Blunt cerebrovascular injury (BCVI) can often be asymptomatic until complications such as cerebral ischaemia develop. It is essential to screen patients who present with signs of vascular injury or those with high-risk injury patterns through CT angiography as part of the clinical assessment.
Confirmed injuries are classified using the Biffl scale, which helps in determining treatment plans. Initiation of antithrombotic therapy should occur promptly when safe, and regular vascular imaging is advised following local protocols. Involvement of trauma, stroke, and neurointerventional specialists should be acquired for severe or symptomatic cases.
BCVI entails non-penetrating trauma to the carotid or vertebral arteries, with lesions that may include intimal injuries, dissections, intramural haematomas, pseudoaneurysms, occlusions, and complete vessel transections. This condition appears in 1-3% of blunt trauma patients; however, its prevalence is significantly higher in high-risk groups.
The main risk factor for patients is not immediate bleeding but rather the delayed onset of cerebral ischaemia, which can be triggered by thrombosis, distal emboli, or progressive occlusion of the vessel. Strokes typically manifest within the first 72 hours after the injury, often occurring prior to any alarming neurological or vascular symptoms. Enhanced screening can lead to increased detection rates, and starting antithrombotic treatment correlates with lower incidences of stroke and mortality.
Blunt cerebrovascular injury occurs primarily via stretching, compression, or direct disruption of the carotid or vertebral arteries. Factors such as hyperextension or rotation can tether arteries to adjacent vertebrae, which may precipitate injury, especially in cases of neck trauma, cervical spine fractures, or intraoral injuries.
The internal carotid artery is especially susceptible where it has greater mobility, while the vertebral artery faces risks where it traverses through the cervical spine. Cervical spine injuries along with ligament damage are important indicators of potential vertebral artery involvement.
Many cases of BCVI remain clinically silent during initial trauma assessments. Even when intimal injury is present, neurological symptoms may develop later due to thrombosis or progressive occlusion. Factors such as associated traumatic brain injury, sedation, and other distracting injuries can obscure the clinical presentation.
When clinical signs are evident, they typically indicate anterior or posterior circulation ischaemia without definitively confirming BCVI. Symptoms correlate more closely with the affected circulation rather than identifying the specific injured vessel. Common early symptoms and neurological manifestations include:
Patients considered at risk for BCVI should receive urgent vascular imaging post-resuscitation and stabilization. Those without overt vascular or neurological signs should follow a screening protocol guided by the injury mechanism and associated injuries.
The Expanded Denver criteria categorize screening indicators into three groups:
The criteria help facilitate timely CTA when these clinical indicators are present.
CT angiography serves as the initial imaging modality for suspected BCVI cases due to its rapid and available nature. The CTA should cover both carotid and vertebral arteries through the aortic arch to the skull base.
In cases where CTA findings are negative but suspicion remains high, further imaging or specialist reassessment may be warranted.
The Biffl scale provides a standardized approach for classifying BCVI based on angiographic appearance:
Antithrombotic therapy should commence when feasible, significantly reducing stroke rates and mortality. No consensus exists for the best regimen; however, antiplatelet therapy may be more effective than anticoagulation based on existing observational studies.
Follow-up imaging via CTA is suggested around seven days post-injury to monitor abnormalities or progression, with therapy typically lasting three months or longer based on individual circumstances. Endovascular treatments for certain severe cases may become necessary but are approached with caution due to associated risks.
Carefully monitoring new or worsening neurological findings is critical, with immediate re-evaluation advised to guide potential interventions.