BLUNT CEREBROVASCULAR INJURY - THE CASE FOR UNIVERSAL SCREENING.

Current evidence-based screening algorithms for blunt cerebrovascular injury (BCVI) may miss more than 30% of carotid or vertebral artery injuries. We implemented universal screening for BCVI with CT angiography (CTA) of the neck at our level 1 trauma center, hypothesizing that only universal screening would identify all clinically relevant BCVIs. METHODS Adult blunt trauma activations from 7/2017 through 8/2019 underwent full-body CT scan including CTA neck with a 128-slice CT scanner. We calculated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of common screening criteria. We determined independent risk factors for BCVI using multivariate analyses. RESULTS 4,659 patients fulfilled inclusion criteria, 2.7% (n = 126) of which had 158 BCVIs. For the criteria outlined in the ACS TQIP Best Practices Guidelines, sensitivity, specificity, PPV, NPV, and accuracy were 72.2%, 64.9%, 6.8%. 98.5%, and 65.2%, respectively; for the risk factors suggested in the more extensive "expanded Denver criteria", they were 82.5%, 50.4%, 5.3%, 98.9%, and 51.4%, respectively. 23% (n = 14) of patients with BCVI grade 3 or higher would not have been captured by any screening criteria. Cervical spine, facial, and skull base fractures were the strongest predictors of BCVI with odds ratios and 95% confidence intervals of 8.1 (5.4 - 12.1), 5.7 (2.2 - 15.1), and 2.7 (1.5 - 4.7), respectively. 83% (n = 105) of patients with BCVI received antiplatelet agents or therapeutic anticoagulation, with 4% (n = 5) experiencing a bleeding complication, 3% (n = 4) BCVI progression, and 8% (n = 10) a stroke. CONCLUSIONS Almost 20% of patients with BCVI, including a quarter of those with BCVI grade 3 or higher, would have gone undiagnosed by even the most extensive and sensitive BCVI screening criteria. Implementation of universal screening should strongly be considered to ensure the detection of all clinically relevant BCVIs. LEVEL OF EVIDENCE Diagnostic study, level III.