Universal computed tomography angiography screening for blunt cerebrovascular injury: a systematic review of improved detection, clinical outcomes, and cost-effectiveness

Background: Blunt cerebrovascular injury (BCVI) is a serious complication of trauma that can lead to stroke if not detected early. Current selective screening criteria may miss a significant number of cases, prompting interest in universal computed tomography angiography (CTA) screening. We aim to evaluate whether universal CTA screening improves detection of BCVI compared with selective risk-factor–based screening in adult trauma patients, and to assess its impact on injury grade detection, clinical outcomes (stroke, mortality), cost-effectiveness, and imaging-related risks. Methods: A systematic review was conducted using PubMed, Embase, Cochrane, ProQuest, and Google Scholar through March 2026. Studies comparing universal versus selective CTA screening for BCVI in adult trauma patients were included. Data on detection, outcomes, and cost-effectiveness were extracted. Results: A total of 1,362 records were identified, with 8 studies included after screening. Selective screening criteria missed 16%–37% of BCVI cases compared with universal CTA. Universal screening improved detection of both low- and high-grade injuries. Stroke incidence ranged from 8%–10%, with some cases occurring in patients without traditional risk factors. Imaging-related complications were low (AKI ~1.4%). Cost-effectiveness analyses showed universal CTA remained below willingness-to-pay thresholds (~$71,949/QALY) and improved quality-adjusted life years. Conclusion: Universal CTA screening for BCVI can be suggested as a diagnostic modality as it appears to improve detection of both low and high-grade injuries that may be missed with selective approaches. Additionally, CTA-based screening was deemed to be cost effective. Although limited, current evidence suggests that imaging-related harms are low, supporting the consideration of broader CTA screening strategies in appropriately selected trauma populations.