Time to stroke: A Western Trauma Association multicenter study of blunt cerebrovascular injuries

Burlew, Clay Cothren; Sumislawski, Joshua J.; Behnfield, Charles D; McNutt, Michelle K.; McCarthy, James J.; Sharpe, John P.; Croce, Martin A.; Bala, Miklosh; Kashuk, Jeffry L.; Spalding, M Chance; Beery, Paul R.; John, Scott; Hunt, Darren J.; Harmon, Laura; Stein, Deborah M.; Callcut, Rachael A.; Wybourn, Chris; Sperry, Jason L.; Anto, Vincent; Dunn, Julie; Veith, Jacob; Brown, Carlos V R; Celii, Amanda; Zander, Tyler L; Coimbra, Raúl; Berndtson, Allison E.; Moss, Tovah; Malhotra, Ajai K.; Hazelton, Joshua P.; Linden, Kimberly; West, Michael A.; Alam, Hasan B.; Williams, Aaron M.; Kim, Jennie; Inaba, Kenji; Moulton, Steve; Choi, Young Mee; Warren, Harry L; Collier, Bryan; Ball, Chad G.; Savage, Stephanie A.; Hartwell, Jennifer L.; Cullinane, Daniel C.; Zielinski, Martin D.; Ray-Zack, Mohamed D.; Morse, Bryan C.; Rhee, Peter; Rutherford, Edmund J.; Udekwu, Pascal; Reynolds, Charles; Toschlog, Eric A.; Gondek, Steve; Ju, Tammy; Haan, James M.; Lightwine, Kelly; Kulvatunyou, Narong; Coates, Brian; Khouqeer, Ahmed F.; Todd, Stephanie; Zarzaur, Ben L.; Waller, Christine J.; Kallies, Kara J.; Neideen, Todd; Eddine, Savo Bou Zein; Peck, Kimberly A.; Dunne, Casey E.; Kramer, Kristina; Bokhari, Faran; Dhillon, Tejveer S.; Galante, Joseph M.; Cohen, Mitchell J.

doi:10.1097/ta.0000000000001989

Cited by 58 publications

(28 citation statements)

References 29 publications

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“…Our median time to stroke was 2.0 days, with a range of 0-12 days. This is similar to prior studies by Burlew et al (21) and Cothren el al (15), in which median times to stroke were 2.0 days (range, 0-46 days) and 2.1 days (range, 0-10 days), respectively.…”

Section: Discussionsupporting

confidence: 91%

Natural History of Blunt Cerebrovascular Injury: Experience Over a 10-year Period at a Level I Trauma Center

Christensen

Call

et al. 2020

Radiology

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Background: Blunt cerebrovascular injury (BCVI) is associated with increased stroke and mortality risk. However, the most appropriate follow-up strategy remains uncertain. Purpose:To better understand the natural history of BCVI and help define the most optimal timing and length of follow-up imaging. Materials and Methods:In this retrospective HIPAA-compliant study, data from all patients treated for BCVI at a level I trauma center between April 1, 2005, and June 30, 2015, were reviewed. For patients with at least one follow-up study, time-to-event analysis was performed to assess the trend in injury evolution. Association of injury grade and injury evolution was also assessed. The Fisher exact test and multivariable logistic regression were used to evaluate association of the number of injured vessels, vessel grade, and vessel type (internal carotid artery, vertebral artery) with BCVI-associated stroke.Results: A total of 1204 patients (800 men; mean age ± standard deviation, 45 years ± 22) with 1604 vessel injuries were evaluated. High-grade (grades 3-5) injuries were less likely to resolve (hazard ratio [HR], 0.2; P < .001) than low-grade injuries. High-grade injuries were more likely to progress than low-grade injuries (HR, 3.3; P = .005). Of the injuries that improved or resolved (343 of 419 [81.9%]), 76% (259 of 343) changed within 30 days after the initial injury, and the remaining 24% (84 of 343) changed between 30 and 90 days. Of the injuries that progressed (46 of 419 [11.0%]), 87% (40 of 46) changed within 90 days. Beyond 90 days, no improvement or resolution occurred, and only 1.4% (six of 419) of injuries progressed. Higher injury grade Address correspondence to L.W.

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Section: Discussionsupporting

confidence: 91%

Natural History of Blunt Cerebrovascular Injury: Experience Over a 10-year Period at a Level I Trauma Center

Christensen

Call

et al. 2020

Radiology

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“…The key findings are that BCVI and acute stroke are relatively common in trauma patients, and two thirds of acute strokes are present on admission. This proportion is higher than reported in “Time to Stroke,” a recent multicenter study, which found that stroke was present on admission in only one third of patients with BCVI 1 . However, this study did not consistently use MRI to diagnose stroke and did not use a universal CTA screening strategy across all centers.…”

Section: Discussioncontrasting

confidence: 57%

Imaging analysis of ischemic strokes due to blunt cerebrovascular injury

Abraham

Black

Griffin

et al. 2022

J Trauma Acute Care Surg

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BACKGROUNDThe timing of stroke onset among patients with blunt cerebrovascular injury (BCVI) is not well understood. All blunt trauma patients at our institution undergo a screening computed tomographic angiography (CTA) of the neck. Most patients with CTA evidence of BCVI are treated with aspirin, and all patients with clinical evidence of stroke are treated with aspirin and undergo magnetic resonance imaging (MRI) of the brain. We conducted a retrospective review to determine the incidence of stroke upon admission and following admission.METHODSAll neck CTAs and head MRIs obtained in blunt trauma patients were reviewed from August 2017 to August 2019. All CTAs that were interpreted as showing BCVI were individually reviewed to confirm the diagnosis of BCVI. Stroke was defined as brain MRI evidence of new ischemic lesions, and each MRI was reviewed to identify the brain territory affected. We extracted the time to aspirin administration and the timing of stroke onset from patients' electronic health records.RESULTSOf the 6,849 blunt trauma patients, 479 (7.0%) had BCVIs. Twenty-four patients (5.0%) with BCVI had a stroke on admission. Twelve (2.6%) of the remaining 455 patients subsequently had a stroke during their hospitalization. The incidence of stroke among patients with BCVI was 7.5%; 2.6% were potentially preventable. Only 5 of the 12 patients received aspirin before the onset of stroke symptoms. All 36 patients with BCVI and stroke had thromboembolic lesions in the territory supplied by an injured vessel.CONCLUSIONWith universal screening, CTA evidence of BCVI is common among blunt trauma patients. Although acute stroke is also relatively common in this population, two thirds of strokes are already evident on admission. One third of BCVI-related strokes occur after admission and often relatively early, necessitating rapid commencement of preventative treatment. Further studies are required to demonstrate the value of antithrombotic administration in preventing stroke in BCVI patients.LEVEL OF EVIDENCEPrognostic and Epidemiologic; Level IV.

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“…38,48,55 In addition, AP agents carry a theoretical advantage in that the mechanism of stroke in BCVI is typically artery-to-artery embolism, and AP agents are argued to be more appropriate in this pathophysiological context. 65 In their multicenter study reviewing BCVI stroke timing, Burlew et al 45 found that in patients who sustained stroke on treatment, twice as many patients were on AP agents versus anticoagulation. However, they did not collect information on all patients with BCVI; thus, the actual percentage of patients treated with AP agents versus systemic heparin could not be determined.…”

Section: Discussionmentioning

confidence: 99%

“…We could not carry out statistical analysis for radiographic progression rates and overall functional outcomes, but these outcomes appeared similar between the two groups. In the largest study of BCVI patients who suffered from stroke, Burlew et al 45 reported that 63 (51.6%) of 122 patients treated with APs and 70 (63.1%) of 111 patients treated with anticoagulation agents had neurologic improvement, when the different types of AC or AP therapies were pooled. 45 This suggests that anticoagulation therapy with heparin may be preferable in patients who have already suffered from a stroke, in terms of secondary prevention and improving overall clinical outcome.…”

Section: Discussionmentioning

confidence: 99%

Antithrombotic choice in blunt cerebrovascular injuries: Experience at a tertiary trauma center, systematic review, and meta-analysis

Priola

Mathieu

et al. 2021

J Trauma Acute Care Surg

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BACKGROUND:Blunt cerebrovascular injuries (BCVIs) may occur following trauma and lead to ischemic stroke if untreated. Antithrombotic therapy decreases this risk; however, the optimal agent has yet to be determined in this population. The aim of this study was to compare the risk-benefit profile of antiplatelet (AP) versus anticoagulant (AC) therapy in rates of ischemic stroke and hemorrhagic complications in BCVI patients. METHODS:We performed a retrospective review of BCVI patients at our tertiary care Trauma hospital from 2010 to 2015, and a systematic review and meta-analysis of the literature. The OVID Medline, Embase, Web of Science, and Cochrane Library databases were searched from inception to September 16, 2019. References of included publications were searched manually for other relevant articles. The search was limited to articles in humans, in patients 18 years or older, and in English. Studies that reported treatment-stratified clinical outcomes following AP or AC treatment in BCVI patients were included. Exclusion criteria included case reports, case series with n < 5, review articles, conference abstracts, animal studies, and non-peer-reviewed publications. Data were extracted from each study independently by two reviewers, including study design, country of origin, sex and age of patients, Injury Severity Score, Biffl grade, type of treatment, ischemic stroke rate, and hemorrhage rate. Pooled estimates using odds ratio (OR) were combined using a random-effects model using a Mantel-Hanzel weighting. The main outcome of interest was rate of ischemic stroke due to BCVI, and the secondary outcome was hemorrhage rate based on AC or AP treatment. RESULTS:In total, there were 2044 BCVI patients, as reported in the 22 studies in combination with our institutional data. The stroke rate was not significantly different between the two treatment groups (OR, 1.27; 95% confidence interval, 0.40-3.99); however, the hemorrhage rate was decreased in AP versus AC treated groups (OR, 0.38; 95% confidence interval, 0.15-1.00). CONCLUSION:Based on this meta-analysis, both AC and AP seem similarly effective in preventing ischemic stroke, but AP is better tolerated in the trauma population. This suggests that AP therapy may be preferred, but this should be further assessed with prospective randomized trials.

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Time to stroke: A Western Trauma Association multicenter study of blunt cerebrovascular injuries

Abstract: Prognostic/Epidemiologic, level III.

Cited by 58 publications

References 29 publications

Natural History of Blunt Cerebrovascular Injury: Experience Over a 10-year Period at a Level I Trauma Center

Natural History of Blunt Cerebrovascular Injury: Experience Over a 10-year Period at a Level I Trauma Center

Imaging analysis of ischemic strokes due to blunt cerebrovascular injury

Antithrombotic choice in blunt cerebrovascular injuries: Experience at a tertiary trauma center, systematic review, and meta-analysis

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