Optimizing screening for blunt cerebrovascular injuries

Biffl, Walter L.; Moore, Ernest E.; Offner, Patrick J.; Brega, Kerry E.; Franciose, Reginald J.; Elliott, Joseph P.; Burch, Jon M.

doi:10.1016/s0002-9610(99)00245-7

Cited by 276 publications

(214 citation statements)

References 20 publications

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“…Patients with all four factors had 93% probability of having injury to the carotid artery. On the other hand, the only independent predictor of vertebral artery injury was cervical spine fracture, and patients with cervical spine fracture had 33% probability of vertebral artery injury 5,15,23 . In our study, one patient (3.7%) with Grade II carotid injury did not have any concomitant injuries in the head and neck.…”

Section: Discussionmentioning

confidence: 97%

“…At our institution, the selection of trauma patients for BCVI screening is based on the injury mechanism, physical signs, and associated injuries according to the Denver Criteria 22,23 . The risk-based screening mechanism has shown a high yield, with BCVI found in 27% to 44% of patients with risk factors 2,6,7,14,15 . The high incidence of BCVI in our study population shows that a risk-based selection mechanism is an effective practice to screen for BCVI in blunt trauma patients.…”

Section: Discussionmentioning

confidence: 99%

“…In terms of associated injuries, blunt carotid injuries most commonly occurred with traumatic brain injury (72.2%) and basal skull fractures (55.6%) while all of the blunt vertebral injuries were associated with cervical fractures. Previous studies have identified independent predictors of carotid artery injury based on multivariate regression analysis: a Glasgow Coma Score less than or equal to 6, petrous bone fracture, diffuse axonal brain injury, and LeFort II or III fracture 15 . Patients with all four factors had 93% probability of having injury to the carotid artery.…”

Section: Discussionmentioning

confidence: 99%

“…As a result, isolated blunt carotid injuries without concurrent head and neck trauma are more likely. However, the absence of a cervical spine injury is not a useful predictor to rule out vascular injury 3 , and up to 20% of patients with BCVI may not fulfill the commonly reported screening criteria 8,15 .…”

Section: Discussionmentioning

confidence: 99%

“…authors have advocated screening protocols to identify BCVI in asymptomatic patients based on injury patterns and mechanism 15,16 . Although four-vessel angiogram has been considered the gold standard exam to diagnose BCVI, it is invasive, time-consuming, and not readily available 8,17,18 .…”

mentioning

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: 97%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

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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Anticoagulation Is the Gold Standard Therapy for Blunt Carotid Injuries to Reduce Stroke Rate

Cothren¹

2004

Arch Surg

265

186

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blunt trauma admissions to our level I center, of which 643 underwent screening angiography for blunt CAI on the basis of a protocol including injury patterns and symptoms. Patients without contraindications underwent anticoagulation immediately for documented lesions.Setting: A state-designated, level I urban trauma center.Patients: Of the 643 patients undergoing screening angiography, 114 (18%) had confirmed CAI.Intervention: Early angiographic diagnosis and prompt anticoagulation.Main Outcome Measures: Diagnosis, stroke rate, and complications stratified by method of intervention.Results: A CAI was identified in 114 patients during the 7-year study period; the majority were men (71%), with a mean±SD age of 34±1.3 years and a mean±SD Injury Severity Score of 29±1.5. Seventy-three patients underwent anticoagulation after diagnosis (heparin in 54, lowmolecular-weight heparin in 2, antiplatelet agents in 17); none had a stroke. Of the 41 patients who did not receive anticoagulation (because of a contraindication in 27, symptoms before diagnosis in 9, and carotid coil or stent in 5), 19 patients (46%) developed neurologic ischemia. Ischemic neurologic events occurred in 100% of patients who presented with symptoms before angiographic diagnosis and those receiving a carotid coil or stent without anticoagulation.Conclusions: Our prospective evaluation of blunt CAIs suggests that early diagnosis and prompt anticoagulation reduce ischemic neurologic events and their disability. The optimal anticoagulation regimen, however, remains to be established.

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Blunt Carotid Artery Injury

et al. 2004

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Background: Blunt carotid artery injury (BCI) remains a rare but potentially lethal condition. Recent studies recommend that aggressive screening based on broad criteria (hyperextension-hyperflexion mechanism of injury, basilar skull fracture, cervical spine injury, midface fracture, mandibular fracture, diffuse axonal brain injury, and neck seat-belt sign) increases the rate of diagnosis of BCI by 9-fold. If this recommendation becomes a standard of care, it will require a major consumption of resources and may give rise to liability claims. The benefits of aggressive screening are unclear because the natural history of asymptomatic BCI is unknown and the existing treatments are controversial. Hypothesis:The lack of an aggressive angiographic screening protocol does not result in delayed BCI diagnosis or BCI-related neurologic deficits.Methods: A 10-year medical record review of patients with BCI was undertaken in 2 level I academic trauma centers. In both centers, urgent screening for BCI was performed in patients with focal neurologic signs or neurologic symptoms unexplainable by results of computed tomography of the brain as well as in selected patients undergoing angiography for another reason.(REPRINTED) ARCH SURG/ VOL 139, JUNE 2004 WWW.ARCHSURG.COM 609

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Optimizing screening for blunt cerebrovascular injuries

Cited by 276 publications

References 20 publications

Blunt Cerebrovascular Injuries: Diagnosis and Management Outcomes

Blunt Cerebrovascular Injuries: Diagnosis and Management Outcomes

Anticoagulation Is the Gold Standard Therapy for Blunt Carotid Injuries to Reduce Stroke Rate

Blunt Carotid Artery Injury

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