientras que las ramas secundarias tuvieron un menor diámetro. Se constató además una arteria Calloso Marginal accesoria (AU)

An elevated incidence of cerebrovascular diseases in middle and advanced ages of life occurs nowadays, with a significant tendency to decrease the death rate in early ages of life. The system of the Callosomarginal Artery constitutes a multivariable complex because of its origin, trajectory, ramifications and territories of irrigation; involving great difficulties to surgeon because it hinders the surgical diagnosis and procedures opposite innumerable neurovascular entities. A descriptive study was done to fifty human brains to describe it from the micro anatomic viewpoint, stuffing each cerebral hemisphere with it correspondent arterial system. It was then checked that the Callosomarginal artery is a variable vessel because of its origin and trajectory. Constant and inconstant branches were identified, being generally unique and double, with origin in different segments and with a great prevalence of common trunks for two or more arteries. The external size of the Callosomarginal artery was larger in the main trunk, while the secondary branches had a smaller diameter. A Callosomarginal accessorial artery was also noted (AU)

Trauma vascular mortal / Deaths by human vascular trauma

El trauma vascular es causa de alta mortalidad dentro de la variedad de traumas que sufre la población. Esta en relación directa al calibre y sitio del vaso afectado, así como al tiempo transcurrido entre el trauma y la acción médica. El análisis de los datos recopilados en 291 fallecidos por trauma vascular mortal fue el objetivo de este estudio realizado en un periodo de 10 años. La mayor incidencia se presento en el grupo de 25 a 34 años, así como en el sexo masculino. Los fines de semana acumularon los mayores por cientos de ocurrencia y en especial en los horarios nocturnos de 6 pm a 6 am, con el 66,6% de los casos. Los producidos por armas blancas ocuparon el 64,7% de su etiología, seguido por los accidentes del transito y las armas de fuego con el 22,6% y el 8,9%, respectivamente. El mayor numero de casos, 227, fallecieron en el lugar del hecho, 51 en el hospital y 13 en el trayecto hacia la unidad asistencial. Los homicidios ocurrieron en el 58,1% y los intentos suicidas en el 5,8%. Las heridas a nivel de los vasos toráxicos con el 41,9% provocaron el mayor numero de muertes, siguiéndoles en orden decreciente los abdominales con el 24,7%, cráneo y extremidades en el 15,1% para ambos y en menor proporción los cráneo faciales con solo el 3,2%. Los datos ofrecidos muestran la importancia que tiene el trauma vascular como causa de mortalidad en la población, así como la peligrosidad de los fines de semana y el horario nocturno. Las medidas de vigilancia y protección a la población deben ser extremadas para evitar la producción de los hechos causantes de trauma vascular mortal

Vascular trauma is cause of high mortality inside variety of traumas that the population suffers. This is indirect relationship to the caliber and place of the affected vessels, as well as the time lapsed between the trauma and medical action. The analysis of the data gathered in 291 deaths by human vascular trauma was the objective of this study carried out in a 10 - year's period. The highest percentage was present during the weekends especially during the evening from 6 pm to 6 am with 66.6% of the cases. Those Anales de Cirugía Cardíaca y Vascular 2005;11(2):64-68 Correspondencia: Yasmín Rodríguez Ríos Villuendas, 208 Sta Clara. Villa Clara 50100 Cuba Trauma vascular mortal Original produced by knife cut, represented 64.7%, followed by traffic accident and firearms recorded 22.6% and 8.9% respectively. The greatest number of cases, 227, died in situ, 51 died in the hospital and 13 died on the way to health unit. Homicides represented 58.1% and the suicidal attempts 5.8%. The wounds of the thoracic vessels whit 41.9% greatest number of the deaths, followed by lesser abdominal wounds with 24.7%, skull and extremities in 15.1% and the facial skull wounds in 3.2%. The data offered show the incidence of vascular trauma as the cause of mortality in the population, as well as the danger of the weekends and evening schedule. Surveillance and safety measures protection to the population should be reforced to avoid the production of human vascular trauma

Helical computed tomographic angiography: an excellent screening test for blunt cerebrovascular injury.

BACKGROUND: Blunt cerebrovascular injury (BCVI) carries a high morbidity and mortality, especially when diagnosis is delayed. Recent studies have shown that increased recognition of these injuries is achieved with prompt screening, allowing for early treatment and better outcome. Controversy still exists, however, on the best screening test. This study was used to evaluate the role of helical computed tomographic angiography (CTA) of the carotid and vertebral arteries in the early screening of BCVI. METHODS: All patients deemed at risk for BCVI underwent CTA within 24 hours of admission. Patients with a negative CTA test underwent no further radiologic evaluation of the cerebral vasculature. Those patients with positive or equivocal CTA results underwent four-vessel cerebral arteriography as a confirmatory test. Data were collected on the radiologic interpretation of all studies and patient clinical course. RESULTS: Four hundred eighty-six patients fulfilled the criteria for screening and underwent CTA. Nineteen patients were diagnosed with 25 BCVIs during the period of study. There were 7 carotid injuries and 18 vertebral injuries. Eighteen of 19 patients with BCVI were screened with CTA. Seventeen patients were asymptomatic at the time of screening. Results of CTA for BCVI were as follows: sensitivity, 100%; specificity, 94.0%; prevalence (screened patients), 3.7%; positive predictive value, 37.5%; and negative predictive value, 100%. Except for one patient in whom the CTA was clearly misinterpreted by the radiologist, no patient with a negative CTA examination was subsequently found to have a missed injury. CONCLUSION: CTA is an excellent test with which to screen for BCVI.

Extent and distribution of vascular brain injury in pediatric road fatalities.

This study used a multidisciplinary approach to examine the brains of pediatric road trauma fatalities in the Sydney area over a 3-year period. The brains of 32 children (0-16 years) were examined: 20 pedestrians, nine passengers, and three cyclists. The extent and distribution of brain injury was assessed, peak linear head acceleration determined, and the severity of brain damage was compared to that previously reported for adults using the same scoring method. Skull fractures (20/32) and subarachnoid haemorrhage (22/32) were the commonest head injuries. In general, the neuropathology was similar to that seen in adults, with a high percentage of damage in the corpus callosum and gliding contusions within the subcortical white matter. Intracerebral hemorrhage was relatively rare. For frontal and occipital head impacts, the corpus callosum was the most injured part of the brain, followed by the deep central structures and the temporal lobes, whereas for lateral impacts, the injuries were more evenly distributed. Comparison of the current data for children with the vascular injury sector scores reported for adults suggests that the brains of children are more severely damaged for the same peak linear head acceleration.