Highlights
- •Blunt cerebrovascular injuries are rare but associated with serious complications.
- •Antithrombotics are used to avert the common complication of ischemic stroke.
- •Most strokes here occurred between hospital arrival and antithrombotic initiation.
- •Interruption of treatment was associated with increased risk of ischemic stroke.
- •Antithrombotic regimen was not associated with stroke or bleeding complications.
Abstract
Background: Blunt cerebrovascular injuries (BCVIs) are associated with long-term neurological
effects. The first-line treatment for BCVIs is antithrombotics, but consensus on the
optimal choice and timing of treatment is lacking. Methods: This was a retrospective study on patients aged at least 18 years admitted to 6 level
1 trauma centers between 1/1/2014 and 12/31/2017 with grade 1-4 BCVI and treated with
antithrombotics. Differences in treatment practices were examined across the 6 centers.
The primary outcome was ischemic stroke, and secondary outcomes were related to bleeding
complications: blood transfusion and intracranial hemorrhage (ICH). Treatment characteristics
examined were time to diagnosis and first computerized tomography angiography, time
of total treatment course, time on each antithrombotic (anticoagulants, antiplatelets,
combination), time from hospital arrival to antithrombotic initiation, and treatment
interruption, i.e., treatment halted for a surgical procedure and restarted postoperatively.
Chi-square, Fisher exact, Spearman's rank-order correlation, Wilcoxon rank-sum, Kruskal-Wallis,
and Cox proportional hazards models with time-varying covariates were used to evaluate
associations with the outcomes. Results: A total of 189 patients with BCVI were included. The median (IQR) time from arrival
to antithrombotic initiation was 27 (8-61) hours, and 28% of patients had treatment
interrupted. The ischemic stroke rate was 7.5% (n = 14), with most strokes (64%, n = 9)
occurring between arrival and treatment initiation. Treatment interruption was associated
with ischemic stroke (75% of patients with stroke had an interruption versus 24% of
patients with no stroke; P < .01). Time on anticoagulants was not associated with ischemic stroke (P = .78), transfusion (P = .43), or ICH (P = .96). Similarly, time on antiplatelets (P = .54, P = .65, P = .60) and time on combination therapy (P = .96, P = .38, P = .57) were not associated with these outcomes. Conclusions: The timing and consistency of antithrombotic administration are critical in preventing
adverse outcomes in patients with BCVI. Most ischemic strokes in this study population
occurred between arrival and antithrombotic initiation, representing events that may
potentially be intervened upon by earlier treatment. Future studies should examine
the safety of continuing treatment through surgical procedures.
Key Words
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Article info
Publication history
Published online: April 15, 2020
Accepted:
March 3,
2020
Received in revised form:
January 15,
2020
Received:
November 4,
2019
Footnotes
Funding: None; internal funding only.
Identification
DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104804
Copyright
© 2020 Elsevier Inc. All rights reserved.
