Acute arterial infarcts in patients with severe head injuries

Abstract

Aims and Objectives

To study the incidence, demographic profile, and outcome of patients with severe closed head injuries who develop acute arterial infarcts.

Materials and Methods

Patients with severe head injury (Glasgow coma score (GCS) ≤8) presenting within 8 h of injury in the Department of Neurosurgery over a period of 5 months were enrolled in the study. Patients with penetrating head injury, infarct due to herniation and iatrogenic arterial injuries were excluded from the study. Only arterial infarcts developing within 8 h of injury were included in the study. A computed tomography (CT) head was done on all patients within 8 h of injury and repeated if necessary. Arterial infarct was defined as well-demarcated wedge-shaped hypodensity corresponding to an arterial territory on plain CT of the head. Outcome was assessed using Glasgow outcome score (GOS) at 1 month post-injury or at death (whichever came earlier).

Results

Forty-four patients of severe head injury were included in the study during the above period. Of these, four patients (9.1%) had arterial infarcts on the initial CT scan. The male:female ratio was 1:3. The mean age was 54 years (range 3–85 years). Two patients had infarcts in the middle cerebral artery distribution and two in the superior cerebellar artery distribution. Poor outcome (GOS 1–3) was seen in 100% of the patients with arterial infarct compared to 52.5% (n=21) in patients with severe head injury without arterial infarct.

Conclusions

A significant percentage of patients with severe head injury have arterial infarcts on admission, which may imply arterial injury. Our study shows that these patients have a poorer prognosis vis-à-vis patient without these findings

Key words

Arterial dissection - arterial infarct - computerized tomography - epidemiology - head injury - trauma

• References

• 1 Hart RG, Easton JD. Dissections of cervical and cerebral arteries. Neurol Clin 1983; 1: 155-182
• 2 Sasaki O, Ogawa H, Koike T, Koizumi T, Tanaka R. A clinicopathological study of dissecting aneurysms of the intracranial vertebral artery. J Neurosurg 1991; 75: 874-882
• 3 Biller J, Hingtgen WL, Adams HP. Cervicocephalic arterial dissections: A ten year experience. Arch Neurol 1986; 43: 1234-1238
• 4 Stehbens WE. Pathology of cerebral blood vessels. M Louis: Mosby; 1972. p 1-97
• 5 Petito CK. Cerebrovascular diseases. In: Nelson JS, Schochet SS. editors Principles and practice of neuro-pathology. St. Louis: Mosby; 1993. p 436-458
• 6 Li MS, Smith BM, Espinosa J, Brown RA, Richardson P, Ford R. Nonpenetrating trauma to the carotid artery: Seven cases and a literature review. J Trauma 1994; 36: 265-272
• 7 Mobbs RJ, Chandran KN. Traumatic middle cerebral artery occlusion: Case report and review of pathogenesis. Neurol India 2001; 49: 158-161
• 8 Rommel O, Niedeggen A, Tegenthoff M, Kiwitt P, Botel U, Malin JP. Carotid and vertebral artery injury following severe head and cervical spine trauma. Cerebrovasc Dis 1999; 9: 202-209
• 9 Cogbill TH, Moore EE, Meissner M. The spectrum of blunt injury to the carotid injury: A multicenter perspective. J Trauma 1994; 37: 473-479
• 10 Davis JW, Holbrook TL, Hoyt DB. Blunt carotid artery dissection: Incidence, associated injuries, screening, and treatment. J Trauma 1990; 30: 1514-1517
• 11 Wilkinson IM. The vertebral artery. Extracranial and intracranial structure. Arch Neurol 1972; 27: 392-396
• 12 Gunning AJ, Pickering GW, Robb-Smith AHT. Mural thrombosis of the internal carotid artery and subsequent embolism. Q J Med 1964; 33: 155-195
• 13 Raney AA. Cerebral embolism following minor wounds of the carotid artery: Report of an autopsy. Arch Neurol Psychiatry 1948; 60: 425-439
• 14 Wilikins RH, Odom GL. Intracranial arterial spasm associated with craniocerebral trauma. J Neurosurg 1970; 32: 626-633
• 15 Dragon R, Saranchak H, Lakin P, Strauch G. Blunt injuries to the carotid and vertebral arteries. Am J Surg 1981; 141: 497-500
• 16 Gianotta SL, Ahmadi J. Vascular lesions with head injury. In: Wilkins RH, Rengachary SS. editors Neurosurgery. New York: McGraw-Hill; 1985. p 1678-1688
• 17 Bishara SN, Dempster AG, Mee EW. Vertebral artery occlusion associated with closed head injury: Report of three cases. Br J Neurosurg 1989; 3: 495-501
• 18 Fisher CM. Occlusion of the vertebral arteries causing transient basilar symptoms. Arch Neurol 1970; 22: 13-19
• 19 Tian HL, Geng Z, Cui YH, Hu J, Xu T, Cao HL. et al Risk factors for posttraumatic cerebral infarction in patients with moderate or severe head trauma. Neurosurg Rev 2008; 31: 431-436
• 20 Tawil I, Stein DM, Mirvis SE, Scalea TM. Posttraumatic cerebral infarction: Incidence, outcome, and risk factors. J Trauma 2008; 64: 849-853