Blunt traumatic occlusion of the internal carotid and vertebral arteries: Clinical article

Ryan P. Morton, Brian W. Hanak, Michael R. Levitt, Kathleen R. Fink, Eric Peterson, Marcelo D. Vilela, Louis J. Kim, Randall M. Chesnut

Research output: Contribution to journalArticle

16 Citations (Scopus)

Abstract

Object. The stroke rate, management, and outcome after blunt cerebrovascular occlusion (Biffl Grade IV injury) is not well defined, given the rarity of the disease. Both hemodynamic failure and embolic mechanisms have been implicated in the pathophysiology of subsequent stroke after blunt cerebrovascular occlusion. In this study, the authors evaluated their center's experience with Biffl Grade IV injuries, focusing on elucidating the mechanisms of stroke and their optimal management. Methods. A retrospective review identified all internal carotid artery (ICA) or vertebral artery (VA) Biffl Grade IV injuries over a 7-year period at a single institution. Results. Fifty-nine Biffl Grade IV injuries were diagnosed affecting 11 ICAs, 44 unilateral VAs, and 2 bilateral VAs. The stroke rates were 64%, 9%, and 50%, respectively. Of the 11 Biffl Grade IV ICA injuries, 5 presented with stroke while 2 developed delayed stroke. An ipsilateral posterior communicating artery greater than 1 mm on CT angiography was protective against stroke due to hemodynamic failure (p = 0.015). All patients with Biffl Grade IV injuries affecting the ICA who had at least 8 emboli per hour on transcranial Doppler (TCD) ultrasonography developed an embolic pattern of stroke (p = 0.006). Treatment with aspirin versus dual antiplatelet therapy had a similar effect on stroke rate in the ICA group (p = 0.5) and all patients who suffered stroke either died (n = 3) or required a decompressive hemicraniectomy with subsequent poor outcome (n = 4). All 10 strokes associated with Biffl Grade IV VA injuries were embolic and clinically asymptomatic. In VA Biffl Grade IV injury, neither the presence of emboli nor treatment with antiplatelet agents affected stroke rates. Conclusions. At the authors' institution, traumatic ICA occlusion is rare but associated with a high stroke rate. Robust collateral circulation may mitigate its severity. Embolic monitoring with TCD ultrasonography and prophylactic antiplatelet therapy should be used in all ICA Biffl Grade IV injuries. Unilateral VA Biffl Grade IV injury is the most common type of traumatic occlusion and is associated with significantly less morbidity. Embolic monitoring using TCD and prophylactic antiplatelet therapy do not appear to be beneficial in patients with traumatic VA occlusion.

Original languageEnglish (US)
Pages (from-to)1446-1450
Number of pages5
JournalJournal of Neurosurgery
Volume120
Issue number6
DOIs
StatePublished - 2014

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Vertebral Artery
Internal Carotid Artery
Stroke
Wounds and Injuries
Doppler Transcranial Ultrasonography
Cerebrovascular Disorders
Embolism
Hemodynamics
Carotid Artery Injuries
Therapeutics
Collateral Circulation
Platelet Aggregation Inhibitors
Aspirin
Arteries

Keywords

  • Biffl grade
  • Blunt cerebrovascular injury
  • Emboli
  • Internal carotid artery
  • Stroke
  • TCD
  • Trauma
  • Traumatic brain injury
  • Vascular disorders
  • Vertebral artery

ASJC Scopus subject areas

  • Clinical Neurology
  • Surgery

Cite this

Morton, R. P., Hanak, B. W., Levitt, M. R., Fink, K. R., Peterson, E., Vilela, M. D., ... Chesnut, R. M. (2014). Blunt traumatic occlusion of the internal carotid and vertebral arteries: Clinical article. Journal of Neurosurgery, 120(6), 1446-1450. https://doi.org/10.3171/2014.2.JNS131658

Blunt traumatic occlusion of the internal carotid and vertebral arteries : Clinical article. / Morton, Ryan P.; Hanak, Brian W.; Levitt, Michael R.; Fink, Kathleen R.; Peterson, Eric; Vilela, Marcelo D.; Kim, Louis J.; Chesnut, Randall M.

In: Journal of Neurosurgery, Vol. 120, No. 6, 2014, p. 1446-1450.

Research output: Contribution to journalArticle

Morton, RP, Hanak, BW, Levitt, MR, Fink, KR, Peterson, E, Vilela, MD, Kim, LJ & Chesnut, RM 2014, 'Blunt traumatic occlusion of the internal carotid and vertebral arteries: Clinical article', Journal of Neurosurgery, vol. 120, no. 6, pp. 1446-1450. https://doi.org/10.3171/2014.2.JNS131658
Morton, Ryan P. ; Hanak, Brian W. ; Levitt, Michael R. ; Fink, Kathleen R. ; Peterson, Eric ; Vilela, Marcelo D. ; Kim, Louis J. ; Chesnut, Randall M. / Blunt traumatic occlusion of the internal carotid and vertebral arteries : Clinical article. In: Journal of Neurosurgery. 2014 ; Vol. 120, No. 6. pp. 1446-1450.
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abstract = "Object. The stroke rate, management, and outcome after blunt cerebrovascular occlusion (Biffl Grade IV injury) is not well defined, given the rarity of the disease. Both hemodynamic failure and embolic mechanisms have been implicated in the pathophysiology of subsequent stroke after blunt cerebrovascular occlusion. In this study, the authors evaluated their center's experience with Biffl Grade IV injuries, focusing on elucidating the mechanisms of stroke and their optimal management. Methods. A retrospective review identified all internal carotid artery (ICA) or vertebral artery (VA) Biffl Grade IV injuries over a 7-year period at a single institution. Results. Fifty-nine Biffl Grade IV injuries were diagnosed affecting 11 ICAs, 44 unilateral VAs, and 2 bilateral VAs. The stroke rates were 64{\%}, 9{\%}, and 50{\%}, respectively. Of the 11 Biffl Grade IV ICA injuries, 5 presented with stroke while 2 developed delayed stroke. An ipsilateral posterior communicating artery greater than 1 mm on CT angiography was protective against stroke due to hemodynamic failure (p = 0.015). All patients with Biffl Grade IV injuries affecting the ICA who had at least 8 emboli per hour on transcranial Doppler (TCD) ultrasonography developed an embolic pattern of stroke (p = 0.006). Treatment with aspirin versus dual antiplatelet therapy had a similar effect on stroke rate in the ICA group (p = 0.5) and all patients who suffered stroke either died (n = 3) or required a decompressive hemicraniectomy with subsequent poor outcome (n = 4). All 10 strokes associated with Biffl Grade IV VA injuries were embolic and clinically asymptomatic. In VA Biffl Grade IV injury, neither the presence of emboli nor treatment with antiplatelet agents affected stroke rates. Conclusions. At the authors' institution, traumatic ICA occlusion is rare but associated with a high stroke rate. Robust collateral circulation may mitigate its severity. Embolic monitoring with TCD ultrasonography and prophylactic antiplatelet therapy should be used in all ICA Biffl Grade IV injuries. Unilateral VA Biffl Grade IV injury is the most common type of traumatic occlusion and is associated with significantly less morbidity. Embolic monitoring using TCD and prophylactic antiplatelet therapy do not appear to be beneficial in patients with traumatic VA occlusion.",
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AU - Hanak, Brian W.

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AU - Fink, Kathleen R.

AU - Peterson, Eric

AU - Vilela, Marcelo D.

AU - Kim, Louis J.

AU - Chesnut, Randall M.

PY - 2014

Y1 - 2014

N2 - Object. The stroke rate, management, and outcome after blunt cerebrovascular occlusion (Biffl Grade IV injury) is not well defined, given the rarity of the disease. Both hemodynamic failure and embolic mechanisms have been implicated in the pathophysiology of subsequent stroke after blunt cerebrovascular occlusion. In this study, the authors evaluated their center's experience with Biffl Grade IV injuries, focusing on elucidating the mechanisms of stroke and their optimal management. Methods. A retrospective review identified all internal carotid artery (ICA) or vertebral artery (VA) Biffl Grade IV injuries over a 7-year period at a single institution. Results. Fifty-nine Biffl Grade IV injuries were diagnosed affecting 11 ICAs, 44 unilateral VAs, and 2 bilateral VAs. The stroke rates were 64%, 9%, and 50%, respectively. Of the 11 Biffl Grade IV ICA injuries, 5 presented with stroke while 2 developed delayed stroke. An ipsilateral posterior communicating artery greater than 1 mm on CT angiography was protective against stroke due to hemodynamic failure (p = 0.015). All patients with Biffl Grade IV injuries affecting the ICA who had at least 8 emboli per hour on transcranial Doppler (TCD) ultrasonography developed an embolic pattern of stroke (p = 0.006). Treatment with aspirin versus dual antiplatelet therapy had a similar effect on stroke rate in the ICA group (p = 0.5) and all patients who suffered stroke either died (n = 3) or required a decompressive hemicraniectomy with subsequent poor outcome (n = 4). All 10 strokes associated with Biffl Grade IV VA injuries were embolic and clinically asymptomatic. In VA Biffl Grade IV injury, neither the presence of emboli nor treatment with antiplatelet agents affected stroke rates. Conclusions. At the authors' institution, traumatic ICA occlusion is rare but associated with a high stroke rate. Robust collateral circulation may mitigate its severity. Embolic monitoring with TCD ultrasonography and prophylactic antiplatelet therapy should be used in all ICA Biffl Grade IV injuries. Unilateral VA Biffl Grade IV injury is the most common type of traumatic occlusion and is associated with significantly less morbidity. Embolic monitoring using TCD and prophylactic antiplatelet therapy do not appear to be beneficial in patients with traumatic VA occlusion.

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KW - Internal carotid artery

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KW - Traumatic brain injury

KW - Vascular disorders

KW - Vertebral artery

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