Management of blunt cerebrovascular injury (BCVI) in the multisystem injury patient with contraindications to immediate anti-thrombotic therapy

McNutt, Michelle K.; Kale, A. Cozette; Kitagawa, Ryan S.; Turkmani, Ali; Fields, David W.; Baraniuk, Sarah; Gill, Brijesh S.; Cotton, Bryan A.; Moore, Laura J.; Wade, Charles E.; Day, Arthur L.; Holcomb, John B.

doi:10.1016/j.injury.2017.07.036

Cited by 47 publications

(32 citation statements)

References 21 publications

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“…Possible benefits of antithrombotic treatment must be weighed against any potential risks such as worsening of intracranial hemorrhage or existing hematomas in other solid organs as these patients often have multiple injuries. However, recent studies on BCVI and concomitant intracranial, intraspinal or solid organ injuries have shown no difference in hemorrhagic worsening between treated or untreated patients [ 7 , 43 , 68 , 70 , 71 ].…”

Section: Resultsmentioning

confidence: 99%

Best practice guidelines for blunt cerebrovascular injury (BCVI)

Brommeland

Helseth

Aarhus

et al. 2018

Scand J Trauma Resusc Emerg Med

108

126

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Blunt cerebrovascular injury (BCVI) is a non-penetrating injury to the carotid and/or vertebral artery that may cause stroke in trauma patients. Historically BCVI has been considered rare but more recent publications indicate an overall incidence of 1–2% in the in-hospital trauma population and as high as 9% in patients with severe head injury. The indications for screening, treatment and follow-up of these patients have been controversial for years with few clear recommendations. In an attempt to provide a clinically oriented guideline for the handling of BCVI patients a working committee was created. The current guideline is the end result of this committees work. It is based on a systematic literature search and critical review of all available publications in addition to a standardized consensus process. We recommend using the expanded Denver screening criteria and CT angiography (CTA) for the detection of BCVI. Early antithrombotic treatment should be commenced as soon as considered safe and continued for at least 3 months. A CTA at 7 days to confirm or discard the diagnosis as well as a final imaging control at 3 months should be performed.Electronic supplementary materialThe online version of this article (10.1186/s13049-018-0559-1) contains supplementary material, which is available to authorized users.

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Section: Resultsmentioning

confidence: 99%

Best practice guidelines for blunt cerebrovascular injury (BCVI)

Brommeland

Helseth

Aarhus

et al. 2018

Scand J Trauma Resusc Emerg Med

108

126

View full text Add to dashboard Cite

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“…Additionally, it is important to note that pediatric BCVI is substantially less severe than adult BCVI at the same center as reported by our group. 38 We suspect that this lack of severity is multifactorial. Children have a relatively greater elastic resilience of their vessels compared with adults and have more elastic bone and soft tissues surrounding the vessels that can better absorb the kinetic energy of high-impact blunt trauma.…”

Section: Looking To the Future: Determining The Optimal Treatment Formentioning

confidence: 99%

Pediatric blunt cerebrovascular injury: the McGovern screening score

Herbert

Venkataraman

Turkmani

et al. 2018

Journal of Neurosurgery: Pediatrics

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OBJECTIVEThe objective of this study was to assess the incidence, diagnosis, and treatment of pediatric blunt cerebrovascular injury (BCVI) at a busy Level 1 trauma center and to develop a tool for accurately predicting pediatric BCVI and the need for diagnostic testing.METHODSThis is a retrospective cohort study of a prospectively collected database of pediatric patients who had sustained blunt trauma (patient age range 0–15 years) and were treated at a Level 1 trauma center between 2005 and 2015. Digital subtraction angiography, MR angiography, or CT angiography was used to confirm BCVI. Recently, the Utah score has emerged as a screening tool specifically targeted toward evaluating BCVI risk in the pediatric population. Using logistical regression and adding mechanism of injury as a logit, the McGovern score was able to use the Utah score as a starting point to create a more sensitive screening tool to identify which pediatric trauma patients should receive angiographic imaging due to a high risk for BCVI.RESULTSA total of 12,614 patients (mean age 6.6 years) were admitted with blunt trauma and prospectively registered in the trauma database. Of these, 460 (3.6%) patients underwent angiography after blunt trauma: 295 (64.1%), 107 (23.3%), 6 (1.3%), and 52 (11.3%) patients underwent CT angiography, MR angiography, digital subtraction angiography, and a combination of imaging modalities, respectively. The BCVI incidence (n = 21; 0.17%) was lower than that in a comparable adult group (p < 0.05). The mean patient was age 10.4 years with a mean follow-up of 7.5 months. Eleven patients (52.4%) were involved in a motor vehicle collision, with a mean Glasgow Coma Scale score of 8.6. There were 8 patients (38.1%) with carotid canal fracture, 6 patients (28.6%) with petrous bone fracture, and 2 patients (9.5%) with infarction on initial presentation. Eight patients (38.1%) were managed with observation alone. The Denver, modified Memphis, Eastern Association for the Surgery of Trauma (EAST), and Utah scores, which are the currently used screening tools for BCVI, misclassified 6 (28.6%), 6 (28.6%), 7 (33.3%), and 10 (47.6%) patients with BCVI, respectively, as “low risk” and not in need of subsequent angiographic imaging. By incorporating the mechanism of injury into the score, the McGovern score only misclassified 4 (19.0%) children, all of whom were managed conservatively with no treatment or aspirin.CONCLUSIONSWith a low incidence of pediatric BCVI and a nonsurgical treatment paradigm, a more conservative approach than the Biffl scale should be adopted. The Denver, modified Memphis, EAST, and Utah scores did not accurately predict BCVI in our equally large cohort. The McGovern score is the first BCVI screening tool to incorporate the mechanism of injury into its screening criteria, thereby potentially allowing physicians to minimize unnecessary radiation and determine which high-risk patients are truly in need of angiographic imaging.

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“…There have been efforts to construct evidence-based guidelines for treating BCVI patients [5,9,31]. According to guidelines, the indication criteria for computed tomography angiography (CTA) of cervical arteries would use extended Denver protocol, which includes signs and symptoms for BCVI, e.g., focal neurological deficit, expanding cervical hematoma, neurological deficit inconsistent of head computed tomography (CT), and stroke on CT/magnetic resonance imaging (MRI), or risk factors of BCVI, e.g., high-energy trauma, facial fractures, CSI, and TBI with thoracic injuries [9,13,14].…”

Section: This Article Is Part Of the Topical Collection On Brain Traumamentioning

confidence: 99%

Occurrence and prognostic effect of cervical spine injuries and cervical artery injuries with concomitant severe head injury

et al. 2020

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Background Blunt cerebrovascular injuries (BCVIs) and cervical spinal injuries (CSIs) are not uncommon injuries in patients with severe head injury and may affect patient recovery. We aimed to assess the independent relationship between BCVI, CSI, and outcome in patients with severe head injury. Methods We identified patients with severe head injury from the Helsinki Trauma Registry treated during 2015-2017 in a large level 1 trauma hospital. We assessed the association between BCVI and SCI using multivariable logistic regression, adjusting for injury severity. Our primary outcome was functional outcome at 6 months, and our secondary outcome was 6-month mortality. Results Of 255 patients with a cervical spine CT, 26 patients (10%) had a CSI, and of 194 patients with cervical CT angiography, 16 patients (8%) had a BCVI. Four of the 16 BCVI patients had a BCVI-related brain infarction, and four of the CSI patients had some form of spinal cord injury. After adjusting for injury severity in multivariable logistic regression analysis, BCVI associated with poor functional outcome (odds ratio [OR] = 6.0, 95% CI [confidence intervals] = 1.4-26.5) and mortality (OR = 7.9, 95% CI 2.0-31.4). We did not find any association between CSI and outcome. Conclusions We found that BCVI with concomitant head injury was an independent predictor of poor outcome in patients with severe head injury, but we found no association between CSI and outcome after severe head injury. Whether the association between BCVI and poor outcome is an indirect marker of a more severe injury or a result of treatment needs further investigations.

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Management of blunt cerebrovascular injury (BCVI) in the multisystem injury patient with contraindications to immediate anti-thrombotic therapy

Cited by 47 publications

References 21 publications

Best practice guidelines for blunt cerebrovascular injury (BCVI)

Best practice guidelines for blunt cerebrovascular injury (BCVI)

Pediatric blunt cerebrovascular injury: the McGovern screening score

Occurrence and prognostic effect of cervical spine injuries and cervical artery injuries with concomitant severe head injury

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