Trust, but verify: the importance of additional imaging after BCVI screening

Clinical practice guidelines recommend screening for blunt cerebrovascular injury (BCVI) based on the Denver Criteria. BCVI is typically treated with antithrombotic therapy, which may be high-risk in patients with concomitant brain or spine injuries. At our center, we often perform additional imaging in high-risk patients after positive initial screening for BCVI. Our study investigates how frequently follow-up imaging changes diagnosis and management of patients screening positive for BCVI.

A cross-sectional study of all trauma patients admitted to a level 1 trauma center with cervical spine or facial fractures between May 2019 and December 2022 was performed. Chart review was conducted to identify all patients who had a positive screening study for BCVI. Individual charts were reviewed for BCVI screening and additional imaging test modality and results, as well as timing and specifics of treatment recommendations.

A total of 2668 patients met inclusion criteria. 1407 of these patients received BCVI screening, 11 with Magnetic Resonance Angiography (MRA) and 1396 with Computed Tomography Angiography (CTA). Of those screened, 254 (9.5%) had with positive or equivocal findings, of which 197 (77.6%) patients received a second study, including 2 patients who received multiple studies. Additional imaging studies resulted in a change in the diagnosis in 96 patients (48.7%), including 105 studies (53.3%) that found no injury or chronic findings. The results of additional studies changed patient management in in 64 (32.5%) cases.

In our study, follow-up BCVI imaging frequently identified discordant findings in a third of screening tests. This suggests that starting antiplatelet or anticoagulation therapy based on screening studies alone could result in overtreatment in a high-risk patient population.