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World Neurosurgery Feb 2021Cerebrovascular injury (CVI) is a potentially devastating complication of gunshot wounds to the head (GSWH), with yet unclear incidence and prognostic implications. Few...
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.
Topics: Adult; Anterior Cerebral Artery; Arterial Occlusive Diseases; Basilar Artery; Carotid Artery Injuries; Carotid Artery, Internal; Cerebral Angiography; Cerebrovascular Trauma; Cohort Studies; Computed Tomography Angiography; Cranial Sinuses; Craniotomy; Female; Head Injuries, Penetrating; Hospital Mortality; Humans; Intensive Care Units; Intracranial Pressure; Length of Stay; Male; Middle Aged; Middle Cerebral Artery; Monitoring, Physiologic; Retrospective Studies; Sinus Thrombosis, Intracranial; Suicide, Attempted; Ventriculostomy; Vertebral Artery; Violence; Wounds, Gunshot; Young Adult
PubMed: 33227526
DOI: 10.1016/j.wneu.2020.11.078 -
European Journal of Trauma and... Dec 2019Traumatic subclavian vascular injury (TSVI) is rare but often fatal. The precise diagnosis of TSVI remains challenging mainly because of its occult nature, less typical...
PURPOSE
Traumatic subclavian vascular injury (TSVI) is rare but often fatal. The precise diagnosis of TSVI remains challenging mainly because of its occult nature, less typical presentations, and being overlooked in the presence of polytrauma. Compared to penetrating injuries, it is even more difficult to identify TSVI in patients who have blunt injuries and no visible bleeding. The risk factors associated with TSVI in patients with thoracic trauma are unclear. The aims of this study were to identify risk factors for TSVI in a cohort of patients with thoracic vascular injuries and to report outcomes after clinical treatment.
METHODS
From January 2009 to June 2017, 39586 patients were admitted to our hospital (a level I trauma center) due to trauma, and 136 patients with thoracic vascular injury were enrolled in this study. We retrospectively reviewed data from medical records including demographic characteristics, injury scoring systems (RTS, ISS, NISS, TRISS and AIS), management and outcomes. Patients were further divided into the TSVI group (patients with TSVI) and the non-TSVI group (patients with thoracic vascular injuries other than TSVI). Univariate and multivariate analyses were used to identify independent risk factors.
RESULTS
The enrolled 136 patients suffered mostly from blunt trauma (89.0%) and 22 of them had TSVI. When compared to the non-TSVI group, the TSVI group had lower Glasgow Coma Scale (GCS) scores (p = 0.002; especially GCS ≤ 12), less concurrent abdominal injury (p < 0.001), lower Injury Severity Scales (ISS) (p = 0.007) and New Injury Severity Scales (NISS) (p < 0.002) but had higher Abbreviated Injury Scales (AIS) of the head ≥ 3 (p = 0.009) and rates of clavicular or scapular fractures (p = 0.013). No difference was detected between the two groups with regard to age, gender, trauma mechanism, vital signs on arrival, or rate of facial and extremities injury. In multivariate regression analyses, GCS ≤ 12, AIS of the head ≥ 3 and the presence of clavicular or scapular fractures were independent risk factors for TSVI (p = 0.026, p = 0.043 and p = 0.005, respectively) after adjustment for confounding factors. Open and endovascular repair were two surgical procedures utilized for these TSVI patients with an overall mortality rate of 18.2%. No difference was found between these groups with regard to mortality rate and the length of ICU stay, but the patients in the TSVI group had a shorter length of hospital stay.
CONCLUSIONS
Our results suggest that GCS ≤ 12, AIS of the head ≥ 3 and the presence of clavicular or scapular fractures were independent risk factors for TSVI in patients with thoracic vascular injuries. For patients with thoracic trauma, TSVI should be considered for prompt management when patients exhibit concurrent injuries to the head, clavicle or scapula.
Topics: Adult; Endovascular Procedures; Female; Glasgow Coma Scale; Humans; Injury Severity Score; Male; Multiple Trauma; Prognosis; Retrospective Studies; Risk Factors; Subclavian Artery; Subclavian Vein; Tertiary Care Centers; Trauma Centers; Treatment Outcome; Vascular System Injuries; Wounds, Nonpenetrating
PubMed: 30627733
DOI: 10.1007/s00068-018-01070-5 -
Postgraduate Medical Journal May 1994
Topics: Adult; Angiography, Digital Subtraction; Aortography; Arteriovenous Fistula; Carotid Artery Diseases; Carotid Artery Injuries; Carotid Artery, External; Humans; Jugular Veins; Male; Neck Injuries; Wounds, Stab
PubMed: 8016010
DOI: 10.1136/pgmj.70.823.367 -
BMJ Case Reports Mar 2022Vascular injury is a common complication in firearm injuries; however, intravascular missile embolism is relatively rare. There are only 38 documented cases of...
Vascular injury is a common complication in firearm injuries; however, intravascular missile embolism is relatively rare. There are only 38 documented cases of intravascular missile embolisation to the heart. Bullet embolisms are difficult to diagnose even with multiple diagnostic modalities and even once identified, the most optimal choice of surgical management is debated. Our patient presented with a gunshot wound to the right posterior shoulder. Cardiac focused assessment with sonography for trauma, chest X-ray, CT and echocardiogram were performed, showing missile location adjacent to the right ventricle with inconclusive evidence of pericardial injury. Exploratory median sternotomy was performed, revealing intact pericardium and injury to the superior vena cava (SVC) with bullet embolisation to the right ventricle. The patient became temporarily asystolic secondary to haemorrhage from the SVC injury. Cardiac massage was performed, dislodging the missile into the inferior vena cava. A venotomy was performed to retrieve the bullet and vascular injuries were primarily repaired.
Topics: Embolism; Firearms; Foreign-Body Migration; Humans; Vena Cava, Superior; Wounds, Gunshot
PubMed: 35260401
DOI: 10.1136/bcr-2021-247252 -
Journal of Medical Case Reports May 2021Only a small portion of horse injuries are related to horse bites. In the majority of these occurrences, injuries are minor and self-treated. However, in some cases, the...
INTRODUCTION
Only a small portion of horse injuries are related to horse bites. In the majority of these occurrences, injuries are minor and self-treated. However, in some cases, the injury may be destructive and limb- and life-threatening. In these instances, the patient requires complex surgery and compound perioperative care.
CASE REPORT
We present the case of a 35-year-old Albanian male farm-worker in whom a horse bite caused an extensive lacero-contusive and avulsive wound to the arm. The wound resulted in injury to the brachial artery, brachial and basilic vein, and biceps and brachialis muscles. Nerve structures and underlying humerus remained intact. The initial management of the severe hemorrhagic shock caused by the bleeding at the site of injury included reconstruction of the brachial artery by interposing saphenous graft and that of the brachial vein by termino-terminal anastomosis. Basilic vein was ligated. The wound was extensively debrided, and after a drain was placed in the wound, biceps and brachialis muscles were reconstructed. The patient received several units of red blood cells and fresh frozen plasma before and after surgery, as well as antibiotic, antitetanic, and antirabies prophylaxes. He had several consecutive necrectomies in the following days. However, due to postoperative sepsis and hemorrhagic shock at time of admission, the patient developed acute renal failure, therefore requiring several hemodialysis sessions. After his general and local condition was stabilized, the patient also underwent several reconstructive surgeries.
CONCLUSION
Horse bites of large extent require a multidisciplinary approach. The composition of the team of physicians needed for treatment varies depending on the degree of the injury and eventual complications. In the case of our patient, emergency department physicians, vascular and plastic surgeons, intensive care specialists, nephrologists, and infective care specialists were involved. In different instances, the inclusion of other specialists may be necessary to save and functionalize the limbs of the patient, or save his/her life.
Topics: Animals; Arm; Bites and Stings; Brachial Artery; Female; Horses; Humans; Male; Muscles; Veins
PubMed: 34030734
DOI: 10.1186/s13256-021-02863-w -
Hand (New York, N.Y.) May 2017The purpose of this study is to describe a novel technique using an interposition vein graft for thumb replantation in these severe avulsion injuries.
BACKGROUND
The purpose of this study is to describe a novel technique using an interposition vein graft for thumb replantation in these severe avulsion injuries.
METHODS
From 2002 to 2012, 8 patients underwent interposition venous bridge grafting from the dorsal radial artery at the anatomic snuffbox to the ulnar digital artery of the thumb. All patients had a traumatic thumb amputation with a severe injury to the ulnar digital artery. The technique began with bony stabilization; the radial artery at the anatomic snuffbox is exposed, vein graft harvested, and microsurgical end-to-side (proximally) and end-to-end (distally) anastomoses are carried out.
RESULTS
The average time to the operating room was 7.4 hours and time to reperfusion was 9.5 hours. At 3.1 years of follow-up, all 8 thumbs remained viable, without any need for revision procedures. The only complication was a metacarpal shaft nonunion treated successfully with iliac crest bone grafting. At last follow-up, all patients reported no or mild pain, with an average metacarpophalangeal (MCP) range of motion of 46.5°, and intact but diminished 2-point discrimination. All patients were able to return to work full-time.
CONCLUSIONS
Due to the challenging nature of thumb avulsion injuries and the pronated position of the thumb, novel salvage alternatives are important. We describe a technique when no proximal vessels are available, using a vein to bridge the dorsal radial artery to the ulnar digital artery of the thumb. This novel arterial reconstruction has shown promise in thumb replantation associated with severe avulsion injuries.
Topics: Adult; Amputation, Traumatic; Anastomosis, Surgical; Humans; Male; Middle Aged; Radial Artery; Replantation; Thumb; Ulnar Artery; Vascular Surgical Procedures; Veins; Young Adult
PubMed: 28453337
DOI: 10.1177/1558944716661997 -
Ulusal Travma Ve Acil Cerrahi Dergisi =... Dec 2022The management of hepatic trauma has a historical progress from mandatory operation with selective non-operative treatment, to non-operative treatment with selective...
BACKGROUND
The management of hepatic trauma has a historical progress from mandatory operation with selective non-operative treatment, to non-operative treatment with selective operation. Liver resection (LR) seems to have a minimal role in the management of liver injury. However, surgical treatment becomes the only life-saving treatment in cases with severe liver trauma.
METHODS
It is a retrospective presentation of five cases with severe blunt liver injury whose were admitted at our center during the 8-year period.
RESULTS
The median age of patients was 30.8 (23-43). The most frequent mechanism of injury was pedestrian struck (60%). Two of five cases were transferred to our hospital from rural state hospitals after initial attempt to achieving hemostasis. The majority of liver injury was grade V (80%). The right lobe of the liver was injured in different extensions. Major vascular injury was associated to liver injury in four of five cases. The right hepatectomy (n=1), resectional debridement of segments 5, 6, and 7 (n=1), posterior sectorectomy (n=2), and segment 7 resection (n=1) were performed for hemostasis. Vascular injuries in the junction of inferior vena cava and right hepatic vein (n=1), the anterior surface of the right hepatic vein (n=1), the junction of segment 7 hepatic vein and right hepatic vein (n=1), the main portal vein (n=1), and the right renal vein (n=1) were repaired. Median operation time was 162 min (120-180 min). Operative mortality was 20%. Reoperation was needed in three of four survived cases. In-hospital complications were observed in two of four survived cases. Median stay in intensive care unit and hospital was 12.4 days (1-48 days) and 28.2 days (1-65 days), respectively.
CONCLUSION
When a severe liver injury is unresponsive to packing, the surgeon must always keep in mind that extensive maneuvers for vascular control and LR are required for bleeding control.
Topics: Humans; Hepatectomy; Retrospective Studies; Liver; Vena Cava, Inferior; Hepatic Veins; Wounds, Nonpenetrating
PubMed: 36588513
DOI: 10.14744/tjtes.2021.89678 -
International Journal of Legal Medicine Mar 2018In the first years of life, subdural haemorrhage (SDH) within the cranial cavity can occur through accidental and non-accidental mechanisms as well as from birth-related...
In the first years of life, subdural haemorrhage (SDH) within the cranial cavity can occur through accidental and non-accidental mechanisms as well as from birth-related injury. This type of bleeding is the most common finding in victims of abusive head trauma (AHT). Historically, the most frequent cause of SDHs in infancy is suggested to be traumatic damage to bridging veins traversing from the brain to the dural membrane. However, several alternative hypotheses have been suggested for the cause and origin of subdural bleeding. It has also been suggested by some that bridging veins are too large to rupture through the forces associated with AHT. To date, there have been no systematic anatomical studies on infant bridging veins. During 43 neonatal, infant and young child post-mortem examinations, we have mapped the locations and numbers of bridging veins onto a 3D model of the surface of a representative infant brain. We have also recorded the in situ diameter of 79 bridging veins from two neonatal, one infant and two young children at post-mortem examination. Large numbers of veins, both distant from and directly entering the dural venous sinuses, were discovered travelling between the brain and dural membrane, with the mean number of veins per brain being 54.1 and the largest number recorded as 94. The mean diameter of the bridging veins was 0.93 mm, with measurements ranging from 0.05 to 3.07 mm. These data demonstrate that some veins are extremely small and subjectively, and they appear to be delicate. Characterisation of infant bridging veins will contribute to the current understanding of potential vascular sources of subdural bleeding and could also be used to further develop computational models of infant head injury.
Topics: Brain; Brain Mapping; Child Abuse; Child, Preschool; Craniocerebral Trauma; Female; Forensic Pathology; Hematoma, Subdural; Humans; Imaging, Three-Dimensional; Infant; Infant, Newborn; Magnetic Resonance Imaging; Male; Veins
PubMed: 29075919
DOI: 10.1007/s00414-017-1714-3 -
Injury Sep 2016Alcohol, a common risk factor for injury, has direct toxic effects on the liver. The use of lactate clearance has been well described as an indicator of the adequacy of...
INTRODUCTION
Alcohol, a common risk factor for injury, has direct toxic effects on the liver. The use of lactate clearance has been well described as an indicator of the adequacy of resuscitation in injured patients. We investigated whether acutely injured patients with positive blood alcohol content (+BAC) had less lactate clearance than sober patients.
METHODS
We conducted a retrospective cohort study of acutely injured patients treated at an urban Level 1 trauma centre between January 2010 and December 2012. Blood alcohol and venous lactate levels were measured on all patients at the time of arrival. Study subjects were patients transported directly from the scene of injury, who had an elevated lactate concentration on arrival (≥3.0mmol/L) and at least one subsequent lactate measurement within 24h after admission. Lactate clearance ([Lactate1-Lactate2]/Lactate1) was calculated for all patients. Chi-squared tests were used to compare values from sober and intoxicated subjects. Lactate clearance was plotted against alcohol levels and stratified by age and Injury Severity Score (ISS).
RESULTS
Serial lactate concentration measurements were obtained in 3910 patients; 1674 of them had +BAC. Patients with +BAC were younger (mean age: 36.6 [SD 14.7] vs 41.0 [SD 19.9] years [p=0.0001]), were more often male (83.4% vs 75.9% [p=0.0001]), had more minor injuries (ISS<9) (33.8% vs 27.1% [p=0.0001]), had a lower in-hospital mortality rate (1.4% vs 3.9% [p=0.0001]), but also had lower average lactate clearance (37.8% vs 47.6% [p=0.0001]). The lactate clearance of the sober patients (47.6 [SD 33.5]) was twice that of those with +BAC >400 (23.5 [SD 6.5]). Lactate clearance decreased with increasing BAC irrespective of age and ISS.
CONCLUSIONS
In a large group of acutely injured patients, a dose-dependent decrease in lactate clearance was seen in those with elevated BAC. This relationship will cause a falsely elevated lactate reading or prolong lactate clearance and should be taken into account when evaluating patients with +BAC.
Topics: Adolescent; Adult; Aged; Alcohol Drinking; Biomarkers; Female; Hospital Mortality; Humans; Injury Severity Score; Lactates; Male; Maryland; Middle Aged; Multiple Trauma; Outcome Assessment, Health Care; Predictive Value of Tests; Resuscitation; Retrospective Studies; Survival Rate; Trauma Centers; Urban Population; Wounds and Injuries; Young Adult
PubMed: 27025567
DOI: 10.1016/j.injury.2016.03.007 -
Annals of the Royal College of Surgeons... Sep 2021Penetrating injuries to the subclavian artery carry a high mortality rate, especially when the patient presents in shock. Rapid and effective haemorrhage control is...
Penetrating injuries to the subclavian artery carry a high mortality rate, especially when the patient presents in shock. Rapid and effective haemorrhage control is challenging due to the anatomical location at the thoracic outlet. Historically, vessel ligation has been used to control bleeding, but this is often performed late, when metabolic exhaustion is established, and is associated with upper-limb ischaemia and limb loss. Rapid proximal control through the chest with temporary intravascular shunting is the damage control technique of choice to temporise blood loss and restore perfusion until the patient is physiologically optimised for a delayed definitive vascular repair. We describe a case of vascular damage control in a patient after gunshot wound.
Topics: Humans; Male; Saphenous Vein; Subclavian Artery; Subclavian Vein; Wounds, Gunshot; Young Adult
PubMed: 34464576
DOI: 10.1308/rcsann.2020.7100