Blunt cerebrovascular injury

Last revised by Daniel J Bell on 26 Aug 2022

Blunt cerebrovascular injury (BCVI), sometimes called blunt cervicovascular injury or blunt carotid and vertebral artery injury, refers to a spectrum of injuries to the cervical carotid and vertebral arteries due to blunt trauma.

Blunt cerebrovascular injury is often part of multitrauma 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, blunt cerebrovascular 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 collisions. A direct blow to the neck or base of the skull may cause injury to the carotid or vertebral arteries.

Blunt cerebrovascular injury can affect multiple vessels (18-38%) and occurs in typical locations where there is relative fixation 1:

Several screening tools have been developed to identify those at risk of blunt cerebrovascular injury and limit the use of angiography:

In general, BCVI is at higher risk if there is a high energy transfer mechanism along with clinical or imaging evidence of significant craniofacial, cervical, or upper thoracic injuries. About 70% are associated with cervical spine fractures 8.

The Biffl scale 2 describes the vascular injury on angiography (either CTA or DSA) on a scale of I to V, with higher grades of carotid injury associated with a high risk of stroke.

Signs on CT angiography of blunt cerebrovascular injury include 1

  • minimal intimal injury (irregularity)
  • intimal flap
  • dissection with or without intramural hematoma
  • pseudoaneurysm
  • transection
  • vessel occlusion
  • AV fistula

The signs of blunt cerebrovascular injury on digital subtraction angiography (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, blunt cerebrovascular injury has high morbidity and mortality, primarily from cerebral infarction. The risk for stroke with carotid injury depends on the grade of injury (see separate article on Biffl grade). The risk of cerebral infarction following BCVI is reduced with antithrombotic therapy, but this can be a difficult management decision as often there is also concomitant intracranial hemorrhage from the primary trauma. In select cases, stenting of the injured vessel or open surgical repair is performed.

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Cases and figures

  • 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 5: VA
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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 8: vertebral artery with large stroke
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  • Case 9: C2 hangman's fracture with Biffl grade III right VA injury
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