VESS10 - Routine Angiography is Not Indicated in Patients with Blunt Cerebrovascular Injury

Objectives: Blunt cerebrovascular injury (BCVI) of the carotid or vertebral arteries can result in long-term neurological injury. Early diagnosis and treatment are imperative to limit neurological insults. Diagnosis has shifted from invasive digital subtraction angiography (DSA) to CT angiography. We hypothesized routine DSA for low-grade BCVI is not indicated for diagnosis or follow-up and is associated with unnecessary costs and complications.

Methods: Patients with BCVI were identified by ICD 9/10 codes from the institutional trauma registry from January 1, 2010-December 31st, 2021. We analyzed the charts of patients with BCVI of the vertebral and carotid arteries. The baseline demographics and characteristics are described. Descriptive statistics were performed. Univariate analysis was performed to determine differences between DSA and no-DSA patients. Correlation of noninvasive imaging and DSA results were calculated.

Results: 251 patients with BCVI were identified (183 vertebral (73%), 67 (26%) carotid, 6 (1%) both). Patient demographics are presented in Table 1. All patients were diagnosed initially by CT angiography. Consultation was placed to the neurosurgery service (96%), vascular surgery service (2%), or both (2%). DSA was performed in 164 patients (43 Carotid, 116 Vertebral, 5 both), all done by neurosurgery, the majority (72%) done within 24 hours from diagnosis. Most patients (98%) were asymptomatic with 5 patients presenting with stroke like symptoms. Intervention was done in 9 patients (Table 2) which were planned based on CTA or symptoms. All patients were treated medically with antiplatelets (69%) or anticoagulation (14%). BCVI injury grade was similar between CTA/MRA and DSA in most patients 88 (79%); downgraded in 15 (13%) patients where no BCVI was appreciated on DSA and upgraded in 9 (8%) patients for vessel occlusion or pseudoaneurysm formation. Overall, there was strong correlation between CTA and DSA (Spearman R=0.87, p< 0.01). DSA related complications included groin access complications (2.5%) and iatrogenic cerebral artery injury (1.8%). Delayed intervention was required in one patient for growing pseudoaneurysm noted on non-invasive imaging.

Conclusions: Routine confirmatory DSA following axial imaging does not change the management of patients with BCVI, neither on presentation, nor on follow up. Given the advances and ready availability of axial imaging, the benefit of routine DSA in this patient population does not justify the associated cost and procedural complications. Development of an algorithm that incorporates follow-up non-invasive imaging once BCVI is identified with duplex ultrasound or CTA is warranted.