Evaluating the use and utility of noninvasive angiography in diagnosing traumatic blunt cerebrovascular injury.
BACKGROUND
Digital subtraction angiography (DSA) is the gold standard for radiographic diagnosis of blunt cerebrovascular injury (BCVI), but use of computed tomography angiography (CTA) and magnetic resonance angiography (MRA) has increased dramatically in BCVI screening. This study explores the utility, effectiveness, and cost of noninvasive CTA and MRA screening for BCVI.


METHODS
Medical records of 2,025 consecutive adults evaluated for acute blunt neck trauma and BCVI were reviewed retrospectively. The incidence of BCVI, level(s) of cervical injury, involvement of foramina transversaria and internal carotid canals, presence of bony dislocation or subluxation, and subsequent treatment received were assessed. Asymptomatic patients were analyzed based on fracture and injury patterns. The cost effectiveness of CTA compared with DSA and the effects of CTA sensitivity and screening yield were determined.


RESULTS
Of reviewed patients, 196 received CTA or MRA. Thirty-eight patients (19.4%) were diagnosed with BCVI. Screening yield in patients symptomatic at presentation was 48.8%. Large-vessel internal carotid, vertebral, anterior spinal, and basilar artery occlusion were associated with a positive screen, as were concurrent stroke and spinal cord injury (p < 0.01). Of patients with injuries found with noninvasive imaging, 50.0% of BCVI involved C1-3 fracture, 34.2% involved subluxation, and 65.8% involved foramina transversaria. In both symptomatic and asymptomatic patients, CTA screening was more cost effective than DSA.


CONCLUSIONS
Noninvasive imaging is a safe, accurate, and cost-effective tool for BCVI screening. Symptomatic presentation was the best predictor of BCVI. Significant cost savings were realized using CTA rather than DSA, with similar effectiveness and patient outcomes.


METHODS
Diagnostic study, level III; economic analysis, level IV.
Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan 48109, USA. antwang@umich.edu
Anthony C
AC
Wang
Michael A
MA
Charters
Jayesh P
JP
Thawani
Khoi D
KD
Than
Stephen E
SE
Sullivan
Gregory P
GP
Graziano
D000328:Adult; D000368:Aged; D000704:Analysis of Variance; D015901:Angiography, Digital Subtraction / Q000191:economics / Q000706:statistics & numerical data; D001930:Brain Injuries / Q000175:diagnosis* / Q000401:mortality* / Q000628:therapy; D002533:Cerebral Angiography / Q000191:economics / Q000706:statistics & numerical data; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D003952:Diagnostic Imaging / Q000191:economics* / Q000379:methods*; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D015601:Injury Severity Score; D018810:Magnetic Resonance Angiography / Q000191:economics / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D012042:Registries; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D015996:Survival Rate; D014057:Tomography, X-Ray Computed / Q000191:economics / Q000706:statistics & numerical data; D014949:Wounds, Nonpenetrating / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy