From the Department of Neurosurgery, (M.M., M.S., W.S.), Institute of Clinical Radiology (P.B.S.), University Hospital Münster, Münster; Department of Diagnostic and Interventional Neuroradiology (U.H.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Trauma, Hand and Reconstructive Surgery (H.D., R.H., M.R.), University Hospital Münster, Münster, Germany; and Centre for Trauma Sciences, Blizard Institute (S.G.), Queen Mary University of London, London, United Kingdom.
J Trauma Acute Care Surg. 2020 Jun;88(6):789-795. doi: 10.1097/TA.0000000000002682.
Blunt cerebrovascular injuries (BCVI) can significantly impact morbidity and mortality if undetected and, therefore, untreated. Two diagnostic concepts are standard practice in major trauma management: Application of clinical screening criteria (CSC) does or does not recommend consecutive computed tomography angiography (CTA) of head and neck. In contrast, liberal CTA usage integrates into diagnostic protocols for suspected major trauma. First, this study's objective is to assess diagnostic accuracy of different CSC for BCVI in a population of patients diagnosed with BCVI after the use of liberal CTA. Second, anatomical locations and grades of BCVI in CSC false negatives are analyzed.
The hospital database at University Hospital Münster was retrospectively searched for BCVI diagnosed in patients with suspicion of major trauma 2008 to 2015. All patients underwent a diagnostic protocol including CTA. No BCVI risk stratification or CSC had been applied beforehand. Three sets of CSC were drawn from current BCVI practice management guidelines and retrospectively applied to the study population. Primary outcome was false-negative recommendation for CTA according to CSC. Secondary outcome measures were stroke, mortality, mechanism of injury, multivessel BCVI, location and grade of BCVI.
From 4,104 patients with suspicion of major trauma, 91 (2.2%) were diagnosed with 126 BCVI through liberal usage of CTA. Sensitivities of different CSC ranged from 57% to 84%. Applying the set of CSC with the highest sensitivity, false-negative BCVIs were found more often in the petrous segment of the carotid artery (p = 0.01) and more false negatives presenting with pseudoaneurysmatic injury were found in the vertebral artery (p = <0.01).
This study provides further insight into the common debate of correct assessment of BCVI in trauma patients. Despite following current practice management guidelines, a large number of patients with BCVI would have been missed without liberal CTA usage. Larger-scale observational studies are needed to confirm these results.
Diagnostic study, Level III.
如果未检测到且未治疗钝性脑血管损伤 (BCVI)，可能会显著影响发病率和死亡率。在大创伤管理中，有两个诊断概念是标准做法：应用临床筛选标准 (CSC) 要么推荐，要么不推荐连续进行头颈部计算机断层血管造影 (CTA)。相比之下，广泛的 CTA 使用整合到疑似大创伤的诊断方案中。首先，本研究的目的是评估在使用广泛的 CTA 后诊断为 BCVI 的患者人群中，不同 CSC 对 BCVI 的诊断准确性。其次，分析 CSC 假阴性的 BCVI 的解剖位置和等级。
回顾性地在明斯特大学医院的医院数据库中搜索 2008 年至 2015 年间疑似大创伤患者中诊断出的 BCVI。所有患者均接受了包括 CTA 在内的诊断方案。在此之前，没有进行 BCVI 风险分层或 CSC。从当前的 BCVI 实践管理指南中抽取了三组 CSC，并将其回顾性地应用于研究人群。主要结局是根据 CSC 对 CTA 的假阴性推荐。次要结局指标是中风、死亡率、损伤机制、多血管 BCVI、BCVI 的位置和等级。
在 4104 例疑似大创伤的患者中，有 91 例（2.2%）通过广泛使用 CTA 诊断出 126 例 BCVI。不同 CSC 的敏感性范围为 57%至 84%。应用敏感性最高的 CSC 组，更多的假阴性 BCVI 出现在颈内动脉岩骨段（p = 0.01），更多的假阴性椎动脉出现假性动脉瘤损伤（p = <0.01）。
本研究进一步深入探讨了在创伤患者中正确评估 BCVI 的常见争议。尽管遵循了当前的实践管理指南，但如果不广泛使用 CTA，将会错过大量的 BCVI 患者。需要进行更大规模的观察性研究来证实这些结果。
诊断研究，III 级。
