Bonow Robert H, Witt Cordelie E, Mosher Bryan P, Mossa-Basha Mahmud, Vavilala Monica S, Rivara Frederick P, Cuschieri Joseph, Arbabi Saman, Chesnut Randall M
1Harborview Injury Prevention Research Center, University of Washington, Seattle, WA. 2Department of Neurological Surgery, University of Washington, Seattle, WA. 3Department of Surgery, University of Washington, Seattle, WA. 4University of Washington School of Medicine, Seattle, WA. 5Department of Radiology, University of Washington, Seattle, WA. 6Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA. 7Department of Pediatrics, University of Washington, Seattle Children's Research Institute, Seattle, WA.
Crit Care Med. 2017 Oct;45(10):e1011-e1017. doi: 10.1097/CCM.0000000000002549.
To assess whether microemboli burden, assessed noninvasively by bedside transcranial Doppler ultrasonography, correlates with risk of subsequent stroke greater than 24 hours after hospital arrival among patients with blunt cerebrovascular injury. The greater than 24-hour time frame provides a window for transcranial Doppler examinations and therapeutic interventions to prevent stroke.
Retrospective cohort study.
Level I trauma center.
One thousand one hundred forty-six blunt cerebrovascular injury patients over 10 years.
None.
We identified 1,146 blunt cerebrovascular injury patients; 54 (4.7%) experienced stroke detected greater than 24 hours after arrival. Among those with isolated internal carotid artery injuries, five of nine with delayed stroke had positive transcranial Dopplers (at least one microembolus detected with transcranial Dopplers) before stroke, compared with 46 of 248 without (risk ratio, 5.05; 95% CI, 1.41-18.13). Stroke risk increased with the number of microemboli (adjusted risk ratio, 1.03/microembolus/hr; 95% CI, 1.01-1.05) and with persistently positive transcranial Dopplers over multiple days (risk ratio, 16.0; 95% CI, 2.00-127.93). Among patients who sustained an internal carotid artery injury with or without additional vessel injuries, positive transcranial Dopplers predicted stroke after adjusting for ipsilateral and contralateral internal carotid artery injury grade (adjusted risk ratio, 2.91; 95% CI, 1.42-5.97). No patients with isolated vertebral artery injuries had positive transcranial Dopplers before stroke, and positive transcranial Dopplers were not associated with delayed stroke among patients who sustained a vertebral artery injury with or without additional vessel injuries (risk ratio, 0.90; 95% CI, 0.21-3.83).
Microemboli burden is associated with higher risk of stroke due to internal carotid artery injuries, but monitoring was not useful for vertebral artery injuries.
评估对于钝性脑血管损伤患者，通过床旁经颅多普勒超声检查无创评估的微栓子负荷是否与入院24小时后发生后续卒中的风险相关。超过24小时的时间范围为经颅多普勒检查和预防卒中的治疗干预提供了一个窗口。
回顾性队列研究。
一级创伤中心。
10年间1146例钝性脑血管损伤患者。
无。
我们纳入了1146例钝性脑血管损伤患者；54例（4.7%）在入院24小时后发生卒中。在孤立性颈内动脉损伤患者中，9例延迟性卒中患者中有5例在卒中前经颅多普勒检查呈阳性（经颅多普勒检查至少检测到1个微栓子），而248例未发生延迟性卒中的患者中有46例呈阳性（风险比，5.05；95%CI，1.41 - 18.13）。卒中风险随微栓子数量增加（调整后风险比，1.03/微栓子/小时；95%CI，1.01 - 1.05）以及经颅多普勒检查连续多天持续呈阳性而增加（风险比，16.0；95%CI，2.00 - 127.93）。在伴有或不伴有其他血管损伤的颈内动脉损伤患者中，经颅多普勒检查呈阳性在调整同侧和对侧颈内动脉损伤分级后可预测卒中（调整后风险比，2.91；95%CI，1.42 - 5.97）。孤立性椎动脉损伤患者在卒中前经颅多普勒检查均未呈阳性，并且在伴有或不伴有其他血管损伤的椎动脉损伤患者中，经颅多普勒检查呈阳性与延迟性卒中无关（风险比，0.90；95%CI，0.21 - 3.83）。
微栓子负荷与颈内动脉损伤导致的卒中风险较高相关，但监测对椎动脉损伤无用。
