EVALUATION AND MANAGEMENT OF BLUNT CEREBROVASCULAR INJURY: A PRACTICE MANAGEMENT GUIDELINE FROM THE EASTERN ASSOCIATION FOR THE SURGERY OF TRAUMA.

BACKGROUND: Blunt cerebrovascular injuries (BCVIs) are associated with significant morbidity and mortality. This guideline evaluates several aspects of BCVI diagnosis and management including the role of screening protocols, criteria for screening cervical spine injuries, and the use of antithrombotic therapy and endovascular stents. METHODS: Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, a taskforce of the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of currently available evidence. Four population, intervention, comparison, and outcome questions were developed to address diagnostic and therapeutic issues relevant to BCVI. RESULTS: A total of 98 articles were identified. Of these, 23 articles were selected to construct the guidelines. In these studies, the detection of BCVI increased with the use of a screening protocol vs. no screening protocol (OR 4.74, 95% CI 1.76-12.78; p = 0.002), as well as among patients with high-risk versus low-risk cervical spine injuries (OR 12.7, CI, 6.24-25.62; p = 0.003). The use of antithrombotic therapy vs. no antithrombotic therapy resulted in a decreased risk of stroke (OR 0.20, CI 0.06-0.65; p < 0.0001) and mortality (OR 0.17, CI 0.08-0.34; p < 0.0001). There was no significant difference in the risk of stroke among patients with Grade II or III injuries who underwent stenting as an adjunct to antithrombotic therapy vs. antithrombotic therapy alone (OR=1.63, CI=0.2-12.14; p = 0.63). CONCLUSIONS: We recommend using a screening protocol to identify patients at-risk for BCVI. Among patients with high-risk cervical spine injuries, we recommend screening CTA to detect BCVI. For patients with low-risk risk cervical injuries, we conditionally recommend performing a CTA to detect BCVI. We recommend the use of antithrombotic therapy in patients diagnosed with BCVI. Finally, we recommend against the routine use of endovascular stents as an adjunct to antithrombotic therapy in patients with Grade II or III BCVIs. LEVEL OF EVIDENCE: Systematic Review/Meta-analysis, level IIIStudy DesignDiagnostic test, therapeutic.