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The Western Trauma Association has promulgated recommendations for the management of blunt cerebrovascular injury (BCVI) — an often occult but difficult-to-treat and potentially deadly injury.
Evaluation: BCVI should be suspected in patients with arterial hemorrhage from the neck, mouth, nose, or ears; large or expanding cervical hematoma; cervical bruit (in patients <50); focal or lateralizing neurological deficit; evidence of cerebral infarction on computed tomography (CT) or magnetic resonance imaging (MRI); or neurological deficit that is incongruous with CT or MRI findings.
Risk Factors: High-risk factors include Le Fort II or III midface fracture; basilar skull fracture involving the carotid canal; closed head injury consistent with diffuse axonal injury with Glasgow Coma Scale score <6; cervical vertebral body or transverse foramen fracture, subluxation, or ligamentous injury at any level; or any fracture at C1–C3.
Screening: CT angiography (CTA) is the preferred screening tool for BCVI. Four-vessel biplanar cerebral arteriography, duplex ultrasonography, and MRI are not recommended as screening tools. However, arteriography is recommended to definitively exclude injury in symptomatic patients with normal findings on CTA.
Primary Management: First-line treatment is nonsurgical, especially for lower-grade injuries. Heparin is generally preferred over antiplatelet agents for prevention of stroke in patients with lower-grade injuries. Grade V injuries (transection with free extravasation) require immediate surgical repair; endovascular techniques should be used if the lesion is not accessible.
Follow-up: Repeat imaging is recommended 7 to 10 days after injury or for any change in neurological status.
Stenting: Stents have been used successfully to maintain vascular patency in patients with pseudoaneurysm (injury grade III) or severe vessel narrowing (grade IV). Stents should be placed several days after injury. Antithrombotic therapy after stenting is recommended to avoid dislodging unstable thrombi.
Chronic Treatment: Long-term antithrombotic therapy is recommended unless follow-up studies demonstrate complete healing.
Biffl WL et al. Western Trauma Association critical decisions in trauma: Screening for and treatment of blunt cerebrovascular injuries. J Trauma 2009 Dec; 67:1150.
Comment
These recommendations are based mostly on case series; no class I evidence exists. The recommendations thus are a work in progress, but they constitute a reasonable approach to BCVI.