Universal Screening for Blunt Cerebrovascular Injury?

July 13, 2020

Written by Clay Smith

Spoon Feed
Clinical decision tools had poor diagnostic accuracy compared with universal CTA for blunt cerebrovascular injury (BCVI). Up to 23% of serious injuries may have been missed without universal screening.

Why does this matter?
Current screening rules for BCVI are cumbersome, with up to 17 criteria. A recent meta-analysis showed that we should probably be doing more neck CTAs than we are. BCVI is associated with up to 25% mortality or stroke. Should we just do CTA on all patients with serious blunt trauma?

Scan ‘em all?
This retrospective review included 4,659 major trauma activations over 2 years at a single level 1 trauma center after a process change in which all major trauma activations received routine neck CTA through the circle of Willis as part of the pan-scan CT imaging protocol. Prevalence of any BCVI was 2.7% (126 out of 4,659). Comparing universal neck CTA as the gold standard: “ACS TQIP Best Practices Guidelines, sensitivity, specificity, PPV, NPV, and accuracy were 72.2%, 64.9%, 6.8%. 98.5%, and 65.2%, respectively; for the risk factors suggested in the more extensive ‘expanded Denver criteria’, they were 82.5%, 50.4%, 5.3%, 98.9%, and 51.4%, respectively.” In all, 23% (14/61) of patients with grade III BCVI or greater would have been missed with both the ACS and Denver screening tools. Most patients (83%) were treated with an antiplatelet agent or anticoagulation. Bleeding complications occurred in 4% (5 patients); BCVI progression in 3% (4 patients); 8% had a stroke (10 patients). Four of the ten strokes were present on admission. My thoughts – there is little risk to this approach. Patients are already receiving radiation and IV contrast. The incremental cost increase is minimal as well. The clinical decision rules are so cumbersome and exhaustive as to render them impractical. After reading this, I am wondering if universal screening might be the right way to go.

Source
BLUNT CEREBROVASCULAR INJURY – THE CASE FOR UNIVERSAL SCREENING.  J Trauma Acute Care Surg. 2020 Jun 8. doi: 10.1097/TA.0000000000002824. [Epub ahead of print]

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