Southwestern Surgical Congress
Expanded screening criteria for blunt cerebrovascular injury: a bigger impact than anticipated

Presented at the 2016 Southwestern Surgical Congress Annual Meeting, Coronado, CA.
https://doi.org/10.1016/j.amjsurg.2016.09.016Get rights and content

Abstract

Background

We implemented expanded screening criteria for blunt cerebrovascular injuries (BCVIs) in an attempt to capture the remaining 20% of patients not historically identified with earlier protocols. We hypothesized that these expanded criteria would capture the additional 20% of BCVI patients not previously identified.

Methods

Screening criteria for BCVI were expanded in 2011 after identifying new injury patterns. The study population included 4 years prior (2007 to 2010; classic) and following (2011 to 2014; expanded) implementation of expanded criteria.

Results

BCVIs were identified in 386 patients: 150 during the classic period (2.36% incidence) and 236 in the expanded period (2.99% incidence). In the expanded period, 155 patients were imaged based on classic screening criteria, 62 on expanded criteria (21 complex skull fractures, 20 upper rib fractures, 6 mandible fractures, 2 scalp degloving, 1 great vessel injury, and 12 combination), and 19 for other injuries and symptoms.

Conclusions

There was a significant increase in the identification of BCVI following the adoption of expanded screening criteria, resulting in a substantial reduction of missed injuries. Expanded criteria should be adopted when screening for BCVI.

Section snippets

Methods

Screening protocols for BCVI based on injury mechanism, injury patterns, or symptoms have been used at Denver Health Medical center, a state-certified and American College of Surgeons–verified Level I regional trauma center since 1996. In 2011, we implemented expanded screening criteria based on our prior analysis in an effort to identify BCVI in patients while they were asymptomatic. To compare a preimplementation period to a postimplementation period, we analyzed the 4 years (2007 to 2010)

Results

During the 8-year study period, 386 patients with BCVIs were identified out of 14,270 blunt trauma admissions. The mean age of the patient population was 39 ± .9 years (range 2 to 85 years) and the majority (61%) was men. Of the 386 patients with identified BCVIs, 346 (90%) were asymptomatic, whereas 40 had signs of stroke or cerebral ischemia. There were 161 patients with carotid artery injuries (CAIs), 165 patients with vertebral artery injuries (VAI), and 60 patients with combined CAI and

Comments

Prevention of BCVI-related stroke has been vigorously pursued for the past 2 decades. Aggressive screening protocols and the early institution of antithrombotic therapy has reduced the BCVI-related stroke rate from 20% to less than 1% in patients receiving treatment.11, 21 With the advent of reliable noninvasive imaging modalities to diagnose BCVI,2, 3, 4, 5, 6, 7, 8 expanded screening protocols have been advocated in an attempt to capture the vast majority of BCVI patients during their

Conclusions

In our experience, adoption of the expanded screening criteria for BCVI captured the majority of the historically identified 20% of BCVI that are difficult to identify. In addition, implementing the expanded criteria increased our overall identification of BCVI beyond what was expected. With expanded criteria, the incidence of BCVI approaches 3% of all blunt trauma admissions. Currently, one-quarter of all patients diagnosed with BCVI are identified solely with the new screening indications:

References (40)

  • C.C. Burlew et al.

    Imaging for blunt carotid and vertebral artery injuries

    Surg Clin North Am

    (2011)
  • E.M. Paulus et al.

    Blunt cerebrovascular injury screening with 64-channel multidetector computed tomography: more slices finally cut it

    J Trauma Acute Care Surg

    (2014)
  • A.L. Eastman et al.

    CTA-based screening reduces time to diagnosis and stroke rate in blunt cervical vascular injury

    J Trauma

    (2009)
  • W.L. Biffl et al.

    Sixteen-slice computed tomographic angiography is a reliable noninvasive screening test for clinically significant blunt cerebrovascular injuries

    J Trauma

    (2006)
  • J.D. Berne et al.

    Sixteen-slice multi-detector computed tomographic angiography improves the accuracy of screening for blunt cerebrovascular injury

    J Trauma

    (2006)
  • N.P. Schneidereit et al.

    Utility of screening for blunt vascular neck injuries with computed tomographic angiography

    J Trauma

    (2006)
  • A.L. Eastman et al.

    Computed tomographic angiography for the diagnosis of blunt cervical vascular injury: is it ready for primetime?

    J Trauma

    (2006)
  • G.H. Utter et al.

    Sixteen-slice CT angiography in patients with suspected blunt carotid and vertebral artery injuries

    J Am Coll Surg

    (2006)
  • C.C. Burlew et al.

    Endovascular stenting is rarely necessary for the management of blunt cerebrovascular injuries

    J Am Coll Surg

    (2014)
  • A.E. Wagenaar et al.

    Early repeat imaging is not warranted for high-grade blunt cerebrovascular injuries

    J Trauma Acute Care Surg

    (2014)
  • C.C. Cothren et al.

    Treatment for blunt cerebrovascular injuries: equivalence of anticoagulation and antiplatelet agents

    Arch Surg

    (2009)
  • R.A. Callcut et al.

    Early treatment of blunt cerebrovascular injury with concomitant hemorrhagic neurologic injury is safe and effective

    J Trauma Acute Care Surg

    (2012)
  • J.M. DiCocco et al.

    Optimal outcomes for patients with blunt cerebrovascular injury (BCVI): tailoring treatment to the lesion

    J Am Coll Surg

    (2011)
  • W.L. Biffl et al.

    Optimizing screening for blunt cerebrovascular injuries

    Am J Surg

    (1999)
  • W.L. Biffl et al.

    The unrecognized epidemic of blunt carotid arterial injuries: early diagnosis improves neurologic outcome

    Ann Surg

    (1998)
  • T.C. Fabian et al.

    Blunt carotid injury. Importance of early diagnosis and anticoagulant therapy

    Ann Surg

    (1996)
  • W.L. Biffl et al.

    The devastating potential of blunt vertebral arterial injuries

    Ann Surg

    (2000)
  • C.C. Cothren et al.

    Cervical spine fracture patterns mandating angiography to rule out blunt cerebrovascular injury

    Surgery

    (2007)
  • D.M. Stein et al.

    Blunt cerebrovascular injuries: does treatment always matter?

    J Trauma

    (2009)
  • K.P. Emmett et al.

    Improving the screening criteria for blunt cerebrovascular injury: the appropriate role for computed tomography angiography

    J Trauma

    (2011)
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    The authors declare no conflicts of interest.

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