Künt boyun travması olan vakalarda boyun arteriyel sisteminin postmortem anjiografi yöntemi ile değerlendirilmesi

Öz

AMAÇ: Boyun, baş ile gövde arasında, başı desteklemedeki rolüne ek olarak kafa ve vücut arasında bulunan damar ve sinirler için bir kanal, sindirim ve solunum sistemi için de bir geçiş yolu olan vücut bölgesidir. Bu çalışmada hayati açıdan önemli yapılar içeren boyun bölgesinde çok farklı mekanizmalarla meydana gelebilecek yaralanmalarda, invaziv otopsi girişimlerinden önce boyun arteryel sisteminin anjiografik yöntem ile incelenmesinin hem tanıda hem de triajda sağlayacağı yararlar araştırılmıştır. YÖNTEM: Çalışma kapsamında İstanbul Morg İhtisas Dairesinde künt boyun travması olan vakalarda ve travması olmayan seçilmiş kontrol vakalarında henüz kafa ve boyun bölgesi açılmadan göğüs açılarak arcus aorta bölgesinde truncus brachiocephalicus’a, subklavian arterin ilk bölümüne ve karotis arterlere ulaşılarak bu bölgeden radyokontrast madde verilmiş ve arteriyel sistem radyolojik olarak görüntülenmiştir. Bu şekilde tespit edilen anatomik yapı görüntüleri kayda alınmış, değerlendirilmiş ve görüntülemenin etkinliği tartışılmıştır. BULGULAR: Bu çalışmada 9’u travmatik bulgulara sahip 24 vakada boyun bölgesinde bulunan ve yaralanması hayati risk doğuran en önemli yapılardan biri olan büyük arteriyel yapıların anjiografik incelemelerinde künt boyun travması olduğu düşünülen vakalarda diseksiyon ve arteriovenöz fistül gibi direkt ölüm ile ilişkili olabilecek yaralanmalar tespit edilmekle birlikte posttravmatik trombozlar gibi ölüme katkısı olabilecek ancak adli otopsilerde zorlukla ulaşılabilecek bölgelerde bulunan arteriyel yapılara ait önemli bulgular da elde edilmiştir. Ayrıca büyük arterlerin travmatik ve bazı cerrahi operasyonlarda iyatrojenik olarak yaralanmasına neden olabilecek damar varyasyonları 6 vakada açık şekilde izlenmiştir. SONUÇ: Boyun arteriyel sisteminin postmortem anjiografik yöntemler ile incelenmesinin otopsi süresini uzatmayan, henüz daha cilt altı katmanlar açılmadan ve dolayısıyla artefakt oluşturmadan boyun arteriyel sisteminin değerlendirilmesini sağlayan bir yöntem olduğu görülmüş, özellikle endikasyonu doğru konularak rutin bir şekilde uygulanması ile hem tanı koydurucu hem de otopsi tekniğini yönlendirici bir teknik olarak ön plana çıkmıştır.

Anahtar Kelimeler

• Otopsi
• boyun arteriyel sistemi
• postmortem anjiografi

Evaluation of neck arterial system via postmortem angiography techniques on cases with blunt neck trauma

Öz

INTRODUCTION: The neck is the part of the body that connects the head and the torso, a conduit for the vessels and nerves between the head and the rest of the body, in addition to its role in supporting the head and serving as the passageway for the digestive and respiratory systems. This study investigated the benefits of neck arterial system angiography techniques in both diagnosis and triage before invasive autopsy techniques following injuries that may affect the many mechanisms in the neck region, which contains vitally important structures. METHODS: Within the scope of the study, in cases with blunt neck trauma and selected control cases without trauma in the Istanbul Morgue Department, the chest was opened without opening the head and neck region. The truncus brachiocephalicus in the arcus aorta region, the first part of the subclavian artery, and the carotid arteries were reached. Radiocontrast was applied from this region and the arterial system evaluated. Anatomical structure images were recorded and evaluated, and the effectiveness of imaging was discussed. RESULTS: The causes of death were given using 906 different phrases in 16,523 reports. When general classification was performed, these could be grouped under 131 headings. When the causes of death given in the Morgue Department were classified via both the proposed coding system and the ICD-10 codes, the lists of the leading 20 causes of death were similar in descriptive statistical data. CONCLUSION: It was observed that examination of the neck arterial system with postmortem angiographic methods allows the evaluation of the neck arterial system without opening subcutaneous layers and thus without creating artefacts and does not prolong the autopsy period, especially with the correct indication and its routine application. This has come to the fore as both a diagnostic technique and a technique that guides the autopsy procedure.

Anahtar Kelimeler

• Autopsy
• neck arterial system
• postmortem angiography

Kaynakça

1. Payne-James J, Jones R, Karch SB, Manlove J. Simpson’s Forensic Medicine. Great Britain: Hodder Arnold Ltd; 2011.
2. Franz RW, Willette PA, Wood MJ, Wright ML, Hartman JF. A systematic review and meta-analysis of diagnostic screen- ing criteria for blunt cerebrovascular injuries. Journal of the American College of Surgeons 2012;214 3 :313-27.
3. Ariyada K, Shibahashi K, Hoda H, Watanabe S, Nishida M, Hanakawa K, et al. Bilateral Internal Carotid and Left Vertebral Artery Dissection after Blunt Trauma: A Case Report and Lit- erature Review. Neurologia Medico-Chirurgica 2019:cr.2018-0239.
4. Malhotra A, Camacho M, Ivatury R, Davis I, Komorowski D, Leung D, et al. Computed tomographic angiography for the di- agnosis of blunt carotid/vertebral artery injury: a note of cau- tion. Annals of Surgery 2007;246 4 :632-43.
5. Berne J, Norwood S, McAuley C, Vallina V, Creath R, McLarty J. The high morbidity of blunt cerebrovascular injury in an un- screened population: More evidence of the need for mandatory screening protocols. Journal of the American College of Sur- geons 2001;192 3 :314-21.
6. Weber C, Lefering R, Kobbe P, Horst K, Pishnamaz M, Sellei R. Blunt cerebrovascular artery injury and stroke in severely injured patients: an international multicenter analysis. World Journal of Surgery 2018;42 7 :2043-53.
7. Laitt R, Lewis T, Bradshaw J. Blunt carotid arterial trauma. Clinical Radiology 1996;51 2 :117-22.
8. Kasantikul V, Ouellet J, Smith T. Head and neck injuries in fatal motorcycle collisions as determined by detailed autopsy. Traffic Injury Prevention 2003;4 3 :255-62.

9. Kaiser C, Schnabel A, Berkefeld J, Bratzke H. Traumatic rup- ture of the intracranial vertebral artery due to rotational accel- eration. Forensic Science International 2008;182 1-3 :e15-7.
10. Lee C, Gray L, Maguire J. Traumatic vertebral artery injury: detailed clinicopathologic and morphometric analysis of 6 cas- es. The American Journal of Forensic Medicine and Pathology ;30 2 :134-6.
11. DiMaio VJ, DiMaio D. Forensic Pathology. 2 ed: CRC press; 2001.
12. Aggrawal A, Setia P. Vertebral artery dissection revisited. Journal of Clinical Pathology 2006;59 9 :1000-2.
13. Bromilow A, Burns J. Technique for removal of the verte- bral arteries. Journal of clinical pathology. 1985;38 12 :1400.
14. Fabian T, Patton Jr H, Croce M, Minard G, Kudsk K, Pritchard F. Blunt carotid injury. Importance of early diagnosis and anticoagulant therapy. Annals of Surgery 1996;223 5 :513.
15. Kerwin A, Bynoe R, Murray J, Hudson E, Close T, Gifford R, et al. Liberalized screening for blunt carotid and vertebral artery injuries is justified. Journal of Trauma and Acute Care Surgery 2001;51 2 :308-14.
16. Miller P, Fabian T, Croce M, Cagiannos C, Williams J, Vang M. Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Annals of Sur- gery 2002;236 3 :386.
17. Christine C, Francesco D, Paul V, Cristian P, Alejandro D, Stefano B, et al. Postmortem computed tomography angiography vs. conventional autopsy: advantages and inconveniences of each method. International Journal of Legal Medicine 2013;127 5 :981-9.
18. Komiyama M, Morikawa T, Nakajima H, Nishikawa M, Yasui T. High incidence of arterial dissection associated with left vertebral artery of aortic origin. Neurologia Medico-Chirurgica 2001;41 1 :8-12.
19. Gabrielli R, Rosati M. Ataxia and vertigo due to anomalous origin of the left vertebral artery. Journal of Vascular Surgery 2013;58 3 :803.
20. Yuan S. Aberrant origin of vertebral artery and its clinical implications. Brazilian Journal of Cardiovascular Surgery 2016;31 1 :52-9.
21. Liechty J, Shields T, Anson B. Variations pertaining to the aortic arches and their branches; with comments on surgically important types. Quarterly Bulletin of the Northwestern University Medical School 1957;31 2 :136.
22. Nayak S, Pai M, Prabhu L, D’Costa S, Shetty P. Anatomical organization of aortic arch variations in the India: embryological basis and review. Jornal Vascular Brasileiro 2006;5 2 :95- 100.
23. Natsis K, Tsitouridis I, Didagelos M, Fillipidis A, Vlasis K, Tsikaras P. Anatomical variations in the branches of the human aortic arch in 633 angiographies: Clinical significance and literature review. Surgical and Radiologic Anatomy 2009;31 5 :319.
24. Jakanani G, Adair W. Frequency of variations in aortic arch anatomy depicted on multidetector CT. Clinical radiology 2010;65 6 :481-7.
25. Al-Okaili R, Schwartz E. Bilateral aortic origins of the vertebral arteries with right vertebral artery arising distal to left subclavian artery: case report. Surgical Neurology 2007;67 2 :174-6.
26. Trattnig S, Matula C, Karnel F, Daha K, Tschabitscher M, Schwaighofer B. Difficulties in examination of the origin of the vertebral artery by duplex and colour-coded Doppler sonography: anatomical considerations. Neuroradiology 1993;35 4 :296-9.
27. Palmer J. Anomalous origin of the left vertebral artery and its significance in selective femoro-cerebral catheterisation. Australasian Radiology 1976;20 3 :225-8.
28. Thali MJ, Viner MD, Brogdon BG. Brogdon’s Forensic Radiology: CRC Press; 2010.
29. Bolliger S, Filograna L, Spendlove D, Thali M, Dirnhofer S, Ross S. Postmortem imaging-guided biopsy as an adjuvant to minimally invasive autopsy with CT and postmortem angiography: A feasibility study. American Journal of Roentgenology 2010;195 5 :1051-6.
30. Ross S, Bolliger S, Ampanozi G, Oesterhelweg L, Thali M, Flach P. Postmortem CT angiography: capabilities and limitations in traumatic and natural causes of death. Radiographics 2014;34 3 :830-46.
31. Bruguier C, Mosimann P, Vaucher P, Uské A, Doenz F, Jackowski C. Multi-phase postmortem CT angiography: Recognizing technique-related artefacts and pitfalls. International Journal of Legal Medicine 2013;127 3 :639-52.