Multicenter Evaluation of Functional Outcomes After Blunt Cerebrovascular Injury in Severe Traumatic Brain Injury

BACKGROUND AND OBJECTIVES: Despite investigations into blunt cerebrovascular injury (BCVI) in patients with computed tomography-positive traumatic intracranial injury, BCVI's effect on long-term neurological outcomes in patients with severe traumatic brain injury (sTBI) is not well characterized. We investigated independent factors predicting functional recovery in these patients. METHODS: This retrospective cohort study included 177 patients with radiographically confirmed BCVI and sTBI (Glasgow Coma Scale score ≤8) treated from 2015 to 2024 at 2 US level 1 trauma centers. The main outcome was favorable functional recovery (Glasgow Outcome Scale-extended score = 4-8) at 30 and 180 days. Univariate analysis identified potential predictors ( P < .2), which were tested for collinearity and analyzed with stepwise multivariate logistic regression. Variables included demographics, injury details, BCVI grade, cerebrovascular interventions, antithrombotic therapy (AT), and in-hospital complications. RESULTS: In univariate analysis, favorable outcomes were linked to younger age, higher presenting Glasgow Coma Scale scores, lower Injury Severity Scores, lower Marshall scores, and AT use (all P < .05). Early AT therapy demonstrated the strongest independent association with favorable functional recovery at 30 (odds ratio 3.74, 95% CI 1.84-7.59) and 180 (odds ratio 4.20, 95% CI 1.72-10.25) days. Multiple-vessel BCVI predicted unfavorable outcome at 30 days, although this effect was diminished by 180 days. Importantly, >90% of patients demonstrated stable intracranial hemorrhage after AT initiation, and early ischemic strokes occurred predominately before therapy. Endovascular stenting, although used selectively, was associated with better long-term outcomes. In-hospital complications were strongly linked to poor recovery. CONCLUSION: In patients with concomitant sTBI and BCVI, AT, specifically antiplatelet therapy, was independently linked to better functional recovery by 6 months and carried a low risk for hemorrhage progression. Injury severity, comorbidity burden, and systemic complications were major determinants of outcome. These findings support early, carefully monitored treatment—even in the setting of sTBI—and highlight the importance of minimizing secondary complications to optimize recovery.