title: Screening and detection of blunt vertebral artery injury in patients with upper cervical fractures: the role of cervical CT and CT angiography.
abstract: OBJECTIVE
  To evaluate the clinical utility of nonenhanced CT (NECT)-based screening criteria and CTA in detection of blunt vertebral artery injury (BVAI) in trauma patients with C1 and/or C2 fractures.
  
  
  METHODS
  We retrospectively reviewed the clinical records of all blunt trauma patients with C1 and/or C2 fractures between 8/2006 and 9/2011. Cervical CTA was prompted by cervical fractures involving/adjacent to a transverse foramen, and/or subluxation on NECT. Two neuroradiologists independently reviewed the CTA studies, and graded the BVAI.
  
  
  RESULTS
  210 patients were included; of these, 124 underwent CTA (21/124 with digital subtraction angiography, DSA), and 2 underwent DSA only. Overall, 30/126 suffered BVAI. Among 21 patients who underwent both CTA and DSA, there was 1 false negative and 1 false positive (both grade 1). There was strong interobserver agreement regarding CTA-based BVAI detection (kappa=0.93, p<0.001) and grading (kappa=0.90, p<0001). Only 3/30 BVAI patients suffered a posterior circulation stroke; none of the patients who had a negative CTA or were not selected for CTA, based on NECT screening criteria, suffered symptomatic stroke. While C1/C2 comminuted fracture was more common in patients with high grade BVAI (p=0.039), simultaneous C3-C7 comminuted fracture increased the overall BVAI risk (p=0.011).
  
  
  CONCLUSIONS
  CTA reliably detects symptomatic BVAI in patients with upper cervical fractures. Utilization of NECT-based screening criteria such as transverse foraminal involvement or subluxation may be adequate in deciding whether to perform CTA, as no patients who were not selected for CTA suffered a symptomatic stroke. However, CTA may miss lower grade, asymptomatic BVAI.
authors.affiliation: Department of Radiology, University of Minnesota Medical Center, Minneapolis, MN, USA. Electronic address: spayab@gmail.com.
authors.forename: Seyedmehdi
authors.initials: S
authors.lastname: Payabvash
authors.affiliation: Department of Radiology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN, USA. Electronic address: mckinrad@umn.edu.
authors.forename: Alexander M
authors.initials: AM
authors.lastname: McKinney
authors.affiliation: Department of Radiology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN, USA. Electronic address: zeke.mckinney@hcmed.org.
authors.forename: Zeke J
authors.initials: ZJ
authors.lastname: McKinney
authors.affiliation: Department of Radiology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN, USA. Electronic address: palme018@umn.edu.
authors.forename: Christopher S
authors.initials: CS
authors.lastname: Palmer
authors.affiliation: Department of Radiology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN, USA. Electronic address: truwit@umn.edu.
authors.forename: Charles L
authors.initials: CL
authors.lastname: Truwit
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000792:Angiography / Q000379:methods*; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging / Q000293:injuries*; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000379:methods; D008875:Middle Aged; D009104:Multiple Trauma / Q000000981:diagnostic imaging; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D016103:Spinal Fractures / Q000000981:diagnostic imaging*; D014057:Tomography, X-Ray Computed / Q000379:methods*; D014711:Vertebral Artery / Q000000981:diagnostic imaging* / Q000293:injuries*; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging*; D055815:Young Adult
keywords: CT angiography; Cervical fracture; Digital subtraction angiography; Subluxation; Transverse foramen fracture; Vertebral artery injury