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ARTICLES: R. Marino, R. Gasparotti, L. Pinelli, D. Manzoni, P. Gritti, D. Mardighian, and N. Latronico Posttraumatic cerebral infarction in patients with moderate or severe head trauma Neurology 2006; 67: 1165-1171 [Abstract] [Full text] [PDF]

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Posttraumatic cerebral infarction in patients with moderate or severe head trauma

Ranjith K Menon, John W Norris   (26 February 2007)

Reply from the Authors

Nicola Latronico, Rosa Marino, Lorenzo Pinelli and Roberto Gasparotti   (26 February 2007)

Posttraumatic cerebral infarction in patients with moderate or severe head trauma 26 February 2007
Ranjith K Menon, St. George's University of London, Clinical Neurosciences Cranmer Terrace, London SW 17 0RE, United Kingdom, John W Norris Send Correspondence to journal: Re: Posttraumatic cerebral infarction in patients with moderate or severe head trauma drranjuygc{at}yahoo.co.uk Ranjith K Menon, et al.	Marino et al documented the importance of cerebral infarction in patients with moderate or severe head injury. [1] They concluded that CT diagnosed cerebral infarction is a relevant outcome measure in future therapeutic trials of head injury. However, we were surprised that they did not include cerebral angiography as part of their diagnostic workup, since many of the infarctions they encountered could be due to dissection of the extra cranial cervical arteries. In an article by Berne et al, patients deemed at risk of blunt cerebral vascular injury had CT within 24 hrs of admission and all with positive CTA results further underwent four vessel cerebral angiographies. [2] Nineteen of 486 patients who were screened had 25 vascular injuries: 7 carotid and 18 vertebral arteries. Most importantly, the majority were neurologically asymptomatic at the time of screening. Perhaps Marino et al should have included some form of noninvasive cerebral angiography since cervical artery dissection may occur silently in patients following cervical injuries but may have serious consequences in prognosis, recovery, and treatment. This would influence not only the way that the patients' necks are handled in the acute phase following trauma, but also helps to decide on the use of antithrombotic agents and even stenting the arterial lesions. References 1. Marino R, Gasparotti R, Pinelli L et al. Posttraumatic cerebral infarction in patients with moderate or severe head trauma. Neurology 2006; 67:1165-1171 2. Berne JD, Norwood SH, McAuley CE, Villareal DH. Helical computed tomographic angiography: An excellent screening test for blunt cerebrovascular injury. Journal of Trauma Injury, Infection and Critical Care 2004; 57:11-19. The authors report no conflicts of interest.
Reply from the Authors 26 February 2007
Nicola Latronico, University of Brescia Piazzale Ospedali Civili, 1 - 25123 Brescia, Italy, Rosa Marino, Lorenzo Pinelli and Roberto Gasparotti Send Correspondence to journal: Re: Reply from the Authors latronic{at}med.unibs.it Nicola Latronico, et al.	We appreciate the comments by Menon and Norris concerning the use of angiography and computed tomography angiography (CTA) in head trauma patients at risk of blunt cerebrovascular injury (BCVI). Arterial dissection, pseudoaneurysm, arteriovenous fistula, arterial laceration and occlusion are uncommon complications of blunt trauma, the frequency being in the order of 1.03%. [3] Cerebral angiography has been considered the primary method to assess vascular injuries but due to the low frequency of these lesions and the questionable improvement of outcome and dubious cost effectiveness of such practice, [4] its screening role has been challenged. CTA has become an increasingly accessible examination in emergency departments, with the ability for faster scanning times, increased resolution and larger field of view after the advent of multi-slice technology, [3] yet data on this technique has been either limited or disappointing until very recently. [5] In the paper by Berne et al [2], cerebral angiography --the gold diagnostic standard--was performed only in the 18 patients with abnormal CTA. None of 438 patients with normal CTA underwent cerebral angiography, therefore the reported sensitivity (100%) and specificity (94%) were unreliable. Our retrospective study covered the period from 1998 and 2001 during which a multi-slice CT technology was not yet available at our institution. Menon and Norris stated that undetected BCVI “may have serious consequences in prognosis, recovery and treatment." However, treatment options of BCVI in severe head trauma are very limited; anticoagulant treatment is often precluded and endovascular treatment is generally reserved for patients who are symptomatic or for those with a pseudoaneurysm on follow-up examinations. Increased awareness and appropriate screening are necessary to improve the detection of BCVI. CTA is a promising diagnostic tool but further studies with adequate methodology are needed to definitely support CTA as a screening technique for BCVI in severe head trauma. References 3. Nunez DB, Jr., Berkmen T. Imaging of blunt cerebrovascular injuries. Eur J Radiol 2006;59:317-326. 4. Mayberry JC, Brown CV, Mullins RJ, Velmahos GC. Blunt carotid artery injury: the futility of aggressive screening and diagnosis. Arch Surg 2004;139:609-612. 5. Eastman AL, Chason DP, Perez CL, McAnulty AL, Minei JP. Computed tomographic angiography for the diagnosis of blunt cervical vascular injury: is it ready for primetime? J Trauma 2006;60:925-929. Disclosure: The authors report no conflicts of interest.