Existence of knowledge silos in the adult blunt cerebrovascular injury literature

BackgroundBlunt cerebrovascular injuries (BCVI) remain a significant source of disability and mortality among trauma patients. The purpose of the present study was to determine whether knowledge silos exist in the overall BCVI literature.MethodsAn object-oriented programmatic script written in Python programming language was used to extract and categorize articles and references on the topic of BCVI. Additionally, each BCVI article was searched for by digital object identifier in the other BCVI references to build a network analysis and visualize topic reference patterns. Analyses were performed using Stata V.14.2 (StataCorp).ResultsA total of 306 articles with 10 282 references were included for analysis. Of these, 24% (74) were published in neurosurgery journals, 45% (137) were published in trauma journals, and 31% (95) were published in a journal of another specialty. Similar proportions were found when categorized by author departmental affiliation. Trauma surgery authors disproportionately referenced articles in the trauma literature, compared with neurosurgeons (73.5% vs. 48.0%, p<0.0001), and other authors. The biggest factor influencing reference proportions was the specialty of the publishing journal. Finally, a network analysis revealed that there are more trauma BCVI articles, and there are more frequently cited trauma BCVI articles by all specialties.ConclusionsThis study revealed the existence of a one-way knowledge silo in the BCVI literature. However, a robust preference by both trauma and neurosurgery to cite trauma references when publishing in trauma journals may indicate a possible conscious curating of citations by authors to increase the likelihood of publication. These observations highlight the need for an active role by journal editors, peer reviewers, and authors to actively foster diversity of citations and cross-specialty collaboration to improve dissemination of information between these specialties.Level of evidenceLevel IV. Observational study.

Abstract 1122‐000114: Blunt Traumatic Vertebral Artery Injury: Incidence, Treatment, and Outcomes

Introduction : Blunt cerebrovascular injury (BCVI) refers to any injury to the carotid or vertebral arteries sustained via blunt trauma. Computed tomographic angiography (CTA) has become a standard and widely available screening tool for BCVI, often allowing injuries to be detected on admission. Prior research has shown that BCVI is associated with subsequent stroke. Treatment protocols vary by institution, and the optimal treatment method for these injuries is not standardized. Methods : This research was approved by the IRB. All patients presenting to a level 1 trauma center from 2011 to 2018 were screened for inclusion using the Primordial Database imaging report search tool (San Mateo, CA). All included patients underwent CTA within 24 hours of presentation. Patients were excluded if they had penetrating injury, age <16 years, or concomitant carotid injury. Data was retrospectively collected. Injuries were graded according to the criteria of Biffl et al. Treatment and follow up imaging of BCVI was determined by the vascular neurosurgeon on call. Results : A total of 2819 patients underwent screening CTA, with 156 patients (5.5%) identified with isolated vertebral artery injuries. Sixteen patients (10%) had bilateral vertebral artery injuries, for a total of 172 injured vertebral arteries. There was a male predominance (n = 97, 62%). Ninety‐two patients (59%) had a cervical spine fracture at the level of injury. Three posterior circulation strokes were detected, all within 24 hours of admission, prior to starting any treatment. Treatment regimens included aspirin (n = 135 vessels), clopidigrel (n = 1), anticoagulation (n = 2), or no treatment (n = 18). Follow up imaging was available for 84 patients (98 arteries). Three patients had worsening Biffl grade on follow‐up CTA, and the remainder were stable or improved. The three worsened injuries were all grade 2 on initial presentation. Conclusions : In our patient population, isolated blunt vertebral artery injuries were treated with multiple regimens. The majority of patients in our group were treated with aspirin; no strokes were detected after the initiation of therapy, regardless of the treatment modality or the fate of the injured. Our study is not randomized and the treatment groups are not evenly distributed. Further investigation is required to address the optimal method and duration of treatment for blunt vertebral artery injury. However, our data suggest that aspirin alone may be sufficient therapy for isolated vertebral artery injuries.

P.196 Antiplatelet, anticoagulant, or endovascular treatment for stroke prevention in blunt cerebrovascular injury: Retrospective review, systematic review and meta-analysis

Background: Ischemic stroke occurs following trauma-related blunt cerebrovascular injury (BCVI) in up to 20% of cases. Preventative treatment includes antiplatelets, anticoagulants, and/or endovascular treatment (ET), but the optimal choice remains unclear. The objective of this study was to compare the ischemic stroke rate between these three treatments. Methods: Following PRISMA guidelines, we queried the OVID Medline, Embase, Web of Science, and Cochrane Library databases from September 2019 to inception to identify studies reporting treatment-stratified outcomes in BCVI patients. Meta-analysis was performed to compare outcomes between the treatment groups, using odds ratios. Retrospective review of our institutional experience with BCVI outcomes was performed and added to the meta-analysis. Results: Analysis of seven comparative studies of antiplatelets (n=334) versus anticoagulation (n=325) found no significant difference in ischemic stroke rate (OR 1.27, 95%CI 0.40-3.99), but a decrease in hemorrhagic complications (OR 0.38, 95%CI 0.15-1.00). Analysis of seven comparative studies of antiplatelets/anticoagulants (n=805) versus ET (n=235) also found no significant difference in stroke rate (OR 0.71, 95%CI 0.35-1.42). Conclusions: Antiplatelets and anticoagulants were similarly effective in reducing ischemic stroke risk in BCVI, but antiplatelets were better tolerated in this trauma population. The addition of endovascular treatment did not further reduce stroke risk compared to antiplatelets or anticoagulants alone.

Blunt Cerebrovascular Injury with Severe Head Injury

Blunt Cerebrovascular Injury (BCVI) are rare and comprises of less than 1% of total head injury in our tertiary neurocenter. This leads to significant morbidity and mortality of patient. This case report is to focus on the BCVI with head injury. Because of rarity of this disease, there’s no treatment guidelines. However whatever the treatment we have is based on the experience of the surgeons/physician our case came to our Emergency Room with alleged history of lying along the road side in pool of blood .He was evaluated in peripheral hospital and he was later transferred to our center. Patient on evaluation was found to have transaction of Right ICA just distal to right Common carotid artery bifurcation. There was associated fracture of spinous process C5, C6. Probable mechanism of injury was sudden hyperextension of neck. Patient presented with delayed stroke following BCVI. He was managed with Right Decompressive hemicraniectomy and anticoagulation therapy was started for Right ICA injury. Thus early diagnosis and treatment of Blunt Cerebrovascular injury is essential in traumatic brain injury patients with risk factors for BCVI for definitive treatment of vascular injury with either stenting or surgery and thereby limiting morbidity and mortality of the patient.