+ Why screen? BCVI relatively rare- about 0.5-2%

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1 Kathleen R. Fink, MD University of Washington UW Medicine EMS & Trauma Conference September 27, 2016 Why screen? BCVI relatively rare- about 0.5-2% (0.075% 1.55%) Catastrophic potential (stroke) Aggressive use of diagnostic testing advocated to detect injuries before stroke 1

2 Prevent This MRI PD Head CT Diffusion Trace From becoming this Head CT: Anterior and middle cerebral artery infarct 2

3 Major Questions Who to image? How to image? Who to treat? How to treat? Major Questions Who to image? How to image? Who to treat? How to treat? 3

4 Modified Denver criteria: Signs/symptoms of BCVI Arterial hemorrhage from nose or mouth Carotid bruit in patient < 50 years old Expanding cervical hematoma Focal neurological deficit Neurologic examination incongruous with head CXT findins Stroke on follow up CT/MR Modified Denver criteria: Risk Factors for BCVI High-energy transfer mechanism with: Lefort II or III fracture Cervical spine fracture patterns: Subluxation Fractures extending into the transverse foramen Fractures of C1-C3 Basilar skull fracture with carotid canal involvement Petrous bone fracture Diffuse axonal injury with GCS<6 Hear hanging with anoxic brain injury 4

5 Seatbelt Sign: Original criteria Seatbelt sign should not be used in isolation to trigger diagnostic workup DiPerna et al Am Surg 2002 Desai AJNR 2014 Eastern Assoc for Surgery of Trauma (EAST) 2010 Reviewed literature Classified articles at I, II, or III data Class I: Randomized controlled trials (0) Class II: Prospective and retrospective studies based on clearly reliable data. Types of studies include: observational cohort studies and case control studies. (27) Class III: Uncontrolled retrospective studies including clinical series, database or registry reviews, large series of case reviews, and expert opinion (41) 5

6 EAST recommendations Level I: Convincingly justifiable based on available scientific evidence along (class I or maybe strong class II data) Level II: Reasonably justifiable by evidence and strongly supported by expert opinion (class II or a preponderance of class III data) Level III: Supported by available data, but adequate evidence is lacking (class III data) EAST Guidelines: Screen for BCVI if: 1. Neuro signs/sx 2. Epistaxis 3. GCS 8 4. Petrous bone fracture 5. Diffuse axonal injury 6. Cervical spine fracture 1. (Especially C1-C3 and/or foramen transversarium) 7. Cervical spine subluxation or rotational component 8. Lefort II or III facial fractures Level 2 Level 3 Bromberg et al. J Trauma Feb;68(2):

7 EAST Guidelines: Pediatric trauma Pediatric trauma patients should be evaluated using same criteria as adult population Bromberg et al. J Trauma Feb;68(2):471-7 How good are the modified Denver criteria? Prospectively accumulated BCVI data base in adults (18 years and older) 20% of patients with BCVI did not meet standard screening criteria, and 66% were asymptomatic at diagnosis. J Trauma Acute Care Surg Feb;72(2):330-5; 7

8 Maximalist approach Minimalist approach 8

9 High risk factors for BCVI. Harborview Screening criteria: 1. LeFort II or III facial fracture. 2. Mandible fracture (clinical discretion/high energy mechanism). 3. All skull base fractures (This includes sphenoid, petrous temporal, clivus, ethmoid, occipital bone and occipital condyle fractures). 4. Any fracture of C1, C2 or C3. (Screening is not necessary for type I and II dens fractures that result from a ground-level fall) 5. Traumatic cervical spine subluxation. 6. Cervical spine fracture extending to the transverse foramen. 7. Cervical spine fracture with thoracic or lumbar spine fractures. 8. Great vessel injury in the thorax ( Great vessel refers to intrathoracic portions of the aorta, brachiocephalic, carotid, and subclavian arteries). Signs or Symptoms of BCVI. Harborview Screening criteria: Arterial hemorrhage from the neck, mouth, nose or ears. Gunshot wounds to the head, face or neck Near hanging resulting in cerebral anoxia Large or expanding cervical hematoma. Carotid bruit in a patient < 50 years Cerebral infarction on CT or MRI Unexplained central or lateralizing neurological deficit, TIA or Horner s syndrome Diffuse axonal injury with GCS < 6. 9

10 Notes: Harborview Screening criteria: * Consider screening with CTA for mandible fractures based on clinical judgment. High risk mechanisms include motor vehicle collisions, motorcycle collisions, bicycle collisions, pedestrian vs. car, all-terrain vehicle collisions, fall from a horse, falls from height (greater than standing), diving and when the mandible fracture appears to be a result of high energy blunt force. If there is concern that the apparent vertebral artery injury is due to vascular compression secondary to spine subluxation, consider repeat imaging following spine reduction. In patients with massive hemorrhage, consider immediate angioembolization. A catheter angiogram should be performed in these patients during the procedure. Who not to screen: Harborview Screening criteria: Neck CTA for patients not meeting the above criteria should only be obtained following consultation between the clinical service (surgical fellow or clinical attending) and the neuroradiology fellow (or attending). The following should not be used as a sole indicator for BCVI screening. Cervical abrasions without other signs or risk factors for injury (e.g. seat belt sign on the neck). 10

11 EAST Guidelines: How should we screen? Catheter angiography Level 2 Multislice CTA (8 detector or greater) Level 3 Bromberg et al. J Trauma Feb;68(2):471-7 Protocol: CTA 16/64/128-slice MDCT and now DE-CT Non-contrast head CTA Timing bolus Dynamic injection 3-4 cc/sec mm sections: arch to sella Oblique sagittal and coronal reformats 11

12 Pan Scan: CT Trauma Panscan includes whole body CT scan with CTA of Chest and upper abdomen Cervical spine included CTA of the neck Screening Retro out dedicated CTA with reformats EAST Guidelines: What is not adequate for screening? 1. Carotid Duplex Level 2 2. CTA with 4-slice or less multidetector array (not sensitive or specific enough) Bromberg et al. J Trauma Feb;68(2):

13 DUS in Dissection ECA ICA False lumen Flis, Jäger and Sidhu, Eur Rad 2007 MR T1 fat sat 13

14 MR-2D TOF MR-3D Gad MRA 14

15 Protocol: MRA Axial T1 or Proton Density with fat-saturation 2D TOF arch to Circle of Willis 3D gad-enhanced MRA Imaging Dissections MR Better soft tissue contrast Better infarct visibility CT Easier to get in ED More widely available Can see acute thrombus, even if not met Hb 15

16 Grading of BCVI Grade I II III IV V Description Irregularity with < 25% stenosis Luminal clot/intimal flap -OR- > 25% stenosis Pseudoaneurysm Occlusion Transection with extravasation -OR- Large arteriovenous fistula Bifflet al J Trauma (5): Why do we care about grade? For carotid injuries, higher grade correlated with increased risk of stroke. Injuries have different risk profiles for progression/healing Grade I tend to heal regardless of therapy. Grade II progressed regardless of treatment (reimage) Grade III 8 % healed. May need treatment if enlarge Grade IV tend not to recanalize Grade V require treatment or lethal 16

50% 100% 6% 38% 27% 28% 100% Burlewand Biffl, SurgClinN Am 91

17 Stroke rate by BCVI grade Carotid artery injury Vertebral artery injury Grade of Injury Stroke Rate % 14% 26% 50% 100% 6% 38% 27% 28% 100% Burlewand Biffl, SurgClinN Am 91 (2011) Grade I: < 25% luminal narrowing Left Vert, Lateral 17

18 Grade I: < 25% luminal narrowing Left CCA, 2 views Fall from bike Criteria: Skull base fracture 18

19 Grade II: Intimal flap Hard to see on coronal reformat: Use source images! 19

20 Grade II: 25% luminal narrowing RT CCA 20

21 Grade II: 25% luminal narrowing Follow up imaging, 15 days later: 21

$fracture,$

22 Pseudoaneurysm developed This is why follow up imaging is obtained. Type III odontoid fracture, elderly person 22

23 Grade III: Pseudoaneurysm C5-6 fracture dislocation Foramen transversarium 23

24 Grade IV: Occlusion Grade V: AV fistula 24

$C6 C7 foramen transversarium fracture Note vertebral artery$

25 C6 C7 foramen transversarium fracture Note vertebral artery hasn t entered yet. C7 Blunt cerebrovascular injury: cerebral 25

$fracture$ CTA

26 Indication for imaging: Skull base fracture Initial CTA Intracranial pseudoaneurysm 26

27 3 weeks later Increased in size! 25 year old restrained passenger, rollover MVC? 27

28 CTA DSA 28

29 Traumatic carotid cavernous fistula Increased size of left cavernous sinus Proptosis almost out of FOV CTA with lobular structures Asymmetric cavernous sinus enhancement (*caution) Venous injury 29

30 Posterior fossa extraaxial hemorrhage CT venogram Posterior fossa epidural Near expected location of transverse sinus Evaluate the venous structures! 30

$CTA criteria: skull base fracture Needs CTA$ dedicated CTA and CT venogram Forego post

31 CTA criteria: skull base fracture Needs CTA and CTV Options: Evaluate veins on CTA Obtain dedicated CTA and CT venogram Forego post contrast head CT and get venous phase CT instead. 31

32 Venous injury: intraluminal thombus Gunshot wound to head Venous Pseudoaneurysm * 32

33 Penetrating injury Gunshot wound to head 33

34 Venous injuries No screening criteria per se Evaluate venous structures on CTA Spectrum: Extrinsic compression Thrombosis Pseudoaneurysm Occlusion 34

35 Nail gun injury 35

36 3 Nails: 2 intracranial Is it safe to remove them? 36

37 No major arterial injury No major venous injury 37

38 Gunshot wound to neck. Bright red bleeding per mouth 38

39 Occlusion, intraluminal thrombus Active extravasation Rt Vert AP Rt Vert Lateral 39

40 Treatment: Angiography is diagnostic With DSA, can subtract radiopaque objects No streak artifact Angiogram can be therapeutic Embolize bleeding vessels BCVI screening references Jones TS, Burlew CC, Kornblith LZ, et al. Blunt cerebrovascular injuries in the child. Am J Surg. Jul 2012;204(1):7-10. Burlew CC, Biffl WL, Moore EE, Barnett CC, Johnson JL, Bensard DD. Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis. J Trauma Acute Care Surg. Feb 2012;72(2): ; discussion , quiz 539. Franz RW, Willette PA, Wood MJ, Wright ML, Hartman JF. A systematic review and metaanalysis of diagnostic screening criteria for blunt cerebrovascular injuries. J Am Coll Surg. Mar 2012;214(3): Berne JD, Cook A, Rowe SA, Norwood SH. A multivariate logistic regression analysis of risk factors for blunt cerebrovascular injury. J Vasc Surg. Jan 2010;51(1): Blunt Cerebrovascular Injuries Algorithm ; njuries/introduction.html. Steenburg SD, Sliker CW. Craniofacial gunshot injuries: an unrecognised risk factor for blunt cervical vascular injuries? Eur Radiol. Sep 2012;22(9):

41 Thank you! Kathleen Fink Hard rain comes down on the University of Washington, Seattle campus. February 18th, Photo by Katherine B. Turner 41

Multidetector CTA for Diagnosing Blunt Cerebrovascular Injuries

Multidetector CTA for Diagnosing Blunt Cerebrovascular Injuries 4 th Nordic Trauma Course 2006 Stuart E. Mirvis, M.D., FACR Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland