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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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Hego C, Rousseau G, Abback PS, Pommier R, Hamada SR, Bergis B, Jurcisin I, Diallo A, Paugam-Burtz C, Sigaut S, Gauss T, Moyer JD. Long-term outcome following blunt cerebrovascular injuries: occurrence of ischemic complications, treatment, and outcome. Eur J Trauma Emerg Surg 2022; 48:3131-3140. [DOI: 10.1007/s00068-021-01860-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 12/11/2021] [Indexed: 11/03/2022]
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Shibahashi K, Hoda H, Ishida T, Motoshima T, Sugiyama K, Hamabe Y. Derivation and validation of a quantitative screening model for blunt cerebrovascular injury. J Neurosurg 2021; 135:1129-1138. [PMID: 33578388 DOI: 10.3171/2020.8.jns202589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 08/24/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to derive and validate a new screening model using a nomogram that allows clinicians to quantify the risk of blunt cerebrovascular injury (BCVI). METHODS In this study, the authors examined 258,935 patients from a prospectively collected nationwide Japanese database (January 2009-December 2018) who experienced blunt injury. Patients were randomly divided into training (n = 129,468) and validation (n = 129,467) cohorts. First, the authors investigated the prevalence of BCVI, which was defined as blunt injury to any intracranial vessel, the extracranial vertebral artery, the extracranial carotid (common, internal) artery, or the internal jugular vein. Then, a new arterial BCVI screening model using a nomogram was derived, based on multivariate logistic regression analysis through quantifying the association of potential predictive factors with BCVI in the training cohort. The model's discriminatory ability was validated using the area under the receiver operating characteristic curve (AUC) in the validation cohort. RESULTS Multivariate analysis in the training cohort showed that 13 factors were significantly associated with arterial BCVI and were included in our model. These factors were 1) male sex; 2) high-energy impact; 3) hypotension on hospital arrival; 4) Glasgow Coma Scale score < 9; 5) injury to the face; 6) injury to the neck; 7) injury to the spine; 8) skull base fracture; 9) cervical spine fracture or subluxation; and those with negative associations, i.e., 10) injury to the lower-extremity region; 11) supratentorial subdural hemorrhage; 12) lumbar spine fracture or subluxation; and 13) soft tissue injury of the face. In the validation cohort, the model had an AUC of 0.83 (95% CI 0.81-0.86). When the definition of BCVI was narrowed to include only carotid (common, internal) and vertebral artery injuries, the AUC of the model in predicting these injuries was 0.89 (95% CI 0.87-0.91). CONCLUSIONS A new screening model that incorporates an easy-to-use nomogram to quantify the risk of BCVI and assist clinicians in identifying patients who warrant additional evaluation was established.
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Affiliation(s)
- Keita Shibahashi
- 1Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo; and
| | - Hidenori Hoda
- 1Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo; and
| | - Takuto Ishida
- 1Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo; and
| | - Takayuki Motoshima
- 2Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kazuhiro Sugiyama
- 1Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo; and
| | - Yuichi Hamabe
- 1Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo; and
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Black JA, Abraham PJ, Abraham MN, Cox DB, Griffin RL, Holcomb JB, Hu PJ, Kerby JD, Liptrap EJ, Thaci B, Harrigan MR, Jansen JO. Universal screening for blunt cerebrovascular injury. J Trauma Acute Care Surg 2021; 90:224-231. [PMID: 33502144 DOI: 10.1097/ta.0000000000003010] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Blunt cerebrovascular injury (BCVI) can result in thromboembolic stroke. Many trauma centers selectively screen patients with cervical computed tomographic angiography (CTA) based on clinical criteria. In 2016, our institution adopted universal screening for BCVI for all blunt trauma patients. The aim of this study was to accurately determine the incidence of BCVI and to evaluate the diagnostic performance of the Denver criteria (DC), expanded Denver criteria (eDC), and Memphis criteria (MC) in selecting patients for screening. METHODS Retrospective cohort study of adult (≥16 years) blunt trauma patients who presented to the Level I trauma center at University of Alabama at Birmingham. We reviewed all CTA reports and selected CTA images to obtain the true incidence rate of BCVI. We then evaluated the diagnostic performance of the DC, eDC, and MC. RESULTS A total of 6,800 patients who had suffered blunt trauma were evaluated, of whom 6,287 (92.5%) had a neck CTA. Of these, 480 (7.6%) patients had CTA evidence of BCVI. The eDC identified the most BCVI cases (sensitivity 74.7%) but had the lowest positive predictive value (14.6%). The DC and MC had slightly greater positive predictive values (19.6% and 20.6%, respectively) and had the highest diagnostic ability in terms of likelihood ratio (2.8 and 2.9) but had low sensitivity (57.5% and 47.3%). Consequently, if relying on the traditional screening criteria, the DC, eDC, and MC would have respectively resulted in 42.5%, 25.3%, and 52.7% of patients with BCVI identified by universal screening not receiving a neck CTA to screen for BCVI. CONCLUSION Blunt cerebrovascular injury is even more common than previously thought. The diagnostic performance of selective clinical screening criteria is poor. Consideration should be given to the implementation of universal screening for BCVI using neck CTA in all blunt trauma patients. LEVEL OF EVIDENCE Diagnostic, level III.
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Affiliation(s)
- Jonathan A Black
- From the Division of Acute Care Surgery, Department of Surgery, (J.A.B, D.B.C., J.B.H., P.J.H., J.D.K., J.O.J.); Department of Surgery (P.J.A., M.N.A.), School of Public Health (R.L.G.), Department of Neurosurgery (E.J.L., M.R.H.), and Department of Radiology (B.T.), University of Alabama at Birmingham, Birmingham, Alabama
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Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2020; 88:875-887. [DOI: 10.1097/ta.0000000000002668] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Diagnostic accuracy of different clinical screening criteria for blunt cerebrovascular injuries compared with liberal state of the art computed tomography angiography in major trauma. J Trauma Acute Care Surg 2020; 88:789-795. [DOI: 10.1097/ta.0000000000002682] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Abu Mughli R, Wu T, Li J, Moghimi S, Alem Z, Nasir MU, Abdellatif W, Nicolaou S. An Update in Imaging of Blunt Vascular Neck Injury. Can Assoc Radiol J 2020; 71:281-292. [PMID: 32174162 DOI: 10.1177/0846537120909468] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Traumatic injuries of the cervical carotid and vertebral arteries, collectively referred to as blunt cerebrovascular injury (BCVI), can result in significant patient morbidity and mortality, with one of the most feared outcomes being cerebrovascular ischemia. Systematic imaging-guided screening for BCVI aims for early detection to guide timely management. In particular, accurate detection of the severity and grade of BCVI is paramount in guiding initial management. Furthermore, follow-up imaging is required to decide the duration of antithrombotic therapy. In this article, classification of the grades of BCVI and associated imaging findings will be outlined and diagnostic pitfalls and mimickers that can confound diagnosis will be described. In addition, updates to existing screening guidelines and recent efforts of criteria modification to improve detection of BCVI cases will be reviewed. The advent of postprocessing tools applied to conventional computed tomography (CT) angiograms and new diagnostic tools in dual energy CT for improved detection will also be discussed.
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Affiliation(s)
- Rawan Abu Mughli
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Tong Wu
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Jessica Li
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Saba Moghimi
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Zersenay Alem
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Muhammad Umer Nasir
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Waleed Abdellatif
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Savvas Nicolaou
- Radiology Department, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
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Sharma P, Hegde R, Kulkarni A, Sharma S, Soin P, Kochar PS, Kumar Y. Traumatic vertebral artery injury: a review of the screening criteria, imaging spectrum, mimics, and pitfalls. Pol J Radiol 2019; 84:e307-e318. [PMID: 31636765 PMCID: PMC6798777 DOI: 10.5114/pjr.2019.88023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 05/01/2019] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Traumatic vertebral artery injury (TVAI) can have a varied clinical presentation and appearance on imaging. In this review, we present the screening criteria, spectrum of imaging features, grading, and imaging pitfalls of TVAI. Our review focuses on the imaging of TVAI on computed tomography angiography (CTA), magnetic resonance angiography (MRA), and cases of TVAI mimics. IMAGING The imaging spectrum on CTA can range from either focal or long segment luminal stenosis (the most common findings), smooth or tapered narrowing of lumen, string of pearls appearance, concentric intramural haematoma, intimal flap (the most definite sign), and double lumen of the artery. On time-of-flight MRA, the most common findings include loss of flow void within the vessel due to slow flow, thrombosis or occlusion, and hyperintense signal within the vessel wall due to intramural haematoma on T1 fat-saturated images. CONCLUSION The reader should be aware of the screening criteria, common and uncommon findings, variant anatomy, artifacts, and mimics of TVAI when evaluating cases of craniocervical trauma, to be competent in calling in or ruling out injury.
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Affiliation(s)
- Pranav Sharma
- Yale New Haven Health Bridgeport Hospital, Connecticut, USA
| | - Rahul Hegde
- Yale New Haven Health Bridgeport Hospital, Connecticut, USA
| | | | | | - Priti Soin
- Weil Cornell College Of Medicine, New York, USA
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AlBayar A, Sullivan PZ, Blue R, Leonard J, Kung DK, Ozturk AK, Chen HI, Schuster JM. Risk of Vertebral Artery Injury and Stroke Following Blunt and Penetrating Cervical Spine Trauma: A Retrospective Review of 729 Patients. World Neurosurg 2019; 130:e672-e679. [PMID: 31279109 DOI: 10.1016/j.wneu.2019.06.187] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Cervical spine trauma (CST) may result in vertebral artery injury (VAI), increasing the risk of developing stroke. Stroke risk following CST is poorly reported. METHODS In total, 729 patients with CST were retrospectively analyzed, including rates of VAI, age at injury, cause of injury, cardiovascular history, smoking history, substance abuse history, embolization therapy, and antiplatelet or anticoagulant therapy prior or after injury. VAIs were identified and graded following the Modified Denver Criteria for Blunt Cerebrovascular Injury using magnetic resonance angiography and computed tomography angiography. Brain scans were reviewed for stroke rates and statistically significant variations. RESULTS Thirty-three patients suffered penetrating trauma, whereas 696 patients experienced blunt trauma. In total, 81 patients met the criteria for analysis with confirmed VAI. VAI was more common in penetrating injury group compared with blunt injury group (64% vs. 9%, P < 0.0005). However, low-grade VAI (less than grade III) was more common in blunt injury group versus penetrating group (37% vs. 14%, P < 0.05). The frequency of posterior circulation strokes did not vary significantly between groups (26.3% vs. 13.8%, P = 0.21). Cardiovascular comorbidities were significantly more common in the blunt group (50%, P = 0.0001) compared with the penetrating group (0%). CONCLUSIONS VAI occurs with a high incidence in penetrating CST. Although stroke risk following penetrating and blunt CST did not vary significantly, they resulted in serious complications in a group of patients. Further study of this patient population is required to provide high-level, evidence-based preventions for VAI complications.
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Affiliation(s)
- Ahmed AlBayar
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Patricia Zadnik Sullivan
- Department of Neurosurgery, Surgical Critical Care and Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - Rachel Blue
- Department of Neurosurgery, Surgical Critical Care and Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - Jennifer Leonard
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - David K Kung
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ali K Ozturk
- Department of Neurosurgery, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - H Isaac Chen
- Department of Neurosurgery, Surgical Critical Care and Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA; Department of Neurosurgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - James M Schuster
- Department of Neurosurgery, Surgical Critical Care and Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
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Nally MC, Kling C, Hocking KM, Lillemoe H, Boll JM, Curci JA, Garrard CL, Naslund TC, Valentine RJ. Follow-up imaging of traumatic vertebral artery dissections is unnecessary in asymptomatic patients. J Vasc Surg 2019; 69:1704-1709. [DOI: 10.1016/j.jvs.2018.09.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 09/27/2018] [Indexed: 11/27/2022]
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Brommeland T, Helseth E, Aarhus M, Moen KG, Dyrskog S, Bergholt B, Olivecrona Z, Jeppesen E. Best practice guidelines for blunt cerebrovascular injury (BCVI). Scand J Trauma Resusc Emerg Med 2018; 26:90. [PMID: 30373641 PMCID: PMC6206718 DOI: 10.1186/s13049-018-0559-1] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 10/10/2018] [Indexed: 01/12/2023] Open
Abstract
Blunt cerebrovascular injury (BCVI) is a non-penetrating injury to the carotid and/or vertebral artery that may cause stroke in trauma patients. Historically BCVI has been considered rare but more recent publications indicate an overall incidence of 1-2% in the in-hospital trauma population and as high as 9% in patients with severe head injury. The indications for screening, treatment and follow-up of these patients have been controversial for years with few clear recommendations. In an attempt to provide a clinically oriented guideline for the handling of BCVI patients a working committee was created. The current guideline is the end result of this committees work. It is based on a systematic literature search and critical review of all available publications in addition to a standardized consensus process. We recommend using the expanded Denver screening criteria and CT angiography (CTA) for the detection of BCVI. Early antithrombotic treatment should be commenced as soon as considered safe and continued for at least 3 months. A CTA at 7 days to confirm or discard the diagnosis as well as a final imaging control at 3 months should be performed.
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Affiliation(s)
- Tor Brommeland
- Department of Neurosurgery, Oslo University Hospital Ullevål, Kirkeveien 166, 0450 Oslo, Norway
| | - Eirik Helseth
- Department of Neurosurgery, Oslo University Hospital Ullevål, Kirkeveien 166, 0450 Oslo, Norway
- Faculty of Medicine, University of Oslo, Problemveien 7, 0315 Oslo, Norway
| | - Mads Aarhus
- Department of Neurosurgery, Oslo University Hospital Ullevål, Kirkeveien 166, 0450 Oslo, Norway
| | - Kent Gøran Moen
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Medical Imaging, Nord-Trondelag Health Trust, Levanger, Norway
| | - Stig Dyrskog
- Department of Neurointensive care, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus, C, Denmark
| | - Bo Bergholt
- Department of Neurosurgery, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus, C, Denmark
| | - Zandra Olivecrona
- Department of Anestesia and Intensive care, Section for Neurosurgery, Faculty of Health and Medicine, Department for Medical Sciences, Södre Grev Rosengatan, 70185 Örebro, Sweden
| | - Elisabeth Jeppesen
- National Trauma Registry, Department of Research and Development, Division of Orthopedics, Oslo University Hospital, NO-0424 Oslo, Norway
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Letter to the Editor Regarding "Increased detection of blunt carotid and vertebral artery injury after implementation of diagnostic imaging pathway in level 1 trauma centre in Western Australia". Injury 2018; 49:738-739. [PMID: 29366548 DOI: 10.1016/j.injury.2018.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 01/15/2018] [Indexed: 02/02/2023]
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