First EDition: News for and about the practice of emergency medicine
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Antithrombotics Appear Safe in BCVI with Concomitant Injuries
BY M. ALEXANDER OTTO
FRONTLINE MEDICAL NEWS
Researchers from the University of Tennessee Health Science Center, Memphis advised that antiplatelet or heparin therapy should not be withheld in patients with blunt cerebrovascular injury, even if they have concomitant traumatic brain or solid organ injuries.
With close monitoring, “initiation of early antithrombotic therapy for patients with BCVI [blunt cerebrovascular injury] and concomitant TBI [traumatic brain injury] or SOI [solid organ injury] does not increase the risk of worsening TBI or SOI above baseline.” It is safe, effective, and “should not be withheld,” the researchers concluded after a review of 119 BCVI patients with concomitant injuries.
Seventy-four (62%) had TBIs, 26 (22%) had SOIs, and 19 (16%) had both. At some institutions, antithrombotic therapy—the mainstay for BCVI to prevent secondary ischemic stroke—would have been delayed or withheld for fear of triggering hemorrhagic complications.
But at the Health Science Center in Memphis, “we have an extremely cooperative group of neurosurgeons who take BCVI as seriously as we do, and actually allow us, more often than not, to start antithrombotic therapy pretty much immediately after the injury is identified,” investigator and surgery resident Dr Charles Shahan said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
As a result, 85 patients (71%) received heparin infusions with goal-activated partial thromboplastin times of 45 to 60 seconds, and the rest antiplatelet therapy, typically 81 mg of aspirin. The center generally uses heparin for TBI patients because of its short half-life, and aspirin for others.
Antithrombosed BCVI patients did as well as did historical controls. TBIs deteriorated—meaning worsening on clinical or computed tomography exam, or delayed operative intervention—in 7% of TBI patients with BCVI, versus 10% of TBI patients without BCVI (P = .34). Three percent of SOI patients had delayed laparotomies versus 5% of SOI patients without BCVI (P = .54). None of the BCVI patients stopped antithrombotics because of complications. The results held regardless of the type of TBI, SOI, or antithrombotic used.
Overall, 11 patients (9%) had BCVI-related strokes. Without antithrombotic therapy, stroke rates in BCVI can approach 40%. “Our extremely early use of antithrombotic therapy does not appear to increase our rate of worsening of our hemorrhagic injures and also gets our stroke rate within acceptable limits,” Dr Shahan said.
Lower the CT to Check the Heart for Embolic Sources in Acute Stroke
BY M. ALEXANDER OTTO
FRONTLINE MEDICAL NEWS
When evaluating a patient with an acute ischemic stroke, enlarging the field of computed tomography angiography (CTA) to include the heart might quickly identify sources of cardiogenic emboli and other problems that could otherwise be missed, according to a small study conducted by investigators from the National University Hospital, Singapore.
Dr Leonard Yeo and colleagues recruited 20 consecutive acute ischemic stroke patients who presented within 4.5 hours of symptom onset. The mean patient age in the study was 64 years, and about 60% of the subjects were men. Patients were excluded if they had contraindications to intravenous contrast, or were unable to provide informed consent.
In addition to their usual brain CTA protocol that spanned from the arch of aorta to the circle of Willis, investigators enlarged the field of scanning to include the heart. All CTA images were read by the treating neurologist and radiologist. They found that one patient had a localized dissection in the ascending aorta, another with a ventricular thrombus, and a third with an atrial appendage blood clot. Both thrombus cases were confirmed by transesophageal echocardiography (TEE), and the patients were started on anticoagulation the next day. At 3 months, none of the patients had died, and eight (40%) had modified Rankin Scale scores of 0 to 1.
The two-phase, 64-slice nongated cardiac CTAs were done in the same sitting as the brain CTA. Doing so added only a few seconds to the scan, with no extra contrast or meaningful increase in radiation.
“Scans with 1-mm thick slices are best for screening for thrombus and structural abnormalities that cause embolism. Remarkably, [even without gating], the detail is excellent. There’s very little downside [to this, and] it maximizes your return on scans that are already a part of most acute stroke protocols,” said Dr Yeo, a neurologist at the hospital.
