Blunt Cerebrovascular Injury – When to CTA

April 20, 2020

Written by Clay Smith

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Use a screening protocol to determine which trauma patients to order CTA of the head and neck. It detects more blunt cerebrovascular injuries (BCVI), which leads to more treatment, which reduces risk of stroke and mortality.

Why does this matter?
It’s often a quandary which patient to order CTA of the neck in the setting of blunt trauma. There is no easy rule to remember. Even if we scan, does finding these injuries make a difference?

Pick a protocol and use it.
This was a meta-analysis with 23 studies of BCVI. They found the more you look with CTA, the more you find. OR was 4.7 for detecting injuries with vs without a screening protocol in place. Also, CTA was more likely to show BCVI with high-risk (such as fractures through neuroforamina) vs low-risk c-spine injury (OR 12.7). Antithrombotic therapy vs none reduced stroke and mortality: risk of stroke, OR 0.20; mortality, OR 0.17; both were highly statistically significant. Patients with stents did no better than those treated medically. So, what protocol should you use? Two are put forward: Denver and Memphis. Denver criteria are extensive and impossible to remember. It’s more a question of who does not warrant a CTA. What I take away is that I should probably be doing more neck CTA scans than I’m currently doing. Here are the Denver Criteria for your reference.

Denver Criteria

Signs/Symptoms of BCVI

• Potential arterial hemorrhage from neck/nose/mouth

• Cervical bruit in patient < 50 years old

• Expanding cervical hematoma

• Focal neurologic defect: TIA, hemiparesis, vertebrobasilar symptoms, Horner’s Syndrome

• Neurologic deficit inconsistent with head CT

• Stroke on CT or MRI

Risk factors for BCVI

• High energy transfer mechanism

• Displaced mid-face fracture (LeFort II or III)

• Mandible fracture

• Complex skull fracture/basilar skull fracture/occipital condyle fracture

• Severe traumatic brain injury with GCS < 6

• Cervical spine fracture, subluxation or ligamentous injury at any level

• Near hanging with anoxic brain injury

• Clothesline type injury or seat belt abrasion with significant swelling, pain, or altered mental status

• TBI with thoracic injuries

• Scalp degloving

• Thoracic vascular injuries

• Blunt cardiac rupture

• Upper rib fractures

Source
EVALUATION AND MANAGEMENT OF BLUNT CEREBROVASCULAR INJURY: A PRACTICE MANAGEMENT GUIDELINE FROM THE EASTERN ASSOCIATION FOR THE SURGERY OF TRAUMA.  J Trauma Acute Care Surg. 2020 Mar 14. doi: 10.1097/TA.0000000000002668. [Epub ahead of print]

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