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Blunt cerebrovascular injuries: Redefining screening criteria in the era of noninvasive diagnosis

Burlew, Clay Cothren MD; Biffl, Walter L. MD; Moore, Ernest E. MD; Barnett, Carlton C. MD; Johnson, Jeffrey L. MD; Bensard, Denis D. MD

The Journal of Trauma and Acute Care Surgery: February 2012 - Volume 72 - Issue 2 - p 330–337
doi: 10.1097/TA.0b013e31823de8a0
AAST 2011 Papers
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Background: Screening for blunt cerebrovascular injuries (BCVIs) and early treatment has virtually eliminated injury-related strokes. Screening protocols developed in the 1990s captured ∼80% of ultimately identified BCVI. With the availability of noninvasive diagnosis with computed tomographic angiography, broader indications for screening seem warranted. The purpose of this study was to identify injury patterns of patients with BCVI that are not currently recommended screening criteria.

Methods: Our prospective BCVI database, initiated in 1997, was queried through December 2010. Indications for screening, injury mechanism, and outcomes were analyzed. Patients younger than 18 years were excluded.

Results: During the 14-year study period, 585 BCVIs were identified in 418 patients (66% men; age, 40 years ± 0.7 years). Eighty-three (20%) patients with BCVI did not have standard screening criteria; 66% were asymptomatic at diagnosis. Injury patterns in these patients included mandible fracture (27 patients), complex skull fractures (21 patients), traumatic brain injury with thoracic trauma (6 patients), scalp degloving (6 patients), and great vessel or cardiac injuries (4 patients). Other injuries (11 patients) and no injuries (8 patients) were identified in the remainder. Of the 307 asymptomatic patients who received antithrombotic treatment, one patient suffered stroke (0.3%) and one patient a transient ischemic attack (0.3%).

Conclusions: A significant number of patients suffering BCVI are not captured by current screening guidelines. Screening for BCVI should be considered in patients with mandible fractures, complex skull fractures, traumatic brain injury with thoracic injuries, scalp degloving, and thoracic vascular injuries.

Level of Evidence: II, prognostic study.

Denver, Colorado

From the Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, Denver, Colorado.

Submitted: September 1, 2011, Revised: October 4, 2011, Accepted: October 17, 2011.

Presented at the 2011 American Association for the Surgery of Trauma Annual Meeting, Chicago, Illinois.

Address for reprints: Clay Cothren Burlew, MD, FACS, Department of Surgery, Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204; email: clay.cothren@dhha.org.

© 2012 Lippincott Williams & Wilkins, Inc.