Blunt Carotid Artery Injury

Mayberry, John; Brown, Carlos; Mullins, Richard J.; Velmahos, George C.; Thal, Erwin R.; Mansour, M. Ashraf; Wisner, David H.; Peter, Edward T.; Berne, Thomas V.; Jurkovich, Gregory J.; Shatney, Clayton H.

doi:10.1001/archsurg.139.6.609

Cited by 90 publications

(22 citation statements)

References 24 publications

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“…He suggested that screening protocols based on injuries had a low potential for stroke prevention. 22 Likewise, Stein et al 8 found in a review of 200 injuries at a level-1 trauma center with an aggressive screening protocol that 44% had infarcts at admission and 30% had contraindications to therapy. Aggressive screening protocols also tend to identify lower-grade asymptomatic injuries that may heal spontaneously and never pose significant risk of stroke.…”

Section: Discussionmentioning

confidence: 99%

Trends in the Diagnosis and Outcomes of Traumatic Carotid and Vertebral Artery Dissections among Medicare Beneficiaries

Newhall

Gottlieb

Stone

et al. 2016

Annals of Vascular Surgery

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Background Early identification of carotid and vertebral artery dissections has been advocated to reduce stroke among trauma patients. We sought to characterize trends in the diagnosis of traumatic carotid and vertebral artery dissections and association changes in stroke rate among Medicare beneficiaries. Methods Using Medicare claims, we created a cohort of 5,961 beneficiaries admitted with a new traumatic carotid or vertebral artery dissection from 2001 to 2012. We calculated rates of stroke during hospitalization and 90 days of discharge. We calculated rates of carotid imaging using computed tomography-angiography, carotid duplex, and plain angiography index hospitalization. To study concurrent secular trends, we created a secondary cohort of patients admitted after any traumatic injury from 2001 to 2012 and determined rates of stroke and carotid imaging within this cohort. Results From 2001 to 2012, incidence of traumatic carotid dissection increased 72% among Medicare beneficiaries (1.1–1.76 per 100,000 patients; rate ratio [RR], 1.72; 95% CI, 1.6–1.9, P < 0.001). Among patients diagnosed with traumatic carotid or vertebral artery dissections, the combined in-hospital and 90-day stroke rate did not change significantly (4.9% in 2001; 5.2% in 2012; RR, 1.06; 95% CI, 0.93–1.20; P = 0.094). Likewise, there was little change in mortality (10.3%; RR, 1.01; 95% CI, 0.95–1.06; P = 0.88). Among all trauma patients, the use of computed tomography angiography has increased 16-fold (2–35 per 100,000 patients; RR, 16.7; 95% CI, 13–19; P < 0.0001). Conclusions Despite increased diagnosis of carotid or vertebral artery dissection, there has been little change in stroke risk among trauma patients. Efforts to more effectively target imaging and treatment for these patients are necessary.

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Section: Discussionmentioning

confidence: 99%

Trends in the Diagnosis and Outcomes of Traumatic Carotid and Vertebral Artery Dissections among Medicare Beneficiaries

Newhall

Gottlieb

Stone

et al. 2016

Annals of Vascular Surgery

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“…Many studies of stroke in this setting were limited by factors including a lack of a precise definition of ischemic stroke, a lack of patient evaluation by investigators with neurological expertise, a failure to distinguish patients presenting with a stroke due to TCVI from patients with initially asymptomatic TCVI who go on to develop a stroke, and a failure to distinguish stroke from other causes of neurological injury in patients with polytrauma. It is clear that the majority of ischemic strokes due to TCVI occur relatively early, either prior to admission or within 72 h of the injury [4, 10, 12, 30]. It is useful to divide patients with TCVI into 2 categories: (1) patients with an ischemic stroke at the time of initial diagnosis of TCVI and (2) patients who are found to have an initially asymptomatic TCVI, discovered with screening, and who are at risk of stroke.…”

Section: Mechanism and Risk Of Ischemic Strokementioning

confidence: 99%

“…Several studies have found that a significant subset of patients with TCVI-related stroke suffered the ischemic event prior to admission to the hospital or prior to initial vascular imaging [10, 12, 30]. In these patients, the stroke likely occurred at the time of the original arterial injury, during transport to the hospital, or during the early phase following admission.…”

Section: Mechanism and Risk Of Ischemic Strokementioning

confidence: 99%

“…In these patients, the stroke likely occurred at the time of the original arterial injury, during transport to the hospital, or during the early phase following admission. In a report of blunt trauma patients in 2 level I trauma centers, 9 out of 11 patients (82%) with TCVI-related stroke had the stroke within 2 h of the injury [30]. Two other similar studies identified an ischemic stroke on initial imaging in 44% [10] and 67% [12] of patients.…”

Section: Mechanism and Risk Of Ischemic Strokementioning

confidence: 99%

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Blunt Traumatic Extracranial Cerebrovascular Injury and Ischemic Stroke

Foreman¹,

Harrigan²

2017

Cerebrovasc Dis Extra

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Background: Ischemic stroke occurs in a significant subset of patients with blunt traumatic cerebrovascular injury (TCVI). The patients are victims of motor vehicle crashes, assaults or other high-energy collisions, and suffer ischemic stroke due to injury to the extracranial carotid or vertebral arteries. Summary: An increasing number of patients with TCVI are being identified, largely because of the expanding use of computed tomography angiography for screening patients with blunt trauma. Patients with TCVI are particularly challenging to manage because they often suffer polytrauma, that is, numerous additional injuries including orthopedic, chest, abdominal, and head injuries. Presently, there is no consensus about optimal management. Key Messages: Most literature about TCVI and stroke has been published in trauma, general surgery, and neurosurgery journals; because of this, and because these patients are managed primarily by trauma surgeons, patients with stroke due to TCVI have been essentially hidden from view of neurologists. This review is intended to bring this clinical entity to the attention of clinicians and investigators with specific expertise in neurology and stroke.

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“…Screening protocols call for CTA imaging of blunt trauma patients with risk factors for TCVI, such as cervical spine injuries and skull base fractures. Screening of asymptomatic patients is somewhat controversial [38], as some data indicates that a significant number of ischemic strokes due to TCVI occur prior to diagnosis [2,43], and that asymptomatic TCVI lesions may carry a relatively low risk of subsequent stroke, particularly when some variety of antithrombotic therapy is used. Thus, the situation with extracranial TCVI may be analogous to extracranial atherosclerotic disease, in that asymptomatic lesions carry a much more benign prognosis than symptomatic lesions.…”

Section: Discussionmentioning

confidence: 99%

Management of blunt extracranial traumatic cerebrovascular injury: a multidisciplinary survey of current practice

et al. 2011

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BackgroundExtracranial traumatic cerebrovascular injury (TCVI) is present in 1-3% of all blunt force trauma patients. Although options for the management of patients with these lesions include anticoagulation, antiplatelet agents, and endovascular treatment, the optimal management strategy for patients with these lesions is not yet established.ObjectiveMultidisciplinary survey of clinicians about current management of TCVI.MethodsA six-item multiple-choice survey was sent by electronic mail to a total of 11,784 neurosurgeons, trauma surgeons, stroke neurologists, and interventional radiologists. The survey included questions about their choice of imaging, medical management, and the use of endovascular techniques. Survey responses were analyzed according to stated specialty.ResultsSeven hundred eighty-five (6.7%) responses were received. Overall, a total of 325 (42.8%) respondents favored anticoagulation (heparin and/or warfarin), 247 (32.5%) favored antiplatelet drugs, 130 (17.1%) preferred both anticoagulation and antiplatelet drugs, and 57 (7.5%) preferred stenting and/or embolization. Anticoagulation was the most commonly preferred treatment among vascular surgeons (56.9%), neurologists (50.2%) and neurosurgeons (40.7%), whereas antiplatelet agents were the most common preferred treatment among trauma surgeons (41.5%). Overall, 158 (20.7%) of respondents recommended treatment of asymptomatic dissections and traumatic aneurysms, 211 (27.7%) did not recommend it, and 39.4% recommended endovascular treatment only if there is worsening of the lesion on follow-up imaging.ConclusionsThese data demonstrate the wide variability of physicians' management of traumatic cerebrovascular injury, both on an individual basis, and between specialties. These findings underscore the need for multicenter, randomized trials in this field.

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Blunt Carotid Artery Injury

Cited by 90 publications

References 24 publications

Trends in the Diagnosis and Outcomes of Traumatic Carotid and Vertebral Artery Dissections among Medicare Beneficiaries

Trends in the Diagnosis and Outcomes of Traumatic Carotid and Vertebral Artery Dissections among Medicare Beneficiaries

Blunt Traumatic Extracranial Cerebrovascular Injury and Ischemic Stroke

Management of blunt extracranial traumatic cerebrovascular injury: a multidisciplinary survey of current practice

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