Penetrating injury to the head and neck: influence of cerebrovascular injury on outcomes and agreement between vascular imaging modalities.

OBJECTIVE

Delays in identification and management of penetrating cerebrovascular injury (PCVI) can lead to poor outcomes. With improvements in computed tomography angiography (CTA) there remains controversy regarding the role of digital subtraction angiography (DSA).

METHODS

Consecutive patients with penetrating injury to the head or neck evaluated with both CTA and DSA at a single level 1 trauma center were included. CTA's performances for identifying an injury, identifying the correct vessel, and correctly classifying the injury with DSA as the gold standard were determined. Outcomes included favorable clinical outcome at discharge (Modified Rankin Scale 0-2), length of stay (LOS), and routine discharge disposition.

RESULTS

A total of 95 patients were included. CTA identified 69 injuries in 54 patients while DSA identified 79 injuries in 58 patients. For identifying an arterial injury, CTA was 72.6% accurate, 74.1% sensitive, and 70.3% specific. The PPV was 79.6% and the NPV was 63.4%. For identifying the correct vessel injured, CTA was 96.2% accurate and the Cohen's Kappa (K) was 0.95. For characterizing the injury type, CTA was 70.0% accurate and K was 0.58. Biffl grade 5 injuries were associated with greater odds of unfavorable clinical outcome at discharge (OR 3.60, 95% CI 1.05-13.35; p = 0.046). Biffl grade 4 injuries were associated with greater odds of nonroutine discharge disposition (OR 4.39, 95% CI 1.23-18.37; p = 0.029).

CONCLUSION

CTA had low sensitivity, accuracy, and NPV for detecting PCVI. This highlights potential limitations of CTA as a screening tool and strengthens the role of DSA for patients with penetrating head and neck injuries.