View source for Blunt cerebrovascular injury

==Background==
*BCVI includes: intimal flap/dissection, intramural hematoma, pseudoaneurysm, occlusion, and transection of the carotid or vertebral arteries
*'''~50% of BCVI-related strokes occur before hospital arrival'''; the other half are '''preventable with screening and early treatment'''<ref name="PMC"/>
*Carotid and vertebral arteries are '''equally affected'''; carotid injuries carry higher mortality
*Even with screening criteria, '''~20% of BCVI may be missed''' — some institutions now advocate universal CTA of the neck in all significant blunt trauma<ref name="REBEL">Blunt Cerebrovascular Injury: Universal Imaging for All? ''REBEL EM''. 2020.</ref>
*Blunt cerebrovascular injury (BCVI) is a non-penetrating injury to the '''carotid and/or vertebral arteries''' that may be '''clinically silent initially''' but can cause '''devastating stroke''' if not identified and treated.<ref name="EAST">Blunt Cerebrovascular Injury Practice Management Guideline. ''EAST''. 2020.</ref> 
*Incidence is 1-2% of blunt trauma admissions but up to '''9% in severe head injury'''. 
*Screening with the [[Denver Screening Criteria]] and '''CTA''' has reduced the stroke rate from ~15% to '''<1%''' in asymptomatic patients.<ref name="PMC">Blunt Cerebrovascular Injuries: Advances in Screening, Imaging, and Management Trends. ''AJNR''. 2021. PMC7655313.</ref> 


==Clinical Features==
* Most patients are asymptomatic at initial presentation — this is why screening is critical
*Symptomatic patients may present with:
** Acute stroke symptoms (hemiparesis, aphasia, facial droop) — may be delayed hours to days after injury
** Expanding cervical hematoma
** Arterial hemorrhage from neck, nose, or mouth
** Cervical bruit in a young patient (uncommon but specific)
** Horner syndrome (ptosis, miosis, anhidrosis) — from carotid dissection disrupting sympathetic fibers
** Neurologic deficit inconsistent with CT head findings — think BCVI if stroke territory doesn't match the head injury pattern

==Differential Diagnosis==
{{Blunt neck trauma DDX}}

==Evaluation==
===Workup===
* Apply Modified Denver Screening Criteria — obtain CTA if '''ANY ONE''' is present:<ref name="BPG">Best practice guidelines for BCVI. ''Scand J Trauma Resusc Emerg Med''. 2018. PMC6206718.</ref>

'''Signs/symptoms:'''
*Arterial hemorrhage from neck/nose/mouth
*Cervical bruit in patient <50 years
*Expanding cervical hematoma
*Focal neurologic deficit (TIA, hemiparesis, Horner syndrome)
*Neurologic deficit inconsistent with head CT findings
*Stroke on CT or MRI

'''Risk factors (injury pattern):'''
* Cervical spine fracture (any level, excluding isolated spinous/transverse process fractures)
*C1-C3 fracture, subluxation, or ligamentous injury
*Fracture through the '''transverse foramen'''
* Le Fort II or III facial fractures
* Basilar skull fracture involving the carotid canal
* Diffuse axonal injury with GCS <6
* Near-hanging or '''[[Strangulation|strangulation]]''' with anoxic brain injury
*Mandible fractures
*Complex skull fractures
*Scalp degloving
*Thoracic vascular injury
*Blunt cardiac rupture

* CTA of the neck (from aortic arch through circle of Willis): '''imaging modality of choice'''; sensitivity/specificity ~98%/100% with modern ≥16-slice CT<ref name="PMC"/>
*'''Do NOT wait for symptoms''' to image — the whole point is to screen '''asymptomatic''' patients before they stroke

===Diagnosis===
* Biffl Grading Scale (determines management):

{| class="wikitable"
|-
! Grade !! Injury !! Stroke risk
|-
| '''I''' || Intimal irregularity or dissection with <25% luminal narrowing || Low
|-
| '''II''' || Dissection/intramural hematoma with ≥25% luminal narrowing, intraluminal thrombus, or raised intimal flap || Moderate
|-
| '''III''' || Pseudoaneurysm || Moderate-high
|-
| '''IV''' || Complete occlusion || High
|-
| '''V''' || Transection with active extravasation || Highest; hemorrhagic emergency
|}

*Many '''grade I-II injuries heal''' spontaneously within 7-10 days with antithrombotic therapy
* Follow-up CTA at 7-10 days is standard to reassess injury progression or healing

==Management==
*'''Start antithrombotic therapy (ATT) as soon as safely possible''' — this is the single most important intervention to prevent stroke<ref name="EAST"/>
**ATT reduces stroke risk: OR 0.20 (80% reduction) and mortality: OR 0.17<ref name="EAST"/>
* Preferred antithrombotic regimens:
** Aspirin 325 mg daily — most commonly used; simplest; adequate for most grade I-II injuries
** Aspirin + clopidogrel — used at some centers for higher-grade injuries
** Heparin infusion (target PTT 40-50) — alternative, especially if higher-grade injury or concern for thrombus progression
* When ATT is contraindicated (intracranial hemorrhage, solid organ injury, other active bleeding):
** Discuss with trauma surgery/neurosurgery — risk-benefit must be weighed case by case
**Some centers delay ATT 24-72 hours until bleeding risk stabilizes; others accept the stroke risk temporarily
**'''Do not simply omit ATT''' without a documented plan — untreated BCVI has a '''21% stroke rate'''<ref name="EAST"/>
* Grade V (transection with active hemorrhage): emergent hemorrhage control — direct pressure, emergent endovascular intervention, or operative repair
* Grade III-IV: ATT ± endovascular stenting (decision made by vascular surgery/interventional radiology at follow-up; not an ED decision)
* Consult: trauma surgery, and as needed neurosurgery and/or vascular surgery/interventional radiology

==Disposition==
* All patients with confirmed BCVI: admit to trauma service with serial neurologic examinations
* Start ATT in the ED if no contraindication — do not defer to the floor
* Follow-up CTA at 7-10 days — document this plan; many grade I-II injuries resolve; grade III+ may progress and require intervention
* If screening criteria are met but CTA is negative: admit the trauma patient per standard protocols; a negative CTA has very high NPV — no further BCVI-specific follow-up needed unless new neurologic symptoms develop
* Document clearly: Denver screening criteria met, CTA result, Biffl grade if positive, ATT initiated (and agent/dose), and follow-up imaging plan

==See Also==
*[[Vertebral artery dissection]]
*[[Carotid artery dissection]]
*[[Penetrating neck trauma]]
*[[Cervical fractures and dislocations]]
*[[Strangulation]]
*[[Stroke]]
*[[Traumatic brain injury]]

==External Links==
*[https://www.east.org/education-resources/practice-management-guidelines/details/blunt-cerebrovascular-injury-evaluation-and-management-of EAST — Blunt Cerebrovascular Injury Practice Management Guideline (2020)]
*[https://pmc.ncbi.nlm.nih.gov/articles/PMC6206718/ Scand J Trauma — Best practice guidelines for BCVI (2018)]
*[https://pmc.ncbi.nlm.nih.gov/articles/PMC7655313/ AJNR — Blunt Cerebrovascular Injuries: Advances in Screening, Imaging, and Management (2021)]
*[https://www.emra.org/emresident/article/blunt-cerebrovascular-injury EMRA — A Review of Blunt Cerebrovascular Injuries]

==References==
<references/>

[[Category:Trauma]]
[[Category:Neurology]]