Routine CTA screening identifies blunt cerebrovascular injuries missed by clinical risk factors

OBJECTIVES: Current guidelines for screening for blunt cerebrovascular injury (BCVI) are commonly based on the expanded Denver criteria, a set of risk factors that identifies patients who require CT-angiographic (CTA) screening for these injuries. Based on previously published data from our center, we have adopted a more liberal screening guideline than those outlined in the expanded Denver criteria. This entails routine CTA of the neck for all blunt trauma patients already undergoing CT of the cervical spine and/or CTA of the chest. The aim of this study was to analyze the incidence of patients with BCVI who did not meet any of the risk factors included in the expanded Denver criteria. METHODS: A retrospective review of all patients diagnosed with BCVI between June 2014 and December 2019 at a Level I Trauma Center were identified from the trauma registry. Medical records were reviewed for the presence or absence of risk factors as outlined in the expanded Denver criteria. Demographic data, time to CTA and treatment, BCVI grade, Glasgow Coma Scale and Injury Severity Score were collected. RESULTS: During the study period, 17 054 blunt trauma patients were evaluated, and 29% (4923) underwent CTA of the neck to screen for BCVI. 191 BCVIs were identified in 160 patients (0.94% of all blunt trauma patients, 3.25% of patients screened with CTA). 16% (25 of 160) of patients with BCVI had none of the risk factors outlined in the Denver criteria. CONCLUSION: Our findings indicate that reliance on the expanded Denver criteria alone for BCVI screening will result in missed injuries. We recommend CTA screening in all patients with blunt trauma undergoing CT of the cervical spine and/or CTA of the chest to minimize this risk. LEVEL OF EVIDENCE: Level III, therapeutic/care management.