Cerebrovascular Blunt Injury (Suspected)

Population Covered By The Guidance

This pathway provides guidance on the imaging of blunt trauma patients who are at increased risk of cerebrovascular injury.

Lead Researcher: Sian Chin

Experts & Contributors: Ferry Dharsono, Ravinder Dhillon, Sudhakar Rao

Date reviewed: August 2018

Date Published: March 2019

Image 1a (Angiogram): A carotid angiogram in a 33 year old male involved in a motor bicycle accident reveals complete occlusion of the right internal carotid artery in its supraclinoid portion (arrow).

Blunt Cerebrovascular Injury

Image 1b (Computed Tomography): Large right middle cerebral artery territory infarct with mass effect (arrow).

Blunt Cerebrovascular Injury

  • Blunt cerebrovascular injury (BCVI) is a rare but serious sequela of trauma that occurs in approximately 1% of all blunt trauma victims
  • Morbidity and mortality is due to stroke which occurs in 10-21% of cases. Although some cases present with stroke, a number cases are initially asymptomatic and may have a delayed neurological event 10-72 hours after trauma
  • Symptoms relate to the vascular territories of the carotid and vertebral arteries. Vertebral artery injuries can result in posterior circulation strokes which may present as motor or sensory deficits, vertigo, ataxia, visual field deficits, dysarthria, dysphagia or loss of consciousness
  • There is evidence that anticoagulation or use of antiplatelet agents reduce the rate of stroke in BCVI, so there may be benefit from screening asymptomatic patients who are at increased risk. The exact optimal medical treatment regimen is yet to be determined
  • Clinical screening criteria with a sensitivity approaching 100% are yet to be defined. The most commonly used modified Denver screening criteria may miss 20-37% of BCVI. The New Denver Criteria are broader and identify more BCVIs, however the trade-off is that more patients will have unnecessary investigations. 5% of BCVIs may not fit into the listed New Denver Criteria
  • The New Denver Criteria identify injuries that are associated with BCVI if they are associated with a high energy mechanism
  • CT angiogram is the non-invasive screening tool of choice for BCVI in selected patients
  • MRI/MRA may be indicated as a second-line investigation for patients with new or persistent neurological signs concerning for BCVI, but a normal CTA
  • Invasive angiography (or digital subtraction angiography, DSA) is generally only indicated for therapeutic intervention. It is considered the gold standard diagnostic test for BCVI, but it has a number of disadvantages including cost, availability, and 1% risk of adverse events including stroke

Date of literature search: April-May 2018

The search methodology is available on request. Email

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

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  42. Berne JD, Reuland KS, Villarreal DH, McGovern TM, Rowe SA, Norwood SH. Sixteen-slice multi-detector computed tomographic angiography improves the accuracy of screening for blunt cerebrovascular injury. J Trauma. 2006;60(6):1204-9; discussion 9-10. (Level III evidence). View the reference
  43. Miller PR, Fabian TC, Croce MA, Cagiannos C, Williams JS, Vang M, et al. Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Ann Surg. 2002;236(3):386-93; discussion 93-5. (Level II evidence). View the reference
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SYMBOL RRL EFFECTIVE DOSE RANGE
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Minimal radiation Minimal < 1 millisieverts
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Medium radiation Medium 5-10 mSv
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Disclaimer

Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.

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