title: Blunt cerebrovascular injury screening guidelines: what are we willing to miss?
abstract: BACKGROUND
  Blunt cerebrovascular injury (BCVI) is reported to occur in approximately 2% of blunt trauma patients, with a stroke rate of up to 20%. Guidelines for BCVI screening are based on clinical and radiographic findings. We hypothesized that liberal screening of the neck vasculature, as part of initial computed tomographic (CT) imaging in blunt trauma patients with significant mechanisms of injury, identifies BCVI that may go undetected.
  
  
  METHODS
  As per protocol, patients at risk for significant injuries undergo a noncontrast head CT scan followed by a multislice CT scan (40-slice or 64-slice) incorporating an intravenous contrast-enhanced pass from the circle of Willis through the pelvis (whole-body CT [WBCT] scan). The trauma registry was retrospectively reviewed, and all patients with BCVI from 2009 to 2012 were analyzed. Patients undergoing WBCT scan were then identified, and records were reviewed for BCVI indicators (skull base fracture, cervical spine injury, displaced facial fracture, mandible fracture, Glasgow Coma Scale score ≤ 8, flexion mechanism, hard signs of neck vascular injury, or focal neurologic deficit).
  
  
  RESULTS
  Of 16,026 patients evaluated during the study period, 256 (1.6%) were diagnosed with BCVI. The population consisted of 185 patients with suspected BCVI after WBCT scan. One hundred twenty-nine patients (70%) had at least one indicator for BCVI screening, while 56 (30%) had no radiographic or clinical risk factors; 48 of the 56 patients underwent confirmatory CT angiography of the neck within 71 hours of initial WBCT scan, with 35 patients having 45 injuries.
  
  
  CONCLUSIONS
  More liberalized screening for BCVI during initial CT imaging in trauma patients clinically judged to have sufficient mechanism is warranted. Using current BCVI screening guidelines leads to missed BCVI and risk of stroke.
  
  
  METHODS
  Diagnostic study, level III.
authors.affiliation: From the University of Maryland Medical Center (B.R.B., R.T., C.S., A.L., T.M.S., D.M.S.), Shock Trauma and Anesthesiology Research-Organized Research Center (J.K.), R Adams Cowley Shock Trauma Center, Baltimore, Maryland.
authors.forename: Brandon Robert
authors.initials: BR
authors.lastname: Bruns
authors.forename: Ronald
authors.initials: R
authors.lastname: Tesoriero
authors.forename: Joseph
authors.initials: J
authors.lastname: Kufera
authors.forename: Clint
authors.initials: C
authors.lastname: Sliker
authors.forename: Adriana
authors.initials: A
authors.lastname: Laser
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Scalea
authors.forename: Deborah M
authors.initials: DM
authors.lastname: Stein
mesh_terms: D005260:Female; D015600:Glasgow Coma Scale; D016489:Head Injuries, Closed / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging; D006801:Humans; D008297:Male; D008875:Middle Aged; D009333:Neck / Q000098:blood supply / Q000000981:diagnostic imaging; D059906:Neuroimaging / Q000592:standards; D017410:Practice Guidelines as Topic / Q000592:standards; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000209:etiology; D014057:Tomography, X-Ray Computed / Q000592:standards; D051598:Whole Body Imaging / Q000592:standards