List Archives

Wed Aug 17 13:19:54 BST 2005

Speaking of therapies sans evidence based support, I recently posted this on a vascular server list.

What's the consensus for anticoagulation for blunt traumatic carotid artery dissection amongst our seasoned trauma docs?

regards, Meredith

Young restrained female in high speed MVC, developing sudden dense left hemispheric paresis after admission for seemingly moderate orthopedic injuries. Repeat head CT negative; MRI /c acute MCA infarct. MRA /c abrupt cutoff of L ICA at bifurcation. Confirmatory angiography /c classic skull-base level ICA tapering to complete occlusion, no other pathology.

Neurosurgery questions my recommendation for anticoagulation, stating that there are no data to support efficacy in the case of dissection (!!)

Much to my surprise, there is in fact very, very little in the literature, and NO randomized prospective trials. Indeed, Cochrane review from 2003 advises that it's use cannot be supported based on existing data (or more precisely, the lack of existing data). Yet this concept is axiomatic in trauma and vascular surgical texts.

There ARE data which show that the majority of strokes secondary to dissection are embolic in nature, and the reasoning behind the heparin is - of course - that the formation of intralumenal thrombus is the underlying culprit addressed by anticoagulation. So, on that teleological evidence I will continue to use and recommend anticoagulation under these circumstances.

docrickfry at aol.com wrote:
...Bring back the bloodletting, the most underappreciated art in the history of medicine!
ERF 

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carotid dissection - heparin?