Blunt cerebrovascular injury
Updates to Article Attributes
Blunt cerebrovascular injury (BCVI) is a uncommon but serious consequence of blunt trauma to the head and neck.
Epidemiology
It is often part of multitrauma with a large blunt trauma CTA series reporting an incidence of ~1% 3.
Pathology
Primary the injury is caused by longitudinal stretching 1 and injury to the vessel. Acceleration-deceleration can cause rotation and hyperextension of the neck stressing the craniocervical vessels. This is the mechanism for the most common cause of BCVI, motor vehicle accidents. A direct blow to the neck or base of skull may injury the carotid or vertebral arteries.
BCVI can affect multiple vessels (18-38%) and occurs in typical locations 1:
-
internal carotid artery (ICA)
- cervical ICA just below the skull base
- petrous ICA
- cavernous ICA
-
vertebral artery
- cervical vertebral artery as it passes through the transverse foramina
Screening
Several screening tools have been developed to identify those at risk of BCVI and limit the use of DSA:
In general BCVI is at higher risk if there is 1:
- severe facial injuries
- severe cervical spine injuries
- fractures involving the transverse foramen
- fractures of C1 to C3
- cervical spinal subluxation
- base of skull fractures, especially those involving the carotid canal
- diffuse axonal injuries
- near hanging
- major thoracic trauma
Classification
The Biffl scale 2 describes the vascular injury on angiography (either CTA or DSA) and has prognostic and therapeutic implications, with higher grades associated with a high risk of cerebral infarction:
- grade I: mild intimal injury or irregular intima
- grade II: dissection with raised intimal flap / intramural haematoma with luminal narrowing >25% / intraluminal thrombosis
- grade III: pseudoaneurysm
- grade IV: vessel occlusion/thrombosis
- grade V: vessel transection
This scale is also known as the Denver scale, which is not to be confused with the Denver criteria, a set of clinical and risk factors that promote CTA screening for BCVI.
Radiographic features
CT
Signs on CT angiography of vascular injury include 1
- minimal intima injury (irregularity)
- intimal flap
- dissection with or without intramural haematoma
- pseudoaneurysm
- transection
- vessel occlusion
- AV fistula
Angiography
The signs of BCVI on DSA are the same as CTA. A 2011 study of screening 32-channel multidetector CT compared to DSA showed that DSA is far more sensitive than CTA 4.
Differential diagnosis
- technical and patient artifact
- normal vascular variants
- atherosclerotic plaque
Treatment and prognosis
Undiagnosed there is high morbidity and mortality, primarily from cerebral infarction. The risk of cerebral or posterior fossa infarction following BCVI is reduced with anticoagulation but this can be a difficult management decision as often there is also concomitant intracranial haemorrhage from the primary trauma. In select cases stenting of the injuried vessel is performed.
-<li><a href="/articles/denver-crietria-for-blunt-cerebrovascular-injury">Denver criteria</a></li>- +<li>
- +<a href="/articles/denver-criteria-for-blunt-cerebrovascular-injury-1">Denver criteria</a> <sup>6</sup>
- +</li>
-</ul><h5>Classification</h5><p>The <a href="/articles/biffl-criteria-for-blunt-cerebrovascular-injury">Biffl scale</a> <sup>2</sup> describes the vascular injury on angiography (either CTA or DSA) and has prognostic and therapeutic implications, with higher grades associated with a high risk of cerebral infarction:</p><ul>- +</ul><h5>Classification</h5><p>The <a href="/articles/biffl-scale-for-blunt-cerebrovascular-injury">Biffl scale</a> <sup>2</sup> describes the vascular injury on angiography (either CTA or DSA) and has prognostic and therapeutic implications, with higher grades associated with a high risk of cerebral infarction:</p><ul>
-</ul><h4>Radiographic features</h4><h5>CT</h5><p>Signs on CT angiography of vascular injury include <sup>1</sup></p><ul>- +</ul><p>This scale is also known as the <strong>Denver scale</strong>, which is not to be confused with the <a title="Denver criteria for blunt cerebrovascular injury" href="/articles/denver-criteria-for-blunt-cerebrovascular-injury-1">Denver criteria</a>, a set of clinical and risk factors that promote CTA screening for BCVI.</p><h4>Radiographic features</h4><h5>CT</h5><p>Signs on CT angiography of vascular injury include <sup>1</sup></p><ul>
References changed:
- 6. Cothren C & Moore E. Blunt Cerebrovascular Injuries. Clinics (Sao Paulo). 2005;60(6):489-96. <a href="https://doi.org/10.1590/s1807-59322005000600011">doi:10.1590/s1807-59322005000600011</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/16358140">Pubmed</a>
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