Antithrombotic therapy and outcomes of cervical arterial dissection in the trauma patient: a case series
Tóm tắt
The use of antithrombotic therapy (anticoagulants and/or antiplatelets) in the setting of traumatic cervical arterial dissection (CAD) for the prevention of stroke remains controversial. This issue is further complicated by the frequent co-existence of intracranial hemorrhage (ICH) and other intracranial injuries, and also the wide variability in treatment due to a lack of evidence-based guidance. To address these controversies, a registry in a major Level I trauma center was created. The purpose of this investigation was to compare the safety of antithrombotic therapy in post-traumatic CAD. Analysis from the first year is presented. All cervical dissections from the year 2005 were identified in patients at least 18 years of age by diagnosis code from radiology and trauma databases. Presence of arterial injury and grade, and other intracranial disease or injury such as stroke was diagnosed by a trauma radiologist and adjudicated by a neuroradiologist. Fifty-five patients with cervical artery dissection were identified. Fourteen patients presented with a total of 20 acute, post-traumatic intracranial hemorrhages (ICH). Seven of the 14 patients with ICH were treated with antithrombotic therapy, and none extended their intracranial hemorrhages. Of the 41 patients without pre-existing ICH, 28 were treated with antithrombotic therapy and only one developed an interval hematoma. Among all 55 cases, two patients developed an acute ischemic stroke in the territory of the dissected artery after admission; both patients were in the untreated group. In so far as antithrombotic therapy may offer benefit in preventing early ischemic stroke following cervical artery dissection, these data suggest withholding antiplatelet or other antithrombotics following trauma may not be warranted, even in the setting of intracranial hemorrhage. From a safety perspective, this registry-based case series indicates antithrombotic management of arterial injury did not contribute to development or progression of ICH, even in patients with pre-existing ICH. This data suggest that instituting early antithrombotic therapy presents a low risk of ICH or hemorrhage extension among traumatic cervical dissection patients.
Tài liệu tham khảo
Lee JS, Yong SW, Bang OY, Shin YS, Kim BM, Kim SY: Comparison of spontaneous intracranial vertebral artery dissection with large artery disease. Arch Neurol. 2006, 63: 1738-1744. 10.1001/archneur.63.12.1738.
Engelter ST, Lyrer PA, Kirsch EC, Steck AJ: Long-term follow-up after extracranial internal carotid artery dissection. Eur Neurol. 2000, 44: 199-204. 10.1159/000008236.
Bogousslavsky J, Pierre P: Ischemic stroke in patients under age 45. Neurol Clin. 1992, 10: 113-124.
Lyrer P, Engelter S: Antithrombotic drugs for carotid artery dissection. Stroke. 2004, 35: 613-614. 10.1161/01.STR.0000112970.63735.FC.
Bok AP, Peter JC: Carotid and vertebral artery occlusion after blunt cervical injury: the role of MR angiography in early diagnosis. J Trauma. 1996, 40: 968-972. 10.1097/00005373-199606000-00017.
Fabian TC, Patton JH, Croce MA, Minard G, Kudsk KA, Pritchard FE: Blunt carotid injury. Importance of early diagnosis and anticoagulant therapy. Ann Surg. 1996, 223: 513-522. 10.1097/00000658-199605000-00007. discussion 522-515
Scheid R, Zimmer C, Schroeter ML, Ballaschke O, von Cramon DY: The clinical spectrum of blunt cerebrovascular injury. Neurologist. 2006, 12: 255-262. 10.1097/01.nrl.0000243977.17242.ab.
Huang YC, Chen YF, Wang YH, Tu YK, Jeng JS, Liu HM: Cervicocranial arterial dissection: experience of 73 patients in a single center. Surg Neurol. 2009, 72 (Suppl 2): S20-7. 10.1016/j.surneu.2008.10.002. discussion S27
Dziewas R, Konrad C, Drager B, Evers S, Besselmann M, Lüdemann P, Kuhlenbäumer G, Stögbauer F, Ringelstein EB: Cervical artery dissection--clinical features, risk factors, therapy and outcome in 126 patients. J Neurol. 2003, 250: 1179-1184. 10.1007/s00415-003-0174-5.
Lee VH, Brown RD, Mandrekar JN, Mokri B: Incidence and outcome of cervical artery dissection: a population-based study. Neurology. 2006, 67: 1809-1812. 10.1212/01.wnl.0000244486.30455.71.
Redekop GJ: Extracranial carotid and vertebral artery dissection: a review. Can J Neurol Sci. 2008, 35: 146-152.
Biousse V, D'Anglejan-Chatillon J, Touboul PJ, Amarenco P, Bousser MG: Time course of symptoms in extracranial carotid artery dissections. A series of 80 patients. Stroke. 1995, 26: 235-239.
Arauz A, Hoyos L, Espinoza C, Cantu C, Barinagarrementeria F, Roman G: Dissection of cervical arteries: Long-term follow-up study of 130 consecutive cases. Cerebrovasc Dis. 2006, 22: 150-154. 10.1159/000093244.
Jennett B, Bond M: Assessment of outcome after severe brain damage. Lancet. 1975, 1: 480-484. 10.1016/S0140-6736(75)92830-5.
Cothren CC, Moore EE, Biffl WL, Ciesla DJ, Ray CE, Johnson JL, Moore JB, Burch JM: Anticoagulation is the gold standard for blunt carotid injuries to reduce stroke rate. Arch Surg. 2004, 139 (5): 540-5. 10.1001/archsurg.139.5.540. discussion 545-6