use CTA neck to assess for blunt cerebrovascular injury

This patient is presenting with considerable face and neck trauma in a setting of high-energy blunt trauma to the head with a Glasgow Coma Scale score consistent with a severe traumatic brain injury. This is an indication for CT angiography of the neck to assess for blunt cerebrovascular injury (choice B is correct). Blunt cerebrovascular injury of the carotid or vertebral arteries is graded into 5 categories according to the degree of vascular injury by the modified Denver criteria. Blunt cerebrovascular injury occurs in between 0.5% to 3.3% of blunt trauma cases but can have dramatic preventable stroke with a mortality rate up to 25%. Aggressive early screening for blunt cerebrovascular injury has reduced the rate of stroke from cerebrovascular injury from 20% to less than 1%. The expanded Denver criteria are used for identification of who should be screened for blunt cerebrovascular injury. These criteria include signs and symptoms as well as risk factors for blunt cerebrovascular injury. Any of these criteria mean the patient should undergo CT angiography of the neck urgently.

Signs and symptoms, including the following:

  • Arterial bleeding from the neck, nose, or mouth
  • Expanding cervical hematoma
  • Cervical bruit in a patient younger than 50 years
  • Focal neurologic deficits (transient ischemic attack, hemiparesis, Horner syndrome)
  • Ischemic stroke on CT scanning

MRI risk factors for blunt cerebrovascular injury, such as the following:

  • High-energy transfer mechanism
  • Displaced midface fracture (LeFort II or III: LeFort II fractures involve the nasal bones, medial-anterior orbital walls, inferior orbital rims, orbital floor, and a transverse fracture of the posterior maxilla and pterygoid plates. LeFort III fractures separate the maxilla from the skull base through transverse separation of the nasofrontal suture, medial orbital wall, and lateral orbital wall of the zygomaticofrontal suture, zygomatic arch, and pterygoid plates.)
  • Mandible fracture
  • Complex skull or basilar skull or occipital condyle fracture
  • Severe traumatic brain injury
  • Glasgow Coma Scale score of less than 6
  • Cervical spine fracture, subluxation, or ligamentous injury at any level
  • Near hanging with anoxic brain injury
  • Neck clothesline-type injury, seat belt abrasion, swelling, or pain
  • Traumatic brain injury with thoracic injuries
  • Scalp degloving
  • Thoracic vascular injuries
  • Blunt cardiac rupture
  • Upper rib fractures

The sensitivity of the expanded Denver criteria is 83%, the specificity is 50%, the positive predictive value is 5%, the negative predictive value is 99%, and the accuracy is 51% compared with results from universal screening CT angiography of the neck for all trauma patients. The percentage of patients with grade 3 or greater blunt cerebrovascular injury who were missed with use of the expanded Denver criteria was 23%. This has been a case some institutions have made for universal screening CT angiography of the neck for all blunt trauma patients. 

MRI of the brain will be an important future step in a patient without intracranial hemorrhage to explain neurologic status. However, CT angiography of the neck must be performed first given his numerous injuries meeting the Expanded Denver Criteria, as this will change his treatment and potentially prevent stroke (choice A is incorrect).

The sensitivity of CT of the cervical spine is 98.5%, with a negative predictive value of 99.97%. Clinical assessment of the cervical spine in patients who are neurologically intact reduces this to 0%. MRI of the cervical spine can be used to assess for cervical spine injury when a patient cannot be cleared clinically, like this patient, because of his traumatic brain injury. However, CT angiography to assess for blunt cerebrovascular injury takes precedence over clearing the cervical spine because the cervical collar can be left in place (choice C is incorrect).

Repeat CT scanning of the brain at 6 h is occasionally used in patients receiving anticoagulation with no intracranial hemorrhage on initial CT scanning of the brain. This is a young patient with no medical problems, and repeat CT scanning of the brain is unlikely to show new abnormalities (choice D is incorrect).12345678

A 29-year-old man with no medical history is presenting after an assault. His airway is patent, and he has bilateral breath sounds. His heart rate is 90/min, and his BP is 130/70 mm Hg. His Glasgow Coma Scale score is 6, and he is intubated for airway protection. He has extensive facial bruising and swelling, as well as bruising circumferentially of the neck. A cervical collar is in place. CT scanning of the head and neck demonstrates a LeFort II fracture and first rib fracture. There are no intracranial hemorrhages or cervical spine fractures.

What is the next urgent imaging study that must be performed to guide further management?

A 20-year-old man presents after being found in his home during an intentional self-injury by hanging. When found at home, he was unconscious and cyanotic in appearance but with a palpable pulse. He underwent intubation in the field and was brought to the emergency department where he remained comatose. CT scanning without contrast material of the head and cervical spine revealed no bone or soft-tissue injury and no acute abnormality of the brain. Urine drug screening results were positive for fentanyl. On ICU day 1, 24 h after presentation, the patient is now awake and following commands; however, he cannot move his left arm or leg. A repeat noncontrast-enhanced CT scan of the head is obtained and shown in Figure 1.

Which of the following tests is most likely to help diagnose the mechanism of the patient’s neurologic deficit?

Footnotes

  1. SEEK Questionnaires ↩

  2. Bush L, Brookshire R, Roche B, et al. Evaluation of cervical spine clearance by computed tomographic scan alone in intoxicated patients with blunt trauma. JAMA Surg. 2016;151(9):807-813. PubMed ↩

  3. Crawford JD, Allan KM, Patel KU, et al. The natural history of indeterminate blunt cerebrovascular injury. JAMA Surg. 2015;150(9):841-847. PubMed ↩

  4. Funk, G. Facial Fracture Management Handbook - Malar complex fractures. University of Iowa Health Care https://medicine.uiowa.edu/iowaprotocols/facial-fracture-management-handbook-malar-complex-fractures. Accessed March 28, 2022. ↩

  5. Geddes AE, Burlew CC, Wagenaar AE, et al. Expanded screening criteria for blunt cerebrovascular injury: a bigger impact than anticipated. Am J Surg. 2016;212(6):1167-1174. PubMed ↩

  6. Grigorian A, Kabutey NK, Schubl S, et al. Blunt cerebrovascular injury incidence, stroke-rate, and mortality with the expanded Denver criteria. Surgery. 2018;164(3):494-499. PubMed ↩

  7. Inaba K, Byerly S, Bush LD, et al; WTA C-Spine Study Group. Cervical spinal clearance: a prospective Western Trauma Association multi-institutional trial. J Trauma Acute Care Surg. 2016;81(6):1122-1130. PubMed ↩

  8. Leichtle SW, Banerjee D, Schrader R, et al. Blunt cerebrovascular injury: The case for universal screening. J Trauma Acute Care Surg. 2020;89(5):880-886. PubMed ↩