BCVI (Blunt Cerebrovascular Injury) Screening

Original Date: 11/2013 | Last Review Date: 07/2024
Purpose: To identify patients at risk for BCVI and screen appropriately.

Background:

While blunt cerebrovascular injuries (BCVI) occur in only 0.5-1.2%1, 2 of blunt trauma patients, the complications of missed injury resulting in stroke are devastating.  A clinically latent period ranging from 10 -72 hours provides a short window of opportunity to both make the diagnosis of BCVI and initiate treatment prior to the onset of neurologic consequence.  Treatment is inexpensive, effective, and has shown to decrease stroke rates from 21 to 0.5%3.  We acknowledge formal cerebral angiography remains the gold standard for diagnosis of BCVI4, however our institution uses neck CT angiography (CTA) for BCVI screening due to its near-immediate availability and high sensitivity for BCVI screening.

Signs and symptoms of BCVI are indications for immediate CTA neck and include:

  • Potential arterial hemorrhage from neck, nose and/or mouth
  • Cervical bruit in patients < 50 years of age
  • Cervical hematoma
  • Focal neurologic defect (TIA, hemiparesis, vertebrobasilar symptoms, Horner’s Syndrome, etc)

Injury patterns resulting from high energy transfer (including flexion/extension injuries) place the patient at high risk for BCVI and are indications for CTA neck5. These include:

  • Complex mid-face fractures (LeFort II or III)
  • Mandible fracture
  • Basilar skull fracture or occipital condyle fracture
  • Severe TBI with GCS < 6
  • Neurological exam discordant with head CT findings
  • Near-hanging with anoxic brain injury
  • Seatbelt or other clothesline-type injury with significant swelling, pain, or altered mental status
  • Combined TBI and major thoracic injury
  • Scalp degloving injury
  • Thoracic vascular injury
  • New stroke on CT or MRI

CTA neck should be performed at the time of initial trauma CT scans in patients where concern for BCVI is high. If the need for CTA neck is decided after the original contrasted scans, it should be performed within 6 hours of arrival to the ER.  If the patient requiring BCVI screening is at high risk for contrast induced nephropathy, discussion with the trauma attending should occur prior to performance of CTA neck. If the patient is unable to get a CTA neck in a timely fashion, consider starting non-enteric coated aspirin 325 mg daily in the patient with no contraindication to therapy (TBI, SCI) prior to confirming the diagnosis.

If clinical suspicion of BCVI remains high despite a negative CTA neck, please consult the Neurosurgery Vascular service (713-327-0536) for cerebral angiogram and start non-enteric coated aspirin 325 mg daily immediately in the patient with no contraindication to therapy (TBI, SCI).

Information regarding the management and treatment of BCVI can be found here.

References:

  1. Miller PR, Fabian TC, Croce MA, Cagiannos C. Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Annals of …. 2002.
  2. Stein DM, Boswell S, Sliker CW, Lui FY, Scalea TM. Blunt Cerebrovascular Injuries: Does Treatment Always Matter? The Journal of Trauma: Injury, Infection, and Critical Care. 2009;66(1):132–144. doi:10.1097/TA.0b013e318142d146.
  3. Cothren CC, Biffl WL, Moore EE, Kashuk JL, Johnson JL. Treatment for blunt cerebrovascular injuries: equivalence of anticoagulation and antiplatelet agents. Arch Surg. 2009;144(7):685–690. doi:10.1001/archsurg.2009.111.
  4. Paulus EM, Fabian TC, Savage SA, et al. Blunt cerebrovascular injury screening with 64-channel multidetector computed tomography: More slices finally cut it. J Trauma Acute Care Surg. 2014;76(2):279–285. doi:10.1097/TA.0000000000000101.
  5. Burlew CC, Biffl WL, Moore EE, Barnett CC, Johnson JL, Bensard DD. Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis. J Trauma Acute Care Surg. 2012;72(2):330–5– discussion 336–7– quiz 539. doi:10.1097/TA.0b013e31823de8a0.
  6. Biffl WL, Cothren CC, Moore EE, et al. Western Trauma Association Critical Decisions in Trauma: Screening for and Treatment of Blunt Cerebrovascular Injuries. The Journal of Trauma: Injury, Infection, and Critical Care. 2009;67(6):1150–1153. doi:10.1097/TA.0b013e3181c1c1d6.
  7. Cothren CC, Moore EE, Biffl WL, et al. Anticoagulation Is the Gold Standard Therapy for Blunt Carotid Injuries to Reduce Stroke Rate. Arch Surg. 2004;139(5):540–546.
    doi:10.1001/archsurg.139.5.540.
  8. Emmett KP, Fabian TC, DiCocco JM, Zarzaur BL, Croce MA. Improving the screening criteria for blunt cerebrovascular injury: the appropriate role for computed tomography angiography. J Trauma. 2011;70(5):1058–63– discussion 1063–5. doi:10.1097/TA.0b013e318213f849.
  9. ]Bruns BR, Tesoriero R, Kufera J, et al. Blunt cerebrovascular injury screening guidelines. Journal of Trauma and Acute Care Surgery. 2014;76(3):691–695. doi:10.1097/TA.0b013e3182ab1b4d.