Blunt cerebrovascular injury: incidence and long-term follow-up

Abstract

Purpose Blunt cerebrovascular injuries (BCVI), which can result in ischemic stroke, are identified in 1-2% of all blunt trauma patients. Computed tomography angiography (CTA) scanning has improved and is the diagnostic modality of choice in BCVI suspected patients. Data about long-term functional outcomes and the incidence of ischemic stroke after BCVI are limited. The aim of this study was to determine BCVI incidence in relation to imaging modality improvements and to determine long-term functional outcomes. Methods All consecutive trauma patients from 2007 to 2016 with BCVI were identified from the level 1 trauma center prospective trauma database. Three periods were identified where CTA diagnostic modalities for trauma patients were improved. Long-term functional outcomes using the EuroQol six-dimensional (EQ-6D™) were determined. Results Seventy-one BCVI patients were identified among the 12.122 (0.59%) blunt trauma patients. In the first period BCVI incidence among the overall study cohort, polytrauma, basilar skull fracture and cervical trauma subgroups was found to be 0.3%, 0.9%, 1.2%, 4.6%, respectively, which more than doubled towards the third period (0.8, 2.4, 1.9 and 8.5% respectively). Ischemic stroke as a result of BCVI was found in 20 patients (28%). In-hospital stroke rate was lower in patients receiving antiplatelet therapy (p < 0.01). Six in-hospital deaths were BCVI related. Long-term follow-up (follow-up rate of 83%) demonstrated lower functional outcomes compared to Dutch reference populations (p < 0.01). Ischemic stroke was identified as a major cause of functional impairment at long-term follow-up. Conclusions Improved CTA diagnostic modalities have increased BCVI incidence. Furthermore, BCVI patients reported significant functional impairment at long-term follow-up. Antiplatelet therapy showed a significant effect on in-hospital stroke rate reduction.

An Update in Imaging of Blunt Vascular Neck Injury

“…1 A recent study demonstrated increased detection rates for BCVI in trauma patients from 0.3% in 2007 to 0.8% in 2016 after improvement of computed tomography angiography (CTA) scanning technique—increasing the slice number from 64 to 256 and increasing intravenous (IV) contrast injection rates from 3 to 6 mL/s—and the addition of CTA to the standard trauma CT protocol. 5 After introduction of a standardized screening criteria in 2007 in Australia, BCVI detection rates increased 2-fold from 0.52% to 1.06%. 4 More recent data report a 3% incidence of BCVI 7 in trauma patients, 3.8% incidence of TVAI in geriatric trauma patients, 8 8.5% incidence in patients with cervical trauma, 5 and up to 9% incidence of BCVI in patients with severe head injury.…”

“…The in-hospital mortality rate from 2005 to 2016 was 8% to 10.2% and the ischemic stroke rate was 23% to 28%. 5,14…”

“…The vertebral and carotid arteries are affected in 68% to 74% and 32% to 46% of all BCVI cases, respectively. [3][4][5]…”

Endovascular treatment of blunt injury of the extracranial internal carotid artery: the prospect and dilemma

“…Extracranial traumatic vascular injury is present in approximately 1% to 2% of patients after blunt trauma, and the incidence of extracranial ICA injury ranges from 0.08 to 0.33%, among which 52-79% of these patients are asymptomatic. For most of these patients, conservative medical treatment is sufficient [2,[6][7][8][9][10]. However, for a small number of patients with disastrous implications, surgical intervention is needed [11].…”

Different strokes: differences in the characteristics and outcomes of BCVI and non-BCVI strokes in trauma patients

“…In a study from the Netherlands, Hundersmarck et al demonstrated that patients with BCVIs have worse long-term functional outcomes than those in the general trauma population. 16 In addition, patients with BCVI and ischemic stroke had worse long-term outcomes in terms of mobility and self-care than patients with BCVI alone. Patients with BCVI and traumatic brain injury had worse cognitive outcomes.…”