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Blunt cerebrovascular injury screening with 64-channel multidetector computed tomography: More slices finally cut it

Paulus, Elena M. MD; Fabian, Timothy C. MD; Savage, Stephanie A. MD, MS; Zarzaur, Ben L. MD, MPH; Botta, Vandana BS; Dutton, Wesley BS; Croce, Martin A. MD

Journal of Trauma and Acute Care Surgery: February 2014 - Volume 76 - Issue 2 - p 279–285
doi: 10.1097/TA.0000000000000101
AAST 2013 Plenary Paper
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BACKGROUND Aggressive screening to diagnose blunt cerebrovascular injury (BCVI) results in early treatment, leading to improved outcomes and reduced stroke rates. While computed tomographic angiography (CTA) has been widely adopted for BCVI screening, evidence of its diagnostic sensitivity is marginal. Previous work from our institution using 32-channel multidetector CTA in 684 patients demonstrated an inadequate sensitivity of 51% (Ann Surg. 2011,253: 444–450). Digital subtraction angiography (DSA) continues to be the reference standard of diagnosis but has significant drawbacks of invasiveness and resource demands. There have been continued advances in CT technology, and this is the first report of an extensive experience with 64-channel multidetector CTA.

METHODS Patients screened for BCVI using CTA and DSA (reference) at a Level 1 trauma center during the 12-month period ending in May 2012 were identified. Results of CTA and DSA, complications, and strokes were retrospectively reviewed and compared.

RESULTS A total of 594 patients met criteria for BCVI screening and underwent both CTA and DSA. One hundred twenty-eight patients (22% of those screened) had 163 injured vessels: 99 (61%) carotid artery injuries and 64 (39%) vertebral artery injuries. Sixty-four–channel CTA demonstrated an overall sensitivity per vessel of 68% and specificity of 92%. The 52 false-negative findings on CTA were composed of 34 carotid artery injuries and 18 vertebral artery injuries; 32 (62%) were Grade I injuries. Overall, positive predictive value was 36.2%, and negative predictive value was 97.5%. Six procedure-related complications (1%) occurred with DSA, including two iatrogenic dissections and one stroke.

CONCLUSION Sixty-four–channel CTA demonstrated a significantly improved sensitivity of 68% versus the 51% previously reported for the 32-channel CTA (p = 0.0075). Sixty-two percent of the false-negative findings occurred with low-grade injuries. Considering complications, cost, and resource demand associated with DSA, this study suggests that 64-channel CTA may replace DSA as the primary screening tool for BCVI.

LEVEL OF EVIDENCE Diagnostic study, level III.

From the Division of Trauma, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee.

Submitted: September 13, 2013, Revised: October 28, 2013, Accepted: October 30, 2013.

This study was presented at the 72nd Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery, September 18–21, 2013, in San Francisco, California.

Address for reprints: Timothy C. Fabian, MD, Department of Surgery, University of Tennessee Health Science Center, 910 Madison Bldg, 2nd Floor, Memphis, TN 38163; email: tfabian@uthsc.edu.

© 2014 Lippincott Williams & Wilkins, Inc.