VESS20 - Risk Factors for Stroke in Penetrating Cerebrovascular Injuries

Objectives: Penetrating cerebrovascular injuries (PCVI) are associated with a high incidence of mortality and neurologic events. The optimal treatment strategy of PCVI, especially when damage control measures are required, remains controversial. The aim of this study is to describe the management of PCVI and patient outcomes at a level 1 trauma center where vascular injuries are predominantly managed by trauma surgeons.

Methods: An institutional trauma registry was queried for patients with PCVI from 2011-2021. Patients with common carotid artery (CCA), internal carotid artery (ICA), or vertebral artery (VA) injuries were included for analysis while external carotid injuries were excluded. The primary outcome was postoperative in-hospital stroke. The secondary outcome was in-hospital mortality. Primary comparison was arterial repair (primary repair or interposition graft) vs ligation/embolization vs temporary intravascular shunting at the index procedure.

Results: 54 patients with PCVI were analyzed. Overall, the in-hospital stroke rate was 17% and in-hospital mortality was 26%. The stroke rates for CCA, ICA, and VA injuries were 26%, 13%, and 4%, respectively. Twenty-four patients (44%) underwent emergent interventions for PCVI (88% open, 8% endovascular, 4% hybrid). Primary repair (21%) and interposition grafting (25%) were the most common procedures. Three of 11 (27%) patients who underwent arterial repair had a postoperative stroke. Zero of 5 patients managed with arterial ligation or embolization developed postoperative stroke. Four of 5 (80%) patients who were initially managed with temporary intravascular shunting, as damage control prior to definitive repair at later operation, developed a postoperative in-hospital stroke. Compared to ligation, temporary intravascular shunting was associated with a higher risk of stroke (P=0.048). Of the 30 patients (56%) that underwent non-operative management, 1 patient with ICA occlusion and 1 patient with CCA intimal injury developed in-hospital stroke. Time to repair and repair type (open, endovascular, hybrid) were not associated with postoperative stroke.

Conclusions: Temporary intravascular shunting as a damage control strategy for arterial PCVI was associated with a high incidence of postoperative stroke. Further investigation is needed into the factors related to this finding and whether the use of temporary intravascular shunting in PCVI is an advisable strategy.