# Management of Blunt Cerebrovascular Injuries (BCVI)
### **Management of Blunt Extra – Cranial Carotid and Vertebral Artery Injury in Adults (BCVI)**
#### **PURPOSE: **
To define guidelines in caring for the trauma patient with diagnosis of blunt extra – cranial carotid and vertebral artery injuries (BCVI)
** **
#### **GUIDELINE: **
Screening (Denver Criteria)
Signs/Symptoms
· Potential arterial hemorrhage from neck/nose/mouth
· Cervical bruit (<50 years old)
· Expanding cervical hematoma
· Focal neurologic defect: TIA, hemiparesis, vertebrobasilar symptoms, Horner’s syndrome
· Neurologic deficit inconsistent with head CT
· Stroke on CT or MRI
Risk Factors for BCVI
· High-energy transfer mechanism
· Displaced midface fracture (Lefort II or 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
· Clothesline type injury or seat belt abrasion with significant swelling, pain, or altered mental status
· TBI with thoracic injuries
· Scalp degloving
· Thoracic vascular injuries
· Blunt cardiac rupture
· Upper rib fracture
Screening Modality
High quality CT Angiography of the neck is an acceptable modality.
Digital subtraction 4-vessel angiography may be required if metallic foreign bodies prevent adequate visualization on CTA
Duplex Ultrasound is *not* adequate for screening for BCVI.
\*\*\* If CTA is ordered to screen for BCVI, a TEG needs to be drawn\*\*\*
Grading Scale
Grade 1 – Intimal irregularity with < 25% narrowing.
Grade 2 – Dissection or intramural hematoma with > 25% narrowing
Grade 3 – Pseudoaneurysm
Grade 4 – Occlusion
Grade 5 – Transection with extravasation
Treatment
Patients with extracranial carotid and vertebral artery injuries should be treated as outlined below unless: Arterial transection with active hemorrhage is present and/or risk of bleeding from other traumatic injuries prohibits the use of anticoagulation.
Recommendation based on injury grade
Grade 1 and 2
· 81 mg Aspirin
Grade 3
· 81 mg Aspirin
· Neurosurgeon and/or Neuro Interventionalist consultation
· Unlikely to resolve spontaneously with antithrombotic therapy alone. Close follow-up needed.
· Stenting should be avoided due to increased risk for stent thrombosis.
Grade 4
· 81 mg Aspirin
· Neurosurgeon and/or Neuro Interventionalist consultation
· Goal to prevent propagation of thrombus
Grade 5
· Neurosurgeon and/or Neuro Interventionalist consultation
· Endovascular intervention depending on clinical picture:
- - - - Cerebral ischemic events despite the use of anticoagulation or antiplatelet therapy.
- Progressing luminal stenosis despite adequate antithrombotic therapy
- Clinical or radiographic evidence of cerebral perfusion failure due to inadequate collateral blood flow.
- Vertebral artery pseudoaneurysms, as they can rupture into the spinal canal producing epidural and subarachnoid hemorrhage
- Carotid pseudoaneurysms do not require *urgent* endovascular therapy, as they pose no significant risk of bleeding.
\*\*\*Should results of TEG reveal a hypercoagulable state in the setting of BCVI (MA >63 or angle > 77), strong consideration for early initiation of antithrombotic therapy should be made despite competing risk factors due to increased risk for CVA\*\*\*
Monitoring
· Repeat CTA at 7-days post injury for injury grades 1-3 to assess for resolution of injury and monitor for any progression of luminal stenosis despite antithrombotic therapy, which may benefit from endovascular intervention
· Continued aspirin for 3 months
· CTA is recommended at 3 months to determine the status of the BCVI and the need for further medical or endovascular therapy.
**APPROVAL: **
Author: Bennett J. Berning, MD
Reviewer: Division of Acute Care Surgery, University of Nebraska Medical Center
Approval Date: 1/12/2022
**References:**
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