Laser Adriana, Kufera Joseph A, Bruns Brandon R, Sliker Clint W, Tesoriero Ronald B, Scalea Thomas M, Stein Deborah M
Department of Surgery, University of Maryland, Baltimore, MD.
National Study Center for Trauma & EMS, School of Medicine, University of Maryland, Baltimore, MD.
Surgery. 2015 Sep;158(3):627-35. doi: 10.1016/j.surg.2015.03.063. Epub 2015 Jun 9.
Our whole-body computed tomography protocol (WBCT), used to image patients with polytrauma, consists of a noncontrast head computed tomography (CT) followed by a multidetector computed tomography (40- or 64- slice) that includes an intravenous, contrast-enhanced scan from the face through the pelvis. WBCT is used to screen for blunt cerebrovascular injury (BCVI) during initial CT imaging of the patient with polytrauma and allows for early initiation of therapy with the goal of avoiding stroke. WBCT has not been directly compared with CT angiography (CTA) of the neck as a screening tool for BCVI. We hypothesize that WBCT is a valid modality to diagnose BCVI compared with neck CTA, thus screening patients with polytrauma for BCVI and limiting the need for subsequent CTA.
A retrospective review of the trauma registry was conducted for all patients diagnosed with BCVI from June 2009 to June 2013 at our institution. All injuries, identified and graded on initial WBCT, were compared with neck CTA imaging performed within the first 72 hours. Sensitivity was calculated for WBCT by the use of CTA as the reference standard. Proportions of agreement also were calculated between the grades of injury for both imaging modalities.
A total of 319 injured vessels were identified in 227 patients. On initial WBCT 80 (25%) of the injuries were grade I, 75 (24%) grade II, 45 (14%) grade III, 41 (13%) grade IV, and 58 (18%) were classified as indeterminate: 27 vertebral and 31 carotid lesions. Twenty (6%) of the 319 injuries were not detected on WBCT but identified on subsequent CTA (9 grade I, 7 grade II, 4 grade III); 6 vertebral and 14 carotid. For each vessel type and for all vessels combined, WBCT demonstrated sensitivity rates of over 90% to detect BCVI among the population of patients with at least one vessel injured. There was concordant grading of injuries between WBCT and initial diagnostic CTA in 154 (48% of all injuries). Lower grade injures were more discordant than higher grades (55% vs 13%, respectively; P < .001). Grading was upgraded 8% of the time and downgraded 25%.
WBCT holds promise as a rapid screening test for BCVI in the patient with polytrauma to identify injuries in the early stage of the trauma evaluation, thus allowing more rapid initiation of treatment. In addition, in those patients with high risk for BCVI but whose WBCT results are negative for BCVI, neck CTA should be considered to more confidently exclude low-grade injuries.
我们用于对多发伤患者进行成像的全身计算机断层扫描方案（WBCT），包括先进行一次非增强头部计算机断层扫描（CT），随后进行一次多探测器计算机断层扫描（40层或64层），该扫描包括从面部到骨盆的静脉内对比增强扫描。WBCT用于在多发伤患者的初始CT成像期间筛查钝性脑血管损伤（BCVI），并允许早期开始治疗以避免中风。WBCT尚未与颈部CT血管造影（CTA）作为BCVI的筛查工具进行直接比较。我们假设与颈部CTA相比，WBCT是诊断BCVI的有效方式，从而对多发伤患者进行BCVI筛查并减少后续CTA的需求。
对2009年6月至2013年6月在我们机构被诊断为BCVI的所有患者的创伤登记资料进行回顾性分析。将在初始WBCT上识别并分级的所有损伤与在最初72小时内进行的颈部CTA成像进行比较。以CTA作为参考标准计算WBCT的敏感性。还计算了两种成像方式损伤分级之间的一致性比例。
在227例患者中总共识别出319条受伤血管。在初始WBCT上，80例（25%）损伤为I级，75例（24%）为II级，45例（14%）为III级，41例（13%）为IV级，58例（18%）被分类为不确定：27例为椎体病变，31例为颈动脉病变。319例损伤中有20例（6%）在WBCT上未被检测到，但在后续CTA上被识别（9例I级，7例II级，4例III级）；6例椎体病变和14例颈动脉病变。对于每种血管类型以及所有血管合并计算，在至少有一条血管受伤的患者群体中，WBCT检测BCVI的敏感性率超过90%。WBCT与初始诊断CTA之间损伤分级一致的有154例（占所有损伤的48%）。较低级别的损伤比较高级别的损伤更不一致（分别为55%对13%；P <.001）。分级上调的时间占8%，下调的时间占25%。
WBCT有望作为对多发伤患者进行BCVI的快速筛查试验，以便在创伤评估的早期阶段识别损伤，从而允许更快速地开始治疗。此外，对于那些BCVI高危但WBCT结果为BCVI阴性的患者，应考虑进行颈部CTA以更有把握地排除低级别损伤情况。
