Management of Blunt Cerebrovascular Injuries (BCVI)

Management of Blunt Extra – Cranial Carotid and Vertebral Artery Injury in Adults (BCVI)

Author: Bennett J. Berning, MD
Reviewer(s): Division of Acute Care Surgery, University of Nebraska Medical Center

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.