Screening for blunt cerebrovascular injuries is cost-effective.
BACKGROUND
Recent reports have argued that screening for blunt carotid injury is futile and have called for a cost analysis. Our data previously supported screening asymptomatic trauma patients for blunt cerebrovascular injury (BCVI) to prevent associated neurologic sequelae. Our hypothesis is that aggressive angiographic screening for BCVI based on a patient's injury pattern and symptoms allows for early diagnosis and treatment and is cost-effective because it prevents ischemic neurological events (INEs).


METHODS
Beginning in January 1996, we began comprehensive screening using 4-vessel cerebrovascular angiography based on injury patterns; these patients have been followed-up prospectively. Patients without contraindications received antithrombotic therapy immediately for documented BCVI.


RESULTS
From January 1996 through June 2004, there were 15,767 blunt-trauma patient admissions to our state-designated level I urban trauma center, of which 727 patients underwent screening angiography. Twenty-one patients presented with signs or symptoms of neurologic ischemia before diagnosis. BCVI was identified in 244 patients (34% screening yield); the majority were men (68%) with a mean age of 35 +/- 3.7 years and mean Injury Severity Score of 28 +/- 3.8. Asymptomatic patients (n = 187) were treated (heparin in 117, low molecular-weight heparin in 11, and antiplatelet in 59); 1 patient had a stroke (0.5%). Using estimated stroke rate by grade of injury, we averted neurologic events in 32 asymptomatic patients with antithrombotic treatment. Of the 48 asymptomatic patients who did not receive adequate anticoagulation, 10 (21%) had an INE. Patients with BCVI-related neurologic events had a statistically higher percentage requiring discharge to rehabilitation facilities (50% vs. 77% for carotid artery injury [CAI]), a higher percentage requiring rehabilitation for BCVI-related stroke (0% vs. 55% for CAI), and a higher stroke-related mortality rate (0% vs. 21% for CAI and 0% vs. 17% for vertebral artery injury) than those without neurologic events.


CONCLUSIONS
The cost of long-term rehabilitation care and human life after BCVI-associated neurologic events is substantial. Surgeons caring for the multiply injured should screen for carotid and vertebral artery injuries in high-risk patients.
Cothren
C Clay
CC
Department of Surgery, Denver Health Medical Center and the University of Colorado Health Sciences Center, 777 Bannock St., Denver, CO 80204, USA. clay.cothren@dhha.org
Moore
Ernest E
EE
Ray
Charles E
CE
Ciesla
David J
DJ
Johnson
Jeffrey L
JL
Moore
John B
JB
Burch
Jon M
JM
D000328:Adult; D020212:Carotid Artery Injuries / Q000000981:diagnostic imaging* / Q000191:economics / Q000209:etiology; D002533:Cerebral Angiography / Q000191:economics*; D003362:Cost-Benefit Analysis; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D019838:Neck Injuries / Q000150:complications / Q000000981:diagnostic imaging / Q000191:economics; D011446:Prospective Studies; D015599:Trauma Severity Indices; D014711:Vertebral Artery / Q000000981:diagnostic imaging / Q000293:injuries