Blunt Cerebrovascular Injury (BCVI)

Blunt Cerebrovascular Injury (BCVI)

David Ray Velez, MD

Table of Contents

Definition and Risk
Screening
Classification
Treatment

Definition and Risk

Definition: Blunt Injury to the Carotid or Vertebral Arteries

Associated with Increased Risk for Stroke (1-10%) and Mortality – Highest Risk in the First 72 Hours

Incidence of BCVI with Cervical Spine Injuries

  • High-Risk Cervical Spine Injuries: 17%
  • Low-Risk Cervical Spine Injuries: 2-9%

Screening

Screen All High-Risk Patients with a CTA of the Neck

  • May Consider Screening Even for Low-Risk Cervical Spine Injuries
  • Some Promote Universal Screening for All Patients

Expanded Denver Criteria

  • Signs/Symptoms of BCVI:
    • Arterial Hemorrhage from Neck/Nose/Mouth
    • Cervical Bruit
    • Expanding Cervical Hematoma
    • Focal Neurologic Deficit
    • Neurologic Deficit Inconsistent with Head CT Findings
    • Ischemic Stroke on CT or MRI
  • Risk Factors for BCVI:
    • High-Energy Mechanism
    • Displaced Midface Fracture (LeFort II/III)
    • Mandible Fracture
    • Complex Skull Fracture, Basilar Skull Fracture, Occipital Condyle Fracture
    • Severe TBI with GCS < 6
    • Cervical Spine Fracture, Subluxation, or Ligamentous Injury at Any Level
    • Near Hanging with Anoxic Brain Injury
    • Cervical Seatbelt Sign
    • Cervical Clothesline Type Injury
    • TBI with Thoracic Injury
    • Scalp Degloving
    • Thoracic Vascular Injuries
    • Blunt Cardiac Rupture
    • Upper Rib Fractures

Memphis Criteria

  • Unexplained Neurologic Deficit
  • Horner’s Syndrome
  • LeFort II/III
  • Cervical Spine Injury
  • Skull Base Fracture Involving the Foramen Lacerum
  • Neck Soft Tissue Injury (Seatbelt Injury or Hanging)

Classification

Biffl/Denver Grading Scale

  • Grade I: Luminal Irregularity or Dissection with < 25% Narrowing
  • Grade II: Dissection or Intramural Hematoma with > 25% Narrowing, Intraluminal Thrombus, or Raised Intimal Flap
  • Grade III: Pseudoaneurysm
  • Grade IV: Occlusion or Total Thrombosis
  • Grade V: Transection

Treatment

Primary Treatment: Antithrombotic Therapy to Decrease the Risk of Stroke and Mortality

  • Exact Regimen Debated – Aspirin (81 vs 325 mg) or Heparin (PTT Goal 40-50 s)

Grade II-IV BCVI with Neurologic Symptoms Should Consider Endovascular Stenting

  • *Avoid Routine Stenting in Grade II-III BCVI

Grade V Transection Requires Emergent Surgical Intervention

  • Short Segment: Primary Anastomosis
  • Large Segment: Saphenous Vein Graft
  • Unstable: Ligation

Consider Repeat CTA After 7 Days to Monitor Progression