CT Angiographic Screening for Blunt Cerebrovascular Injury: Increased Utilization After Inclusion of Strangulation...

Progress has been made in the screening for blunt cerebrovascular injury (BCVI) since the publication of our institution's guidelines in the late 1990s, with successive updates aimed at improving detection. In recent years, we have anecdotally observed a marked increase in CTA usage across various mechanisms, but particularly strangulation. We sought to evaluate how progressive expansion of screening criteria affected utilization and BCVI detection at our institution.

All CTA studies for BCVI performed at Denver Health between 7/1/2024 and 8/31/2024 were identified. Charts were reviewed for the presence of risk factors as reported in the Denver BCVI Criteria from the published Expanded Denver Criteria (2012), Modified Denver Criteria (2016), and non-published in-house (2020) criteria. Additional variables included BCVI status, mechanism, and demographics.

253 patients were identified. Three variations of the Denver BCVI Criteria were applied. 71.1% (180/253) of scanned patients met the 2012 criteria, 82.6% (209/253) the 2016 criteria, and 93.7% (237/253) met the in-house 2020 criteria. 17.0% (43/253) of the cohort were found to have BCVI. Using the 2012 criteria, 90.7% (39/43) of positive BCVI met screening criteria, while 97.7% (42/43) met the 2016 and in-house (2020) criteria. The most common indication for screening was strangulation (24.9%, 63/253). The rate of BCVI for non-strangulation indications was 22.1% (42/190), while the rate of BCVI for strangulation indications was 0-1.6% (0-1/63). 55.6% (35/63) of the strangulation scans met screening criteria using the older 2012 and 2016 criteria.

Most patients screened for BCVI by our in-house criteria met the screening threshold (93.7%), but the rate of detected BCVI between the Modified Denver Criteria (2016) and in-house (2020) criteria is the same. The only substantive difference between the two variations is the addition of strangulation as a risk factor for BCVI. Strangulation has become our most common indication for screening but does not increase the rate of detected BCVI. Our results suggest that most of our strangulation patients should not be screened with CTA. There is a great need for an evidenced based screening criterion for BCVI in the setting of strangulation.