Screening for and Treatment of Blunt
Cerebrovascular Injuries Algorithm
Annotation for Point I
It has been recommended that patients receive long-term antithrombotic therapy,11,12 but the optimal drug and duration have not been studied. In the absence of documented healing of the vessel, it is reasonable to provide some treatment, as stroke has been reported as long as 14 years after injury. Coumadin was recommended in early series,11,12 but with the apparent efficacy of antiplatelet therapy in the early period, it seems that long-term antiplatelet therapy is preferable to warfarin for its safety and cost profile. Aspirin and clopidogrel have different mechanisms of action; in addition, some individuals are resistant to the effects of one or both drugs. Several studies have evaluated the safety and efficacy of dual antiplatelet therapy (aspirin combined with clopidogrel) in a number of clinical situations. Dual therapy is indicated in the setting of acute coronary syndromes and percutaneous coronary interventions, with or without stent placement. On the other hand, it is not recommended in patients who have had a stroke or transient ischemic attack, based on increased bleeding risk and the lack of benefit or increase in mortality.38 More studies are necessary to determine the risk:benefit of dual therapy in BCVI. Lifelong antiplatelet therapy is recommended if the lesion persists. Aspirin is currently the agent of choice, but newer agents with reversible effects may be preferable in the future. Platelet mapping may one day assist in choice of drug and dose.