Article
A liberal CT angiography screening protocol to detect blunt cerebrovascular injuries in trauma patients – a good strategy?
Breite Indikationsstellung der CT-Angiographie zur Identifizierung traumatischer Läsionen zerebrovaskulärer Gefäße – eine gute Strategie?
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Authors
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Philipp Nagel
- Universitätsklinikum Schleswig-Holstein, Klinik für Neurochirurgie, Lübeck, Deutschland
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Konstantin Michalas
- Universitätsklinikum Schleswig-Holstein, Klinik für Neurochirurgie, Lübeck, Deutschland
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Claudia Ditz
- Universitätsklinikum Schleswig-Holstein, Klinik für Neurochirurgie, Lübeck, Deutschland
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Hannes Schacht
- Universitätsklinikum Schleswig-Holstein, Klinik für Neuroradiologie, Lübeck, Deutschland
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Alexander Neumann
- Universitätsklinikum Schleswig-Holstein, Klinik für Neuroradiologie, Lübeck, Deutschland
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Volker M. Tronnier
- Universitätsklinikum Schleswig-Holstein, Klinik für Neurochirurgie, Lübeck, Deutschland
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Jan Küchler
- Universitätsklinikum Schleswig-Holstein, Klinik für Neurochirurgie, Lübeck, Deutschland
| Published: | June 26, 2020 |
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Outline
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Objective: High energy trauma may cause blunt cerebrovascular injuries (BCVIs). There is a consensus about the use of CT angiography (CTA) to detect BCVIs but no agreement exist concerning the exact indication for CTA in trauma patients. On the one hand an early identification of BCVIs may prevent serious complications like cerebral ischemic stroke. Otherwise a CTA also consists of relevant radiation to the patient and a risk of contrast agent associated nephrotoxicity. Thus, we aimed to evaluate the effectiveness of a liberal CTA screening strategy for the detection of BCVIs in trauma patients.
Methods: We screened all patients, who were admitted to our Level I trauma center during a 2-year period. Inclusion criteria:
- i. admission to the hospital’s trauma room and
- ii. a traumatic injury.
Following the hospital’s guideline, all patients with a high energy trauma or a suspected BCVI underwent CTA imaging.
Results: We identified 1317 patients, fulfilling the inclusion criteria. Traffic accidents (n=739, 56%) were the leading trauma mechanism, followed by falls (n=446, 34%). A CTA imaging was conducted in 588 patients (45%), consisting of 12 patients (1%) with BCVIs. The BCVIs were classified as Denver Grading Scale Grade II (n=6) and Grade IV (n=6). Blunt injury of the internal carotid artery was more frequent (n=8, 67%) than injuries of the vertebral artery (n=4, 33%). Bilateral BCVIs were present in 2 patients (17%). 2 patients underwent an endovascular stenting and antiplatelet therapy (APT), 4 received only APT and 6 did not receive a specific therapy. BCVIs were associated with a high risk for intrahospital stroke (n=2, 17%) and mortality (n=3, 25%). Logistic regression analysis identified the Glasgow coma scale, intracranial lesions, C-spine fractures and visceral injuries as risk factors for BCVIs.
Conclusion: BCVI is a rare condition in trauma patients and its occurrence is associated with high morbidity and mortality, even in case of an early detection using CTA. A liberal CTA-indication strategy efficiently identifies BCVIs but contains many negative findings as well.
There is a need for further prospective studies comparing this strategy with evidence-based decision rules to improve the decision making in trauma patients.
