Natural history and nonoperative management of penetrating cerebrovascular injury.

Abstract

There is a modern precedent for nonoperative management of select penetrating cerebrovascular injuries (PCVIs); however, there is minimal data to guide management. This study assessed treatments, radiographic injury progression, and outcomes for all patients with PCVIs managed at an urban Level I trauma center from 2016 to 2021 that underwent initial nonoperative management (NOM). Fourteen patients were included. There were 11,635 trauma admissions, 378 patients with blunt cerebrovascular injury, and 18 patients with operatively-managed PCVI during this timeframe. All patients received antithrombotic therapy, but this was delayed in some due to concomitant injuries. Three patients had stroke (21%): two before antithrombotic initiation, and one with unclear timing relative to treatment. Three patients underwent endovascular interventions. On follow-up imaging, 14% had injury resolution, 36% were stable, 21% worsened, and 29% had no follow-up vascular imaging. One patient died (7%), one had a bleeding complication (7%), and no patient required delayed operative intervention. Early initiation of antithrombotic therapy, early surveillance imaging, and selective use of endovascular interventions are important for nonoperative management of PCVI.