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Hiatt KD, Agarwal R, Oravec CS, Johnson EC, Patel NP, Geer CP, Wolfe SQ, Zapadka ME. Blunt Cerebrovascular Injury: Are We Overscreening Low-Mechanism Trauma? AJNR Am J Neuroradiol 2023; 44:1296-1301. [PMID: 37827720 PMCID: PMC10631538 DOI: 10.3174/ajnr.a8004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 08/21/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND AND PURPOSE Screening patients with trauma for blunt cerebrovascular injury with neck CTA is a common practice, but there remains disagreement regarding which patients should be screened. We reviewed adult blunt cerebrovascular injury data from a level 1 trauma center to investigate whether screening is warranted in low-mechanism trauma. MATERIALS AND METHODS We reviewed all neck CTAs performed on adult trauma patients in the emergency department during the 2019 calendar year. Clinical and imaging risk factors for blunt cerebrovascular injury, trauma mechanism, initial neck CTA interpretations, results from subsequent CTA and DSA studies, antiplatelet and anticoagulant treatments, and outcome data were recorded. RESULTS One thousand one hundred thirty-six neck CTAs met the inclusion criteria, of which 965 (85%) were interpreted as having negative findings; 125, as having indeterminate findings (11%); and 46, as having positive findings (4%). Review of subsequent imaging and clinical documentation led to classification of 40 indeterminate studies (32%) as true-positives and 85 (68%) as false-positives. Blunt cerebrovascular injury was identified in 77 (12.6%) cases meeting and in 9 (1.7%) cases not meeting the expanded Denver criteria. The subset of 204 low-mechanism trauma cases (ground-level falls, blunt assaults, and low-impact motor vehicle collisions) not meeting the expanded Denver criteria (18% of the entire data set) could have been excluded from screening with 1 questionable injury and 0 ischemic strokes missed and 12 false-positive cases prevented. CONCLUSIONS We advocate reservation of blunt cerebrovascular injury screening in low-mechanism trauma for patients meeting the expanded Denver criteria. Further research is needed to determine the behavior of indeterminate cases and to establish criteria for separating true-positive from false-positive findings.
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Affiliation(s)
- Kevin D Hiatt
- From the Wake Forest School of Medicine (K.S.H., R.A., C.S.O., N.P.P., C.P.G., S.Q.W., M.E.Z.). Winston-Salem, North Carolina
- Department of Radiology (K.D.H., C.P.G., S.Q.W., M.E.Z.), Atrium Health Wake Forest Baptist
| | - Raghav Agarwal
- From the Wake Forest School of Medicine (K.S.H., R.A., C.S.O., N.P.P., C.P.G., S.Q.W., M.E.Z.). Winston-Salem, North Carolina
| | - Chesney S Oravec
- From the Wake Forest School of Medicine (K.S.H., R.A., C.S.O., N.P.P., C.P.G., S.Q.W., M.E.Z.). Winston-Salem, North Carolina
- Department of Neurological Surgery (C.S.O., S.Q.W.), Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Erica C Johnson
- Department of General Surgery (E.C.J.), Virginia Commonwealth University Health, Richmond, Virginia
| | - Nishk P Patel
- From the Wake Forest School of Medicine (K.S.H., R.A., C.S.O., N.P.P., C.P.G., S.Q.W., M.E.Z.). Winston-Salem, North Carolina
| | - Carol P Geer
- From the Wake Forest School of Medicine (K.S.H., R.A., C.S.O., N.P.P., C.P.G., S.Q.W., M.E.Z.). Winston-Salem, North Carolina
- Department of Radiology (K.D.H., C.P.G., S.Q.W., M.E.Z.), Atrium Health Wake Forest Baptist
| | - Stacey Q Wolfe
- From the Wake Forest School of Medicine (K.S.H., R.A., C.S.O., N.P.P., C.P.G., S.Q.W., M.E.Z.). Winston-Salem, North Carolina
- Department of Radiology (K.D.H., C.P.G., S.Q.W., M.E.Z.), Atrium Health Wake Forest Baptist
- Department of Neurological Surgery (C.S.O., S.Q.W.), Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Michael E Zapadka
- From the Wake Forest School of Medicine (K.S.H., R.A., C.S.O., N.P.P., C.P.G., S.Q.W., M.E.Z.). Winston-Salem, North Carolina
- Department of Radiology (K.D.H., C.P.G., S.Q.W., M.E.Z.), Atrium Health Wake Forest Baptist
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Le DT, Barhorst KA, Castiglione J, Yang GL, Shah SJ, Harlan SS, Keegan SP, Jandarov RA, Ngwenya LB, Prestigiacomo CJ. Blunt cerebrovascular injury in the geriatric population. Neurosurg Focus 2020; 49:E10. [PMID: 33002862 DOI: 10.3171/2020.7.focus20499] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Blunt cerebrovascular injury (BCVI) is associated with high rates of neurological morbidity and mortality. The detection and management of BCVI has improved with advances in imaging and sensitive screening protocols. Few studies have explored how these injuries specifically affect the geriatric population. The purpose of this retrospective analysis was to investigate the presentation and prognosis of BCVI in the elderly population and to assess its clinical implications in the management of these patients. METHODS All patients presenting to the University of Cincinnati (UC) level I trauma center between February 2017 and December 2019 were screened for BCVI and entered into the prospectively maintained UC Neurotrauma Registry. Patients with BCVI confirmed by CT angiography underwent retrospective chart reviews to collect information regarding demographics, positive screening criteria, cause of injury, antithrombotic agent, injury location, Denver Grading Scale, hospital and ICU length of stay, and discharge disposition. Patients were divided into geriatric (age ≥ 65 years) and adult (age < 65 years) subgroups. Continuous variables were analyzed using the Student t-test and categorical variables with the Pearson chi-square test. RESULTS Of 124 patients with BCVI, stratification by age yielded 23 geriatric and 101 adult patients. Injury in the geriatric group was associated with significantly higher mortality (p = 0.0194). The most common cause of injury in the elderly was falls (74%, 17/23; p < 0.0001), whereas motor vehicle accidents were most common in the adult group (38%, 38/100; p = 0.0642). With respect to the location of injury, carotid (p = 0.1171) and vertebral artery (p = 0.6981) injuries did not differ significantly for the geriatric group. The adult population presented more often with Denver grade I injuries (p < 0.0001), whereas the geriatric population presented with grade IV injuries (p = 0.0247). Elderly patients were more likely to be discharged to skilled nursing facilities (p = 0.0403) and adults to home or self-care (p = 0.0148). CONCLUSIONS This study is the first to characterize BCVI to all cervical and intracranial vessels in the geriatric population. Older age at presentation is significantly associated with greater severity, morbidity, and mortality from injury, with no preference for the particular artery injured. These findings carry important clinical implications for adapting practice in an aging population.
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Affiliation(s)
- Diana T Le
- 1University of Cincinnati College of Medicine
| | | | | | - George L Yang
- 2Department of Neurological Surgery, University of Cincinnati College of Medicine
| | - Sanjit J Shah
- 2Department of Neurological Surgery, University of Cincinnati College of Medicine
| | - Sarah S Harlan
- 3Division of Pharmaceutical Sciences, James L. Winkle College of Pharmacy, University of Cincinnati; and
| | - Shaun P Keegan
- 3Division of Pharmaceutical Sciences, James L. Winkle College of Pharmacy, University of Cincinnati; and
| | - Roman A Jandarov
- 4Division of Biostatistics and Bioinformatics, Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Laura B Ngwenya
- 2Department of Neurological Surgery, University of Cincinnati College of Medicine
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Merrill S, Clifton W, Valero-Moreno F, Damon A, Rahmathulla G. Vertebral Artery Injury with Coinciding Unstable Cervical Spine Trauma: Mechanisms, Evidence-based Management, and Treatment Options. Cureus 2020; 12:e7225. [PMID: 32274283 PMCID: PMC7141798 DOI: 10.7759/cureus.7225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Unstable traumatic cervical spine fracture is a commonly encountered neurosurgical issue. Concomitant vertebral artery injuries present a challenge in surgical decision-making regarding the timing and order of surgical intervention with respect to endovascular intervention and internal fixation of the unstable fracture. Currently, there are no studies that have specifically examined stroke rate or outcomes for patients who have vertebral artery injuries and unstable cervical spine fractures with respect to temporal treatment course. The purpose of this paper is to review the current evidence for the standards of diagnosis and management of vertebral artery injuries with coinciding unstable cervical spine injuries and propose an evidence-based algorithm for workup and treatment.
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Affiliation(s)
- Sarah Merrill
- Neurological Surgery, Mayo Clinic Alix School of Medicine, Scottsdale, USA
| | | | | | - Aaron Damon
- Neurological Surgery, Mayo Clinic, Jacksonville, USA
| | - Gazanfar Rahmathulla
- Neurological Surgery, University of Florida College of Medicine, Gainesville, USA
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