Advertisement

Update on Treatment of Blunt Cerebrovascular Injuries

  • C. Patrick Shahan
  • Timothy C. FabianEmail author
Trauma to the Neck (W Biffl, Section Editor)
  • 2 Downloads
Part of the following topical collections:
  1. Topical Collection on Trauma to the Neck

Abstract

Purpose of Review

This article focuses on the recent practices and advancements in the treatment of blunt cerebrovascular injuries (BCVI), and also to identify areas of future study.

Recent Findings

It remains clear that antithrombotic therapy is the mainstay of therapy for preventing BCVI-related stroke. There is no difference in the type of antithrombotic therapy used, but it is critical that treatment be initiated as early as possible post-injury. The use of endovascular stents has declined dramatically from the previous decade, and their true utility in the treatment of these injuries remains unclear. One of the biggest challenges that remains in treating BCVI is when to initiate therapy in patients with concomitant injuries that may prevent treatment early post-injury, when treatment is in fact most critical.

Summary

Antithrombotic therapy remains effective in the treatment of BCVI. The BCVI-related stroke rates reported across the literature remain stable between 5 and 10%. The treatment will most likely remain similar for the foreseeable future; however, there remain unknowns regarding the nuances of treatment that are mostly attributable to the relative rarity of the injuries.

Keywords

BCVI Blunt cerebrovascular injury Blunt carotid injury Stroke Carotid trauma 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare no conflicts of interest relevant to this manuscript.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Verneuil M. Contusions multiples deire violent hemiplegie droite signes de compression cerebrale. Paris: Bull Acad Natl Med. 1872.Google Scholar
  2. 2.
    Yamada S, Kindt GW, Youmans JR. Carotid artery occlusion due to nonpenetrating injury. J Trauma. 1967;7(3):333–42.CrossRefGoogle Scholar
  3. 3.
    Krajewski LP, Hertzer NR. Blunt carotid artery trauma: report of two cases and review of the literature. Ann Surg. 1980;191(3):341–6.CrossRefGoogle Scholar
  4. 4.
    Fabian TC, George SM Jr, Croce MA, Mangiante EC, Voeller GR, Kudsk KA. Carotid artery trauma: management based on mechanism of injury. J Trauma. 1990;30(8):953–61 discussion 61-3.CrossRefGoogle Scholar
  5. 5.
    Byrnes MC, Irwin E, Roach R, James M, Horst PK, Reicks P. Therapeutic anticoagulation can be safely accomplished in selected patients with traumatic intracranial hemorrhage. World J Emerg Surg. 2012;7(1):25.CrossRefGoogle Scholar
  6. 6.
    Shahan CP, Magnotti LJ, McBeth PB, Weinberg JA, Croce MA, Fabian TC. Early antithrombotic therapy is safe and effective in patients with blunt cerebrovascular injury and solid organ injury or traumatic brain injury. J Trauma Acute Care Surg. 2016;81(1):173–7.CrossRefGoogle Scholar
  7. 7.
    Cothren CC, Biffl WL, Moore EE, Kashuk JL, Johnson JL. Treatment for blunt cerebrovascular injuries: equivalence of anticoagulation and antiplatelet agents. Arch Surg. 2009;144(7):685–90.CrossRefGoogle Scholar
  8. 8.
    •• Burlew CC, Sumislawski JJ, Behnfield CD, McNutt MK, McCarthy J, Sharpe JP, et al. Time to stroke: a Western Trauma Association multicenter study of blunt cerebrovascular injuries. J Trauma Acute Care Surg. 2018;85(5):858–66 This multi-institutional study identifies the time window for highest risk of BCVI-related stroke and highlights the importance of early treatment. CrossRefGoogle Scholar
  9. 9.
    Duke BJ, Ryu RK, Coldwell DM, Brega KE. Treatment of blunt injury to the carotid artery by using endovascular stents: an early experience. J Neurosurg. 1997;87(6):825–9.CrossRefGoogle Scholar
  10. 10.
    Edwards NM, Fabian TC, Claridge JA, Timmons SD, Fischer PE, Croce MA. Antithrombotic therapy and endovascular stents are effective treatment for blunt carotid injuries: results from longterm followup. J Am Coll Surg. 2007;204(5):1007–13 discussion 14-5.CrossRefGoogle Scholar
  11. 11.
    Coldwell DM, Novak Z, Ryu RK, Brega KE, Biffl WL, Offner PJ, et al. Treatment of posttraumatic internal carotid arterial pseudoaneurysms with endovascular stents. J Trauma. 2000;48(3):470–2.CrossRefGoogle Scholar
  12. 12.
    Cothren CC, Moore EE, Biffl WL, Ciesla DJ, Ray CE, Johnson JL, et al. Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg. 2004;139(5):540–5 discussion 5-6.CrossRefGoogle Scholar
  13. 13.
    Cothren CC, Moore EE, Ray CE Jr, Ciesla DJ, Johnson JL, Moore JB, et al. Carotid artery stents for blunt cerebrovascular injury: risks exceed benefits. Arch Surg. 2005;140(5):480–5 discussion 5-6.CrossRefGoogle Scholar
  14. 14.
    • Shahan CP, Sharpe JP, Stickley SM, Manley NR, Filiberto DM, Fabian TC, et al. The changing role of endovascular stenting for blunt cerebrovascular injuries. J Trauma Acute Care Surg. 2018;84(2):308–11 This study performed at our institution relays our current practice for the use of stents in treating BCVI. CrossRefGoogle Scholar
  15. 15.
    Biffl WL, Ray CE, Moore EE, Franciose RJ, Aly S, Heyrosa MG, et al. Treatment-related outcomes from blunt cerebrovascular injuries: importance of routine follow-up arteriography. Ann Surg. 2002;235(5):699–706 discussion −7.CrossRefGoogle Scholar
  16. 16.
    Grandhi R, Weiner GM, Agarwal N, Panczykowski DM, Ares WJ, Rodriguez JS, et al. Limitations of multidetector computed tomography angiography for the diagnosis of blunt cerebrovascular injury. J Neurosurg. 2017;28:1–6.Google Scholar
  17. 17.
    Shahan CP, Magnotti LJ, Stickley SM, Weinberg JA, Hendrick LE, Uhlmann RA, et al. A safe and effective management strategy for blunt cerebrovascular injury: avoiding unnecessary anticoagulation and eliminating stroke. J Trauma Acute Care Surg. 2016;80(6):915–22.CrossRefGoogle Scholar
  18. 18.
    Paulus EM, Fabian TC, Savage SA, Zarzaur BL, Botta V, Dutton W, et al. Blunt cerebrovascular injury screening with 64-channel multidetector computed tomography: more slices finally cut it. J Trauma Acute Care Surg. 2014;76(2):279–83 discussion 84-5.CrossRefGoogle Scholar
  19. 19.
    Shahan CP, Croce MA, Fabian TC, Magnotti LJ. Impact of continuous evaluation of technology and therapy: 30 years of research reduces stroke and mortality from blunt cerebrovascular injury. J Am Coll Surg. 2017;224(4):595–9.CrossRefGoogle Scholar
  20. 20.
    Fabian TC, Patton JH Jr, Croce MA, Minard G, Kudsk KA, Pritchard FE. Blunt carotid injury. Importance of early diagnosis and anticoagulant therapy. Ann Surg. 1996;223(5):513–22 discussion 22-5.CrossRefGoogle Scholar
  21. 21.
    Biffl WL, Moore EE, Elliott JP, Ray C, Offner PJ, Franciose RJ, et al. The devastating potential of blunt vertebral arterial injuries. Ann Surg. 2000;231(5):672–81.CrossRefGoogle Scholar
  22. 22.
    Berne JD, Norwood SH, McAuley CE, Vallina VL, Creath RG, McLarty J. The high morbidity of blunt cerebrovascular injury in an unscreened population: more evidence of the need for mandatory screening protocols. J Am Coll Surg. 2001;192(3):314–21.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of SurgeryUniversity of Tennessee Health Science CenterMemphisUSA

Personalised recommendations