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Lau KW, Chen CT, Chen CC, Lin TC, Yeap MC, Hsieh PC, Chuang CC, Wang YC, Yang ST, Liu ZH. Clinical outcomes among patients with concurrent blunt cerebrovascular injury and traumatic intracranial hemorrhage. J Neurol Sci 2024; 466:123216. [PMID: 39255590 DOI: 10.1016/j.jns.2024.123216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 07/28/2024] [Accepted: 09/02/2024] [Indexed: 09/12/2024]
Abstract
BACKGROUND Blunt cerebrovascular injury (BCVI) accounts for 1-3 % of patients with blunt trauma, which should be promptly diagnosed and managed due to risk of cerebral infarction and death. Antithrombotic therapy had been proven to reduce risk of stroke and mortality. However, due to concern of hematoma progression, treatment suggestion is still inconclusive for patients with concurrent traumatic intracranial hemorrhage. MATERIALS AND METHODS We performed a retrospective, observational study from 2002 to 2020 at a Level I trauma center, all patients with BCVI and concurrent traumatic intracranial hemorrhage were recruited. Patients' demographics, initial CT findings, severity of BCVI, treatment and outcomes were documented and analyzed to define possible risk factors of death and stroke. RESULTS Among all 57 patients, 49 (86.0 %) patients had injury at ICA, 6 (10.5 %) had VA injury, and 2 (3.5 %) suffered from both. Targeted treatments for BCVI were provided to 33 (57.9 %) patient, mostly endovascular intervention (78.8 %), antithrombotic treatment was given to 11 (19.3 %) patients. At 3-month follow-up, 17 (29.8 %) patients expired, and 18 (31.6 %) patients had cerebral infarction due to BCVI. We identified more severe initial CT findings (p = 0.016), higher head Abbreviated Injury Scale (p = 0.049) and initial life-threatening events (p = 0.047) as risk factors of death, and traumatic basal cistern subarachnoid hemorrhage(SAH) (p = 0.040) as single risk factor of cerebral infarction. CONCLUSIONS Around one-thirds of patients with concurrent BCVI and traumatic intracranial hemorrhage were death or suffered from cerebral infarction within 3 months, with severity of initial head injury and SAH at basal cistern as risk factors, respectively.
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Affiliation(s)
- Ka-Wei Lau
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Chun-Ting Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Ching-Chang Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Tzu-Chin Lin
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Mun-Chun Yeap
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Po-Chuan Hsieh
- Department of Neurosurgery, New Taipei Municipal Tucheng Hospital (Built and Operated by Chang Gung Medical Foundation), New Taipei, Taiwan
| | - Chi-Cheng Chuang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Yu-Chi Wang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Shun-Tai Yang
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan; Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Zhuo-Hao Liu
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan; School of Medicine, National Tsing Hua University, Hsinchu, Taiwan.
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Sanjuan J, Cuellar Bahamón AM, Marmolejo MDM, Sendoya JE, Yamid Quintero Y, García-Perdomo HA. Antiaggregation Versus Anticoagulation for Stroke, Bleeding, and Mortality in Patients With Blunt Carotid Injury: A Systematic Review and Meta-Analysis. Cardiol Rev 2024:00045415-990000000-00316. [PMID: 39180474 DOI: 10.1097/crd.0000000000000765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2024]
Abstract
To assess the effectiveness and safety of antiplatelet therapy compared with anticoagulation therapy in preventing stroke occurrence following blunt carotid injuries. A comprehensive search was conducted on Medline, Central, and Embase using mesh criteria, yielding 1236 articles. Additionally, 3 studies met the inclusion criteria. Two review authors independently extracted data from randomized controlled trials, controlled clinical trials, and nonrandomized studies comparing anticoagulant and antiplatelet therapies for carotid blunt trauma. Primary outcomes included stroke, transient ischemic attack, and mortality, with secondary outcomes encompassing major extracranial bleeding events. Drug dosage, treatment duration, and follow-up data were extracted and analyzed. Only 1 randomized trial was identified, and 3 studies met all exclusion and inclusion criteria (comprising 796 patients). The odds of stroke [1.13, 95% confidence interval (CI), 0.30-4.24], transient ischemic attack (1.01, 95% CI, 0.14-6.59), and major bleeding (0.94, 95% CI, 0.02-2.77) resulted in no significant differences between the 2 interventions. Nevertheless, additional studies with robust designs and strong evidence are required to assess antiplatelet and anticoagulation drugs, dosing, timing, and outcomes in patients with carotid blunt trauma, ultimately enabling the formulation of recommendations.
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Affiliation(s)
- Juan Sanjuan
- From the Department of Surgery, Fundación Santa Fe de Bogotá, Bogotá, Hospital Serena del Mar, Cartagena de Indias, Colombia
| | | | | | - Jesús E Sendoya
- Department of Surgery, Southcolombian University, Neiva, Colombia
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Choi Y, Jeon J, Ha EJ, Kim CK, Seo HG, Oh BM, Leigh JH. Elevated Risk of Stroke in Young Adults After Traumatic Brain Injury: A Nationwide Study of 1 Million Individuals. J Am Heart Assoc 2024; 13:e033453. [PMID: 39136301 DOI: 10.1161/jaha.123.033453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/15/2024] [Indexed: 08/22/2024]
Abstract
BACKGROUND Although stroke is commonly perceived as occurring in older adults, traumatic brain injury, one of the risk factors for stroke, is a leading cause of death in the younger adults. This study evaluated stroke risk in young-to-middle-aged adults based on traumatic brain injury severity and stroke subtypes. METHODS AND RESULTS For this retrospective, population-based, cohort study, data of adults aged 18 to 49 years who were diagnosed with traumatic brain injury were obtained from the Korean National Health Insurance Service between 2010 and 2017. Traumatic brain injury history was measured based on the International Classification of Diseases, Tenth Revision (ICD-10), codes. Posttraumatic brain injury stroke risk was analyzed using a time-dependent Cox regression model. At baseline, 518423 patients with traumatic brain injury and 518 423 age- and sex-matched controls were included. The stroke incidence rate per 1000 person-years was 3.82 in patients with traumatic brain injury and 1.61 in controls. Stroke risk was approximately 1.89 times as high in patients with traumatic brain injury (hazard ratio, 1.89 [95% CI, 1.84-1.95]). After excluding stroke cases that occurred within 12 months following traumatic brain injury, these significant associations remained. In the subgroup analysis, patients with brain injury other than concussion had an approximately 9.34-fold risk of intracerebral hemorrhage than did the controls. CONCLUSIONS Stroke prevention should be a priority even in young-to-middle-aged adult patients with traumatic brain injury. Managing stroke risk factors through regular health checkups and modifying health-related behaviors is necessary to prevent stroke.
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Affiliation(s)
- Yoonjeong Choi
- Department of Rehabilitation Medicine Seoul National University Hospital Seoul Republic of Korea
- National Traffic Injury Rehabilitation Research Institute, National Traffic Injury Rehabilitation Hospital Yangpyeong Republic of Korea
| | - Jooeun Jeon
- Department of Rehabilitation Medicine Seoul National University Hospital Seoul Republic of Korea
- National Traffic Injury Rehabilitation Research Institute, National Traffic Injury Rehabilitation Hospital Yangpyeong Republic of Korea
| | - Eun Jin Ha
- Department of Critical Care Medicine Seoul National University Hospital Seoul Republic of Korea
- Department of Neurosurgery Seoul National University Hospital, Seoul National University College of Medicine Seoul Republic of Korea
| | - Chi Kyung Kim
- Department of Neurology Korea University Guro Hospital and College of Medicine Seoul Republic of Korea
| | - Han Gil Seo
- Department of Rehabilitation Medicine Seoul National University Hospital Seoul Republic of Korea
- Department of Rehabilitation Medicine Seoul National University College of Medicine Seoul Republic of Korea
| | - Byung-Mo Oh
- Department of Rehabilitation Medicine Seoul National University Hospital Seoul Republic of Korea
- Department of Rehabilitation Medicine Seoul National University College of Medicine Seoul Republic of Korea
| | - Ja-Ho Leigh
- Department of Rehabilitation Medicine Seoul National University Hospital Seoul Republic of Korea
- National Traffic Injury Rehabilitation Research Institute, National Traffic Injury Rehabilitation Hospital Yangpyeong Republic of Korea
- Department of Rehabilitation Medicine Seoul National University College of Medicine Seoul Republic of Korea
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Turaczyk Kolodziej DA, Lung M, Lilienthal M, Galet C, Mani V, Skeete D. Shifting Perspectives: Equal Blunt Cerebrovascular Risk in Low-Versus High-Energy Cervical Fracture. J Surg Res 2024; 300:63-70. [PMID: 38795674 PMCID: PMC11246807 DOI: 10.1016/j.jss.2024.04.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 04/11/2024] [Accepted: 04/22/2024] [Indexed: 05/28/2024]
Abstract
INTRODUCTION Clinical implications of screening for blunt cerebrovascular injury (BCVI) after low-energy mechanisms of injury (LEMI) remain unclear. We assessed BCVI incidence and outcomes in LEMI versus high-energy mechanisms of injury (HEMI) patients. METHODS In this retrospective cohort study, blunt trauma adults admitted between July 2015 and June 2021 with cervical spine fractures, excluding single spinous process, osteophyte, and chronic fractures were included. Demographics, comorbidities, injuries, screening and treatment data, iatrogenic complications, and mortality were collected. Our primary end point was to compare BCVI rates between LEMI and HEMI patients. RESULTS Eight hundred sixty patients (78%) were screened for BCVI; 120 were positive for BCVI. LEMI and HEMI groups presented similar BCVI rates (12.6% versus 14.4%; P = 0.640). Compared to HEMI patients (n = 95), LEMI patients (n = 25) were significantly older (79 ± 14.9 versus 54.3 ± 17.4, P < 0.001), more likely to be on anticoagulants before admission (64% versus 23.2%, P < 0.001), and less severely injured (LEMI injury severity score 10.9 ± 6.6 versus HEMI injury severity score 18.7 ± 11.4, P = 0.001). All but one LEMI and 90.5% of the HEMI patients had vertebral artery injuries with no significant difference in BCVI grades. One HEMI patient developed acute kidney injury because of BCVI screening. Eleven HEMI patients developed BCVI-related stroke with two related mortalities. One LEMI patient died of a BCVI-related stroke. CONCLUSIONS BCVI rates were similar between HEMI and LEMI groups when screening based on cervical spine fractures. The LEMI group exhibited no screening or treatment complications, suggesting that benefits may outweigh the risks of screening and potential bleeding complications from treatment.
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Affiliation(s)
| | - Michael Lung
- Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Michele Lilienthal
- Acute Care Surgery Division, Department of Surgery, University of Iowa, Iowa City, Iowa
| | - Colette Galet
- Acute Care Surgery Division, Department of Surgery, University of Iowa, Iowa City, Iowa
| | - Vishnu Mani
- Acute Care Surgery Division, Department of Surgery, University of Iowa, Iowa City, Iowa
| | - Dionne Skeete
- Acute Care Surgery Division, Department of Surgery, University of Iowa, Iowa City, Iowa.
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Asaadi S, Khoury CB, Han J, Rosenthal MG, Murga AG, Dye J, Mukherjee K, Lopez-Gonzalez M, Kershisnik I, Crandall ML, Tabrizi MB. Stroke Prevention in Blunt Cerebrovascular Injury: Role of Aspirin 81 mg. Ann Vasc Surg 2024; 105:1-9. [PMID: 38492727 DOI: 10.1016/j.avsg.2023.12.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/18/2023] [Accepted: 12/17/2023] [Indexed: 03/18/2024]
Abstract
BACKGROUND The stroke rate in blunt cerebrovascular injury (BCVI) varies from 25% without treatment to less than 8% with antithrombotic therapy. There is no consensus on the optimal management to prevent stroke BCVI. We investigated the efficacy and safety of oral Aspirin (ASA) 81 mg to prevent BCVI-related stroke compared to historically reported stroke rates with ASA 325 mg and heparin. METHODS A single-center retrospective study included adult trauma patients who received oral ASA 81 mg for BCVI management between 2013 and 2022. Medical records were reviewed for demographic and injury characteristics, imaging findings, treatment-related complications, and outcomes. RESULTS Eighty-four patients treated with ASA 81 mg for BCVI were identified. The mean age was 41.50 years, and 61.9% were male. The mean Injury Severity Score and Glasgow Coma Scale were 19.82 and 12.12, respectively. A total of 101 vessel injuries were identified, including vertebral artery injuries in 56.4% and carotid artery injuries in 44.6%. Traumatic brain injury was found in 42.9%, and 16.7% of patients had a solid organ injur. Biffl grade I (52.4%) injury was the most common, followed by grade II (37.6%) and grade III (4.9%). ASA 81 mg was started in the first 24 hours in 67.9% of patients, including 20 patients with traumatic brain injury and 8 with solid organ injuries. BCVI-related stroke occurred in 3 (3.5%) patients with Biffl grade II (n = 2) and III (n = 1). ASA-related complications were not identified in any patient. The mean length of stay in the hospital was 10.94 days, and 8 patients died during hospitalization due to complications of polytrauma. Follow-up with computed tomography angiography was performed in 8 (9.5%) patients, which showed improvement in 5 and a stable lesion in 3 at a mean time of 58 days after discharge. CONCLUSIONS In the absence of clear guidelines regarding appropriate medication, BCVI management should be individualized case-by-case through a multidisciplinary approach. ASA 81 mg is a viable option for BCVI-related stroke prevention compared to the reported stroke rates (2%-8%) with commonly used antithrombotics like heparin and ASA 325 mg. Future prospective studies are needed to provide insight into the safety and efficacy of the current commonly used agent in managing BCVI.
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Affiliation(s)
- Sina Asaadi
- Division of Acute Care Surgery, Department of Surgery, Loma Linda University, Loma Linda, CA
| | - Christopher B Khoury
- Division of Acute Care Surgery, Department of Surgery, Loma Linda University, Loma Linda, CA
| | - Julia Han
- Division of Acute Care Surgery, Department of Surgery, Loma Linda University, Loma Linda, CA
| | - Martin G Rosenthal
- Division of Acute Care Surgery, Department of Surgery, Loma Linda University, Loma Linda, CA
| | - Allen G Murga
- Division of Vascular Surgery, Department of Surgery, Loma Linda University, Loma Linda, CA
| | - Justin Dye
- Department of Neurological Surgery, Loma Linda University, Loma Linda, CA
| | - Kaushik Mukherjee
- Division of Acute Care Surgery, Department of Surgery, Loma Linda University, Loma Linda, CA
| | | | - Ian Kershisnik
- Division of Acute Care Surgery, Department of Surgery, Loma Linda University, Loma Linda, CA
| | - Marie L Crandall
- Department of Surgery, University of Florida Health-Jacksonville, Jacksonville, FL
| | - Maryam B Tabrizi
- Division of Acute Care Surgery, Department of Surgery, Loma Linda University, Loma Linda, CA.
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Bar-Or D, Jarvis S, Lensing F, Bassa D, Carrick M, Palacio Lascano C, Busch M, Hamilton D, Acuna D, Greenseid S, Ojala D. The effect of circle of willis anatomy and scanning practices on outcomes for blunt cerebrovascular injuries. Scand J Trauma Resusc Emerg Med 2024; 32:57. [PMID: 38886775 PMCID: PMC11181559 DOI: 10.1186/s13049-024-01225-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 05/27/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Limited research has explored the effect of Circle of Willis (CoW) anatomy among blunt cerebrovascular injuries (BCVI) on outcomes. It remains unclear if current BCVI screening and scanning practices are sufficient in identification of concomitant COW anomalies and how they affect outcomes. METHODS This retrospective cohort study included adult traumatic BCVIs at 17 level I-IV trauma centers (08/01/2017-07/31/2021). The objectives were to compare screening criteria, scanning practices, and outcomes among those with and without COW anomalies. RESULTS Of 561 BCVIs, 65% were male and the median age was 48 y/o. 17% (n = 93) had a CoW anomaly. Compared to those with normal CoW anatomy, those with CoW anomalies had significantly higher rates of any strokes (10% vs. 4%, p = 0.04), ICHs (38% vs. 21%, p = 0.001), and clinically significant bleed (CSB) before antithrombotic initiation (14% vs. 3%, p < 0.0001), respectively. Compared to patients with a normal CoW, those with a CoW anomaly also had ischemic strokes more often after antithrombotic interruption (13% vs. 2%, p = 0.02).Patients with CoW anomalies were screened significantly more often because of some other head/neck indication not outlined in BCVI screening criteria than patients with normal CoW anatomy (27% vs. 18%, p = 0.04), respectively. Scans identifying CoW anomalies included both the head and neck significantly more often (53% vs. 29%, p = 0.0001) than scans identifying normal CoW anatomy, respectively. CONCLUSIONS While previous studies suggested universal scanning for BCVI detection, this study found patients with BCVI and CoW anomalies had some other head/neck injury not identified as BCVI scanning criteria significantly more than patients with normal CoW which may suggest that BCVI screening across all patients with a head/neck injury may improve the simultaneous detection of CoW and BCVIs. When screening for BCVI, scans including both the head and neck are superior to a single region in detection of concomitant CoW anomalies. Worsened outcomes (strokes, ICH, and clinically significant bleeding before antithrombotic initiation) were observed for patients with CoW anomalies when compared to those with a normal CoW. Those with a CoW anomaly experienced strokes at a higher rate than patients with normal CoW anatomy specifically when antithrombotic therapy was interrupted. This emphasizes the need for stringent antithrombotic therapy regimens among patients with CoW anomalies and may suggest that patients CoW anomalies would benefit from more varying treatment, highlighting the need to include the CoW anatomy when scanning for BCVI. LEVEL OF EVIDENCE Level III, Prognostic/Epidemiological.
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Affiliation(s)
- David Bar-Or
- Swedish Medical Center, Englewood, CO, USA.
- Injury Outcomes Network, Colorado, , Englewood, United States.
| | - Stephanie Jarvis
- Swedish Medical Center, Englewood, CO, USA
- Injury Outcomes Network, Colorado, , Englewood, United States
| | | | - David Bassa
- Medical City Plano, Texas, , Plano, United States
| | | | | | | | | | - David Acuna
- Wesley Medical Center, Kansas, , Wichita, United States
| | | | - Daniel Ojala
- Saint Anthony Hospital, Colorado, , Lakewood, United States
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Momic J, Yassin N, Kim MY, Walser E, Smith S, Ball I, Moffat B, Parry N, Vogt K. Antiplatelets versus anticoagulants in the treatment of blunt cerebrovascular injury (BCVI) - A systematic review and meta-analysis. Injury 2024; 55:111485. [PMID: 38452701 DOI: 10.1016/j.injury.2024.111485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/20/2024] [Accepted: 02/25/2024] [Indexed: 03/09/2024]
Abstract
INTRODUCTION Blunt cerebrovascular injury (BCVI) occurs in 1-3% of blunt traumas and is associated with stroke, disability, and mortality if unrecognized and untreated. Early detection and treatment are imperative to reduce the risk of stroke, however, there is significant variation amongst centers and trauma care providers in the specific medical management strategy used. This study compares antiplatelets vs. anticoagulants to determine BCVI-related stroke risk and bleeding complications to better understand the efficacy and safety of various treatment strategies. METHODS A systematic review of MEDLINE, Embase, and Cochrane CENTRAL databases was conducted with the assistance of a medical librarian. The search was supplemented with manual review of the literature. Included studies reported treatment-stratified risk of stroke following BCVI. All studies were screened independently by two reviewers, and data was extracted in duplicate. Meta-analysis was conducted using pooled estimates of odds ratios (OR) with a random-effects model using Mantel-Haenszel methods. RESULTS A total of 3315 studies screened yielded 39 studies for inclusion, evaluating 6552 patients (range 8 - 920 per study) with a total of 7643 BCVI. Stroke rates ranged from 0% to 32.8%. Amongst studies included in the meta-analysis, there were a total of 405 strokes, with 144 (35.5%) occurring on therapy, for a total stroke rate of 4.5 %. Meta-analysis showed that stroke rate after BCVI was lower for patients treated with antiplatelets vs. anticoagulants (OR 0.57; 95% CI 0.33-0.96, p = 0.04); when evaluating only the 9 studies specifically comparing ASA to heparin, the stroke rate was similar between groups (OR 0.43; 95% CI 0.15-1.20, p = 0.11). Eleven studies evaluated bleeding complications and demonstrated lower risk of bleeding with antiplatelets vs. anticoagulants (OR 0.29; 95% CI 0.13-0.63, p = 0.002); 5 studies evaluating risk of bleeding complications with ASA vs. heparin showed lower rates of bleeding complications with ASA (OR 0.16; 95% CI 0.04-0.58, p = 0.005). CONCLUSIONS Treatment of patients with BCVI with antiplatelets is associated with lower risks of stroke and bleeding complications compared to treatment with anticoagulants. Use of ASA vs. heparin specifically was not associated with differences in stroke risk, however, patients treated with ASA had fewer bleeding complications. Based on this evidence, antiplatelets should be the preferred treatment strategy for patients with BCVI.
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Affiliation(s)
- Jovana Momic
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada.
| | - Nouf Yassin
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Mella Y Kim
- Schulich School of Medicine and Dentistry, University of Western Ontario, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - Eric Walser
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Shane Smith
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada; Division of Vascular Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Ian Ball
- Department of Medicine, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Bradley Moffat
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Neil Parry
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Kelly Vogt
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
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Golubkova AA, Liebe HL, Leiva TD, Stewart KE, Sarwar Z, Hunter CJ, Johnson JJ. Blunt Cerebrovascular Injury in Pediatric Hanging Victims. Am Surg 2023; 89:5897-5903. [PMID: 37253687 DOI: 10.1177/00031348231180929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
INTRODUCTION Incidence of blunt cerebrovascular injury (BCVI) following hanging in the pediatric population is ill-defined. Current guidelines recommend screening imaging during the initial trauma evaluation. Necessity of screening is questioned given BCVI is considered rare after hanging, especially when asymptomatic. This study aims to elucidate the incidence of BCVI in pediatric hangings and determine the value of radiographic work-up. METHODS A retrospective cohort study was performed of pediatric hangings reported to the National Trauma Data Bank (NTDB), 2017-2019. Imaging, diagnoses, and findings suggestive of BCVI, such as Glasgow Coma Scale (GCS) ≤8, presence of cervical injury, and soft tissue injury were considered. Statistical analysis was carried out to compare incidence. RESULTS 197 patients met study criteria, with 179 arriving in the trauma bay with signs of life. BCVI incidence was 5.6% (10 of 179). Computed Tomography Angiography (CTA) of the neck was the only reported screening modality in this data set. A CTA was completed in 46% of the cases. DISCUSSION BCVI incidence following pediatric hanging is more common than previously thought. Less than half of patients had a CTA reported in this cohort. This may result in an underestimate. Given the potentially devastating consequences of a missed BCVI, the addition of CTA to initial work-up may be worthwhile to evaluate for cervical vascular injury, but further studies into the outcomes of children who do receive prophylactic therapy are needed.
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Affiliation(s)
- Alena A Golubkova
- Division of Pediatric Surgery, Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Heather L Liebe
- Division of Pediatric Surgery, Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Tyler D Leiva
- Division of Pediatric Surgery, Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Kenneth E Stewart
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Zoona Sarwar
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Catherine J Hunter
- Division of Pediatric Surgery, Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Jeremy J Johnson
- Division of Pediatric Surgery, Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Lamour D, Solano JJ, Rutherford J, Alter SM. Cerebellar Infarction from a Vertebral Artery Dissection after Blunt Chest Injury: A Case Report. Clin Pract Cases Emerg Med 2023; 7:230-233. [PMID: 38353190 PMCID: PMC10855282 DOI: 10.5811/cpcem.1301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 08/02/2023] [Accepted: 08/23/2023] [Indexed: 02/18/2024] Open
Abstract
Introduction Traumatic vertebral artery dissections resulting in stroke are relatively rare occurrences, especially in the absence of classic physical examination findings. Case Report We present the case of a 30-year-old male with chest pain following a car axle falling onto his chest while trying to change a tire. He was discharged from the emergency department after having a negative workup for thoracic injury. Six hours later, the patient returned with headache and was found to have a cerebellar stroke secondary to vertebral artery dissection. After hospitalization, the patient was discharged home without any neurological deficits. Conclusion As they are usually asymptomatic, up to 80% of patients with blunt cerebrovascular injury will have delayed or missed diagnoses. Given the increased awareness of vascular injuries and their high morbidity, physicians should maintain a high index of suspicion for this diagnosis.
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Affiliation(s)
- Daniella Lamour
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Department of Emergency Medicine, Boca Raton, Florida
- Bethesda Hospital East, Department of Emergency Medicine, Boynton Beach, Florida
- Delray Medical Center, Department of Emergency Medicine, Delray Beach, Florida
| | - Joshua J. Solano
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Department of Emergency Medicine, Boca Raton, Florida
- Bethesda Hospital East, Department of Emergency Medicine, Boynton Beach, Florida
- Delray Medical Center, Department of Emergency Medicine, Delray Beach, Florida
| | | | - Scott M. Alter
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Department of Emergency Medicine, Boca Raton, Florida
- Bethesda Hospital East, Department of Emergency Medicine, Boynton Beach, Florida
- Delray Medical Center, Department of Emergency Medicine, Delray Beach, Florida
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Hiatt KD, Agarwal R, Oravec CS, Johnson EC, Patel NP, Geer CP, Wolfe SQ, Zapadka ME. Blunt Cerebrovascular Injury: Are We Overscreening Low-Mechanism Trauma? AJNR Am J Neuroradiol 2023; 44:1296-1301. [PMID: 37827720 PMCID: PMC10631538 DOI: 10.3174/ajnr.a8004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 08/21/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND AND PURPOSE Screening patients with trauma for blunt cerebrovascular injury with neck CTA is a common practice, but there remains disagreement regarding which patients should be screened. We reviewed adult blunt cerebrovascular injury data from a level 1 trauma center to investigate whether screening is warranted in low-mechanism trauma. MATERIALS AND METHODS We reviewed all neck CTAs performed on adult trauma patients in the emergency department during the 2019 calendar year. Clinical and imaging risk factors for blunt cerebrovascular injury, trauma mechanism, initial neck CTA interpretations, results from subsequent CTA and DSA studies, antiplatelet and anticoagulant treatments, and outcome data were recorded. RESULTS One thousand one hundred thirty-six neck CTAs met the inclusion criteria, of which 965 (85%) were interpreted as having negative findings; 125, as having indeterminate findings (11%); and 46, as having positive findings (4%). Review of subsequent imaging and clinical documentation led to classification of 40 indeterminate studies (32%) as true-positives and 85 (68%) as false-positives. Blunt cerebrovascular injury was identified in 77 (12.6%) cases meeting and in 9 (1.7%) cases not meeting the expanded Denver criteria. The subset of 204 low-mechanism trauma cases (ground-level falls, blunt assaults, and low-impact motor vehicle collisions) not meeting the expanded Denver criteria (18% of the entire data set) could have been excluded from screening with 1 questionable injury and 0 ischemic strokes missed and 12 false-positive cases prevented. CONCLUSIONS We advocate reservation of blunt cerebrovascular injury screening in low-mechanism trauma for patients meeting the expanded Denver criteria. Further research is needed to determine the behavior of indeterminate cases and to establish criteria for separating true-positive from false-positive findings.
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Affiliation(s)
- Kevin D Hiatt
- From the Wake Forest School of Medicine (K.S.H., R.A., C.S.O., N.P.P., C.P.G., S.Q.W., M.E.Z.). Winston-Salem, North Carolina
- Department of Radiology (K.D.H., C.P.G., S.Q.W., M.E.Z.), Atrium Health Wake Forest Baptist
| | - Raghav Agarwal
- From the Wake Forest School of Medicine (K.S.H., R.A., C.S.O., N.P.P., C.P.G., S.Q.W., M.E.Z.). Winston-Salem, North Carolina
| | - Chesney S Oravec
- From the Wake Forest School of Medicine (K.S.H., R.A., C.S.O., N.P.P., C.P.G., S.Q.W., M.E.Z.). Winston-Salem, North Carolina
- Department of Neurological Surgery (C.S.O., S.Q.W.), Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Erica C Johnson
- Department of General Surgery (E.C.J.), Virginia Commonwealth University Health, Richmond, Virginia
| | - Nishk P Patel
- From the Wake Forest School of Medicine (K.S.H., R.A., C.S.O., N.P.P., C.P.G., S.Q.W., M.E.Z.). Winston-Salem, North Carolina
| | - Carol P Geer
- From the Wake Forest School of Medicine (K.S.H., R.A., C.S.O., N.P.P., C.P.G., S.Q.W., M.E.Z.). Winston-Salem, North Carolina
- Department of Radiology (K.D.H., C.P.G., S.Q.W., M.E.Z.), Atrium Health Wake Forest Baptist
| | - Stacey Q Wolfe
- From the Wake Forest School of Medicine (K.S.H., R.A., C.S.O., N.P.P., C.P.G., S.Q.W., M.E.Z.). Winston-Salem, North Carolina
- Department of Radiology (K.D.H., C.P.G., S.Q.W., M.E.Z.), Atrium Health Wake Forest Baptist
- Department of Neurological Surgery (C.S.O., S.Q.W.), Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Michael E Zapadka
- From the Wake Forest School of Medicine (K.S.H., R.A., C.S.O., N.P.P., C.P.G., S.Q.W., M.E.Z.). Winston-Salem, North Carolina
- Department of Radiology (K.D.H., C.P.G., S.Q.W., M.E.Z.), Atrium Health Wake Forest Baptist
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11
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D'Souza K, Norman M, Rebchuk AD, Samarasinghe N, Hounjet CD, Griesdale DE, Joos E, Field TS. Efficacy of Antithrombotic Therapy and Risk of Hemorrhagic Complication in Blunt Cerebrovascular Injury Patients with Concomitant Injury: A Systematic Review. J Am Coll Surg 2023; 237:663-672. [PMID: 37222430 DOI: 10.1097/xcs.0000000000000771] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND The risk-benefit balance of antithrombotic therapy administration for blunt cerebrovascular injuries (BCVI) patients with concomitant injuries at high risk for bleeding is an ongoing therapeutic conundrum for trauma clinicians. We performed a systematic review to assess the reported efficacy and safety of treatment in this population with respect to prevention of ischemic stroke and risk of hemorrhagic complications. STUDY DESIGN A systematic electronic literature search of MEDLINE, EMBASE, Cochrane Library, and Web of Science databases was performed from January 1, 1996 to December 31, 2021. Studies were included if they reported treatment-stratified clinical outcomes after antithrombotic therapy in BCVI patients with concomitant injuries at high risk of bleeding into a critical site. Data were extracted from selected studies by two independent reviewers, including the main outcomes of interest were BCVI-related ischemic stroke rates and rates of hemorrhagic complications. RESULTS Of the 5,999 studies reviewed, 10 reported on the effects of treating BCVI patients with concurrent traumatic injuries and were included for review. In the pooled data, among patients with BCVI and concomitant injury who received any form of antithrombotic therapy, the BCVI-related stroke rate was 7.6%. The subgroup of patients who did not receive therapy had an overall BCVI-related stroke rate of 34%. The total rate of hemorrhagic complications in the treated population was 3.4%. CONCLUSIONS In BCVI patients with concomitant injuries at high risk for bleeding, antithrombotic use reduces the risk of ischemic strokes with a low reported risk of serious hemorrhagic complications.
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Affiliation(s)
- Karan D'Souza
- From the Section of Acute Care Surgery and Trauma, Division of General Surgery (D'Souza, Samarasinghe, Joos), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mathew Norman
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Alexander D Rebchuk
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Neurosurgery, Department of Surgery (Rebchuk, Hounjet), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nadeesha Samarasinghe
- From the Section of Acute Care Surgery and Trauma, Division of General Surgery (D'Souza, Samarasinghe, Joos), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Celine D Hounjet
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Neurosurgery, Department of Surgery (Rebchuk, Hounjet), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Donald Eg Griesdale
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Critical Care Medicine (Griesdale), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Emilie Joos
- From the Section of Acute Care Surgery and Trauma, Division of General Surgery (D'Souza, Samarasinghe, Joos), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Thalia S Field
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Vancouver Stroke Program, Division of Neurology (Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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12
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Kim M, Subah G, Cooper J, Fortunato M, Nolan B, Bowers C, Prabhakaran K, Nuoman R, Amuluru K, Soldozy S, Das AS, Regenhardt RW, Izzy S, Gandhi C, Al-Mufti F. Neuroendovascular Surgery Applications in Craniocervical Trauma. Biomedicines 2023; 11:2409. [PMID: 37760850 PMCID: PMC10525707 DOI: 10.3390/biomedicines11092409] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/12/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023] Open
Abstract
Cerebrovascular injuries resulting from blunt or penetrating trauma to the head and neck often lead to local hemorrhage and stroke. These injuries present with a wide range of manifestations, including carotid or vertebral artery dissection, pseudoaneurysm, occlusion, transection, arteriovenous fistula, carotid-cavernous fistula, epistaxis, venous sinus thrombosis, and subdural hematoma. A selective review of the literature from 1989 to 2023 was conducted to explore various neuroendovascular surgical techniques for craniocervical trauma. A PubMed search was performed using these terms: endovascular, trauma, dissection, blunt cerebrovascular injury, pseudoaneurysm, occlusion, transection, vasospasm, carotid-cavernous fistula, arteriovenous fistula, epistaxis, cerebral venous sinus thrombosis, subdural hematoma, and middle meningeal artery embolization. An increasing array of neuroendovascular procedures are currently available to treat these traumatic injuries. Coils, liquid embolics (onyx or n-butyl cyanoacrylate), and polyvinyl alcohol particles can be used to embolize lesions, while stents, mechanical thrombectomy employing stent-retrievers or aspiration catheters, and balloon occlusion tests and super selective angiography offer additional treatment options based on the specific case. Neuroendovascular techniques prove valuable when surgical options are limited, although comparative data with surgical techniques in trauma cases is limited. Further research is needed to assess the efficacy and outcomes associated with these interventions.
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Affiliation(s)
- Michael Kim
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Galadu Subah
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Jared Cooper
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Michael Fortunato
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Bridget Nolan
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Christian Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM 87108, USA
| | - Kartik Prabhakaran
- Department of Surgery, Division of Trauma and Acute Care Surgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Rolla Nuoman
- Department of Neurology, Maria Fareri Children’s Hospital, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Krishna Amuluru
- Goodman Campbell Brain and Spine, Indianapolis, IN 46032, USA
| | - Sauson Soldozy
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Alvin S. Das
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Robert W. Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
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13
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Suzuki H, Funaba M, Imajo Y, Yokogawa N, Sasagawa T, Ando K, Nakashima H, Segi N, Funayama T, Eto F, Watanabe K, Yamane J, Furuya T, Nakajima H, Hasegawa T, Terashima Y, Ikegami S, Inoue G, Kaito T, Kato S. Blunt Cerebrovascular Injury in the Elderly with Traumatic Cervical Spine Injuries: Results of a Retrospective Multi-Center Study of 1512 Cases in Japan. J Neurotrauma 2023. [PMID: 36719766 DOI: 10.1089/neu.2022.0180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
This study is nationwide retrospective multi-center study to investigate the incidence and characteristics of blunt cerebrovascular injury (BCVI) in elderly Japanese patients with traumatic cervical spine injuries (CSI) including spinal cord injury (SCI) without major bone injury. The study enrolled 1512 patients (average age: 75.8 ± 6.9 years; 1007 males, 505 females) from 33 nationwide institutions, and 391 (26%) of the participants had digital subtraction angiography and/or computed tomography angiography. Fifty-three patients were diagnosed as having BCVI by angiography. We assessed neurological evaluation, comorbidities and classification of CSI in the elderly patients with/without BCVI and collected 6-month follow-up data on treatment, complications, and patient outcome. We also statistically analyzed the relative risk (RR) and relationship between BCVI and other factors. Significant differences were identified between BCVI (+) (n = 53) and (-) (n = 1459) patients with American Spinal Injury Association Impairment Scale (ASIA) A, C, D, cervical fracture, C3-7 injury level (AO type F and/or C), cervical dislocation, spinal surgery for CSI, tetraplegia type of SCI, and/or head injury. Fifty-three (3.5%) elderly patients had CSI complicated by BCVI including 10 (19%) cases of Denver grade I, four (7%) of grade II, 1 (2%) of grade III, 29 (55%) of grade IV, and nine (17%) of grade V. Sixteen cases were treated by interventional radiology. Rates of mortality and brain infarction from BCVI were 0.13% and 0.40%, respectively. RR of BCVI was significantly higher in the elderly cervical injury patients with head injury, severe neurological deficit, ASIA A (RR: 4.33), cervical fracture at the C3-7 level (RR: 7.39), and cervical dislocation at the C1-6 level (RR: 3.06-7.18). In conclusion, 53 (3.5%) elderly patients were complicated with BCVI. BCVI more frequently complicated head injury, severe neurological deficit (ASIA A or tetraplegia), AO type F, and/or C fractures and cervical dislocation in these patients. Six patients (11%) suffered brain infarction and two patients died from BCVI.
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Affiliation(s)
- Hidenori Suzuki
- Department of Orthopedics Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Masahiro Funaba
- Department of Orthopedics Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Yasuaki Imajo
- Department of Orthopedics Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Noriaki Yokogawa
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Ishikawa, Japan
| | - Takeshi Sasagawa
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Ishikawa, Japan.,Department of Orthopedics Surgery, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Kei Ando
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Hiroaki Nakashima
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Naoki Segi
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Toru Funayama
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Fumihiko Eto
- Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan
| | - Kota Watanabe
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Junichi Yamane
- Department of Orthopedic Surgery, National Hospital Organization Murayama Medical Center, Tokyo, Japan
| | - Takeo Furuya
- Department of Orthopedic Surgery, Graduate school of Medicine, Chiba University, Chiba, Japan
| | - Hideaki Nakajima
- Department of Orthopedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Tomohiko Hasegawa
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yoshinori Terashima
- Department of Orthopedic Surgery, Sapporo Medical University, Sapporo, Japan.,Department of Orthopedic Surgery, Matsuda Orthopedic Memorial Hospital, Sapporo, Japan
| | - Shota Ikegami
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Gen Inoue
- Department of Orthopedic Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Takashi Kaito
- Department of Orthopedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Satoshi Kato
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Ishikawa, Japan
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14
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Ali A, Broome JM, Tatum D, Abdullah Y, Black J, Tyler Simpson J, Salim A, Duchesne J, Taghavi S. Cost-Effectiveness of Universal Screening for Blunt Cerebrovascular Injury: A Markov Analysis. J Am Coll Surg 2023; 236:468-475. [PMID: 36440860 DOI: 10.1097/xcs.0000000000000490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Blunt cerebrovascular injury (BCVI) is a significant cause of morbidity and mortality after blunt trauma. Numerous screening strategies exist, although which is used is institution- and physician-dependent. We sought to identify the most cost-effective screening strategy for BCVI, hypothesizing that universal screening would be optimal among the screening strategies studied. STUDY DESIGN A Markov decision analysis model was used to compare the following screening strategies for identification of BCVI: (1) no screening; (2) Denver criteria; (3) extended Denver criteria; (4) Memphis criteria; and (5) universal screening. The base-case scenario modeled 50-year-old patients with blunt traumatic injury excluding isolated extremity injures. Patients with BCVI detected on imaging were assumed to be treated with antithrombotic therapy, subsequently decreasing risk of stroke and mortality. One-way sensitivity analyses were performed on key model inputs. A single-year horizon was used with an incremental cost-effectiveness ratio threshold of $100,000 per quality-adjusted life-year. RESULTS The most cost-effective screening strategy for patients with blunt trauma among the strategies analyzed was universal screening. This method resulted in the lowest stroke rate, mortality, and cost, and highest quality-adjusted life-year. An estimated 3,506 strokes would be prevented annually as compared with extended Denver criteria (incremental cost-effectiveness ratio of $71,949 for universal screening vs incremental cost-effectiveness ratio of $12,736 for extended Denver criteria per quality-adjusted life-year gained) if universal screening were implemented in the US. In 1-way sensitivity analyses, universal screening was the optimal strategy when the incidence of BCVI was greater than 6%. CONCLUSIONS This model suggests universal screening may be the cost-effective strategy for BCVI screening in blunt trauma for certain trauma centers. Trauma centers should develop institutional protocols that take into account individual BCVI rates.
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Affiliation(s)
- Ayman Ali
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ali, Broome, Tatum, Abdullah, Tyler Simpson, Duchesne, Taghavi)
- the Department of Surgery, Duke University School of Medicine, Durham, NC (Ali)
| | - Jacob M Broome
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ali, Broome, Tatum, Abdullah, Tyler Simpson, Duchesne, Taghavi)
| | - Danielle Tatum
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ali, Broome, Tatum, Abdullah, Tyler Simpson, Duchesne, Taghavi)
| | - Youssef Abdullah
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ali, Broome, Tatum, Abdullah, Tyler Simpson, Duchesne, Taghavi)
| | - Jonathan Black
- the Department of Surgery, University of Alabama at Birmingham, Birmingham, AL (Black)
| | - John Tyler Simpson
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ali, Broome, Tatum, Abdullah, Tyler Simpson, Duchesne, Taghavi)
| | - Ali Salim
- the Department of Surgery, Brigham and Women's Hospital, Boston, MA (Salim)
| | - Juan Duchesne
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ali, Broome, Tatum, Abdullah, Tyler Simpson, Duchesne, Taghavi)
| | - Sharven Taghavi
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ali, Broome, Tatum, Abdullah, Tyler Simpson, Duchesne, Taghavi)
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15
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Schmidt JC, Huang DD, Fleming AM, Brockman V, Hennessy EA, Magnotti LJ, Schroeppel T, McFann K, Hamilton LD, Dunn JA. Missed blunt cerebrovascular injuries using current screening criteria - The time for liberalized screening is now. Injury 2023; 54:1342-1348. [PMID: 36841698 DOI: 10.1016/j.injury.2023.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 01/18/2023] [Accepted: 02/07/2023] [Indexed: 02/27/2023]
Abstract
Diagnostic Criteria Study BACKGROUND: The morbidity and mortality associated with ischemic stroke attributable to blunt cerebrovascular injury (BCVI) warrant aggressive screening. The Denver Criteria (DC) and Expanded Denver Criteria (eDC) have imprecise elements that can be difficult and subjective in application and can delay or prevent screening. We hypothesize these screening criteria lack adequate ability to consistently identify BCVI and that the use of a liberalized screening approach with CT angiography (CTA) is superior without increasing risk of acute kidney injury (AKI). METHODS This was a multi-institutional retrospective cohort study of trauma patients who presented between 2015-2020 with radiographically confirmed BCVI diagnosed using each institutions' liberalized screening protocol, defined as automatic CTA of the head and neck for all patients undergoing head and neck CT. Outcomes of interest included AKI, stroke, and death due to BCVI. Outcomes were reported as frequency, percent, and 95% confidence interval as calculated by the Clopper-Pearson method. Incidence of medical follow-up within 1 year of first medical visit was quantified as the median and inter-quartile range of days to follow-up visit. RESULTS We identified 433 BCVI patients with a mean age of 45.2 (standard deviation 18.9) years, 256 men and 177 women, 1.73 m (0.10) tall, and weighed 80.3 kg (20.3). Forty-one patients had strokes (9.5% [95% confidence interval 6.9, 12.6] and 12 patients (2.8% [1.4, 4.5]) had mortality attributable to BCVI. Of 433 total cases, 132 (30.5% [26.2, 35.1]) would have been missed by DC and 150 (34.6% [30.2, 39.3]) by eDC. Incidence of AKI in our BCVI population was 6 (1.4% [0.01, 3.0]). CONCLUSIONS BCVI would be missed over 30% of the time using the DC and eDC compared to liberalized use of screening CTA. Risk of AKI due to CTA did not occur at a clinically meaningful level, supporting liberal CTA screening.
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Affiliation(s)
- Julia C Schmidt
- UCHealth North Medical Center of the Rockies, 2500 Rocky Mountain Avenue, Loveland, CO 80538, USA
| | - Dih-Dih Huang
- University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
| | - Andrew M Fleming
- University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
| | - Valerie Brockman
- UCHealth Memorial Hospital Central, 1400 Boulder Street, Colorado Springs, CO 80909, USA
| | - Elizabeth A Hennessy
- UCHealth Memorial Hospital Central, 1400 Boulder Street, Colorado Springs, CO 80909, USA
| | - Louis J Magnotti
- University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
| | - Thomas Schroeppel
- UCHealth Memorial Hospital Central, 1400 Boulder Street, Colorado Springs, CO 80909, USA
| | - Kim McFann
- UCHealth North Medical Center of the Rockies, 2500 Rocky Mountain Avenue, Loveland, CO 80538, USA
| | - Landon D Hamilton
- UCHealth North Medical Center of the Rockies, 2500 Rocky Mountain Avenue, Loveland, CO 80538, USA
| | - Julie A Dunn
- UCHealth North Medical Center of the Rockies, 2500 Rocky Mountain Avenue, Loveland, CO 80538, USA.
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16
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Azad TD, Raj D, Ahmed K, Ran K, Materi J, Dardick J, Olexa J, Musharbash F, Lubelski D, Witham T, Bydon A, Theodore N, Byrne JP, Haut E. Predictors of Blunt Cerebrovascular Injury, Stroke, and Mortality in Patients with Cervical Spine Trauma. World Neurosurg 2023; 169:e251-e259. [PMID: 36334717 DOI: 10.1016/j.wneu.2022.10.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 10/28/2022] [Accepted: 10/29/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Blunt cerebrovascular injury (BCVI), defined as blunt traumatic injury to the carotid or vertebral arteries, is associated with significant risk of stroke and mortality. Cervical spine trauma is a recognized risk factor for BCVI. OBJECTIVE The objective of this study was to identify significant predictors of BCVI and its sequelae in patients with known cervical spine injury. METHODS Patients from 2007 to 2018 with blunt cervical spine injury diagnoses were identified in the National Trauma Data Bank. Multivariable logistic regression models were used to identify patient baseline and injury characteristics associated with BCVI, stroke, and mortality. RESULTS We identified 229,254 patients with cervical spine injury due to blunt trauma. The overall rate of BCVI was 1.6%. Factors associated with BCVI in patients with cervical spine injury included lower Glasgow Coma Scale, motor vehicle crash, higher Injury Severity Score, concomitant traumatic brain or spinal cord injury, and current smoking status. BCVI was a strong predictor of stroke (odds ratio, 8.2; 95% confidence interval, 5.7-12.0) and was associated with mortality (odds ratio, 1.7; 95% confidence interval, 1.3-2.2). Stroke occurred in 3.3% of patients with BCVI versus 0.02% for patients without BCVI. CONCLUSIONS While BCVI is rare following cervical spine injury due to blunt trauma, it is a significant predictor of stroke and mortality. The risk factors associated with BCVI, stroke, and mortality identified here should be used in the development of more effective predictive tools to improve care.
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Affiliation(s)
- Tej D Azad
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Divyaansh Raj
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kowsar Ahmed
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kathleen Ran
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joshua Materi
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joseph Dardick
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joshua Olexa
- Department of Neurosurgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Farah Musharbash
- Department of Orthopedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Timothy Witham
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ali Bydon
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - James P Byrne
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Elliott Haut
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA.
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Bounajem MT, McNally JS, Baker C, Colby S, Grandhi R. Emergent neurovascular imaging in patients with blunt traumatic injuries. FRONTIERS IN RADIOLOGY 2022; 2:1001114. [PMID: 37492683 PMCID: PMC10365007 DOI: 10.3389/fradi.2022.1001114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 08/25/2022] [Indexed: 07/27/2023]
Abstract
Blunt cerebrovascular injuries (BCVIs) are commonly encountered after blunt trauma. Given the increased risk of stroke incurred after BCVI, it is crucial that they are promptly identified, characterized, and treated appropriately. Current screening practices generally consist of computed tomography angiography (CTA), with escalation to digital subtraction angiography for higher-grade injuries. Although it is quick, cost-effective, and readily available, CTA suffers from poor sensitivity and positive predictive value. A review of the current literature was conducted to examine the current state of emergent imaging for BCVI. After excluding reviews, irrelevant articles, and articles exclusively available in non-English languages, 36 articles were reviewed and included in the analysis. In general, as CTA technology has advanced, so too has detection of BCVI. Magnetic resonance imaging (MRI) with sequences such as vessel wall imaging, double-inversion recovery with black blood imaging, and magnetization prepared rapid acquisition echo have notably improved the utility for MRI in characterizing BCVIs. Finally, transcranial Doppler with emboli detection has proven to be associated with strokes in anterior circulation injuries, further allowing for the identification of high-risk lesions. Overall, imaging for BCVI has benefited from a tremendous amount of innovation, resulting in better detection and characterization of this pathology.
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Affiliation(s)
- Michael T. Bounajem
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - J. Scott McNally
- Department of Radiology, University of Utah, Salt Lake City, UT, United States
| | - Cordell Baker
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Samantha Colby
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
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Diagnostic accuracy of computed tomography angiography (CTA) for diagnosing blunt cerebrovascular injury in trauma patients: a systematic review and meta-analysis. Eur Radiol 2021; 32:2727-2738. [PMID: 34854931 PMCID: PMC8921112 DOI: 10.1007/s00330-021-08379-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/08/2021] [Accepted: 10/02/2021] [Indexed: 11/06/2022]
Abstract
Objectives Previous literature showed that the diagnostic accuracy of computed tomographic angiography (CTA) is not equally comparable with that of the rarely used golden standard of digital subtraction angiography (DSA) for detecting blunt cerebrovascular injuries (BCVI) in trauma patients. However, advances in CTA technology may prove CTA to become equally accurate. This study investigated the diagnostic accuracy of CTA in detecting BCVI in comparison with DSA in trauma patients. Methods An electronic database search was performed in PubMed, EMBASE, and Cochrane Library. Summary estimates of sensitivity, specificity, positive and negative likelihood, diagnostic odds ratio, and 95% confidence intervals were determined using a bivariate random-effects model. Results Of the 3293 studies identified, 9 met the inclusion criteria. Pooled sensitivity was 64% (95% CI, 53–74%) and specificity 95% (95% CI, 87–99%) The estimated positive likelihood ratio was 11.8 (95%, 5.6–24.9), with a negative likelihood ratio of 0.38 (95%, 0.30–0.49) and a diagnostic odds ratio of 31 (95%, 17–56). Conclusion CTA has reasonable specificity but low sensitivity when compared to DSA in diagnosing any BCVI. An increase in channels to 64 slices did not yield better sensitivity. There is a risk for underdiagnosis of BCVI when only using DSA to confirm CTA-positive cases, especially in those patients with low-grade injuries. Key Points • Low sensitivity and high specificity were seen in identifying BCVI with CTA as compared to DSA. • Increased CTA detector channels (≤ 64) did not lead to higher sensitivity when detecting BCVI. • The use of CTA instead of DSA may lead to underdiagnosis and, consequently, undertreatment of BCVI.
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19
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Al Babtain I, Abdullah M Alsahly M, A Aba Alkhail AB, Almutib JT, Al Otaibi RAF, Alsalamah ASH, Asseri YM, Ahmed AO. The Relationship Between Cerebrovascular Injuries and Craniomaxillofacial Fractures: Findings From a Tertiary Hospital in Saudi Arabia. Cureus 2021; 13:e17959. [PMID: 34660147 PMCID: PMC8515776 DOI: 10.7759/cureus.17959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2021] [Indexed: 11/08/2022] Open
Abstract
Background and objective Blunt cerebrovascular injuries (BCVIs) can lead to serious outcomes, particularly because they are difficult to detect in the acute phase. There are studies that have described the association between cerebrovascular injuries and craniomaxillofacial (CMF) fractures; however, no such study has been conducted among a Saudi population. In light of this, we conducted this study to evaluate the correlation between BCVI and CMF fractures among the local population in Saudi Arabia. In addition, the most common types of fractures associated with BCVI were identified. Methods This retrospective cohort study was conducted at the King Abdulaziz Medical City, a tertiary hospital in Riyadh, Saudi Arabia. All eligible patients with CMF fractures who were hospitalized at the King Abdulaziz Medical City were included. Consecutive patients were screened; no sampling or randomization was required. Patients with penetrating or avulsive mechanisms of injury were excluded. Results Out of a total of 1,560 patients included in the study, 1,537 (98.5%) had CMF fractures, while 23 (1.5%) had BCVIs. None of the patients with CMF fractures had BCVIs. Among the patients with BCVIs, 12 (52.2%) were men and 11 (47.8%) were women. The mean age of these patients was 46.91 ± 17.04 years. Among patients with CMF fractures, 1,071 (69.7%) were men and 466 (30.3%) were women. Their mean age was 23.93 ± 17.36 years. Conclusion The study did not identify any correlation between BCVI and CMF fractures; however, further studies with larger samples across multiple centers are needed to validate our findings and gain deeper insight into the relationship between BCVI and CMF fractures.
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Affiliation(s)
| | | | | | - Jehad T Almutib
- Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Rakan Ahmed F Al Otaibi
- Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
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20
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Ronaldi AE, Polcz JE, Robertson HT, Walker PF, Bozzay JD, Dubose JJ, White PW, Rasmussen TE, White JM. A multi-registry analysis of military and civilian penetrating cervical carotid artery injury. J Trauma Acute Care Surg 2021; 91:S226-S232. [PMID: 34039922 DOI: 10.1097/ta.0000000000003296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Penetrating cervical carotid artery injury is an uncommon but high-stake scenario associated with stroke and death. The objective of this study was to characterize and compare penetrating carotid injury in the military and civilian setting, as well as provide considerations for management. METHODS Cohorts with penetrating cervical carotid artery injury from the Department of Defense Trauma Registry (2002-2015) and the American Association for the Surgery of Trauma Prospective Observation Vascular Injury Treatment Registry (2012-2018) were analyzed. A least absolute shrinkage and selection operator multivariate analysis using random forest-based imputation was performed to identify risk factors affecting stroke and mortality. RESULTS There were a total of 157 patients included in the study, of which 56 (35.7%) were military and 101 (64.3%) were civilian. The military cohort was more likely to have been managed with open surgery (87.5% vs. 44.6%, p < 0.001) and to have had any procedure to restore or maintain flow to the brain (71.4% vs. 35.6%, p < 0.001), while the civilian cohort was more likely to undergo nonoperative management (45.5% vs. 12.5%, p < 0.001). Stroke rate was higher within the military cohort (41.1% vs. 13.9%, p < 0.001); however, mortality did not differ between the groups (12.5% vs. 17.8%, p = 0.52). On multivariate analysis, predictors for stroke were presence of a battle injury (log odds, 2.1; p < 0.001) and internal or common carotid artery ligation (log odds 1.5, p = 0.009). For mortality outcome, protective factors included a high Glasgow Coma Scale on admission (log odds, -0.21 per point; p < 0.001). Increased admission Injury Severity Score was a predictor of mortality (log odds, 0.05 per point; p = 0.005). CONCLUSION The stroke rate was higher in the military cohort, possibly reflecting complexity of injury; however, there was no difference in mortality between military and civilian patients. For significant injuries, concerted efforts should be made at carotid reconstruction to reduce the occurrence of stroke. LEVEL OF EVIDENCE Retrospective cohort analysis, level III.
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Affiliation(s)
- Alley E Ronaldi
- From the Department of Surgery (A.E.R., J.E.P., P.F.W., J.D.B., P.W.W., T.E.R., J.M.W.), Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Surgical Critical Care Initiative, Bethesda (H.T.R.); and R Adams Cowley Shock Trauma Center (J.J.D.), University of Maryland Medical System, Baltimore, Maryland
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21
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Wang G, Li C, Piao J, Xu B, Yu J. Endovascular treatment of blunt injury of the extracranial internal carotid artery: the prospect and dilemma. Int J Med Sci 2021; 18:944-952. [PMID: 33456352 PMCID: PMC7807178 DOI: 10.7150/ijms.50275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 12/18/2020] [Indexed: 11/15/2022] Open
Abstract
The extracranial internal carotid artery (ICA) refers to the anatomic location that reaches from the common carotid artery proximally to the skull base distally. The extracranial ICA belongs to the C1 segment of the Bouthillier classification and is at considerable risk for injury. Currently, the understanding of endovascular treatment (EVT) for blunt injury of the extracranial ICA is limited, and a comprehensive review is therefore important. In this review, we found that extracranial ICA blunt injury should be identified in patients presenting after blunt trauma, including classical dissection, pseudoaneurysm, and stenosis/occlusion. Computed tomography angiography (CTA) is the first-line method for screening for extracranial ICA blunt injury, although digital subtraction angiography (DSA) remains the "gold standard" in imaging. Antithrombotic treatment is effective for stroke prevention. However, routine EVT in the form of stenting should be reserved for patients with prolonged neurological symptoms from arterial stenosis or considerably enlarged pseudoaneurysm. Endovascular repair is now emerging as a favored therapeutic option given its demonstrated safety and positive clinical and radiographic outcomes.
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Affiliation(s)
- Guangming Wang
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
| | - Chao Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, 130021, China
| | - Jianmin Piao
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
| | - Baofeng Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
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McNutt MK, Slovacek C, Rosenbaum D, Indupuru HKR, Zhang X, Cotton BA, Harvin J, Wade CE, Savitz SI, Kao LS. Different strokes: differences in the characteristics and outcomes of BCVI and non-BCVI strokes in trauma patients. Trauma Surg Acute Care Open 2020; 5:e000457. [PMID: 32984546 PMCID: PMC7493120 DOI: 10.1136/tsaco-2020-000457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/14/2020] [Accepted: 04/21/2020] [Indexed: 01/13/2023] Open
Abstract
Background Although strokes are rare in trauma patients, they are associated with worse functional and cognitive outcomes and decreased mobility. Blunt cerebrovascular injury (BCVI)–related strokes and mortality have decreased, likely due to refined screening and treatment algorithms in trauma literature; however, there is a paucity of research addressing non-BCVI strokes in trauma. The purpose of this study is to evaluate the incidence, etiology, and risk factors of stroke in our trauma population in order to identify preventive strategies. Methods This study was a retrospective review of all adult trauma patients admitted to a level 1 trauma hospital who suffered a stroke during trauma admission from 2010 to 2017. Data were collected from the prospectively maintained trauma and stroke databases. Stroke etiology was determined by a vascular neurologist. Results Of the 43 674 adult trauma patients admitted during the study period, 99 (0.2%) were diagnosed with a stroke during the index admission. Twenty-one (21%) strokes were due to BCVI. Seventy-eight (79%) strokes were due to non-BCVI etiologies. Patients with non-BCVI strokes were older, less severely injured, and had more medical comorbidities compared with patients with a BCVI stroke. While patients with a BCVI stroke were more likely to suffer multiple traumatic injuries from MVC (76% vs 28%, p<0.001), non-BCVI strokes had more isolated extremity injuries from fall mechanism (55% vs 10%, p<0.001). Over the study period, the age and incidence of stroke and BCVI (p<0.001) increased. However, the rate of BCVI strokes decreased while the rate of non-BCVI strokes increased. Discussion The incidence of stroke has increased despite aggressive screening and treatment of BCVI. This increase is primarily due to non-BCVI strokes which are associated with advanced age and medical comorbidities after low mechanism traumatic injury. Medical optimization of comorbid conditions during trauma hospitalization will become increasingly important for stroke prevention as the population ages. Level of evidence: Level III
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Affiliation(s)
- Michelle K McNutt
- Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Cedar Slovacek
- University of Texas McGovern Medical School, Houston, Texas, USA
| | - David Rosenbaum
- Neurosurgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | | | - Xu Zhang
- Center for Clinical and Translational Sciences, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Bryan A Cotton
- Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - John Harvin
- Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Charles E Wade
- Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Sean I Savitz
- UTHealth Institute for Stroke and Cerebrovascular Disease, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Lillian S Kao
- Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
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Predictors of surgical management of high grade blunt splenic injuries in adult trauma patients: a 5-year retrospective cohort study from an academic level I trauma center. Patient Saf Surg 2020; 14:32. [PMID: 32774457 PMCID: PMC7398213 DOI: 10.1186/s13037-020-00257-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/21/2020] [Indexed: 12/13/2022] Open
Abstract
Backgrounds Splenic injury accounts for 40% of all injuries after blunt abdominal trauma. Blunt splenic injury in hemodynamically unstable patients is preferably treated by splenectomy. Nowadays hemodynamically stable patients with low grade splenic injuries are mostly treated by non-operative management (NOM). However no consensus exists about the management of high grade splenic injuries in hemodynamically stable patients. Therefore the aim of this study was to analyze patients with high grade splenic injuries in our institution. Methods We retrospectively included all patients with a splenic injury presented to our level I trauma center during the 5-year period from January 1, 2012, until December 31, 2017. Baseline characteristics, data regarding complications and mortality were collected from the electronic patient registry. Patients were grouped based on splenic injury and the treatment they received. Results A total of 123 patients were included, of which 93 (75.6%) were male with a median age of 31 (24–52) and a median injury severity score of 27 (17–34). High grade injuries (n = 28) consisted of 20 Grade IV injuries and 8 grade V injuries. Splenectomy was required in 15/28 (53.6%) patients, of whom all remained hemodynamically unstable after resuscitation, including all grade V injuries. A total of 13 patients with high grade injuries were treated with spleen preserving therapy. Seven of these patients received angio-embolization. One patient went for laparotomy and the spleen was treated with a hemostatic agent. Secondary hemorrhage was present in 3 of these patients (initial treatment: 1 embolization/ 2 observational), resulting in a success rate of 76.9%. There is no mortality seen in patient with high grade splenic injuries. Conclusion Non-operative treatment in high grade splenic injuries is a safe treatment modality in hemodynamically stable patients. Hemodynamic status and peroperative bleeding, not injury severity or splenic injury grade were the drivers for surgical management by splenectomy. This selected cohort of patients must be closely monitored to prevent adverse outcomes from secondary delayed bleeding in case of non-operative management.
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Barrera D, Sercy E, Orlando A, Mains CW, Madayag R, Carrick MM, Tanner A, Lieser M, Acuna D, Yon J, Bar-Or D. Associations of Antithrombotic Timing and Regimen with Ischemic Stroke and Bleeding Complications in Blunt Cerebrovascular Injury. J Stroke Cerebrovasc Dis 2020; 29:104804. [PMID: 32305279 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104804] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/15/2020] [Accepted: 03/03/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Blunt cerebrovascular injuries (BCVIs) are associated with long-term neurological effects. The first-line treatment for BCVIs is antithrombotics, but consensus on the optimal choice and timing of treatment is lacking. METHODS This was a retrospective study on patients aged at least 18 years admitted to 6 level 1 trauma centers between 1/1/2014 and 12/31/2017 with grade 1-4 BCVI and treated with antithrombotics. Differences in treatment practices were examined across the 6 centers. The primary outcome was ischemic stroke, and secondary outcomes were related to bleeding complications: blood transfusion and intracranial hemorrhage (ICH). Treatment characteristics examined were time to diagnosis and first computerized tomography angiography, time of total treatment course, time on each antithrombotic (anticoagulants, antiplatelets, combination), time from hospital arrival to antithrombotic initiation, and treatment interruption, i.e., treatment halted for a surgical procedure and restarted postoperatively. Chi-square, Fisher exact, Spearman's rank-order correlation, Wilcoxon rank-sum, Kruskal-Wallis, and Cox proportional hazards models with time-varying covariates were used to evaluate associations with the outcomes. RESULTS A total of 189 patients with BCVI were included. The median (IQR) time from arrival to antithrombotic initiation was 27 (8-61) hours, and 28% of patients had treatment interrupted. The ischemic stroke rate was 7.5% (n = 14), with most strokes (64%, n = 9) occurring between arrival and treatment initiation. Treatment interruption was associated with ischemic stroke (75% of patients with stroke had an interruption versus 24% of patients with no stroke; P < .01). Time on anticoagulants was not associated with ischemic stroke (P = .78), transfusion (P = .43), or ICH (P = .96). Similarly, time on antiplatelets (P = .54, P = .65, P = .60) and time on combination therapy (P = .96, P = .38, P = .57) were not associated with these outcomes. CONCLUSIONS The timing and consistency of antithrombotic administration are critical in preventing adverse outcomes in patients with BCVI. Most ischemic strokes in this study population occurred between arrival and antithrombotic initiation, representing events that may potentially be intervened upon by earlier treatment. Future studies should examine the safety of continuing treatment through surgical procedures.
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MESH Headings
- Adult
- Blood Transfusion
- Brain Injuries, Traumatic/diagnostic imaging
- Brain Injuries, Traumatic/drug therapy
- Brain Injuries, Traumatic/etiology
- Brain Ischemia/diagnostic imaging
- Brain Ischemia/etiology
- Brain Ischemia/therapy
- Cerebral Hemorrhage, Traumatic/diagnostic imaging
- Cerebral Hemorrhage, Traumatic/etiology
- Cerebral Hemorrhage, Traumatic/therapy
- Drug Administration Schedule
- Female
- Fibrinolytic Agents/administration & dosage
- Fibrinolytic Agents/adverse effects
- Humans
- Male
- Middle Aged
- Practice Patterns, Physicians'
- Retrospective Studies
- Risk Factors
- Stroke/diagnostic imaging
- Stroke/etiology
- Stroke/therapy
- Time Factors
- Time-to-Treatment
- Treatment Outcome
- United States
- Wounds, Nonpenetrating/diagnostic imaging
- Wounds, Nonpenetrating/drug therapy
- Wounds, Nonpenetrating/etiology
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Affiliation(s)
- Daniel Barrera
- Trauma Services Department, St. Anthony Hospital, Lakewood, Colorado
| | - Erica Sercy
- Trauma Research Department, St. Anthony Hospital, Lakewood, Colorado; Trauma Research Department, Swedish Medical Center, Englewood, Colorado; Trauma Research Department, Penrose Hospital, Colorado Springs, Colorado; Trauma Research Department, Medical City Plano, Plano, Texas; Trauma Research Department, Research Medical Center, Kansas City, Missouri; Trauma Research Department, Wesley Medical Center, Wichita, Kansas
| | - Alessandro Orlando
- Trauma Research Department, St. Anthony Hospital, Lakewood, Colorado; Trauma Research Department, Swedish Medical Center, Englewood, Colorado; Trauma Research Department, Penrose Hospital, Colorado Springs, Colorado; Trauma Research Department, Medical City Plano, Plano, Texas; Trauma Research Department, Research Medical Center, Kansas City, Missouri; Trauma Research Department, Wesley Medical Center, Wichita, Kansas
| | | | - Robert Madayag
- Trauma Services Department, St. Anthony Hospital, Lakewood, Colorado
| | | | - Allen Tanner
- Trauma Services Department, Penrose Hospital, Colorado Springs, Colorado
| | - Mark Lieser
- Trauma Services Department, Research Medical Center, Kansas City, Missouri
| | - David Acuna
- Trauma Services Department, Wesley Medical Center, Wichita, Kansas
| | - James Yon
- Trauma Services Department, Swedish Medical Center, Englewood, Colorado
| | - David Bar-Or
- Trauma Research Department, St. Anthony Hospital, Lakewood, Colorado; Trauma Research Department, Swedish Medical Center, Englewood, Colorado; Trauma Research Department, Penrose Hospital, Colorado Springs, Colorado; Trauma Research Department, Medical City Plano, Plano, Texas; Trauma Research Department, Research Medical Center, Kansas City, Missouri; Trauma Research Department, Wesley Medical Center, Wichita, Kansas.
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