Shahan Charles P, Magnotti Louis J, Stickley Shaun M, Weinberg Jordan A, Hendrick Leah E, Uhlmann Rebecca A, Schroeppel Thomas J, Hoit Daniel A, Croce Martin A, Fabian Timothy C
From the Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee.
J Trauma Acute Care Surg. 2016 Jun;80(6):915-22. doi: 10.1097/TA.0000000000001041.
Few injuries have produced as much debate with respect to management as have blunt cerebrovascular injuries (BCVIs). Recent work (American Association for the Surgery of Trauma 2013) from our institution suggested that 64-channel multidetector computed tomographic angiography (CTA) could be the primary screening tool for BCVI. Consequently, our screening algorithm changed from digital subtraction angiography (DSA) to CTA, with DSA reserved for definitive diagnosis of BCVI following CTA-positive study results or unexplained neurologic findings. The current study was performed to evaluate outcomes, including the potential for missed clinically significant BCVI, since this new management algorithm was adopted.
Patients who underwent DSA (positive CTA finding or unexplained neurologic finding) over an 18-month period subsequent to the previous study were identified. Screening and confirmatory test results, complications, and BCVI-related strokes were reviewed and compared.
A total of 228 patients underwent DSA: 64% were male, with mean age and Injury Severity Score (ISS) of 43 years and 22, respectively. A total of 189 patients (83%) had a positive screening CTA result. Of these, DSA confirmed injury in 104 patients (55%); the remaining 85 patients (45%) (false-positive results) were found to have no injury on DSA. Five patients (4.8%) experienced BCVI-related strokes, unchanged from the previous study (3.9%, p = 0.756); two were symptomatic at trauma center presentation, and three occurred while receiving appropriate therapy. No patient with a negative screening CTA result experienced a stroke.
This management scheme using 64-channel CTA for screening coupled with DSA for definitive diagnosis was proven to be safe and effective in identifying clinically significant BCVIs and maintaining a low stroke rate. Definitive diagnosis by DSA led to avoidance of potentially harmful anticoagulation in 45% of CTA-positive patients (false-positive results). No strokes resulted from injuries missed by CTA.
Diagnostic study, level III.
很少有损伤在处理方面引发像钝性脑血管损伤（BCVI）这样多的争议。我们机构最近的研究（美国创伤外科学会，2013年）表明，64排多层螺旋CT血管造影（CTA）可能是BCVI的主要筛查工具。因此，我们的筛查方案从数字减影血管造影（DSA）改为CTA，DSA则保留用于在CTA检查结果阳性或有无法解释的神经系统表现后对BCVI进行确诊。本研究旨在评估自从采用这种新的处理方案以来的结果，包括遗漏具有临床意义的BCVI的可能性。
确定在前一项研究之后的18个月内接受DSA检查（CTA检查结果阳性或有无法解释的神经系统表现）的患者。回顾并比较筛查和确诊检查结果、并发症以及与BCVI相关的中风情况。
共有228例患者接受了DSA检查：64%为男性，平均年龄和损伤严重度评分（ISS）分别为43岁和22分。共有189例患者（83%）CTA筛查结果为阳性。其中，DSA证实104例患者（55%）存在损伤；其余85例患者（45%）（假阳性结果）DSA检查未发现损伤。5例患者（4.8%）发生了与BCVI相关的中风，与前一项研究相比无变化（3.9%，p = 0.756）；2例在创伤中心就诊时出现症状，3例在接受适当治疗时发生。CTA筛查结果为阴性的患者均未发生中风。
这种采用64排CTA进行筛查并结合DSA进行确诊的处理方案，在识别具有临床意义的BCVI和维持低中风发生率方面被证明是安全有效的。DSA确诊避免了45%的CTA阳性患者（假阳性结果）接受潜在有害的抗凝治疗。未发生因CTA漏诊损伤而导致的中风。
诊断性研究，III级。
