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.

Early Pharmacologic Therapy in Patients With Blunt Cerebrovascular Injury and TBI: Is it Safe and Effective? An EAST Multicenter Study

BACKGROUND

Blunt cerebrovascular injury (BCVI) with concurrent traumatic brain injury (TBI) presents increased risk of both ischemic stroke and bleeding. This study investigated the safety and survival benefit of BCVI treatment (antithrombotic and/or anticoagulant therapy) in this population. We hypothesized that treatment would be associated with fewer and later strokes in patients with BCVI and TBI without increasing bleeding complications.

METHODS

Patients with head AIS >0 were selected from a database of BCVI patients previously obtained for an observational trial. A Kaplan-Meier analysis compared stroke survival in patients who received BCVI treatment to those who did not. Logistic regression was used to evaluate for confounding variables.

RESULTS

Of 488 patients, 347 (71.1%) received BCVI treatment and 141 (28.9%) did not. BCVI treatment was given at a median of 31 h post-admission. BCVI treatment was associated with lower stroke rate (4.9% vs 24.1%, P < .001 and longer stroke-free survival (P < .001), but also less severe systemic injury. Logistic regression identified motor GCS and BCVI treatment as the only predictors of stroke. No patients experienced worsening TBI because of treatment.

DISCUSSION

Patients with BCVI and TBI who did not receive BCVI treatment had an increased rate of stroke early in their hospital stay, though this effect may be confounded by worse motor deficits and systemic injuries. BCVI treatment within 2-3 days of admission may be safe for patients with mean head AIS of 2.6. Future prospective trials are needed to confirm these findings and determine optimal timing of BCVI treatment in TBI patients with BCVI.

A Retrospective Analysis of the Clinical Use and Utility of Advanced Imaging in the Evaluation of Near-Hanging and Strangulation Injuries at a Canadian Level One Trauma Centre

INTRODUCTION

Computed tomography (CT) of the neck is highly sensitive and may effectively rule-out cervical spine, cerebrovascular, and aerodigestive injuries after blunt and penetrating trauma. However, CT may be overutilized in the evaluation of hanging or strangulation injuries. The objective of this study was to determine the diagnostic yield of CT imaging among patients evaluated for hanging or strangulation mechanisms at a Canadian level-1 trauma center.

METHODS

All adult patients evaluated for hanging or strangulation injuries over an eight-year period were reviewed. The primary outcome was the diagnostic yield of CT imaging for major aerodigestive, cervical spine, cerebrovascular, or neurological injuries. Multiple logistic regression were performed to determine predictive factors for the use of CT imaging and the identification of injury on imaging.

RESULTS

Among 124 patients evaluated for hanging or strangulation injuries during the study period, 101 (80%) were evaluated with CT of the head or neck. A total of 26 injuries were identified in 21 patients (18 anoxic brain injuries, 4 aerodigestive, 3 cerebrovascular, and 1 of cervical spine injury). The overall diagnostic yield of neck CT for cervical injuries was 7.8%, 4.7% for laryngeal-tracheal injuries, 3.5% for carotid and vertebral artery injuries, and 1.1% for cervical spine injury. The diagnostic yield of CT head for anoxic brain injury was 22.8%. Factors predicting the use of CT imaging were abnormal physical exam findings (RR 1.7 95% CI [1.2, 2.3]) and transfer accepted by the trauma team leader (RR 1.3 95% CI [1.1, 1.5]).

CONCLUSION

CT imaging is often used in the evaluation of patients presenting with hanging or strangulation mechanisms. Seven cerebrovascular, aerodigestive, or cervical spine injuries were identified on imaging during the study period, representing a diagnostic yield of 7%. No injuries were identified among patient with a normal GCS or physical exam. Factors predicting the use of CT imaging included transfer accepted by the trauma team leader and abnormal physical exam findings. The variable clinical presentation of near-hanging and strangulation injuries and the relatively low diagnostic yield of CT imaging should prompt the development of tools and institutional protocols to guide the evaluation of hanging and strangulation injuries.

Missed blunt cerebrovascular injuries using current screening criteria - The time for liberalized screening is now

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.

Important underground roosts for bats in Bulgaria: current state and priorities for conservation

Bulgaria has a very rich bat fauna and large colonies of bats can be found in caves, mines and other underground roosts. Respectively, there are more than 107 underground roosts that are listed as important bat sites, most of which are protected by statutory laws and are of national or international importance. Despite the existence of formal protection, many roosts face anthropogenic disturbances due to the popularity of outdoor activities, such as caving and the lack of actual regulation. Currently, the evaluation was only based on the size of the colony and the presence of protected species. However, this approach is limited to roosts that contain high diversity and neglects the ones that contain high biotic importance that are highly threatened by various threats. Here, we evaluated conservation priorities and identified the most vulnerable underground bat roosts in Bulgaria, using the Bat Cave Vulnerability Index and proposed measures to adequately protect sites. We found that 32% of the Bulgarian bat roosts assessed are at a "high priority" level for conservation and protection, while 39% are at a "medium priority" that may require constant monitoring. This novel and integrative approach applied to bat roost prioritisation in the country enabled the detection of sites that need urgent conservation attention and is the first step in establishing better strategies for the bat monitoring network in Bulgaria.

Existence of knowledge silos in the adult blunt cerebrovascular injury literature

Background

Blunt cerebrovascular injuries (BCVI) remain a significant source of disability and mortality among trauma patients. The purpose of the present study was to determine whether knowledge silos exist in the overall BCVI literature.

Methods

An object-oriented programmatic script written in Python programming language was used to extract and categorize articles and references on the topic of BCVI. Additionally, each BCVI article was searched for by digital object identifier in the other BCVI references to build a network analysis and visualize topic reference patterns. Analyses were performed using Stata V.14.2 (StataCorp).

Results

A total of 306 articles with 10 282 references were included for analysis. Of these, 24% (74) were published in neurosurgery journals, 45% (137) were published in trauma journals, and 31% (95) were published in a journal of another specialty. Similar proportions were found when categorized by author departmental affiliation. Trauma surgery authors disproportionately referenced articles in the trauma literature, compared with neurosurgeons (73.5% vs. 48.0%, p<0.0001), and other authors. The biggest factor influencing reference proportions was the specialty of the publishing journal. Finally, a network analysis revealed that there are more trauma BCVI articles, and there are more frequently cited trauma BCVI articles by all specialties.

Conclusions

This study revealed the existence of a one-way knowledge silo in the BCVI literature. However, a robust preference by both trauma and neurosurgery to cite trauma references when publishing in trauma journals may indicate a possible conscious curating of citations by authors to increase the likelihood of publication. These observations highlight the need for an active role by journal editors, peer reviewers, and authors to actively foster diversity of citations and cross-specialty collaboration to improve dissemination of information between these specialties.

Level of evidence

Level IV. Observational study.

Treatment strategies for patients with concurrent blunt cerebrovascular and traumatic brain injury

Patients who present with traumatic brain injury (TBI) combined with blunt cerebrovascular injuries (BCVI) are difficult to manage, in part because treatment for each entity may exacerbate the other. It is necessary to develop a treatment paradigm that ensures maximum benefit while mitigating the opposing risks. A cohort of 150 patients from 2015 to present, with either internal carotid artery (ICA) and/or vertebral artery (VA) dissections or pseudoaneurysms, was cross-referenced with those who had sustained TBI. Of the 38 patients identified with both TBI and BCVI, 25 suffered ICA injuries, 10 had VA injuries and 3 had combined ICA/VA injuries. Unilateral BCVI occurred in 30 patients, while 8 had bilateral BCVI. Two patients required surgical intervention for TBI, and 5 patients required endovascular intervention for BCVI. Positive emboli detection studies (EDS) on transcranial dopplers (TCD) were demonstrated in 19 patients, with 9 patients having radiographic evidence of stroke. Anti-platelet therapy was initiated in 32 patients, and anti-coagulation in 10 patients, without new or worsening intracranial hemorrhages (ICH). Overall, 76% of patients were able to be discharged home or to rehabilitation, with good recovery demonstrated in 73% of the patients who had appropriate follow-up. In the setting of concurrent TBI and BCVI, use of anti-platelet/coagulation to prevent stroke can be safe if monitored closely. Here we describe a treatment paradigm which weighs the risk and benefits of therapies based on severity of ICH and stroke prevention, which tended to result in good disposition and recovery.

Characterizing Blunt Cerebrovascular Injuries and Stroke: A Single Center Retrospective Study

OBJECTIVE

To highlight the occurrence of ischemic stroke after blunt cerebrovascular injuries and discuss the neurologist's role in preventing and managing ischemic strokes in this trauma population.

METHODS

A retrospective chart review was performed and included data from 2016 to 2019 from a Level I trauma center. Demographics, injury mechanism, ischemic stroke occurrence, interventions, and neurology consultations were examined and descriptive statistics were utilized to characterize the nature of ischemic strokes and their management.

RESULTS

A total of forty patients (81% male, average age 44) presented with blunt cerebrovascular injury, nine of whom later developed ischemic stroke. Eighteen patients had a carotid artery injury with six developing ischemic stroke. Twenty-seven patients had a vertebral artery injury with three developing ischemic stroke. Six of the nine ischemic strokes occurred on hospital day two, whereas neurology was generally consulted on hospital day four.

CONCLUSIONS

A considerable portion of patients may go on to develop ischemic stroke following blunt cerebrovascular injuries. Polytrauma may interfere with prompt diagnosis which may contribute to delayed anti-thrombotic therapy for ischemic stroke prevention. Neurologists have the opportunity to reduce ischemic stroke burden in this trauma population and patients may benefit from earlier neurology consultation.

Blunt cerebrovascular injury in the geriatric population

OBJECTIVE

Blunt cerebrovascular injury (BCVI) is associated with high rates of neurological morbidity and mortality. The detection and management of BCVI has improved with advances in imaging and sensitive screening protocols. Few studies have explored how these injuries specifically affect the geriatric population. The purpose of this retrospective analysis was to investigate the presentation and prognosis of BCVI in the elderly population and to assess its clinical implications in the management of these patients.

METHODS

All patients presenting to the University of Cincinnati (UC) level I trauma center between February 2017 and December 2019 were screened for BCVI and entered into the prospectively maintained UC Neurotrauma Registry. Patients with BCVI confirmed by CT angiography underwent retrospective chart reviews to collect information regarding demographics, positive screening criteria, cause of injury, antithrombotic agent, injury location, Denver Grading Scale, hospital and ICU length of stay, and discharge disposition. Patients were divided into geriatric (age ≥ 65 years) and adult (age < 65 years) subgroups. Continuous variables were analyzed using the Student t-test and categorical variables with the Pearson chi-square test.

RESULTS

Of 124 patients with BCVI, stratification by age yielded 23 geriatric and 101 adult patients. Injury in the geriatric group was associated with significantly higher mortality (p = 0.0194). The most common cause of injury in the elderly was falls (74%, 17/23; p < 0.0001), whereas motor vehicle accidents were most common in the adult group (38%, 38/100; p = 0.0642). With respect to the location of injury, carotid (p = 0.1171) and vertebral artery (p = 0.6981) injuries did not differ significantly for the geriatric group. The adult population presented more often with Denver grade I injuries (p < 0.0001), whereas the geriatric population presented with grade IV injuries (p = 0.0247). Elderly patients were more likely to be discharged to skilled nursing facilities (p = 0.0403) and adults to home or self-care (p = 0.0148).

CONCLUSIONS

This study is the first to characterize BCVI to all cervical and intracranial vessels in the geriatric population. Older age at presentation is significantly associated with greater severity, morbidity, and mortality from injury, with no preference for the particular artery injured. These findings carry important clinical implications for adapting practice in an aging population.

Blunt carotid injury with thrombotic occlusion: Is an intervention always required for best outcome?

Blunt cerebrovascular injuries are rare, comprises of 0.08 to 0.33% of all traumatic blunt injuries. Depending on the grade of severity, they may heal with minimal consequences or may lead to debilitating and devastating stroke. Surgically accessible lesions are infrequent and hence endovascular management is preferred modality for high-grade lesions. We hereby present a case of complete thrombosis of the common carotid artery, which couldn't receive either surgical or endovascular treatment due to low resource settings. The patient developed a stroke after 18 h of trauma, which, however, recovered completely and dramatically within 96 h. To the best of our knowledge, such rapid and complete recovery from stroke secondary to blunt carotid injury managed non-operatively hasn't been reported in literature so far. Our report adds to the scarce but growing body of evidence recommending conservative management in BCVI in absence of enlarging pseudoaneurysm and dissection with near-complete stenosis.

Screening for blunt cerebrovascular injuries in pediatric trauma patients

BACKGROUND

Adult imaging for blunt cerebrovascular injuries (BCVI) is based on the Denver and Memphis screening criteria where CT angiogram (CTA) is performed for any one of the criteria being positive. These guidelines have been extrapolated to the pediatric population. We hypothesize that the current adult criteria applied to pediatrics lead to unnecessary CTA in pediatric trauma patients.

STUDY DESIGN

At our center, a 9-year retrospective study revealed that strict adherence to the Denver and Memphis criteria would have resulted in 332 unnecessary CTAs out of 2795 trauma patients with only 0.3% positive for BCVI. We also conducted a retrospective chart review of 776,355 pediatric trauma patients in the National Trauma Data Bank (NTDB) from 2007 to 2014. Data collection included children between ages 0 and 18, ICD-9 search for blunt cerebrovascular injury, and ICD-9 codes that applied to both Denver and Memphis criteria.

RESULTS

Of 776,355 pediatric trauma activations, 81,294 pediatric patients in the NTDB fit the Denver/Memphis criteria for screening CTA neck or angiography based on ICD-9 codes, while only 2136 patients suffered BCVI. Strict utilization of the Denver/Memphis criteria would have led to a negative CTA in 79,158 (97.4%) patients. Multivariate regression analysis indicates that patients with skull base fracture, cervical spine fractures, cervical spine fracture with cervical cord injury, traumatic jugular venous injury, and cranial nerve injury should be considered part of the screening criteria for BCVI.

CONCLUSION

Our study suggests the Denver and Memphis criteria are inadequate screening criteria for CTA looking for BCVI in the pediatric blunt trauma population. New criteria are needed to adequately indicate the need for CT angiography in the pediatric trauma population.

LEVEL OF EVIDENCE

IV.

Case Series of Adolescents With Stroke-Like Symptoms Following Head Trauma

BACKGROUND

Studies cite the incidence of pediatric blunt cerebrovascular injuries (BCVI) ranges from 0.03% to 1.3%. While motor vehicle incidents are a known high-risk mechanism, we are the first to report on football injuries resulting in BCVI.

CASE REPORT

Case 1 is a 14-year-old male football player who presented with slurred speech and facial droop 16 h after injury that had resulted in unilateral stinger on the field. The patient had a negative brain computed tomography (CT) at the onset of symptoms. Given progression of symptoms over the next 24 h, re-evaluation with CT angiography (CTA) of brain and neck showed left internal carotid artery (ICA) dissection, and magnetic resonance imaging of the brain showed left middle cerebral artery infarct. Case 2 is a 16-year-old male football player who presented with headache and right hemiparesis immediately following a tackle injury. CT brain and neck were negative at an outside hospital, but he was transferred to us for progressive symptoms, and then CTA showed a left ICA dissection with distal emboli, including occlusive involvement of the intracranial left ICA. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The diagnosis of BCVI requires a high level of suspicion. Focal neurologic deficits are consistently a risk factor across all screening criteria, including the Denver, Utah, Memphis, and Eastern Association for the Surgery of Trauma. These current screening criteria, however, may not be sufficient to diagnosis BCVI in children. The addition of the mechanism of injury and attention to the patient's clinical presentation and examination are important to prevent missed diagnosis and poor neurologic outcomes.

Augmenting Denver criteria yields increased BCVI detection, with screening showing markedly increased risk for subsequent ischemic stroke

Purpose

BCVI may lead to ischemic stroke, disability, and death, while being often initially clinically silent. Screening criteria for BCVI based on clinical findings and trauma mechanism have improved detection, with Denver criteria being most common. Up to 30% of patients do not meet BCVI screening criteria. The aim of this study was to analyze the effect of augmented Denver criteria on detection, and to determine the relative risk for ischemic stroke.

Methods

Denver screening criteria were augmented by any high-energy trauma of the cervical spine, thorax, abdomen, or pelvis. All acute blunt trauma WBCT including CT angiography (CTA) over a period of 38 months were reviewed retrospectively by two Fellowship-trained radiologists, as well as any cerebral imaging after the initial trauma.

Results

1544 WBCT studies included 374 CTA (m/f = 271/103; mean age 41.5 years). Most common mechanisms of injury were MVA (51.5%) and fall from a height (22.3%). We found 72 BCVI in 56 patients (15.0%), with 13 (23.2%) multiple lesions. The ICA was affected in 49 (68.1%) and the vertebral artery in 23 (31.9%) of cases. The most common injury level was C2, with Biffl grades I and II most common in ICA, and II and IV in VA. Interobserver agreement was substantial (Kappa = 0.674). Of 215 patients imaged, 16.1% with BCVI and 1.9% of the remaining cases had cerebral ischemic stroke (p < .0001; OR = 9.77; 95% CI 3.3–28.7). Eleven percent of patients with BCVI would not have met standard screening criteria.

Conclusions

The increase in detection rate for BCVI justifies more liberal screening protocols.

Bilateral vertebral artery transection following blunt trauma

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All documented blunt cerebrovascular artery transections have demonstrated a one hundred percent mortality rate to date.

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These injuries occur in patients with coexisting injuries, limiting the ability to attribute a given neurologic outcome to any one injury.

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These injuries must be distinguished from the better-studied blunt carotid artery injuries, as each responds to treatment differently.

Introduction

Blunt vertebral artery injury (BVI) is a potentially catastrophic event associated with a variety of trauma mechanisms, particularly in the setting of cervical spine injury. Early detection and treatment of BVI and blunt carotid artery injury (BCI) – collectively termed blunt cerebrovascular injuries (BCVI) – is a known determinant of favorable outcomes, except in the case of complete transection injuries. The limited existing reports of these injuries demonstrate a 100% mortality rate regardless of the management approach taken, and further investigation is essential in better understanding the nature of the injury and improving patient outcomes.

Presentation of case

A 55 year old previously healthy patient was brought to the Emergency Department following a motor vehicle collision. The patient was alert upon arrival to the ED and complained of neck pain. Initial assessment was significant for open fracture of the left upper extremity, swelling of the anterior neck, and no purposeful movements noted of the lower extremities. Shortly thereafter, the patient showed a sudden decline in mental status and became hemodynamically unstable. Focused Assessment with Sonography for Trauma was positive, and after remaining unstable despite resuscitation efforts, the patient was brought emergently to the operating room.

Discussion

Following exploratory laparotomy for bleeding control and washout of the open fracture, CT angiogram of the head and neck was obtained. This revealed significant C5–C6 dissociation as well as bilateral vertebral artery transection and large prevertebral hematoma. Prior to any further surgical intervention, the patient’s neurologic function continued to decline, and brain CT demonstrated infarcts in the posterior cerebral artery distribution. Brain death was confirmed the next day, and all care was subsequently withdrawn.

Conclusions

Analysis of outcomes in patients with BCVI suggests that BVI should be distinguished from the better-studied CVI. Each injury type has been found to possess its own distinct risk factors, likelihoods of progression, and surgical accessibility, all of which affect management. Data on complete vessel transections remains limited for all BCVIs, with no documented cases of bilateral BVI to date. Our case study supports the 100% mortality rate seen in previously reported BCVI transections. Furthermore, our findings suggest that BVI transections occur in patients with coexisting injuries, which challenges the ability to attribute a single neurologic outcome to any one injury.

Pediatric blunt cerebrovascular injury: the McGovern screening score

OBJECTIVE The objective of this study was to assess the incidence, diagnosis, and treatment of pediatric blunt cerebrovascular injury (BCVI) at a busy Level 1 trauma center and to develop a tool for accurately predicting pediatric BCVI and the need for diagnostic testing. METHODS This is a retrospective cohort study of a prospectively collected database of pediatric patients who had sustained blunt trauma (patient age range 0-15 years) and were treated at a Level 1 trauma center between 2005 and 2015. Digital subtraction angiography, MR angiography, or CT angiography was used to confirm BCVI. Recently, the Utah score has emerged as a screening tool specifically targeted toward evaluating BCVI risk in the pediatric population. Using logistical regression and adding mechanism of injury as a logit, the McGovern score was able to use the Utah score as a starting point to create a more sensitive screening tool to identify which pediatric trauma patients should receive angiographic imaging due to a high risk for BCVI. RESULTS A total of 12,614 patients (mean age 6.6 years) were admitted with blunt trauma and prospectively registered in the trauma database. Of these, 460 (3.6%) patients underwent angiography after blunt trauma: 295 (64.1%), 107 (23.3%), 6 (1.3%), and 52 (11.3%) patients underwent CT angiography, MR angiography, digital subtraction angiography, and a combination of imaging modalities, respectively. The BCVI incidence (n = 21; 0.17%) was lower than that in a comparable adult group (p < 0.05). The mean patient was age 10.4 years with a mean follow-up of 7.5 months. Eleven patients (52.4%) were involved in a motor vehicle collision, with a mean Glasgow Coma Scale score of 8.6. There were 8 patients (38.1%) with carotid canal fracture, 6 patients (28.6%) with petrous bone fracture, and 2 patients (9.5%) with infarction on initial presentation. Eight patients (38.1%) were managed with observation alone. The Denver, modified Memphis, Eastern Association for the Surgery of Trauma (EAST), and Utah scores, which are the currently used screening tools for BCVI, misclassified 6 (28.6%), 6 (28.6%), 7 (33.3%), and 10 (47.6%) patients with BCVI, respectively, as "low risk" and not in need of subsequent angiographic imaging. By incorporating the mechanism of injury into the score, the McGovern score only misclassified 4 (19.0%) children, all of whom were managed conservatively with no treatment or aspirin. CONCLUSIONS With a low incidence of pediatric BCVI and a nonsurgical treatment paradigm, a more conservative approach than the Biffl scale should be adopted. The Denver, modified Memphis, EAST, and Utah scores did not accurately predict BCVI in our equally large cohort. The McGovern score is the first BCVI screening tool to incorporate the mechanism of injury into its screening criteria, thereby potentially allowing physicians to minimize unnecessary radiation and determine which high-risk patients are truly in need of angiographic imaging.

Management of blunt cerebrovascular injury (BCVI) in the multisystem injury patient with contraindications to immediate anti-thrombotic therapy

INTRODUCTION

Practice management guidelines for screening and treatment of patients with blunt cerebrovascular injury (BCVI) have been associated with a decreased risk of ischemic stroke.

TREATMENT

of patients with BCVI and multisystem injuries that delays immediate antithrombotic therapy remains controversial. The purpose of this study was to determine the timing of BCVI treatment initiation, the incidence of stroke, and bleeding complications as a result of antithrombotic therapy in patients with isolated BCVI in comparison to those with BCVI complicated by multisystem injuries.

MATERIALS AND METHODS

This study was a retrospective review of all adult blunt trauma patients admitted to a level 1 trauma center from 2009 to 2014 with a diagnosis of BCVI.

RESULTS

A total of 28,305 blunt trauma patients were admitted during the study period. Of these, 323 (1.1%) had 481 BCEVIs and were separated into two groups. Isolated BCVI was reported in 111 (34.4%) patients and 212 (65.6%) patients had accompanying multisystem injuries (traumatic brain injury (TBI), solid organ injury, or spinal cord injury) that contraindicated immediate antithrombotic therapy.

TREATMENT

started in patients with isolated BCVI at a median time of 30.3 (15, 52) hours after injury in contrast to 62.4 (38, 97) hours for those with multisystem injuries (p<0.001). The incidence of stroke was identical (9.9%) between groups and no bleeding complications related to antithrombotic therapy were identified.

CONCLUSION

The lack of bleeding complications and equivalent stroke rates between groups suggests that the presence of TBI, solid organ injury, and spinal cord injury are not contraindications to anti-thrombotic therapy for stroke prevention in patients with BCVI.

Increased detection of blunt carotid and vertebral artery injury after implementation of diagnostic imaging pathway in level 1 trauma centre in Western Australia

BACKGROUND

The incidence of Blunt Carotid Artery and Vertebral Artery Injury (BCVI) is relatively low in modern trauma practice. However, these injuries may be associated with severe neurological consequences. Following the introduction of a Diagnostic Imaging Pathway in Department of Health of Western Australia, we hypothesized that this injury would be less likely to be missed, and accordingly diagnosed more frequently.

METHOD

A review of all major trauma (Injury Severity Scale>15) admissions at the State Major Trauma Centre in Royal Perth Hospital was undertaken from 1995 until 2013. BCVI was identified from the hospital's trauma registry. The medical records of these patients were then reviewed.

RESULT

58 of 7451 (0.78%) major trauma patients were diagnosed of BCVI during the study period. An increased incidence, from 0.52% (20/3880) to 1.06% (38/3571), was seen after the introduction of the Diagnostic Imaging Pathway in 2007 (p=0.010). The majority of the cases were caused by motor vehicle crashes, with 66% (n=38) of the cases sustaining concomitant head or cervical spine injury. Other commonly associated injuries included chest, extremity and thoracic spine injury.

CONCLUSION

Our study reports a significant increase in the diagnosis of BCVI among major traumas after the introduction of a Diagnostic Imaging Pathway for the screening of this injury in 2007. The previously low incidence of BCVI compared with other centres' reports indicated possible previous under-screening and diagnosis of this injury.