Diagnostic Imaging Pathways - Suspected Blunt Cerebrovascular Injury
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This pathway provides guidance on the imaging of blunt trauma patients who are at increased risk of cerebrovascular injury.
Date reviewed: August 2018
Date of next review: August 2021
Published: March 2019
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Images
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| 1a |
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Blunt Cerebrovascular Injury Image 1a (Angiogram): A carotid angiogram in a 33 year old male involved in a motor bicycle accident reveals complete occlusion of the right internal carotid artery in its supraclinoid portion (arrow). |
| 1b |
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Image 1b (Computed Tomography): Large right middle cerebral artery territory infarct with mass effect (arrow). |
Teaching Points
Teaching Points
- Blunt cerebrovascular injury (BCVI) is a rare but serious sequela of trauma that occurs in approximately 1% of all blunt trauma victims
- Morbidity and mortality is due to stroke which occurs in 10-21% of cases. Although some cases present with stroke, a number cases are initially asymptomatic and may have a delayed neurological event 10-72 hours after trauma
- Symptoms relate to the vascular territories of the carotid and vertebral arteries. Vertebral artery injuries can result in posterior circulation strokes which may present as motor or sensory deficits, vertigo, ataxia, visual field deficits, dysarthria, dysphagia or loss of consciousness
- There is evidence that anticoagulation or use of antiplatelet agents reduce the rate of stroke in BCVI, so there may be benefit from screening asymptomatic patients who are at increased risk. The exact optimal medical treatment regimen is yet to be determined
- Clinical screening criteria with a sensitivity approaching 100% are yet to be defined. The most commonly used modified Denver screening criteria may miss 20-37% of BCVI. The New Denver Criteria are broader and identify more BCVIs, however the trade-off is that more patients will have unnecessary investigations. 5% of BCVIs may not fit into the listed New Denver Criteria
- The New Denver Criteria identify injuries that are associated with BCVI if they are associated with a high energy mechanism
- CT angiogram is the non-invasive screening tool of choice for BCVI in selected patients
- MRI/MRA may be indicated as a second-line investigation for patients with new or persistent neurological signs concerning for BCVI, but a normal CTA
- Invasive angiography (or digital subtraction angiography, DSA) is generally only indicated for therapeutic intervention. It is considered the gold standard diagnostic test for BCVI, but it has a number of disadvantages including cost, availability, and 1% risk of adverse events including stroke
bcv
Blunt Cerebrovascular Injury (BCVI) Screening
- BCVI is an injury to the carotid and vertebral arteries, often secondary to direct trauma
- Incidence ranges between 0.18% - 1.63% of blunt trauma admissions, and is reportedly as high as 2.7% in patients with an Injury Severity Score (ISS) of ≥16 1,2
- Stroke occurs in 10-21% of cases. 3-7 Although some cases present with stroke, a number of cases are initially asymptomatic, and may have a delayed neurological event 10-72 hours after trauma. 8-10 This presents an opportunity for early identification and avoidance of potentially significant morbidity and mortality within this typically young cohort
- Introducing screening criteria has led to increased detection of BCVI 11 and is associated with a reduction in mortality and delayed stroke rate following the use of antiplatelet agents or anticoagulants. 12-15 However, the exact optimal medical treatment regimen is yet to be determined 16,17
- A meta-analysis found cervical spine injury and thoracic injury were associated with a significantly increased chance of BCVI. 1 Mandibular fractures, when associated with a high-energy transfer mechanism, were also linked to an increased risk of BCVI 18
- Unfortunately no validated diagnostic criteria to select patients in which to screen for BCVI exists that approaches 100% sensitivity. 19 More liberal screening criteria may be indicated to enhance detection rates. 20-22 The modified Denver screening criteria have been developed to select patients who should undergo screening for BCVI 15,23-25 however, these may miss 20-37% of BCVI 26-28
- The New Denver Criteria 26 are broader and identify more BCVIs, 21 however the trade-off is that more patients will have unnecessary investigations. 5% of BCVIs may not fit into the listed New Denver Criteria 21
- Non-fatal strangulation is an uncommon injury that may be missed on history taking, especially when the injury is part of domestic violence or sexual assault. There have been cases of stroke presenting up to six months after the initial injury due to carotid dissection. 29 Some BCVI from strangulation will have no clinical signs 30,31
- Case series suggest that if there is a history of strangulation, CTA should be considered if there is: loss of consciousness, visual changes, facial, intra-oral or conjunctival petechial haemorrhage, incontinence, dysphonia/aphonia, dyspnoea, subcutaneous emphysema or neurological signs or symptoms, even if the presentation is delayed 32
cta
Computed Tomography Angiogram (CTA)
- CT Angiography (CTA) is the recommended screening test for BCVI. 24,25 It also enables the visualisation of the vertebral column and spinal canal, the aerodigestive tract and associated soft tissues of the neck
- Metanalyses of reported trials (conducted on machines ranging from older single slice helical CT scanners to 64 slice MDCTs) report a pooled 66% sensitivity and 97% specificity compared to digital subtraction angiography (DSA). 33 Pooled sensitivity remained ≤80% among studies using ≥16 slice scanners 33
- Sensitivities and specificities of recent prospective studies using ≥16 slice CTAs compared to DSA as the gold standard range from 41-97.7% and 86-100% respectively 34-37
- There is a false positive rate associated with CTA 38-39 which precludes its replacement of DSA as the diagnostic gold standard in BCVI at present, but its non-invasiveness, rapidity and availability make CTA a popular screening modality in the trauma setting
- Screening high-risk populations for blunt cerebrovascular injuries appears cost-effective 40
- Invasive angiography (or digital subtraction angiography, DSA) is generally only indicated for therapeutic intervention. It is considered the gold standard diagnostic test for BCVI, 16,19,25 but it has a number of disadvantages including cost, availability, and 1% risk of adverse events including stroke 41,42 so it is not recommended for screening
mri
Magnetic Resonance Imaging/Angiography (MRI/MRA)
- Magnetic Resonance Angiography may be used as a second-line investigation for BCVI in patients with a normal CTA but ongoing or new neurological signs that are concerning for BCVI
- Sensitivity of 47-75% has been reported. 43,44 However, in many cases ventilatory and monitoring equipment are often incompatible with MRI machines. Likewise the time required to perform the scan, and inability to gain access to an acutely unwell patient, preclude the widespread use of this technique for initial screening 19
References
References
Date of literature search: April-May 2018
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Franz RW, Willette PA, Wood MJ, Wright ML, Hartman JF. A systematic review and meta-analysis of diagnostic screening criteria for blunt cerebrovascular injuries. J Am Coll Surg. 2012;214(3):313-27. (Level II evidence). View the reference
- Mutze S, Rademacher G, Matthes G, Hosten N, Stengel D. Blunt cerebrovascular injury in patients with blunt multiple trauma: diagnostic accuracy of duplex Doppler US and early CT angiography. Radiology. 2005;237(3):884-92. (Level IV evidence). View the reference
- Cothren CC, Moore EE, Ray CE, Jr., Ciesla DJ, Johnson JL, Moore JB, et al. Screening for blunt cerebrovascular injuries is cost-effective. Am J Surg. 2005;190(6):845-9. (Level III evidence). View the reference
- Ramadan F, Rutledge R, Oller D, Howell P, Baker C, Keagy B. Carotid artery trauma: a review of contemporary trauma center experiences. J Vasc Surg. 1995;21(1):46-55; discussion -6. (Level III evidence). View the reference
- Crawford JD, Allan KM, Patel KU, Hart KD, Schreiber MA, Azarbal AF, et al. The Natural History of Indeterminate Blunt Cerebrovascular Injury. JAMA surgery. 2015;150(9):841-7. (Level III evidence). View the reference
- Stein DM, Boswell S, Sliker CW, Lui FY, Scalea TM. Blunt cerebrovascular injuries: does treatment always matter? J Trauma. 2009;66(1):132-43; discussion 43-4. (Level III evidence). View the reference
- Griessenauer CJ, Fleming JB, Richards BF, Cava LP, Cure JK, Younan DS, et al. Timing and mechanism of ischemic stroke due to extracranial blunt traumatic cerebrovascular injury. J Neurosurg. 2013;118(2):397-404. (Level III evidence). View the reference
- Mokri B, Piepgras DG, Houser OW. Traumatic dissections of the extracranial internal carotid artery. J Neurosurg. 1988;68(2):189-97. (Level IV evidence). View the reference
- Krajewski LP, Hertzer NR. Blunt carotid artery trauma: report of two cases and review of the literature. Ann Surg. 1980;191(3):341-6. (Level IV evidence). View the reference
- Fabian TC, George SM, Jr., Croce MA, Mangiante EC, Voeller GR, Kudsk KA. Carotid artery trauma: management based on mechanism of injury. J Trauma. 1990;30(8):953-61; discussion 61-3. (Level III evidence). View the reference
- Sinnathamby M, Rao SV, Weber DG. Increased detection of blunt carotid and vertebral artery injury after implementation of diagnostic imaging pathway in level 1 trauma centre in Western Australia. Injury. 2017;48(9):1917-21. (Level II evidence). View the reference
- Schneidereit NP, Simons R, Nicolaou S, Graeb D, Brown DR, Kirkpatrick A, et al. Utility of screening for blunt vascular neck injuries with computed tomographic angiography. J Trauma. 2006;60(1):209-15; discussion 15-6. (Level III evidence). View the reference
- Eastman AL, Muraliraj V, Sperry JL, Minei JP. CTA-based screening reduces time to diagnosis and stroke rate in blunt cervical vascular injury. J Trauma. 2009;67(3):551-6; discussion 5-6. (Level III evidence). View the reference
- Shahan CP, Croce MA, Fabian TC, Magnotti LJ. Impact of Continuous Evaluation of Technology and Therapy: 30 Years of Research Reduces Stroke and Mortality from Blunt Cerebrovascular Injury. J Am Coll Surg. 2017;224(4):595-9. (Level III evidence). View the reference
- Cothren CC, Moore EE, Biffl WL, Ciesla DJ, Ray CE, Jr., Johnson JL, et al. Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg. 2004;139(5):540-5; discussion 5-6. (Level II evidence). View the reference
- Foreman PM, Harrigan MR. Blunt Traumatic Extracranial Cerebrovascular Injury and Ischemic Stroke. Cerebrovascular Diseases Extra. 2017;7(1):72-83. (Review article). View the reference
- Eastham S. Blunt cerebrovascular injuries in trauma. Int J Surg. 2016;33(Pt B):251-3. (Review article). View the reference
- Kelts G, Maturo S, Couch ME, Schmalbach CE. Blunt cerebrovascular injury following craniomaxillofacial fractures: A systematic review. Laryngoscope. 2017;127(1):79-86. (Review article). View the reference
- Liang T, Plaa N, Tashakkor AY, Nicolaou S. Imaging of blunt cerebrovascular injuries. Semin Roentgenol. 2012;47(4):306-19. (Review article). View the reference
- Liang T, Tso DK, Chiu RY, Nicolaou S. Imaging of blunt vascular neck injuries: a review of screening and imaging modalities. AJR Am J Roentgenol. 2013;201(4):884-92. (Review article). View the reference
- Geddes AE, Burlew CC, Wagenaar AE, Biffl WL, Johnson JL, Pieracci FM, et al. Expanded screening criteria for blunt cerebrovascular injury: a bigger impact than anticipated. Am J Surg. 2016;212(6):1167-74. (Level III evidence). View the reference
- Grabowski G, Robertson RN, Barton BM, Cairns MA, Webb SW. Blunt Cerebrovascular Injury in Cervical Spine Fractures: Are More-Liberal Screening Criteria Warranted? Global spine journal. 2016;6(7):679-85. (Level III evidence). View the reference
- Biffl WL, Moore EE, Offner PJ, Brega KE, Franciose RJ, Elliott JP, et al. Optimizing screening for blunt cerebrovascular injuries. Am J Surg. 1999;178(6):517-22. (Level III evidence). View the reference
- Bromberg WJ, Collier BC, Diebel LN, Dwyer KM, Holevar MR, Jacobs DG, et al. Blunt cerebrovascular injury practice management guidelines: the Eastern Association for the Surgery of Trauma. J Trauma. 2010;68(2):471-7. (Guideline). View the reference
- Biffl WL, Cothren CC, Moore EE, Kozar R, Cocanour C, Davis JW, et al. Western Trauma Association critical decisions in trauma: screening for and treatment of blunt cerebrovascular injuries. J Trauma. 2009;67(6):1150-3. (Guideline). View the reference
- Burlew CC, Biffl WL, Moore EE, Barnett CC, Johnson JL, Bensard DD. Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis. The journal of trauma and acute care surgery. 2012;72(2):330-5; discussion 6-7, quiz 539. (Level II evidence). View the reference
- Jacobson LE, Ziemba-Davis M, Herrera AJ. The limitations of using risk factors to screen for blunt cerebrovascular injuries: the harder you look, the more you find. World Journal of Emergency Surgery : WJES. 2015;10:46. (Level III evidence). View the reference
- Bruns BR, Tesoriero R, Kufera J, Sliker C, Laser A, Scalea TM, et al. Blunt cerebrovascular injury screening guidelines: what are we willing to miss? The journal of trauma and acute care surgery. 2014;76(3):691-5. (Level III evidence). View the reference
- Malek AM, Higashida RT, Halbach VV, Dowd CF, Phatouros CC, Lempert TE, et al. Patient presentation, angiographic features, and treatment of strangulation-induced bilateral dissection of the cervical internal carotid artery. Report of three cases. J Neurosurg. 2000;92(3):481-7. (Level IV evidence). View the reference
- Gill JR, Cavalli DP, Ely SF, Stahl-Herz J. Homicidal Neck Compression of Females: Autopsy and Sexual Assault Findings. Academic Forensic Pathology. 2013;3(4):454-7. (Level III evidence). View the reference
- Clarot F, Vaz E, Papin F, Proust B. Fatal and non-fatal bilateral delayed carotid artery dissection after manual strangulation. Forensic Sci Int. 2005;149(2-3):143-50. (Level IV evidence). View the reference
- Smock W, Sturgeon S. Recommendations for the medical/radiographic evaulation of acute adult, non-fatal strangulation. Training Institute of Strangulation Prevention; 2017. (Guidelines). View the reference
- Roberts DJ, Chaubey VP, Zygun DA, Lorenzetti D, Faris PD, Ball CG, et al. Diagnostic accuracy of computed tomographic angiography for blunt cerebrovascular injury detection in trauma patients: a systematic review and meta-analysis. Ann Surg. 2013;257(4):621-32. (Level I evidence). View the reference
- Goodwin RB, Beery PR, 2nd, Dorbish RJ, Betz JA, Hari JK, Opalek JM, et al. Computed tomographic angiography versus conventional angiography for the diagnosis of blunt cerebrovascular injury in trauma patients. J Trauma. 2009;67(5):1046-50. (Level II evidence). View the reference
- Eastman AL, Chason DP, Perez CL, McAnulty AL, Minei JP. Computed tomographic angiography for the diagnosis of blunt cervical vascular injury: is it ready for primetime? J Trauma. 2006;60(5):925-9; discussion 9. (Level II evidence). View the reference
- Malhotra AK, Camacho M, Ivatury RR, Davis IC, Komorowski DJ, Leung DA, et al. Computed tomographic angiography for the diagnosis of blunt carotid/vertebral artery injury: a note of caution. Ann Surg. 2007;246(4):632-42; discussion 42-3. (Level II-III evidence). View the reference
- Paulus EM, Fabian TC, Savage SA, Zarzaur BL, Botta V, Dutton W, et al. Blunt cerebrovascular injury screening with 64-channel multidetector computed tomography: more slices finally cut it. The journal of trauma and acute care surgery. 2014;76(2):279-83; discussion 84-5. (Level III evidence). View the reference
- Grandhi R, Weiner GM, Agarwal N, Panczykowski DM, Ares WJ, Rodriguez JS, et al. Limitations of multidetector computed tomography angiography for the diagnosis of blunt cerebrovascular injury. J Neurosurg. 2017:1-6. (Level II evidence). View the reference
- Shahan CP, Magnotti LJ, Stickley SM, Weinberg JA, Hendrick LE, Uhlmann RA, et al. A safe and effective management strategy for blunt cerebrovascular injury: Avoiding unnecessary anticoagulation and eliminating stroke. The journal of trauma and acute care surgery. 2016;80(6):915-22. (Level III evidence). View the reference
- Kaye D, Brasel KJ, Neideen T, Weigelt JA. Screening for blunt cerebrovascular injuries is cost-effective. J Trauma. 2011;70(5):1051-6; discussion 6-7. (Level II-III evidence). View the reference
- Willinsky RA, Taylor SM, TerBrugge K, Farb RI, Tomlinson G, Montanera W. Neurologic complications of cerebral angiography: prospective analysis of 2,899 procedures and review of the literature. Radiology. 2003;227(2):522-8. (Level II evidence). View the reference
- Berne JD, Reuland KS, Villarreal DH, McGovern TM, Rowe SA, Norwood SH. Sixteen-slice multi-detector computed tomographic angiography improves the accuracy of screening for blunt cerebrovascular injury. J Trauma. 2006;60(6):1204-9; discussion 9-10. (Level III evidence). View the reference
- Miller PR, Fabian TC, Croce MA, Cagiannos C, Williams JS, Vang M, et al. Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Ann Surg. 2002;236(3):386-93; discussion 93-5. (Level II evidence). View the reference
- Biffl WL, Ray CE, Jr., Moore EE, Mestek M, Johnson JL, Burch JM. Noninvasive diagnosis of blunt cerebrovascular injuries: a preliminary report. J Trauma. 2002;53(5):850-6. (Level II evidence). View the reference
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