In a patient involved in a rollover motor‑vehicle accident with no cervical‑spine fracture on plain radiographs or computed tomography and no neurologic deficits or external neck signs, is a routine computed tomography angiogram of the neck required?

CT Angiography After Rollover MVA Without C-Spine Fracture

Routine CT angiography of the neck is NOT required in a patient with a rollover MVA who has a negative cervical spine CT, no neurologic deficits, and no external neck signs. 1

Risk Stratification for Blunt Cerebrovascular Injury (BCVI)

The decision to perform CTA neck depends on specific high-risk criteria, not simply the mechanism of rollover MVA:

High-Risk Criteria Requiring CTA Neck

You should obtain CTA neck if ANY of the following are present:

• Cervical spine fracture patterns involving:

  • Subluxation or dislocation 2
  • Extension through the foramen transversarium 2
  • C1-C3 fractures (particularly C2 fractures, which account for the majority of vertebral artery injuries) 2, 3

• Neurologic findings:

  • Focal neurologic deficit unexplained by head CT 4, 5
  • Decreased Glasgow Coma Scale 6
  • Stroke symptoms 2

• Physical examination findings:

  • Arterial hemorrhage from neck/face 5
  • Cervical bruit in patients <50 years 5
  • Expanding cervical hematoma 5
  • Significant anterior neck trauma with swelling (clothesline-type mechanism) 5

• Associated injuries:

  • Basilar skull fracture 2
  • Severe facial fractures 2
  • Concurrent blunt carotid injury 6

Your Patient Does NOT Meet High-Risk Criteria

Since your patient has:

• No cervical spine fracture on CT
• No neurologic deficits
• No external neck signs

This patient does NOT require routine CTA neck. 1

Evidence Supporting This Approach

The ACR Appropriateness Criteria explicitly state that CTA imaging is best reserved for patients with a high index of suspicion for cervical arterial injury 1. The mechanism of rollover MVA alone, without the high-risk features listed above, does not constitute sufficient indication for CTA.

Research demonstrates that:

• Only 0.49% of trauma patients screened had vertebral artery injury 6
• Positive CTA rarely altered surgical treatment of cervical spine injuries when ordered off-protocol 3
• Independent predictors of vertebral artery injury include female sex, decreased GCS, cervical spine fracture, and concurrent carotid injury—none of which your patient has 6

Clinical Algorithm

For patients with rollover MVA and negative cervical spine CT:

1. Perform detailed neurologic examination looking for any focal deficits 4, 5
2. Examine neck carefully for hematoma, bruit, or anterior trauma signs 5
3. If examination is completely normal → CTA neck is NOT indicated 1
4. If any high-risk features present → Obtain CTA neck 4, 5

Important Caveats

• Do not confuse cervical spine clearance with vascular screening: Your patient's cervical spine is already cleared by CT, but this addresses bony/ligamentous injury, not vascular injury 1

• Delayed presentation is possible but rare: BCVI can present with delayed stroke, but this occurs in patients with unrecognized injuries who had risk factors that should have prompted initial screening 5, 2

• Cost and radiation considerations: Unnecessary CTA exposes patients to approximately 4000 mGy/cm radiation and 100 mL contrast, with charges around $3925 per study 3

When to Consider MRI Instead

MRI cervical spine (not MRA) may be indicated if:

• Patient develops new neurologic symptoms despite negative CT 1, 7
• Persistent severe neck pain with concern for ligamentous injury 1
• Clinical suspicion for spinal cord injury 1, 8

However, for vascular screening specifically, MRA has lower sensitivity than CTA (75% vs 90-100%) and is not preferred in the acute trauma setting 1.