A.M. Gochi1, C.J. Susai1, N. Alcasid1, K. Barrientos1, K. Gonzalez-Gallo1, G.P. Victorino1, C. Jackson1, A.E. Mendoza1 1University Of California – San Francisco East Bay, Highland Hospital Department Of Surgery, Oakland, CA, USA
Introduction: Treatment for grade 1 blunt cerebrovascular injuries (BCVI) (lesions involving < 25% of the arterial lumen) involves anti-platelets or anticoagulation (AC) followed by repeat imaging within 7 days after initial injury, with a low risk of future cerebrovascular accidents (CVA). However, the optimal duration of medical treatment is unknown, with recommendations advocating for lifelong treatment. We hypothesize that this population, due to its inherent risk for loss to follow up, continue to be at risk for CVA post discharge (DC) and require lifelong therapy after DC.
Methods: A retrospective review of patients at our level 1 trauma center from January 1, 2016 to July 01, 2024 with BCVI was performed. We assessed timing to initial and repeat CTAs, as well as medical treatment (MT), duration, and adherence. Our outcomes were prevalence of CVA, injury grade progression, and post DC CVA outcome and follow up.
Results: Thirty patients had grade 1 BCVIs on initial CTA (40% vertebral, 40% carotid, and 16% with high concern for injury without definitive dissection). Majority (63%) were male with median age 37 years. Motor vehicle crash (MVC) was the most common mechanism of injury (MOI) (46%), with a median injury severity scale 17. 15 (50%) were found to have concomitant traumatic brain injuries/hemorrhage, with 5 (17%) necessitating neurosurgical intervention. 17 (56.7%) underwent repeat imaging, with a mean time of 10.2 days; 6 (20%) had stable findings, 8 (26%) injuries resolved, 2 (6%) had BCVI progression and 1 (3%) progressed to brain death. 25 (80%) were started on MT (21- aspirin, 1- apixaban, 1-heparin, 2- Coumadin, and 5 with none given concomitant injuries). The DC plan for 30% was to continue ASA for 3 months with repeat imaging at 3 months. The remaining patients had a wide variation in treatment recommendations. The in-hospital CVA rate was 3%, and mortality was 6%; these patients were started on MT (Table 1).
Of the 22 patients on MT post DC, 2 patients had ASA discontinued after repeat imaging, and 1 had progression of subdural hemorrhage (SDH) with death. There were 2 patients lost to follow up, while 10 were found to not continue ASA post discharge. Of the 5 patients, not on MT post DC, 1 had progression of SDH with death, and 1 had progression of subarachnoid hemorrhage (SAH) with CVA and death within 30 days post DC.
Conclusion: Our findings demonstrate that lifelong medical treatment past discharge may be necessary for patients given the prevalence of CVA after discharge in our study. Current guidelines regarding management of grade 1 BCVI are mixed and may not apply to all populations as outpatient trauma and neurosurgical follow up may be ineffective in providing oversight needed to mitigate morbidity.