Additional Diagnostic Imaging and Monitoring in Moderate‑to‑Severe Traumatic Brain Injury

Vascular Imaging (CTA/MRA/DSA)

Early CT angiography of the supra‑aortic and intracranial arteries is recommended when specific vascular‑injury risk factors are present (e.g., cervical spine fracture, unexplained focal neurological deficit, Claude Bernard‑Horner syndrome, Le Fort II/III facial fracture, soft‑tissue neck injury, basilar skull fracture)【1】【2】.
Even without classic risk factors, CTA should be considered in the most severely injured patients whose neurological examination may be limited【1】.
If CTA is normal but clinical suspicion for arterial dissection remains high, the work‑up should be completed with MR angiography or digital subtraction angiography【1】.
The American College of Radiology endorses CTA for suspected traumatic vascular injury as a Class IIa recommendation【3】.

When the initial or follow‑up non‑contrast CT is negative but neurological findings remain unexplained, a non‑contrast brain MRI is recommended (Class I)【3】.
T2* and susceptibility‑weighted imaging (SWI) sequences are recommended (Class IIa) for detecting diffuse axonal injury across acute, early sub‑acute, and chronic stages【3】.
SWI detects approximately 30 % more TBI‑related lesions than CT and conventional MRI【3】.
MRI (including contrast‑enhanced studies) is up to 30 % more sensitive than CT for identifying acute traumatic intracranial injury【2】【4】.
Contrast‑enhanced MRI may be used to better visualize sub‑acute brain contusions (Class IIb)【3】.

Routine cervical‑spine CT should be performed as part of the initial imaging strategy in severe TBI patients【1】.
The French Society of Anaesthesia and Intensive Care Medicine recommends immediate brain and cervical CT in severe TBI (Grade 1+ recommendation)【1】.

Initial CT findings guide decisions regarding neurosurgical intervention and the need for invasive monitoring such as ICP measurement【1】.

A repeat non‑contrast head CT is indicated for any neurological deterioration (Class I)【3】.
Routine scheduled follow‑up CT in the absence of clinical change has limited value【3】.

Maintain systolic blood pressure > 110 mm Hg during the diagnostic work‑up, as hypotension worsens neurological outcomes【1】.
Do not delay the initial CT in favor of MRI; CT remains the reference standard for rapid identification of surgically treatable lesions【1】.