Cothren C Clay, Moore Ernest E, Ray Charles E, Ciesla David J, Johnson Jeffrey L, Moore John B, Burch Jon M
Department of Surgery, Denver Health Medical Center and the University of Colorado Health Sciences Center, 777 Bannock St., Denver, CO 80204, USA.
Am J Surg. 2005 Dec;190(6):845-9. doi: 10.1016/j.amjsurg.2005.08.007.
Recent reports have argued that screening for blunt carotid injury is futile and have called for a cost analysis. Our data previously supported screening asymptomatic trauma patients for blunt cerebrovascular injury (BCVI) to prevent associated neurologic sequelae. Our hypothesis is that aggressive angiographic screening for BCVI based on a patient's injury pattern and symptoms allows for early diagnosis and treatment and is cost-effective because it prevents ischemic neurological events (INEs).
Beginning in January 1996, we began comprehensive screening using 4-vessel cerebrovascular angiography based on injury patterns; these patients have been followed-up prospectively. Patients without contraindications received antithrombotic therapy immediately for documented BCVI.
From January 1996 through June 2004, there were 15,767 blunt-trauma patient admissions to our state-designated level I urban trauma center, of which 727 patients underwent screening angiography. Twenty-one patients presented with signs or symptoms of neurologic ischemia before diagnosis. BCVI was identified in 244 patients (34% screening yield); the majority were men (68%) with a mean age of 35 +/- 3.7 years and mean Injury Severity Score of 28 +/- 3.8. Asymptomatic patients (n = 187) were treated (heparin in 117, low molecular-weight heparin in 11, and antiplatelet in 59); 1 patient had a stroke (0.5%). Using estimated stroke rate by grade of injury, we averted neurologic events in 32 asymptomatic patients with antithrombotic treatment. Of the 48 asymptomatic patients who did not receive adequate anticoagulation, 10 (21%) had an INE. Patients with BCVI-related neurologic events had a statistically higher percentage requiring discharge to rehabilitation facilities (50% vs. 77% for carotid artery injury [CAI]), a higher percentage requiring rehabilitation for BCVI-related stroke (0% vs. 55% for CAI), and a higher stroke-related mortality rate (0% vs. 21% for CAI and 0% vs. 17% for vertebral artery injury) than those without neurologic events.
The cost of long-term rehabilitation care and human life after BCVI-associated neurologic events is substantial. Surgeons caring for the multiply injured should screen for carotid and vertebral artery injuries in high-risk patients.
最近的报告认为，对钝性颈动脉损伤进行筛查是徒劳的，并呼吁进行成本分析。我们之前的数据支持对无症状创伤患者进行钝性脑血管损伤（BCVI）筛查，以预防相关的神经后遗症。我们的假设是，基于患者的损伤模式和症状对BCVI进行积极的血管造影筛查能够实现早期诊断和治疗，并且具有成本效益，因为它可以预防缺血性神经事件（INEs）。
从1996年1月开始，我们基于损伤模式开始使用四血管脑血管造影进行全面筛查；这些患者接受了前瞻性随访。无禁忌症的患者一旦确诊为BCVI，立即接受抗栓治疗。
从1996年1月至2004年6月，我们州指定的一级城市创伤中心共收治了15767例钝性创伤患者，其中727例患者接受了血管造影筛查。21例患者在诊断前出现神经缺血的体征或症状。244例患者被确诊为BCVI（筛查阳性率为34%）；大多数为男性（68%），平均年龄为35±3.7岁，平均损伤严重度评分为28±3.8。无症状患者（n = 187）接受了治疗（117例使用肝素，11例使用低分子肝素，59例使用抗血小板药物）；1例患者发生中风（0.5%）。通过按损伤分级估计中风发生率，我们通过抗栓治疗避免了32例无症状患者发生神经事件。在48例未接受充分抗凝治疗的无症状患者中，10例（21%）发生了INE。与无神经事件的患者相比，发生BCVI相关神经事件的患者中，需要出院到康复机构的比例在统计学上更高（50%对颈动脉损伤[CAI]的77%），因BCVI相关中风需要康复治疗的比例更高（0%对CAI的55%），中风相关死亡率更高（0%对CAI的21%以及0%对椎动脉损伤的17%）。
BCVI相关神经事件后的长期康复护理成本和生命代价巨大。治疗多发伤患者的外科医生应对高危患者筛查颈动脉和椎动脉损伤。
