What is the management for a patient with a scapula fracture and carotid dissection?

Management of Scapula Fracture with Carotid Dissection

Initiate antithrombotic therapy immediately for 3-6 months with either anticoagulation (heparin followed by warfarin) or antiplatelet agents (aspirin, clopidogrel, or aspirin-dipyridamole combination), while managing the scapula fracture conservatively or surgically based on orthopedic indications, recognizing that the carotid dissection takes priority for preventing stroke. 1

Immediate Diagnostic Confirmation

• Obtain CT angiography (CTA) of the head and neck with IV contrast as the preferred initial imaging modality, which has 100% sensitivity for detecting carotid dissection and can visualize the entire vessel from aortic arch to intracranial segments. 2, 3
• Perform concurrent brain imaging (MRI or CT) to assess for acute ischemic complications, as 50-95% of patients develop cerebral or retinal ischemia after initial warning symptoms. 2
• Look specifically for dissection flap, differential flow in true and false lumens, intramural hematoma, and pseudoaneurysm formation on vascular imaging. 1

Critical Clinical Assessment

• Recognize that trauma causing scapula fracture represents significant force and should raise immediate suspicion for carotid dissection, as penetrating trauma and blunt cervical trauma are established risk factors. 1
• Assess for warning signs including ipsilateral headache or neck pain, Horner syndrome (ptosis, miosis, anhidrosis), and any focal neurological deficits suggesting stroke or TIA. 1
• Document any sudden or excessive neck movement at time of injury, as hyperflexion/hyperextension mechanisms increase dissection risk. 2

Antithrombotic Management (Primary Treatment)

The American Heart Association/American Stroke Association provides Class IIa recommendation for antithrombotic treatment for at least 3-6 months in patients with carotid dissection associated with ischemic stroke or TIA. 1

Anticoagulation Option:

• Start with unfractionated heparin IV at initial dose of 5,000 units IV bolus followed by continuous infusion of 20,000-40,000 units/24 hours, adjusting to maintain aPTT 1.5-2.5 times control. 4
• Transition to warfarin with target INR 2.0-3.0, continuing full heparin therapy until INR reaches stable therapeutic range for several days before discontinuing heparin. 4, 5
• Continue anticoagulation for 3-6 months, then transition to antiplatelet therapy once symptoms resolve. 1

Antiplatelet Option:

• Aspirin monotherapy, clopidogrel monotherapy, or combination extended-release dipyridamole plus aspirin are reasonable alternatives. 1
• This option may be preferred if the scapula fracture requires surgical fixation, as anticoagulation significantly increases bleeding risk in orthopedic procedures. 1

Orthopedic Management Considerations

• Coordinate timing of scapula fracture surgery with antithrombotic therapy, recognizing that potent antiplatelet drugs like clopidogrel increase surgical bleeding risk but delaying therapy raises stroke risk. 1
• If urgent scapula fixation is required, consider antiplatelet therapy over anticoagulation to minimize perioperative hemorrhage while maintaining stroke prevention. 1
• For non-displaced or minimally displaced scapula fractures managed conservatively, anticoagulation can be initiated without surgical bleeding concerns. 1

Monitoring and Follow-up

• Perform serial neurological examinations to detect any progression of ischemic symptoms. 1
• Monitor for hemorrhagic complications of anticoagulation, including checking platelet counts, hematocrit, and occult blood in stool throughout treatment. 4
• Obtain repeat vascular imaging at 3-6 months to assess vessel healing and guide duration of antithrombotic therapy. 1

Escalation Criteria

Reserve surgical or endovascular revascularization exclusively for patients with persistent or recurrent ischemic symptoms despite optimal antithrombotic therapy. 1

• Carotid angioplasty and stenting might be considered when ischemic neurological symptoms have not responded to antithrombotic therapy (Class IIb recommendation). 1
• Endovascular intervention has shown safety and efficacy in selected high-risk patients with recurrent TIAs or contraindications to anticoagulation. 6

Critical Pitfalls to Avoid

• Do not delay antithrombotic therapy while awaiting orthopedic consultation, as stroke prevention takes priority and the window for preventing ischemic complications is narrow. 1
• Avoid assuming the scapula fracture is the only significant injury—high-energy trauma causing scapula fractures frequently involves multiple vascular injuries including bilateral dissections. 7
• Do not use highly concentrated heparin vials (10,000 units/mL) without careful verification, as fatal medication errors have occurred. 4
• Recognize that the prognosis with appropriate antithrombotic treatment is usually favorable, but untreated dissection carries 50-95% risk of cerebral or retinal ischemia. 1, 2