Blunt Cerebrovascular Injuries: Diagnosis and Treatment

Miller, Preston R.; Fabian, Timothy C.; Bee, Tiffany K.; Timmons, Shelly D.; Chamsuddin, Abbas; Finkle, Rimma; Croce, Martin A.

doi:10.1097/00005373-200108000-00009

Cited by 291 publications

(316 citation statements)

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“…The optimal treatment of BCVI has been a subject of debate. The use of systemic anticoagulation to reduce neurological complications of BCVI was first described by Fabian et al 26 and has been adopted as standard therapy in clinical practice 4,17,26,27 . Previous study has shown that in even in asymptomatic, untreated patients with BCVI, the rate of neurological complications can be as high as 21.5% 28 .…”

Section: Discussionmentioning

confidence: 99%

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Blunt Cerebrovascular Injuries: Diagnosis and Management Outcomes

Wei

Montanera

Selchen

et al. 2010

Can. j. neurol. sci.

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574In recent years, blunt cerebrovascular injury (BCVI) is gaining attention as an important sequela of nonpenetrating trauma to the neck and skull base. Blunt cerebrovascular injury affects approximately 1% of all blunt trauma admissions, and the reported incidence is as high as 2.7% in centres with aggressive screening protocols [1][2][3][4][5][6][7][8] . The pattern of BCVI consists of vascular transection, dissection, thrombosis, and formation of pseudoaneurysm or arteriovenous fistula (AVF) 9,10 . The majority of these injuries occur during motor vehicle accidents, with variable rates of carotid and vertebral artery involvement reported in the literature [11][12][13] . If untreated, BCVI can be fatal and result in devastating neurological sequelae, with mortality and morbidity rates reported up to 38% and 67% respectively 14 .One of the difficulties in initiating treatment for BCVI is related to the variable symptomatology. While approximately ABSTRACT: Background: Blunt cerebrovascular injury (BCVI) to the carotid and vertebral arteries is a potentially devastating injury in trauma patients. The optimal management for BCVI has not been standardized. At our institution, 64-slice multi-detector computed tomographic angiography (CTA) has been used as the initial screening exam for BCVI in patients who met predefined screening criteria. The purpose of this study is to review the incidence of CTA-diagnosed BCVI in at-risk patients and to evaluate the treatment and clinical outcome of patients with BCVI. Methods: This study included trauma patients with a positive diagnosis of BCVI on CTA during a 41-month study period. The medical records and relevant radiographic findings were retrospectively reviewed. Results: Twenty seven of 222 blunt trauma patients evaluated with CTA had a positive diagnosis of BCVI, with an occurrence rate of 12.2%. Traumatic brain injury (72.2%) and basal skull fractures (55.6%) were the most frequent associated injuries with carotid trauma while 100% of blunt vertebral injuries occurred in the setting of cervical fractures. Fourteen (51.8%) patients received medical therapy; Eleven (40.7%) patients received conservative treatment. Endovascular treatment was attempted in a single case of vertebral arteriovenous fistula. BCVI-related stroke was found in four patients (14.8%), one of whom developed an infarct while on medical treatment. Conclusions: BCVI is found in a significant portion of blunt trauma patients with identifiable risk factors, and screening CTA has high diagnostic yield in detecting these lesions. Medical therapy is the mainstay of treatment at our institution; however, BCVI-related stroke may occur despite treatment. RÉSUMÉ: Diagnostic et résultats du traitement des traumatismes cérébrovasclaires contondants. Contexte :Le traumatisme cérébrovasculaire contondant (TCVC) à la carotide et aux artères vertébrales est une lésion qui peut être dévastatrice chez les patients qui ont subi un traumatisme. Le traitement optimal du TCVC n'a pas été standardisé. Dans notre institutio...

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Section: Discussionmentioning

confidence: 99%

“…Blunt cerebrovascular injury affects approximately 1% of all blunt trauma admissions, and the reported incidence is as high as 2.7% in centres with aggressive screening protocols [1][2][3][4][5][6][7][8] . The pattern of BCVI consists of vascular transection, dissection, thrombosis, and formation of pseudoaneurysm or arteriovenous fistula (AVF) 9,10 .…”

mentioning

confidence: 99%

Blunt Cerebrovascular Injuries: Diagnosis and Management Outcomes

Wei

Montanera

Selchen

et al. 2010

Can. j. neurol. sci.

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“…In more than 30% of cases, the diagnostics for BCVI are not started until a symptom caused by the vessel injury appears [20].…”

Section: Discussionmentioning

confidence: 99%

“…Because of an incidence of 0.24-1.03% in all casualties of blunt cerebrovascular injuries [5,7,12,20,21], a feasible screening algorithm which considers on factors and tracer diagnoses that determines a BCVI is strongly required. These factors and tracer diagnoses have been introduced by the Denver [6] and Memphis trauma groups [16] and have been used in many studies [8,13,14].…”

Section: Discussionmentioning

confidence: 99%

Blunt cerebrovascular injuries in acute trauma care: a screening protocol

et al. 2011

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Introduction Blunt cerebrovascular injuries (BCVI) of the extra-or intracerebral vessels are frequently observed lesions which may lead to thrombembolic events with focal neurological deficits, stroke or death particularly in patients \60 years. However, a comprehensive standardised clinical algorithm for screening and management of these secondary injuries is still lacking. Materials and methods We developed a standardised screening protocol applicable for mild as well as severely injured patients. In this prospective cohort study, we evaluated the feasibility of this diagnostic algorithm in a level 1 trauma centre setting. Trauma patients who met the inclusion criteria underwent a computed tomographic angiography (CTA) as part of standard diagnostic procedure at admission. All suspicions or positive findings were reevaluated by a conventional four-vessel catheter angiography within the first 72 h after trauma. Within this period, anticoagulation with low-dose heparin was started. BCVI confirmation indicated a shift to systemic heparinisation with overlapping phenprocoumon therapy for at least 6 months. All patients were reevaluated after 6 months by another four-vessel angiography. Depending on the diagnostic findings, oral anticoagulation may be discontinued or continued for another 6 months.Results A total of 44 patients (8 male, 6 female, age range 19-95 years) were included in the study. 20 BCVIs were detected in 16 patients (36.3%). The most common injuries identified were Biffl Type II (40%) and Type IV lesions (30%). 86.4% of the patients received a CTA upon admission, 93.2% of which were conducted within 12 h posttrauma. None of the patients had a secondary thrombembolic neurological event during the hospital stay or within 3 months postdischarge. Conclusion Our results indicate that implementation of the screening protocol can prevent strokes in patients without primary thrombembolic neurological deficits.

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“…13 More recent evidence using a refined heparin regimen (target APTT of 40-50 s, no bolus) or anti-platelet agents in 39/ 50 patients with blunt VAI before the onset of ischaemia found a stroke rate of 2.6% compared to 54% in the untreated group. 14 In patients with vertebral artery injury and evidence of posterior circulation stroke, anticoagulation with heparin results in better outcomes and is recommended as treatment. 13 Current guidelines do not recommend screening of patients with cervical spine injuries for evidence of blunt vertebral or carotid artery injuries.…”

Section: Discussionmentioning

confidence: 99%