Clinical and radiographic outcomes following traumatic Grade 1 and 2 carotid artery injuries: a 10-year retrospective analysis from a Level I trauma center. The Parkland Carotid and Vertebral Artery Injury Survey

Abstract

T he management of blunt cerebrovascular injuries (BCVIs), including low-grade blunt carotid artery injuries (BCIs), remains controversial; however, antiplatelet agents or anticoagulation continue to be firstline treatments, with endovascular stenting typically reserved for symptomatic or higher-grade injuries. 5,7,8,16,19,26 Whereas our earlier reports explored blunt vertebral artery injuries (BVIs), this current report presents our evaluation of Grade 1 and 2 BCIs. Imaging, progression of injury, and outcomes of these lower-grade BCIs were analyzed to abbreviatioNs ASA = acetylsalicylic acid; BCI = blunt carotid artery injury; BCVI = blunt cerebrovascular injury; BVI = blunt vertebral artery injury; CTA = CT angiography; DSA = digital subtraction angiography; MVC = motor vehicle collision. obJect Proper screening, management, and follow-up of Grade 1 and 2 blunt carotid artery injuries (BCIs) remains controversial. These low-grade BCIs were analyzed to define their natural history and establish a rational management plan based on lesion progression and cerebral infarction. methods A retrospective review of a prospectively maintained database of all blunt traumatic carotid and vertebral artery injuries treated between August 2003 and April 2013 was performed and Grade 1 and 2 BCIs were identified. Grade 1 injuries are defined as a vessel lumen stenosis of less than 25%, and Grade 2 injuries are defined as a stenosis of the vessel lumen between 25% and 50%. Demographic information, radiographic imaging, number of imaging sessions performed per individual, length of radiographic follow-up, radiographic outcome at end of follow-up, treatment(s) provided, and documentation of ischemic stroke or transient ischemic attack were recorded. results One hundred seventeen Grade 1 and 2 BCIs in 100 patients were identified and available for follow-up. The mean follow-up duration was 60 days. Final imaging of Grade 1 and 2 BCIs demonstrated that 64% of cases had resolved, 13% of cases were radiographically stable, and 9% were improved, whereas 14% radiographically worsened. Of the treatments received, 54% of cases were treated with acetylsalicylic acid (ASA), 31% received no treatment, and 15% received various medications and treatments, including endovascular stenting. There was 1 cerebral infarction that was thought to be related to bilateral Grade 2 BCI, which developed soon after hospital admission. coNclusioNs The majority of Grade 1 and 2 BCIs remained stable or improved at final follow-up. Despite a 14% rate of radiographic worsening in the Grade 1 and 2 BCIs cohort, there were no adverse clinical outcomes associated with these radiographic changes. The stroke rate was 1% in this low-grade BCIs cohort, which may be an overestimate. The use of ASA or other antiplatelet or anticoagulant medications in these low-grade BCIs did not appear to correlate with radiographic injury stability, nor with a decreased rate of cerebral infarction. Although these data suggest that these Grade 1 and 2 BCIs may require less intensive r...

Imaging and Management of Blunt Cerebrovascular Injury

“…A study from the Denver group (69) demonstrated a stroke rate of 38% in grade II injury, 27% in grade III injury, and 28% in grade IV injury. It is worth mentioning that recent reports call into question the previously reported stroke rate as overestimations, suggesting that the true stroke rate may be closer to 5% (59,70). A lower calculated rate may result from increased discovery of asymptomatic low-grade lesions at screening.…”

Blunt Traumatic Extracranial Cerebrovascular Injury and Ischemic Stroke

“…It is important to note that this system was developed based on DSA and that it is difficult to distinguish type 1, 2, and 3 TCVI with CTA alone. Many contemporary studies investigating the frequency and prognosis of type 1–3 lesions have primarily employed CTA alone [4, 23, 26, 27, 28, 29]; therefore, the reliability of these reports, in precisely distinguishing between TCVI types, is limited. However, CTA can reliably identify type 4 lesions (complete artery occlusion).…”

“…Patients who are found to have an asymptomatic TCVI on screening imaging and then are treated with antithrombotic therapy appear to have an overall risk of ischemic stroke of up to 20% [10, 12, 21, 25, 26, 31, 32, 33, 34, 35]. Studies reporting on initially asymptomatic patients treated with antiplatelet agents indicate a risk of stroke of up to 11% [10, 12, 21, 26, 31, 32, 33, 34, 36].…”

“…Studies reporting on initially asymptomatic patients treated with antiplatelet agents indicate a risk of stroke of up to 11% [10, 12, 21, 26, 31, 32, 33, 34, 36]. Studies reporting on initially asymptomatic patients treated with anticoagulation indicate a risk of stroke of up to 20% [10, 32].…”

Editorial: Mild narrowing of the cervical carotid is noted

“…8 The introduction of screening protocols with CT angiography (CTA) has resulted in an increase in the diagnosis of these lesions in trauma patients, and there is a real question of what to do when the radiologist's report reads "mild narrowing of the cervical ICA." The fact that despite a significant amount of literature on the subject the authors chose to study this topic reveals how much uncertainty remains regarding the management of these lesions.…”