Aspirin versus anticoagulation for stroke prophylaxis in blunt cerebrovascular injury: a propensity-matched retrospective cohort study

View More View Less
  • 1 Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle;
  • 2 Department of Neurological Surgery, University of Washington, Seattle, Washington;
  • 3 Department of Surgery, University of Colorado, Denver, Colorado;
  • 4 Departments of Radiology,
  • 5 Surgery,
  • 6 Anesthesiology and Pain Medicine, and
  • 7 Pediatrics, University of Washington, Seattle, Washington
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

OBJECTIVE

The goal of this study was to compare the odds of stroke 24 hours or more after hospital arrival among patients with blunt cerebrovascular injury (BCVI) who were treated with therapeutic anticoagulation versus aspirin.

METHODS

The authors conducted a retrospective cohort study at a regional level I trauma center including all patients with BCVI who were treated over a span of 10 years. Individuals with stroke on arrival or within the first 24 hours were excluded, as were those receiving alternative antithrombotic drugs or procedural treatment. Exact logistic regression was used to examine the association between treatment and stroke, adjusting for injury grade. To account for the possibility of residual confounding, propensity scores for the likelihood of receiving anticoagulation were determined and used to match patients from each treatment group; the difference in the probability of stroke between the two groups was then calculated.

RESULTS

A total of 677 patients with BCVI receiving aspirin or anticoagulation were identified. A total of 3.8% (n = 23) of 600 patients treated with aspirin sustained a stroke, compared to 11.7% (n = 9) of 77 receiving anticoagulation. After adjusting for injury grade with exact regression, anticoagulation was associated with higher likelihood of stroke (OR 3.01, 95% CI 1.00–8.21). In the propensity-matched analysis, patients who received anticoagulation had a 15.0% (95% CI 3.7%–26.3%) higher probability of sustaining a stroke compared to those receiving aspirin.

CONCLUSIONS

Therapeutic anticoagulation may be inferior to aspirin for stroke prevention in BCVI. Prospective research is warranted to definitively compare these treatment strategies.

ABBREVIATIONS BCVI = blunt cerebrovascular injury; ED = emergency department; ICA = internal carotid artery; ISS = Injury Severity Score; TCD = transcranial Doppler; VA = vertebral artery.

Supplementary Materials

    • Supplemental Figure and Table (PDF 313 KB)

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Correspondence Robert H. Bonow: University of Washington, Seattle, WA. rbonow@uw.edu.

INCLUDE WHEN CITING Published online March 26, 2021; DOI: 10.3171/2020.10.JNS201836.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Bonow RH, Witt CE, Mosher BP, . Transcranial Doppler microemboli monitoring for stroke risk stratification in blunt cerebrovascular injury. Crit Care Med. 2017;45(10):e1011e1017.

    • Search Google Scholar
    • Export Citation
  • 2

    Stein DM, Boswell S, Sliker CW, . Blunt cerebrovascular injuries: does treatment always matter?. J Trauma. 2009;66(1):132144.

  • 3

    Cogbill TH, Moore EE, Meissner M, . The spectrum of blunt injury to the carotid artery: a multicenter perspective. J Trauma. 1994;37(3):473479.

    • Search Google Scholar
    • Export Citation
  • 4

    Stein SC, Levine JM, Nagpal S, LeRoux PD. Vasospasm as the sole cause of cerebral ischemia: how strong is the evidence?. Neurosurg Focus. 2006;21(3):E2.

    • Search Google Scholar
    • Export Citation
  • 5

    Eastman AL, Muraliraj V, Sperry JL, Minei JP. CTA-based screening reduces time to diagnosis and stroke rate in blunt cervical vascular injury. J Trauma. 2009;67(3):551556.

    • Search Google Scholar
    • Export Citation
  • 6

    Scott WW, Sharp S, Figueroa SA, . Clinical and radiographic outcomes following traumatic Grade 3 and 4 carotid artery injuries: a 10-year retrospective analysis from a Level 1 trauma center. The Parkland Carotid and Vertebral Artery Injury Survey. J Neurosurg. 2015;122(3):610615.

    • Search Google Scholar
    • Export Citation
  • 7

    Scott WW, Sharp S, Figueroa SA, . Clinical and radiological outcomes following traumatic Grade 3 and 4 vertebral artery injuries: a 10-year retrospective analysis from a Level I trauma center. The Parkland Carotid and Vertebral Artery Injury Survey. J Neurosurg. 2015;122(5):12021207.

    • Search Google Scholar
    • Export Citation
  • 8

    Burlew CC, Sumislawski JJ, Behnfield CD, . Time to stroke: a Western Trauma Association multicenter study of blunt cerebrovascular injuries. J Trauma Acute Care Surg. 2018;85(5):858866.

    • Search Google Scholar
    • Export Citation
  • 9

    Tso MK, Lee MM, Ball CG, . Clinical utility of a screening protocol for blunt cerebrovascular injury using computed tomography angiography. J Neurosurg. 2017;126(4):10331041.

    • Search Google Scholar
    • Export Citation
  • 10

    Miller PR, Fabian TC, Croce MA, . Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Ann Surg. 2002;236(3):386395.

    • Search Google Scholar
    • Export Citation
  • 11

    Biffl WL, Cothren CC, Moore EE, . Western Trauma Association critical decisions in trauma: screening for and treatment of blunt cerebrovascular injuries. J Trauma. 2009;67(6):11501153.

    • Search Google Scholar
    • Export Citation
  • 12

    Biffl WL, Moore EE, Ryu RK, . The unrecognized epidemic of blunt carotid arterial injuries: early diagnosis improves neurologic outcome. Ann Surg. 1998;228(4):462470.

    • Search Google Scholar
    • Export Citation
  • 13

    Miller PR, Fabian TC, Bee TK, . Blunt cerebrovascular injuries: diagnosis and treatment. J Trauma. 2001;51(2):279286.

  • 14

    Cothren CC, Moore EE, Biffl WL, . Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg. 2004;139(5):540546.

    • Search Google Scholar
    • Export Citation
  • 15

    Biffl WL, Ray CE Jr, Moore EE, . Treatment-related outcomes from blunt cerebrovascular injuries: importance of routine follow-up arteriography. Ann Surg. 2002;235(5):699707.

    • Search Google Scholar
    • Export Citation
  • 16

    Morton RP, Levitt MR, Emerson S, . Natural history and management of blunt traumatic pseudoaneurysms of the internal carotid artery: the Harborview algorithm based off a 10-year experience. Ann Surg. 2016;263(4):821826.

    • Search Google Scholar
    • Export Citation
  • 17

    Morton RP, Hanak BW, Levitt MR, . Blunt traumatic occlusion of the internal carotid and vertebral arteries. J Neurosurg. 2014;120(6):14461450.

    • Search Google Scholar
    • Export Citation
  • 18

    Griessenauer CJ, Fleming JB, Richards BF, . Timing and mechanism of ischemic stroke due to extracranial blunt traumatic cerebrovascular injury. J Neurosurg. 2013;118(2):397404.

    • Search Google Scholar
    • Export Citation
  • 19

    Catapano JS, Israr S, Whiting AC, . Management of extracranial blunt cerebrovascular injuries: experience with an aspirin-based approach. World Neurosurg. 2020;133:e385e390.

    • Search Google Scholar
    • Export Citation
  • 20

    Harrigan MR, Weinberg JA, Peaks Y-S, . Management of blunt extracranial traumatic cerebrovascular injury: a multidisciplinary survey of current practice. World J Emerg Surg. 2011;6(1):1117.

    • Search Google Scholar
    • Export Citation
  • 21

    Bromberg WJ, Collier BC, Diebel LN, . Blunt cerebrovascular injury practice management guidelines: the Eastern Association for the Surgery of Trauma. J Trauma. 2010;68(2):471477.

    • Search Google Scholar
    • Export Citation
  • 22

    Cothren CC, Biffl WL, Moore EE, . Treatment for blunt cerebrovascular injuries: equivalence of anticoagulation and antiplatelet agents. Arch Surg. 2009;144(7):685690.

    • Search Google Scholar
    • Export Citation
  • 23

    Burlew CC, Biffl WL, Moore EE, . Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis. J Trauma Acute Care Surg. 2012;72(2):330337,539.

    • Search Google Scholar
    • Export Citation
  • 24

    American College of Surgeons. ACS NTDB National Trauma Data Standard: Data Dictionary. 2015 Admissions. July 2015. Accessed November 20, 2020. https://www.facs.org/-/media/files/quality-programs/trauma/ntdb/ntds/data-dictionaries/ntds-data-dictionary-2015.ashx

    • Search Google Scholar
    • Export Citation
  • 25

    Biffl WL, Moore EE, Offner PJ, . Blunt carotid arterial injuries: implications of a new grading scale. J Trauma. 1999;47(5):845853.

  • 26

    Lyrer P, Engelter S. Antithrombotic drugs for carotid artery dissection. Cochrane Database Syst Rev. 2010;(10):CD000255.

  • 27

    Markus HS, Hayter E, Levi C, . Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial. Lancet Neurol. 2015;14(4):361367.

    • Search Google Scholar
    • Export Citation
  • 28

    Koupenova M, Kehrel BE, Corkrey HA, Freedman JE. Thrombosis and platelets: an update. Eur Heart J. 2017;38(11):785791.

  • 29

    Shahan CP, Magnotti LJ, McBeth PB, . Early antithrombotic therapy is safe and effective in patients with blunt cerebrovascular injury and solid organ injury or traumatic brain injury. J Trauma Acute Care Surg. 2016;81(1):173177.

    • Search Google Scholar
    • Export Citation
  • 30

    Callcut RA, Hanseman DJ, Solan PD, . Early treatment of blunt cerebrovascular injury with concomitant hemorrhagic neurologic injury is safe and effective. J Trauma Acute Care Surg. 2012;72(2):338346.

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 1375 1375 1375
Full Text Views 197 197 197
PDF Downloads 101 101 101
EPUB Downloads 0 0 0