Penetrating Injury to the Head and Neck: Influence of Cerebrovascular Injury on Outcomes and Agreement Between Vascular Imaging Modalities

Introduction: There is a paucity of data on patients with penetrating head/neck trauma evaluated with digital subtraction angiography (DSA). We sought to evaluate outcomes and agreement between computed tomography angiography (CTA) and DSA in patients with penetrating injury to the head/neck.

Methods: Consecutive patients presenting with penetrating trauma to the head/neck age ≥16 years evaluated with DSA at a level 1 trauma center over 4 years were included. Outcomes included dichotomized discharge modified Rankin Scale (mRS [0-2 = favorable, 3-6 = unfavorable]), length of stay (LOS), and discharge disposition. Multivariate models were created for each outcome adjusting for demographic and injury characteristics.

Results: 97 patients (mean age 31.4 years, 86% male) met inclusion criteria. The most common mechanism was gunshot wound (90.7%). Injury sites included face (41.2%), head (18.6%), and neck (40.2%). There were 88 vascular injuries identified by CTA and 83 by DSA. The locations of injury on DSA included external carotid artery (n = 37), extracranial internal or common carotid artery (17), extracranial vertebral artery (17), intracranial anterior circulation (7), and intracranial posterior circulation (5). Concordance between CTA and DSA identification of vessel injury was minimal (Cohen’s Kappa = 0.31) and concordance between CTA and DSA classification of vessel injury was weak (Cohen’s Kappa = 0.43). Lower GCS (OR 0.88, 95%CI 0.79-0.99; p = 0.03) and intracranial vascular injury (OR 20.1, 95%CI 1.53-712.5; p = 0.04) were associated with unfavorable discharge mRS. Bilateral non-reactive pupils were associated with longer LOS (p = 0.009) and injury to the face (p = 0.04) was associated with shorter LOS. Intracranial vascular injury was associated with lower odds of discharge home (OR 0.05, 95%CI 0.004-0.58; p = 0.02).

Conclusion : Agreement between CTA and DSA findings among patients presenting with penetrating injury to the head/neck were poor, highlighting the role of DSA.