{
  "abstract": "Introduction Management of Biffl grade 3 pseudoaneurysms varies across institutions. Guidelines recommend conservative management for most patients, but more aggressive intervention for pseudoaneurysms deemed high risk. However, optimal criteria for conservative versus endovascular management, and the role of surveillance imaging and transcranial doppler (TCD) monitoring in risk stratification, remain unclear. We performed a retrospective analysis to characterize real-world practice patterns, identify predictors of stroke, and assess whether current surveillance strategies enable timely intervention.Methods We performed a retrospective review of 46 patients with pseudoaneurysms of the carotid or vertebral arteries at a single institution between 2021-2024. Patients presenting with concomitant pathology requiring immediate endovascular intervention (e.g. carotid cavernous fistula or extravasation) were excluded. We analyzed pseudoaneurysm size, radiographic progression, microembolic signal (MES) detected on TCD, intervention decisions (medical vs. endovascular), and stroke occurrence. Timing of TCD and progression relative to stroke events was assessed. The primary outcome was ischemic stroke. Statistical analysis included Fisher’s exact test, Wilcoxon rank-sum, logistic regression, and receiver operating characteristic (ROC) analysis to identify optimal size thresholds. Exploratory multifactorial risk stratification combined size, progression, and MES burden.Results Management Patterns: All patients were initiated on antithrombotic therapy per institutional protocol. Medical management alone was employed in 96% of patients (44/46), with 4.3% (2/46) undergoing endovascular intervention. Overall stroke rate was 13.6% (6/46), at median time to stroke 20.6 hours post-presentation.Pseudoaneurysm Progression: Radiographic progression occurred in 26% (12/46) of pseudoaneurysm patients at median 30 days post-presentation. Progression was associated with stroke, with 33% (4/12) experiencing stroke versus 6% (2/34) without progression (p=0.033). However, 75% (3/4) of strokes occurred before progression was detected on surveillance CT imaging, and no patients with progression underwent endovascular intervention (0/12).Size-Based Risk Stratification: Pseudoaneurysm size had a significant relationship with stroke risk. In logistic regression, each 1mm increase was associated with increased stroke odds (OR 1.43, 95% CI 1.01-2.10, p=0.048). ROC analysis identified an optimal threshold of 6.8mm (AUC=0.655, sensitivity 50%, specificity 89%, NPV 92%). Dichotomized analysis supported this: pseudoaneurysms ≥7mm had higher stroke rates compared to <7mm (42.9% vs. 8.3%, p=0.045). Both patients with pseudoaneurysms ≥10mm developed stroke (100%).TCD Monitoring: 61% (28/46) of patients received TCD monitoring, but often after stroke events (80% of strokes preceded TCD), limiting assessment of predictive value.Multifactorial Risk: Descriptively, patients with ≥2 of the assessed risk features (size ≥7mm, radiographic progression, positive MES burden on TCD) had 60% (3/5) stroke rate versus 0% (0/13) with no risk features (p=0.01).Conclusion Risk stratification based on progression or MES burden may be limited by timing in relation to stroke occurrence. Small pseudoaneurysms (<7mm) demonstrate high negative predictive value (92%) supporting conservative management, while larger pseudoaneurysms (≥7mm: 43% stroke) may warrant heightened surveillance or intervention consideration. These exploratory thresholds require validation. Implementation of earlier surveillance may improve risk stratification and timely intervention in high-risk patients.Disclosures P. Bi: None. M. Rager: None. D. Nistal: None. R. Bonow: None. S. Chen: None.",
  "authors": [
    {
      "affiliations": [
        "Neurosurgery, University of Washington, Seattle, WA"
      ],
      "name": "P Bi"
    },
    {
      "affiliations": [
        "Neurosurgery, University of Washington, Seattle, WA"
      ],
      "name": "M Rager"
    },
    {
      "affiliations": [
        "Neurosurgery, University of Washington, Seattle, WA"
      ],
      "name": "D Nistal"
    },
    {
      "affiliations": [
        "Neurosurgery, University of Washington, Seattle, WA"
      ],
      "name": "R Bonow"
    },
    {
      "affiliations": [
        "Neurosurgery, University of Washington, Seattle, WA"
      ],
      "name": "S Chen"
    }
  ],
  "title": "E-240 Management of pseudoaneurysms in high-grade blunt cerebrovascular injury: practice patterns and predictors of stroke",
  "uid": "6fbd0d9e-07c1-5df9-a47c-164608738c2b"
}