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Published on: March 26, 2019
Selective screening falls short: A review of universal screening for blunt cerebrovascular injury
John P Gaspich1, Angelica L Solomon2, Taylor A Nordan2
1Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02116, USA; Center for Surgery and Public Health, Mass General Brigham, One Brigham Circle, 1620 Tremont Street, Boston, MA 02120, USA.
Background:
Blunt cerebrovascular injury (BCVI) poses significant risk of devastating neurologic injury following blunt trauma. Selective screening criteria miss numerous clinically relevant injuries. Early diagnosis and treatment reduce these negative sequelae. Emerging data have prompted expanded interest in universal screening; however, no consensus screening strategy exists. This review evaluates the current state of BCVI screening.
Methods:
A narrative literature review was performed evaluating universal and liberalized BCVI screening criteria. A structured PubMed search was supplemented by manual review of references, trauma society abstracts, and other grey literature. Eligible studies included peer reviewed literature examining universal or liberalized BCVI screening among adult blunt trauma patients. Given the paucity of available data and relative heterogeneity in study design, findings were synthesized qualitatively.
Results:
Eight studies were included for evaluation. Across contemporary cohorts, various screening criteria including extended Denver, Memphis, and Western Trauma Association, miss 16-79% of BCVI identified under universal or liberalized screening protocols. Universal screening studies report BCVI incidence ranging from 2.7% to 7.6%. Reported rates of contrast-associated acute kidney injury and major bleeding were low, though rarely examined. Cost-modeling suggests universal screening may be economically favorable, particularly if BCVI incidence is greater than 6%.
Conclusions:
Selective screening guidelines lack sufficient sensitivity to detect all clinically significant BCVI, including those of high grade. Universal or liberalized CTA screening increases detection and facilitates treatment in a timely manner, potentially reducing BCVI-associated stroke rates. Although current literature is limited and prospective studies are needed, current evidence supports strong consideration of universal or liberalized BCVI screening protocols for blunt trauma patients.
