The Natural History of Indeterminate Blunt Cerebrovascular Injury

JAMA Surg. 2015 Sep;150(9):841-7. doi: 10.1001/jamasurg.2015.1692.


Importance: The Denver criteria grade blunt cerebrovascular injuries (BCVIs) but fail to capture many patients with indeterminate findings on initial imaging.

Objective: To evaluate outcomes and clinical significance of indeterminate BCVIs (iBCVIs).

Design, setting, and participants: A retrospective review of all patients treated for BCVIs at our institution from January 1, 2007, through July 31, 2014, was completed. Patients were divided into 2 groups: those with true BCVIs as defined by the Denver criteria and those with iBCVIs, which was any initial imaging suggestive of a cerebrovascular arterial injury not classifiable by the Denver criteria.

Main outcomes and measures: Primary outcomes were rate of resolution of iBCVIs, freedom from cerebrovascular accident (CVA) or transient ischemic attack (TIA), and 30-day mortality.

Results: We identified 100 patients with 138 BCVIs: 79 with true BCVIs and 59 with iBCVIs. With serial imaging, 23 iBCVIs (39.0%) resolved and 21 (35.6%) remained indeterminate, whereas 15 (25.4%) progressed to true BCVI. The rate of CVA or TIA in the iBCVI group was 5.1% compared with 15.2% in the true BCVI group (P = .06). Of the 15 total CVAs or TIAs, 11 (73.3%) resulted from carotid injury and 4 (26.7%) from vertebral artery occlusion (P = .03). By Kaplan-Meier analysis, there was no difference in freedom from CVA or TIA for the 2 groups (P = .07). Median clinical follow-up was 91 days. Overall and 30-day mortality for the entire series were 17.4% and 15.2%, respectively. There was no difference in long-term or 30-day mortality between true BCVI and iBCVI groups.

Conclusions and relevance: Detection of iBCVI has become a common clinical conundrum with improved and routine imaging. Indeterminate BCVI is not completely benign, with 25.4% demonstrating anatomical progression to true BCVI and 5.1% developing cerebrovascular symptoms. We therefore recommend serial imaging and antiplatelet therapy for iBCVI.

MeSH terms

  • Adult
  • Cerebrovascular Trauma / diagnosis*
  • Cerebrovascular Trauma / mortality
  • Female
  • Humans
  • Injury Severity Score
  • Kaplan-Meier Estimate
  • Male
  • Middle Aged
  • Poland / epidemiology
  • Retrospective Studies
  • Tomography, X-Ray Computed / methods*
  • Wounds, Nonpenetrating / diagnosis*
  • Wounds, Nonpenetrating / mortality