Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma

Abstract

BACKGROUND Blunt cerebrovascular injuries (BCVIs) are associated with significant morbidity and mortality. This guideline evaluates several aspects of BCVI diagnosis and management including the role of screening protocols, criteria for screening cervical spine injuries, and the use of antithrombotic therapy (ATT) and endovascular stents. METHODS Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, a taskforce of the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of currently available evidence. Four population, intervention, comparison, and outcome questions were developed to address diagnostic and therapeutic issues relevant to BCVI. RESULTS A total of 98 articles were identified. Of these, 23 articles were selected to construct the guidelines. In these studies, the detection of BCVI increased with the use of a screening protocol versus no screening protocol (odds ratio [OR], 4.74; 95% confidence interval [CI], 1.76–12.78; p = 0.002), as well as among patients with high-risk versus low-risk cervical spine injuries (OR, 12.7; 95% CI, 6.24–25.62; p = 0.003). The use of ATT versus no ATT resulted in a decreased risk of stroke (OR, 0.20; 95% CI, 0.06–0.65; p < 0.0001) and mortality (OR, 0.17; 95% CI, 0.08–0.34; p < 0.0001). There was no significant difference in the risk of stroke among patients with Grade II or III injuries who underwent stenting as an adjunct to ATT versus ATT alone (OR, 1.63; 95% CI, 0.2–12.14; p = 0.63). CONCLUSION We recommend using a screening protocol to detect BCVI in blunt polytrauma patients. Among patients with high-risk cervical spine injuries, we recommend screening computed tomography angiography to detect BCVI. For patients with low-risk risk cervical injuries, we conditionally recommend performing a computed tomography angiography to detect BCVI. We recommend the use of ATT in patients diagnosed with BCVI. Finally, we recommend against the routine use of endovascular stents as an adjunct to ATT in patients with Grade II or III BCVIs. LEVEL OF EVIDENCE Guidelines, Level III.

Treatment of asymptomatic blunt cerebrovascular injury (BCVI): a systematic review

“…26 28 The Eastern Association for the Surgery of Trauma in 2020 summarized results from 10 studies on the role of antithrombotics compared with no antithrombotics, favoring antithrombotics for stroke prevention with an OR of 0.20 (95% CI 0.06 to 0.65). 26 Our review clearly agrees with this finding, although we chose not to perform a metaanalysis due to the high risk of bias and heterogeneity of study patients. We found that not treating asymptomatic BCVI had a stroke rate as high as 25%, compared with almost any other treatment modality where the stroke rate was <10%.…”

“…Major trauma society guidelines recommend antithrombotic therapy, but evidence regarding specific agents, dose, and duration has not been established. 25 26 Clear indications for more invasive therapies, such as endovascular repair or surgery, are also not well established.…”

First line Treatment of Traumatic Carotid Cavernous Fistulas Using Covered Stents at Level 1 Regional Trauma Center

“…TCCF should be considered, and patients with severe head and facial trauma must undergo imaging during the initial evaluation. In our trauma center, computed tomography angiography is performed based on the Denver criteria [ 11 , 17 ].…”

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

“…Low-grade extracranial ICA blunt injury should be treated with early systemic anticoagulation or antiplatelet therapy [6,[48][49][50][51]. The Eastern Association for the Surgery of Trauma recommends against the routine use of endovascular stents as an adjunct to antithrombotic therapy in patients with asymptomatic grade II or stable III extracranial ICA blunt injuries [52,53].…”