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Published on: April 1, 2019
Natural History of Blunt Cerebrovascular Injury: Experience Over a 10-year Period at a Level I Trauma Center
Lei Wu1, Diana Christensen1, Lindsey Call1
1From the Departments of Radiology (L.W., D.C., L.C., J.V., C.C., D.S.H., M.M.B.) and Neurologic Surgery (C.W., R.H.B.), University of Washington, 1959 NE Pacific St, Seattle, WA 98195-0005; and Department of Surgery, University of Colorado, Denver, Colo (C.W.).
Insights
Most blunt cerebrovascular injury (BCVI) changes resolve within 90 days. Follow-up imaging for BCVI is unlikely to be beneficial beyond this 90-day window, suggesting a need to redefine imaging protocols.
Area of Science:
- Trauma Surgery
- Vascular Surgery
- Neurology
- Radiology
Background:
- Blunt cerebrovascular injury (BCVI) increases stroke and mortality risk.
- Optimal follow-up imaging strategies for BCVI remain unclear.
- Understanding BCVI natural history is crucial for defining follow-up protocols.
Purpose of the Study:
- To analyze the natural history of blunt cerebrovascular injury.
- To determine the optimal timing and duration for follow-up imaging in BCVI patients.
Main Methods:
- Retrospective review of 1204 BCVI patients from a level I trauma center (2005-2015).
- Time-to-event analysis to assess injury evolution trends.
- Fisher exact test and logistic regression to identify stroke risk factors.
Main Results:
- High-grade BCVI injuries were less likely to resolve and more likely to progress than low-grade injuries.
- 81.9% of injuries improved or resolved, with 76% of changes occurring within 30 days.
- 87% of progressions occurred within 90 days; no significant changes were observed beyond 90 days.
- Higher injury grade, carotid artery involvement, and multiple injured vessels increased stroke risk.
Conclusions:
- Most BCVI-related changes occur within the first 30 days.
- Injury evolution rarely happens after 90 days.
- Follow-up imaging beyond 90 days for BCVI is unlikely to yield significant findings.
Abstract:
Background Blunt cerebrovascular injury (BCVI) is associated with increased stroke and mortality risk. However, the most appropriate follow-up strategy remains uncertain. Purpose To better understand the natural history of BCVI and help define the most optimal timing and length of follow-up imaging. Materials and Methods In this retrospective HIPAA-compliant study, data from all patients treated for BCVI at a level I trauma center between April 1, 2005, and June 30, 2015, were reviewed. For patients with at least one follow-up study, time-to-event analysis was performed to assess the trend in injury evolution. Association of injury grade and injury evolution was also assessed. The Fisher exact test and multivariable logistic regression were used to evaluate association of the number of injured vessels, vessel grade, and vessel type (internal carotid artery, vertebral artery) with BCVI-associated stroke. Results A total of 1204 patients (800 men; mean age ± standard deviation, 45 years ± 22) with 1604 vessel injuries were evaluated. High-grade (grades 3-5) injuries were less likely to resolve (hazard ratio [HR], 0.2; P < .001) than low-grade injuries. High-grade injuries were more likely to progress than low-grade injuries (HR, 3.3; P = .005). Of the injuries that improved or resolved (343 of 419 [81.9%]), 76% (259 of 343) changed within 30 days after the initial injury, and the remaining 24% (84 of 343) changed between 30 and 90 days. Of the injuries that progressed (46 of 419 [11.0%]), 87% (40 of 46) changed within 90 days. Beyond 90 days, no improvement or resolution occurred, and only 1.4% (six of 419) of injuries progressed. Higher injury grade (adjusted odds ratio, 2.0 per one-grade increase [95% confidence interval {CI}: 1.6, 2.4]; P < .001), carotid injuries versus vertebral artery injuries (49 of 420 [11.7%] vs 35 of 667 [5.2%]; P < .001), and increasing number of vessels injured per patient (adjusted odds ratio, 1.6 per one-vessel increase [95% CI: 1.3, 2.2]; P < .001) were associated with increased risk for BCVI-related stroke. Conclusion Most blunt cerebrovascular injury-related changes occurred within 30 days; changes rarely occurred beyond 90 days. Follow-up imaging is therefore unlikely to be helpful beyond 90 days. © RSNA, 2020 See also the editorial by Talbott in this issue.
