Blunt Traumatic Vertebral Artery Injuries: Incidence, Therapeutic Management, and Outcomes

Prognostic factors associated with risk of stroke following blunt cerebrovascular injury: A systematic review and meta-analysis

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.

Blunt Cerebrovascular Injury: Are We Overscreening Low-Mechanism Trauma?

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.