Title: Is Universal Screening Clinically Meaningful? A Single Center Retrospective Review of Blunt Cerebrovascular Injury, Screening, and Stroke Rates in Blunt Trauma Patients

Author(s): Charles Renner, MD; Michael Sauder, DO; Joseph Mayer, MD; Bader Kiwan, DO; Gianmarino Gianfrate, DO; Gregory Huang, MD

Email: crenner1@mercy.com

Introduction: There exists a debate both nationally in the Trauma community and locally in every trauma bay: In a blunt trauma patient, should a CT angiogram of the neck be ordered? Historically, 1-3% of patients have been found to have blunt cerebrovascular injury (BCVI) after blunt trauma [1]. High energy blunt trauma can result in the disruption of the extracerebral vasculature’s intima, resulting in a nidus for platelet activation and thrombus formation. The most dreaded complication of BCVI is migration of thrombus distally, resulting in a stroke. 10-20% of patients with BCVI suffer a stroke, typically within the first 72 hours post trauma [2,3]. The Eastern Association for the Surgery of Trauma strongly recommends that trauma centers have a screening protocol in place to detect BCVI. If BCVI is recognized, antiplatelet or antithrombotic therapy can be initiated, which has been shown to lower stroke rate [3]. Currently, our institution uses a screening protocol based off of the well validated Expanded Denver Criteria [4]. In 2016, the University of Alabama at Birmingham began screening all blunt trauma patients with a CTA neck. Out of 6287 patients screened, they found a 7.6% rate of BCVI. This rate of BCVI is much higher than historic data, so the question becomes: Is universal screening clinically meaningful? Further, would the institution of universal screening prevent any stokes?

Methods: A retrospective review was performed using a community level 1 trauma center registry. All patients who had a blunt trauma from January 1, 2023 – December 31, 2023 were included. All strokes that occurred in blunt trauma patients were noted. Since the registry does not record BCVIs, the database was queried for all patients with a Chest, Head, or Neck Abbreviated Injury Scale >1. The patients’ electronic medical records were then reviewed for the presence or absence of a CT angiogram of the neck performed during their trauma admission, along with the radiologist’s interpretation. With this data, the rates of patients screened, rates of BCVIs by Biffl grade, Injury Severity Score (ISS), and mortality rates were obtained. All statistics were performed in Microsoft Word. A student’s t test was used to compare ISS between screened patients with and without BCVI. Mortality rates between these groups were compared using a Chi Squared Analysis.

Results: 2142 blunt trauma patients were analyzed. 274 (12.8%) of blunt trauma patients were screened using the expanded Denver Criteria. 31 (11.3%) patients had a BCVI. The total rate of BCVI in our blunt trauma population was 1.4%. 35 BCVIs were identified in 31 patients. In total, 14 blunt trauma patients had a stroke during their trauma admission. 2 (14.3%) of these strokes were associated with BCVIs. All patients with a stroke eventually received a CTA neck as part of their workup, confirming only 2 of 14 stroke patients had a BCVI. Both stokes had carotid BCVIs – one was a Biffl Grade 2 that progressed to a Grade 4, and the other was a Grade 4. Neither received treatment for their BCVI due to concomitant injuries. Importantly, both of these stroke patients fell within the Expanded Denver Criteria and were screened with a CTA neck before the stroke. The ISS for screened patients with a BCVI was significantly higher than those who did not have BCVI (21.8 vs. 16.3, p= 0.03). While higher, the mortality rate between screened patients with and without BCVI was not statistically significant (16.1% vs. 7.4%, p=0.09).

Discussion/Conclusion: In our sampled population of 2142 blunt trauma patients, all strokes associated with BCVI were identified using the Expanded Denver Criteria. Our data suggests that the institution of universal BCVI screening would not have helped in the identification of BCVIs leading to strokes. While identification of BCVIs may increase with universal screening, the clinical relevance of this practice should be questioned.