Evaluating Blunt Cerebrovascular Injury Screening in High-Energy Trauma Patients: A Rural Trauma Center Study

Blunt cerebrovascular injury (BCVI) is an uncommon but potentially devastating complication of blunt trauma. Current screening guidelines, such as the expanded Denver Criteria (eDC), rely on clinical and radiological indicators but may miss up to 20% of cases. In August 2023, our rural Level 1 trauma center implemented a new protocol that screens all blunt trauma patients with high-energy mechanisms (HEM) for BCVI. We hypothesized that the HEM protocol would identify more BCVI cases than the eDC.

This two-phase cohort study at a rural Level I trauma center evaluated BCVI screening in adult trauma patients. The retrospective preimplementation phase (May 2020-May 2022) utilized the eDC. The prospective postimplementation phase (August 2023-August 2024) implemented a HEM protocol. In the preimplementation phase, the diagnostic performance of the eDC and retrospectively applied HEM protocol was assessed. In the postimplementation phase, HEM protocol adherence and its diagnostic performance (actual versus ideal) were assessed. Detected BCVI rates and stroke incidences were compared between cohorts.

Among 2670 preimplementation patients, the detected BCVI rate was 1.5% (n = 39). The eDC achieved 76.9% sensitivity and 84.6% specificity; the HEM protocol achieved 94.9% sensitivity and 37.1% specificity. Among 1006 postimplementation patients, the detected BCVI rate was 1.8% (n = 18). The HEM protocol, as it was actually implemented, achieved 100% sensitivity, 37.0% specificity, 2.8% positive predictive value, and 100.0% negative predictive value. The ideal implementation of the HEM protocol achieved 100.0% sensitivity, 26.2% specificity, 2.4% positive predictive value, and 100.0% negative predictive value. Protocol adherence was 85.7%. Stroke incidence remained 0.2% in both phases. Increased computed tomography angiography screening did not significantly alter detected BCVI rates or stroke incidence.

The HEM protocol demonstrated higher sensitivity for BCVI detection compared to the eDC, reducing missed injuries. Although the overall detected BCVI rate and stroke incidence did not significantly change, the HEM protocol decreased missed BCVI cases observed under eDC screening. Earlier identification may facilitate timely antithrombotic treatment; however, the impact on stroke outcomes could not be determined in this study and requires larger studies. These findings suggest liberalized BCVI screening in blunt trauma patients with HEM, offering a practical balance between sensitivity and resource use in rural trauma settings.