Management of simultaneous traumatic brain injury and aortic injury

Abstract

Object. Simultaneous traumatic brain injury (TBI) and aortic injury has been considered unsurvivable for many years because treatments such as sedation and blood pressure goals conflict for these 2 conditions. Additionally, surgical interventions for aortic injury often require full anticoagulation, which is contraindicated in patients with TBI. For these reasons, and due to the relative rarity of aortic injury/TBI, little data are available to guide treating physicians.Methods. A retrospective review was performed on all simultaneous TBI and aortic injury cases from 2000 to 2012 at a university-affiliated, Level I trauma center. Patient demographics, imaging studies, interventions, and outcomes were analyzed. Traumatic brain injury/aortic injury cases treated with endovascular stenting were specifically studied to determine trends in procedure timing, use of anticoagulation, and neurological outcome.Results. Thirty-three patients with concurrent TBI and aortic injury were identified over a 12-year period. The median patient age was 44 years (range 16-86 years) and the overall mortality rate after imaging diagnosis was 46%. All surviving patients were awake and neurologically functional at discharge, and 83% were discharged home or to rehabilitation facilities. Patients who died had a higher Injury Severity Scale score (p = 0.006). Severe TBI (p = 0.045) or hemodynamic instability (p = 0.015) upon arrival to the hospital was also correlated with increased mortality rates. Thirty-three percent of aortic injury/TBI patients (n = 11) underwent endovascular stenting, and 7 of these patients received intravenous anticoagulation therapy at the time of surgery. Six of these 7 anticoagulation-treated patients experienced no significant progression on postoperative brain CT, whereas 1 patient died of hemodynamic instability prior to undergoing further imaging.Conclusions. Simultaneous TBI and aortic injury is a rare condition with a historically poor prognosis. However, these results suggest that many patients can survive with a good quality of life. Technological advances such as endovascular aortic stenting may improve patient outcome, and anticoagulation is not absolutely contraindicated after TBI. Key woRDS • aortic injury • traumatic brain injury • aortic stentAbbreviations used in this paper: GCS = Glasgow Coma Scale; ISS = Injury Severity Scale; SAH = subarachnoid hemorrhage; SDH = subdural hematoma; TBI = traumatic brain injury.

Early antithrombotic therapy is safe and effective in patients with blunt cerebrovascular injury and solid organ injury or traumatic brain injury

“…Byrnes et al 14 looked at therapeutic anticoagulation in patients with TBI and found that it can be safe; however, only two of the patients in that study were anticoagulated within 24 hours of their injury. Kitagawa et al 16 studied concurrent TBI and aortic injuries and found that six patients who received full anticoagulation intraoperatively during repair of their aortic injury had no progression of TBI; however, they did not report the time from injury in these patients.…”

“…As was noted earlier, there has been very limited literature about the early use of AT in patients with TBI. 14,16 Fortunately, the neurosurgeons at our institution have the same respect for BCVI as we do and allow for almost immediate initiation of AT in most patients, and this includes patients with an intracranial pressure monitor. A repeat head CT is performed if there is a neurologic examination change or once the aPTT reaches at least a therapeutic level to evaluate for worsening of the injury.…”

Graded Aerobic Treadmill Testing in Adolescent Traumatic Brain Injury Patients

“…Furthermore, TBI patients can also harbor coexisting orthopedic, vascular, pulmonary, or hematological conditions that may also limit exercise capacity. [39][40][41][42][43] In this study, two treadmill tests were terminated by the treatment team. One test was terminated late in the study because of patient ataxia and imbalance secondary to previously known right-sided weakness.…”

Endovascular management of penetrating and non-penetrating aortic injury

“…It might be prudent to treat a lowgrade aortic injury with thoracic endovascular aortic repair (TEVAR), for example, if the non-operative management strategy runs counter to the optimal strategy for the management of a signifi cant non-aortic injury. Such might be the case in synchronous brain and aortic injury, where the goals of increasing cerebral perfusion pressure and decreasing aortic shear stress are likely to be diametrically opposed [37].…”

“…For patients with clinically threatening but stable aortic injuries (grade II-III injuries in the UT Houston paradigm, and moderate grade injuries in the University of Washington paradigm), TEVAR should be performed as soon as the signifi cant non-aortic injuries have been adequately stabilized [11,34]. Non-urgent repair of such aortic injuries will undoubtedly lead to rare cases of progression, rupture, and aortic-related mortality, but delayed repair in those cases will likely be dictated by an equally lethal burden of non-aortic injuries [37]. For patients able to tolerate delayed repair, the time interval may allow for the regression of intramural hematoma or intimal injuries, resulting in more stable endograft landing zones.…”