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Blunt Cerebrovascular Injury in Patients with Blunt Multiple Trauma: Diagnostic Accuracy of Duplex Doppler US and Early CT Angiography¹

¹ From the Institute of Radiology (G.R., S.M.), Department of Orthopaedic and Trauma Surgery (G.M.), and Center for Clinical Research (D.S.), Unfallkrankenhaus Berlin Trauma Center, Warener Str 7, 12683 Berlin, Germany; and Institute of Radiology, Ernst-Moritz-Arndt University of Greifswald, Greifswald, Germany (N.H.). Received December 25, 2004; revision requested February 28, 2005; revision received March 18; accepted April 15. Address correspondence to D.S. (e-mail: dirk.stengel{at}ukb.de).

View larger version (37K): [in a new window]   Figure 1a. Flow charts of the study profile according to Standards for Reporting of Diagnostic Accuracy recommendations. (a) Study period between January 1998 and October 2002. * = One patient underwent both MR angiography and DSA. (b) Study period between November 2002 and October 2003. * = Three patients underwent both MR angiography and DSA.

View larger version (40K): [in a new window]   Figure 1b. Flow charts of the study profile according to Standards for Reporting of Diagnostic Accuracy recommendations. (a) Study period between January 1998 and October 2002. * = One patient underwent both MR angiography and DSA. (b) Study period between November 2002 and October 2003. * = Three patients underwent both MR angiography and DSA.

View larger version (58K): [in a new window]   Figure 2a. Images in an 18-year-old woman with multiple trauma (ie, right-sided serial rib fractures and pneumothorax, lung contusions, splenic rupture, liver contusion, right-sided second-degree open femoral fracture, left-sided closed femoral fracture) after a car accident. (a) Initial longitudinal Doppler US scan suggests intimal dissection in right internal carotid artery (indicated by a sharp peak followed by turbulent blood flow caused by the flapping membrane). (b) Diminished Doppler signal (longitudinal plane) implies subtotal occlusion of distal left internal carotid artery. (c) Transverse three-dimensional time-of-flight MR angiogram (repetition time, 35 msec; echo time, 6.9 msec; flip angle, 20°; field of view, 220 mm; one signal acquired; matrix, 512 x 512; acquisition time, 5 minutes 22 seconds) shows dissection flap (solid arrow) in right internal carotid artery, subtotal stenosis of left internal carotid artery with reduction of intraluminal signal intensity (open arrow), and pseudoaneurysm (arrowheads). (d) Corresponding right anterior oblique DSA image verifies high-grade irregular stenosis (open arrow) of right internal carotid artery at the C2 level. Note normal vessel width distal to the carotid canal (solid arrow). (e) Lateral DSA image reveals left internal carotid artery with continuous luminal narrowing (open arrows), pseudoaneurysm (solid arrow), and subtotal occlusion (arrowhead) close to the entry of carotid canal.

View larger version (66K): [in a new window]   Figure 2b. Images in an 18-year-old woman with multiple trauma (ie, right-sided serial rib fractures and pneumothorax, lung contusions, splenic rupture, liver contusion, right-sided second-degree open femoral fracture, left-sided closed femoral fracture) after a car accident. (a) Initial longitudinal Doppler US scan suggests intimal dissection in right internal carotid artery (indicated by a sharp peak followed by turbulent blood flow caused by the flapping membrane). (b) Diminished Doppler signal (longitudinal plane) implies subtotal occlusion of distal left internal carotid artery. (c) Transverse three-dimensional time-of-flight MR angiogram (repetition time, 35 msec; echo time, 6.9 msec; flip angle, 20°; field of view, 220 mm; one signal acquired; matrix, 512 x 512; acquisition time, 5 minutes 22 seconds) shows dissection flap (solid arrow) in right internal carotid artery, subtotal stenosis of left internal carotid artery with reduction of intraluminal signal intensity (open arrow), and pseudoaneurysm (arrowheads). (d) Corresponding right anterior oblique DSA image verifies high-grade irregular stenosis (open arrow) of right internal carotid artery at the C2 level. Note normal vessel width distal to the carotid canal (solid arrow). (e) Lateral DSA image reveals left internal carotid artery with continuous luminal narrowing (open arrows), pseudoaneurysm (solid arrow), and subtotal occlusion (arrowhead) close to the entry of carotid canal.

View larger version (138K): [in a new window]   Figure 2c. Images in an 18-year-old woman with multiple trauma (ie, right-sided serial rib fractures and pneumothorax, lung contusions, splenic rupture, liver contusion, right-sided second-degree open femoral fracture, left-sided closed femoral fracture) after a car accident. (a) Initial longitudinal Doppler US scan suggests intimal dissection in right internal carotid artery (indicated by a sharp peak followed by turbulent blood flow caused by the flapping membrane). (b) Diminished Doppler signal (longitudinal plane) implies subtotal occlusion of distal left internal carotid artery. (c) Transverse three-dimensional time-of-flight MR angiogram (repetition time, 35 msec; echo time, 6.9 msec; flip angle, 20°; field of view, 220 mm; one signal acquired; matrix, 512 x 512; acquisition time, 5 minutes 22 seconds) shows dissection flap (solid arrow) in right internal carotid artery, subtotal stenosis of left internal carotid artery with reduction of intraluminal signal intensity (open arrow), and pseudoaneurysm (arrowheads). (d) Corresponding right anterior oblique DSA image verifies high-grade irregular stenosis (open arrow) of right internal carotid artery at the C2 level. Note normal vessel width distal to the carotid canal (solid arrow). (e) Lateral DSA image reveals left internal carotid artery with continuous luminal narrowing (open arrows), pseudoaneurysm (solid arrow), and subtotal occlusion (arrowhead) close to the entry of carotid canal.

View larger version (126K): [in a new window]   Figure 2d. Images in an 18-year-old woman with multiple trauma (ie, right-sided serial rib fractures and pneumothorax, lung contusions, splenic rupture, liver contusion, right-sided second-degree open femoral fracture, left-sided closed femoral fracture) after a car accident. (a) Initial longitudinal Doppler US scan suggests intimal dissection in right internal carotid artery (indicated by a sharp peak followed by turbulent blood flow caused by the flapping membrane). (b) Diminished Doppler signal (longitudinal plane) implies subtotal occlusion of distal left internal carotid artery. (c) Transverse three-dimensional time-of-flight MR angiogram (repetition time, 35 msec; echo time, 6.9 msec; flip angle, 20°; field of view, 220 mm; one signal acquired; matrix, 512 x 512; acquisition time, 5 minutes 22 seconds) shows dissection flap (solid arrow) in right internal carotid artery, subtotal stenosis of left internal carotid artery with reduction of intraluminal signal intensity (open arrow), and pseudoaneurysm (arrowheads). (d) Corresponding right anterior oblique DSA image verifies high-grade irregular stenosis (open arrow) of right internal carotid artery at the C2 level. Note normal vessel width distal to the carotid canal (solid arrow). (e) Lateral DSA image reveals left internal carotid artery with continuous luminal narrowing (open arrows), pseudoaneurysm (solid arrow), and subtotal occlusion (arrowhead) close to the entry of carotid canal.

View larger version (119K): [in a new window]   Figure 2e. Images in an 18-year-old woman with multiple trauma (ie, right-sided serial rib fractures and pneumothorax, lung contusions, splenic rupture, liver contusion, right-sided second-degree open femoral fracture, left-sided closed femoral fracture) after a car accident. (a) Initial longitudinal Doppler US scan suggests intimal dissection in right internal carotid artery (indicated by a sharp peak followed by turbulent blood flow caused by the flapping membrane). (b) Diminished Doppler signal (longitudinal plane) implies subtotal occlusion of distal left internal carotid artery. (c) Transverse three-dimensional time-of-flight MR angiogram (repetition time, 35 msec; echo time, 6.9 msec; flip angle, 20°; field of view, 220 mm; one signal acquired; matrix, 512 x 512; acquisition time, 5 minutes 22 seconds) shows dissection flap (solid arrow) in right internal carotid artery, subtotal stenosis of left internal carotid artery with reduction of intraluminal signal intensity (open arrow), and pseudoaneurysm (arrowheads). (d) Corresponding right anterior oblique DSA image verifies high-grade irregular stenosis (open arrow) of right internal carotid artery at the C2 level. Note normal vessel width distal to the carotid canal (solid arrow). (e) Lateral DSA image reveals left internal carotid artery with continuous luminal narrowing (open arrows), pseudoaneurysm (solid arrow), and subtotal occlusion (arrowhead) close to the entry of carotid canal.

View larger version (82K): [in a new window]   Figure 3a. Color duplex Doppler US scans of dissected right internal carotid artery in a 19-year-old man who had a motorbike accident with frontal impact. (a) Longitudinal B-mode scan shows occlusion of the false lumen by low-echo thrombi (solid arrow) and a patent vessel lumen (open arrow). (b) Spectral longitudinal Doppler scan shows increased flow velocity in the true lumen. Dissection was proved at MR angiography. Patient later died of severe brain trauma with refractory edema and cerebellar herniation.

View larger version (62K): [in a new window]   Figure 3b. Color duplex Doppler US scans of dissected right internal carotid artery in a 19-year-old man who had a motorbike accident with frontal impact. (a) Longitudinal B-mode scan shows occlusion of the false lumen by low-echo thrombi (solid arrow) and a patent vessel lumen (open arrow). (b) Spectral longitudinal Doppler scan shows increased flow velocity in the true lumen. Dissection was proved at MR angiography. Patient later died of severe brain trauma with refractory edema and cerebellar herniation.

View larger version (149K): [in a new window]   Figure 4a. Contrast-enhanced CT angiograms of cervical spine and neck in a 45-year-old patient with multiple trauma (cerebral and lung contusions, intraabdominal bleeding, unstable pelvic fracture) after crush injury, accompanied by bilateral internal carotid artery dissection. Anticoagulation was initiated with low-molecular-weight heparin. (a) Transverse angiogram of carotid arteries shows right-sided subtotal occlusion (arrowheads = false lumen, open arrow = true lumen) and left-sided pseudoaneurysm with dissection flap (solid arrow). (b) Corresponding coronal multiplanar reconstruction of carotid arteries shows right-sided subtotal occlusion (arrowheads = false lumen, open arrows = true lumen) and left-sided pseudoaneurysm with dissection flap (solid arrows).

View larger version (128K): [in a new window]   Figure 4b. Contrast-enhanced CT angiograms of cervical spine and neck in a 45-year-old patient with multiple trauma (cerebral and lung contusions, intraabdominal bleeding, unstable pelvic fracture) after crush injury, accompanied by bilateral internal carotid artery dissection. Anticoagulation was initiated with low-molecular-weight heparin. (a) Transverse angiogram of carotid arteries shows right-sided subtotal occlusion (arrowheads = false lumen, open arrow = true lumen) and left-sided pseudoaneurysm with dissection flap (solid arrow). (b) Corresponding coronal multiplanar reconstruction of carotid arteries shows right-sided subtotal occlusion (arrowheads = false lumen, open arrows = true lumen) and left-sided pseudoaneurysm with dissection flap (solid arrows).

View larger version (45K): [in a new window]   Figure 5a. Graphs depict expected diagnostic values at (a) duplex Doppler US and (b) CT angiography in disclosing blunt carotid dissection. The upper 95% confidence limit of US is still above the lower 95% confidence limit of CT angiography, marking a significant difference in sensitivity in favor of CT angiography.

View larger version (33K): [in a new window]   Figure 5b. Graphs depict expected diagnostic values at (a) duplex Doppler US and (b) CT angiography in disclosing blunt carotid dissection. The upper 95% confidence limit of US is still above the lower 95% confidence limit of CT angiography, marking a significant difference in sensitivity in favor of CT angiography.