Chasing down cerebrovascular injury is a controversial topic. The incidence of injury to carotid or vertebral arteries following blunt trauma is extremely low, with relative rarity varying by practice setting. Because of its general infrequency, many settings utilize the “Memphis” or “Denver” screening criteria to improve the value of imaging.
These authors, however, describe their implementation of a universal screening protocol for BCVI as routine component of their “whole-body” CT for “all major adult blunt trauma activations”. The data set analyzed is a retrospective local trauma registry from their level 1 trauma center, and 4,687 activations fulfilled their inclusion criteria. The overall incidence of BCVI in their population was 2.7%, with about half of those being grade 3 or higher (pseudoaneurysm or worse).
Based on case review of these 126 patients with BCVIs, only 91 (72%) would have met the current American College of Surgeons guidelines for imaging, with a handful additional more picked up by expanded Denver criteria. The authors’ conclusion – universal screening should be considered – ties in a bit with their bias towards whole-body CT, presuming these additional detected injuries represent potential reduced downstream morbidity and mortality.
It should be clear, however, these data have somewhat limited generalizability to most of Emergency Medicine. The individuals with BCVI in their cohort suffered substantial numbers of skull base fractures, cervical spine fractures, traumatic brain injuries, and had in-hospital mortality of 12.7%. Outside the context of major trauma, universal screening for BCVI will be of limited value. For the vast majority of us, continuing to refer to the most recent EAST recommendations for selective screening remains a reasonable practice. In the narrower context of major trauma referrals, these data could inform more expansive screening protocols, while universal screening for all major trauma is still likely one step too far.
“Blunt Cerebrovascular Injury – The Case for Universal Screening”
https://journals.lww.com/jtrauma/Abstract/9000/BLUNT_CEREBROVASCULAR_INJURY___THE_CASE_FOR.97839.aspx