Modified Split-Scan Computed Tomography (CT) Diagnostics of Severely Injured Patients: First Results from a Level I Trauma Center Using a Dedicated Head-and-Neck CT-Angiogram for the Detection of Cervical Artery Dissections

Abstract

Introduction: Traumatic cervical artery dissections are associated with high mortality and morbidity in severely injured patients. After finding even higher incidences than reported before, we decided to incorporate a dedicated head-and-neck computed tomography angiogram (CT-A) in our imaging routine for patients who have been obviously severely injured or, according to trauma mechanism, are suspected to be severely injured. Materials and Methods: A total of 134 consecutive trauma patients with an ISS ≥ 16 admitted to our level I trauma center during an 18 month period were included. All underwent standardized whole-body CT in a 256-detector row scanner with a dedicated head-and-neck CT-A realized as single-bolus split-scan routine. Incidence, mortality, patient and trauma characteristics, and concomitant injuries were recorded and analyzed in patients with carotid artery dissection (CAD) and vertebral artery dissection (VAD). Results: Of the 134 patients included, 7 patients had at least one cervical artery dissection (CeAD; 5.2%; 95% CI 1.5–9.0%). Six patients (85.7%) had carotid artery dissections, with one patient having a CAD of both sides and one patient having a CAD and contralateral VAD combined. Two patients (28.6%) showed a VAD. Overall mortality was 14.3%, neurologic morbidity was 28.6%. None of the patients showed any attributable neurologic symptoms on admission. The new scanning protocol led to further 5 patients with suspected CeAD during the study period, all ruled out by additional magnetic resonance imaging with angiogram (MRI/MR-A). Conclusion: A lack of specific neurologic symptoms on admission urges the need for a dedicated imaging pathway for severely injured patients, reliable for the detection of cervical artery dissections. Although our modified CT protocol with mandatory dedicated CT-A led to false positives requiring additional magnetic resonance imaging, it likely helped reduce possible therapeutic delays.

Prognostic Significance of Multifactorial Analysis in Complex Cervical Aero-Digestive Trauma Cases

“…When an experienced technician performs this scan, the sensitivity of the ultrasound compared to a conventional angiographic scan as a reference technique is 90% to 95% for lesions that require interventional treatment. This examination may omit lesions with preserved flow, such as intimate denudation or pseudoaneurysms [19][20][21][22][23]. In our study, the Doppler ultrasound had a sensitivity of 70% and a specificity of 55% and was shown in 10 patients out of 106 with injuries caused by accidental mechanisms.…”

Necessity of Immediate MRI Imaging in the Acute Care of Severely Injured Patients

“…Figure 1 shows a clinical application with therapy-relevant information gained through MRI. In a previous paper, we were able to demonstrate the benefit of this imaging in the context of cervical vascular diagnostics and recommended the implementation of this imaging option [ 10 ] in clinical routine. This approach is reinforced by Yamada et al, who proposed a concept of early MRI diagnostic in suspected lesions of cervical vessels, allowing an earlier administration of treatment, which, in turn, contributes to a good clinical outcome [ 11 ].…”

“…We, for now, recommend sagittal T1, T2, and T2 STIR plus axial T2 in suspected spine trauma. For cervical artery dissections, axial PD and T1 fat-sat plus contrast-enhanced MR-angiography and/or time-of-flight MR-angiography, especially for dissections near or within the skull base, revealed a lot of dissections in a step-up approach [ 10 ]. Fast whole-body sequences, e.g., DWIBS (diffusion-weighted imaging with background suppression), should be evaluated as an add-on for patients undergoing spine MRI anyways or for child trauma MRI.…”

“…With recent technical improvements for CT-A protocols and scanners, detection rates of cervical artery dissections rise [ 18 ]. In parallel, MR imaging is speeding up significantly and can offer additional or confirmatory information in doubtful cases [ 10 , 19 ]. To our knowledge, a prospective study comparing state-of-the-art MR-A and CT-A is missing.…”

New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient

“…Based on an analysis of a trauma registry, the authors successfully validated mTICCS against well-established and more sophisticated algorithms and found that it presents an useful tool to predict the need for massive transfusion early [2]. Focusing on neurological aspects (D-problem), Popp et al validated a CT protocol with mandatory dedicated computer tomography angiography (CT-A) to detect cervical artery dissections in severely injured patients [3]. From the results of their monocentric, prospective study, the authors concluded that their imaging pathway is likely to reduce possible therapeutic delays.…”