Hangman fracture (Levine and Edwards grade 2) and vertebral artery traumatic pseudoaneurysm (Biffl grade 3)


This case is a good example of a Biffl grade 3 injury to the vertebral artery.

The Biffl grade for blunt cerebrovascular injury (BCVI) describes a 5-part scale of injury features:

  • grade I:  mild intimal injury or irregular intima
  • grade II: dissection with raised intimal flap / intramural hematoma with luminal narrowing >25% / intraluminal thrombosis
  • grade IIIpseudoaneurysm
  • grade IV: vessel occlusion/thrombosis
  • grade V: vessel transection