Introduction: The incidence of stroke after blunt cerebrovascular injury (BCVI) varies considerably in the literature. We sought to define the acute stroke rate for the most severe form of BCVI: complete traumatic parent artery occlusion (Biffl IV).
Methods: All CT angiography reports of the head or neck from 2005-2011 at a high-volume level one trauma center were reviewed. An electronic search identified a subpopulation with complete traumatic occlusion (Biffl IV) of the vertebral artery (VA) or internal carotid artery (ICA) artery. Acute strokes were diagnosed by clinical exam (confirmed by MRI) or MRI alone.
Results: Over this 7 year period almost 1100 BCVI were seen. Of these 1100, fifty (4.5%) were complete occlusions or Biffl IV injuries. The Biffl IV category was subdivided into the following: 8 ICA, 40 unilateral VA, and 2 bilateral VA.
Six patients (75%) with ICA occlusion developed acute stroke despite treatment with aspirin (n=2), clopidogrel and aspirin (n=2), or heparin infusion (n=1). One patient with clinical brain death shortly after presentation received no treatment. Three of these five survivors required decompressive hemicraniectomy due to malignant swelling of the infarcted territory. All three of these patients had a poor outcome (mRS 3-5) at last follow up.
Three of 40 patients (7.5%) with Biffl IV vertebral injuries developed infarction, two of whom received aspirin and clopidogrel. All 3 infarctions were clinically silent.
Both patients with bilateral VA Biffl IV injuries were treated with aspirin alone. One suffered infarctions to the cerebellum and brainstem, but was already quadriplegic from a cervical spine injury. The other patient remained clinically asymptomatic.
Conclusions: Complete traumatic parent artery occlusion is rare but dangerous, with 20% developing acute stroke. While less common than VA injury, ICA occlusion was associated with a much higher rate of acute and clinically relevant stroke (75% vs 7.5%).
Patient Care: Emphasize how potentially co-morbid BCVI is, particularly the ICA injuries, and lead to discussion on how to optimally treat these patients to prevent traumatic stroke.
Learning Objectives: By the conclusion of this session, participants should be able to describe the stroke risk of the patients with Biffl IV injuries, discuss the importance of stroke prevention, and discuss possible ways to identify the higher risk patients sooner.