Objective To prospectively examine outcomes associated with an aggressive screening protocol for blunt cerebrovascular injury (BCVI), and to compare the accuracy of computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) versus conventional angiography with respect to BCVI diagnosis. Summary Background Data In the past 5 years, BCVI (carotid and vertebral arteries) has been recognized with increasing frequency. Initial studies described blunt carotid injuries and their associated morbidity, while more recent reports have established the devastating potential of blunt vertebral injuries. It has been suggested that early diagnosis and anticoagulation will improve outcomes and that less-invasive diagnostic techniques than conventional angiography are desirable for screening. However, there are neither established screening criteria nor studies comparing optimal diagnostic modalities. Methods The screened population included all patients with cervical spine fractures, LeFort II or III facial fractures, Horner's syndrome, skull base fractures involving the foramen lacerum, neck soft tissue injury, or neurological abnormalities unexplained by intracranial injuries. Patients underwent screening with four-vessel cerebral angiography. During the first half of the study, patients also underwent helical CTA. Selected patients during this same period underwent MRA. At the time of diagnosis, anticoagulant or antiplatelet therapy was instituted unless clinically contraindicated. Results of this screening protocol were compared to a previously published cohort with cerebrovascular injuries (1995-1999) from the authors' institution. Results Two hundred sixteen patients were screened over a 2-year period (3.5% of all blunt trauma admissions). Angiography identified 24 patients with carotid artery injuries (CAI) and 43 patients with vertebral artery injuries (VAl) for an overall screening yield of 29%. While the incidence of CAI remained similar between the current study and the previous study group, the incidence of VAI diagnosis increased. Stroke rates in those with CAI were also similar between the two periods. The stroke rate in VAI, however, was markedly lower at 0% as compared to 14% in the previous group. Comparison of CTA and MRA with cerebral angiography in 143 patients demonstrated sensitivities of 47% and 50%, respectively, for CAI; sensitivities were 53% (CTA) and 47% (MRA) for VAI. Conclusions Aggressive screening of patients with blunt head and neck trauma identified an incidence of BCVI in 1.03% of blunt admissions. Early identification, which led to early treatment, significantly reduced stroke rates in patients with VAI, but provided no outcome improvement with CAI. More encompassing screening may be required to improve outcomes for patients with CAI. However, less-invasive diagnostic techniques (CTA and MRA) are inadequate for screening. Technological advances are necessary before abandonment of conventional angiography, which remains the standard for diagnosis.

Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes.

Objective
To assess the impact of routine follow-up arteriography on the management and outcome of patients with acute blunt cerebrovascular injuries (BCVI).

Treatment-Related Outcomes From Blunt Cerebrovascular Injuries: Importance of Routine Follow-Up Arteriography

Objective To determine the benefit of screening for blunt carotid arterial injuries (BCI) in patients who are asymptomatic Background Data Blunt carotid arterial injuries have the potential for devastating complications Published studies report 23% to 28% mortality rates, with 48% to 58% of survivors having permanent severe neurologic deficits Most patients have neurologic deficits when the injury is diagnosed The authors hypothesized that screening patients who are asymptomatic and instituting early therapy would improve neurologic outcome Methods The Trauma Registry of the author's Level I Trauma Center identified patients with BCI from 1990 through 1997 Beginning in August 1996, the authors implemented a screening for BCI Arteriography was used for diagnosis Patients without specific contraindications were anticoagulated Endovascular stents were deployed in the setting of pseudoaneurysms Results Thirty-seven patients with BCI were identified among 15,331 blunt-trauma victims (024%) Dunng the screening period, 25 patients were diagnosed with BCI among 2902 admissions (086%); 13 (52%) were asymptomatic Overall, eight patients g died, and seven of the survivors had permanent severe neuroy logic deficits Excluding those dying of massive brain injury and patients admitted with coma and brain injury, mortality associated with BCI was 15%, with severe neurologic morbidity in 16% of survivors The patients who were asymptomatic at diagnosis y had a better neurologic outcome than those who were symptomatic Symptomatic patients who were anticoagulated showed a trend toward greater neurologic improvement at the time of discharge than those who were not anticoagulated Conclusions Screening allows the identification of asymptomatic BCI and thereby facilitates early systemic anticoagulation, which is associated with improved neurologic outcome The role of endovascular stents in the treatment of blunt traumatic pseudoaneurysms remains to be defined

The Unrecognized Epidemic of Blunt Carotid Arterial Injuries: Early Diagnosis Improves Neurologic Outcome

This is a recommended management algorithm from the Western Trauma Association addressing the diagnostic evaluation and management of blunt cerebrovascular injuries (BCVI) in adult patients. Because there are no published prospective randomized clinical trials that have generated class I data, the recommendations herein are based on published observational studies and expert opinion of Western Trauma Association members. The algorithm (Fig. 1) and accompanying comments represent a safe and sensible approach that could be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this guideline to formulate their own local protocols. The algorithm contains letters at decision points; the corresponding paragraphs in the text elaborate on the thought process and cite the pertinent literature. The annotated algorithm is intended to (a) serve as a quick bedside reference for clinicians; (b) foster more detailed patient care protocols that will allow for prospective data collection and analysis to identify best practices; and (c) generate research projects to answer specific questions concerning decision making in the management of adults with BCVI.

Western Trauma Association critical decisions in trauma: screening for and treatment of blunt cerebrovascular injuries

Background:Screening for blunt cerebrovascular injuries (BCVIs) and early treatment has virtually eliminated injury-related strokes. Screening protocols developed in the 1990s captured ∼80% of ultimately identified BCVI. With the availability of noninvasive diagnosis with computed tomographic angiog

Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis.

Pulmonary compliance of cardiac arrest victims. a reassessment

Objective To determine lung compliance in patients who had out-of-hospital cardiac arrests. Methods A prospective, observational study of patients suffering nontraumatic cardiopulmonary arrest and requiring CPR at one university hospital ED. Following termination of resuscitation efforts, lung compliance was measured. Measurements were made while inflating the lung from 250 mL to 2,000 mL (in 250-mL increments) using a calibrated supersyringe. Airway flow and pressure were measured at the endotracheal tube with a pneumotachograph and a pressure transducer. Flow and pressure signals were recorded by a respiratory monitor and used to construct pressure-volume curves for calculation of lung compliance. Results The 25 cardiac arrest patients (17 men, eight women) had a mean (+/- SD) age of 65 +/- 7 years. Mean lung compliance was 0.051 +/- 0.011 L/cm H2O. Lung compliance was smaller at low lung volumes, suggesting the presence of alveolar collapse. Compliance values from 500 mL to 1,500 mL were similar. Compliance also diminished with increasing duration of CPR. Conclusions One previous publication suggested that lung compliance following resuscitation is 0.022 L/cm H2O. The results of this study, using the accepted standard measurements of static lung compliance, suggest that true compliance is twice this value. This finding has important ramifications for future research on ventilation during resuscitation and current ventilation standards.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1553-2712.1995.tb03100.x

Lung compliance following cardiac arrest.

Background: Blunt carotid artery trauma remains a rare but potentially devastating injury. Early detection and treatment remain the goals of management. Our objective was to identify patients sustaining blunt carotid injuries at a regional trauma center and report on the incidence, demographics, diagnostic workup, management, and outcome. Study Design: A retrospective chart review was performed of patients sustaining blunt carotid artery injury between 1990 and 1996. Results: Twenty patients were identified during the 7-year period. All patients suffered blunt trauma, with motor vehicle accidents being the most common mechanism, and the internal carotid the most frequently injured vessel. Associated injuries were present in all patients, with head (65%) or chest (65%) injuries being the most common. The combination of head and chest trauma (45%) was found to be associated with a 14-fold increase in the likelihood of carotid injury. Cerebral angiography was diagnostic in all patients and the majority were treated nonoperatively with anticoagulation. Twenty percent of patients were discharged with a normal neurologic exam, while 45% left with a significant neurologic deficit. Overall mortality was 5%. Conclusions: Blunt carotid injuries are rare but are associated with significant morbidity and mortality. The combination of craniofacial and chest wounds should raise the index of suspicion for blunt carotid injury. Anticoagulation was associated with the least morbidity.

https://www.journalacs.org/article/S1072-7515(01)00886-9/pdf

Blunt carotid artery injuries.

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Pulmonary compliance of cardiac arrest victims. a reassessment

Lung compliance following cardiac arrest.

Blunt carotid artery injuries.