Antiplatelets versus anticoagulants in the treatment of blunt cerebrovascular injury (BCVI) - A systematic review and meta-analysis.

INTRODUCTION: Blunt cerebrovascular injury (BCVI) occurs in 1-3% of blunt traumas and is associated with stroke, disability, and mortality if unrecognized and untreated. Early detection and treatment are imperative to reduce the risk of stroke, however, there is significant variation amongst centers and trauma care providers in the specific medical management strategy used. This study compares antiplatelets vs. anticoagulants to determine BCVI-related stroke risk and bleeding complications to better understand the efficacy and safety of various treatment strategies. METHODS: A systematic review of MEDLINE, Embase, and Cochrane CENTRAL databases was conducted with the assistance of a medical librarian. The search was supplemented with manual review of the literature. Included studies reported treatment-stratified risk of stroke following BCVI. All studies were screened independently by two reviewers, and data was extracted in duplicate. Meta-analysis was conducted using pooled estimates of odds ratios (OR) with a random-effects model using Mantel-Haenszel methods. RESULTS: A total of 3315 studies screened yielded 39 studies for inclusion, evaluating 6552 patients (range 8 - 920 per study) with a total of 7643 BCVI. Stroke rates ranged from 0% to 32.8%. Amongst studies included in the meta-analysis, there were a total of 405 strokes, with 144 (35.5%) occurring on therapy, for a total stroke rate of 4.5 %. Meta-analysis showed that stroke rate after BCVI was lower for patients treated with antiplatelets vs. anticoagulants (OR 0.57; 95% CI 0.33-0.96, p = 0.04); when evaluating only the 9 studies specifically comparing ASA to heparin, the stroke rate was similar between groups (OR 0.43; 95% CI 0.15-1.20, p = 0.11). Eleven studies evaluated bleeding complications and demonstrated lower risk of bleeding with antiplatelets vs. anticoagulants (OR 0.29; 95% CI 0.13-0.63, p = 0.002); 5 studies evaluating risk of bleeding complications with ASA vs. heparin showed lower rates of bleeding complications with ASA (OR 0.16; 95% CI 0.04-0.58, p = 0.005). CONCLUSIONS: Treatment of patients with BCVI with antiplatelets is associated with lower risks of stroke and bleeding complications compared to treatment with anticoagulants. Use of ASA vs. heparin specifically was not associated with differences in stroke risk, however, patients treated with ASA had fewer bleeding complications. Based on this evidence, antiplatelets should be the preferred treatment strategy for patients with BCVI.

Prognostic factors associated with risk of stroke following blunt cerebrovascular injury: A systematic review and meta-analysis.

BACKGROUND & OBJECTIVES: Blunt cerebrovascular injury (BCVI) includes carotid and/or vertebral artery injury following trauma, and conveys an increased stroke risk. We conducted a systematic review and meta-analysis to provide a comprehensive summary of prognostic factors associated with risk of stroke following BCVI. METHODS: We searched the EMBASE and MEDLINE databases from January 1946 to June 2023. We identified studies reporting associations between patient or injury factors and risk of stroke following BCVI. We performed meta-analyses of odds ratios (ORs) using the random effects method and assessed individual study risk of bias using the QUIPS tool. We separately pooled adjusted and unadjusted analyses, highlighting the estimate with the higher certainty. RESULTS: We included 26 cohort studies, involving 20,458 patients with blunt trauma. The overall incidence of stroke following BCVI was 7.7 %. Studies were predominantly retrospective cohorts from North America and included both carotid and vertebral artery injuries. Diagnosis of BCVI was most commonly confirmed with CT angiography. We demonstrated with moderate to high certainty that factors associated with increased risk of stroke included carotid artery injury (as compared to vertebral artery injury, unadjusted odds ratio [uOR] 1.94, 95 % CI 1.62 to 2.32), Grade III Injury (as compared to grade I or II) (uOR 2.45, 95 % CI 1.88 to 3.20), Grade IV injury (uOR 3.09, 95 % CI 2.20 to 4.35), polyarterial injury (uOR 3.11 (95 % CI 2.05 to 4.72), occurrence of hypotension at the time of hospital admission (adjusted odds ratio [aOR] 1.32, 95 % CI 0.87 to 2.03) and higher total body injury severity (aOR 5.91, 95 % CI 1.90 to 18.39). CONCLUSION: Local anatomical injury pattern, overall burden of injury and flow dynamics contribute to BCVI-related stroke risk. These findings provide the foundational evidence base for risk stratification to support clinical decision making and further research.

Blunt Cerebrovascular Injury Complications in Aging Adults: A National Trauma Database Study.

INTRODUCTION: Blunt cerebrovascular injury (BCVI) is defined as a nonpenetrating injury to the carotid or vertebral arteries which can be highly morbid. Because BCVI is rare, most studies have been devoted to triaging trauma patients for BCVI identification, with little data available regarding the complications these patients experience after initial evaluation. Here, we analyze the association of complications during admission for BCVI patients. METHODS: The National Trauma Databank was queried from 2007 to 2014 for adults ≥65 y old. Demographics, incidence of BCVI, and injury data were evaluated using univariate analysis. Rates of inpatient complications due to acutely acquired infections and strokes were evaluated using univariate and multivariable analysis. RESULTS: We identified 666,815 non-BCVI and 552 BCVI patients. Patients with a BCVI were typically male, White, younger (65-75-y-old), had three or more comorbidities, and had Medicare insurance. BCVI patients had a mild head injury upon arrival at the emergency department and experienced a motor vehicle accident/fall. The median length of stay in the intensive care unit, days spent on a ventilator, and presence of polytrauma were higher among BCVI patients. BCVI patients had increased odds of experiencing a stroke and pneumonia as complications while admitted compared to their non-BCVI counterparts. CONCLUSIONS: Postinjury, patients who suffered a BCVI had higher odds of stroke and pneumonia than patients who did not experience a BCVI. Additional studies are needed to determine the modifiable risk factors associated with BCVIs among aging adults.

Management Patterns and Outcomes After Traumatic Brain Injury With Associated Blunt Cerebrovascular Injury.

BACKGROUND AND OBJECTIVES: Although blunt cerebrovascular injuries (BCVIs) are relatively common in patients with traumatic brain injuries (TBIs), uncertainty remains regarding optimal management strategies to prevent neurological complications, morbidity, and mortality. Our objectives were to characterize common care patterns; assess the prevalence of adverse outcomes, including stroke, functional deficits, and death, by BCVI grade; and evaluate therapeutic approaches to treatment in patients with BCVI and TBI. METHODS: Patients with TBI and BCVI treated at our Level I trauma center from January 2016 to December 2020 were identified. Presenting characteristics, treatment, and outcomes were captured for univariate and multivariate analyses. RESULTS: Of 323 patients with BCVI, 145 had Biffl grade I, 91 had grade II, 49 had grade III, and 38 had grade IV injuries. Lower-grade BCVIs were more frequently managed with low-dose (81 mg) aspirin ( P < .01), although all grades were predominantly treated with high-dose (150-600 mg) aspirin ( P = .10). Patients with low-grade BCVIs had significantly fewer complications ( P < .01) and strokes ( P < .01). Most strokes occurred in the acute time frame (<24 hours), including 10/11 (90.9%) grade IV-related strokes. Higher BCVI grade portended elevated risk of stroke (grade II odds ratio [OR] 5.3, grade III OR 12.2, and grade IV OR 19.6 compared with grade I; all P < .05). The use of low- or high-dose aspirin was protective against mortality (both OR 0.1, P < .05). CONCLUSION: In patients with TBI, BCVIs impart greater risk for stroke and other associated morbidities as their severity increases. It may prove difficult to mitigate high-grade BCVI-related stroke, considering most events occur in the acute window. The paucity of late time frame strokes suggest that current management strategies do help mitigate risks.

Association between cervical fracture patterns and blunt cerebrovascular injury when screened with computed tomographic angiography.

BACKGROUND CONTEXT: Prior studies have demonstrated a close association between cervical spine fractures and blunt cerebrovascular injuries (BCVI). Undiagnosed BCVI is a feared complication because of the potentially catastrophic outcomes in a missed posterior circulation stroke. Computed tomography angiography (CTA) is commonly used to screen BCVI in the trauma setting. However, determining which cervical fracture patterns mandate screening is still not clearly known. PURPOSE: The aim of this retrospective review is to further elucidate which fracture patterns are associated with BCVI when using CTA and may mandate screening. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: All patients that presented to our trauma and emergency departments with a blunt cervical spine fracture from January 2018 to December 2021. Inclusion criteria included blunt cervical trauma and the use of CTA for BCVI screening. Exclusion criteria included patients under the age of 18, penetrating cervical trauma, and use any imaging modality besides CTA for BCVI screening. OUTCOME MEASURES: Patient demographics (age, gender, Glasgow coma scale, hospital length of stay (LOS), intensive care unit LOS, mechanism of energy of injury, polytrauma status), fracture location, fracture pattern (anterior arch, dens, dislocations/subluxations, facet, hangman, Jefferson, lamina, lateral mass, occipital condyle dissociation, occipital condyle, pedicle, posterior arch, spinous process, transverse process, transverse foramen, and vertebral body), and whether the patient sustained a BCVI or CVA. METHODS: If a patient had multiple fracture levels or fracture patterns, each level and pattern was counted as a separate BCVI. Multilevel fractures were defined as any patient with fractures at two distinct cervical levels. Differences between the patients who had a BCVI and those who did not were analyzed using independent sample t-tests for continuous variables and the chi-square or Fisher exact test for categorical variables. Odds ratios and 95% confidence intervals were calculated to assess likelihood between patient characteristics/fracture characteristics and BCVI. RESULTS: A total of 690 patients were identified as having a blunt cervical spine injury. A total of 453 patients (66%) underwent screening for BCVI with CTA. Among patients who underwent CTA, BCVI was diagnosed in 138 patients (30%), VAI in 119 patients (26%), CAI in 30 patients (7%), and 11 patients were diagnosed with both a VAI and CAI (2%). Overall, among all patients there were 9 strokes, all in patients identified with a BCVI (1%). No individual cervical level was associated with increased risk of BCVI, but when combined, OC-C3 fractures were associated with an increased risk (OR: 1.4, 95% CI: 1.0-1.9, p-value: .006). Multilevel fractures were also associated with an increased risk (OR: 1.7, 95% CI: 1.1-2.3, p-value: .01). The only fracture pattern associated with increased risk of BCVI were fractures associated with a dislocation/subluxation (OR: 3.8, 95% CI: 1.9-7.8, p-value = .0001). CONCLUSIONS: The only fracture pattern associated with an increased risk of BCVI were fractures associated with dislocation/subluxation. The only fracture levels associated with BCVI were combined OC-C3 and multilevel fractures. We recommend that any upper cervical fracture (OC-C3), multilevel fracture, or fracture with dislocation/subluxation undergo screening for BCVI.

Injury patterns and mortality associated with near-hanging in children.

BACKGROUND: The pathophysiology of near-hanging in children is different from that of adults due to anatomic, physiologic, and injury-related mechanisms, with evidence suggesting that blunt cerebrovascular injuries (BCVI) and cervical spine injuries (CSI) are uncommon. We sought to estimate the incidence of secondary injuries and their association with mortality in pediatric near-hanging victims. METHODS: We performed a retrospective observational study of children (≤17 years) with a diagnosis code for hanging between October 1, 2015 and February 28, 2023 who presented to one of 47 geographically diverse US children's hospitals. We evaluated the incidence of the following secondary injuries: cerebral edema, pneumothorax, pulmonary edema, BCVI, and CSI. We performed Fisher's exact test with Bonferroni correction to identify associations between intentionality, sex, age, and secondary injuries with mortality. RESULTS: We included 1929 children, of whom 33.8% underwent neuroimaging, 45.9% underwent neck imaging, and 38.7% underwent neck angiography. The most common injury was cerebral edema (24.0%), followed by pulmonary edema (3.2%) and pneumothorax (2.8%). CSI (2.1%) and BCVI (0.9%) occurred infrequently. Cerebral edema, pneumothorax, pulmonary edema, and younger age (≤12 years) were associated with mortality. CONCLUSIONS: In this multi-center study of pediatric near-hanging victims, BCVI and CSI occurred rarely and were not associated with mortality. While children in our study underwent neck imaging more frequently than head imaging, cerebral edema occurred more often than other injury types and imparted the highest mortality risk. Given the rarity of BCVI and CSI, a selective approach to neck imaging may be warranted in pediatric near-hanging events.

Prognostic Neuroimaging Biomarkers in Acute Vascular Brain Injury and Traumatic Brain Injury.

Prognostic imaging biomarkers after acute brain injury inform treatment decisions, track the progression of intracranial injury, and can be used in shared decision-making processes with families. Herein, key established biomarkers and prognostic scoring systems are surveyed in the literature, and their applications in clinical practice and clinical trials are discussed. Biomarkers in acute ischemic stroke include computed tomography (CT) hypodensity scoring, diffusion-weighted lesion volume, and core infarct size on perfusion imaging. Intracerebral hemorrhage biomarkers include hemorrhage volume, expansion, and location. Aneurysmal subarachnoid biomarkers include hemorrhage grading, presence of diffusion-restricting lesions, and acute hydrocephalus. Traumatic brain injury CT scoring systems, contusion expansion, and diffuse axonal injury grading are reviewed. Emerging biomarkers including white matter disease scoring, diffusion tensor imaging, and the automated calculation of scoring systems and volumetrics are discussed.

Blunt Cerebrovascular Injury: Are We Overscreening Low-Mechanism Trauma?

BACKGROUND AND PURPOSE: Screening patients with trauma for blunt cerebrovascular injury with neck CTA is a common practice, but there remains disagreement regarding which patients should be screened. We reviewed adult blunt cerebrovascular injury data from a level 1 trauma center to investigate whether screening is warranted in low-mechanism trauma. MATERIALS AND METHODS: We reviewed all neck CTAs performed on adult trauma patients in the emergency department during the 2019 calendar year. Clinical and imaging risk factors for blunt cerebrovascular injury, trauma mechanism, initial neck CTA interpretations, results from subsequent CTA and DSA studies, antiplatelet and anticoagulant treatments, and outcome data were recorded. RESULTS: One thousand one hundred thirty-six neck CTAs met the inclusion criteria, of which 965 (85%) were interpreted as having negative findings; 125, as having indeterminate findings (11%); and 46, as having positive findings (4%). Review of subsequent imaging and clinical documentation led to classification of 40 indeterminate studies (32%) as true-positives and 85 (68%) as false-positives. Blunt cerebrovascular injury was identified in 77 (12.6%) cases meeting and in 9 (1.7%) cases not meeting the expanded Denver criteria. The subset of 204 low-mechanism trauma cases (ground-level falls, blunt assaults, and low-impact motor vehicle collisions) not meeting the expanded Denver criteria (18% of the entire data set) could have been excluded from screening with 1 questionable injury and 0 ischemic strokes missed and 12 false-positive cases prevented. CONCLUSIONS: We advocate reservation of blunt cerebrovascular injury screening in low-mechanism trauma for patients meeting the expanded Denver criteria. Further research is needed to determine the behavior of indeterminate cases and to establish criteria for separating true-positive from false-positive findings.

Does the type of craniomaxillofacial fracture (CMF) differ between patients with intracranial hemorrhage (ICH) and those with blunt cerebrovascular injury (BCVI)? A retrospective study.

The purpose of the present study was to investigate and compare craniomaxillofacial fracture (CMF) type in patients with intracranial hemorrhage (ICH) versus blunt cerebrovascular injury (BCVI). A retrospective cohort study was performed. The predictor variables were the types of CMF. The primary outcomes variables were ICH and BCVI. Secondary outcomes were death and survival with or without neurological sequelae. Descriptive, bivariate, and multiple logistic regression statistics were computed, and the significance level was set at P ≤ 0.05. The sample was composed of 1440 patients with a mean age of 46.6 years ±24 years, and 71% were men. Pure orbital wall (odds ratio [OR]), 3.62; 95% confidence interval [CI], 1.32-12.69; P < 0.022), Le Fort III (OR, 16.08; 95% CI, 5.89-43.50; P < 0.001), cranial vault (OR, 9.74; 95% CI, 3.83.24.32; P < 0.001), skull base (OR, 9.42; 95% CI, 3.86-24.02; P < 0.001) and cervical fractures (OR, 5.50; 95% CI, 1.65-15.97; P = 0.003) were significantly associated with BCVI. All of the CMFs (P < 0.001), except for Le Fort I (OR, 0.79; 95% CI, 0.18-2.63; P = 0.731), nasal (OR, 1.05; 95% CI, 0.77-1.42; P = 0.758), and mandibular (OR, 0.68; 95% CI, 0.45-1.01; P = 0.066) fractures, were significantly associated with ICH. Secondary outcomes were negatively influenced by ICH and BCVI (P < 0.001). Within the limitations of the study it seems that Le Fort I and nasal fractures could be protective of cerebrovascular injuries, by cushioning impact forces. On the other hand it seems that patients with pure orbital wall, Le Fort III and cranio-cervical fractures are more prone to having concomitant life-threatening cerebrovascular injuries. This category of patients should have an immediate and comprehensive neurological assessment and CT angiography to rule out BCVI and to determine its severity.

Trauma mechanisms and patterns of blunt cervical vascular injury: A descriptive study using a nationwide trauma registry.

OBJECTIVE: Blunt cervical vascular injury (BCVI) is a non-penetrating trauma to the carotid and/or vertebral vessels following a direct injury to the neck or by the shearing of the cervical vessels. Despite its potentially life-threatening nature, important clinical features of BCVI such as typical patterns of co-occurring injuries for each trauma mechanism are not well known. To address this knowledge gap, we described the characteristics of patients with BCVI to identify the pattern of co-occurring injuries by common trauma mechanisms. METHODS: This is a descriptive study using a Japanese nationwide trauma registry from 2004 through 2019. We included patients aged ≥13 years presenting to the emergency department (ED) with BCVI, defined as a blunt trauma to any of the following vessels: common/internal carotid artery, external carotid artery, vertebral artery, external jugular vein, and internal jugular vein. We delineated characteristics of each BCVI classified according to three damaged vessels (common/internal carotid artery, vertebral artery, and others). In addition, we applied network analysis to unravel patterns of co-occurring injuries among patients with BCVI by four common trauma mechanisms (car accident, motorcycle/bicycle accident, simple fall, and fall from a height). RESULTS: Among 311,692 patients who visited the ED for blunt trauma, 454 (0.1%) patients had BCVI. Patients with common/internal carotid artery injuries presented to the ED with severe symptoms (e.g., the median Glasgow Coma Scale was 7) and had high in-hospital mortality (45%), while patients with vertebral artery injuries presented with relatively stable vital signs. Network analysis showed that head-vertebral-cervical spine injuries were common across four trauma mechanisms (car accident, motorcycle/bicycle accident, simple fall, and fall from a height), with co-occurring injuries of the cervical spine and vertebral artery being the most common injuries due to falls. In addition, common/internal carotid artery injuries were associated with thoracic and abdominal injuries in patients with car accidents. CONCLUSIONS: Based on analyses of a nationwide trauma registry, we found that patients with BCVI had distinct patterns of co-occurring injuries by four trauma mechanisms. Our observations provide an important basis for the initial assessment of blunt trauma and could support the management of BCVI.

Mortality and morbidity following initiation of anticoagulant or antiplatelet treatment for blunt cerebrovascular injury.

OBJECTIVE: Cerebrovascular accidents (CVA) are potential sequelae of blunt cerebrovascular injuries (BCVI). To minimize their risk, medical therapy is used commonly. It is unclear if anticoagulant or antiplatelet medications are superior for decreasing CVA risk. It is also unclear as to which confer fewer undesirable side effects specifically in patients with BCVI. The aim of this study was to compare outcomes between nonsurgical patients with BCVI with hospital admission records who were treated with anticoagulant medications and those who were treated with antiplatelet medications. METHODS: We performed a 5-year (2016-2020) analysis of the Nationwide Readmission Database. We identified all adult trauma patients who were diagnosed with BCVI and treated with either anticoagulant or antiplatelet agents. Patients who were diagnosed with index admission CVA, intracranial injury, hypercoagulable states, atrial fibrillation, and or moderate to severe liver disease were excluded. Those who underwent vascular procedures (open and/or endovascular approaches) and or neurosurgical treatment were also excluded. Propensity score matching (1:2 ratio) was performed to control for demographics, injury parameters, and comorbidities. Index admission and 6-month readmission outcomes were examined. RESULTS: We identified 2133 patients with BCVI who were treated with medical therapy; 1091 patients remained after applying the exclusion criteria. A matched cohort of 461 patients (anticoagulant, 159; antiplatelet, 302) was obtained. The median patient age was 72 years (interquartile range [IQR], 56-82 years), 46.2% of patients were female, falls were the mechanism of injury in 57.2% of cases, and the median New Injury Severity Scale score was 21 (IQR, 9-34). Index outcomes with respect to (1) anticoagulant treatments followed by (2) antiplatelet treatments and (3) P values are as follows: mortality (1.3%, 2.6%, 0.51), median length of stay (6 days, 5 days; P < .001), and median total charge (109,736 USD, 80,280 USD, 0.12). The 6-month readmission outcomes are as follows: readmission (25.8%, 16.2%, <0.05), mortality (4.4%, 4.6%, 0.91), ischemic CVA (4.9%, 4.1%, P = not significant [NS]), gastrointestinal hemorrhage (4.9%, 10.2%, 0.45), hemorrhagic CVA (0%, 0.41%, P = NS), and blood loss anemia (19.5%, 12.2%, P = NS). CONCLUSIONS: Anticoagulants are associated with a significantly increased readmission rate within 6 months. Neither medical therapy is superior to one another in the reduction of the following: index mortality, 6-month mortality, and 6-month readmission with CVA. Notably, antiplatelet agents seem to be associated with increased hemorrhagic CVA and gastrointestinal hemorrhage on readmission, although neither association is statistically significant. Still, these associations underscore the need for further prospective studies of large sample sizes to investigate the optimal medical therapy for nonsurgical patients with BCVI with hospital admission records.

Risk factors for blunt cerebrovascular injury in the pediatric patient: A systematic review.

BACKGROUND: While blunt cerebrovascular injury (BCVI) is a rare complication of blunt trauma, it is associated with significant morbidity and mortality. In the pediatric population, unique anatomy and development require screening criteria that accurately diagnose these injuries while limiting unwarranted radiation. METHODS: We searched Medline OVID, EMBASE, and Cochrane Library databases for studies that investigated the risk factors of BCVI in individuals younger than 18 years of age. We adhered to the Preferred Reporting Items in Systematic Reviews and Meta-Analyses (PRISMA) guidelines and assessed the quality of each study using the Newcastle-Ottawa Scale. We compared key characteristics of the papers, including incidence of BCVI, incidence of risk factors, and statistical significance of risk factors. RESULTS: Of 1304 studies, 16 met the inclusion criteria. Of these, 15 were retrospective cohort studies and one was a retrospective case control study. Most of the studies included all pediatric blunt trauma admissions, but four only included those which underwent imaging, one only included those with cervical seatbelt sign, and one excluded those who did not survive 24-h post-admission. The ages included as pediatric varied between papers. Papers examined different risk factors and reported differing statistical significances. Though no single risk factor was found to be statistically significant in every study, cervical spine and skull fractures were found to be significant by most. Maxillofacial fractures, depressed GCS score, and stroke were found to be statistically significant by multiple studies. Twelve studies examined cervical soft tissue injury, and none found it to be statistically significant. CONCLUSIONS: The risk factors most found to be statistically significant for BCVI were cervical spine fracture (10/16 studies), skull fracture (9/16), maxillofacial fractures (7/16), depressed GCS score (5/16), and stroke (5/16). There is a need for prospective studies on this topic. LEVEL OF EVIDENCE: Level III, Systematic Review.

Comparing the Denver criteria sets for blunt trauma: a retrospective study of cases in Edmonton, Alberta.

OBJECTIVE: To determine whether a more conservative Denver criterion set could reduce unnecessary CT angiography (CTA) studies when screening for blunt cerebrovascular injury (BCVI) following blunt trauma. METHODS: Following ethics approval, a retrospective chart review of 447 consecutive patients undergoing emergency CTA at two large teaching hospitals was conducted to determine the presence of risk factors for each Denver criterion set. Imaging studies of adults conducted between January 2016 and June 2020 containing sufficient clinical information for accurate classification were included in the study. Specificity, sensitivity, and predictive values were calculated. A two-sided Fisher exact test was used to evaluate the association between each iteration of the Denver criteria and the presence of BCVI. RESULTS: The specificities of the Original, Modified, and Expanded Denver criteria were 43.58%, 34.32%, and 24.85%, respectively. Positive-predictive values (PPV) followed a different trend, with respective values of 2.77%, 3.06%, and 2.78%. Sensitivity and negative-predictive values (NPV) were found to be 100% for each criterion set. Being positive for a criterion set, and the presence of BCVI, was statistically significant for the original Denver criteria (p = 0.021, n = 443), but not the modified (p = 0.100, n = 345) or expanded Denver criteria (p = 0.202, n = 333). CONCLUSION: Use of the modified and expanded Denver criteria leads to the overuse of cerebrovascular imaging on patients suffering blunt force trauma. ADVANCES IN KNOWLEDGE: The original Denver criteria may more appropriately identify subjects for further evaluation with CTA than the current standard, while retaining diagnostic efficacy for BCVI.

Ultrasound, photoacoustic, and magnetic resonance imaging to study hyperacute pathophysiology of traumatic and vascular brain injury.

BACKGROUND AND PURPOSE: Cerebrovascular dynamics and pathomechanisms that evolve in the minutes and hours following traumatic vascular injury in the brain remain largely unknown. We investigated the pathophysiology evolution in mice within the first 3 hours after closed-head traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH), two significant traumatic vascular injuries. METHODS: We took a multimodal imaging approach using photoacoustic imaging, color Doppler ultrasound, and MRI to track injury outcomes using a variety of metrics. RESULTS: Brain oxygenation and velocity-weighted volume of blood flow (VVF) values significantly decreased from baseline to 15 minutes after both TBI and SAH. TBI resulted in 19.2% and 41.0% ipsilateral oxygenation and VVF reductions 15 minutes postinjury, while SAH resulted in 43.9% and 85.0% ipsilateral oxygenation and VVF reduction (p < .001). We found partial recovery of oxygenation from 15 minutes to 3 hours after injury for TBI but not SAH. Hemorrhage, edema, reduced perfusion, and altered diffusivity were evident from MRI scans acquired 90-150 minutes after injury in both injury models, although the spatial distribution was mostly focal for TBI and diffuse for SAH. CONCLUSIONS: The results reveal that the cerebral oxygenation deficits immediately following injuries are reversible for TBI and irreversible for SAH. Our findings can inform future studies on mitigating these early responses to improve long-term recovery.

Blunt Cerebrovascular Injury in Pediatric Hanging Victims.

INTRODUCTION: Incidence of blunt cerebrovascular injury (BCVI) following hanging in the pediatric population is ill-defined. Current guidelines recommend screening imaging during the initial trauma evaluation. Necessity of screening is questioned given BCVI is considered rare after hanging, especially when asymptomatic. This study aims to elucidate the incidence of BCVI in pediatric hangings and determine the value of radiographic work-up. METHODS: A retrospective cohort study was performed of pediatric hangings reported to the National Trauma Data Bank (NTDB), 2017-2019. Imaging, diagnoses, and findings suggestive of BCVI, such as Glasgow Coma Scale (GCS) ≤8, presence of cervical injury, and soft tissue injury were considered. Statistical analysis was carried out to compare incidence. RESULTS: 197 patients met study criteria, with 179 arriving in the trauma bay with signs of life. BCVI incidence was 5.6% (10 of 179). Computed Tomography Angiography (CTA) of the neck was the only reported screening modality in this data set. A CTA was completed in 46% of the cases. DISCUSSION: BCVI incidence following pediatric hanging is more common than previously thought. Less than half of patients had a CTA reported in this cohort. This may result in an underestimate. Given the potentially devastating consequences of a missed BCVI, the addition of CTA to initial work-up may be worthwhile to evaluate for cervical vascular injury, but further studies into the outcomes of children who do receive prophylactic therapy are needed.

Efficacy of Antithrombotic Therapy and Risk of Hemorrhagic Complication in Blunt Cerebrovascular Injury Patients with Concomitant Injury: A Systematic Review.

BACKGROUND: The risk-benefit balance of antithrombotic therapy administration for blunt cerebrovascular injuries (BCVI) patients with concomitant injuries at high risk for bleeding is an ongoing therapeutic conundrum for trauma clinicians. We performed a systematic review to assess the reported efficacy and safety of treatment in this population with respect to prevention of ischemic stroke and risk of hemorrhagic complications. STUDY DESIGN: A systematic electronic literature search of MEDLINE, EMBASE, Cochrane Library, and Web of Science databases was performed from January 1, 1996 to December 31, 2021. Studies were included if they reported treatment-stratified clinical outcomes after antithrombotic therapy in BCVI patients with concomitant injuries at high risk of bleeding into a critical site. Data were extracted from selected studies by two independent reviewers, including the main outcomes of interest were BCVI-related ischemic stroke rates and rates of hemorrhagic complications. RESULTS: Of the 5,999 studies reviewed, 10 reported on the effects of treating BCVI patients with concurrent traumatic injuries and were included for review. In the pooled data, among patients with BCVI and concomitant injury who received any form of antithrombotic therapy, the BCVI-related stroke rate was 7.6%. The subgroup of patients who did not receive therapy had an overall BCVI-related stroke rate of 34%. The total rate of hemorrhagic complications in the treated population was 3.4%. CONCLUSIONS: In BCVI patients with concomitant injuries at high risk for bleeding, antithrombotic use reduces the risk of ischemic strokes with a low reported risk of serious hemorrhagic complications.

Upper cervical spine fracture patterns and blunt cerebrovascular injuries.

PURPOSE: To determine patterns of C1 and C2 vertebral fractures that are associated with blunt cerebrovascular injury (BCVI). METHODS: Retrospective chart review of clinical and imaging reports at a level 1 trauma center over 10 consecutive years was conducted in patients with C1 and C2 fractures. Student t-test and chi-squared analyses were used to determine associations between fracture levels and fracture types with the presence of BCVI on CTA and/or MRI or stroke on CT and/or MRI. RESULTS: Multilevel fractures were associated with higher incidence of BCVI compared to isolated C1 or C2 fractures (p < 0.01), but not with stroke (p = 0.16). There was no difference in incidence of BCVI or stroke between isolated C1 and isolated C2 fractures (p = 0.46, p = 0.25). Involvement of the transverse foramen (TF) alone was not associated with BCVI or stroke (p = 0.10-0.40, p = 0.34-0.43). However, TF fractures that were comminuted or contained fracture fragment(s) were associated with increased BCVI (p < 0.01, p = 0.02), though not with stroke (p = 0.11, p = 0.09). In addition, high-energy mechanism of injury was also associated with BCVI (p < 0.01) and stroke (p < 0.01). CONCLUSION: C1 and C2 fractures are associated with BCVI in the presence of high-energy mechanism of injury, concomitant fractures of other cervical vertebral body levels, comminuted TF fractures, or TF fractures with internal fragments. Attention to these fracture parameters is important in evaluating C1 and C2 fractures for BCVI.

Electrocardiogram properties and risk of covert brain infarction and other magnetic resonance imaging abnormalities in a stroke-free population.

OBJECTIVES: This study aimed to investigate the association between electrocardiogram (ECG) abnormalities and silent vascular brain injury as defined by cerebral magnetic resonance imaging (MRI) in a stroke-free community-based population. METHODS: A total of 5888 participants were studied from the Cardiovascular Health Study (CHS), a prospective cohort of community-living older adults. Standard 12-lead ECGs measured prior to MRI scan were used. MRI scans were conducted at years 4-6 and 10-11. The primary outcome was presence of incident covert brain infarcts (CBIs) on the 2nd MRI examination, excluding previous CBIs and stroke occurrence. Secondary outcomes included white matter, ventricular, and sulcal atrophy on the 1st MRI. Logistic and multiple linear regression models were used to assess the relationship between ECG findings and silent vascular brain injury. RESULTS: Left axis deviation before MRI scan was related to presence of incident CBIs (odds ratio [OR]: 1.45; 95% CI: 1.01-2.08, p = .047). A long QT interval was associated with severe white matter hyperintensity (OR: 1.36; 95% CI: 1.04-1.77, p = .024). Minor Q and QS waves with ST-T abnormalities were positively related to sulcal atrophy (ß: 0.43, 95% CI: 0.06-0.81, p = .023). CONCLUSIONS: Our study found that ECG abnormalities were related to presence of CBIs, white matter hyperintensity, and sulcal atrophy on MRI in a stroke-free relderly population. Specifically, those with left axis deviation had an increased risk of presence of CBIs.