Impact of Continuous Evaluation of Technology and Therapy: 30 Years of Research Reduces Stroke and Mortality from Blunt Cerebrovascular Injury

• Published in: Journal of the American College of Surgeons Vol. 224; no. 4; pp. 595 - 599
• Main Authors: Shahan, Charles P., Croce, Martin A., Fabian, Timothy C., Magnotti, Louis J.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.04.2017
• Subjects: Adult; Aged; Cerebrovascular Trauma - complications; Cerebrovascular Trauma - diagnosis; Cerebrovascular Trauma - mortality; Cerebrovascular Trauma - therapy; Female; Humans; Incidence; Injury Severity Score; Male; Middle Aged; Retrospective Studies; Stroke - epidemiology; Stroke - etiology; Treatment Outcome; Wounds, Nonpenetrating - complications; Wounds, Nonpenetrating - diagnosis; Wounds, Nonpenetrating - mortality; Wounds, Nonpenetrating - therapy; CTA; DSA; BCVI
• ISSN: 1072-7515; 1879-1190
• DOI: 10.1016/j.jamcollsurg.2016.12.008

Blunt cerebrovascular injury (BCVI) was underdiagnosed until the 1990s when blunt carotid injuries were found to be more common than historically described. Technological advancements and regionalization of trauma care have resulted in increased screening and improved diagnosis of BCVI. The aim of this study was to demonstrate that systematic evaluation of the screening and diagnosis of BCVI, combined with early and aggressive treatment, have led to reductions in BCVI-related stroke and mortality. Patients with BCVI from 1985 to 2015 were identified and stratified by age, sex, and Injury Severity Score. BCVI-related stroke and mortality rates were then calculated and compared. Patients were divided into 5 eras based on changes in technology, screening, or treatment algorithms at our institution. Five hundred and sixty-four patients were diagnosed with BCVI: 508 carotid artery and 267 vertebral artery injuries. Sixty-five percent of patients were male, mean age was 41 years, and mean Injury Severity Score was 27. Incidence of BCVI diagnosis increased from 0.33% to approximately 2% of all blunt trauma (p < 0.001) during the study period. Ninety (14%) patients suffered BCVI-related stroke, with the incidence of stroke significantly decreasing over time from 37% to 5% (p < 0.001). Twenty-eight (5%) patients died as a direct result of BCVI, and BCVI-related mortality also decreased significantly over time from 24% to 0% (p < 0.001). Although increased screening has resulted in a higher incidence of injuries over time, BCVI-related stroke and mortality have decreased significantly. Continuous critical evaluation of evolving technology and diagnostic and treatment algorithms has contributed substantially to those improved outcomes. Appraisals of technological advances, preferably through prospective multi-institutional studies, should advance our understanding of these injuries and lead to even lower stroke rates.