BCVI (Blunt Cerebrovascular Injury) Screening

Original Date: 11/2013 | Last Review Date: 05/2014
Purpose: To identify patient to screen for BCVI.

Background:
While blunt cerebrovascular injuries (BCVI) occurs in only 0.5 to 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 make the diagnosis and initiate treatment (anti-thrombotic therapy or anticoagulation) prior to the onset of neurologic damage. Treatment is inexpensive and effective, shown to decrease the stroke rate from 21 to 0.5%3. While cerebral angiogram remains the gold standard for diagnosis of BCVI4, our institution utilizes multi-slice CTA secondary to immediate availability and improved CT technology. The clinical challenge is to identify patients at high risk of BCVI to make a prompt diagnosis and initiate treatment. Treatment of BCVI with other injuries contradicting immediate anti-platelet/anti-coagulation is controversial and is currently being studied at this institution.

Procedure:
The following injury patterns resulting from high energy transfer mechanism (including flexion/extension injuries) place the patient at high risk for BCVI and are indications for CTA neck5.

  • Complex facial fractures (LeFort II or III)
  • Mandible fracture
  • Basilar skull fracture or occipital condyle fracture
  • Cervical vertebral body or transverse foramen fracture at any level (C1-7)
  • Any fracture at level C1-C3
  • Cervical subluxation or ligamentous injury at any level
  • Severe traumatic brain injury (TBI) with GCS < 6
  • Neurological exam incongruous with head CT
  • Near hanging with anoxic brain injury
  • Seatbelt or other clothesline-type injury with significant swelling, pain, or AMS
  • combined TBI and major thoracic injury
  • Scalp degloving injury
  • Thoracic vascular injury

The following signs and symptoms of BCVI are indications for CTA neck

  • potential arterial hemorrhage from neck/nose/mouth
  • cervical bruit in patient < 50 years of age
  • cervical hematoma
  • focal neurologic defect: TIA, hemiparesis, vertebrobasilar symptoms, Horner’s Syndrome
  • neurologic deficit inconsistent with head CT
  • stroke on CT or MRI

Diagnosis:

Screening CTA neck should be performed no later than 6 hours from time of ED arrival. Ideally, the CTA neck is performed at the time of the original diagnostic CT scan for blunt trauma once the above risk factors are identified. If the need for CTA neck is decided after the original IV contrast CT scan, discussion with the responsible attending should occur in patients at high risk for contrast-induced nephropathy. For these high-risk patients, a 1 liter bolus of LR should be given prior to repeat 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, solid organ injury) 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, solid organ injury). Consider angiogram if CTA neck is positive for injury and patient has a contraindication to aspirin (active peptic ulcer, documented aspirin allergy, hemophilia, von Willebrand’s disease).

Please notify the trauma neurosurgery team once the diagnosis of BCVI is made at one of the following numbers:
NSGY portable phone: 713-704-7929
NSGY pager: 713-327-3219

 

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.