Blunt Cerebrovascular Injuries: Early Recognition and Stroke Prevention in the Emergency Department - Stroke EXTRA Supplement (Stroke CME) -

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Publication Date: December 2020 (Volume 22, Supplement 12)

CME Credits: 4 AMA PRA Category 1 Credits™. CME expires 12/15/2023. This course is included with an Emergency Medicine Practice subscription

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Stroke credits, subject to your state and institutional approval.

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Introduction

Blunt cerebrovascular injuries include cervical carotid dissections and vertebral artery dissections that are due to blunt trauma. Although the overall incidence is low, dissections remain a common cause of stroke in children, young adults, and trauma patients. Symptoms of dissection, such as headache, neck pain, and dizziness, are commonly seen in the emergency department, but may not be apparent in the obtunded trauma patient or may not be recognized as being due to a dissection. A missed diagnosis of cervical artery dissection can result in devastating neurologic sequelae, and emergency clinicians must act quickly to recognize this diagnosis and begin treatment as soon as possible. This supplement reviews the application of advanced screening criteria, imaging options, and antithrombotic treatment for patients with blunt cerebrovascular injuries, with a focus on reducing the occurrence of ischemic stroke.

Excerpt From This Issue

You arrive for your shift in the ED on a busy Friday night. Your first patient is a 29-year-old man who was the restrained driver in a motor vehicle crash in which he ran off the road at a high speed. He was intubated on the scene for airway protection. On examination, he has a GCS score of 6T, a large scalp laceration, symmetric pupils, and he withdraws all extremities from painful stimulation. His cardiac, pulmonary, and abdominal examinations are without significant findings, and his extremities have scattered abrasions. His initial trauma imaging includes a portable chest x-ray, a noncontrast CT of the head and cervical spine, and a CT of the abdomen/pelvis with contrast. The head CT showed a diffuse axonal injury and a temporal bone fracture. The remainder of the imaging showed no significant traumatic injuries. What else should be done at this point? What are his biggest risks right now? Is the temporal bone fracture concerning?

As you are pondering these questions, your next patient arrives. He is a healthy 42-year-old man who came to the ED due to neck pain. He was involved in a low-speed rear-end motor vehicle crash 2 days prior and felt fine, but today he developed severe pain in the left side of his neck that radiates to his left jaw. On examination, he has diffuse paraspinal tenderness that you presume to be muscle spasm, no apparent jaw abnormalities that would cause his pain, and his neurologic examination is negative. You obtain a CT of the head and cervical spine without contrast, which are both read as negative. You think there is only musculoskeletal involvement, but you keep wondering about the jaw pain. What else could this be? You give him some pain medications and decide to check on him later.