Screening and Management of BCVIs in blunt trauma patients

Luke Phillips
Emergency Consultant

Alfred Health

Video Content: Dr Barry Cunningham

A 60yo M presents to the trauma centre after his 4WD vehicle collided with a semi-trailer at 90km/hr. He was entrapped in the vehicle for more than 1 hour. At scene he has an unrecordable blood pressure and has had bilateral finger thoracostomies. He has received 4 units of blood en-route. On arrival to the ED he has suspected chest and head injuries and a large bore MAC line is inserted into his left subclavian vein, a massive transfusion protocol is commenced, chest drains inserted and upon stabilisation he is intubated for transfer to CT for a pan scan. En-route the ED registrar asks if we should image his carotid arteries to exclude a carotid injury?

Having recently completed a senior registrar rotation through the Alfred Trauma service, Dr Barry Cunningham presented this lightning learning on BCVI to our registrars at their weekly teaching session.

Blunt Cerebrovascular Injury (BCVI) is a non-penetrating injury to the carotid and/or the vertebral arteries. Motor vehicle accidents are the most common cause however we do see patients with BCVIs who fall, have sports related injuries or strangulations. It is caused by either a stretching or impingement of the vessel wall with forceful movements of the head and neck during an acute injury. This can be from a direct blow, hyperextension with rotation, skull base fracture involving the carotid canal or blunt intra-oral trauma.  An intimal tear is formed with exposure of the sub-intimal layers to blood products and either a thrombus, pseudoaneurysm, wall haematoma or vessel occlusion can occur. 

Figure: Traumatic cerebrovascular injuries. A, Intimal disruption. B, Intimal disruption with thrombus formation. C, Elastic laminae disruption allowing traumatic aneurysm formation (arrows). D, Hematoma within the artery wall with luminal stenosis. (Harrigan et al (2020)) 

BCVI is associated with poorer predicted outcomes and higher morbidity and mortality in trauma patients. A significant number of patients go onto suffer strokes during their inpatient stay or have a stroke pre-hospital. It is a commonly missed injury as it typically has a latent period between the time of injury and onset of symptoms.

CT angiography of the neck is the current imaging modality of choice

 

Who do we screen here at the Alfred?

ALFRED BCVI CRITERIA (based on Modified Denver  Criteria)

Clinical: Imaging:
  • Seat belt or other abrasion of neck
  • C1- C3 Cervical spine fracture, subluxation or ligamentous injury
  • Cervical haematoma or bruit
  • Fracture through foramen transversarium
  • Scalp de-gloving
  • Mandibular Le Fort II & III fractures
  • Arterial haemorrhage from wound / mouth / nose / ears
  • Base of skull fracture involving carotid canal
  • Unexplained neurological deficit including GCS ≤8
  • Acute infarction on CT brain
  • Horner’s syndrome and TIAs associated with blunt trauma
  • Closed head injury with diffuse axonal injury
  • Severe chest injuries
  • Sternal or 1st/2nd rib fractures

Carotid Angio CT if ≥1 positive criteria

 

 

How are BCVI’s Graded?

Grading of BCVI

Grade Finding Implication
I luminal irregularity or dissection with <25% luminal narrowing

3% stroke rate

7% chance of  progression

II dissections with ≥25% luminal narrowing, intraluminal thrombus, or a raised intimal flap

70% risk of progression

III pseudoaneurysm tend to persist
IV complete occlusion 44% stroke rate
V transection of the carotid artery with free extravasation of contrast or significant AV fistula 100% mortality
What are the treatment options?
  • C-spine immobilisation for 2-3weeks
  • Antithrombotic treatment
    • Grade I BCVI dissections are treated with aspirin 300mg loading dose followed by 100mg daily initially.
    • Grades II-IV should be treated with either antiplatelet therapy or intravenous heparin – APTT target 50-60 sec depending on the perceived risk of clot propagation against embolization.
    • If there is intracranial involvement of the dissection, then anticoagulation should be avoided and aspirin 100mg daily should be administered.
    • Any initiation of antithrombotic treatment needs to be individualised and take into consideration other aspects of a patient’s traumatic injuries and general medical condition.
  • Endovascular Stents +/- Thrombolysis (rare)
  • Surgical (rarer)
Key References:  

Biffl WL, Cothren CC, Moore EE, et al. Western Trauma Association critical decisions in trauma: screening for and treatment of blunt cerebrovascular injuries. J Trauma 2009;67:1150–53 doi:10.1097/TA.0b013e3181c1c1d6 pmid:20009659

 

Kim DY, Biffl W, Bokhari F, Brakenridge S, Chao E, Claridge JA, Fraser D, Jawa R, Kasotakis G, Kerwin A, Khan U, Kurek S, Plurad D, Robinson BRH, Stassen N, Tesoriero R, Yorkgitis B, Como JJ. Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma. (2020) The journal of trauma and acute care surgery. 88 (6): 875-887. doi:10.1097/TA.0000000000002668 – Pubmed

 

Cothren CC, Moore EE, Ray CE, Johnson JL, Moore JB, Burch JM. Cervical spine fracture patterns mandating screening to rule out blunt cerebrovascular injury. (2007) Surgery. 141 (1): 76-82. doi:10.1016/j.surg.2006.04.005 – Pubmed

 

Burlew CC, Biffl WL, Moore EE, Barnett CC, Johnson JL, Bensard DD. Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis. (2012) The journal of trauma and acute care surgery. 72 (2): 330-5; discussion 336-7, quiz 539. doi:10.1097/TA.0b013e31823de8a0 – Pubmed

 

Brommeland, T., Helseth, E., Aarhus, M. et al. Best practice guidelines for blunt cerebrovascular injury (BCVI). Scand J Trauma Resusc Emerg Med 26, 90 (2018). https://doi.org/10.1186/s13049-018-0559-1

 

Alfred Guidelines for the Investigation and Management of BCVIs (2019)

 

Harrigan MR. Ischemic Stroke due to Blunt Traumatic Cerebrovascular Injury. Stroke. 2020 Jan;51(1):353-360. doi: 10.1161/STROKEAHA.119.026810. Epub 2019 Dec 11. PMID: 31822250.

Luke Phillips

Luke Phillips

Emergency Consultant, Alfred Health

Luke is an Emergency Physician at Alfred Health in Melbourne and is currently the co-ordinator for point of care ultrasound education within the department.

Luke has a special interest in the use of ultrasound for critically unwell patients, in trauma management and in the use of ultrasound to guide procedures and improve patient safety in the ED. In addition to ultrasound, Luke has developed a Certificate of Emergency Medicine for the Alfred Emergency and Trauma Centre’s International Program and also has special interests in airway management and simulation.

Luke is the creator and editor of the open access education website and blog – pocusgeelong.com, a reviewer for the POCUS section for Life in the Fast Lane weekly review and an instructor with Ultrasound Training Solutions in Melbourne.

Luke is currently a Co-Chair of the Victorian branch of the Emergency Medicine Ultrasound Group (EMUGS) and has completed a number of CCPU units through ASUM. His twitter handle is @lukemphillips