See also: [[Cervical spine trauma radiology#Blunt Cerebrovascular injury - Denver Criteria|Denver criteria]], [[Non-fatal strangulation]], [[Neck and spine trauma#Penetrating neck injury|Penetrating neck injury]] (“hard” and “soft” signs), [[Blunt laryngeal injury]] See: [RMH - BCVI protocol](x-devonthink-item://5F189646-B4D7-4D06-81B8-FDE901059E3A) > - BCVI involve damage to [[carotid and vertebral artery dissection|carotid and vertebral arteries]] and carry a high risk of ischaemic [[Stroke]]. > - up to 50% of patients develop symptoms **> 12 hours after initial injury** ; ∴ , early screening is essential # Standard of Practice ## Indications for CTA COW adapted from the Extended [[Denver]] criteria ### Clinical Criteria: - hanging/[[Non-fatal strangulation|strangulation]] - seat belt sign - clothesline mechanism of injury - unable to assess neurology (coma/intubated) + high energy mechanism - [[pupil exam#Horner Syndrome|Horner's syndrome]] or other neurological deficit (eg those associated with [[carotid and vertebral artery dissection]] ) or [[Cranial nerve palsies]] - cervical haematoma or bruit (also see criteria for [[Neck and spine trauma#Penetrating neck injury|Penetrating neck injury]]) - arterial haemorrhage or bruit - scalp degloving ### Radiological criteria - any [[Neck and spine trauma|c-spine trauma]] including [[Cervical spine trauma radiology#Occipital condyle fracture|Occipital condyle fracture]] - [[Head trauma radiology#Base of skull fracture|Base of skull fracture]] or other complex skull fracture - [[Chest trauma radiology|Chest injuries]] that include 1st and/or 2nd rib fracture - [[Facial trauma radiology#Le Fort fractures|Le Fort]] 2 or 3 facial fractures - Mandibular fractures in high energy mechanism - cerebral infarction ## Biffl classification of BCVI and stroke risk | Grade | description | risk of stroke | Management | | ----- | -------------------------------------------------------------------------------------------------------------- | -------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | I | Luminal irregularity or dissection with <25% luminal narrowing | 6% | - Aspirin 100mg 6 weeks<br>- no follow up imaging<br>- educate patient about stroke signs on discharge | | II | dissection or intramural haematoma with ≥ 25% luminal narrowing, intraluminal thrombus, or raised intimal flap | 14% | - Aspirin 100mg<br>- MRI or CT perfusion if not clinically assessable<br>- +/- surgical repair (IR +/- vascular surgery)<br>- repeat CTA in 3 months<br>- stroke clinic follow up at 3 months (if no intervention needed) | | III | pseudoaneurysm | 26% | - MRI or perfusion CT if not clinically assessable <br>- repair if surgery accessible (IR or vascular surgery)<br>- aspirin 100mg post repair<br>- early CTA 7 days post | | IV | Occlusion | 50% | - MRI or CT perfusion if not clinically assessable<br>- vascular surgery +/- IR<br>- ensure adequate [[Cerebral blood flow and CPP\|Cerebral perfusion pressure]] ~70 | | V | Transection with free extravasation or carotid-cavernous fistula | 100% | - IR / vascular surgery | # Background ## Mechanism of Injury - BCVI most commonly occurs following high energy deceleration mechanisms, such as high speed MVA, falls > 3m, hanging, [[Non-fatal strangulation]], or direct trauma to head, neck, or face. - vascular injury is usually an intimal tear → subendothelial collagen exposed → platelet aggregation and thrombus formation is triggered → can lead to vessel occlusion or embolisation - highest risk is usually - C1-3 fracture - subluxation - fractures through transverse foramina - complex fractures