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Time to stroke

A Western Trauma Association multicenter study of blunt cerebrovascular injuries

Burlew, Clay Cothren MD; Sumislawski, Joshua J. MD; Behnfield, Charles D. MD; McNutt, Michelle K. MD; McCarthy, James MD; Sharpe, John P. MD; Croce, Martin A. MD; Bala, Miklosh MD; Kashuk, Jeffry MD; Spalding, M. Chance DO, PhD; Beery, Paul R. MD; John, Scott MD; Hunt, Darren J. MD; Harmon, Laura MD; Stein, Deborah M. MD, MPH; Callcut, Rachael MD, MSPH; Wybourn, Chris MD; Sperry, Jason MD; Anto, Vincent; Dunn, Julie MD; Veith, Jacob P. MD; Brown, Carlos V. R. MD; Celii, Amanda MD; Zander, Tyler L.; Coimbra, Raul MD, PhD; Berndtson, Allison E. MD; Moss, Tovah Z. MD; Malhotra, Ajai K. MD; Hazelton, Joshua P. DO; Linden, Kimberly MD; West, Michaela MD, PhD; Alam, Hasan B. MD; Williams, Aaron M. MD; Kim, Jennie MD; Inaba, Kenji MD; Moulton, Steve MD; Choi, Young Mee MBBS, MPH; Warren, Harry L. MD; Collier, Bryan DO; Ball, Chad G. MD; Savage, Stephanie MD; Hartwell, Jennifer L. MD; Cullinane, Daniel C. MD; Zielinski, Martin D. MD; Ray-Zack, Mohamed D. MBBS; Morse, Bryan C. MS, MD; Rhee, Peter MD; Rutherford, Edmund J. MD; Udekwu, Pascal MBBS, MBA, MHA; Reynolds, Cassandra MD; Toschlog, Eric MD; Gondek, Steve MD; Ju, Tammy MD; Haan, James M. MD; Lightwine, Kelly L. MPH; Kulvatunyou, Narong MD; Coates, Brian DO; Khouqeer, Ahmed F. MD; Todd, S. Rob MD; Zarzaur, Ben MD; Waller, Christine J. MD; Kallies, Kara J. MS; Neideen, Todd; Eddine, Savo Bou Zein MD; Peck, Kimberly A. MD; Dunne, Casey E. MPH; Kramer, Kristina MD; Bokhari, Faran MD; Dhillon, Tejveer S. MD, MAS; Galante, Joseph M. MD; Cohen, Mitchell J. MD

Journal of Trauma and Acute Care Surgery: November 2018 - Volume 85 - Issue 5 - p 858–866
doi: 10.1097/TA.0000000000001989
Editor's Choice

BACKGROUND Screening for blunt cerebrovascular injuries (BCVIs) in asymptomatic high-risk patients has become routine. To date, the length of this asymptomatic period has not been defined. Determining the time to stroke could impact therapy including earlier initiation of antithrombotics in multiply injured patients. The purpose of this study was to determine the time to stroke in patients with a BCVI-related stroke. We hypothesized that the majority of patients suffer stroke between 24 hours and 72 hours after injury.

METHODS Patients with a BCVI-related stroke from January 2007 to January 2017 from 37 trauma centers were reviewed.

RESULTS During the 10-year study, 492 patients had a BCVI-related stroke; the majority were men (61%), with a median age of 39 years and ISS of 29. Stroke was present at admission in 182 patients (37%) and occurred during an Interventional Radiology procedure in six patients. In the remaining 304 patients, stroke was identified a median of 48 hours after admission: 53 hours in the 144 patients identified by neurologic symptoms and 42 hours in the 160 patients without a neurologic examination and an incidental stroke identified on imaging. Of those patients with neurologic symptoms, 88 (61%) had a stroke within 72 hours, whereas 56 had a stroke after 72 hours; there was a sequential decline in stroke occurrence over the first week. Of the 304 patients who had a stroke after admission, 64 patients (22%) were being treated with antithrombotics when the stroke occurred.

CONCLUSIONS The majority of patients suffer BCVI-related stroke in the first 72 hours after injury. Time to stroke can help inform clinicians about initiation of treatment in the multiply injured patient.

LEVEL OF EVIDENCE Prognostic/Epidemiologic, level III.

From the Department of Surgery (C.C.B., J.J.S., C.D.B., M.J.C.), Denver Health Medical Center, Denver, Colorado; Department of Surgery (M.K.M., J.M.), McGovern Medical School, University of Texas Health Science Center, Houston, Texas; Department of Surgery (J.P.S., M.A.C.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.B., J.K.), Hadassah Hebrew University Medical Center, Jerusalem, Israel; Department of Surgery (M.B., J.K.), Assia Medical Group/Tel Aviv University School of Medicine, Tel Aviv, Israel; Department of Surgery (M.C.S., P.R.B.), Grant Medical Center, Columbus, Ohio; Department of Surgery (S.J., D.J.H.), Erlanger Health System, Chattanooga, Utah; Department of Surgery (L.H., D.M.S.), R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery (R.C., C.W.), University of California, San Francisco, San Francisco, California; Department of Surgery (J.S., V.A.), University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery (J.D.), University of Colorado Health North Medical Center of the Rockies, Loveland, Colorado; Department of Surgery (J.P.V., C.V.R.B.), Dell Medical School, University of Texas at Austin, Austin, Texas; Department of Surgery (A.C., T.L.Z.), Oklahoma University Health Science Center, Oklahoma City, Oklahoma; Department of Surgery (R.C., A.E.B.), University of California, San Diego, La Jolla, California; Department of Surgery (T.Z.M., A.K.M.), University of Vermont Medical Center, Burlington, Vermont; Department of Surgery (J.P.H., K.L.), Cooper University Hospital, Camden, New Jersey; Department of Surgery (M.W.), North Memorial Health, Robbinsdale, Minnesota; Department of Surgery (H.B.A., A.M.W.), University of Michigan, Ann Arbor, Michigan; Department of Surgery (J.K., K.I.), University of Southern California, Los Angeles, California; Department of Surgery (S.M., Y.M.C.), Children's Hospital Colorado, Aurora, Colorado; Department of Surgery (H.L.W., B.C.), Virginia Tech Carilion School of Medicine, Roanoke, Virginia; Department of Surgery (C.G.D.), University of Calgary, Calgary, Alberta, Canada; Department of Surgery (S.S., J.L.H.), Indiana University School of Medicine, Indianapolis, Indiana; Department of Surgery (D.C.C.), Marshfield Clinic, University of Wisconsin School of Medicine, Madison, Wisconsin; Department of Surgery (M.D.Z., M.D.R.-Z.), Mayo Clinic, Rochester, Minnesota; Department of Surgery (B.C.M.), Grady Memorial Hospital, Chickasha Oklahoma; Department of Surgery (E.J.R., P.U.), WakeMed Health & Hospitals, Raleigh, North Carolina; Department of Surgery (C.R., E.T.), East Carolina University, Greenville, North Carolina; Department of Surgery (S.G., T.J.), George Washington University Hospital, Washington, District of Columbia; Department of Surgery (J.M.H., K.L.L.), Via Christi Hospital, Wichita, Kansas; Department of Surgery (N.K., B.C.), Banner-University of Arizona Tucson, Tucson, Arizona; Department of Surgery (A.F.K., S.R.T.), Baylor College of Medicine/Ben Taub Hospital, Houston, Texas; Department of Surgery (B.Z.), Eskenazi Health, Indianapolis, Indiana; Department of Surgery (C.J.W., K.J.K.), Gundersen Health System, La Crosse, Wisconsin; Department of Surgery (T.N., S.B.Z.E.), Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Surgery (K.A.P., C.E.D.), Scripps Mercy Hospital, San Diego, California; Department of Surgery (K.K., F.B.), John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois; Department of Surgery (T.S.D., J.M.G.), and University of California, Davis, Davis, California.

Submitted: February 16, 2018, Revised: May 4, 2018, Accepted: May 12, 2018, Published online: May 30, 2018.

Address for reprints: Clay Cothren Burlew, MD, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock St, MC 0206, Denver, CO 80204; email:

© 2018 Lippincott Williams & Wilkins, Inc.