Incidence and Trends in the Diagnosis of Traumatic Extracranial Cerebrovascular Injury in the Nationwide Inpatient Sample Database,2003

Abstract

Patients with traumatic extracranial cerebrovascular injury (TCVI) comprise about 1% of all blunt trauma admissions according to numerous single-center studies. However, previous studies have used aggressive screening protocols; these studies may not reflect common practice and the overall incidence of TCVI. The annual incidence of the diagnosis of TCVI from 2003 to 2010 was estimated using the Nationwide Inpatient Sample (NIS). For comparison, a systematic review of previous studies of the incidence of the diagnosis of TCVI was conducted. The estimated total number of admissions with TCVI ranged from 1283 to 2652; these admissions represented 0.46–0.95% of all blunt trauma admissions. There was a significant increase in the incidence of TCVI during the study period. A total of 49 studies of TCVI reported incidences of diagnosis ranging from 0.03% to 4.8%. In conclusion, the annual nationwide incidence of the diagnosis of TCVI is increasing. Although NIS incidences of the diagnosis of TCVI are at the low end of the range of previous reports, the increasing incidence in the NIS data likely reflects increasing use of aggressive screening protocols.

Introduction

Blunt traumatic extracranial cerebrovascular injury (TCVI) has become increasingly recognized among trauma patients in recent years, largely because of the widespread use of screening computed tomography angiography (CTA) as integral to trauma protocols.^{1

–10} Estimates of the incidence of the diagnosis of TCVI among all patients with blunt trauma, from numerous single center studies and several multicenter reports, range from 0.075% to 1.6%.^11
–13 Rates of neurological morbidity and mortality attributable to TCVI have been reported to be as high as 50% and 40%, respectively.^{9, 14
–16} However, national estimates of the incidence of TCVI are lacking, and the overall public health burden of TCVI remains to be determined. A number of publications, including guidelines published by the Eastern Association for the Surgery of Trauma¹⁷ have called for multicenter trials, to determine optimal strategies for the management of patients with TCVI. However, a concrete understanding of the global significance of TCVI is necessary before large-scale resources are committed to clinical trials.

The purpose of this study was to determine the incidence of the diagnosis of TCVI in the United States, using the Nationwide Inpatient Sample (NIS) for the years 2003–2010. The NIS is the largest all-payer hospital inpatient database in the United States. It contains data from a 20% stratified sample of nonfederal United States hospitals, representing ∼8,000,000 hospital admissions each year. For comparison, a review of other relevant studies of the incidence of the diagnosis of TCVI was also undertaken.

Methods

Data source

The Nationwide Inpatient Sample (NIS) databases for the years 2003 through 2010 were used to produce estimates of national traumatic extracranial vascular diagnoses in the United States. NIS is the largest all-payer inpatient database developed as part of Healthcare Cost and Utilization Project (HCUP) by the Agency for Health Care Research and Quality (ARHQ). This project was approved by the Institutional Review Board.

Study population

Extracranial blunt TCVI was defined as a hospital admission with at least one extracranial vascular diagnosis (EVD) and a documented external cause of non-penetrating injury (ECOI) in the NIS database. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes used to identify EVDs with or without prior history of trauma are listed in Table 1. These codes were used to scan through the 15 diagnosis positions in each year database for EVD. Although it is possible to have more than one EVD per patient, only one diagnosis event was considered in the analysis. To identify the trauma cases, we searched the NIS databases using HCUP Clinical Classification Software (CCS) for ICD-9-CM E codes (Table 2). The CCS E codes collapse ICD-9-CM codes for external cause of injury into smaller clinically meaningful categories. Of the four positions for ECOI, only the first listed external cause of injury was employed in the identification and classification of the trauma cases. The incidence of TCVI was calculated by dividing the frequencies of TCVI by all selected injuries.

Table 1.

Diagnosis Codes Indicating Extracranial Vascular Diagnosis

Extracranial vascular diagnosis	Code
Occlusion and stenosis of carotid artery	433.1
Occlusion and stenosis of carotid artery without cerebral infarction	433.10
Occlusion and stenosis of carotid artery with cerebral infarction	433.11
Occlusion and stenosis of vertebral artery	433.2
Occlusion and stenosis of carotid artery without cerebral infarction	433.20
Occlusion and stenosis of vertebral artery with cerebral infarction	433.21
Occlusion and stenosis of multiple and bilateral precerebral arteries	433.3
Occlusion and stenosis of multiple and bilateral precerebral arteries without cerebral infarction	433.20
Occlusion and stenosis of multiple and bilateral precerebral arteries with cerebral infarction	433.21
Occlusion and stenosis of other specified precerebral artery	433.8
Occlusion and stenosis of other specified precerebral artery without cerebral infarction	433.80
Occlusion and stenosis of other specified precerebral artery with cerebral infarction	433.81
Occlusion and stenosis of other unspecified precerebral artery	433.9
Occlusion and stenosis of other unspecified precerebral artery without cerebral infarction	433.90
Occlusion and stenosis of other unspecified precerebral artery with cerebral infarction	433.91
Dissection of carotid artery	443.21
Dissection of vertebral artery	443.24
Aneurysm of artery of neck	442.81
Injury to carotid artery	900.0
Injury to carotid artery unspecified	900.00
Injury to common carotid artery	900.01
Injury to external carotid artery	900.02
Injury to internal carotid artery	900.03
Injury to multiple blood vessels of head and neck	900.82
Injury to other specified blood vessels of head and neck	900.89
Injury to unspecified blood vessel of head and neck	900.9
Injury to other specified blood vessels of head and neck, other	900.8

Table 2.

E Codes Indicating Blunt Trauma Cause of Injury

Mechanism of injury	E codes included
Motor vehicle crash	E810-E819 (.0, .1), E958.5 E968.5 E988.5
Pedestrians struck	E810–E819 (.7)
Bicycle	E810–E819 (.6)
Motorcycle	E810–E819 (.2, .3)
Falls from any height	E880 (.0, .1 .9), E881 (.0, .1), E882, E883 (.0, .1, .2, .9), E884 (.0, .1)
Falls at same level	E880.0 to E886.9, E888, E957(0–.9), E968.1, E987 (.0–.9) excluding those defined in “falls from any height” above
Assault (struck by fists, kicked, assaulted)	E960.0
Assault with object (struck by object during assault, pistol, baseball bat, concrete block)	E968.2
Assault with vehicle	E968.5

Statistical analysis

The NIS databases were analyzed using SAS 9.2 statistical software (SAS Institute, Cary, NC) for the 8 year study period. National estimates of the diagnosis of TEVD in the United States were obtained by PROC SURVEYMEANS and PROC SURVEYFREQ procedures in the SAS statistical package. These procedures take into consideration the weighting, clustering, and stratification involved in the NIS sampling technique. Changes in incidence rates over time were assessed with a Cochran–Armitage trend test.

Literature review

The PubMed database was searched up to December, 2013. The following text words were used: blunt trauma OR non-penetrating trauma in combination with AND carotid artery or vertebral artery. Studies were included only if the incidence of extracranial carotid artery and/or vertebral artery injuries were reported among the overall number of blunt trauma admissions. Single case reports were excluded. To assess eligibility, the reviewer (M.R.H.) screened titles and abstracts and reviewed relevant full-text articles. Reference lists of relevant studies were searched for additional sources.

Results

NIS data

Total estimated numbers of blunt trauma admissions and blunt trauma admissions with TCVI are listed in Table 3 and graphed in Figure 1. Although the number of admissions for blunt trauma did not change markedly, hospitalizations for TCVI increased significantly from 1308 in 2003 to 2652 in 2010 (97.3%, p<0.001). The incidence rate rose from 0.46% in 2003 to 0.95% in 2010. Of the mechanisms of injury, motor vehicle traffic (MVT) was the most common, responsible for 59.3–74.7% of TCVI admissions (Table 1). The next most common mechanisms were falls from any height (8.6–15.5%), motorcycle crashes (6.5–15.3%), pedestrians being struck (4.2–8.8%), and assault with an object (1.9–4.9%). Relatively uncommon were bicycle accidents (1.1–3.5%) and assault with a vehicle (0–0.4%).

FIG. 1.

Numbers and incidences of traumatic cerebrovascular injury admissions among blunt trauma admissions.

Table 3.

Incidences and Mechanisms of Traumatic Cerebrovascular Injury (TCVI) in the Nationwide Inpatient Sample, 2003–2010

		2003	2004	2005	2006	2007	2008	2009	2010	p value^a
Blunt injuries		286,568	292,251	254,382	267,760	251,978	176,842	241,868	280,568
TCVI		1308	1666	1259	1546	1667	1283	1948	2652	<0.001
Incidence rates of TCVI (%)		0.46	0.57	0.49	0.58	0.66	0.73	0.81	0.95
	Assault with an object	45 (3.4)	45 (2.7)	62 (4.9)	44 (2.8)	32 (1.9)	50 (3.9)	58 (3.0)	81 (3.2)
	Assault with a vehicle	NR	0	0	0	NR	0	11 (0.5)	0
	Bicycle	21 (1.6)	58 (3.5)	14 (1.1)	40 (2.6)	36 (2.2)	28 (2.2)	51 (2.6)	65 (2.6)
Mechanism	Fall from any height	119 (9.1)	144 (8.6)	183 (14.6)	164 (10.6)	202 (12.1)	199 (15.5)	245 (12.6)	307 (12.0)
	Motor vehicle crash	977 (74.7)	1194 (71.7)	841 (66.7)	1025 (66.3)	1159 (69.5)	761 (59.3)	1179 (60.6)	1542 (60.2)
	Motorcycle	88 (6.7)	124 (7.4)	90 (7.1)	158 (10.2)	144 (8.6)	147 (11.4)	231 (11.8)	391 (15.3)
	Pedestrian struck	55 (4.2)	101 (6.1)	70 (5.6)	116 (7.5)	89 (5.4)	98 (7.6)	172 (8.8)	176 (6.9)

Cochran-Armitage Trend test comparing blunt injuries with and without TCVI.

Healthcare Cost and Utilization Project (HCUP) privacy protection policy prohibits reporting of data on groups of patients ≤10 in number.

NR, not reported.

Other studies reporting on the incidence of TCVI

A search of the literature produced 49 relevant studies, from 1990 to 2013 (Table 4). A total of 27 studies reported on the incidence of both carotid artery and vertebral artery injuries,^{1,3

–6,8,11
–13,15,16,18

–33} 17 reported on carotid injuries only,^{10, 34

–49} and 5 reported on vertebral artery injuries only.^50

–54 Some of these reports were from the same center during the same period, and, therefore, some of the samples may have overlapped. For the studies including both carotid and vertebral artery injuries, the incidences of TCVI diagnoses among all blunt trauma admissions ranged from 0.03% to 4.8%. No trend in incidences was observed over the time period of the studies. The most common causes of injury were motor vehicle crashes and other forms of road trauma (50–89%). Other common causes of injury were falls (6–18%) and assault (2–21%). Male gender (57–79%) was more common than female gender in most studies. Most patients were in the fourth or fifth decade of life. Only three studies including both carotid and vertebral artery injuries included data on ethnicity; all four found that that Caucasians were the most common ethnic group. One study found Hispanics to be the next most common ethnic group,²⁵ whereas the other two found African Americans to be the second most common ethnic group.^5,30

Table 4.

Studies Reporting on Incidence of Blunt Extracranial Traumatic Cerebrovascular Injury

Vessels included	First author	Year	Incidence (%)	Sex (% Male)	Age (Mean±SD yrs)	Race	Mechanism of injury	Comments
Carotid and vertebral arteries	Cothren¹³	2009	1.6	65	37±0.8	…	MVC 59%; Falls 12%; Automobile/pedestrian 9%
	Rogers¹⁵	1999	0.11	…	36.9	…	MVC 53%; Falls 24%; Pedestrian struck 6%
	Berne¹⁸	2001	0.49	…	…	…	MVC 65%; Direct cervical blow 18%; Fall from a height 12%
	Kerwin¹⁹	2001	1.1	57	33	…	MVC 71%; Assault 14%; MCC 5%
	Miller²⁰	2001	0.9	60	37	…	CAI Patients: MVC 80%; Pedestrian struck 5%; assaults 5% VAI Group: MVC 80%; Falls 6%; Assaults 4%
	Biffl²¹	2002	1.55	68	35.6±1.1	…	MVC 50%; Fall 11%; Other 29%
	McKevitt¹¹	2002	0.075	68	36.2	…	MVC 65%; MCC 15%; Fall 10%
	Miller¹	2002	1.03	56	37.6	…	MVC 78%; Fall 4%; Pedestrian struck 4%
	Berne⁴	2004	0.6	…	…	…	MVC 79%; Assault 5%; All terrain vehicle accident 5%
	Cothren²²	2005	1.5	68	35±3.7	…	…
	Mutze²³	2005	0.9; 2.7	Single Section CT: 54 Multiple detector row CT: 73	Single section CT: 25.8±12.6 Multiple detector row CT:33.6±17.5	…	Single section CT: Traffic accident 84.6%; Fall from height 7%; Other 7%; Multiple detector row CT: Traffic accident 91%; Fall from height 9%	Screening with ultrasound or CTA, respectively
	Berne²⁴	2006	1.2	…	…	…	MVC 58%; MCC 17%; Fall onto head 8%
	Biffl⁸	2006	0.66	68	38	…	MVC 51%; Fall 16%; Assault 11%
	Eastman²⁵	2006	1.25	65	39.5±19.9	White 55.8%; Hispanic 30.2%; Black 13.9%	MVC 81.4%; Fall 11.6%; MCC 4.7%
	Schneidereit¹⁶	2006	1.1	74	41.2±16.4	…	MVC 53%; Falls 15.7%; pedestrian struck 10.4%
	Cothren²⁶	2007	1.5	67	36±3.8	…	Motor vehicle related 71%; Auto-pedestrian 9%; Falls 7%
	Malhotra³	2007	0.3	57	38±1.7	…	MVC 89%; Assault 2%; MCC 2%
	Risgaard²⁷	2007	0.18	79	33±13	…	Road trauma 64%; Interpersonal violence 21%; Sporting 7%
	Sliker²	2008	1.6	66	39	…	MVC 82%; MCC 16%; Pedestrian struck by motor vehicle 6%
	Eastman⁶	2009	0.86	…	38.7±18.5	…	…
	Goodwin⁵	2009	1.1	74	43±17.8	Caucasian 85.4%; African American 12.7%; Hispanic 1.9%	…
	Stein²⁸	2009	1.2	58	42±18.0	…	MCV 58%; MCC 14%; Fall 10.9%
	Berne²⁹	2010	1.03	64	39.8	…	…
	Franz³⁰	2010	0.84	66	47.8±16.6	Caucasian 97%; African American 3%	MVC 62%; Fall from a height 14%; MCC 10%
	Gladstone³¹	2010	0.93	85	32.74±12.51	…	MVC 49%; Car-pedestrian accident 24%; Fall from height 18%
	Hwang³²	2010	0.64	70	Median Age: 32	…	MVC 50%; MCC 13%; Fall 13%
	Bonatti³³	2013	3.3%	…	…	…	MVC 50%; MCC 13%; Fall 13%
Carotid artery only	Davis³⁴	1990	0.08	57	35±19	…	MVC 71%; Bicycle crashes 14%; Ski crash 7%
	Fabian³⁵	1996	0.33	64	34	…	MVC 82%; MCC 7%; Assaults 6%
	Laitt³⁶	1996	0.4	63	35.9	…	Road traffic accidents 63%; Assault 13%; Fall from horse 13%
	Parikh³⁷	1997	0.24	40	33	…	MVC 100%
	Biffl³⁸	1998	0.86	76	35.1±2.8	…	MVC 41%; Fall 14%; Pedestrian struck 14%
	Carrillo³⁹	1999	0.14	60	Age range: 10–58	…	MVC 85%; Falls 6%; Assault 6%;
	Kraus⁴⁰	1999	0.27	37	35	…	Vehicular trauma 81%; Assaults 13%
	Lew⁴⁸	1999	0.03	60	5.5±5.8	…	MVC 27%; Struck by motor vehicle 27%; Fall 27%	Pediatric cases only
	Hughes⁴¹	2000	0.21	29	35	…	MVC 100%
	McKevitt⁴²	2002	0.09	64	35.4±12.4	…	MVC 79%; Fall 7%; Skiing 7%
	Wahl⁴³	2002	0.45	…	42±9.8	…	MVC 73%; Falls 9%; Assault 5%
	Cothren⁴⁴	2004	4.8	71	34±1.3	…	MVC 79%; Fall 11%; Other 10%
	Mayberry⁴⁵	2004	0.05	…	28±12	…	MVC 47%; MCC 12%; Industrial mishap 12%
	Borisch¹⁰	2007	4.6	76	40.8±20.1	…	MVC or MCC 68%; Falls from a great height 18%; Pedestrian struck 8%
	Edwards⁴⁶	2007	0.35	62	37	…	MVC 85%; Pedestrian struck 4%; Fall 3%
	Li⁴⁷	2010	0.05	Conservative treatment: 64% Operative treatment: 81%	Conservative treatment: 35±16.6 Operative treatment: 35±16.9	…	…	Data from National Trauma Databank
	Ciapetti⁴⁹	2010	2.2%	…	31	…	MCC 33%; Fall 33%; MVC 17%; Bicycle crash 17%
Vertebral artery only	Thibodeaux⁵⁰	1997	0.2	…	…	…	…
	Biffl⁵¹	2000	0.53	66	38.9±2.3	…	MVC 58%; Fall 13%; Pedestrian struck 11%
	Cothren⁵²	2003	0.73	63	38±1.4	…	MVC 63%; Auto pedestrian 5%; MCC 4%
	Spaniolas⁵³	2008	0.075	68	42±19	…	…
	Berne⁵⁴	2009	0.53	…	…	…	MVC 75%; MCC 7%; Diving accident 7%

CTA, computed tomographic angiography; MVC, motor vehicle crash; MCC. motorcycle crash.

Discussion

This study found that the total annual estimated number of hospital admissions with TCVI as a diagnosis ranged from 1308 to 2652 during the years 2003–2010. The population of the United States was estimated to be 308,745,538 in 2010;⁵⁵ with 2652 estimated TCVI admissions in that year, the incidence of TCVI for 2010 was 0.86 per 100,000 population. For comparison, the incidence of hospitalization for traumatic brain injury is ∼79.0 per 100,000 population.⁵⁶

This study found an overall incidence of the diagnosis of TCVI among all blunt trauma admissions of 0.46–0.95%. These results are at the lower end of the range of reported incidences of carotid and vertebral artery TCVI in the other studies found in the literature review, which ranged from 0.03% to 4.8%. There are several possible explanations for this. First, most of the centers in the other studies employed comprehensive screening protocols with CTA. That is, all blunt trauma patients with risk factors for TCVI, such as cervical spine fractures and severe brain injuries, had neck CTAs to investigate for TCVI. Many of the centers included in the NIS database likely did not use CTA screening protocols during the study period. Second, most of the other studies were from level I trauma centers, and these centers are likely to manage a higher concentration of patients with polytrauma and associated TCVI than many centers included in the NIS. Third, a number of other studies reported TCVI diagnosed only with CTA and not confirmed with cerebral angiography, which is still considered to be the gold standard for imaging of the carotid and vertebral arteries. The accuracy of CTA in this setting is limited and varies according to study. The false positive rate of CTA for screening for TCVI has been found to be as high as 37%.³ Therefore, because the other studies may have included some false positive CTA results, the resulting TCVI incidences in the other studies may have been higher than the true incidences. A fourth possibility is that the total numbers of blunt trauma admissions in this study were overestimated, leading to underestimation of TCVI incidences. However, the total numbers of blunt trauma admissions found in this study are comparable to estimates of total annual national admissions for trauma reported in other studies, including the NIS⁵⁷ and the National Electronic Injury Surveillance System All Injury Program (NEISS-AIP).⁵⁸

This study found a significant increase in the incidence the diagnosis of TCVI over time. Another study, using the National Trauma Database, also found a significant increase in the diagnosis of blunt traumatic vertebral artery injuries over time, from 2001 to 2005.⁵³ This is likely because of the increasing use of CTA screening protocols, as well as more sensitive later generation 16- and 64-detector CT scanners.

The results of this study regarding gender, age, ethnicity, and cause of injury are similar to the findings in the other studies. This observation provides some degree of confirmation that the patient data set in the present study matches the patients detailed in other reports of TCVI.

There are several limitations to the present study. First, the retrospective design of this study carries the potential for selection bias and error. We attempted to indirectly confirm the validity of the incidence data in the present study by comparing the results with those of other studies found in the literature review. The similarities between the present findings and other published studies suggest that the patients in these studies were similar. Second, the NIS, being a very large database, is likely to contain some amount of coding error and variability in coding. For example, the diagnosis of TCVI is likely to be underreported in centers without CTA screening protocols, and the NIS database is limited to 15 diagnoses per admission; patients with polytrauma may have>15 diagnoses.

Conclusion

Data from the NIS about the number of patients with TCVI admitted to hospitals in the United States on an annual basis is within the range of incidences of the diagnosis of TCVI among trauma patients reported by individual and small groups of centers. The fact that the NIS incidences lie toward the lower end of the range of previously reported incidences is likely because of the relatively comprehensive screening protocols used by the centers that have published their data. The NIS incidences have risen over time, and this is likely attributable to more widespread use of screening of trauma patients.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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Incidence and Trends in the Diagnosis of Traumatic Extracranial Cerebrovascular Injury in the Nationwide Inpatient Sample Database,2003–2010

Abstract

Introduction

Methods

Data source

Study population

Statistical analysis

Literature review

Results

NIS data

Other studies reporting on the incidence of TCVI

Discussion

Conclusion

Footnotes

Author Disclosure Statement

References