Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma

Dennis Y Kim¹, Walter Biffl, Faran Bokhari, Scott Brakenridge, Edward Chao, Jeffrey A Claridge, Douglas Fraser, Randeep Jawa, George Kasotakis, Andy Kerwin, Uzer Khan, Stan Kurek, David Plurad, Bryce R H Robinson, Nicole Stassen, Ron Tesoriero, Brian Yorkgitis, John J Como

Affiliations

Affiliation

¹ From the Division of Trauma/Acute Care Surgery/Surgical Critical Care, Department of Surgery (D.Y.K.), Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance; Trauma Surgery Department, Scripps Memorial Hospital La Jolla (W.B.), La Jolla, California; Department of Trauma and Burn Surgery, Stroger Hospital of Cook County (F.B.), Rush University, Chicago, Illinois; Department of Surgery (S.B.), University of Florida, Gainesville, Florida; Department of Surgery, Jacobi Medical Center (E.C.), Bronx, New York; Department of Surgery, MetroHealth Medical Center (J.A.C., J.J.C.), Cleveland, Ohio; Department of Surgery, UNLV School of Medicine (D.F.), Las Vegas, Nevada; Division of Trauma, Emergency Surgery, and Surgical Critical Care, School of Medicine (R.J.), Stony Brook University, Stony Brook, New York; Department of Surgery, University of Florida College of Medicine - Jacksonville (A.K., B.Y.), Jacksonville, Florida; Department of Surgery, Duke University (G.K.), Durham, North Carolina; Department of Surgery, Western Virginia University (U.K.), Morgantown, West Virginia; Department of Surgery (S.K.), Chippenham-Johnston Willis Medical Center, NorthStar Trauma Surgery, Richmond, Virginia; Department of Surgery, Riverside Community Hospital (D.P.), Riverside, California; Division of Trauma and Critical Care, Department of Surgery, Harborview Medical Center (B.R.H.R.), University of Washington, Seattle, Washington; Division of Acute Care and Trauma Surgery, Department of Surgery, Rochester University Medical Center (N.S.), Rochester, New York; and Department of Surgery, University of Maryland Medical Center (R.T.), Baltimore, Maryland.

PMID: 32176167
DOI: 10.1097/TA.0000000000002668

Practice Guideline

Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma

Dennis Y Kim et al. J Trauma Acute Care Surg. 2020 Jun.

. 2020 Jun;88(6):875-887.

doi: 10.1097/TA.0000000000002668.

Authors

Affiliation

¹ From the Division of Trauma/Acute Care Surgery/Surgical Critical Care, Department of Surgery (D.Y.K.), Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance; Trauma Surgery Department, Scripps Memorial Hospital La Jolla (W.B.), La Jolla, California; Department of Trauma and Burn Surgery, Stroger Hospital of Cook County (F.B.), Rush University, Chicago, Illinois; Department of Surgery (S.B.), University of Florida, Gainesville, Florida; Department of Surgery, Jacobi Medical Center (E.C.), Bronx, New York; Department of Surgery, MetroHealth Medical Center (J.A.C., J.J.C.), Cleveland, Ohio; Department of Surgery, UNLV School of Medicine (D.F.), Las Vegas, Nevada; Division of Trauma, Emergency Surgery, and Surgical Critical Care, School of Medicine (R.J.), Stony Brook University, Stony Brook, New York; Department of Surgery, University of Florida College of Medicine - Jacksonville (A.K., B.Y.), Jacksonville, Florida; Department of Surgery, Duke University (G.K.), Durham, North Carolina; Department of Surgery, Western Virginia University (U.K.), Morgantown, West Virginia; Department of Surgery (S.K.), Chippenham-Johnston Willis Medical Center, NorthStar Trauma Surgery, Richmond, Virginia; Department of Surgery, Riverside Community Hospital (D.P.), Riverside, California; Division of Trauma and Critical Care, Department of Surgery, Harborview Medical Center (B.R.H.R.), University of Washington, Seattle, Washington; Division of Acute Care and Trauma Surgery, Department of Surgery, Rochester University Medical Center (N.S.), Rochester, New York; and Department of Surgery, University of Maryland Medical Center (R.T.), Baltimore, Maryland.

PMID: 32176167
DOI: 10.1097/TA.0000000000002668

Erratum in

Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma: Erratum.
[No authors listed] [No authors listed] J Trauma Acute Care Surg. 2020 Aug;89(2):420. doi: 10.1097/TA.0000000000002828. J Trauma Acute Care Surg. 2020. PMID: 32740642 No abstract available.

Abstract

Background: Blunt cerebrovascular injuries (BCVIs) are associated with significant morbidity and mortality. This guideline evaluates several aspects of BCVI diagnosis and management including the role of screening protocols, criteria for screening cervical spine injuries, and the use of antithrombotic therapy (ATT) and endovascular stents.

Methods: Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, a taskforce of the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of currently available evidence. Four population, intervention, comparison, and outcome questions were developed to address diagnostic and therapeutic issues relevant to BCVI.

Results: A total of 98 articles were identified. Of these, 23 articles were selected to construct the guidelines. In these studies, the detection of BCVI increased with the use of a screening protocol versus no screening protocol (odds ratio [OR], 4.74; 95% confidence interval [CI], 1.76-12.78; p = 0.002), as well as among patients with high-risk versus low-risk cervical spine injuries (OR, 12.7; 95% CI, 6.24-25.62; p = 0.003). The use of ATT versus no ATT resulted in a decreased risk of stroke (OR, 0.20; 95% CI, 0.06-0.65; p < 0.0001) and mortality (OR, 0.17; 95% CI, 0.08-0.34; p < 0.0001). There was no significant difference in the risk of stroke among patients with Grade II or III injuries who underwent stenting as an adjunct to ATT versus ATT alone (OR, 1.63; 95% CI, 0.2-12.14; p = 0.63).

Conclusion: We recommend using a screening protocol to detect BCVI in blunt polytrauma patients. Among patients with high-risk cervical spine injuries, we recommend screening computed tomography angiography to detect BCVI. For patients with low-risk risk cervical injuries, we conditionally recommend performing a computed tomography angiography to detect BCVI. We recommend the use of ATT in patients diagnosed with BCVI. Finally, we recommend against the routine use of endovascular stents as an adjunct to ATT in patients with Grade II or III BCVIs.

Level of evidence: Guidelines, Level III.

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References

1. Biffl WL, Moore EE, Ryu RK, Offner PJ, Novak Z, Coldwell DM, Franciose RJ, Burch JM. The unrecognized epidemic of blunt carotid arterial injuries: early diagnosis improves neurologic outcome. Ann Surg. 1998;228(4):462–470.
1. Kerwin AJ, Bynoe RP, Murray J, Hudson ER, Close TP, Gifford RR, Carson KW, Smith LP, Bell RM. Liberalized screening for blunt carotid and vertebral artery injuries is justified. J Trauma. 2001;51(2):308–314.
1. Miller PR, Fabian TC, Croce MA, Cagiannos C, Williams JS, Vang M, Qaisi WG, Felker RE, Timmons SD. Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Ann Surg. 2002;236(3):386–393.
1. Bruns BR, Tesoriero R, Kufera J, Sliker C, Laser A, Scalea TM, Stein DM. Blunt cerebrovascular injury screening guidelines: what are we willing to miss? J Trauma Acute Care Surg. 2014;76(3):691–695.
1. Geddes AE, Burlew CC, Wagenaar AE, Biffl WL, Johnson JL, Pieracci FM, Campion EM, Moore EE. Expanded screening criteria for blunt cerebrovascular injury: a bigger impact than anticipated. Am J Surg. 2016;212(6):1167–1174.

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Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma

Affiliation

Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma

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Erratum in

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Research Materials