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July 20, 2009

Treatment for Blunt Cerebrovascular Injuries: Equivalence of Anticoagulation and Antiplatelet Agents

Author Affiliations

Author Affiliations: Department of Surgery, Denver Health Medical Center and University of Colorado School of Medicine, Denver.

Arch Surg. 2009;144(7):685-690. doi:10.1001/archsurg.2009.111

Hypothesis  We hypothesize that the 2 antithrombotic treatment regimens, systemic heparin sodium vs antiplatelet agents, are equivalent for the treatment of blunt cerebrovascular injuries (BCVIs) to prevent devastating injury-related strokes.

Design  Retrospective review of a prospective database.

Setting  Level I trauma center.

Patients  Patients with BCVIs from January 1, 1997, to January 1, 2007.

Main Outcome Measures  Incidence of cerebrovascular accident (CVA), stratified by treatment.

Results  During the study period, 422 BCVIs were identified in 301 patients (64.8% men; mean [SEM] age, 37.0 [0.8] years; mean [SEM] injury severity score, 27.0 [0.9]). A total of 22 patients presented with neurologic ischemia, and 5 patients sustained CVAs after embolization and/or stenting of an injury. Treatment was initiated for 282 asymptomatic BCVIs (heparin, 192; aspirin, 67; aspirin and/or clopidogrel, 23); 1 patient had a CVA (0.5%). Of 107 patients with untreated, asymptomatic BCVIs, 23 (21.5%) had a CVA. For untreated patients sustaining BCVI-related CVAs, the mean (SEM) time to diagnosis was 58 (10) hours. For those who did not exhibit symptoms within 2 hours of injury, mean time to diagnosis of CVA was 75 (11) hours. Injury healing rates (heparin, 39%; aspirin, 43%; aspirin/clopidogrel, 46%) and injury progression rates (12%; 10%; 15%) were equivalent between therapeutic regimens.

Conclusions  With an overall CVA risk of 21% and a documented latent period, comprehensive screening, early diagnosis, and institution of antithrombotic therapy for BCVI are clearly warranted. The type of treatment, heparin vs antiplatelet agents, does not appear to affect either stroke risk or injury healing rates.