Blunt injuries to the carotid and vertebral arteries are not as uncommon as we used to think. Unfortunately, there’s a lot of controversy surrounding everything about them: screening, management, and outcome. A paper just out detailed outcomes in a (relatively) large series of these patients.
As expected with this rare injury, it’s a retrospective study. A busy Level I center identified 222 patients with 263 BCVIs over a 4 ½ year period. Twenty four died before discharge and 11 afterwards. Of the remaining patients, only 74 could be located and only 68 could be persuaded to complete an interview and evaluation of their functional status. Functional Independence and Functional Activity Measurements were assessed (FIM/FAM).
Pertinent findings were:
- 8 patients suffered a stroke during their initial hospital stay (5 were present on arrival in the ED)
- 5 additional patients had a stroke after discharge
- Only 20% reached the maximum FIM/FAM scores, even including patients who did not have a stroke
- Patients with stroke had a significantly lower FIM/FAM
- There was no difference in FIM/FAM in patients with carotid vs vertebral injury
Bottom Line: Even though it is limited, this is one of the best studies we will see on BCVI because it’s an uncommon problem at most centers. The most important fact here is that the stroke rate was 19% despite discharge on antiplatelet or anticoagulant medications. And if stroke occurs, it causes significant functional problems, as expected. It’s critically important that this injury be screened and identified appropriately, then given appropriate prophylaxis. More on this tomorrow.
Reference: Functional outcomes following blunt cerebrovascular injury. J Trauma 74(4):955-960, 2013.
Blunt injury to the carotid or vertebral arteries (BCVI) is relatively uncommon, but potentially very deadly. Up to 2% of patients with high energy blunt trauma suffer this injury. Many are not diagnosed until the patient has ischemic symptoms or a stroke. However, more aggressive screening has shown a higher incidence that previously thought and may allow intervention before neurologic injury occurs.
Recently, a series of 222 patients with 263 BCVI was retrospectively reviewed, with an eye toward effectiveness of interventions. A total of 29 strokes occurred in the hospital in these patients, but only 7 of these occurred after diagnosis of the BCVI. Mortality was much higher in the stroke group (34% vs 7%). The authors looked at both medical and interventional therapies.
This paper identified the following items:
- Car crash was the most common mechanism of injury (81%)
- Vertebral arterial injury was slightly more common than carotid artery BUT
- Women were much more likely to sustain a carotid injury
- Older patients were more likely to have a vertebral injury
These authors found that CT angio was not sufficiently sensitive to identify all BCVI. They recommend a formal 4-vessel arteriogram in patients with a negative CT angio who have significant risk factors (unexplained neurologic deficit, Horner’s syndrome, LeFort II or III injury, cervical spine injury, soft tissue injury of the neck).
If a BCVI is identified, the patient should be heparinized until all other injuries are definitively managed. At that point, they should be preloaded with clopidogrel and aspirin and a repeat arteriogram should be performed. Endovascular stenting using a bare metal stent should be performed when possible because it results in the lowest stroke rate and requires the shortest duration of anti-platelet therapies. Patients then continue on aspirin and clopidogrel for an appropriate period of time.
To download the algorithm used by the authors, click here.
Reference: Optimal outcomes for patients with blunt cerebrovascular injury (BCVI): tailoring treatment to the lesion. J Am Coll Surg 212(4):549-559, 2011.