Change in management for digital subtraction angiography-identified false-positive traumatic vertebral artery injury

Abstract

Background: For patients with suspected traumatic vertebral artery injury (TVAI), CT angiography (CTA) is the first-line screening modality. Digital subtraction angiography (DSA) serves as the confirmatory diagnostic imaging, and is the gold standard for cerebrovascular injury assessment, due to its higher sensitivity and specificity. Among patients with TVAI based on CTA who have undergone follow-up DSA, this study aims to investigate how diagnostic information with additional imaging affects clinical management.

Methods: A retrospective review was conducted over 7 years (2016-2023) at a level 1 trauma center for TVAI patients undergoing both CTA and DSA. Pre- and post-DSA approaches to TVAI management were compared and summarized using propensity-score matched analysis.

Results: Among the 69 patients studied, 24.6% were determined to have false-positive TVAI after DSA. The rate of change in management after DSA was significantly different across DSA+ and DSA- cohorts (p = 0.02). The likelihood of a change in management in patients with based on outcome of the DSA was significant (p = 0.03) in the propensity-matched cohort. On average, 3 (NNI = 3.2) patients would need to receive a DSA for one additional patient to undergo a change in management.

Conclusion: This study demonstrates that, despite initial CTA imaging suggestive of TVAI, follow-up DSA imaging negative for TVAI has a significant impact on changing clinical management, including cessation of antithrombotic agents. Thus, for TVAI patients, DSA may be considered in the diagnostic workup for select patients with positive CTA. Larger cohort analyses are needed to refine imaging algorithms and optimize clinical outcomes for TVAI patients.

Keywords: Digital subtraction angiography; cerebrovascular trauma; computed tomography angiography; diagnosis; vertebral artery dissection.

Figure 1.

Computed tomography angiography identified lumen irregularity of the left vertebral artery at the V2 level annotated on sagittal (arrow) (A), coronal (circle) (B), and axial (circle) (C) views. Digital subtraction angiography anteroposterior (D) and lateral views (E) demonstrating normal blood flow; the V2 irregularity identified on computed tomography angiography was a false-positive traumatic vertebral artery injury.

Figure 2.

Computed tomography angiography identified multifocal dissections of the V2 segment of the left cervical vertebral artery at the C5/C6 levels annotated on sagittal (arrow) (A), coronal (arrow) (B), and axial (arrow) (C) views. Digital subtraction angiography anteroposterior (D) and lateral views (E) demonstrate left proximal V2 vertebral artery grade 1 vascular injury. This is an example of a traumatic vertebral artery injury confirmed on both imaging modalities.

Figure 3.

Traumatic vertebral artery injury (TVAI) diagnostic algorithm with digital subtraction angiography (DSA) following positive initial computed tomography angiography (CTA) screening.