Factors associated with stroke formation in blunt cerebrovascular injury: An EAST multicenter study

Abstract

BACKGROUND:Stroke risk factors after blunt cerebrovascular injury (BCVI) are ill-defined. We hypothesized that factors associated with stroke for BCVI would include medical therapy (i.e., Aspirin), radiographic features, and protocolization of care. METHODS:An Eastern Association for the Surgery of Trauma-sponsored, 16-center, prospective, observational trial was undertaken. Stroke risk factors were analyzed individually for vertebral artery (VA) and internal carotid artery (ICA) BCVI. Blunt cerebrovascular injuries were graded on the standard 1 to 5 scale. Data were from the initial hospitalization only. RESULTS:Seven hundred seventy-seven BCVIs were included. Stroke rate was 8.9% for all BCVIs, with an 11.7% rate of stroke for ICA BCVI and a 6.7% rate for VA BCVI. Use of a management protocol ( p = 0.01), management by the trauma service ( p = 0.04), antiplatelet therapy over the hospital stay ( p < 0.001), and Aspirin therapy specifically over the hospital stay ( p < 0.001) were more common in ICA BCVI without stroke compared with those with stroke. Antiplatelet therapy over the hospital stay ( p < 0.001) and Aspirin therapy over the hospital stay ( p < 0.001) were more common in VA BCVI without stroke than with stroke. Percentage luminal stenosis was higher in both ICA BCVI ( p = 0.002) and VA BCVI ( p < 0.001) with stroke. Decrease in percentage luminal stenosis ( p < 0.001), resolution of intraluminal thrombus ( p = 0.003), and new intraluminal thrombus ( p = 0.001) were more common in ICA BCVI with stroke than without, while resolution of intraluminal thrombus ( p = 0.03) and new intraluminal thrombus ( p = 0.01) were more common in VA BCVI with stroke than without. CONCLUSION:Protocol-driven management by the trauma service, antiplatelet therapy (specifically Aspirin), and lower percentage luminal stenosis were associated with lower stroke rates, while resolution and development of intraluminal thrombus were associated with higher stroke rates. Further research will be needed to incorporate these risk factors into lesion specific BCVI management.

Early Pharmacologic Therapy in Patients With Blunt Cerebrovascular Injury and TBI: Is it Safe and Effective? An EAST Multicenter Study

“…Patient data were sourced from an EAST-sponsored, multicenter, observational trial of BCVI outcomes in adult patients conducted at 16 trauma centers from 2018 to 2020. 14 IRB approval and waiver of informed consent were obtained at all centers. Data were entered into a centralized REDCap database.…”

“…Many studies have centered on timing and efficacy of antithrombotic and anticoagulant regimens in all BCVI patients. 13,14 Fewer have focused to the timing of strokes after BCVI; while a single study analyzed stroke timing in isolated BCVI, 9 no similar analysis has been performed exclusive to patients with both BCVI and TBI. BCVI-related strokes often occur within the first 72 h, 3,8,9,15 when providers are most cautious about antithrombotic or anticoagulant therapy in TBI patients.…”

Traumatic Brain Injury and Traumatic Spinal Cord Injury

“…A liberal screening strategy results in identifying more vessel injuries and treating more patients to decrease stroke risk. 51 The Eastern Association for the Surgery of Trauma recommends the use of antithrombotic therapy in patients with blunt polytrauma who are found to have blunt cerebrovascular injury without associated stroke to reduce the risk of stroke and associated mortality, but there is insufficient evidence to guide selection between antiplatelet therapy or anticoagulation. 50 The majority of the evidence supporting this recommendation came from studies that excluded patients with concomitant TBI; multidisciplinary discussion regarding the timing and selection of antithrombotic therapy in this population is recommended.…”

“…While this grading system was derived from digital subtraction angiography findings, CT angiography has become the modality of choice for screening, diagnosing, and grading cerebrovascular injury. A liberal screening strategy results in identifying more vessel injuries and treating more patients to decrease stroke risk 51 . The Eastern Association for the Surgery of Trauma recommends the use of antithrombotic therapy in patients with blunt polytrauma who are found to have blunt cerebrovascular injury without associated stroke to reduce the risk of stroke and associated mortality, but there is insufficient evidence to guide selection between antiplatelet therapy or anticoagulation 50 .…”