Biffl Walter L, Ray Charles E, Moore Ernest E, Mestek Michael, Johnson Jeffrey L, Burch Jon M
Department of Surgery, Rhode Island Hospital/Brown University, Providence, USA.
J Trauma. 2002 Nov;53(5):850-6. doi: 10.1097/00005373-200211000-00008.
In light of their potential for devastating consequences, a liberalized screening approach for blunt cerebrovascular injuries (BCVI) is becoming increasingly accepted. The "gold standard" for diagnosis of BCVI is arteriography; however, noninvasive diagnostic alternatives offer clear advantages. Recent series have demonstrated the ability of computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) to identify BCVI, but have not compared their accuracy with arteriography. We hypothesized that CTA or MRA could reliably identify BCVI, obviating the need for arteriography. The purpose of this study was to determine the accuracy of CTA and MRA in identifying BCVI in asymptomatic patients.
Asymptomatic patients meeting criteria for BCVI screening underwent arteriography, according to our institutional standard. A subset of patients requiring computed tomographic scanning underwent CTA; a subset of patients requiring magnetic resonance imaging underwent MRA. All of the studies were interpreted by radiologists in a blinded manner. Data were analyzed for sensitivity and specificity.
Forty-six patients underwent both CTA and arteriography. Of 23 with a normal CTA examination, 7 (30%) had BCVI on arteriography. Of 23 with an abnormal CTA examination, 8 (35%) had a normal arteriogram. The sensitivity, specificity, positive predictive value, and negative predictive value of CTA were 68%, 67%, 65%, and 70%, respectively. CTA missed 55% of grade I injuries, 14% of grade II injuries, and 13% of grade III injuries. Sixteen patients underwent both MRA and arteriography. One (11%) had a false-negative MRA result, and four (57%) had false-positive MRA results (75% sensitivity, 67% specificity, 43% positive predictive value, 89% negative predictive value).
CTA and MRA can identify BCVI, but they miss grade I, II, and III injuries. Future technical modifications may improve their accuracy. A prospective multicenter trial is warranted to define the capabilities and limitations of these noninvasive modalities. In the interim, arteriography remains the gold standard for diagnosis, but if arteriography is not available, CTA or MRA should be used to screen for BCVI in patients at risk.
鉴于钝性脑血管损伤（BCVI）可能带来毁灭性后果，一种更为宽松的筛查方法正日益被接受。诊断BCVI的“金标准”是动脉造影；然而，非侵入性诊断方法具有明显优势。近期研究系列已证明计算机断层血管造影（CTA）和磁共振血管造影（MRA）能够识别BCVI，但尚未将它们与动脉造影的准确性进行比较。我们假设CTA或MRA能够可靠地识别BCVI，从而无需进行动脉造影。本研究的目的是确定CTA和MRA在识别无症状患者BCVI方面的准确性。
符合BCVI筛查标准的无症状患者按照我们机构的标准接受动脉造影。需要进行计算机断层扫描的部分患者接受CTA检查；需要进行磁共振成像的部分患者接受MRA检查。所有检查均由放射科医生以盲法解读。对数据进行敏感性和特异性分析。
46例患者同时接受了CTA和动脉造影。CTA检查正常的23例患者中，7例（30%）动脉造影显示有BCVI。CTA检查异常的23例患者中，8例（35%）动脉造影正常。CTA的敏感性、特异性、阳性预测值和阴性预测值分别为68%、67%、65%和70%。CTA漏诊了55%的I级损伤、14%的II级损伤和13%的III级损伤。16例患者同时接受了MRA和动脉造影。1例（11%）MRA结果为假阴性，4例（57%）MRA结果为假阳性（敏感性75%，特异性67%，阳性预测值43%，阴性预测值89%）。
CTA和MRA能够识别BCVI，但会漏诊I级、II级和III级损伤。未来的技术改进可能会提高它们的准确性。有必要进行一项前瞻性多中心试验来明确这些非侵入性检查方法的能力和局限性。在此期间，动脉造影仍然是诊断的金标准，但如果无法进行动脉造影，应使用CTA或MRA对有风险的患者进行BCVI筛查。
