- Email: [email protected]
Vascular injury outcomes with screening implementation
Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 9 (2017) 82–84
Contents lists available at ScienceDirect
Interdisciplinary Neurosurgery: Advanced Techniques and Case Management journal homepage: www.inat-journal.com
Neuroanatomical Studies
Vascular injury outcomes with screening implementation☆,☆☆,☆☆☆ James D. Weinberg, MD a, William R. Lightle, BS b, Nirav Patil, MBBS, MPH c, Martin W. Durkin, MD d, Sharon W. Webb, MD e,⁎ a
University of South Carolina School of Medicine, Columbia, SC, United States University of South Carolina School of Medicine Greenville, Greenville, SC, United States Department of Quality Management, Greenville Health System, Greenville, SC, United States d Palmetto Health Richland, Columbia, SC, United States e Southeastern Neurosurgery and Spine Institute, Greenville Health System, Greenville, SC, United States b c
a r t i c l e
i n f o
Article history: Received 25 March 2017 Accepted 16 April 2017 Available online xxxx
a b s t r a c t Blunt carotid and vertebral artery injuries (BCVI) are generally viewed as rare events. Screening guidelines based on the Memphis and Denver data were put into place at Palmetto Health Richland in August of 2008. This study aims to look at the incidence of BCVI 2 years before the guidelines were put into place and then 2 years after. A total of 11,005 trauma patients presented during our study period. 98 patients were determined to have BCVI and met inclusion criteria: 21 in the Control group and 77 in the Screening group. A total of 16 deaths and 14 strokes were recorded in the study population. The odds of patients in the Screening group dying were 29% lower than that of a patient in the Control group [OR: 0.71, (95% CI: 0.20–2.50); p = 0.59], after adjusting for ISS. The odds of developing a stroke in the Screening group were 69% lower than the Control group [OR: 0.31 (0.09–1.08); p = 0.067]. These differences were not statistically significant. The increased BCVI incidence rate and decreased stroke and mortality rate following screening implementation further support the importance of having screening criteria for blunt vascular injury following trauma. © 2017 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction Historically, blunt injury to the carotid or vertebral vessels— collectively named blunt cerebrovascular injury (BCVI)—was considered an uncommon event. The reported incidence rate of BCVI in trauma patients, however, has increased from 0.01% to approximately 1.0%– 2.0% following publication of several landmark papers [1,2] and the subsequent screening, diagnosis, and management recommendations published by the EAST Practice Management Guidelines committee [3]. BCVI is frequently associated with multiple organ injuries. Moreover, recognition and diagnosis upon admission can be missed due to delayed neurologic symptoms (10–72 hour post-trauma) [2,4,5]. Undetected, and thus untreated, BCVIs carry a high stroke (25%–58%) and mortality
Abbreviations: BCVI, blunt cerebrovascular injury; CTA, computed tomography angiogram; GCS, Glasgow coma scale; ISS, injury severity score; LOS, length of stay; SD, standard deviation; IQR, interquartile range. ☆ The authors declare that there are no conflicts of interest. ☆☆ We presented an earlier version of the manuscript as a poster at the AANS conference in San Francisco, CA in 2014. ☆☆☆ The authors declare that there was no funding received for this work from any of the following organizations: National Institutes of Health (NIH); Wellcome Trust, and the Howard Hughes Medical Institute (HHMI). ⁎ Corresponding author. E-mail address: [email protected] (S.W. Webb).
rate (31%–59%) [1,2,6]. These outcomes, however, can often be prevented if the BCVI is detected early and managed with antiplatelets and/or anticoagulation therapy and either surgical or endovascular treatment [1,2,4,7]. Even though a considerable amount of research has been done in the last 20 years, debate remains regarding the value of screening for BCVI in trauma patients, as well as the ideal management. The purpose of this study was to determine whether implementation of BCVI screening and treatment guidelines has impacted the incidence rate of BCVI, as well as patient outcomes, including stroke and mortality. 2. Material and methods Following approval from the Palmetto Health Richland Institutional Review Board, we retrospectively collected, from a prospective database, all trauma patients who presented to the Level 1 trauma center at Palmetto Health Richland between August 1, 2006 and December 31, 2011 (N = 11,005). From these, all patients who had a suspected vascular injury, which was confirmed by conventional angiogram, computed tomography angiogram (CTA), magnetic resonance imaging (MRI), or magnetic resonance angiogram (MRA), were identified according to the criteria proposed by Biffl et al. (n = 120) [4]. Data collection included patient age and gender, mechanism of injury, Glasgow coma scale (GCS), injury severity score (ISS), ICU length of stay (LOS),
http://dx.doi.org/10.1016/j.inat.2017.04.004 2214-7519/© 2017 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
J.D. Weinberg et al. / Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 9 (2017) 82–84
hospital LOS, and type of anticoagulant/medication. Chart and imaging reviews were performed on all 120 patients. Patients under 12 years of age, patients with a vascular injury due to penetrating trauma, and patients with a venous injury were excluded from analysis (n = 22). All remaining eligible patients were included in the study (n = 98). Study patients were divided into 2 groups based on the date the EAST BCVI screening and treatment guidelines were implemented: Group 1 included BCVI patients before the guidelines (Control group; August 1, 2006–July 31, 2008); and Group 2 included those after the guidelines (Screening group; August 1, 2008–December 31, 2011). Primary outcomes included incidence of BCVI (per 1000 trauma admissions), stroke, and death. Bivariate descriptive statistics were used to compare patient characteristics between the two groups (Control vs. Screening). Counts and percentages are reported for categorical variables and were compared using Fisher's exact test. Mean and standard deviation (SD), and median and interquartile range (IQR), are reported for continuous variables and were compared using Student's t-test and Wilcoxon rank-sum test, respectively. Multivariate logistic regression analysis was used to analyze the association of each variable (age, mechanism of injury, GCS, and ISS) with both stroke and death. Variables found to be significant on bivariate analysis were included in logistic model for adjustment. A p-value b 0.05 was considered significant. All statistical analyses were performed with SAS statistical software (SAS enterprise guide 7.1; SAS institute, Cary, NC). 3. Results A total of 11,005 trauma patients presented during our study period. From these, 98 patients were determined to have BCVI and met inclusion criteria: 21 in the Control group and 77 in the Screening group. Patient characteristics are described in Table 1. There were no significant differences between groups in terms of mean patient age (p = 0.19), median GCS (p = 0.11), ICU LOS (p = 0.59), and hospital LOS (p = 0.58). The average patient in both groups was male (76.2% vs. 70.1%) and the most common mechanism of injury was a motor vehicle crash (71.4% vs. 64.9%). The median ISS score, however, was significantly higher in the Control group (29 vs. 19; p = 0.036). Incidence of BCVI was significantly different between groups: the Control group had approximately 5.4 BCVIs per 1000 trauma admissions compared to 10.8 per 1000 trauma admissions in the Screening group (p = 0.004). The proportion of BCVI patients who either had a stroke or died was higher in the Control group but this did not reach statistical significance (38.1% vs. 19.5%; p = 0.08).
Table 1 Patient characteristics.
N Age Mean ± SD Male gender, no. (%) Mechanism of injury, no. (%) Motor vehicle crash Motorcycle crash Fall GCS Mean ± SD Median (IQR) ≤6, no (%) ISS Mean ± SD Median (IQR) ≥16, no. (%) Mortality, no. (%) Stroke, no. (%) Either death or stroke, no. (%) ICU length of stay, median (IQR) Hospital length of stay, median (IQR)
Control group
Screening group
21
77
p
37.9 ± 15.5 16 (76.2)
43.9 ± 19.5 54 (70.1)
0.19 0.78
15 (71.4) 2 (9.5%) 1 (4.7%)
50 (64.9) 7 (9.1%) 6 (7.8)
0.79 0.99 0.99
9.6 ± 6.1 13 (12) 7 (33.3)
11.1 ± 5.4 15 (12) 21 (27.3)
0.30 0.11 0.59
26.1 ± 12.4 29 (18) 16 (76.2) 5 (23.8) 6 (28.6) 8 (38.1) 4 (14) 9 (18)
20.6 ± 12 19 (17) 49 (63.6) 11 (14.3) 8 (10.4) 15 (19.5) 4 (10) 10 (19)
0.06 0.04 0.28 0.32 0.07 0.08 0.59 0.58
83
Table 2 Comparison of mortality and stroke odds ratios by patient group. Outcome
Group
Adjusted odds ratio (95% confidence interval)
p
Mortality
Control Screening ISS Control Screening ISS Control Screening ISS
Referent 0.71 (0.20–2.5) 1.06 (1.01–1.11) Referent 0.31 (0.09–1.08) 1.02 (0.97–1.06) Referent 0.49 (0.16–1.47) 1.05 (1.01–1.09)
0.59
Stroke
Either mortality or stroke
0.013 0.067 0.43 0.20 0.01
A total of 16 deaths and 14 strokes were recorded in the study population. As shown in Table 2, the odds of patients in the Screening group dying was 29% lower than that of a patient in the Control group [OR: 0.71, (95% CI: 0.20–2.50); p = 0.59], after adjusting for ISS. The odds of developing a stroke in the Screening group were 69% lower than the Control group [OR: 0.31 (0.09–1.08); p = 0.067]. These differences were not statistically significant; however, by Akaike information criterion (AIC), the model-containing group was found to be superior to the intercept-only model. There were 23 cases with either death or stroke as an outcome. The multivariate logistic regression analysis model revealed no statistically significant association [OR: 0.49 (0.16–1.47); p = 0.20]. Prior to implementing the EAST screening guidelines, 75% of BCVI patients in the Control group were given warfarin, compared to 2% of BCVI patients in the Screening group (Fig. 1). All BCVI patients in the Control group were given either warfarin (75%) or aspirin (25%). In the Screening group, either a heparin drip (32%) followed by conversion to an antiplatelet regimen was given or antiplatelet medications were started as the first therapy. Aspirin (36%), clopidogrel (16%), or both aspirin and clopidogrel (14%) were used depending on the severity and the endovascular treatment they received. Patients with head injuries were not excluded from treatment of their BCVIs. No treatment regimen was documented as being discontinued due to a worsening of the patient’s head injury. 4. Discussion The average BCVI patient in our study was a young (mid 30s to early 40s) man (71%), which is comparable to other BCVI populations reported in the literature [8,9]. According to Biffl et al. a GCS ≤6 is an independent predictor of carotid arterial injury in BCVI patients [10]. Approximately 29% of our patients had a GCS ≤ 6. Studies have also shown BCVI to be more common in patients with an ISS ≥ 16 [6,11]; this was also true in our study (66% of patients). Last, according to Biffl et al. screening criteria [10], mechanism of BCVI is often associated with cervical hyperextension and rotation, hyperflexion, or direct blow. The Biffl criteria also recommend screening for seat belt abrasions of the anterior neck. Not surprisingly, motor vehicle (67%) and motorcycle (9%) crashes were the top mechanisms of injury, occurring in 76% of our BCVI patients. Following implementation of the Biffl screening criteria our incidence rate of reported BCVIs increased from 5.4 per 1000 trauma admissions to 10.8 per 1000 (p = 0.004). Although our stroke and mortality outcomes between groups were not statistically significant, the odds of patients in the Screening group dying were 29% lower than the patients in the Control group (p = 0.59), and the odds of patients in the Screening group developing a stroke were 69% lower than those the Control group (p = 0.067). Our data further support those in favor of screening trauma patients at risk for BCVI [3,6,12]. Debate regarding the optimal anticoagulation regimen (heparin vs. warfarin vs. aspirin) for BCVI patients continues. The Eastern Association for the Surgery of Trauma Practice Management Guideline
84
J.D. Weinberg et al. / Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 9 (2017) 82–84
Fig. 1. Comparison of Anticoagulation Before and After 8/1/2008.
Committee published a Level II recommendation that grade I and II BCVIs be treated with antithrombotic agents like aspirin or heparin. However, they also published a Level III recommendation that both heparin and antiplatelet therapy can be used with seemingly comparable results [3]. Wahl et al., Cothren et al., and Biffl et al. compared aspirin and heparin, but found no significant differences in outcomes between the two agents [2,5,13]. A more recent study by Cothren et al. compared heparin and antiplatelet agents and found type of treatment to have no impact on the stroke or healing rate [8]. In 2016, Tso and colleagues successfully treated 75% (n = 35) of their BCVI patients with antiplatelet agents [14]. Prior to implementing the screening criteria for BCVI, 75% of our Control patients were treated with warfarin and the remaining 25% with aspirin. Following implementation of BCVI screening only 2% of patients in the Screening group received warfarin, 32% initially received heparin drip followed by conversion to an antiplatelet regimen, 36% were treated with only aspirin, 16% with only clopidogrel, and 14% were given both aspirin and clopidogrel. Based on our findings, we agree with Tso et al. and recommend use of antiplatelet over standard use of anticoagulation. Of note, no complications from heparin or antiplatelets were seen in our study. This study has all the inherent limitations associated with a singlecenter, retrospective study. Furthermore, due to the nature of a retrospective study, certain neurologic events could have occurred that were not reported. Patients were identified from the local trauma database, and all eligible patients were included in the study in order to limit selection bias. The control patients had lower mean GCS and higher ISS because no screening for BCVI was performed at that time and patient’s received treatment only if they developed symptoms. This could account for some of the differences in outcomes seen between the two groups. Low sample size limited our statistical power in analysis. 5. Conclusions The increased BCVI incidence rate and decreased stroke and mortality rate following screening implementation further support the importance of having screening criteria for blunt vascular injury following trauma. Also, use of antiplatelet therapy appears to be a safe and effective treatment modality; however, additional prospective studies are needed to determine the optimal anticoagulation regimen.
References [1] T. Fabian, J. Patton Jr., M.A. Croce, G. Minard, K.A. Kudsk, F.E. Prichard, Blunt carotid injury: importance of early diagnosis and anticoagulant therapy, Ann. Surg. 223 (5) (1996) 513–525. [2] C.C. Cothren, E.E. Moore, W.L. Biffl, D.J. Ciesla, C.E. Ray Jr., J.L. Johnson, J.B. Moore, J.M. Burch, Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate, Arch. Surg. 139 (5) (2004 May) 540–545. [3] W.J. Bromberg, B.C. Collier, L.N. Diebel, K.M. Dwyer, M.R. Holevar, D.G. Jacobs, S.J. Kurek, M.A. Schreiber, T.R. Vogel, Blunt cerebrovascular injury practice management guidelines: the eastern association for the surgery of trauma, J. Trauma 68 (2) (2010 Feb) 471–477. [4] W.L. Biffl, C.C. Cothren, E.E. Moore, R. Kozar, C. Cocanour, J.W. Davis, R.C. McIntyre Jr., M.A. West, F.A. Moore, Western trauma association critical decisions in trauma: screening for and treatment of blunt cerebrovascular injuries, J. Trauma 67 (6) (2009 Dec) 1150–1153. [5] W.L. Biffl, C.E. Ray Jr., E.E. Moore, R.J. Franciose, S. Aly, M.G. Heyrosa, J.L. Johnson, J.M. Burch, Treatment-related outcomes from blunt cerebrovascular injuries: importance of routine follow-up arteriography, Ann. Surg. 235 (5) (2002 May) 699–706. [6] W.L. Biffl, E.E. Moore, R.K. Ryu, P.J. Offner, Z. Novak, D.M. Coldwell, R.J. Franciose, J.M. Burch, The unrecognized epidemic of blunt carotid arterial injuries: early diagnosis improves neurologic outcome, Ann. Surg. 228 (4) (1998 Oct) 462–470. [7] N.M. Edwards, T.C. Fabian, J.A. Claridge, S.D. Timmons, P.E. Fischer, M.A. Croce, Antithrombotic therapy and endovascular stents are effective treatment for blunt carotid injuries: results from longterm followup, J. Am. Coll. Surg. 204 (5) (2007 May) 1007–1013. [8] C.C. Cothren, W.L. Biffl, E.E. Moore, J.L. Kashuk, J.L. Johnson, Treatment for blunt cerebrovascular injuries: equivalence of anticoagulation and antiplatelet agents, Arch. Surg. 144 (7) (2009 Jul) 685–690. [9] C.C. Burlew, W.L. Biffl, E.E. Moore, C.C. Barnett, J.L. Johnson, D.D. Bensard, Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis, J. Trauma Acute Care Surg. 72 (2) (2012 Feb) 330–335. [10] W.L. Biffl, E.E. Moore, P.J. Offner, K.E. Brega, R.J. Franciose, J.P. Elliott, J.M. Burch, Optimizing screening for blunt cerebrovascular injuries, Am. J. Surg. 178 (6) (1999 Dec) 517–522. [11] S. Mutze, G. Rademacher, G. Matthes, N. Hosten, D. Stengel, Blunt cerebrovascular injury in patients with blunt multiple trauma: diagnostic accuracy of duplex Doppler US and early CT angiography, Radiology 237 (3) (2005 Dec) (884-53). [12] C.C. Cothren, E.E. Moore, C.E. Ray Jr., D.J. Ciesla, J.L. Johnson, J.B. Moore, J.M. Burch, Screening for blunt cerebrovascular injuries is cost-effective, Am. J. Surg. 190 (6) (2005 Dec) 845–849. [13] W.L. Wahl, M. Brandt, B.G. Thompson, P.A. Taheri, L.J. Greenfield, Antiplatelet therapy: an alternative to heparin for blunt carotid injury, J. Trauma 52 (5) (2002 May) 896–901. [14] M.K. Tso, M.M. Lee, C.G. Ball, W.F. Morrish, A.P. Mitha, A.W. Kirkpatrick, J.H. Wong, Clinical utility of a screening protocol for blunt cerebrovascular injury using computed tomography angiography, J. Neurosurg. 22 (2016 Apr) 1–9.
Contents lists available at ScienceDirect
Interdisciplinary Neurosurgery: Advanced Techniques and Case Management journal homepage: www.inat-journal.com
Neuroanatomical Studies
Vascular injury outcomes with screening implementation☆,☆☆,☆☆☆ James D. Weinberg, MD a, William R. Lightle, BS b, Nirav Patil, MBBS, MPH c, Martin W. Durkin, MD d, Sharon W. Webb, MD e,⁎ a
University of South Carolina School of Medicine, Columbia, SC, United States University of South Carolina School of Medicine Greenville, Greenville, SC, United States Department of Quality Management, Greenville Health System, Greenville, SC, United States d Palmetto Health Richland, Columbia, SC, United States e Southeastern Neurosurgery and Spine Institute, Greenville Health System, Greenville, SC, United States b c
a r t i c l e
i n f o
Article history: Received 25 March 2017 Accepted 16 April 2017 Available online xxxx
a b s t r a c t Blunt carotid and vertebral artery injuries (BCVI) are generally viewed as rare events. Screening guidelines based on the Memphis and Denver data were put into place at Palmetto Health Richland in August of 2008. This study aims to look at the incidence of BCVI 2 years before the guidelines were put into place and then 2 years after. A total of 11,005 trauma patients presented during our study period. 98 patients were determined to have BCVI and met inclusion criteria: 21 in the Control group and 77 in the Screening group. A total of 16 deaths and 14 strokes were recorded in the study population. The odds of patients in the Screening group dying were 29% lower than that of a patient in the Control group [OR: 0.71, (95% CI: 0.20–2.50); p = 0.59], after adjusting for ISS. The odds of developing a stroke in the Screening group were 69% lower than the Control group [OR: 0.31 (0.09–1.08); p = 0.067]. These differences were not statistically significant. The increased BCVI incidence rate and decreased stroke and mortality rate following screening implementation further support the importance of having screening criteria for blunt vascular injury following trauma. © 2017 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction Historically, blunt injury to the carotid or vertebral vessels— collectively named blunt cerebrovascular injury (BCVI)—was considered an uncommon event. The reported incidence rate of BCVI in trauma patients, however, has increased from 0.01% to approximately 1.0%– 2.0% following publication of several landmark papers [1,2] and the subsequent screening, diagnosis, and management recommendations published by the EAST Practice Management Guidelines committee [3]. BCVI is frequently associated with multiple organ injuries. Moreover, recognition and diagnosis upon admission can be missed due to delayed neurologic symptoms (10–72 hour post-trauma) [2,4,5]. Undetected, and thus untreated, BCVIs carry a high stroke (25%–58%) and mortality
Abbreviations: BCVI, blunt cerebrovascular injury; CTA, computed tomography angiogram; GCS, Glasgow coma scale; ISS, injury severity score; LOS, length of stay; SD, standard deviation; IQR, interquartile range. ☆ The authors declare that there are no conflicts of interest. ☆☆ We presented an earlier version of the manuscript as a poster at the AANS conference in San Francisco, CA in 2014. ☆☆☆ The authors declare that there was no funding received for this work from any of the following organizations: National Institutes of Health (NIH); Wellcome Trust, and the Howard Hughes Medical Institute (HHMI). ⁎ Corresponding author. E-mail address: [email protected] (S.W. Webb).
rate (31%–59%) [1,2,6]. These outcomes, however, can often be prevented if the BCVI is detected early and managed with antiplatelets and/or anticoagulation therapy and either surgical or endovascular treatment [1,2,4,7]. Even though a considerable amount of research has been done in the last 20 years, debate remains regarding the value of screening for BCVI in trauma patients, as well as the ideal management. The purpose of this study was to determine whether implementation of BCVI screening and treatment guidelines has impacted the incidence rate of BCVI, as well as patient outcomes, including stroke and mortality. 2. Material and methods Following approval from the Palmetto Health Richland Institutional Review Board, we retrospectively collected, from a prospective database, all trauma patients who presented to the Level 1 trauma center at Palmetto Health Richland between August 1, 2006 and December 31, 2011 (N = 11,005). From these, all patients who had a suspected vascular injury, which was confirmed by conventional angiogram, computed tomography angiogram (CTA), magnetic resonance imaging (MRI), or magnetic resonance angiogram (MRA), were identified according to the criteria proposed by Biffl et al. (n = 120) [4]. Data collection included patient age and gender, mechanism of injury, Glasgow coma scale (GCS), injury severity score (ISS), ICU length of stay (LOS),
http://dx.doi.org/10.1016/j.inat.2017.04.004 2214-7519/© 2017 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
J.D. Weinberg et al. / Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 9 (2017) 82–84
hospital LOS, and type of anticoagulant/medication. Chart and imaging reviews were performed on all 120 patients. Patients under 12 years of age, patients with a vascular injury due to penetrating trauma, and patients with a venous injury were excluded from analysis (n = 22). All remaining eligible patients were included in the study (n = 98). Study patients were divided into 2 groups based on the date the EAST BCVI screening and treatment guidelines were implemented: Group 1 included BCVI patients before the guidelines (Control group; August 1, 2006–July 31, 2008); and Group 2 included those after the guidelines (Screening group; August 1, 2008–December 31, 2011). Primary outcomes included incidence of BCVI (per 1000 trauma admissions), stroke, and death. Bivariate descriptive statistics were used to compare patient characteristics between the two groups (Control vs. Screening). Counts and percentages are reported for categorical variables and were compared using Fisher's exact test. Mean and standard deviation (SD), and median and interquartile range (IQR), are reported for continuous variables and were compared using Student's t-test and Wilcoxon rank-sum test, respectively. Multivariate logistic regression analysis was used to analyze the association of each variable (age, mechanism of injury, GCS, and ISS) with both stroke and death. Variables found to be significant on bivariate analysis were included in logistic model for adjustment. A p-value b 0.05 was considered significant. All statistical analyses were performed with SAS statistical software (SAS enterprise guide 7.1; SAS institute, Cary, NC). 3. Results A total of 11,005 trauma patients presented during our study period. From these, 98 patients were determined to have BCVI and met inclusion criteria: 21 in the Control group and 77 in the Screening group. Patient characteristics are described in Table 1. There were no significant differences between groups in terms of mean patient age (p = 0.19), median GCS (p = 0.11), ICU LOS (p = 0.59), and hospital LOS (p = 0.58). The average patient in both groups was male (76.2% vs. 70.1%) and the most common mechanism of injury was a motor vehicle crash (71.4% vs. 64.9%). The median ISS score, however, was significantly higher in the Control group (29 vs. 19; p = 0.036). Incidence of BCVI was significantly different between groups: the Control group had approximately 5.4 BCVIs per 1000 trauma admissions compared to 10.8 per 1000 trauma admissions in the Screening group (p = 0.004). The proportion of BCVI patients who either had a stroke or died was higher in the Control group but this did not reach statistical significance (38.1% vs. 19.5%; p = 0.08).
Table 1 Patient characteristics.
N Age Mean ± SD Male gender, no. (%) Mechanism of injury, no. (%) Motor vehicle crash Motorcycle crash Fall GCS Mean ± SD Median (IQR) ≤6, no (%) ISS Mean ± SD Median (IQR) ≥16, no. (%) Mortality, no. (%) Stroke, no. (%) Either death or stroke, no. (%) ICU length of stay, median (IQR) Hospital length of stay, median (IQR)
Control group
Screening group
21
77
p
37.9 ± 15.5 16 (76.2)
43.9 ± 19.5 54 (70.1)
0.19 0.78
15 (71.4) 2 (9.5%) 1 (4.7%)
50 (64.9) 7 (9.1%) 6 (7.8)
0.79 0.99 0.99
9.6 ± 6.1 13 (12) 7 (33.3)
11.1 ± 5.4 15 (12) 21 (27.3)
0.30 0.11 0.59
26.1 ± 12.4 29 (18) 16 (76.2) 5 (23.8) 6 (28.6) 8 (38.1) 4 (14) 9 (18)
20.6 ± 12 19 (17) 49 (63.6) 11 (14.3) 8 (10.4) 15 (19.5) 4 (10) 10 (19)
0.06 0.04 0.28 0.32 0.07 0.08 0.59 0.58
83
Table 2 Comparison of mortality and stroke odds ratios by patient group. Outcome
Group
Adjusted odds ratio (95% confidence interval)
p
Mortality
Control Screening ISS Control Screening ISS Control Screening ISS
Referent 0.71 (0.20–2.5) 1.06 (1.01–1.11) Referent 0.31 (0.09–1.08) 1.02 (0.97–1.06) Referent 0.49 (0.16–1.47) 1.05 (1.01–1.09)
0.59
Stroke
Either mortality or stroke
0.013 0.067 0.43 0.20 0.01
A total of 16 deaths and 14 strokes were recorded in the study population. As shown in Table 2, the odds of patients in the Screening group dying was 29% lower than that of a patient in the Control group [OR: 0.71, (95% CI: 0.20–2.50); p = 0.59], after adjusting for ISS. The odds of developing a stroke in the Screening group were 69% lower than the Control group [OR: 0.31 (0.09–1.08); p = 0.067]. These differences were not statistically significant; however, by Akaike information criterion (AIC), the model-containing group was found to be superior to the intercept-only model. There were 23 cases with either death or stroke as an outcome. The multivariate logistic regression analysis model revealed no statistically significant association [OR: 0.49 (0.16–1.47); p = 0.20]. Prior to implementing the EAST screening guidelines, 75% of BCVI patients in the Control group were given warfarin, compared to 2% of BCVI patients in the Screening group (Fig. 1). All BCVI patients in the Control group were given either warfarin (75%) or aspirin (25%). In the Screening group, either a heparin drip (32%) followed by conversion to an antiplatelet regimen was given or antiplatelet medications were started as the first therapy. Aspirin (36%), clopidogrel (16%), or both aspirin and clopidogrel (14%) were used depending on the severity and the endovascular treatment they received. Patients with head injuries were not excluded from treatment of their BCVIs. No treatment regimen was documented as being discontinued due to a worsening of the patient’s head injury. 4. Discussion The average BCVI patient in our study was a young (mid 30s to early 40s) man (71%), which is comparable to other BCVI populations reported in the literature [8,9]. According to Biffl et al. a GCS ≤6 is an independent predictor of carotid arterial injury in BCVI patients [10]. Approximately 29% of our patients had a GCS ≤ 6. Studies have also shown BCVI to be more common in patients with an ISS ≥ 16 [6,11]; this was also true in our study (66% of patients). Last, according to Biffl et al. screening criteria [10], mechanism of BCVI is often associated with cervical hyperextension and rotation, hyperflexion, or direct blow. The Biffl criteria also recommend screening for seat belt abrasions of the anterior neck. Not surprisingly, motor vehicle (67%) and motorcycle (9%) crashes were the top mechanisms of injury, occurring in 76% of our BCVI patients. Following implementation of the Biffl screening criteria our incidence rate of reported BCVIs increased from 5.4 per 1000 trauma admissions to 10.8 per 1000 (p = 0.004). Although our stroke and mortality outcomes between groups were not statistically significant, the odds of patients in the Screening group dying were 29% lower than the patients in the Control group (p = 0.59), and the odds of patients in the Screening group developing a stroke were 69% lower than those the Control group (p = 0.067). Our data further support those in favor of screening trauma patients at risk for BCVI [3,6,12]. Debate regarding the optimal anticoagulation regimen (heparin vs. warfarin vs. aspirin) for BCVI patients continues. The Eastern Association for the Surgery of Trauma Practice Management Guideline
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Fig. 1. Comparison of Anticoagulation Before and After 8/1/2008.
Committee published a Level II recommendation that grade I and II BCVIs be treated with antithrombotic agents like aspirin or heparin. However, they also published a Level III recommendation that both heparin and antiplatelet therapy can be used with seemingly comparable results [3]. Wahl et al., Cothren et al., and Biffl et al. compared aspirin and heparin, but found no significant differences in outcomes between the two agents [2,5,13]. A more recent study by Cothren et al. compared heparin and antiplatelet agents and found type of treatment to have no impact on the stroke or healing rate [8]. In 2016, Tso and colleagues successfully treated 75% (n = 35) of their BCVI patients with antiplatelet agents [14]. Prior to implementing the screening criteria for BCVI, 75% of our Control patients were treated with warfarin and the remaining 25% with aspirin. Following implementation of BCVI screening only 2% of patients in the Screening group received warfarin, 32% initially received heparin drip followed by conversion to an antiplatelet regimen, 36% were treated with only aspirin, 16% with only clopidogrel, and 14% were given both aspirin and clopidogrel. Based on our findings, we agree with Tso et al. and recommend use of antiplatelet over standard use of anticoagulation. Of note, no complications from heparin or antiplatelets were seen in our study. This study has all the inherent limitations associated with a singlecenter, retrospective study. Furthermore, due to the nature of a retrospective study, certain neurologic events could have occurred that were not reported. Patients were identified from the local trauma database, and all eligible patients were included in the study in order to limit selection bias. The control patients had lower mean GCS and higher ISS because no screening for BCVI was performed at that time and patient’s received treatment only if they developed symptoms. This could account for some of the differences in outcomes seen between the two groups. Low sample size limited our statistical power in analysis. 5. Conclusions The increased BCVI incidence rate and decreased stroke and mortality rate following screening implementation further support the importance of having screening criteria for blunt vascular injury following trauma. Also, use of antiplatelet therapy appears to be a safe and effective treatment modality; however, additional prospective studies are needed to determine the optimal anticoagulation regimen.
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