Medical Minute Recap: Blunt Cerebrovascular Injury (BCVI)

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November 3, 2015 by dailybolusoflr

By: Shaughn Keating, MD

Incidence

  • ~1 of 1,000 (0.1%) patients hospitalized for trauma in the United States 
  • Up to 1% of all blunt trauma patients and 2.7% in patients with an Injury Severity Score of ≥16.

The Big Problem

The majority of these injuries are diagnosed after the development of symptoms secondary to central nervous system ischemia, with a resultant neurologic morbidity of up to 80% and associated mortality of up to 40%.

  • We have therapies that can decrease this risk!   

Who to screen

  • Fractures close to the carotids or vertebrals
    • Basilar skull fractures
    • Cervical vertebral body fractures/fractures extending to transverse foramen
  • Mechanism that can often cause injury
    • Hanging injury
    • Severe hyperflexion or hyperextension
    • Seatbelt or other significant injury to anterior neck
  • Exam findings concerning for BCVI
    • Displaced midface or mandibular fractures from hyperflexion/extension injury
    • Arterial epistaxis after head trauma
    • Any neurologic abnormality that is unexplained by a diagnosed injury
    • GCS <8 or diffuse axonal injury

How to diagnose

  • CTAs have sensitivity and specificity of nearly 100% with modern >16 slice scanners
  • Historically angiography is still gold standard, however limited by time and cost
Treatment
  • Barring contraindications, grades I and II injuries should be treated with antithrombotic agents
    • If heparin is chosen, the infusion should be started without a bolus
  • Grade II injuries progress to higher grade ~70% of the time
  • Grade III rarely resolve with medical management, and invasive therapy should be considered
  • In patients with an early neurologic deficit and an accessible carotid lesion operative or interventional repair should be considered to restore flow
  • Follow-up angiography is recommended in grades I to III injuries. This should be performed 7 days post-injury
References:
Biffl et al. J Trauma. Blunt carotid arterial injuries: implications of a new grading scale.1999 Nov;47(5):845-53.
Bromberg et al. Blunt Cerebrovascular Injury Practice Management Guidelines: The Eastern Association for the Surgery of Trauma. J Trauma. 68 (2): 471-7, Feb 2010

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