Blunt cerebrovascular injury increases risk for ischemic stroke, requires rapid response

LAS VEGAS — Aggressive screening, grading of injury and early initiation of antithrombotic therapy may reduce risk for stroke in patients with blunt cerebrovascular injury, according to a presenter at BRAINWeek 2022.

“Blunt cerebrovascular injury is a rare but serious complication following trauma,” David K. Stone, MD, PhD, a vascular neurologist and medical director of the stroke program at Sarasota Memorial Health System in Florida, said during the presentation.

Blunt cerebrovascular injury (BCVI) occurs in just 1% to 3% of patients who experience blunt force trauma and may result in carotid dissection, vertebral artery dissection and/or pseudoaneurysm formation, Stone stated.

Further, ischemic stroke may occur in up to 20% of patients with BCVI if not recognized and treated early. Untreated BCVI is associated with 30% to 40% of patients with carotid injuries and 10% to 15% of those with vertebral artery injuries.

Common causes of BCVI are motor vehicle accidents, falls, assault, sports injuries and other high-acceleration or deceleration incidents resulting in abnormal neck flexion or rotational trauma.

Aggressive and rapid screening and detection of BCVI may result in reduction of stroke incidence and provide a significant mortality benefit, Stone said.

BCVI is commonly measured through the Denver Grade-based scale based on findings from computed tomographic angiography. The scale progresses from 1 to 5, from less serious vascular injuries to most serious.

“In general, stroke risk increases with the higher the injury grade,” Stone said.

According to Stone, physicians must weigh treatment options in a risk-benefit paradigm based on the possibility of bleeding complications and progression of hemorrhage. Among suggested treatments are antiplatelet agents, which are generally well-tolerated and more easily administered, and heparin, chosen by some as an initial antithrombotic therapy due to ease of reversibility and short half-life for patients who may require surgical intervention.

Endovascular stents, Stone continued, are controversial because of lack of definitive long-term implications. Although stenting demonstrated positive early results for grade II injuries, as it can reduce risk for embolism and rupture by reducing blood flow, the practice is best reserved for cases of persistent injury with neurologic decline or high risk for neurologic decline or for enlarging injury, he added.

Based on the severity of vascular injury via the Denver Grading System, follow-up imaging for BCVI should occur no sooner than 7 to 10 days following injury and then every 3 to 6 months until the injury is healed for grades I and II injuries or based on symptoms for grades III through V injuries.

Long-term therapy for BCVI involves continued antiplatelet therapy for grades I through III until healed or surgical intervention, with grade IV requiring lifelong antiplatelet therapy.

“It’s important to remember most strokes occur within the first 3 days [after BCVI] but can occur afterwards as well,” Stone said. “Once there is vascular injury, it increases the risk for ischemic stroke.”