Tag Archives: vertebral

Complications, Imaging

Best Of EAST #8: Timing Of Reimaging For BCVI

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There are still many questions regarding optimal management of blunt carotid and vertebral arterial injury (BCVI). We know that they may ultimately result in a stroke. And we kind of know how to manage them to try to avoid this. We also know that the grade may change over time, and many vascular surgeons recommend re-imaging at some point.

But when? There are still many questions. A multi-center trial has been collecting observational data on this issue since 2018. The group reviewed three years of data to examine imaging characteristics and stroke rate during the study period.

Here are the factoids:

  • A total of 739 cases were identified at 16 trauma centers
  • The median number of imaging studies was 2, with a range of 1-9 (!). Two thirds received only one study.
  • Injury grade distribution was as follows:
    • Grade 1 – 42%
    • Grade 2 – 30%
    • Grade 3 – 10%
    • Grade 4 – 18%
    • Grade 5 – <1%
  • About 30% changed in grade during the hospitalization, with 7% increasing and 24% decreasing.
  • Average time to change in grade was 7 days
  • Nearly 75% of those that decreased actually resolved. All of the grade 1 lesions resolved.
  • Stroke tended to occur after about one day after admission, although the grade 1 lesions took longer at 4 days
  • Strokes occurred much earlier than grade change

The authors concluded that there should be further investigation about the utility of serial imaging for stroke prevention.

Bottom line: This is basically a “how we did it” study to tease out data on imaging and stroke after BCVI. It’s clear that there is no consensus across trauma centers regarding if and when repeat imaging is done. And it’s not really possible to make any recommendations about repeat imaging based on this study.

However, it does uncover one important fact. It takes a week for the injury grade on CT to change, but strokes occur much earlier and usually within 24 hours! This is important because it makes it clear that it’s crucial to actually make the diagnosis early. Average stroke occurrence was 9% overall. Grade 1 injuries had only a 3% rate, but grades 2-4 were in the 12-15% range. Grade 5 had a 50% stroke rate!

These facts reinforce the importance of identifying as many of these BCVI as possible during the initial evaluation. The abstract I reviewed yesterday confirmed that the existing screening criteria (Memphis, Denver) will miss too many. More liberal imaging is probably indicated. If you missed the post, click here to view it in a new window.

Here are my comments for the authors and presenter:

  • The “change in BCVI grade over time” charts in the abstract are not readable. Please provide clear images during your presentation and explain what they mean. I was confused!
  • Based on your data, do you have any recommendations regarding the utility of re-imaging? Is it necessary in the same hospitalization at all? These patients will receive treatment anyway, and it doesn’t appear to have any impact on stroke rate.
  • Do you have any recommendations regarding the (f)utility of existing screening systems given the early occurrences of stroke in the study? Are you a fan of using energy / mechanism rather than a bullet list of criteria?

This is important work and I can’t wait to look at the data up close.

Reference: BLUNT CEREBROVASCULAR INJURIES: TIMING OF CHANGES TO INJURY GRADE AND STROKE FORMATION ON SERIAL IMAGING FROM AN EAST MULTI-INSTITUTIONAL TRIAL. EAST 35th ASA, oral abstract #34.

Complications, Imaging

Best Of EAST #7: Routine Screening vs Denver Criteria For BCVI

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Currently, blunt carotid and vertebral artery injury (BCVI) is diagnosed using CT angiography of the great vessels and neck. This study is typically ordered when there is some degree of clinical suspicion based on the application of an established screening system. There are currently two such systems in use, Denver and Memphis.

I dedicated a week to BCVI earlier in the year. If you’d like to read the series, click here.

Both screening systems have been updated over the years. There is now a modified Memphis and an expanded Denver system. The reason for the modifications is simple: some patients were not flagged as at risk by the original versions of the systems. Does this mean we should screen more, or even screen everybody?

To answer this question, it’s important to have an idea of the number of patients who actually sustain the injury. This means having a liberal screening policy in place in the first place. The trauma group at Ascension St. Vincent Hospital in Indianapolis liberalized their criteria in 2012 and first published their experience in 2015. In this abstract, they examined their experience in screening all high-energy patients and reviewing how many patients would have been screened using the expanded Denver criteria.

Here are the factoids:

  • This is a single-center, retrospective study carried out over 5.5 years
  • A total of about 17,000 blunt trauma patients were seen, and about 30% underwent CTA neck for BCVI screening
  • About 1% of total patients screened were found to have BCVI, which was about 3% of those who underwent CTA
  • Sixteen percent of patients who actually had BCVI did NOT meet any of the expanded Denver criteria
  • Ten percent of patients with grades III-V injury did not meet any of the criteria

The authors concluded that using the expanded Denver criteria alone will result in missed injuries and that liberalized screen should be considered to decrease risk.

Bottom line: Once again, this is a paper that conforms to my own bias and experience, so I have to work to be critical of it. We have seen delayed diagnoses of this injury at our center using the standard criteria. For that reason, we recently implemented a guideline to add CTA neck on any patient with a mechanism sufficient to warrant CTA chest (we are not automatic pan-scanners).

This is a straightforward descriptive study at a center that has had a liberal BCVI screening guideline for nearly a decade. The only opportunity for bias lies in the specifics of the screening criteria. In St. Vincent’s case, it is simple: any patient with a mechanism sufficient to require CT cervical spine or chest received CTA neck as well.

I would argue that this might be a bit too liberal. There are many elderly patients who fall that require cervical spine CT, but the mechanism should be insufficient to sustain a BCVI. It can be an add-on study if fracture patterns are seen that fall within the Denver or Memphis criteria.

Here are my questions for the authors and presenter:

  • Why choose the Denver criteria? Why not look at Memphis, too? I’m sure you will find similar issues.
  • Did you analyze your elderly falls patients who got their CTA based on your cervical CT criterion? It seems like this could result in substantial overtriage. Did you actually detect any BCVI in this group if they didn’t have one of the classic fracture patterns?

This is an important abstract, and I’m looking forward to hearing all the specifics! It looks like it may be time to seriously consider the energy of the mechanism, if not ditch the criteria altogether.

Reference: ROUTINE CT SCREENING FOR BLUNT CEREBROVASCULAR INJURY IDENTIFIES INJURIES MISSED BY CLINICAL RISK FACTORS. EAST 35th ASA, oral abstract #35.

Complications

Treatment Of BCVI

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In my last post, I reviewed the grading system for blunt carotid and vertebral artery injury (BCVI). Today, we’ll wrap up and discuss treatment.

There are basically three modalities at our disposal for managing BCVI: antithrombotic medication (heparin and/or antiplatelet agents), surgery, and endovascular procedures. The choice of therapy is usually based on surgical accessibility and patient safety for anticoagulation. We do know that a number of studies have shown a decrease in stroke events in patients who are heparinized. Unfortunately, this is not always possible due to associated injuries. Antiplatelet agents are usually tolerated after acute trauma, especially low-dose aspirin. Several studies have shown little difference in outcomes in patients receiving heparin vs aspirin/clopidogrel for BCVI.

So what to do? Here are some broad guidelines:

  • Grade I (intimal flap). Heparin or antiplatelet agents should be given. If heparin can be safely administered, it may be preferable in patients who will need other surgical procedures since it can be rapidly reversed just by stopping the infusion. These lesions generally heal completely on their own, so a followup CT angiogram should be scheduled in 1-2 weeks. Medication can be stopped when the lesion heals.
  • Grade II (flap/dissection/hematoma). These injuries are more likely to progress, so heparin is preferred if it can be safely given. Stenting should be considered, especially if the lesion progresses. Long-term anti-platelet medication may be required.
  • Grade III (pseudoaneurysm). Initial heparin therapy is preferred unless contraindicated. Stable pseudoaneurysms should be followed with CTA every 6 months. If the lesion enlarges, then surgical repair should be carried out in accessible injuries or stenting in inaccessible ones.
  • Grade IV (occlusion). Heparin therapy should be initiated unless contraindicated. Patients who do not suffer a catastrophic stroke may do well with followup antithrombotic therapy. Endovascular treatment does not appear to be helpful.
  • Grade V (transection with extravasation). This lesion is frequently fatal, and the bleeding must be addressed using the best available technique. For lesions that are surgically accessible, the patient should undergo the appropriate vascular procedure. Inaccessible injuries should undergo angiographic treatment and may require embolization to control bleeding without regard for the possibility of stroke.

References:

  1. Scott WW, Sharp S, Figueroa SA, et al. Clinical and radiographic outcomes following traumatic Grade 1 and 2 carotid artery injuries: a 10-year ret-rospective analysis from a Level I trauma center. J Neurosurg 122:1196, 2015.
  2. Scott WW, Sharp S, Figueroa SA, et al. Clinical and radiographic outcomes following traumatic Grade 3 and 4 carotid artery injuries: a 10-year ret-rospective analysis from a Level 1 trauma center. J Neurosurg 122:610, 2015.
  3. Scott WW, Sharp S, Figueroa SA, et al. Clinical and radiological outcomes following traumatic Grade 1 and 2 vertebral artery injuries: a 10-year retrospective analysis from a Level 1 trauma cen-ter. J Neurosurg 121:450, 2015.
  4. Scott WW, Sharp S, Figueroa SA, et al. Clinical and radiological outcomes following traumatic Grade 3 and 4 vertebral artery injuries: a 10-year retrospective analysis from a Level I trauma center. The Parkland Carotid and Vertebral Artery Injury Survey. J Neurosurg 122:1202, 2015.
Complications

How To Grade BCVI

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In my last post, I reviewed the three screening systems for blunt carotid and vertebral artery injury (BCVI). Today, we’ll look at grading them.

Only 10 years ago, it was a major production to identify BCVI. CT angiography was still in its early days, and scanner resolution and radiologist experience were major issues that impacted accuracy.

We’ve come a long way in a relatively short period of time, and current day scanners now have more than adequate resolution. It’s also more common to have a radiologist with special skills reading these studies, the neuroradiologist. For these reasons, CT angiography has become the standard for diagnosis. It is also the most cost-effective. Only in very rare cases do we need to obtain a conventional contrast angiogram.

Once the study has been obtained, it’s time to identify and classify the injury. The Denver group is also responsible for bringing us the grading system for BCVI. See the diagram below.

Here are the details:

Grade I: A mild intimal irregularity is seen. Note the abnormally narrowed area, representing a small intimal injury, possibly with a small amount of clot.

Grade II: This grade has several presentations. There may be an intraluminal thrombosis/hematoma with (left) or without (right) an intimal flap, or a flap alone (center).

Grade III: There is a full-thickness injury to the vessel with a contained extraluminal extravasation (pseudoaneurysm)

Grade IV: The vessel is completely occluded by flap or thrombus

Grade V: The artery is transected and freely extravasating

Here’s a nice diagram:

Remember, we always grade things for a reason! Ultimately, the injury grade will translate into the selection of treatment. We’ll cover that in my next post.

Reference: Blunt carotid arterial injuries: implications of a new grading scale. J Trauma. 1999;47(5): 845-53.

Complications, Head

Screening For BCVI

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In my last post, I described how common we think blunt carotid and vertebral injury (BCVI) really is. Today, I’ll review how we screen for this condition.

Currently, there are three systems in use: Denver, Expanded Denver, and Modified Memphis. Let’s look at each in detail.

Denver BCVI Screening

There is an original Denver screening system, and a more recent modification. The original system was divided into mechanism, physical signs, and radiographic findings. It was rather rudimentary and evolved into the following which uses both signs and symptoms, and high-risk factors.

Signs and symptoms

  • potential arterial hemorrhage from the neck, nose, or mouth
  • cervical bruit in patients <50 years of age
  • expanding cervical hematoma
  • focal neurologic deficit (transient ischemic attack, hemiparesis, vertebrobasilar symptoms, Horner syndrome) incongruous with head CT findings
  • stroke on CT

Risk factors

  • Le Fort II or III mid-face fractures
  • Cervical spine fractures (including subluxations), especially fractures involving transverse foramen or C1-C3 Vertebrae
  • Basilar skull fracture and involvement of carotid canal
  • Diffuse axonal injury with GCS <8
  • Near hanging with anoxic brain injury
  • Seat belt sign (or other soft tissue neck injury) especially if significant associated swelling or altered level of consciousness

The Denver group reviewed their criteria in 2012 and found that 20% of the patients who had identified BCVI did not meet any of their criteria. And obviously, this number cannot include those who were never symptomatic and therefore never discovered.

Based on their analysis, they added several additional risk factors to the original system:

  • Mandible fracture
  • Complex skull fracture/basilar skull fracture/occipital condyle fracture
  • TBI with thoracic injuries
  • Scalp degloving
  • Thoracic vascular injuries
  • Blunt cardiac rupture

The downside of these modifications is that they are a little more complicated to identify. The original criteria were fairly straightforward yes/no items. But “TBI with thoracic injuries?” Both the TBI part and the thoracic injury part are very vague. This modification casts a wider net for BCVI, but the holes in the net are much larger.

Memphis BCVI Screening

Let’s move on to the modified Memphis system for identifying BCVI. It consists of seven findings that overlap significantly with the Denver criteria. The underlined phrases indicated the modifications that were applied to the original criteria.

  • base of skull fracture with involvement of the carotid canal
  • base of skull fracture with involvement of petrous temporal bone
  • cervical spine fracture (including subluxation, transverse foramen involvement, and upper cervical spine fracture)
  • neurological exam findings not explained by neuroimaging
  • Horner syndrome
  • Le Fort II or III fracture pattern
  • neck soft tissue injury (e.g. seatbelt sign, hanging, hematoma)

Interestingly, these modifications were first described in an abstract which was never published as a paper. Yet somehow, they stuck with us.

So there are now two or three possible systems to choose from when deciding to screen your blunt trauma patient. Which one is best?

Let’s go back to the AAST abstract presented by the Birmingham group this year that I mentioned previously. Not only did they determine a more accurate incidence, but they also tested the three major screening systems to see how each fared. See Table 1.

Look at these numbers closely. When any of these systems were applied and the screen was negative, the actual percentage of patients who still actually had the injury ranged from about 25% to 50%! Basically, it was a coin toss with the exception of the Expanded Denver criteria performing a little better.

If you are a patient and you actually have the injury, how often does any screening system pick it up? Oh, about one in five times. Again, this is not what we want to see.

So what to do? The Expanded Denver screen has a lower false negative rate, but the total number of positive screens, and hence the number of studies performed, doubles when it is used.

Here’s how I think about it. BCVI is more common than we thought in major blunt trauma. If not identified, a catastrophic stroke may occur. Current screening systems successfully flag only 50% of patients for imaging. So in my opinion, we need to consider imaging every patient who is already slated to receive a head and cervical spine CT after major blunt trauma! At least until we have a more selective (and reliable) set of screening criteria.

References:

  • (Denver) Optimizing screening for blunt cerebrovascular injuries. Am J Surg. 1999;178:517–522.
  • (Expanded Denver) Blunt cerebrovascular injuries: Redefining screening criteria in the era of noninvasive diagnosis. J Trauma 2012;72(2):330-337.
  • (Memphis) Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Ann Surg. 2002, 236 (3): 386-393.
  • (Modified Memphis) Diagnosis of carotid and vertebral artery injury in major trauma with head injury. Crit care. 2010;14(supp1):S100.