Rationale and Objectives
Blunt cerebrovascular injury (BCVI) is uncommon, but delayed detection can have disastrous consequences. The Denver criteria are the most commonly used screening criteria. We aim to examine the utilization of screening criteria in the emergency department (ED) of our institution and assess whether patients with risk factors were imaged.
Materials and Methods
A survey questionnaire was sent out to radiologists in a large academic institution. A search was performed in the database on the use of CT angiography (CTA) and MR angiography (MRA) among patients with risk factors in the last 11 years.
Results
The survey was sent to 173 radiologists, with 41 responses (35 complete). Most of the physicians (30 out of 35) surveyed selected CTA as their preferred modality to screen for BCVI, whereas the remaining physicians selected MRA. None of the respondents reported routine use of Denver screening criteria or grading scale in their readouts. Only five respondents selected risk factors in the Denver criteria correctly. In the institution search, among the 1331 patients with blunt trauma and risk factors for BCVI, 537 underwent at least one angiographic study (40.3%). There was an increase in the screening rate after February 2010 in all risk factors, but only statistically significant among patients with foramen transversarium fractures and C1–C3 fractures.
Conclusions
Both the Denver screening criteria and grading scale of vascular injury have been underutilized in the ED for patients with risk factors. Greater awareness and utilization of imaging can potentially result in decreased incidence of subsequent stroke in patients with blunt injury.
Introduction
Blunt cerebrovascular injury (BCVI) refers to injuries to the carotid or vertebral arteries from nonpenetrating trauma, which may result in cerebrovascular ischemia. Mortality rates of up to 33% and morbidity rates of up to 58% have been reported . Timely detection of BCVI is critical in the emergency setting as patients may have a 10–72 hours latent, asymptomatic period, and early treatment during this time has been shown to reduce patients’ risk of stroke and to improve patient outcomes .
The annual incidence of BCVI has been reported to be 0.18%–2.7% among all trauma admissions . Increasing incidence of BCVI has been reported, at least partially attributed to its increased awareness, implementation of aggressive screening protocols, and improvements in imaging technology.
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Methods
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TABLE 1
Modified Denver Screening Criteria
Signs and symptoms of BCVI
Risk factors for BCVI High energy transfer mechanism associated with:
TABLE 2
Survey Questions and Choices
Question Options Do you interpret images on trauma and emergency room patients?
Are you fellowship-trained or in fellowship training?
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If yes, in which subspecialty?
Which would be your preferred modality to screen for blunt cerebrovascular injuries (BCVI)?
What would be your estimate for the sensitivity of CTA for BCVI compared to DSA, as a gold standard?
Do you routinely use Denver Screening Criteria (or any evidence-based criteria) to select trauma patients for evaluation of BCVI and Denver injury grading scale?
Which injury pattern would you consider to be high risk for BCVI? (Select multiple if applicable)
When should follow-up imaging be done?
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Results
Survey
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Institution Review
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TABLE 3
Institutional Review Results
Fracture Type Total number of Patients with the Fracture(s) Number of Patients Undergoing CTA Only Number of Patients Undergoing MRA Only Number of Patients Undergoing CTA and MRA Total Number of Patients Screened Skull base 244 61(25.0%) 7(2.9%) 14(5.7%) 82(33.6%) Foramen transversarium 406 245(60.3%) 19(4.7%) 60(14.8%) 324(79.8%) LeFort 158 35(22.2%) 4(2.5%) 3(1.9%) 42(26.6%) C1–C3 642 125(19.5%) 47(7.3%) 37(5.8%) 209(32.6%) Skull base + foramen transversarium 22 16(72.7%) 0(0%) 6(27.3)% 22(100%) Skull base + LeFort 22 13(59.1%) 0(0%) 1(4.5%) 14(63.6%) Skull base + C1–C3 7 2(28.6%) 0(0%) 1(14.3%) 3(42.9%) Foramen transversarium + LeFort 12 10(83.3%) 0(0%) 1(8.3%) 11(91.7%) Foramen transversarium + C1–C3 85 44(51.8%) 5(5.9%) 21(24.7) 70(82.4%) LeFort + C1–C3 3 1(33.3%) 1(33.3%) 1(33.3%) 2(100%) Skull base + foramen transversarium + C1–C3 2 1(50%) 0 1(50%) 2(100%) Skull base + foramen transversarium + LeFort 4 3(75%) 0(0%) 1(25%) 4(100%)
CTA, computed tomography angiography; MRA, magnetic resonance angiography.
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TABLE 4
Institution Data Before EAST Guidelines
Fracture Type Total Number of Patients with the Fracture(s) Number of Patients Undergoing CTA Only Number of Patients Undergoing MRA Only Number of Patients Undergoing CTA and MRA Total Number of Patients Screened Skull base 96 20(20.8%) 4(4.2%) 3(3.1%) 27(28.1%) Foramen transversarium 154 85(55.2%) 6(39.0%) 18(11.7%) 109(70.8%) LeFort 74 13(17.6%) 2(2.7%) 2(2.7%) 17(23.0%) C1–C3 262 55(21.0%) 8(3.1%) 9(3.4%) 72(27.5%) Skull base + foramen transversarium 6 5(83.3%) 0(0%) 1(16.7%) 6(100%) Skull base + LeFort 5 1(20.0%) 0(0%) 0(0%) 1(20.0%) Skull base + C1–C3 4 2(50.0%) 0(0%) 0(0%) 2(50.0%) Foramen transversarium + LeFort 5 5(100%) 0(0%) 0(0%) 5(100%) Foramen transversarium + C1–C3 5 5(100%) 0(0%) 0(0%) 5(100%) LeFort + C1–C3 30 17(56.7%) 2(6.7%) 4(13.3%) 23(76.7%) Skull base + foramen transversarium + C1–C3 1 1(100%) 0(0%) 0(0%) 1(100%) Skull base + foramen transversarium + LeFort 0(NA) 0(NA) 0(NA) 0(NA) 0(NA)
CTA, computed tomography angiography; EAST, Eastern Trauma Society; MRA, magnetic resonance angiography.
TABLE 5
Institutional Data After EAST Guidelines
Fracture Type Total Number of Patients with the Fracture(s) Number of Patients Undergoing CTA Only Number of Patients Undergoing MRA Only Number of Patients Undergoing CTA and MRA Total Number of Patients Screened Skull base 148 41(27.7%) 3(2.0%) 11(7.4%) 55(37.2%) Foramen transversarium 252 160(63.5%) 13(5.2%) 42(16.7%) 215(85.3%) LeFort 84 22(26.2%) 2(2.4%) 1(1.2%) 25(29.8%) C1–C3 380 70(18.4) 39(10.3%) 28(7.4%) 137(36.1%) Skull base + foramen transversarium 16 11(68.8%) 0(0%) 5(31.3%) (100%) Skull base + LeFort 17 12(70.6%) 0(0%) 1(5.9%) 13(76.5%) Skull base + C1–C3 3 0(0%) 0(0%) 1(33.3%) 1(33.3%) Foramen transversarium + LeFort 7 5(71.4%) 0(0%) 1(14.3%) 6(85.7%) Foramen transversarium + C1–C3 55 27(49.1%) 3(54.5%) 17(30.9) 47(85.5%) LeFort + C1–C3 3 1(33.3%) 1(33.3%) 1(33.3%) (100%) Skull base + foramen transversarium + C1–C3 1 0(0%) 0(0%) 1(100%) (100%) Skull base + foramen transversarium + LeFort 4 3(75.0%) 0(0%) 1(25.0%) (100%)
CTA, computed tomography angiography; EAST, Eastern Trauma Society; MRA, magnetic resonance angiography.
TABLE 6
Comparison of Screening Rates Before and After EAST Guidelines
Fracture Type Screening Rate Before February 2010 Screening Rate After February 2010P Value Skull base 28.1 37.2 0.0699 Foramen transversarium 70.8 85.3 0.0004 LeFort 23.0 29.8 0.1679 C1–C3 27.5 36.1 0.0105
EAST, Eastern Trauma Society.
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Discussion
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Conclusion
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