Blunt cerebrovascular injury in rugby and other contact sports: case report and review of the literature

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Blunt cerebrovascular injury in rugby and other contact sports: case report and review of the literature
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English
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Cuellar, Trajan A.
Lottenberg, Lawrence
Moore, Frederick A.
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Bio Med Central ( World Journal of Emergency Surgery)
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Contact sports have long been a part of human existence. The two earliest recorded organized contact games, both of which still exist, include Royal Shrovetide Football played since the 12th century in England and Caid played since 1308 AD in Ireland. Rugby is the premier contact sport played throughout the world with the very popular derivative American football being the premier contact sport of the North American continent. American football in the USA has on average 1,205,037 players at the high school and collegiate level per year while rugby in the USA boasts a playing enrollment of 457,983 at all levels. Recent media have highlighted injury in the context of competitive contact sports including their long-term sequelae such as chronic traumatic encephalopathy (CTE) that had previously been underappreciated. Blunt cerebrovascular injury (BCVI) has become a recognized injury pattern for trauma; however, a paucity of data regarding this injury can be found in the sports trauma literature. We present a case of an international level scrum-half playing Rugby Union at club level for a local non-professional team, in which a player sustained a fatal BCVI followed by a discussion of the literature surrounding sport related BCVI.
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Cuellar et al. World Journal of Emergency Surgery 2014, 9:36 http://www.wjes.org/content/9/1/36; Pages 1-6
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doi:10.1186/1749-7922-9-36 Cite this article as: Cuellar et al.: Blunt cerebrovascular injury in rugby and other contact sports: case report and review of the literature. World Journal of Emergency Surgery 2014 9:36.

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REVIEWOpenAccessBluntcerebrovascularinjuryinrugbyandother contactsports:casereportandreviewofthe literatureTrajanACuellar*,LawrenceLottenbergandFrederickAMooreAbstractContactsportshavelongbeenapartofhumanexistence.Thetwoearliestrecordedorganizedcontactgames, bothofwhichstillexist,includeRoyalShrovetideFootballplayedsincethe12thcenturyinEnglandandCaidplayed since1308ADinIreland.Rugbyisthepremiercontactsportplayedthroughouttheworldwiththeverypopular derivativeAmericanfootballbeingthepremiercontactsportoftheNorthAmericancontinent. AmericanfootballintheUSAhasonaverage1,205,037playersatthehighschoolandcollegiatelevelperyear whilerugbyintheUSAboastsaplayingenrollmentof457,983atalllevels. Recentmediahavehighlightedinjuryinthecontextofcompetitivecontactsportsincludingtheirlong-termsequelae suchaschronictraumaticencephalopathy(CTE)thathadpreviouslybeenunderappreciated.Bluntcerebrovascular injury(BCVI)hasbecomearecognizedinjurypatternfortrauma;however,apaucityofdataregardingthisinjurycan befoundinthesportstraumaliterature. Wepresentacaseofaninternationallevelscrum-halfplayingRugbyUnionatclublevelforalocalnon-professional team,inwhichaplayersustainedafatalBCVIfollowedbyadiscussionoftheliteraturesurroundingsportrelatedBCVI.Casereport25y/omaleplayingRugbyUnionatscrum-halfposition wasengagedinfullcontacttrainingwhenhereceiveda tackle.Theexercisewasasimpletackledrill,withtwo playersatastandingstart10metersapart.Oneplayer runstowardstheothertoinitiateatackle.Thepatient presentedherereceivedthetackleinanunremarkable fashionhittingthegroundwithoutlossofconsciousness, thenstoodupbrieflybeforecollapsing.Hewasnotedto beunresponsiveandreceivedCPRonsceneandadvanced medicalinterventionincludingintubation,placementof IVaccessandresuscitationbeforearrivingasatrauma alerttoUFHealthShandsLevelITraumaCenterin Gainesville,Florida. OnarrivalinthetraumabayhisvitalswereGCS3T, HR60swithabradycardicepisodeto30sthatwasshort lived,andSBP97withon-goingfluidresuscitation. ATLSprimaryandsecondarysurveyswerecompleted alongwithlaboratoryinvestigations.Acentrallineand arteriallinewereplacedalongandthepatientreceiveda CThead24minutesafterambulancearrival.Thisrevealed adiffuseSAHinanon-traumaticpattern.Theimaging protocolwasthenalteredintheCTscannertoinclude aCTangiogramofthehead/neckthatconfirmeda right-sidedinternalcarotiddissectionwithocclusion oftherightICAatthejunctionoftherightcavernous sinusandsupraclinoidICAs.Mannitoland3%salinewere administeredandaventriculostomywasplaced.CSFfluid wasnotedtobegrosslybloody.Maximalmedicaltherapy continuedovernightwithrepeatCTheadrevealingright ICAdissection,largevolumeSAHextendingintohigh convexitysulcibilaterallywithearlycentralincisural herniation,rightMCAandACAstroke,andrightACA distributioncytotoxicedema. At24hrsfollowingadmission,thepatientwasnoted tohavenewleftsidedpupillarydilatationwithICPsthat remainedin70sdespitemaximalmedicaltherapy. Hisclinicalconditioncontinuedtodeteriorateand hewaspronouncedbraindead~36hrsafteradmissionwiththefamilyelectingtowithdrawcareupon arrivalofotherfamilymembers.TwoCTAngiograms *Correspondence: trajancuellar@yahoo.com DivisionofAcuteCareSurgery,DepartmentofSurgery,UniversityofFlorida CollegeofMedicine,Gainesville,FL,USA WORLD JOURNAL OF EMERGENCY SURGERY 2014Cuellaretal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative CommonsAttributionLicense(http://creativecommons.org/licenses/by/4.0),whichpermitsunrestricteduse,distribution,and reproductioninanymedium,providedtheoriginalworkisproperlycredited.TheCreativeCommonsPublicDomain Dedicationwaiver(http://creativecommons.org/publicdomain/zero/1.0/)appliestothedatamadeavailableinthisarticle, unlessotherwisestated.Cuellar etal.WorldJournalofEmergencySurgery 2014, 9 :36 http://www.wjes.org/content/9/1/36

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demonstratinghisGradeIVBCVIinjuryareprovided below(Figures1and2). AlistofDenverBCVIscreeningcriteriaislisted below: TheDenvercriteriaforscreeningforBCVIincontext oftraumaincludesanycervicalfracture,unexplained neurologicaldeficit,basalcranialfractureintothecarotid canal,LeFort2or3fracture,cervicalhematoma,cervical bruit,ischemicstroke,orheadinjurywithGCS<6.Below istheUniversityofFloridaSevereBrainInjuryProtocol whichwasfollowedduringthetreatmentofthispatient (Figure3).DiscussionThusfar,thereexistatotalof3casereportsofcerebrovascularaccidentassociatedwithblunttraumainRugby. Thefirstisa15yearoldplayinghooker(middlefront rowinthescrum)withatraumaassociatedCVAthat presentedwithprimarilysensorysymptomsthatincluded neckpainandparesthesiaofrightarmandleg[1].Hewas removedfromthegameanddidnotreturntoplay. Hedevelopedadditionalsymptomsthefollowingday includingdizzinessandblurredvisionwithongoingright upperextremityparaesthesia.MRimagingrevealed aninfarctintheanteriorli mboftheinternalcapsule Figure1 CTAbraintransverseimagedemonstratingocclusionofrightinternalcarotidartery. Cuellar etal.WorldJournalofEmergencySurgery 2014, 9 :36Page2of6 http://www.wjes.org/content/9/1/36

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andtheheadofthecaudatenucleus.Adiagnosisofcarotid dissectionwasmadeasasourcewithoutangiographybased onhistoryanddistributionofinfarctthepatient.Thiswas treatedconservativelywithout anticoagulationorantiplatelettherapywithnearfullresolutionofhissymptomswith residualnumbnessofthehandatfollowup4weekslater. Thesecondcaseisa31yearoldwhosustaineda ‘ fierce handoff ’ totherightneckwhileplayingbutcontinuedto playwithoutneurologicalsignsorsymptoms[2].Hethen presented2weekslatertotheEDwithrightneckswelling andpainwithshortnessofbreathandadiagnosisof rupturedpseudoaneurysmofthecommoncarotidwas madewithsubsequentopensurgicalintervention.Hehad apresentedtoageneralpractitioneroneweekpostinjury andreceivedantibiotictherapyforaswollenglandinthe neck.Interestinglyhehadnoneurologicalsymptomsor signsaspartofhispresentations. Thethirdisa19yearoldrugbyplayerwhosustained aposteriorsternoclaviculardislocationthatrequiredhe retirefromthegame[3].Hehadnoneurologicalsigns orsymptoms,onlypainassociatedwiththeinjury.He thenpresented3weekspostinjurywithdizzinessand collapseontherugbypitch,whichwasdiagnosedas secondarytotwovascularinjuriesoneoftherightproximalsubclavianarteryandtheotheroftheinnominate artery.Hereceivedsurgicalinterventionincludinga mediansternotomy,andat1yearhadresidualneurological deficitofleftUEandLE. AdditionalcasereportsofBCVIinincludeaseriesof 5casesthatincludeonesport-relatedBCVI.Thiscase wasan18yearoldmalestruckintheneckwhileplaying basketballandwas ‘ moderatelydazed ’ butreenteredthe gameandcontinuedtoplay[4].Hethenpresented2weeks postinjurywithacutehemiplegiaandwasdiagnosedwith carotiddissectionandunderwentsurgicalintervention butdevelopedandlargeleftsidedhemisphericinfarctand expired5dayspostadmission.Thiscaseseriesincluded traumapatientsandhighlightedthedelayednatureof presentationsofBCVIwithnewneurologicaldeficits ascribedtotheinjuriesoccurringaslateas6months Figure2 CTAbraincoronalimagedemonstratingdiminutiverightposteriorcommunicatingartery. Cuellar etal.WorldJournalofEmergencySurgery 2014, 9 :36Page3of6 http://www.wjes.org/content/9/1/36

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postinjury[4].Similarly,acaseseriesfromMayoClinicof 18patients3ofwhichweresportsrelatedinjuries,also notedadelayinpresentationfrom30minutesto10years postinjury[5].Withinthepediatricliteraturethereare individualcasereportsincludingareportof3American footballplayers17,15,and14yearsofagewhosustained cerebellarinfarct,leftpontinestroke,andleftmiddle cerebralinfarctrespectively[6].Theseplayersallhad neurologicalfindingsandalsopresenceofoneorsome ofthefollowingprothromboticmutations:methylene tetrahydrofolatereductasegenevariantC677TandA1298C, PAI1-4G,prothrombin20210. Additionally,thereisareportofa15yearoldwho developedsymptomsduringagameofAmericanfootball withoutobvioustraumaandpresentedtohospitalwitha progressiveneurologicaldeficitascribedtoaleftICA dissectionwithhemisphericinfarctandanultimatelyfatal course4daysfollowingadmission[7].Itisunclearfrom thecasereportwhetherornothewasplaying. Areviewof18casesofsport-relatedBCVI(not includingRugby)wererelatedtoawiderangeofactivities includingcycling,football,Frenchboxing,Hockey,In-line Skating,Scubadiving,Skiing,Softball,Taekwondo, Weightlifting,andWintersports[8].Pathophysiologywas presumedtobeduetoacrushinjurytothecarotidwith disruptiontotheintimain62%ofpatientswithasubintimaldissectionwithinternalcarotiddissectionscarryinga moreseverecourseandworselongtermoutcome. InarecentbroadoverviewofBCVIetiologyisthought tobestretchofthecommoncarotidarteryoverC3-5 duringextremeneckextension[9].Thestrokesthat arisefromtheseinjuriesarethoughttobeeitherembolic fromdislodgedclotfromafocalsiteofintimaldisruption orfromdissectioncausingvesselocclusionorsufficient narrowingtoresultincerebralinfarct.Anatomicvariation intheCircleofWillis,incompletein80%ofthepopulation, contributestotheseverityofcarotidocclusionbyfunctionallymakingtheinternalcarotidarteryanendarteryrather acollateralizedartery.Thisfactisfurthercorroborated fromrecentvascularsurgery literatureregarding2ormore obstructionsoragenesiswithintheCircleofWilliswith inabilitytotoleratecaro tidcrossclamping[10]. Regardingourcasethepatientreceivedatraumatic tacklewhileplayingatscrum-halfposition(back)ina trainingscenario.Suchcontactisinevitableinthecourse oftrainingandplay,however,epidemiologicalstudiesin Rugbydoexistandhavebeenusedtoidentifyriskfactors thatareassociatedwithinjuryandproposeeffective strategiestoreducethenumberofinjuries.Stricter adherencetorehabilitationplans,reductionintheamount Figure3 UniversityofFloridaseverebraininjuryalgorithm. Cuellar etal.WorldJournalofEmergencySurgery 2014, 9 :36Page4of6 http://www.wjes.org/content/9/1/36

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offoulplay,andimprovementinthequalityofthepitch specificallywithregardstohardnesswereidentifiedasrisk factorsforinjury[11].Arecentreviewregardinginjuryin RugbyUnionstatesthatthereisnodifferenceininjury ratebetweenforwardsandbackswiththemajorityof injuriesbeingsustainedinatackleorscrum[12].Indeed themajorityofinjuriesoccurnotduringpracticebutina competitivematchataratioof36:1andusuallytothe backsinthecontextofanopenfieldtackleduringwhich timethereismorehighenergytransferthanother portionsofthegame.Catastrophicspinalinjurieswere notedtoberelativelyrareat1per10,000playersper seasonandagainnormallysustainedinthecontextofthe scrumortackleinopenfieldplay. Americanfootballasportwithsimilargoalstorugby hasbeenstudiedingreaterdetail,butstilllackingin dataresolutiontoidentifyBCVIasasub-cohortof injurypattern.Inareviewarticlein2013Bodenetal[13] notedoutof164traumaticAmericanfootballfatalities onlyonedeathfromvascularinjuryinconjunctionwith cervicalfracturewasfoundbuttherewere5deathsdueto braininjurywithoutascribablecause.Itisconceivablethat BCVImayhavebeeninvolvedinthesedeaths. Additionally,acomparativestudybetweenAmerican FootballandRugbyhasdemonstrateddifferencesin volumeofinjury(3timeshigherinRugbycomparedto Americanfootball)[14].Also,differencesintheinjury patternincludeahigherrateofneckinjuriesinRugby 1.02comparedto6.02per1000playergames[12].The natureofneckinjuriesisalsodifferentwithAmerican Footballplayersexperiencingtraumaticdistractionof thebrachialplexuswithupperextremityneurological symptomsfrequentlycalleda ‘ stinger ’ ,whichwasshown tooccurupto50-65%ofcollegiatelevelAmerican Footballplayers[15].Interestinglythisinjurypattern appearsabsentinRugby. ItmaybeinRugbythemajorityofneurologicalsymptomatologyoftheupperextremityaretheresultofmanifestationsofvascularinjurywithneurologicalsequelae ratherthanneurologicalinjury.Fortheplayerwith symptomsthismeansamorefocusedassessmentof vascularstructuresmaybewarranteduponidentification ofneurologicalsignsorsymptoms. BCVIinthetraumaliteratureisatreatablediseasewith delayshavingseriousconsequences[16-19].Inthetrauma literatureareviewof147,BCVIcaseshighlightedthe positiveeffectoftreatmentwithstrokefoundin25.8%of untreatedpatientsand3.9%oftreatedpatients[18]. Indeedinthetraumapopulation30%ofundiagnosed BCVIwillgoontoproducestrokes[16].UsageofCTAto diagnoseandguidetherapyforBCVIintrauma populationhashadencouragingresultswithgreat reductionsindelayedstrokeratefrom67%to0%and mortalityreductionfrom38%to10%[19].Thesingle bestpredictorofpositivescreeningforBCVIwas symptomaticpresentation[20].Protocolshavebeen publishedregardingspecifictreatmentofinjuryby gradewhichmayguidetreatmentinlow-energysport injuries[21]. AtthehigherlevelofthegameareviewofEliteIrish RugbyPlayersrevealunder-reportingofbluntconcussive injurybyasmuchas41%[22].Thisunderreporting phenomenonisnotrestrictedtoRugbywithonlymoderatereliabilityofreportingconcussiveeventsinformer professionalAmericanFootballplayers[23].ConclusionRugbyUnionisahighenergycontactsportthatis widelyplayedintheUSAwithover2,800activeclubs andover450,000players.Bluntcerebrovascularinjuries associatedwithrugbyarerareeventsbutcanhavesubtle presentationsandultimatelycatastrophicoutcomes.No dataexistsregardingtherateofBCVIincontactsports, theirgrade,ortheirchanceofprogressiontostrokeover time.WhatisknownaboutBCVIinRugbyorother contactsportsisthatitisdocumentedtoexistmainlyin ananecdotalform,whichmayovertimeformacohort ofdata.BCVIoutsidesportswithinthetraumaliterature isnotedtobeprogressivewith29%ofinjuriesdeterioratingovertimeand30%producingstrokeovertime. Additionally,thetimetostrokemaynotbeimmediate withdelaysinpresentationbeingcommoninthesports literature.Treatmentiseffectiveinreducingstrokerate andmortality. AstheRugbyWorldCupof2015approacheswithno dataregardingepidemiologicalstudiesofBCVIinRugby; itisworthnotingthisinjurycanhavedevastatingconsequencesandfurtherstudyisneededtodelineateitsnature andtoensureappropriatescreeningofthoseplayerswho sufferinjurywithneurologicalsigns.Additionally,those playerswhorequiretreatmentandareidentifiedashaving neurologicalsymptomsmaybenefitfromenhancedsymptom/signscreeningtoelucidatethenatureoftheseinjuriesandgatherdatatohelpdelineatestrategiestopredict andpreventacatastrophicoutcomewithtimelymedical intervention.Inclusionofneurologicalscreeningquestions aspartofanassessmentforBCVIbytrainedmedical personnelwithapplicationofCTAngiographyinplayers undergoingCTimagingforTBIormaxillofacialinjury shouldbeconsidered.Mostimportant,robustdocumentationofinjuriesincludingthosewithneurological signs/symptomsshouldbeimplementedtoprovidedata oninjurypatternsinRugbyUnionwithleadership providedbytheInternationalRugbyBoard[24].Competinginterests Theauthorsdeclarethattheyhavenocompetinginterests.Cuellar etal.WorldJournalofEmergencySurgery 2014, 9 :36Page5of6 http://www.wjes.org/content/9/1/36

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Authors ’ contributions Allauthorsreadandapprovedthefinalmanuscript. Acknowledgments AngelaGreakCuellarCPA,CMA,CFEfortheproofreadingofthemanuscript. Received:6March2014Accepted:15April2014 Published:4May2014 References1.PalmerSH: Strokefollowingneckinjuryinarugbyplayer. Injury 1995, 26 (8):555 – 556. 2.ThakoreN,AbbasS,VanniasinghamP: Delayedruptureofcommon carotidarteryfollowingrugbytackleinjury:acasereport. WorldJournal ofEmergencySurgery 2008, 3: 14. 3.MarcusMS,TanV: Cerebrovascularaccidentina19-year-oldpatient:a casereportofposteriorsternoclaviculardislocation. JShoulderElbowSurg 2011, 20 (7):e1 – e4. 4.PozzatiE,GiulianiG,PoppiM,FaenzaA: Blunttraumaticcarotiddissection withdelayedsymptoms. Stroke 1989, 20: 412 – 416. 5.MokriB,PiepgrasD,HouserW: Traumaticdissectionsoftheextracranial internalcarotidartery. JNeurosurg 1988, 68: 189 – 197. 6.BroschJR,GolombMR: Americanchildhoodfootballasapossiblerisk factorforcerebralinfarction. JChildNeurol 2011, 26 (12):1493 – 1498. 7.PatelH,SmithR,GargB: Spontaneousextracranialcarotidartery dissectioninchildren. PediatrNeurol 1995, 13: 55 – 60. 8.DharmasarojaP,DharmasarojaP: Sports-relatedinternalcarotidartery dissection:pathogenesisandtherapeuticpointofview. Neurologist 2008, 14 (5):307 – 311. 9.FabianTC: BluntCerebrovascularInjuries:AnatomicandPathological HeterogeneityCreateManagementEnigmas. JAmCollSurg 2013, 216 (5):873 – 885. 10.MontisciR,SanfilippoR,BuraR,BrancaC,PigaM,SabaL: Statusofthe circleofWillisandintolerancetocarotidcross-clampingduringcarotid endarterectomy. EurJVascEndovascSurg 2013, 45 (2):107 – 112. 11.ChalmersDJ,SamaranayakaA,GulliverP,McNoeB: Riskfactorsforinjuryin rugbyunionfootballinNewZealand:acohortstudy. BrJSportsMedicine 2012, 46: 95 – 102. 12.BrooksJH,KempSP: Recenttrendsinrugbyunioninjuries. ClinSportsMedicine 2008, 27: 51 – 73. 13.BodenBP,BreitI,BeachlerJA,WilliamsA,MuellerFO: Fatalitiesinhigh schoolandcollegefootballplayers. AmJSportsMed 2013, 41: 1108. 14.MarshallSW,WallerAE,DickRW,PughCB,LoomisDP,ChalmersDJ: An ecologicalstudyofprotectiveequipmentandinjuryintwocontact sports. IntJEpidemiol 2002, 31: 587 – 592. 15.ConcannonLG,HarrastMA,HerringSA: Radiatingupperlimbpaininthe contactsportathlete:anupdateontransientquadriparesisandstingers. CurrSportsMedRep 2012, 11 (1):28 – 34. 16.FabianTC,PattonJH,CroceMA,MinardG,KudskKA,PritchardFE: Blunt carotidinjury.Importanceofearlydiagnosisandanticoagulanttherapy. AnnSurg 1996, 223: 513 – 525. 17.WessemV,MeijerJM,LeenenLP,vanderWorpHB,MollFL,deBorstGJ: Blunttraumaticcarotidarterydissectionstillapitall?Therationalefor aggressivescreening. EurJTraumaEmergSurg 2011, 37: 147 – 154. 18.SteinDM,BoswellS,SlikerCW,LuiFY,ScaleaTM: Bluntcerebrovascular injuries:doestreatmentalwaysmatter? JTrauma 2009, 66 (1):132 – 144. 19.SchneidereitNP,SimonsR,NicolaouS,GraebD,BrownDR,KirkpatrickA, RedekopG,McKevittEC,NeyestaniA: Utilityofscreeningforblunt vascularneckinjurieswithcomputedtomographicangiography. JTrauma 2006, 60 (1):209 – 215. 20.WangAC,ChartersMA,ThawaniJP,ThanKD,SullivanSE,GrazianoGP: Evaluatingtheuseandutilityofnoninvasiveangiographyindiagnosing traumaticbluntcerebrovascularinjury. JTraumaAcuteCareSurgery 2012, 72 (6):1601 – 1610. 21.BifflWL,CothrenCC,MooreEE,KozarR,ConcanourC,DavisJW,McIntyreRC Jr,WestMA,MooreFA: Westerntraumaassociationcriticaldecisionsin trauma:screeningforandtreatmentofbluntcerebrovascularinjuries. JTrauma 2009, 67: 1150 – 1153. 22.FraasMR,CoughlanCF,HartEC,McCarthyC: Concussionhistoryand reportingratesineliteIrishrugbyunionplayers. PhysTherSport 2013, doi:10.1016/j.ptsp.2013.08.002. 23.KerrZ,MarshallS,GuskiewiczK: Reliabilityofconcussionhistoryinformer professionalfootballplayers.Medicine&scienceinsports&exercise. MedSciSportsExerc 2012, 44 (3):377 – 382. 24.RafertyM: ConcussionandchronictraumaticencephalopathyinternalrugbyBoard ’ sresponse. BrJofSportsMedicine 2013, 0: 1 – 2.doi:10.1186/1749-7922-9-36 Citethisarticleas: Cuellar etal. : Bluntcerebrovascularinjuryinrugby andothercontactsports:casereportandreviewoftheliterature. World JournalofEmergencySurgery 2014 9 :36. Submit your next manuscript to BioMed Central and take full advantage of: € Convenient online submission € Thorough peer review € No space constraints or color “gure charges € Immediate publication on acceptance € Inclusion in PubMed, CAS, Scopus and Google Scholar € Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit Cuellar etal.WorldJournalofEmergencySurgery 2014, 9 :36Page6of6 http://www.wjes.org/content/9/1/36