Modified Split-Scan Computed Tomography (CT) Diagnostics of Severely Injured Patients: First Results from a Level I Trauma Center Using a Dedicated Head-and-Neck CT-Angiogram for the Detection of Cervical Artery Dissections.

Daniel Popp,Volker Alt,Andreas Schicho,Wolf Bäumler,Claudius Thiedemann,Antonio Ernstberger

doi:10.3390/jcm9082568

Daniel Popp, Volker Alt + Show 4 more

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https://doi.org/10.3390/jcm9082568

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Abstract

Introduction: Traumatic cervical artery dissections are associated with high mortality and morbidity in severely injured patients. After finding even higher incidences than reported before, we decided to incorporate a dedicated head-and-neck computed tomography angiogram (CT-A) in our imaging routine for patients who have been obviously severely injured or, according to trauma mechanism, are suspected to be severely injured. Materials and Methods: A total of 134 consecutive trauma patients with an ISS ≥ 16 admitted to our level I trauma center during an 18 month period were included. All underwent standardized whole-body CT in a 256-detector row scanner with a dedicated head-and-neck CT-A realized as single-bolus split-scan routine. Incidence, mortality, patient and trauma characteristics, and concomitant injuries were recorded and analyzed in patients with carotid artery dissection (CAD) and vertebral artery dissection (VAD). Results: Of the 134 patients included, 7 patients had at least one cervical artery dissection (CeAD; 5.2%; 95% CI 1.5–9.0%). Six patients (85.7%) had carotid artery dissections, with one patient having a CAD of both sides and one patient having a CAD and contralateral VAD combined. Two patients (28.6%) showed a VAD. Overall mortality was 14.3%, neurologic morbidity was 28.6%. None of the patients showed any attributable neurologic symptoms on admission. The new scanning protocol led to further 5 patients with suspected CeAD during the study period, all ruled out by additional magnetic resonance imaging with angiogram (MRI/MR-A). Conclusion: A lack of specific neurologic symptoms on admission urges the need for a dedicated imaging pathway for severely injured patients, reliable for the detection of cervical artery dissections. Although our modified CT protocol with mandatory dedicated CT-A led to false positives requiring additional magnetic resonance imaging, it likely helped reduce possible therapeutic delays.

Highlights

Traumatic cervical artery dissections are associated with high mortality and morbidity in severely injured patients
In November 2018, the whole-body computed tomography (CT) scanning protocol was modified to a single-bolus split-scan approach including a dedicated contrast-enhanced head-and-neck computed tomography angiogram (CT-A) triggered in the Aorta ascendens
One key finding of the results reported here is the need for a diagnostic routine in severely injured patients that is able to reliably detect cervical artery injuries, as none of the patients covered in the recent 18 month period showed symptoms on admission

Summary

Introduction

Traumatic cervical artery dissections are associated with high mortality and morbidity in severely injured patients. With a mortality rate of up to 33% and a neurological morbidity rate of up to 38%, traumatic carotid artery dissections and vertebral artery dissections are serious injuries in complex and severely injured patients [2,3,4]. The majority of these diseases remain initially asymptomatic, which might lead to a missed diagnosis [3,4] and avoidable delays in therapy such as anticoagulation, surgery, or endovascular treatment by thrombectomy or stenting. A contrast-enhanced multidetector computed tomography (CT) of the head, neck, thorax, abdomen, and pelvis according to the S3 guideline is used in severely and multiply injured patients and offers a demonstrable survival advantage [5], even when the mean injury severity score (ISS) was greater than that in patients without standardized imaging

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