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Chapter 2

Blunt Cerebrovascular Injury

Rob Orman, MD and Andrew Petrosoniak, MD
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27:32
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Trauma team leader Andrew Petrosoniak gives a streamlined approach to evaluating patients for blunt cerebrovascular injury.

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Samuel P. -

Would love to hear thoughts on a non (or less) high injury mechanism that results in a mandibular fracture. Currently, the trauma team asks for a CTA on all of these patients. Has always seemed like overkill. The EAST guidelines are similar in that they seem to say extreme hyperextension + fracture should be evaluated for blunt CVA

Rob O., MD -

Hey Samuel! I share your consternation about this and wish there were data to guide imaging in a more skillful way (rather than casting an infinitely wide net). What's out there could be used to support liberal screening for BCVI in mandible fracture patients but, on the other hand, what's out there doesn't really give the answer at all. For example...

This study:
A multivariate logistic regression analysis of risk factors for blunt cerebrovascular injury, found this: cervical spine fracture (CSI) (RR = 10.4), basilar skull fracture (RR = 3.60), and mandible fracture (RR = 2.51) to be most predictive of the presence of BCVI (P < .005).

But they were looking at BCVI patients and then seeing what injuries they had, rather than looking at all mandible fractures and determining the incidence of BCVI.

This one: Isolated Mandibular Fractures and the Risk of Blunt Cerebrovascular Injuries is some of the best data we have, and it's a poster presentation that was never published as an article! From the later part of the poster....

Of the 249 isolated mandible fractures, 1.6% (n=4) were diagnosed with a BCVI. Based on these results, we recommend against including mandible fractures as absolute indicators for angiography, including computed tomographic angiography, to rule out BCVI. In deciding whether to test for BCVI, the mechanism and severity of injury to the head, face, and neck should be weighed against the radiation exposure, intravenous contrast load, expense, and the potential for false positive or incidental findings.

So they would support your feeling of overkill, but obv not the robust data one would like to be able to throw down on the table and say, "Ha!" I wish I had a better answer based on the evidence (such as it is).

Samuel P. -

Very interesting, thanks for the response!

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2.25 AMA PRA Category 1 Credits™ certified by Hippo Education (2020)