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Biffl WL, Moore EE, Kansagra AP, Flores BCCR, Weiss JS. Diagnosis and management of blunt cerebrovascular injuries: What you need to know. J Trauma Acute Care Surg 2024:01586154-990000000-00777. [PMID: 39093622 DOI: 10.1097/ta.0000000000004439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
ABSTRACT Blunt cerebrovascular injuries are not as rare as they were once thought to be-but they still have the same potential for disastrous outcomes. They may occur following any trauma, but more common with higher energy transfer mechanisms. If stroke occurs, prompt recognition and treatment offers the best chance for optimal outcome. Early diagnosis and provision of antithrombotic therapy may prevent strokes, so screening of asymptomatic patients is recommended. Herein we will present what you need to know to diagnose and manage blunt cerebrovascular injury.
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Affiliation(s)
- Walter L Biffl
- From the Division of Trauma/Acute Care Surgery (W.L.B.), Scripps Clinic/Scripps Clinic Medical Group, La Jolla, California Department of Surgery/Trauma (E.E.M.), Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado Denver, Denver, Colorado; Division of Neuroradiology, Department of Radiology (A.P.K.), Santa Clara Valley Medical Center, San Jose, California; Section of Neurosurgery and Neurointerventional Radiology (B.C.C.R.F.), Scripps Memorial Hospital La Jolla; and Division of Vascular Surgery (J.S.W.), Scripps Clinic/Scripps Clinic Medical Group, La Jolla, California
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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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Chatterjee AR, Malhotra A, Curl P, Andre JB, Perez-Carrillo GJG, Smith EB. Traumatic Cervical Cerebrovascular Injury and the Role of CTA: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2024; 223:e2329783. [PMID: 37791730 DOI: 10.2214/ajr.23.29783] [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: 10/05/2023]
Abstract
Traumatic cerebrovascular injury (CVI) involving the cervical carotid and vertebral arteries is rare but can lead to stroke, hemodynamic compromise, and mortality in the absence of early diagnosis and treatment. The diagnosis of both blunt cerebrovascular injury (BCVI) and penetrating CVI is based on cerebrovascular imaging. The most commonly used screening criteria for BCVI include the expanded Denver criteria and the Memphis criteria, each providing varying thresholds for subsequent imaging. Neck CTA has supplanted catheter-based digital subtraction angiography as the preferred screening modality for CVI in patients with trauma. This AJR Expert Panel Narrative Review describes the current state of CTA-based cervical imaging in trauma. We review the most common screening criteria for BCVI, discuss BCVI grading scales that are based on neck CTA, describe the diagnostic performance of CTA in the context of other imaging modalities and evolving treatment strategies, and provide a practical guide for neck CTA implementation.
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Affiliation(s)
- Arindam Rano Chatterjee
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, 510 S Kingshighway, Box 8131, St. Louis, MO 63110
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT
| | - Patti Curl
- Department of Radiology, Neuroradiology Section, University of Washington School of Medicine, Seattle, WA
| | - Jalal B Andre
- Department of Radiology, Neuroradiology Section, University of Washington School of Medicine, Seattle, WA
| | - Gloria J Guzman Perez-Carrillo
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, 510 S Kingshighway, Box 8131, St. Louis, MO 63110
| | - Elana B Smith
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD
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Lee MJ, Weaver DJ, El Dafrawy MH. Extracranial Vertebral Artery Injuries. J Am Acad Orthop Surg 2024:00124635-990000000-01007. [PMID: 38810231 DOI: 10.5435/jaaos-d-24-00244] [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] [Received: 02/29/2024] [Accepted: 04/28/2024] [Indexed: 05/31/2024] Open
Abstract
Paired vertebral arteries (VAs) travel from the subclavian artery through the cervical spine and into the intracranial space where they contribute to posterior cerebral circulation. Blunt and penetrating injuries to the cervical spine risk injury to the VA. Among the most feared complications of vertebral artery injury (VAI) is posterior circulation stroke. Appropriate screening and treatment of these injuries in the trauma setting remain vitally important to aid in the prevention of devastating neurologic sequelae. A robust knowledge of the VA anatomy is required for spine surgeons to avoid VAI during cervical spine approaches and instrumentation. Both anterior and posterior cervical spine surgeries can place the VA at risk. Careful preoperative assessment with the appropriate advanced imaging studies is necessary to verify the course of the VA in the cervical spine and thus prevent iatrogenic injury because anatomic variations along the course of the artery can prove hazardous if not properly anticipated. Iatrogenic VAI can be treated successfully with tamponade. However, in some cases, ligation, repair, or endovascular procedures may be indicated.
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Affiliation(s)
- Michael J Lee
- From the Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL
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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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Tran A, Fernando SM, Rochwerg B, Hawes H, Hameed MS, Dawe P, Garraway N, Evans DC, Kim D, Biffl WL, Inaba K, Engels PT, Vogt K, Kubelik D, Petrosoniak A, Joos E. Prognostic factors associated with risk of stroke following blunt cerebrovascular injury: A systematic review and meta-analysis. Injury 2024; 55:111319. [PMID: 38277875 DOI: 10.1016/j.injury.2024.111319] [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: 11/23/2023] [Revised: 12/23/2023] [Accepted: 01/08/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND & OBJECTIVES Blunt cerebrovascular injury (BCVI) includes carotid and/or vertebral artery injury following trauma, and conveys an increased stroke risk. We conducted a systematic review and meta-analysis to provide a comprehensive summary of prognostic factors associated with risk of stroke following BCVI. METHODS We searched the EMBASE and MEDLINE databases from January 1946 to June 2023. We identified studies reporting associations between patient or injury factors and risk of stroke following BCVI. We performed meta-analyses of odds ratios (ORs) using the random effects method and assessed individual study risk of bias using the QUIPS tool. We separately pooled adjusted and unadjusted analyses, highlighting the estimate with the higher certainty. RESULTS We included 26 cohort studies, involving 20,458 patients with blunt trauma. The overall incidence of stroke following BCVI was 7.7 %. Studies were predominantly retrospective cohorts from North America and included both carotid and vertebral artery injuries. Diagnosis of BCVI was most commonly confirmed with CT angiography. We demonstrated with moderate to high certainty that factors associated with increased risk of stroke included carotid artery injury (as compared to vertebral artery injury, unadjusted odds ratio [uOR] 1.94, 95 % CI 1.62 to 2.32), Grade III Injury (as compared to grade I or II) (uOR 2.45, 95 % CI 1.88 to 3.20), Grade IV injury (uOR 3.09, 95 % CI 2.20 to 4.35), polyarterial injury (uOR 3.11 (95 % CI 2.05 to 4.72), occurrence of hypotension at the time of hospital admission (adjusted odds ratio [aOR] 1.32, 95 % CI 0.87 to 2.03) and higher total body injury severity (aOR 5.91, 95 % CI 1.90 to 18.39). CONCLUSION Local anatomical injury pattern, overall burden of injury and flow dynamics contribute to BCVI-related stroke risk. These findings provide the foundational evidence base for risk stratification to support clinical decision making and further research.
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Affiliation(s)
- Alexandre Tran
- Division of Critical Care, The Ottawa Hospital, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Shannon M Fernando
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Harvey Hawes
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Morad S Hameed
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Phillip Dawe
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Naisan Garraway
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - David C Evans
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Dennis Kim
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Walter L Biffl
- Department of Surgery, Scripps Medical Group, La Jolla, CA, USA
| | - Kenji Inaba
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Paul T Engels
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Canada; Department of Surgery, McMaster University, Hamilton, Canada
| | - Kelly Vogt
- Department of Surgery, University of Western Ontario, London, Canada
| | - Dalibor Kubelik
- Division of Critical Care, The Ottawa Hospital, Ottawa, Canada; Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Andrew Petrosoniak
- Department of Emergency Medicine, University of Toronto, Toronto, Canada
| | - Emilie Joos
- Department of Surgery, University of British Columbia, Vancouver, Canada
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Lamanna JJ, Gutierrez J, Alawieh A, Funk C, Rindler RS, Ahmad F, Howard BM, Gupta SK, Gimbel DA, Smith RN, Pradilla G, Grossberg JA. Association of Cerebrovascular Injury and Secondary Vascular Insult With Poor Outcomes After Gunshot Wound to the Head in a Large Civilian Population. Neurosurgery 2024; 94:240-250. [PMID: 37796002 DOI: 10.1227/neu.0000000000002700] [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: 01/25/2023] [Accepted: 08/02/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Cerebrovascular injury (CVI) after civilian gunshot wound to the head (GSWH) likely contributes to poor outcomes, but little supporting evidence exists. The purpose of this study was to determine whether intracranial CVI from GSWH and secondary vascular insult (stroke or rehemorrhage) were associated with poor outcomes in a large civilian population. METHODS This was a single-institution, retrospective cohort study on patients admitted between January 2014 and July 2022 at a large, metropolitan, level-1 trauma center. Multivariate regression models and propensity score matching were used. RESULTS A total of 512 civilian patients presented with GSWH, and a cohort of 172 (33.5%) met inclusion criteria, with 143 (83.1%) males and a mean (SD) age of 34.3 (±14.2) years. The incidence of intracranial CVI was 50.6% (87/172 patients), and that of secondary vascular insult was 32.2% (28/172 patients). Bifrontal trajectories (adjusted odds ratio [aOR] 13.11; 95% CI 2.45-70.25; P = .003) and the number of lobes traversed by the projectile (aOR 3.18; CI 1.77-5.71; P < .001) were associated with increased odds of resultant CVI. Patients with CVI suffered higher rate of mortality (34% vs 20%; odds ratio [OR] 2.1; CI 0.78-5.85; P = .015) and were less likely to achieve a good functional outcome with a Glasgow Outcome Score of 4-5 (34% vs 68%; OR 0.24; CI 0.1-0.6; P = .004) at follow-up. Furthermore, patients with CVI and resultant secondary vascular insult had even worse functional outcomes (Glasgow Outcome Score 4-5, 16.7% vs 39.0%; aOR 0.012; CI 0.001-0.169, P = .001). CONCLUSION Intracranial CVI from GSWH and associated secondary vascular insult are associated with poor outcomes. Given the high prevalence and potentially reversible nature of these secondary injuries, early screening with vascular imaging and treatment of underlying CVI may prove to be critical to improve outcomes by reducing stroke and rehemorrhage incidence.
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Affiliation(s)
- Jason J Lamanna
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
| | - Juanmarco Gutierrez
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
| | - Chadd Funk
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
| | - Rima S Rindler
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
- Sierra Neurosurgery Group, Reno , Nevada , USA
| | - Faiz Ahmad
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
| | - Sanjay K Gupta
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
| | - David A Gimbel
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
| | - Randi N Smith
- Department of Surgery, Emory University School of Medicine, Atlanta , Georgia , USA
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
| | - Jonathan A Grossberg
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
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Ivanov I, Cataldo M, Cocchiara A, Nguyen R. Vertebral Artery Dissection. BMJ Case Rep 2024; 17:e255923. [PMID: 38195187 PMCID: PMC10806942 DOI: 10.1136/bcr-2023-255923] [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: 01/11/2024] Open
Abstract
Vertebral artery dissections are a rare pathology that carries a high risk of stroke in a younger population. They may be caused by minor mechanisms and the index of suspicion should be high. Treatment with anticoagulation or antiplatelets should follow if no surgical management is indicated.We describe a case of a female in her 30s who fell backward off a swing and rolled over her head and complained of continued posterior neck pain. The patient was found to have a vertebral artery dissection on MRI. The patient was then anticoagulated with high-dose apixaban and low-dose aspirin.The emergency medicine provider should be aware of possible low-impact mechanisms that can cause vertebral artery dissection and should have a high index of suspicion. If surgical management is not indicated, anticoagulation should be initiated.
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Affiliation(s)
- Ivan Ivanov
- Emergency Department, New York City Health and Hospitals Coney Island, Brooklyn, New York, USA
| | - Michael Cataldo
- Emergency Department, New York City Health and Hospitals Coney Island, Brooklyn, New York, USA
| | - Alyssa Cocchiara
- Emergency Department, New York City Health and Hospitals Coney Island, Brooklyn, New York, USA
| | - Rosalee Nguyen
- Emergency Department, New York City Health and Hospitals Coney Island, Brooklyn, New York, USA
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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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Biffl WL, Castelo M, Dandan IS, Lu N, Rivera P, Bayat D. Exploring the role of endovascular interventions in blunt carotid and vertebral artery trauma. Am J Surg 2023; 226:688-691. [PMID: 37604750 DOI: 10.1016/j.amjsurg.2023.07.030] [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: 03/24/2023] [Revised: 07/20/2023] [Accepted: 07/22/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND The role of endovascular interventions (EI) for blunt carotid and vertebral artery injuries (BCI and BVI) is poorly defined. The purpose of this study was to assess the efficacy of EI compared with antithrombotic therapy (AT) to inform future prospective study. METHODS Retrospective review (2017-2022) of records at a Level I trauma center to determine injury, treatment, and outcome information. Primary outcome was stroke. RESULTS 96 patients suffered 106 injuries (74 BVI, 32 BCI). 12 patients underwent 13 EI- 4 therapeutic, 9 prophylactic. Stroke occurred in 12 patients- 6 who had EI. In grade IV BVI, stroke rates are low with both EI and AT. Thrombectomy after stroke improved neurologic function in 4 (100%) of 4 patients. CONCLUSIONS Most strokes occur prior to preventive therapy. Neither AT nor EI is 100% effective in preventing stroke. Thrombectomy may improve neurologic outcomes after stroke. Prospective multicenter study is imperative.
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Affiliation(s)
- Walter L Biffl
- Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA.
| | - Matthew Castelo
- Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA.
| | - Imad S Dandan
- Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA.
| | - Ning Lu
- Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA.
| | - Patricia Rivera
- Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA.
| | - Dunya Bayat
- Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA.
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Stonko DP, Betzold RD, Azar FK, Edwards J, Abdou H, Elansary NN, Gerling KA, White J, Feliciano DV, DuBose JJ, Morrison JJ. Postoperative antiplatelet and/or anticoagulation use does not impact complication or reintervention rates after vein repair of arterial injury: A PROOVIT study. Vascular 2023; 31:777-783. [PMID: 35430941 DOI: 10.1177/17085381221082371] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
INTRODUCTION The use of antiplatelet (AP) and anticoagulation (AC) therapy after autogenous vein repair of traumatic arterial injury is controversial. The hypothesis in this study was that there is no difference in early postoperative outcomes regardless of whether AC, AP, both, or neither are used. METHODS The American Association for the Surgery of Trauma (AAST) PROspective Observational Vascular Injury Treatment (PROOVIT) registry was queried from November, 2013, to January, 2019, for arterial injuries repaired with a vein graft. Demographics and injury characteristics were compared. Need for in-hospital reoperation was the primary outcome in this four-arm study, assessed with two ordinal logistic regression models (1. no therapy vs. AC only vs. AC and AP; 2. no therapy vs. AP only vs. AC and AP). RESULTS 373 patients (52 no therapy, 88 AP only, 77 AC only, 156 both) from 19 centers with recorded Injury Severity Scores (ISS) were identified. Patients who received no therapy were younger than those who received AP (27.0 vs. 34.2, p = 0.02), had higher transfusion requirement (p < 0.01 between all groups) and a different distribution of anatomic injury (p < 0.01). After controlling for age, sex, ISS, platelet count, hemoglobin, pH, lactate, INR, transfusion requirement and anatomic location, there was no association with postoperative medical therapy and in-hospital operative reintervention, or any secondary outcome, including thrombosis (p = 0.67, p = 0.22). CONCLUSIONS Neither AC nor AP alone, nor in combination, impact complication rate after arterial repair with autologous vein. These patients can be safely treated with or without antithrombotics, recognizing that this study did not demonstrate a beneficial effect.
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Affiliation(s)
- David P Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Richard D Betzold
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Faris K Azar
- St Mary's Medical Center, West Palm Beach, Florida Atlantic University, Boca Raton, FL USA
| | - Joseph Edwards
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Hossam Abdou
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Noha N Elansary
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | | | - Joseph White
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - David V Feliciano
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Joseph J DuBose
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jonathan J Morrison
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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12
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Miller PR. Blunt cerebrovascular injury: contribution of Timothy C Fabian MD and investigators from the University of Tennessee at Memphis to our understanding of the injury. Trauma Surg Acute Care Open 2023; 8:e001112. [PMID: 37082306 PMCID: PMC10111917 DOI: 10.1136/tsaco-2023-001112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/16/2023] [Indexed: 04/22/2023] Open
Abstract
Our understanding of blunt cerebrovascular injury (BCVI) has evolved considerably over recent decades. It was once seen as a rare injury that was difficult or impossible to predict and had no useful prevention or treatment measures available. In the late 20th century, work by physicians caring for these injuries began to show that this was not the case. There were distinct risk factors for the injury and the often seen interval between injury and stroke provided an opportunity for stroke prevention. Timothy Fabian and the investigators at Memphis have been one of the groups at the forefront of this type of inquiry for >30 years. The contributions of this group has advanced the care of BCVI immensely. This review examines some of the work done by Dr Fabian and his colleagues and its importance in the care of injured patients.
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Affiliation(s)
- Preston R Miller
- Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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13
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Lauzier D, Chatterjee A, Kansagra A. Neurointerventional management of cerebrovascular trauma. UKRAINIAN INTERVENTIONAL NEURORADIOLOGY AND SURGERY 2022. [DOI: 10.26683/2786-4855-2022-2(40)-41-54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Traumatic cerebrovascular injuries following blunt or penetrating trauma are common and carry a high risk of permanent disability or death. Proper screening, diagnosis, and treatment of these lesions is essential to improve patient outcomes. Advances in imaging continue to improve the accuracy of non-invasive diagnosis of these injuries while new clinical data provide better evidence for optimal management, whether medical or invasive. Here, we review screening, diagnosis, and treatment of traumatic cerebrovascular injuries.
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Abstract
BACKGROUND The timing of stroke onset among patients with blunt cerebrovascular injury (BCVI) is not well understood. All blunt trauma patients at our institution undergo a screening computed tomographic angiography (CTA) of the neck. Most patients with CTA evidence of BCVI are treated with aspirin, and all patients with clinical evidence of stroke are treated with aspirin and undergo magnetic resonance imaging (MRI) of the brain. We conducted a retrospective review to determine the incidence of stroke upon admission and following admission. METHODS All neck CTAs and head MRIs obtained in blunt trauma patients were reviewed from August 2017 to August 2019. All CTAs that were interpreted as showing BCVI were individually reviewed to confirm the diagnosis of BCVI. Stroke was defined as brain MRI evidence of new ischemic lesions, and each MRI was reviewed to identify the brain territory affected. We extracted the time to aspirin administration and the timing of stroke onset from patients' electronic health records. RESULTS Of the 6,849 blunt trauma patients, 479 (7.0%) had BCVIs. Twenty-four patients (5.0%) with BCVI had a stroke on admission. Twelve (2.6%) of the remaining 455 patients subsequently had a stroke during their hospitalization. The incidence of stroke among patients with BCVI was 7.5%; 2.6% were potentially preventable. Only 5 of the 12 patients received aspirin before the onset of stroke symptoms. All 36 patients with BCVI and stroke had thromboembolic lesions in the territory supplied by an injured vessel. CONCLUSION With universal screening, CTA evidence of BCVI is common among blunt trauma patients. Although acute stroke is also relatively common in this population, two thirds of strokes are already evident on admission. One third of BCVI-related strokes occur after admission and often relatively early, necessitating rapid commencement of preventative treatment. Further studies are required to demonstrate the value of antithrombotic administration in preventing stroke in BCVI patients. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level IV.
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Smith S, Allen L, Khwaja K, Joos E, Ball CG, Engels PT, Naji F, Lampron J, Widder S, Minor S, Jessula S, Parry NG, Vogt KN. Management of vascular trauma across Canada: A cohort study with implications for practice. Injury 2022; 53:1662-1666. [PMID: 35012752 DOI: 10.1016/j.injury.2021.12.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 11/30/2021] [Accepted: 12/29/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aim of this study was to provide a description of vascular trauma and its management at trauma centers across Canada. METHODS This retrospective cohort study evaluated patients from 8 Canadian level 1 trauma centers (2011-2015). Medical records were queried to identify adult patients who survived to hospital with major vascular injury. Major vascular injury was defined as injury to named arterial or venous vessels in the legs, arms torso, and neck. Data collected included patient demographics, injury mechanism, injury details, management and clinical outcomes. RESULTS A total of 1330 patients were included. Patients were 76% male with a mean age of 43 (SD 18.8). Reported injuries were 63% blunt, 36% penetrating, and the remainder mixed. The most common specific mechanisms of injury were motor vehicle collision (36%), stabbing (26%), and falls (16%), with gunshot injuries accounting for <5%. Pre-hospital tourniquets were applied in 27 patients (2%). The mean Injury Severity Score (ISS) was 24 (SD 14.5). We identified injuries to named vessels of the neck (32%), thorax (23%), abdomen and pelvis (27%), upper extremity (14%) and lower extremity (10%). Specific vascular injuries included transection (50%), complete occlusion (11%), partial occlusion (39%), and pseudoaneurysm formation (11%). Injuries were managed non-operatively in 32%, with definitive open surgical management (24%), endovascular management (9%) and with damage control techniques in the operating room (3%). Amputation occurred in 10% of lower extremity and 5% of upper extremity injuries. Responsibility for vascular injury management was undertaken by a wide variety of specialists (n = 17). Overall, in-hospital mortality was 13%, and 2% of patients underwent amputation. CONCLUSION This study describes the nature and management of vascular injuries across Canada. The variability in injury mechanisms, management strategies, specialty responsible for management, and outcomes have important implications for practice change and knowledge translation.
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Affiliation(s)
- Shane Smith
- London Health Sciences Centre, London, Ontario, Canada.
| | - Laura Allen
- London Health Sciences Centre, London, Ontario, Canada.
| | - Kosar Khwaja
- McGill University Health Centre, Montreal, Quebec, Canada.
| | - Emilie Joos
- Vancouver Costal Health, Vancouver, British Columbia, Canada.
| | - Chad G Ball
- Foothills Medical Centre, Calgary, Alberta, Canada
| | - Paul T Engels
- Hamilton Health Sciences Centre, Hamilton, Ontario, Canada.
| | - Faysal Naji
- Hamilton Health Sciences Centre, Hamilton, Ontario, Canada.
| | | | - Sandy Widder
- Alberta Health Services, Edmonton, Alberta, Canada.
| | - Sam Minor
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada.
| | - Samuel Jessula
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Neil G Parry
- London Health Sciences Centre, London, Ontario, Canada.
| | - Kelly N Vogt
- London Health Sciences Centre, London, Ontario, Canada.
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16
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Current Concepts in Imaging Diagnosis and Screening of Blunt Cerebrovascular Injuries. Tomography 2022; 8:402-413. [PMID: 35202198 PMCID: PMC8877014 DOI: 10.3390/tomography8010033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/16/2022] [Accepted: 01/29/2022] [Indexed: 11/21/2022] Open
Abstract
Blunt cerebrovascular injury (BCVI) is an often underrecognized injury occurring in the carotid or vertebral arteries, associated with a risk of ischemic stroke and potential for poor neurological outcome or death. Computed tomographic angiography (CTA) is the most common modality for initial screening and diagnosis. Vessel wall intimal injuries, intraluminal thrombus, dissection, intramural hematoma, pseudoaneurysm, vessel transection, and arteriovenous fistula, are potential findings to be considered in approach to imaging. Identification of high-risk trauma patients based on clinical and radiological risk factors can determine patients at risk of BCVI for targeted screening.
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Stonko DP, Betzold RD, Abdou H, Edwards J, Azar FK, Elansary NN, Treffalls RN, Savidge SG, DuBose JJ, Feliciano DV, Morrison JJ. In-hospital outcomes in autogenous vein versus synthetic graft interposition for traumatic arterial injury: A propensity-matched cohort from PROOVIT. J Trauma Acute Care Surg 2022; 92:407-412. [PMID: 34789705 DOI: 10.1097/ta.0000000000003465] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The ideal conduit for traumatic arterial repair is controversial. Autologous vein was compared with synthetic interposition grafts in the acute setting. The primary outcome was in-hospital reoperation or endovascular intervention. METHODS The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry from November 2013 to January 2019 was queried for arterial injuries requiring interposition vein or graft repair. Patients with no recorded Injury Severity Score were excluded, and multiple imputation was used for other missing data. Patients treated with synthetic grafts (SGs) were propensity matched to patients with vein grafts (VGs) to account for preoperative differences. RESULTS Four hundred sixty from 19 institutions were identified, with 402 undergoing VG and 58 SG. In the SG group, 45 were PTFE grafts, 5 were Dacron, and 8 had other conduits. The SG group was more severely injured at admission with more gunshot wounds and higher mean Injury Severity Score, lactate, and first-24-hour transfusion requirement. In addition, the SG cohort had significantly lower admission systolic blood pressure, pH, and hemoglobin. After propensity matching, 51 patients with SG were matched with 87 patients with VG. There were no differences in demographics, clinical parameters, or diagnostic evaluation techniques postmatch. The need for reoperation or endovascular intervention between the matched groups was equivalent (18%; p = 0.8). There was no difference in any secondary outcome including thrombosis, stenosis, pseudoaneurysm, infection, or embolic event, and hospital and intensive care unit length of stay were the same. CONCLUSION American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry data demonstrate that SGs are used in more critically ill patients. After controlling for relevant clinical factors and propensity matching, there is no in-hospital difference in rate of reoperation or endovascular intervention, or any secondary outcome between VG and SG. LEVEL OF EVIDENCE Prognostic and Epidemiolgic, Level III.
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Affiliation(s)
- David P Stonko
- From the Department of Surgery (D.P.S.), The Johns Hopkins Hospital; Department of Surgery, University of Maryland (D.P.S., R.D.B., H.A., J.E., N.N.E., R.N.T., S.G.S., J.J.D., D.V.F., J.J.M.), R. Adams Cowley Shock Trauma Center, Baltimore, Maryland; and Department of Surgery, St. Mary's Medical Center (F.K.A.), West Palm Beach; Florida Atlantic University (F.K.A.), Boca Raton, Florida; and University of Maryland School of Medicine (S.G.S.), Baltimore, Maryland
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18
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Lauzier DC, Chatterjee AR, Kansagra AP. Neurointerventional management of cerebrovascular trauma. J Neurointerv Surg 2021; 14:718-722. [PMID: 34949708 DOI: 10.1136/neurintsurg-2021-017923] [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: 10/19/2021] [Accepted: 12/04/2021] [Indexed: 11/03/2022]
Abstract
Traumatic cerebrovascular injuries following blunt or penetrating trauma are common and carry a high risk of permanent disability or death. Proper screening, diagnosis, and treatment of these lesions is essential to improve patient outcomes. Advances in imaging continue to improve the accuracy of non-invasive diagnosis of these injuries while new clinical data provide better evidence for optimal management, whether medical or invasive. Here, we review screening, diagnosis, and treatment of traumatic cerebrovascular injuries.
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Affiliation(s)
- David C Lauzier
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Arindam R Chatterjee
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA.,Department of Neurological Surgery, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA .,Department of Neurological Surgery, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA
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