Blunt Cerebrovascular Injury

Level 1

No recommendations can be made.

Level 2

No recommendations can be made.

Level 3

No recommendations can be made.

Level 1

No level I recommendations can be made.

Level 2

This refers a grading scheme proposed by Biffl et al.⁶ Grading scale:

• Grade I—intimal irregularity with <25% narrowing;
• Grade II—dissection or intramural hematoma with >25% narrowing;
• Grade III—pseudoaneurysm;
• Grade IV—occlusion; and
• Grade V—transection with extravasation.

1. Barring contraindications, grades I and II injuries should be treated with antithrombotic agents such as aspirin or heparin.

Level 3

This refers a grading scheme proposed by Biffl et al.⁶ Grading scale:

• Grade I—intimal irregularity with <25% narrowing;
• Grade II—dissection or intramural hematoma with >25% narrowing;
• Grade III—pseudoaneurysm;
• Grade IV—occlusion; and
• Grade V—transection with extravasation.

1. Either heparin or antiplatelet therapy can be used with seemingly equivalent results.
2. If heparin is selected for treatment, the infusion should be started without a bolus, a guideline for activated partial thromboplastin time goal cannot be determined.
3. In patients in whom anticoagulant therapy is chosen conversion to warfarin titrated to a prothrombin time-international normalized ratio of 2 to 3 for 3 months to 6 months is recommended.
4. Grade III injuries (pseudoaneurysm) rarely resolve with observation or heparinization, and invasive therapy (surgery or angiointerventional) should be considered. N.B. carotid stents placed without subsequent antiplatelet therapy have been noted to have a high rate of thrombosis in this population.⁷
5. In patients with an early neurologic deficit and an accessible carotid lesion operative or interventional repair should be considered to restore flow.
6. In children who have suffered an ischemic neurologic event (INE), aggressive management of resulting intracranial hypertension up to and including resection of ischemic brain tissue has improved outcome as compared with adults and should be considered for supportive management.

Level 1

No level I recommendation can be made.

Level 2

1. Follow-up angiography is recommended in grades I to III injuries. To reduce the incidence of angiography-related complications, this should be performed 7 days postinjury.

Level 3

There are no level III guidelines for this question.

Level 1

No level I recommendations can be made.

Level 2

1. Diagnostic four-vessel cerebral angiography (FVCA) remains the gold standard for the diagnosis of BCVI.
2. Duplex ultrasound is not adequate for screening for BCVI.
3. Computed tomographic angiography (CTA) with a four (or less)-slice multidetector array is neither sensitive nor specific enough for screening for BCVI.

Level 3

1. Multislice (eight or greater) multidetector CTA has a similar rate of detection for BCVI when compared with historic control rates of diagnosis with FVCA and may be considered as a screening modality in place of FVCA. Conflicting studies have been published however (see the Scientific Rationale section).

Level 1

No level I recommendations can be made.

Level 2

1. Patients presenting with any neurologic abnormality that is unexplained by a diagnosed injury should be evaluated for BCVI.
2. Blunt trauma patients presenting with epistaxis from a suspected arterial source after trauma should be evaluated for BCVI.

Level 3

1. Asymptomatic patients with significant blunt head trauma as defined below are at significantly increased risk for BCVI and screening should be considered. Risk factors are as follows:

• Glasgow Coma Scale score ≤8;
• Petrous bone fracture;
• Diffuse axonal injury;
• Cervical spine fracture particularly those with (i) fracture of C1 to C3 and (ii) fracture through the foramen transversarium;
• Cervical spine fracture with subluxation or rotational component; and
• Lefort II or III facial fractures

1. Pediatric trauma patients should be evaluated using the same criteria as the adult population.