Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes.
- 1 September 2002
- journal article
- research article
- Published by Rockefeller University Press
- Vol. 236 (3), 386-395
- https://doi.org/10.1097/01.sla.0000027174.01008.a0
Abstract
To prospectively examine outcomes associated with an aggressive screening protocol for blunt cerebrovascular injury (BCVI), and to compare the accuracy of computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) versus conventional angiography with respect to BCVI diagnosis. In the past 5 years, BCVI (carotid and vertebral arteries) has been recognized with increasing frequency. Initial studies described blunt carotid injuries and their associated morbidity, while more recent reports have established the devastating potential of blunt vertebral injuries. It has been suggested that early diagnosis and anticoagulation will improve outcomes and that less-invasive diagnostic techniques than conventional angiography are desirable for screening. However, there are neither established screening criteria nor studies comparing optimal diagnostic modalities. The screened population included all patients with cervical spine fractures, LeFort II or III facial fractures, Horner's syndrome, skull base fractures involving the foramen lacerum, neck soft tissue injury, or neurological abnormalities unexplained by intracranial injuries. Patients underwent screening with four-vessel cerebral angiography. During the first half of the study, patients also underwent helical CTA. Selected patients during this same period underwent MRA. At the time of diagnosis, anticoagulant or antiplatelet therapy was instituted unless clinically contraindicated. Results of this screening protocol were compared to a previously published cohort with cerebrovascular injuries (1995-1999) from the authors' institution. Two hundred sixteen patients were screened over a 2-year period (3.5% of all blunt trauma admissions). Angiography identified 24 patients with carotid artery injuries (CAI) and 43 patients with vertebral artery injuries (VAI) for an overall screening yield of 29%. While the incidence of CAI remained similar between the current study and the previous study group, the incidence of VAI diagnosis increased. Stroke rates in those with CAI were also similar between the two periods. The stroke rate in VAI, however, was markedly lower at 0% as compared to 14% in the previous group. Comparison of CTA and MRA with cerebral angiography in 143 patients demonstrated sensitivities of 47% and 50%, respectively, for CAI; sensitivities were 53% (CTA) and 47% (MRA) for VAI. Aggressive screening of patients with blunt head and neck trauma identified an incidence of BCVI in 1.03% of blunt admissions. Early identification, which led to early treatment, significantly reduced stroke rates in patients with VAI, but provided no outcome improvement with CAI. More encompassing screening may be required to improve outcomes for patients with CAI. However, less-invasive diagnostic techniques (CTA and MRA) are inadequate for screening. Technological advances are necessary before abandonment of conventional angiography, which remains the standard for diagnosis.This publication has 17 references indexed in Scilit:
- Liberalized Screening for Blunt Carotid and Vertebral Artery Injuries Is JustifiedJournal Of Trauma-Injury Infection and Critical Care, 2001
- Blunt Carotid Artery InjuriesJournal Of Trauma-Injury Infection and Critical Care, 1999
- Computed Tomographic Angiography as a Screening Modality for Blunt Cervical Arterial InjuriesJournal Of Trauma-Injury Infection and Critical Care, 1999
- Blunt Vascular Injuries of the Head and NeckJournal Of Trauma-Injury Infection and Critical Care, 1998
- The Unrecognized Epidemic of Blunt Carotid Arterial InjuriesAnnals of Surgery, 1998
- Carotid and Vertebral Artery Occlusion after Blunt Cervical InjuryJournal Of Trauma-Injury Infection and Critical Care, 1996
- Blunt Carotid InjuryAnnals of Surgery, 1996
- Magnetic resonance imaging and dynamic CT scan in cervical artery dissections.Stroke, 1994
- The Incidence of Vertebral Artery Injury after Midcervical Spine Fracture or SubluxationNeurosurgery, 1994
- Carotid and vertebral artery dissections: three-dimensional time-of-flight MR angiography and MR imaging versus conventional angiography.Radiology, 1994