Blunt cerebrovascular injury

Dr Craig Hacking et al.

Blunt cerebrovascular injury (BCVI) is an uncommon but serious consequence of blunt trauma to the head and neck.

It is often part of multi-trauma with a significant series of blunt trauma CTA reporting an incidence of approximately 1% 3. A large systematic review and meta-analysis of more than 120,000 trauma patients reported an incidence ranging from 0.18 to 2.7% 7.

Primarily, the injury is caused by longitudinal stretching 1 and injury to the vessels. Acceleration-deceleration can cause rotation and hyperextension of the neck, stressing the craniocervical vessels, which is the mechanism for the most common cause of BCVI: motor vehicle accidents (MVA). A direct blow to the neck or base of the skull may injury the carotid or vertebral arteries.

BCVI can affect multiple vessels (18-38%) and occurs in typical locations 1:

Screening

Several screening tools have been developed to identify those at risk of BCVI and limit the use of digital subtraction angiography (DSA):

In general, BCVI is at higher risk if the following are present 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.

Associations
CT

Signs on CT angiography of vascular injury include 1

  • minimal intimal 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.

When 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 injured vessel is performed.

  • technical and patient artefact
  • normal vascular variants
  • atherosclerotic plaque
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Article Information

rID: 41631
Section: Pathology
Synonyms or Alternate Spellings:
  • BCVI

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Cases and Figures

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    Case 1: VA
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    Case 2: bilateral ICA
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    Case 3: VA
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    Case 4: VA on axial T1 FS MRI
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    Case 6: ICA on 3D MRA
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    Case 7: VA on 3D MRA
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    Case 5: VA
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