Blunt cerebrovascular injuries in acute trauma care: a screening protocol

Abstract

Introduction Blunt cerebrovascular injuries (BCVI) of the extra-or intracerebral vessels are frequently observed lesions which may lead to thrombembolic events with focal neurological deficits, stroke or death particularly in patients \60 years. However, a comprehensive standardised clinical algorithm for screening and management of these secondary injuries is still lacking. Materials and methods We developed a standardised screening protocol applicable for mild as well as severely injured patients. In this prospective cohort study, we evaluated the feasibility of this diagnostic algorithm in a level 1 trauma centre setting. Trauma patients who met the inclusion criteria underwent a computed tomographic angiography (CTA) as part of standard diagnostic procedure at admission. All suspicions or positive findings were reevaluated by a conventional four-vessel catheter angiography within the first 72 h after trauma. Within this period, anticoagulation with low-dose heparin was started. BCVI confirmation indicated a shift to systemic heparinisation with overlapping phenprocoumon therapy for at least 6 months. All patients were reevaluated after 6 months by another four-vessel angiography. Depending on the diagnostic findings, oral anticoagulation may be discontinued or continued for another 6 months.Results A total of 44 patients (8 male, 6 female, age range 19-95 years) were included in the study. 20 BCVIs were detected in 16 patients (36.3%). The most common injuries identified were Biffl Type II (40%) and Type IV lesions (30%). 86.4% of the patients received a CTA upon admission, 93.2% of which were conducted within 12 h posttrauma. None of the patients had a secondary thrombembolic neurological event during the hospital stay or within 3 months postdischarge. Conclusion Our results indicate that implementation of the screening protocol can prevent strokes in patients without primary thrombembolic neurological deficits.

Screening via CT angiogram after traumatic cervical spine fractures: narrowing imaging to improve cost effectiveness. Experience of a Level I trauma center

“…However, even in the high-risk patient population, some have questioned the utility of CTA, as surgical treatment strategies are often made independent of such information and treatment for VAI may be contraindicated due to other organ injuries. 6,29,31,33 Although the complications of VAI may be severe, the incidence of posterior circulation strokes are even rarer, and functional outcomes after VAI are good. 1,4,16,20,33 In the present study, the authors evaluated CTA screening in traumatic cervical spine fractures over a 10-year period in an attempt to elucidate subsets of patients for whom CTA imaging should be performed, and to better characterize the risk stratification of stroke from VAI found on CTA imaging.…”

Imaging Evidence and Recommendations for Traumatic Brain Injury: Advanced Neuro- and Neurovascular Imaging Techniques

“…Implementation of the screening protocol can virtually eliminate injury-related strokes in patients without primary thromboembolic neurologic deficits. 150 Several other injuries and injury patterns can be used to identify patients with a high likelihood of concurrent traumatic neurovascular injuries, and these patterns can be used as indications to screen for traumatic neurovascular injuries. Patients with blunt trauma with a high-velocity mechanism, low Glasgow Coma Scale score, high injury severity score, mandible fracture, complex skull fractures, basilar skull fractures (including carotid canal fractures), scalp degloving, any type of cervical spine injury, traumatic brain injury with thoracic injuries, and/or thoracic vascular imaging are at increased risk for blunt neurovascular injuries (evidence level II).…”

“…For the same reason, 4-vessel DSA is only used in the acute setting in patients with inconclusive CTA interpretation or when an endovascular intervention is considered. 150,160 The description above pertained to blunt neurovascular injuries but also applies to penetrating neck injury. A comprehensive physical examination, combined with CTA of the neck extended to include the circle of Willis, is adequate for triage to effectively identify or exclude vascular and aerodigestive injury after penetrating neck trauma (evidence level III), with endoscopy and angiography serving as second-line evaluation modalities (class IIa recommendation).…”

Optic nerve injury-associated blunt cerebrovascular injury

“…[ 1 – 5 ] Because the clinical signs and symptoms of BCVI are frequently absent at the stage when injuries can be treated to prevent neurologic complications, the diagnosis of BCVI is a challenging task in recent trauma care. Various screening criteria have been advocated, and comprehensive screening for BCVI has shown to increase the detection of BCVI; however, up to 20% to 30% of BCVI could be missed using this set of screening criteria [ 4 , 6 , 7 ] ; therefore, optimal screening criteria have yet to be identified. Current screening criteria mainly focus on screening the extracranial carotid artery or vertebral artery, and only few articles can be found that focus on diagnostic and therapeutic approaches for blunt intracranial carotid injury (BICI).…”