Vascular complications of penetrating brain injury: comparison of helical CT angiography and conventional angiography

Abstract

Object The authors conducted a study to compare the sensitivity and specificity of helical CT angiography (CTA) and digital subtraction angiography (DSA) in detecting intracranial arterial injuries after penetrating traumatic brain injury (PTBI). Methods In a retrospective evaluation of 48 sets of angiograms from 45 consecutive patients with PTBI, 3 readers unaware of the DSA findings reviewed the CTA images to determine the presence or absence of arterial injuries. A fourth reader reviewed all the disagreements and decided among the 3 interpretations. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CTA were calculated on a per-injury basis and in a subpopulation of patients with traumatic intracranial aneurysms (TICAs). Results Sensitivity of CTA for detecting arterial injuries was 72.7% (95% CI 49.8%–89.3%); specificity, 93.5% (95% CI 78.6%–99.2%); PPV, 88.9% (95% CI 65.3%–98.6%); and NPV, 82.9% (95% CI 66.4%–93.4%). All 7 TICAs were correctly identified by CTA. Sensitivity, specificity, PPV, and NPV of CTA in detecting TICAs were 100%. To compare agreement with DSA, the standard of reference, confidence scores categorized as low, intermediate, and high probability yielded an overall effectiveness of 77.8% (95% CI 71.8%–82.9%). Conclusions Computed tomography angiography had limited overall sensitivity in detecting arterial injuries in patients with PTBI. However, it was accurate in identifying TICAs, a subgroup of injuries usually managed by either surgical or endovascular approaches, and non-TICA injuries involving the first-order branches of intracranial arteries.

Cerebrovascular complications of transorbital penetrating intracranial injuries

“…[10,18] According to the recently published large series on vascular complications of penetrating head injury by Bodanapally et al, [13] true incidence of vascular injuries after penetrating head injury is not clearly known because this condition is associated with a high rate of mortality before patients are able to receive medical care. These authors state that the incidence among survivors ranges from 3 to 42%, and they emphasize that previous reports mainly focus on the aneurysms.…”

“…Despite the fact that CT angiogram lacks the sensitivity of the digital subtraction angiogram (DSA), its ability to detect traumatic intracranial aneurysms is very accurate. [13] Risk factors for vascular injury include orbitobasal (including transorbital) entry site, subarachnoid or intraventricular hemorrhage, trajectory within 2 cm or less to the Circle of Willis [13] and blast injury with Glascow Coma Scale 8 or less. [39] These findings should prompt a DSA.…”

“…[10][11][12] Among these complications, transorbital intracranial penetrating vascular injury (TIPVI) stands out as a risk factor for imminent death or disability. [13] Very limited data exist regarding the incidence and management of vascular injuries in TIPI. There are only a handful of cases of vascular complications after TIPI described in the literature.…”

Percutaneous endoscopic removal of a residual foreign body at the orbital-cranial region after transorbital penetrating injury: a novel minimally invasive technique

“…Surgical managements of TPI have always been challenging due to the closeness of trauma to vital structures like foramina opticum and cavernous sinus [2]. There are several reports on the cerebrovascular complications caused by either initial injury or the surgical intervention to remove the foreign body [3]. CTA and DSA are very helpful for the preoperative surgical planning for foreign body removal and correct diagnosis of vascular complications.…”

Brain Magnetic Resonance Imaging for Traumatic Brain Injury

“…CT angiography is, however, an effective screening tool in identifying injury that may require neurosurgical intervention. 96 A recent extensive literature review demonstrated similar test characteristics for MRA and computed tomographic angiography (CTA) in the diagnosis of carotid and vertebral artery dissection. Sensitivity and specificity for both ranged from 50% to 100% when compared to DSA.…”