A Safe and Effective Management Strategy for Blunt Cerebrovascular Injury: Avoiding Unnecessary Anticoagulation and Eliminating Stroke

220 , DISTINCT SHORT-TERM OUTCOMES IN PATIENTS WITH MILD VERSUS RAPIDLY IMPROVING STROKE NOT TREATED WITH THROMBOLYTICS. Romano JG, Smith EE, Liang L, et al. Stroke. 2016;47:1278-1285 Ischemic stroke and the administration of tPA remains a relevant and debated topic in emergency departments across the country. A particular subset of stroke patients of particular interest are those that present with a minor stroke (MS) or rapidly improving stroke (RIS). These populations are often excluded from tPA administration, and this investigation investigated outcomes in these patients. The was a retrospective cohort study from the Get With The Guidelines–Stroke registry. The study identifies patients that were not given tPA, and then by excluding many patients that were not intervened upon for a variety of known reasons (for example those who arrived after the 4.5 hours of symptom onset required for tPA consideration), they identified a population of patients that did not receive tPA because they were either MS or RIS. The authors used multivariate analyses to look at baseline demographics and comorbidities to analyze the outcomes. The two primary outcomes included ability to ambulate independently and discharge directly to home. The study included 42,394 patients, 29.4% of which had MS and 44.2% with RIS, and 26.4% with both RIS and MS. From a demographic perspective, patients with RIS were older, had higher National Institutes of Health Stroke Scale (NIHSS) and had more comorbidities when compared to those with MS. In examining the outcomes of patients with MS and RIS, it was discovered that 27% of these patients cannot ambulate independently, and 27% also are not discharged directly home. While mortality was low in the patient population, the results indicate that there were changes in overall function and quality of life. The study also demonstrated that those with a higher NIHSS had worse outcomes than those with a lower score. The purpose of this study was to examine MS and RIS patients and their overall outcomes. The investigators concluded that there is still a significant population with MS and RIS that have suboptimal outcomes, and the MS and RIS have distinct characteristics and outcomes. The study also identified risk factors for worse outcomes, which include older patients, women, blacks, a history of prior CVA, cardiac disease, diabetes, hypertension and peripheral vascular disease. [Angela Wright, MD Denver Health Medical Center, Denver, CO] Comment: In current practice at most institutions, patients who have RIS or MS preclude the administration of tPA. This study is citing that nearly a quarter of the RIS or MS patients have sub-optimal outcomes, and is suggesting that perhaps these patients should be considered for tPA. This will continue to be a controversial topic, and additional study on the risk-benefit of tPA in the patient population of MS or RIS is necessary.

Abstracts , A SAFE AND EFFECTIVE MANAGEMENT STRATEGY FOR BLUNT CEREBROVASCULAR INJURY: AVOIDING UNNECESSARY ANTICOAGULATION AND ELIMINATING STROKE. Shahan CP, Magnotti LJ, Stickley SM, et al. J Trauma Acute Care Surg. 2016:80:915-922 Blunt cerebrovascular injury (BCVI) are of significant concern after trauma as they can lead to stroke and permanent disability. As a result, the optimal diagnostic algorithm to identify patients at risk for BCVI is important to facilitate early diagnosis and treatment. This was a retrospective study that examined all the patients at a single institution who underwent digital subtraction angiography (DSA). The institution recently implemented a new algorithm for the diagnosis of BVCI: if the patient had a positive computed tomography angiography (CTA) or an unexplained neurologic finding, they underwent DSA. They then used the results of the different imaging modalities to calculate false positives, and to examine how many patient’s had clinically significant complications from anticoagulation, missed diagnosis or iatrogenic concerns with performing of DSA. A total of 228 patients underwent DSA. Of those, 189 of these patients had a positive CTA. After undergoing DSA, it was found that 55% of the patients that had a positive CTA had a confirmed injury. However, this means that 45% of those patients with a positive CTA did not have an injury, demonstrating a very high false positive rate of CTA for BCVI. However, further analysis demonstrated that there were very few complications from placing patients on anticoagulation, in fact the only complication was heparin-induced thrombocytopenia and that was only in one patient. The other patients that were studied were those with an unexplained neurologic findings after trauma, and among these patients, there were 39 patients with a negative CTA. Of those, 92% had a negative DSA, and 8% had a positive DSA, meaning that 8% of the patients with a negative CTA but with an ongoing neurologic abnormalities had an injury that was missed by the CTA. The authors concluded that the CTA is a very non-specific test for BCVI, as there is a significant amount of false positives. This data would suggest that a combination of CTA combined with DSA for positive findings is the most accurate and applicable way to diagnose BCVI. [Angela Wright, MD Denver Health Medical Center, Denver, CO] Comment: Accurate and timely diagnosis of BCVI is essential to optimally care for these patients. Identification of BCVI changes management early after injury as anticoagulation or anti-platelet therapy needs to be initiated. This study suggests that advanced imaging modalities may aid in the diagnosis of BCVI in trauma patients which could result in earlier treatment and improved outcomes. Additional multi-center trials of DSA in the diagnosis of BCVI after trauma to further evaluate patient-centered outcomes are indicated.