Routine angiography is not indicated in patients with blunt cerebrovascular injury

Blunt cerebrovascular injury (BCVI) refers to blunt, traumatic injury of the carotid or vertebral arteries. Prompt treatment of BCVI is imperative due to the risk of long-term neurologic injuries. Treatment depends in part on injury severity according to the Biffl grade. Despite evidence confirming the safety and accuracy of axial imaging, confirmatory digital subtraction angiography (DSA) is still performed with diagnostic and therapeutic intent. We hypothesized that routine invasive DSA is not indicated for patients with low-grade BCVI for diagnosis or follow-up and is associated with unnecessary costs and complications.

We performed a single-center, restrospective study of the diagnosis and management of patients with BCVI at a Level 1 trauma center. Patients with BCVI were identified by International Classification of Diseases-9/10 codes from the institutional trauma registry from January 1, 2010 to December 31st, 2021. We analyzed the charts of patients with BCVI of the vertebral and carotid arteries and collected demographics, characteristics, and management. Descriptive statistics were performed. Univariate analysis was performed to determine differences between DSA and no-DSA patients. Correlation of noninvasive imaging and DSA results were calculated.

A total of 251 patients with BCVI were diagnosed by computed tomography angiography (CTA) (178 vertebral [71%], 67 [26%] carotid, and 6 [2%] both). Consulted services were neurosurgery (96%), vascular surgery (2%), or both (2%). DSA was performed in 164 patients (43 carotid, 116 vertebral, and 5 both), all performed by neurosurgery; the majority (72%) were done within 24 hours from diagnosis. Most patients (98%) were asymptomatic, with five patients presenting with stroke-like symptoms, and only one of these patients underwent DSA for hemiparesis. Intervention was done in nine patients. All patients were treated with antiplatelets (81%) or anticoagulation (17%). BCVI injury grade correlated between CTA/magnetic resonance angiography and DSA in the majority of patients 88 (79%); was downgraded in 15 patients (13%) where no BCVI was appreciated on DSA; and upgraded in nine patients (8%) for vessel occlusion or pseudoaneurysm formation. No management changes resulted from DSA. DSA-related complications included groin access complications (4.2%) and iatrogenic cerebral artery injury (1.8%). Delayed intervention was required in one patient for a growing pseudoaneurysm noted on noninvasive imaging.

Routine DSA following CTA does not change the management of patients with BCVI. DSA is associated with low but significant rates of complications for diagnosing BCVI. An algorithm that incorporates follow-up noninvasive imaging with duplex ultrasound or CTA may be indicated to identify patients who would benefit from DSA.