Blunt carotid artery injury: The futility of aggressive screening and diagnosis

John C. Mayberry, Carlos V. Brown, Richard Mullins, George C. Velmahos, Erwin R. Thal, M. Ashraf Mansour, David H. Wisner, Edward T. Peter, Thomas V. Berne, Gregory J. Jurkovich, Clayton H. Shatney

    Research output: Contribution to journalArticle

    80 Citations (Scopus)

    Abstract

    Background: Blunt carotid artery injury (BCI) remains a rare but potentially lethal condition. Recent studies recommend that aggressive screening based on broad criteria (hyperextension-hyperflexion mechanism of injury, basilar skull fracture, cervical spine injury, midface fracture, mandibular fracture, diffuse axonal brain injury, and neck seat-belt sign) increases the rate of diagnosis of BCI by 9-fold. If this recommendation becomes a standard of care, it will require a major consumption of resources and may give rise to liability claims. The benefits of aggressive screening are unclear because the natural history of asymptomatic BCI is unknown and the existing treatments are controversial. Hypothesis: The lack of an aggressive angiographic screening protocol does not result in delayed BCI diagnosis or BCI-related neurologic deficits. Methods: A 10-year medical record review of patients with BCI was undertaken in 2 level I academic trauma centers. In both centers, urgent screening for BCI was performed in patients with focal neurologic signs or neurologic symptoms unexplainable by results of computed tomography of the brain as well as in selected patients undergoing angiography for another reason. Results: Of 35212 blunt trauma admissions, 17 patients (0.05%) were diagnosed as having BCI. Six showed no evidence of BCI-related neurologic symptoms during hospitalization or prior to death as a result of associated injuries. Eleven sustained a BCI-related stroke, 9 of whom had it within 2 hours of injury. The remaining 2 had a delayed diagnosis (9 and 12 hours after injury) and received only anticoagulation because the lesions were surgically inaccessible. Just 1 of these 2 patients met the criteria for BCI screening and could have been offered earlier treatment, of uncertain benefit, if we had adopted an aggressive screening policy. Conclusions: Of the few patients with BCI, most remain asymptomatic or develop neurologic deficits shortly after injury. Although a widely applied, resource-consuming screening program may increase the rate of early diagnosis of BCI, an improvement in outcome is uncertain. A cost-effectiveness analysis should be done before trauma surgeons accept an aggressive screening protocol as the standard of care.

    Original languageEnglish (US)
    Pages (from-to)609-613
    Number of pages5
    JournalArchives of Surgery
    Volume139
    Issue number6
    DOIs
    StatePublished - Jun 2004

    Fingerprint

    Carotid Artery Injuries
    Medical Futility
    Nonpenetrating Wounds
    Neurologic Manifestations
    Wounds and Injuries
    Standard of Care
    Basilar Skull Fracture
    Seat Belts
    Mandibular Fractures
    Trauma Centers
    Patient Admission
    Delayed Diagnosis
    antineoplaston A10

    ASJC Scopus subject areas

    • Surgery

    Cite this

    Mayberry, J. C., Brown, C. V., Mullins, R., Velmahos, G. C., Thal, E. R., Mansour, M. A., ... Shatney, C. H. (2004). Blunt carotid artery injury: The futility of aggressive screening and diagnosis. Archives of Surgery, 139(6), 609-613. https://doi.org/10.1001/archsurg.139.6.609

    Blunt carotid artery injury : The futility of aggressive screening and diagnosis. / Mayberry, John C.; Brown, Carlos V.; Mullins, Richard; Velmahos, George C.; Thal, Erwin R.; Mansour, M. Ashraf; Wisner, David H.; Peter, Edward T.; Berne, Thomas V.; Jurkovich, Gregory J.; Shatney, Clayton H.

    In: Archives of Surgery, Vol. 139, No. 6, 06.2004, p. 609-613.

    Research output: Contribution to journalArticle

    Mayberry, JC, Brown, CV, Mullins, R, Velmahos, GC, Thal, ER, Mansour, MA, Wisner, DH, Peter, ET, Berne, TV, Jurkovich, GJ & Shatney, CH 2004, 'Blunt carotid artery injury: The futility of aggressive screening and diagnosis', Archives of Surgery, vol. 139, no. 6, pp. 609-613. https://doi.org/10.1001/archsurg.139.6.609
    Mayberry, John C. ; Brown, Carlos V. ; Mullins, Richard ; Velmahos, George C. ; Thal, Erwin R. ; Mansour, M. Ashraf ; Wisner, David H. ; Peter, Edward T. ; Berne, Thomas V. ; Jurkovich, Gregory J. ; Shatney, Clayton H. / Blunt carotid artery injury : The futility of aggressive screening and diagnosis. In: Archives of Surgery. 2004 ; Vol. 139, No. 6. pp. 609-613.
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    abstract = "Background: Blunt carotid artery injury (BCI) remains a rare but potentially lethal condition. Recent studies recommend that aggressive screening based on broad criteria (hyperextension-hyperflexion mechanism of injury, basilar skull fracture, cervical spine injury, midface fracture, mandibular fracture, diffuse axonal brain injury, and neck seat-belt sign) increases the rate of diagnosis of BCI by 9-fold. If this recommendation becomes a standard of care, it will require a major consumption of resources and may give rise to liability claims. The benefits of aggressive screening are unclear because the natural history of asymptomatic BCI is unknown and the existing treatments are controversial. Hypothesis: The lack of an aggressive angiographic screening protocol does not result in delayed BCI diagnosis or BCI-related neurologic deficits. Methods: A 10-year medical record review of patients with BCI was undertaken in 2 level I academic trauma centers. In both centers, urgent screening for BCI was performed in patients with focal neurologic signs or neurologic symptoms unexplainable by results of computed tomography of the brain as well as in selected patients undergoing angiography for another reason. Results: Of 35212 blunt trauma admissions, 17 patients (0.05{\%}) were diagnosed as having BCI. Six showed no evidence of BCI-related neurologic symptoms during hospitalization or prior to death as a result of associated injuries. Eleven sustained a BCI-related stroke, 9 of whom had it within 2 hours of injury. The remaining 2 had a delayed diagnosis (9 and 12 hours after injury) and received only anticoagulation because the lesions were surgically inaccessible. Just 1 of these 2 patients met the criteria for BCI screening and could have been offered earlier treatment, of uncertain benefit, if we had adopted an aggressive screening policy. Conclusions: Of the few patients with BCI, most remain asymptomatic or develop neurologic deficits shortly after injury. Although a widely applied, resource-consuming screening program may increase the rate of early diagnosis of BCI, an improvement in outcome is uncertain. A cost-effectiveness analysis should be done before trauma surgeons accept an aggressive screening protocol as the standard of care.",
    author = "Mayberry, {John C.} and Brown, {Carlos V.} and Richard Mullins and Velmahos, {George C.} and Thal, {Erwin R.} and Mansour, {M. Ashraf} and Wisner, {David H.} and Peter, {Edward T.} and Berne, {Thomas V.} and Jurkovich, {Gregory J.} and Shatney, {Clayton H.}",
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    AU - Brown, Carlos V.

    AU - Mullins, Richard

    AU - Velmahos, George C.

    AU - Thal, Erwin R.

    AU - Mansour, M. Ashraf

    AU - Wisner, David H.

    AU - Peter, Edward T.

    AU - Berne, Thomas V.

    AU - Jurkovich, Gregory J.

    AU - Shatney, Clayton H.

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    N2 - Background: Blunt carotid artery injury (BCI) remains a rare but potentially lethal condition. Recent studies recommend that aggressive screening based on broad criteria (hyperextension-hyperflexion mechanism of injury, basilar skull fracture, cervical spine injury, midface fracture, mandibular fracture, diffuse axonal brain injury, and neck seat-belt sign) increases the rate of diagnosis of BCI by 9-fold. If this recommendation becomes a standard of care, it will require a major consumption of resources and may give rise to liability claims. The benefits of aggressive screening are unclear because the natural history of asymptomatic BCI is unknown and the existing treatments are controversial. Hypothesis: The lack of an aggressive angiographic screening protocol does not result in delayed BCI diagnosis or BCI-related neurologic deficits. Methods: A 10-year medical record review of patients with BCI was undertaken in 2 level I academic trauma centers. In both centers, urgent screening for BCI was performed in patients with focal neurologic signs or neurologic symptoms unexplainable by results of computed tomography of the brain as well as in selected patients undergoing angiography for another reason. Results: Of 35212 blunt trauma admissions, 17 patients (0.05%) were diagnosed as having BCI. Six showed no evidence of BCI-related neurologic symptoms during hospitalization or prior to death as a result of associated injuries. Eleven sustained a BCI-related stroke, 9 of whom had it within 2 hours of injury. The remaining 2 had a delayed diagnosis (9 and 12 hours after injury) and received only anticoagulation because the lesions were surgically inaccessible. Just 1 of these 2 patients met the criteria for BCI screening and could have been offered earlier treatment, of uncertain benefit, if we had adopted an aggressive screening policy. Conclusions: Of the few patients with BCI, most remain asymptomatic or develop neurologic deficits shortly after injury. Although a widely applied, resource-consuming screening program may increase the rate of early diagnosis of BCI, an improvement in outcome is uncertain. A cost-effectiveness analysis should be done before trauma surgeons accept an aggressive screening protocol as the standard of care.

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