Mundinger Gerhard S, Dorafshar Amir H, Gilson Marta M, Mithani Suhail K, Manson Paul N, Rodriguez Eduardo D
Resident, Division of Plastic and Reconstructive Surgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, and Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD.
J Oral Maxillofac Surg. 2013 Dec;71(12):2092-100. doi: 10.1016/j.joms.2013.07.005. Epub 2013 Aug 29.
Blunt internal carotid artery injuries (BCAIs) can result from craniofacial trauma, yet the association between craniofacial fractures and BCAIs is poorly understood.
A retrospective cohort study of patients with blunt-mechanism facial fracture(s) presenting to a large trauma center was undertaken to identify facial fracture patterns predictive of BCAIs. Predictor variables included specific facial fracture patterns. Additional variables included demographic, injury mechanism, and associated injury classifications. Outcome variables included the presence or absence of BCAIs. All radiographic fracture patterns were confirmed by author review of computed tomographic imaging. BCAIs were confirmed and graded using the Biffl system. Differences in fracture patterns and demographic parameters in patients who presented with versus without concomitant BCAIs were compared, and relative risks for BCAI were calculated. Existing Eastern Association for the Surgery of Trauma Level III Blunt Cerebrovascular Injury (BCVI) screening criteria then were applied to the dataset to determine if additional fracture patterns would be useful in BCAI screening as determined by alterations in screening sensitivity and specificity.
Seventy BCAIs were identified in 54 of 4,398 patients with facial fractures (1.2%). Bilateral fractures in each facial third, complex midface, Le Fort, and subcondylar fractures, fractures in association with the cervical spine, and basilar skull fractures were high risk for concomitant BCAI. Twenty percent of BCAIs would not have been captured by existing Eastern Association for the Surgery of Trauma Level III BCVI screening criteria. When patients meeting these screening criteria were removed from the study population, Le Fort I and subcondylar fractures were the only fracture patterns conferring increased risk for BCAI. Addition of these criteria to existing criteria improved the screening negative predictive value.
Specific facial fracture patterns, including bilateral fractures in any facial third and complex midface, Le Fort I, and subcondylar fractures, confer increased risk of BCAI, especially in association with basilar skull fractures. Suspicion for BCAI in these patients may improve diagnosis and enable prompt therapeutic intervention. Addition of Le Fort I fractures to existing BCAI screening criteria improves sensitivity and may be of clinical utility in ruling out BCAIs.
钝性颈内动脉损伤（BCAIs）可由颅面部创伤引起，但颅面部骨折与BCAIs之间的关联尚不清楚。
对一家大型创伤中心收治的钝性机制面部骨折患者进行回顾性队列研究，以确定可预测BCAIs的面部骨折模式。预测变量包括特定的面部骨折模式。其他变量包括人口统计学、损伤机制和相关损伤分类。结果变量包括是否存在BCAIs。所有影像学骨折模式均经作者对计算机断层扫描成像的审查确认。BCAIs采用Biffl系统进行确认和分级。比较有和没有伴发BCAIs的患者骨折模式和人口统计学参数的差异，并计算BCAI的相对风险。然后将现有的东部创伤外科学会III级钝性脑血管损伤（BCVI）筛查标准应用于数据集，以确定额外的骨折模式是否有助于BCAI筛查，通过筛查敏感性和特异性的改变来判断。
在4398例面部骨折患者中的54例（1.2%）中发现了70例BCAIs。每个面部区域的双侧骨折、复杂中面部骨折、Le Fort骨折和髁突下骨折、与颈椎相关的骨折以及颅底骨折伴发BCAI的风险较高。现有东部创伤外科学会III级BCVI筛查标准无法发现20%的BCAIs。当将符合这些筛查标准的患者从研究人群中排除后，Le Fort I骨折和髁突下骨折是仅有的具有BCAI风险增加的骨折模式。将这些标准添加到现有标准中可提高筛查阴性预测值。
特定的面部骨折模式，包括任何面部区域的双侧骨折、复杂中面部骨折、Le Fort I骨折和髁突下骨折，会增加BCAI的风险，特别是与颅底骨折相关时。对这些患者怀疑有BCAIs可能会改善诊断并促使及时进行治疗干预。将Le Fort I骨折添加到现有的BCAI筛查标准中可提高敏感性，可能在排除BCAIs方面具有临床实用性。
