Blunt cerebrovascular injury - Revision history

Danbot: Strip excess bold

2026-03-22T09:26:06Z

Strip excess bold

← Revisión anterior		Revisión del 09:26 22 mar 2026
Línea 1:		Línea 1:
	==Background==		==Background==
	*BCVI includes: intimal flap/dissection, intramural hematoma, pseudoaneurysm, occlusion, and transection of the carotid or vertebral arteries		*BCVI includes: intimal flap/dissection, intramural hematoma, pseudoaneurysm, occlusion, and transection of the carotid or vertebral arteries
	*~~'''~~~50% of BCVI-related strokes occur before hospital arrival~~'''~~; the other half are ~~'''~~preventable with screening and early treatment~~'''~~<ref name="PMC"/>		*~50% of BCVI-related strokes occur before hospital arrival; the other half are preventable with screening and early treatment<ref name="PMC"/>
	*Carotid and vertebral arteries are ~~'''~~equally affected~~'''~~; carotid injuries carry higher mortality		*Carotid and vertebral arteries are equally affected; carotid injuries carry higher mortality
	*Even with screening criteria, ~~'''~~~20% of BCVI may be missed~~'''~~ — some institutions now advocate universal CTA of the neck in all significant blunt trauma<ref name="REBEL">Blunt Cerebrovascular Injury: Universal Imaging for All? ''REBEL EM''. 2020.</ref>		*Even with screening criteria, ~20% of BCVI may be missed — some institutions now advocate universal CTA of the neck in all significant blunt trauma<ref name="REBEL">Blunt Cerebrovascular Injury: Universal Imaging for All? ''REBEL EM''. 2020.</ref>
	*Blunt cerebrovascular injury (BCVI) is a non-penetrating injury to the '''carotid and/or vertebral arteries''' that may be '''clinically silent initially''' but can cause '''devastating stroke''' if not identified and treated.<ref name="EAST">Blunt Cerebrovascular Injury Practice Management Guideline. ''EAST''. 2020.</ref>		*Blunt cerebrovascular injury (BCVI) is a non-penetrating injury to the '''carotid and/or vertebral arteries''' that may be '''clinically silent initially''' but can cause '''devastating stroke''' if not identified and treated.<ref name="EAST">Blunt Cerebrovascular Injury Practice Management Guideline. ''EAST''. 2020.</ref>
	*Incidence is 1-2% of blunt trauma admissions but up to ~~'''~~9% in severe head injury~~'''~~.		*Incidence is 1-2% of blunt trauma admissions but up to 9% in severe head injury.
	*Screening with the [[Denver Screening Criteria]] and ~~'''~~CTA~~'''~~ has reduced the stroke rate from ~15% to ~~'''~~<1%~~'''~~ in asymptomatic patients.<ref name="PMC">Blunt Cerebrovascular Injuries: Advances in Screening, Imaging, and Management Trends. ''AJNR''. 2021. PMC7655313.</ref>		*Screening with the [[Denver Screening Criteria]] and CTA has reduced the stroke rate from ~15% to <1% in asymptomatic patients.<ref name="PMC">Blunt Cerebrovascular Injuries: Advances in Screening, Imaging, and Management Trends. ''AJNR''. 2021. PMC7655313.</ref>


Línea 24:		Línea 24:
	==Evaluation==		==Evaluation==
	===Workup===		===Workup===
	* Apply Modified Denver Screening Criteria — obtain CTA if ~~'''~~ANY ONE~~'''~~ is present:<ref name="BPG">Best practice guidelines for BCVI. ''Scand J Trauma Resusc Emerg Med''. 2018. PMC6206718.</ref>		* Apply Modified Denver Screening Criteria — obtain CTA if ANY ONE is present:<ref name="BPG">Best practice guidelines for BCVI. ''Scand J Trauma Resusc Emerg Med''. 2018. PMC6206718.</ref>

	~~'''~~Signs/symptoms:~~'''~~		Signs/symptoms:
	*Arterial hemorrhage from neck/nose/mouth		*Arterial hemorrhage from neck/nose/mouth
	*Cervical bruit in patient <50 years		*Cervical bruit in patient <50 years
Línea 34:		Línea 34:
	*Stroke on CT or MRI		*Stroke on CT or MRI

	~~'''~~Risk factors (injury pattern):~~'''~~		Risk factors (injury pattern):
	* Cervical spine fracture (any level, excluding isolated spinous/transverse process fractures)		* Cervical spine fracture (any level, excluding isolated spinous/transverse process fractures)
	*C1-C3 fracture, subluxation, or ligamentous injury		*C1-C3 fracture, subluxation, or ligamentous injury
	*Fracture through the ~~'''~~transverse foramen~~'''~~		*Fracture through the transverse foramen
	* Le Fort II or III facial fractures		* Le Fort II or III facial fractures
	* Basilar skull fracture involving the carotid canal		* Basilar skull fracture involving the carotid canal
	* Diffuse axonal injury with GCS <6		* Diffuse axonal injury with GCS <6
	* Near-hanging or ~~'''~~[[Strangulation\|strangulation]]~~'''~~ with anoxic brain injury		* Near-hanging or [[Strangulation\|strangulation]] with anoxic brain injury
	*Mandible fractures		*Mandible fractures
	*Complex skull fractures		*Complex skull fractures
Línea 48:		Línea 48:
	*Blunt cardiac rupture		*Blunt cardiac rupture

	* CTA of the neck (from aortic arch through circle of Willis): ~~'''~~imaging modality of choice~~'''~~; sensitivity/specificity ~98%/100% with modern ≥16-slice CT<ref name="PMC"/>		* CTA of the neck (from aortic arch through circle of Willis): imaging modality of choice; sensitivity/specificity ~98%/100% with modern ≥16-slice CT<ref name="PMC"/>
	*'''Do NOT wait for symptoms''' to image — the whole point is to screen '''asymptomatic''' patients before they stroke		*'''Do NOT wait for symptoms''' to image — the whole point is to screen '''asymptomatic''' patients before they stroke

Línea 69:		Línea 69:
	\|}		\|}

	*Many ~~'''~~grade I-II injuries heal~~'''~~ spontaneously within 7-10 days with antithrombotic therapy		*Many grade I-II injuries heal spontaneously within 7-10 days with antithrombotic therapy
	* Follow-up CTA at 7-10 days is standard to reassess injury progression or healing		* Follow-up CTA at 7-10 days is standard to reassess injury progression or healing

	==Management==		==Management==
	*~~'''~~Start antithrombotic therapy (ATT) as soon as safely possible~~'''~~ — this is the single most important intervention to prevent stroke<ref name="EAST"/>		*Start antithrombotic therapy (ATT) as soon as safely possible — this is the single most important intervention to prevent stroke<ref name="EAST"/>
	**ATT reduces stroke risk: OR 0.20 (80% reduction) and mortality: OR 0.17<ref name="EAST"/>		**ATT reduces stroke risk: OR 0.20 (80% reduction) and mortality: OR 0.17<ref name="EAST"/>
	* Preferred antithrombotic regimens:		* Preferred antithrombotic regimens:

Danbot: Removed excessive bold from bullet lead-ins throughout; bold retained only for critical warnings and key clinical pearls

2026-03-19T12:52:57Z

Removed excessive bold from bullet lead-ins throughout; bold retained only for critical warnings and key clinical pearls

← Revisión anterior		Revisión del 12:52 19 mar 2026
Línea 10:		Línea 10:

	==Clinical Features==		==Clinical Features==
	*~~'''~~Most patients are asymptomatic at initial presentation~~'''~~ — this is why screening is critical		* Most patients are asymptomatic at initial presentation — this is why screening is critical
	*Symptomatic patients may present with:		*Symptomatic patients may present with:
	**~~'''~~Acute stroke symptoms~~'''~~ (hemiparesis, aphasia, facial droop) — may be delayed hours to days after injury		** Acute stroke symptoms (hemiparesis, aphasia, facial droop) — may be delayed hours to days after injury
	**~~'''~~Expanding cervical hematoma~~'''~~		** Expanding cervical hematoma
	**~~'''~~Arterial hemorrhage~~'''~~ from neck, nose, or mouth		** Arterial hemorrhage from neck, nose, or mouth
	**~~'''~~Cervical bruit~~'''~~ in a young patient (uncommon but specific)		** Cervical bruit in a young patient (uncommon but specific)
	**~~'''~~Horner syndrome~~'''~~ (ptosis, miosis, anhidrosis) — from carotid dissection disrupting sympathetic fibers		** Horner syndrome (ptosis, miosis, anhidrosis) — from carotid dissection disrupting sympathetic fibers
	**~~'''~~Neurologic deficit inconsistent with CT head findings~~'''~~ — think BCVI if stroke territory doesn't match the head injury pattern		** Neurologic deficit inconsistent with CT head findings — think BCVI if stroke territory doesn't match the head injury pattern

	==Differential Diagnosis==		==Differential Diagnosis==
Línea 24:		Línea 24:
	==Evaluation==		==Evaluation==
	===Workup===		===Workup===
	*~~'''~~Apply Modified Denver Screening Criteria~~'''~~ — obtain CTA if '''ANY ONE''' is present:<ref name="BPG">Best practice guidelines for BCVI. ''Scand J Trauma Resusc Emerg Med''. 2018. PMC6206718.</ref>		* Apply Modified Denver Screening Criteria — obtain CTA if '''ANY ONE''' is present:<ref name="BPG">Best practice guidelines for BCVI. ''Scand J Trauma Resusc Emerg Med''. 2018. PMC6206718.</ref>

	'''Signs/symptoms:'''		'''Signs/symptoms:'''
Línea 35:		Línea 35:

	'''Risk factors (injury pattern):'''		'''Risk factors (injury pattern):'''
	*~~'''~~Cervical spine fracture~~'''~~ (any level, excluding isolated spinous/transverse process fractures)		* Cervical spine fracture (any level, excluding isolated spinous/transverse process fractures)
	*C1-C3 fracture, subluxation, or ligamentous injury		*C1-C3 fracture, subluxation, or ligamentous injury
	*Fracture through the '''transverse foramen'''		*Fracture through the '''transverse foramen'''
	*~~'''~~Le Fort II or III facial fractures~~'''~~		* Le Fort II or III facial fractures
	*~~'''~~Basilar skull fracture~~'''~~ involving the carotid canal		* Basilar skull fracture involving the carotid canal
	*~~'''~~Diffuse axonal injury~~'''~~ with GCS <6		* Diffuse axonal injury with GCS <6
	*~~'''~~Near-hanging~~'''~~ or '''[[Strangulation\|strangulation]]''' with anoxic brain injury		* Near-hanging or '''[[Strangulation\|strangulation]]''' with anoxic brain injury
	*Mandible fractures		*Mandible fractures
	*Complex skull fractures		*Complex skull fractures
Línea 48:		Línea 48:
	*Blunt cardiac rupture		*Blunt cardiac rupture

	*~~'''~~CTA of the neck~~'''~~ (from aortic arch through circle of Willis): '''imaging modality of choice'''; sensitivity/specificity ~98%/100% with modern ≥16-slice CT<ref name="PMC"/>		* CTA of the neck (from aortic arch through circle of Willis): '''imaging modality of choice'''; sensitivity/specificity ~98%/100% with modern ≥16-slice CT<ref name="PMC"/>
	*'''Do NOT wait for symptoms''' to image — the whole point is to screen '''asymptomatic''' patients before they stroke		*'''Do NOT wait for symptoms''' to image — the whole point is to screen '''asymptomatic''' patients before they stroke

	===Diagnosis===		===Diagnosis===
	*~~'''~~Biffl Grading Scale~~'''~~ (determines management):		* Biffl Grading Scale (determines management):

	{\| class="wikitable"		{\| class="wikitable"
Línea 70:		Línea 70:

	*Many '''grade I-II injuries heal''' spontaneously within 7-10 days with antithrombotic therapy		*Many '''grade I-II injuries heal''' spontaneously within 7-10 days with antithrombotic therapy
	*~~'''~~Follow-up CTA at 7-10 days~~'''~~ is standard to reassess injury progression or healing		* Follow-up CTA at 7-10 days is standard to reassess injury progression or healing

	==Management==		==Management==
	*'''Start antithrombotic therapy (ATT) as soon as safely possible''' — this is the single most important intervention to prevent stroke<ref name="EAST"/>		*'''Start antithrombotic therapy (ATT) as soon as safely possible''' — this is the single most important intervention to prevent stroke<ref name="EAST"/>
	**ATT reduces stroke risk: OR 0.20 (80% reduction) and mortality: OR 0.17<ref name="EAST"/>		**ATT reduces stroke risk: OR 0.20 (80% reduction) and mortality: OR 0.17<ref name="EAST"/>
	*~~'''~~Preferred antithrombotic regimens:~~'''~~		* Preferred antithrombotic regimens:
	**~~'''~~Aspirin 325 mg daily~~'''~~ — most commonly used; simplest; adequate for most grade I-II injuries		** Aspirin 325 mg daily — most commonly used; simplest; adequate for most grade I-II injuries
	**~~'''~~Aspirin + clopidogrel~~'''~~ — used at some centers for higher-grade injuries		** Aspirin + clopidogrel — used at some centers for higher-grade injuries
	**~~'''~~Heparin infusion~~'''~~ (target PTT 40-50) — alternative, especially if higher-grade injury or concern for thrombus progression		** Heparin infusion (target PTT 40-50) — alternative, especially if higher-grade injury or concern for thrombus progression
	*~~'''~~When ATT is contraindicated~~'''~~ (intracranial hemorrhage, solid organ injury, other active bleeding):		* When ATT is contraindicated (intracranial hemorrhage, solid organ injury, other active bleeding):
	**~~'''~~Discuss with trauma surgery/neurosurgery~~'''~~ — risk-benefit must be weighed case by case		** Discuss with trauma surgery/neurosurgery — risk-benefit must be weighed case by case
	**Some centers delay ATT 24-72 hours until bleeding risk stabilizes; others accept the stroke risk temporarily		**Some centers delay ATT 24-72 hours until bleeding risk stabilizes; others accept the stroke risk temporarily
	**'''Do not simply omit ATT''' without a documented plan — untreated BCVI has a '''21% stroke rate'''<ref name="EAST"/>		**'''Do not simply omit ATT''' without a documented plan — untreated BCVI has a '''21% stroke rate'''<ref name="EAST"/>
	*~~'''~~Grade V (transection with active hemorrhage):~~'''~~ emergent hemorrhage control — direct pressure, emergent endovascular intervention, or operative repair		* Grade V (transection with active hemorrhage): emergent hemorrhage control — direct pressure, emergent endovascular intervention, or operative repair
	*~~'''~~Grade III-IV:~~'''~~ ATT ± endovascular stenting (decision made by vascular surgery/interventional radiology at follow-up; not an ED decision)		* Grade III-IV: ATT ± endovascular stenting (decision made by vascular surgery/interventional radiology at follow-up; not an ED decision)
	*~~'''~~Consult:~~'''~~ trauma surgery, and as needed neurosurgery and/or vascular surgery/interventional radiology		* Consult: trauma surgery, and as needed neurosurgery and/or vascular surgery/interventional radiology

	==Disposition==		==Disposition==
	*~~'''~~All patients with confirmed BCVI: admit~~'''~~ to trauma service with serial neurologic examinations		* All patients with confirmed BCVI: admit to trauma service with serial neurologic examinations
	*~~'''~~Start ATT in the ED~~'''~~ if no contraindication — do not defer to the floor		* Start ATT in the ED if no contraindication — do not defer to the floor
	*~~'''~~Follow-up CTA at 7-10 days~~'''~~ — document this plan; many grade I-II injuries resolve; grade III+ may progress and require intervention		* Follow-up CTA at 7-10 days — document this plan; many grade I-II injuries resolve; grade III+ may progress and require intervention
	*~~'''~~If screening criteria are met but CTA is negative:~~'''~~ admit the trauma patient per standard protocols; a negative CTA has very high NPV — no further BCVI-specific follow-up needed unless new neurologic symptoms develop		* If screening criteria are met but CTA is negative: admit the trauma patient per standard protocols; a negative CTA has very high NPV — no further BCVI-specific follow-up needed unless new neurologic symptoms develop
	*~~'''~~Document clearly:~~'''~~ Denver screening criteria met, CTA result, Biffl grade if positive, ATT initiated (and agent/dose), and follow-up imaging plan		* Document clearly: Denver screening criteria met, CTA result, Biffl grade if positive, ATT initiated (and agent/dose), and follow-up imaging plan

	==See Also==		==See Also==

Ostermayer at 10:45, 19 March 2026

2026-03-19T10:45:01Z

← Revisión anterior		Revisión del 10:45 19 mar 2026
Línea 20:		Línea 20:

	==Differential Diagnosis==		==Differential Diagnosis==
	*'''Traumatic brain injury''' (intracranial hemorrhage, contusion, diffuse axonal injury)		{{Blunt neck trauma DDX}}
	*'''Post-traumatic stroke''' from other causes (fat embolism, air embolism, hypotension)
	*'''Vertebral artery dissection''' from minor/trivial trauma (chiropractic manipulation, sports, yoga)
	*'''[[Penetrating neck trauma~~]]''' with vascular injury~~
	*'''Aortic arch injury'''

	==Evaluation==		==Evaluation==

Ostermayer at 10:41, 19 March 2026

2026-03-19T10:41:17Z

← Revisión anterior		Revisión del 10:41 19 mar 2026
Línea 1:		Línea 1:
	Blunt cerebrovascular injury (BCVI) is a non-penetrating injury to the '''carotid and/or vertebral arteries''' that may be '''clinically silent initially''' but can cause '''devastating stroke''' if not identified and treated.<ref name="EAST">Blunt Cerebrovascular Injury Practice Management Guideline. ''EAST''. 2020.</ref> Incidence is 1-2% of blunt trauma admissions but up to '''9% in severe head injury'''. Screening with the '''Modified Denver Criteria''' and '''CTA''' has reduced the stroke rate from ~15% to '''<1%''' in asymptomatic patients.<ref name="PMC">Blunt Cerebrovascular Injuries: Advances in Screening, Imaging, and Management Trends. ''AJNR''. 2021. PMC7655313.</ref> The EM physician's role is to '''know when to screen, order CTA, and start antithrombotic therapy''' before the patient strokes.

	==Background==		==Background==
	*BCVI includes: intimal flap/dissection, intramural hematoma, pseudoaneurysm, occlusion, and transection of the carotid or vertebral arteries		*BCVI includes: intimal flap/dissection, intramural hematoma, pseudoaneurysm, occlusion, and transection of the carotid or vertebral arteries
Línea 6:		Línea 4:
	*Carotid and vertebral arteries are '''equally affected'''; carotid injuries carry higher mortality		*Carotid and vertebral arteries are '''equally affected'''; carotid injuries carry higher mortality
	*Even with screening criteria, '''~20% of BCVI may be missed''' — some institutions now advocate universal CTA of the neck in all significant blunt trauma<ref name="REBEL">Blunt Cerebrovascular Injury: Universal Imaging for All? ''REBEL EM''. 2020.</ref>		*Even with screening criteria, '''~20% of BCVI may be missed''' — some institutions now advocate universal CTA of the neck in all significant blunt trauma<ref name="REBEL">Blunt Cerebrovascular Injury: Universal Imaging for All? ''REBEL EM''. 2020.</ref>
			*Blunt cerebrovascular injury (BCVI) is a non-penetrating injury to the '''carotid and/or vertebral arteries''' that may be '''clinically silent initially''' but can cause '''devastating stroke''' if not identified and treated.<ref name="EAST">Blunt Cerebrovascular Injury Practice Management Guideline. ''EAST''. 2020.</ref>
			*Incidence is 1-2% of blunt trauma admissions but up to '''9% in severe head injury'''.
			*Screening with the [[Denver Screening Criteria]] and '''CTA''' has reduced the stroke rate from ~15% to '''<1%''' in asymptomatic patients.<ref name="PMC">Blunt Cerebrovascular Injuries: Advances in Screening, Imaging, and Management Trends. ''AJNR''. 2021. PMC7655313.</ref>


	==Clinical Features==		==Clinical Features==

Ostermayer: Created page with "Blunt cerebrovascular injury (BCVI) is a non-penetrating injury to the '''carotid and/or vertebral arteries''' that may be '''clinically silent initially''' but can cause '''devastating stroke''' if not identified and treated.Blunt Cerebrovascular Injury Practice Management Guideline. ''EAST''. 2020. Incidence is 1-2% of blunt trauma admissions but up to '''9% in severe head injury'''. Screening with the '''Modified Denver Criteria''' and '''CTA'''..."

2026-03-18T02:48:54Z

Created page with "Blunt cerebrovascular injury (BCVI) is a non-penetrating injury to the '''carotid and/or vertebral arteries''' that may be '''clinically silent initially''' but can cause '''devastating stroke''' if not identified and treated.<ref name="EAST">Blunt Cerebrovascular Injury Practice Management Guideline. ''EAST''. 2020.</ref> Incidence is 1-2% of blunt trauma admissions but up to '''9% in severe head injury'''. Screening with the '''Modified Denver Criteria''' and '''CTA'''..."

Página nueva

Blunt cerebrovascular injury (BCVI) is a non-penetrating injury to the '''carotid and/or vertebral arteries''' that may be '''clinically silent initially''' but can cause '''devastating stroke''' if not identified and treated.<ref name="EAST">Blunt Cerebrovascular Injury Practice Management Guideline. ''EAST''. 2020.</ref> Incidence is 1-2% of blunt trauma admissions but up to '''9% in severe head injury'''. Screening with the '''Modified Denver Criteria''' and '''CTA''' has reduced the stroke rate from ~15% to '''<1%''' in asymptomatic patients.<ref name="PMC">Blunt Cerebrovascular Injuries: Advances in Screening, Imaging, and Management Trends. ''AJNR''. 2021. PMC7655313.</ref> The EM physician's role is to '''know when to screen, order CTA, and start antithrombotic therapy''' before the patient strokes.

==Background==
*BCVI includes: intimal flap/dissection, intramural hematoma, pseudoaneurysm, occlusion, and transection of the carotid or vertebral arteries
*'''~50% of BCVI-related strokes occur before hospital arrival'''; the other half are '''preventable with screening and early treatment'''<ref name="PMC"/>
*Carotid and vertebral arteries are '''equally affected'''; carotid injuries carry higher mortality
*Even with screening criteria, '''~20% of BCVI may be missed''' — some institutions now advocate universal CTA of the neck in all significant blunt trauma<ref name="REBEL">Blunt Cerebrovascular Injury: Universal Imaging for All? ''REBEL EM''. 2020.</ref>

==Clinical Features==
*'''Most patients are asymptomatic at initial presentation''' — this is why screening is critical
*Symptomatic patients may present with:
**'''Acute stroke symptoms''' (hemiparesis, aphasia, facial droop) — may be delayed hours to days after injury
**'''Expanding cervical hematoma'''
**'''Arterial hemorrhage''' from neck, nose, or mouth
**'''Cervical bruit''' in a young patient (uncommon but specific)
**'''Horner syndrome''' (ptosis, miosis, anhidrosis) — from carotid dissection disrupting sympathetic fibers
**'''Neurologic deficit inconsistent with CT head findings''' — think BCVI if stroke territory doesn't match the head injury pattern

==Differential Diagnosis==
*'''Traumatic brain injury''' (intracranial hemorrhage, contusion, diffuse axonal injury)
*'''Post-traumatic stroke''' from other causes (fat embolism, air embolism, hypotension)
*'''Vertebral artery dissection''' from minor/trivial trauma (chiropractic manipulation, sports, yoga)
*'''[[Penetrating neck trauma]]''' with vascular injury
*'''Aortic arch injury'''

==Evaluation==
===Workup===
*'''Apply Modified Denver Screening Criteria''' — obtain CTA if '''ANY ONE''' is present:<ref name="BPG">Best practice guidelines for BCVI. ''Scand J Trauma Resusc Emerg Med''. 2018. PMC6206718.</ref>

'''Signs/symptoms:'''
*Arterial hemorrhage from neck/nose/mouth
*Cervical bruit in patient <50 years
*Expanding cervical hematoma
*Focal neurologic deficit (TIA, hemiparesis, Horner syndrome)
*Neurologic deficit inconsistent with head CT findings
*Stroke on CT or MRI

'''Risk factors (injury pattern):'''
*'''Cervical spine fracture''' (any level, excluding isolated spinous/transverse process fractures)
*C1-C3 fracture, subluxation, or ligamentous injury
*Fracture through the '''transverse foramen'''
*'''Le Fort II or III facial fractures'''
*'''Basilar skull fracture''' involving the carotid canal
*'''Diffuse axonal injury''' with GCS <6
*'''Near-hanging''' or '''[[Strangulation|strangulation]]''' with anoxic brain injury
*Mandible fractures
*Complex skull fractures
*Scalp degloving
*Thoracic vascular injury
*Blunt cardiac rupture

*'''CTA of the neck''' (from aortic arch through circle of Willis): '''imaging modality of choice'''; sensitivity/specificity ~98%/100% with modern ≥16-slice CT<ref name="PMC"/>
*'''Do NOT wait for symptoms''' to image — the whole point is to screen '''asymptomatic''' patients before they stroke

===Diagnosis===
*'''Biffl Grading Scale''' (determines management):

{| class="wikitable"
|-
! Grade !! Injury !! Stroke risk
|-
| '''I''' || Intimal irregularity or dissection with <25% luminal narrowing || Low
|-
| '''II''' || Dissection/intramural hematoma with ≥25% luminal narrowing, intraluminal thrombus, or raised intimal flap || Moderate
|-
| '''III''' || Pseudoaneurysm || Moderate-high
|-
| '''IV''' || Complete occlusion || High
|-
| '''V''' || Transection with active extravasation || Highest; hemorrhagic emergency
|}

*Many '''grade I-II injuries heal''' spontaneously within 7-10 days with antithrombotic therapy
*'''Follow-up CTA at 7-10 days''' is standard to reassess injury progression or healing

==Management==
*'''Start antithrombotic therapy (ATT) as soon as safely possible''' — this is the single most important intervention to prevent stroke<ref name="EAST"/>
**ATT reduces stroke risk: OR 0.20 (80% reduction) and mortality: OR 0.17<ref name="EAST"/>
*'''Preferred antithrombotic regimens:'''
**'''Aspirin 325 mg daily''' — most commonly used; simplest; adequate for most grade I-II injuries
**'''Aspirin + clopidogrel''' — used at some centers for higher-grade injuries
**'''Heparin infusion''' (target PTT 40-50) — alternative, especially if higher-grade injury or concern for thrombus progression
*'''When ATT is contraindicated''' (intracranial hemorrhage, solid organ injury, other active bleeding):
**'''Discuss with trauma surgery/neurosurgery''' — risk-benefit must be weighed case by case
**Some centers delay ATT 24-72 hours until bleeding risk stabilizes; others accept the stroke risk temporarily
**'''Do not simply omit ATT''' without a documented plan — untreated BCVI has a '''21% stroke rate'''<ref name="EAST"/>
*'''Grade V (transection with active hemorrhage):''' emergent hemorrhage control — direct pressure, emergent endovascular intervention, or operative repair
*'''Grade III-IV:''' ATT ± endovascular stenting (decision made by vascular surgery/interventional radiology at follow-up; not an ED decision)
*'''Consult:''' trauma surgery, and as needed neurosurgery and/or vascular surgery/interventional radiology

==Disposition==
*'''All patients with confirmed BCVI: admit''' to trauma service with serial neurologic examinations
*'''Start ATT in the ED''' if no contraindication — do not defer to the floor
*'''Follow-up CTA at 7-10 days''' — document this plan; many grade I-II injuries resolve; grade III+ may progress and require intervention
*'''If screening criteria are met but CTA is negative:''' admit the trauma patient per standard protocols; a negative CTA has very high NPV — no further BCVI-specific follow-up needed unless new neurologic symptoms develop
*'''Document clearly:''' Denver screening criteria met, CTA result, Biffl grade if positive, ATT initiated (and agent/dose), and follow-up imaging plan

==See Also==
*[[Vertebral artery dissection]]
*[[Carotid artery dissection]]
*[[Penetrating neck trauma]]
*[[Cervical fractures and dislocations]]
*[[Strangulation]]
*[[Stroke]]
*[[Traumatic brain injury]]

==External Links==
*[https://www.east.org/education-resources/practice-management-guidelines/details/blunt-cerebrovascular-injury-evaluation-and-management-of EAST — Blunt Cerebrovascular Injury Practice Management Guideline (2020)]
*[https://pmc.ncbi.nlm.nih.gov/articles/PMC6206718/ Scand J Trauma — Best practice guidelines for BCVI (2018)]
*[https://pmc.ncbi.nlm.nih.gov/articles/PMC7655313/ AJNR — Blunt Cerebrovascular Injuries: Advances in Screening, Imaging, and Management (2021)]
*[https://www.emra.org/emresident/article/blunt-cerebrovascular-injury EMRA — A Review of Blunt Cerebrovascular Injuries]

==References==
<references/>

[[Category:Trauma]]
[[Category:Neurology]]