Management of simultaneous traumatic brain injury and aortic injury

Clinical article

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Object

Simultaneous traumatic brain injury (TBI) and aortic injury has been considered unsurvivable for many years because treatments such as sedation and blood pressure goals conflict for these 2 conditions. Additionally, surgical interventions for aortic injury often require full anticoagulation, which is contraindicated in patients with TBI. For these reasons, and due to the relative rarity of aortic injury/TBI, little data are available to guide treating physicians.

Methods

A retrospective review was performed on all simultaneous TBI and aortic injury cases from 2000 to 2012 at a university-affiliated, Level I trauma center. Patient demographics, imaging studies, interventions, and outcomes were analyzed. Traumatic brain injury/aortic injury cases treated with endovascular stenting were specifically studied to determine trends in procedure timing, use of anticoagulation, and neurological outcome.

Results

Thirty-three patients with concurrent TBI and aortic injury were identified over a 12-year period. The median patient age was 44 years (range 16–86 years) and the overall mortality rate after imaging diagnosis was 46%. All surviving patients were awake and neurologically functional at discharge, and 83% were discharged home or to rehabilitation facilities. Patients who died had a higher Injury Severity Scale score (p = 0.006). Severe TBI (p = 0.045) or hemodynamic instability (p = 0.015) upon arrival to the hospital was also correlated with increased mortality rates. Thirty-three percent of aortic injury/TBI patients (n = 11) underwent endovascular stenting, and 7 of these patients received intravenous anticoagulation therapy at the time of surgery. Six of these 7 anticoagulation-treated patients experienced no significant progression on postoperative brain CT, whereas 1 patient died of hemodynamic instability prior to undergoing further imaging.

Conclusions

Simultaneous TBI and aortic injury is a rare condition with a historically poor prognosis. However, these results suggest that many patients can survive with a good quality of life. Technological advances such as endovascular aortic stenting may improve patient outcome, and anticoagulation is not absolutely contraindicated after TBI.

Abbreviations used in this paper:GCS = Glasgow Coma Scale; ISS = Injury Severity Scale; SAH = subarachnoid hemorrhage; SDH = subdural hematoma; TBI = traumatic brain injury.

Article Information

Address correspondence to: M. Ross Bullock, M.D., Ph.D., Department of Neurosurgery, University of Miami Miller School of Medicine, Lois Pope LIFE Center, 1095 NW 14th Terrace, Miami, FL 33136. email: rbullock@med.miami.edu.

Please include this information when citing this paper: published online June 14, 2013; DOI: 10.3171/2013.5.JNS1397.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Axial CT scans demonstrating intracerebral hemorrhage and SAH (left) and aortic injury (right) with extravasation of contrast (arrow, right). The patient was taken for endovascular aortic surgery on the day of injury and received 4000 units of intravenous heparin during the procedure. The patient did not have any significant progression of the intracranial lesions postoperatively.

  • View in gallery

    Flowchart illustrating our procedure for treating patients with aortic injury/TBI. Although an individualized treatment plan is necessary, we have successfully treated patients using this management strategy. AI = aortic injury; DVT = deep venous thrombosis; OR = operating room.

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