Endovascular Stenting Is Rarely Necessary for the Management of Blunt Cerebrovascular Injuries

OBJECT Screening for vertebral artery injury (VAI) following cervical spine fractures is routinely performed across trauma centers in North America. From 2002 to 2007, the total number of neck CT angiography (CTA) studies performed in the Medicare population after trauma increased from 9796 to 115,021. In the era of cost-effective medical care, the authors aimed to evaluate the utility of CTA screening in detecting VAI and reduce chances of posterior circulation strokes after traumatic cervical spine fractures. METHODS A retrospective review of all patients presenting with cervical spine fractures to Northeast Ohio’s Level I trauma institution from 2002 to 2012 was performed. RESULTS There was a total of 1717 cervical spine fractures in patients presenting to Northeast Ohio’s Level I trauma institution between 2002 and 2012. CTA screening was performed in 732 patients, and 51 patients (0.7%) were found to have a VAI. Fracture patterns with increased odds of VAI were C-1 and C-2 combined fractures, transverse foramen fractures, and subluxation of adjacent vertebral levels. Ten posterior circulation strokes were identified in this patient population (0.6%) and found in only 4 of 51 cases of VAI (7.8%). High-risk fractures defined by Denver Criteria, VAI, and antiplatelet treatment of VAI were not independent predictors of stroke. CONCLUSIONS Cost-effective screening must be reevaluated in the setting of blunt cervical spine fractures on a case-by-case basis. Further prospective studies must be performed to elucidate the utility of screening for VAI and posterior circulation stroke prevention, if identified.

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“…6,32 In addition, time constraints to obtain the study make CTA more cost-effective if screening is going to be performed. 11,13 …”

Section: Discussionmentioning

confidence: 99%

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

Lockwood

Smith

Tanenbaum

et al. 2016

SPI

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“…In these cases, endovascular stent placement or, less commonly, resection with patch interposition graft placement or coil embolization may be considered to definitively treat the pseudoaneurysm (Fig 23). Notably, the role of a carotid artery stent for the treatment of a BCVI pseudoaneurysm remains to be defined owing to high occlusion rates (25), and should be reserved for cases with refractory symptoms or with a rapid increase in size (57). No data exist to show any benefit of surgical or endovascular intervention for grade IV injuries.…”

Section: Bcvi Treatmentmentioning

confidence: 99%

Imaging and Management of Blunt Cerebrovascular Injury

2018

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Blunt cerebrovascular injury (BCVI) is a relatively rare but potentially devastating finding in patients with high-energy blunt force trauma or direct cervical and/or craniofacial injury. The radiologist plays an essential role in identifying and grading the various types of vascular injury, including minimal intimal injury, dissection with raised intimal flap or intraluminal thrombus, intramural hematoma, pseudoaneurysm, occlusion, transection, and arteriovenous fistula. Early identification of BCVI is important, as treatment with antithrombotic therapy has been shown to reduce the incidence of postinjury ischemic stroke. Patients with specific mechanisms of injury, particular imaging findings, or certain clinical signs and symptoms have been identified as appropriate and cost-effective for BCVI screening. Although digital subtraction angiography was previously considered the standard examination for screening, technologic improvements have led to its replacement with computed tomographic angiography. Of note, although not appropriate for screening, improvements in magnetic resonance angiography with vessel wall imaging hold promise as supplemental imaging studies that may improve diagnostic specificity for vessel wall injuries. Understanding the screening criteria, imaging modalities of choice, imaging appearances, and grading of BCVI is essential for the radiologist to ensure fast and appropriate diagnosis and treatment. This article details the imaging evaluation of BCVI and discusses the clinical and follow-up imaging implications of specific injury findings. RSNA, 2018.

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“…Options include stenting, occlusion of the vertebral artery or coil embolisation of a pseudoaneurysm (27,45). Some authors have reported significant complication rates associated with endovascular BCVI treatment such as iatrogenic injury, ischaemic neurological injury and vessel occlusion (46,47). There is little evidence regarding the outcomes of VAI treated with endovascular techniques and no studies exist directly comparing endovascular with medical therapy.…”

Section: Endovascular Therapymentioning

confidence: 99%

“…Burlew et al only performed endovascular intervention on 2% of high grade BCVIs in their study. They felt that antithrombotic therapy alone was effective in preventing stroke and negated the risks of endovascular treatment, and the latter should be reserved for symptomatic patients or those with enlarging pseudoaneurysms (47). Consequently, we would suggest that decision making for treatment of these injuries should follow a multidisciplinary approach and involve early consultation with a spinal surgeon, stroke physician, vascular surgeon and interventional radiologist.…”

Section: Endovascular Therapymentioning

confidence: 99%

Blunt vertebral vascular injury in trauma patients: ATLS® recommendations and review of current evidence

et al. 2017

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Blunt cerebrovascular injury (BCVI) encompasses two distinct clinical entities: traumatic carotid artery injury (TCAI) and traumatic vertebral artery injury (TVAI). The latter is the focus of our review. These are potentially devastating injuries which pose a diagnostic challenge in the acute trauma setting. There is still debate regarding the optimal screening criteria, diagnostic imaging modality and treatment methods. In 2012 the American College of Surgeons proposed criteria for investigating patients with suspected TVAI and subsequent treatment methods, caveated with the statement that evidence is limited and still evolving. Here we review the historical evidence and recent literature relating to these recommendations.

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Endovascular Stenting Is Rarely Necessary for the Management of Blunt Cerebrovascular Injuries

Cited by 64 publications

References 28 publications

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

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

Imaging and Management of Blunt Cerebrovascular Injury

Blunt vertebral vascular injury in trauma patients: ATLS® recommendations and review of current evidence

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