A. Grigorian1, N. Kabutey1, S. Schubl1, M. Dolich1, V. Joe1, D. Elfenbein1, C. De Virgilio2, J. Nahmias1 1University Of California – Irvine,Division Of Trauma, Burns & Surgical Critical Care,Orange, CA, USA 2University Of California – Los Angeles,Harbor-UCLA Medicine Center, Department Of Surgery,Los Angeles, CA, USA
Introduction: Screening for blunt cerebrovascular injury (BCVI) (carotid artery injury [CAI] or vertebral artery injury [VAI]) requires computed tomographic angiography (CTA) of the neck. Conventional indications for screening may miss up to 20% of BCVI. Expanded indications for BCVI screening (expanded Denver criteria [eDC]) were created in 2012. The eDC includes additional signs, symptoms and risk factors to help capture that “missing” 20%. We hypothesized that the introduction of eDC would lead to an overall increase in the incidence of BCVI. We also sought to identify risk factors for CAI and VAI, as well as whether an increased detection of BCVI would lead to a decrease in stroke rate and mortality.
Methods: The National Trauma Data Bank was queried for all blunt trauma admissions between 2007-2015. Two groups were stratified based on pre-eDC (2007-2011) or post-eDC era (2012-2015). The primary outcome was the incidence of BCVI. Secondary outcomes were stroke-rate and mortality. After a univariate logistic regression model identified significant covariates we performed a multiple logistic regression for analysis.
Results: Of the total 5,635,700 blunt trauma admissions there were 11,741 BCVIs (97.7% CAI, 2.9% VAI). The pre-eDC group was younger (median, 43.5 vs 47.1) with a higher injury severity score (mean, 10.8 vs 9.3). The post-eDC group had a higher prevalence of smokers (14.1% vs 6.1%), history of stroke (2.3% vs 1.9%) and hypertension (29.6% vs 21.3%) (all p<0.001). There were 5,085 BCVI in the pre-eDC group (0.20%), and 6,656 BCVI in the post-eDC group (0.23%) (p<0.001) translating to a 15% increase incidence of BCVI (OR 1.25, CI 1.20-1.30, p<0.001). The stroke-rate in the post-eDC was significantly higher (5.74% vs 13.49%) (OR 2.75, CI 2.40-3.15, p<0.001). There was no difference in mortality or number of patients with traumatic brain injury (p>0.05). The strongest predictors for BCVI were skull base fracture (OR 3.61, CI 3.46-3.77, p<0.001) and cervical spine fracture (OR 3.43, CI 3.29-3.57, p<0.001). The most significant independent traumatic risk factor for VAI was cervical spine fracture (OR 19.98, CI 15.85-25.19, p<0.001) while skull base fracture was the most significant for CAI (OR 3.62, CI 3.46-3.78, p<0.001). CAI was more likely to be associated with stroke than VAI in blunt trauma victims (OR 19.62, CI 18.25-21.10, p<0.001).
Conclusion: The incidence of BCVI following blunt trauma has significantly increased in the past few years. This increase may be related to the adoption of expanded criteria for CTA of the neck in at risk patients. Skull base fracture was the strongest traumatic risk factor for BCVI. CAI is more likely to be associated with stroke than VAI. Although detection may have increased, the stroke-rate doubled. Future research will be needed to investigate this further.