Augmenting Denver criteria yields increased BCVI detection, with screening showing markedly increased risk for subsequent ischemic stroke

Frank V Bensch,Tuomo T Pyhältö,Seppo K Koskinen,Elina A Varjonen

doi:10.1007/s10140-019-01677-0

Frank V Bensch, Tuomo T Pyhältö + Show 2 more

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https://doi.org/10.1007/s10140-019-01677-0

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Abstract

PurposeBCVI may lead to ischemic stroke, disability, and death, while being often initially clinically silent. Screening criteria for BCVI based on clinical findings and trauma mechanism have improved detection, with Denver criteria being most common. Up to 30% of patients do not meet BCVI screening criteria. The aim of this study was to analyze the effect of augmented Denver criteria on detection, and to determine the relative risk for ischemic stroke.MethodsDenver screening criteria were augmented by any high-energy trauma of the cervical spine, thorax, abdomen, or pelvis. All acute blunt trauma WBCT including CT angiography (CTA) over a period of 38 months were reviewed retrospectively by two Fellowship-trained radiologists, as well as any cerebral imaging after the initial trauma.Results1544 WBCT studies included 374 CTA (m/f = 271/103; mean age 41.5 years). Most common mechanisms of injury were MVA (51.5%) and fall from a height (22.3%). We found 72 BCVI in 56 patients (15.0%), with 13 (23.2%) multiple lesions. The ICA was affected in 49 (68.1%) and the vertebral artery in 23 (31.9%) of cases. The most common injury level was C2, with Biffl grades I and II most common in ICA, and II and IV in VA. Interobserver agreement was substantial (Kappa = 0.674). Of 215 patients imaged, 16.1% with BCVI and 1.9% of the remaining cases had cerebral ischemic stroke (p < .0001; OR = 9.77; 95% CI 3.3–28.7). Eleven percent of patients with BCVI would not have met standard screening criteria.ConclusionsThe increase in detection rate for BCVI justifies more liberal screening protocols.

Highlights

Blunt cerebrovascular injuries (BCVI) are uncommon but potentially devastating injuries in blunt trauma patients
The purpose of this study was to assess the detection rate for BCVI based on augmented Denver criteria in high-energy blunt trauma patients presenting in a single level-one trauma center, and to evaluate the relative risk for ischemic stroke for these patients
The attending trauma surgeon decided on using dual-phased WBCT (dWBCT) protocol based on modified Denver criteria, augmented by the addition of suspected cervical spine injury on any level, and any high-energy deceleration trauma with impact on chest, abdomen, or pelvis

Summary

Introduction

Blunt cerebrovascular injuries (BCVI) are uncommon but potentially devastating injuries in blunt trauma patients. The most common trauma mechanisms are stretching, direct impact, or shearing forces in areas where vessels are either fixed in place or run close to rigid or bony neighboring tissues, mainly affecting the internal carotid (ICA) and vertebral arteries (VA) [1, 2]. The majority of BCVI-related ischemic cerebral infarcts occur during the first couple of days after the injury, but may develop even after weeks or months [5, 6]. Morbidity in blunt carotid injury ranges between 32 and 67% and in blunt vertebral artery injury between 14 and 24%, whereas mortality ranges between 13 and 38% and 8–18%, respectively [1, 7]. Current treatment methods include antiplatelet and anticoagulation therapy as well as endovascular treatment in patients with contraindications for thrombolysis [5, 6, 11]

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