The Natural History of Indeterminate Blunt Cerebrovascular Injury

Abstract

Detection of iBCVI has become a common clinical conundrum with improved and routine imaging. Indeterminate BCVI is not completely benign, with 25.4% demonstrating anatomical progression to true BCVI and 5.1% developing cerebrovascular symptoms. We therefore recommend serial imaging and antiplatelet therapy for iBCVI.

Blunt Traumatic Extracranial Cerebrovascular Injury and Ischemic Stroke

“…However, TCVI differs from spontaneous dissection in several ways. Specifically, (1) most TCVIs are initially asymptomatic and discovered by screening imaging; (2) high-energy TCVI is likely biologically distinct from spontaneous dissections, which are frequently related to underlying connective tissue abnormalities [2]; (3) most blunt trauma patients experience a hypercoagulable state soon after injury [3] that coincides with the time course of ischemic stroke with TCVI, mostly occurring within 72 h of the injury [4]; (4) spontaneous cervical arterial dissections tend to primarily affect the outer arterial wall [5], in contrast to TCVI, in which intimal disruptions are relatively common [6, 7, 8]; and (5) patients with TCVI often have other traumatic injuries, making their management more complex than patients with spontaneous dissection.…”

“…Based on an average annual number of blunt trauma admissions in the US of 2,405,000 [11], up to 48,000 patients with TCVI are admitted each year. Based on studies reporting that 10–20% of patients with TCVI have a stroke [4, 10, 12], TCVI may be responsible for up to 9,600 ischemic strokes in the US per year.…”

“…It is important to note that this system was developed based on DSA and that it is difficult to distinguish type 1, 2, and 3 TCVI with CTA alone. Many contemporary studies investigating the frequency and prognosis of type 1–3 lesions have primarily employed CTA alone [4, 23, 26, 27, 28, 29]; therefore, the reliability of these reports, in precisely distinguishing between TCVI types, is limited. However, CTA can reliably identify type 4 lesions (complete artery occlusion).…”

“…Many studies of stroke in this setting were limited by factors including a lack of a precise definition of ischemic stroke, a lack of patient evaluation by investigators with neurological expertise, a failure to distinguish patients presenting with a stroke due to TCVI from patients with initially asymptomatic TCVI who go on to develop a stroke, and a failure to distinguish stroke from other causes of neurological injury in patients with polytrauma. It is clear that the majority of ischemic strokes due to TCVI occur relatively early, either prior to admission or within 72 h of the injury [4, 10, 12, 30]. It is useful to divide patients with TCVI into 2 categories: (1) patients with an ischemic stroke at the time of initial diagnosis of TCVI and (2) patients who are found to have an initially asymptomatic TCVI, discovered with screening, and who are at risk of stroke.…”

Best practice guidelines for blunt cerebrovascular injury (BCVI)

“…The true incidence of such an ischemic event due to BCVI is largely unknown, but reported in the range of 1–26% in recent literature [ 6 , 16 – 19 ]. There seem to be a higher risk of ischemic events with injury to the carotid than the vertebral artery [ 19 , 20 ]. BCVI is an independent predictor for poor outcome with higher morbidity and mortality rates in trauma patients with this injury, reported as high as 25–50% for those suffering a stroke [ 5 , 19 ].Unfortunately, a substantial number of patients with this injury arrive at the hospital with a stroke in progress [ 6 ].…”