BCVI Management Protocol

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Original Date: 06/2023
Purpose: To optimize multi-disciplinary treatment of BCVI

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General guidelines:

1. NSGY vascular service will:
   • consult on all BCVI patients as soon as lesion identified.
   • Clarify the injury site (segment affected – see below)
   • Add further recommendations for imaging and treatment as needed.
2. All Intracranial BCVI will be immediately evaluated by NSGY vascular faculty
3. Initial management of extracranial BCVI will be directed by the Trauma Service as indicated below, according to the degree of luminal compromise (see BCVI classification system) and the presence/absence of symptoms/signs:

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UTH Classification system for BCVI 

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Extracranial BCVI (includes VA2 intraosseous segment)

ASYMPTOMATIC*	No contraindication	Relative contraindications
ICA
Grade 1-2	ASA	ASA when able
Grade 3-5	Flow studies**	ASA → AC when able if indicated after studies
Vertebral
Grade 1-5	ASA	ASA when able
SYMPTOMATIC* (stroke or imaging)
ICA and VA Grade 1	ASA	ASA when able
ICA and VA Grade 2	AC	ASA when able, then AC
ICA and VA Grade 1-3	Flow studies **	ASA → AC when able if indicated after studies
INTRALUMINAL THROMBUS
ICA and VA, Grade 1-3	AC	ASA → AC when able

* single vessel injury only.  If 2^nd vessel also compromised by injury, hypoplasia, etc. (contralateral ICA, VA) consider flow studies and AC

** flow studies = CT brain perfusion +/- angiogram prior to final treatment recommendation

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Anticoagulation and anti-platelet therapy

Relative contraindications include traumatic brain injury (TBI), SAH, solid organ injury (SOI), and operative spine fractures. In general, initiation of BCVI therapy may safely be started when chemical VTE prophylaxis is administered. Patients warranting earlier therapy should be discussed between services at the faculty level.

ASA = antiplatelet medications = aspirin 325 mg, continue for 3 months

AC = Anticoagulation) = heparin/coumadin x 6 weeks then switch to ASA for 6 weeks

• Use Acute Coronary Syndrome heparin MPP for all BCVI patients
• Loading dose of 60 units/kg should be the default option – discuss exceptions at faculty level
• Goal PTT is 65-85 with starting dose of 12 units/kg/hr with a titration bolus per protocol
• transition to oral anticoagulant prior to discharge

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Repeat Imaging and Clinic Follow-up

asymptomatic grade 1 BCVI	NONE
all other BCVI:	CTA at 3 days and 6 weeks NSGY Vascular Clinic follow-up at 6 weeks BCVI resolved – stop AC or ASA BCVI stable or improved – continue ASA for 6 weeks

Segment site classification system for NSGY Vascular

Segments

CCA (common carotid artery)
ICA1 (proximal cervical ICA)
ICA2 (distal high cervical ICA)
ICA3 (petrous ICA)
ICA4 (cavernous ICA)
ICA5 (clinoidal ICA)
ICA6 (intradural subarachnoid ICA)
VA1 (pre-foraminal)
VA2 (foraminal)
VA3 (distal cervical – the C1-C2 region)
VA4 (intradural subarachnoid)