Clinical utility of a screening protocol for blunt cerebrovascular injury using computed tomography angiography

Abstract

OBJECTIVE Blunt cerebrovascular injury (BCVI) occurs in approximately 1% of the blunt trauma population and may lead to stroke and death. Early vascular imaging in asymptomatic patients at high risk of having BCVI may lead to earlier diagnosis and possible stroke prevention. The objective of this study was to determine if the implementation of a formalized asymptomatic BCVI screening protocol with CT angiography (CTA) would lead to improved BCVI detection and stroke prevention. METHODS Patients with vascular imaging studies were identified from a prospective trauma registry at a single Level 1 trauma center between 2002 and 2008. Detection of BCVI and stroke rates were compared during the 3-year periods before and after implementation of a consensus-based asymptomatic BCVI screening protocol using CTA in 2005. RESULTS A total of 5480 patients with trauma were identified. The overall BCVI detection rate remained unchanged postprotocol compared with preprotocol (0.8% [24 of 3049 patients] vs 0.9% [23 of 2431 patients]; p = 0.53). However, postprotocol there was a trend toward a decreased risk of stroke secondary to BCVI on a trauma population basis (0.23% [7 of 3049 patients] vs 0.53% [13 of 2431 patients]; p = 0.06). Overall, 75% (35 of 47) of patients with BCVI were treated with antiplatelet agents, but no patient developed new or progressive intracranial hemorrhage despite 70% of these patients having concomitant traumatic brain injury. CONCLUSIONS The results of this study suggest that a CTA screening protocol for BCVI may be of clinical benefit with possible reduction in ischemic complications. The treatment of BCVI with antiplatelet agents appears to be safe.

Best practice guidelines for blunt cerebrovascular injury (BCVI)

“…However, studies have shown that focus on this condition in a trauma setting and implementation of standardized handling increases the detection rate and may even decrease stroke rate through earlier imaging and treatment [ 19 , 34 , 39 – 45 ]. Even though no direct comparative studies examining the diagnostic yield of each screening tool exist, the work by Biffl et al is probably the most extensive and best evaluated [ 38 , 40 , 43 , 46 ]. Later known as the Denver screening criteria this clinical tool focus on signs and symptoms of BCVI as well as specific risk factors associated with a high-energy transfer mechanism [ 38 ].…”

Pediatric blunt cerebrovascular injury: the McGovern screening score

“…5,9,33 This is similar to the liberal screening of adult patients who present to the emergency department with possible BCVI. 5,33 While some studies have demonstrated improved BCVI detection using angiographic imaging in the adult population, 45 there is direct evidence that the organ dose that corresponds to a common CT study results in an increased risk of cancer in children. 23 Children are considerably more sensitive to the carcinogenic effects of ionizing radiation and have a longer life expectancy dur-ing which the cancer risk can accumulate and manifest; as a result, no amount of radiation is safe in children.…”

Aspirin for primary prevention of stroke in traumatic cerebrovascular injury: association with increased risk of transfusion

“…Our finding of no hemorrhagic complications directly attributable to aspirin is consistent with other studies of aspirin in the treatment of TCVI. 16,38 Considering that no obvious hemorrhagic events due to aspirin occurred in CTA+ patients, it is likely that the greater transfusion risk in these patients was the result of more subtle effects on blood loss during trauma-related orthopedic and other surgical procedures, and other causes of bleeding due to the trauma > 24 hours after injury.…”