Comparison of anticoagulation and antiplatelet therapy for treatment of blunt cerebrovascular injury in children &lt;10 years of age: a multicenter retrospective cohort study

Ravindra, Vijay M.; Bollo, Robert J.; Dewan, Michael C.; Riva-Cambrin, Jay; Tonetti, Daniel A; Awad, Al Wala; Akbari, S. Hassan A.; Gannon, Stephen; Shannon, Chevis N.; Birkas, Yekaterina; Limbrick, David D.; Jea, Andrew; Naftel, Robert P.; Kestle, John R. W.; Grandhi, Ramesh

doi:10.1007/s00381-020-04672-w

Cited by 8 publications

(7 citation statements)

References 19 publications

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“…Our case supports a role for PED-Shield in the endovascular armamentarium available to address ruptured pseudoaneurysms. The use of antiplatelet therapy in children is commonplace 23 and believed to be safe in the setting of blunt cerebrovascular injury, 24,25 but there is little evidence regarding the lifelong implications of these medications in children, which certainly requires further inquiry.…”

Section: Discussionmentioning

confidence: 99%

Successful flow diversion treatment of ruptured infectious middle cerebral artery aneurysms with the use of Pipeline Flex with Shield technology

Samples¹,

Ravindra

Thoms³

et al. 2021

Interv Neuroradiol

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Background Rupture of infectious intracranial aneurysms (IIAs) is associated with a high likelihood of mortality. Endovascular treatment of IIAs via parent artery sacrifice offers good efficacy and outcomes; however, depending on the lesion’s location, neurologic deficit may result. Case description We describe a pediatric patient with ruptured IIAs off the left middle cerebral artery (MCA) treated with coil embolization and endovascular flow diversion using the Pipeline Flex Embolization Device (PED) with Shield technology. We chose to place a flow diverter because 1) there was a second, more distal IIA not amenable to direct coil embolization, 2) there was significant potential for aneurysm regrowth and need for retreatment, and 3) we believed the diseased parent MCA needed to be reconstructed. Conclusions In the setting of previous hemicraniectomy, PED-Shield gave us the option to discontinue dual antiplatelet therapy should the patient require further neurosurgical intervention. Our case supports a role for PED-Shield to address ruptured pseudoaneurysms.

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Section: Discussionmentioning

confidence: 99%

Successful flow diversion treatment of ruptured infectious middle cerebral artery aneurysms with the use of Pipeline Flex with Shield technology

Samples¹,

Ravindra

Thoms³

et al. 2021

Interv Neuroradiol

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“…After full text analysis, 17 articles were included in the review. [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] The incidence of BCVI in children was reported to be 0.03% to 1.30% of blunt traumatic injuries. 15,17 The strongest predictors for BCVI were the presence of basal skull fracture, cervical spine fracture, intracranial hemorrhage, Glasgow Coma Scale score less than 8, mandible fracture, and injury severity score more than 15.…”

Section: Resultsmentioning

confidence: 99%

Pediatric Blunt Cerebrovascular Injuries

El Tawil,

Nemeth,

Al Sawafi

2023

Pediatr Emer Care

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The low incidence of blunt cerebrovascular injury (BCVI) reported in pediatric studies (<1%) might be related to an underreporting due to both the absence of current screening guidelines and the use of inadequate imaging techniques. This research is a review of the literature limited to the last 5 years (2017-2022) about the approach and management of BCVI in pediatrics. The strongest predictors for BCVI were the presence of basal skull fracture, cervical spine fracture, intracranial hemorrhage, Glasgow Coma Scale score less than 8, mandible fracture, and injury severity score more than 15. Vertebral artery injuries had the highest associated stroke rate of any injury type at 27.6% (vs 20.1% in carotid injury). The sensitivity of the well-established screening guidelines of BCVI varies when applied to the pediatric population (Utah score -36%, 17%, Eastern Association for the Surgery of Trauma (EAST) guideline -17%, and Denver criteria -2%). A recent metaanalysis of 8 studies comparing early computed tomographic angiogram (CTA) to digital subtraction angiography for BCVI detection in adult trauma patients demonstrated high variability in the sensitivity and specificity of CTA across centers. Overall, CTA was found to have a high specificity but low sensitivity for BCVI. The role of antithrombotic as well as the type and duration of therapy remain controversial. Studies suggest that systemic heparinization and antiplatelet therapy are equally effective.

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“…Other studies likewise report no difference in BCVI outcomes depending on antithrombotic regimen used. 25,26 At our center, most patients with BCVI, regardless of grade, were initiated on high-dose aspirin as antithrombotic therapy; however, by a statistically significant margin, those with lower-grade injuries were more frequently initiated on low-dose aspirin. BCVI management is not currently protocolized at our institution, and treatment decisions are made at the discretion of the on-service attending neurosurgeon.…”

Section: Common Care Patterns In-hospital Anticoagulation Vs Antiplat...mentioning

confidence: 98%

Management Patterns and Outcomes After Traumatic Brain Injury With Associated Blunt Cerebrovascular Injury

Findlay,

Sarriera-Valentin,

Earl

et al. 2023

Neurosurgery

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BACKGROUND AND OBJECTIVES: Although blunt cerebrovascular injuries (BCVIs) are relatively common in patients with traumatic brain injuries (TBIs), uncertainty remains regarding optimal management strategies to prevent neurological complications, morbidity, and mortality. Our objectives were to characterize common care patterns; assess the prevalence of adverse outcomes, including stroke, functional deficits, and death, by BCVI grade; and evaluate therapeutic approaches to treatment in patients with BCVI and TBI. METHODS: Patients with TBI and BCVI treated at our Level I trauma center from January 2016 to December 2020 were identified. Presenting characteristics, treatment, and outcomes were captured for univariate and multivariate analyses. RESULTS: Of 323 patients with BCVI, 145 had Biffl grade I, 91 had grade II, 49 had grade III, and 38 had grade IV injuries. Lower-grade BCVIs were more frequently managed with low-dose (81 mg) aspirin (P < .01), although all grades were predominantly treated with high-dose (150-600 mg) aspirin (P = .10). Patients with low-grade BCVIs had significantly fewer complications (P < .01) and strokes (P < .01). Most strokes occurred in the acute time frame (<24 hours), including 10/11 (90.9%) grade IV-related strokes. Higher BCVI grade portended elevated risk of stroke (grade II odds ratio [OR] 5.3, grade III OR 12.2, and grade IV OR 19.6 compared with grade I; all P < .05). The use of low- or high-dose aspirin was protective against mortality (both OR 0.1, P < .05). CONCLUSION: In patients with TBI, BCVIs impart greater risk for stroke and other associated morbidities as their severity increases. It may prove difficult to mitigate high-grade BCVI-related stroke, considering most events occur in the acute window. The paucity of late time frame strokes suggest that current management strategies do help mitigate risks.

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Comparison of anticoagulation and antiplatelet therapy for treatment of blunt cerebrovascular injury in children <10 years of age: a multicenter retrospective cohort study

Cited by 8 publications

References 19 publications

Successful flow diversion treatment of ruptured infectious middle cerebral artery aneurysms with the use of Pipeline Flex with Shield technology

Successful flow diversion treatment of ruptured infectious middle cerebral artery aneurysms with the use of Pipeline Flex with Shield technology

Pediatric Blunt Cerebrovascular Injuries

Management Patterns and Outcomes After Traumatic Brain Injury With Associated Blunt Cerebrovascular Injury

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