Approach to blunt cerebrovascular injury: Clinical sciences

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Introduction 0:00–0:40

Blunt cerebrovascular injury, or BCVI for short, refers to the damage of the carotid or vertebral artery following blunt neck trauma.
These injuries are often caused by motor vehicle collision, fall, strangulation, or even assault like a direct blow to the neck.
BCVI is divided into 5 grades based on the luminal narrowing of the vessels. Regardless of the grade, BCVI has the potential for thrombus formation, vascular occlusion, or vascular wall hematomas which can lead to serious complications like a stroke.
Alright, when evaluating a patient who presents with a chief concern suggestive of a blunt cerebrovascular injury, your first step is to perform a primary survey by assessing their ABCDE.

Acute Management 0:40–2:06

Because BCVI can have associated neck injuries that can compromise the airway, it's important to secure the airway as soon as possible.
Always have a low threshold for endotracheal intubation, or even surgical airway like a cricothyroidotomy if you are unable to intubate.
While securing the airway, make sure to stabilize the cervical spine to prevent further injury. Once the airway is secured, ensure adequate ventilation and provide supplemental oxygen, if needed.
Next, obtain two large bore IVs or an intraosseous line if intravenous access cannot be obtained. Continuously monitor vitals and start appropriate resuscitative measures.
Then, assess for disability by performing a neurological assessment and calculating the Glasgow Coma Scale. Also, perform a pupillary exam looking for unequal or delayed pupillary reflex.
Make sure to lay the patient supine on a flat board for spine immobilization. Finally, expose the patient by removing all clothing and bandages to ensure no injuries are missed.
Just like with any trauma patient, after the exam, place a warm blanket over them to avoid hypothermia. Now that the primary survey is complete, let’s talk about unstable patients that have obvious signs of neurologic deficits.

Unstable Patient 2:06–3:45

In this case, proceed with a secondary survey, which includes a detailed history and physical exam. Be sure to focus on neurological findings.
Additionally, order adjunctive studies including a CT scan of the head, maxillofacial region, and cervical spine, as well as a CT angiography, or CTA for short, of the head and neck.
These patients will likely have a history of high-impact trauma like motor vehicle collision, fall, assault, or strangulation.
On exam, you might find neurological deficits including diminished sensation or motor movements, or even Horner syndrome.
In some cases, you might see associated neck injuries like soft tissue ecchymoses such as a seatbelt sign, or cervical spine tenderness.
CT of the head might show evidence of skull base fracture, while CT of the maxillofacial region might reveal a mandibular fracture or LeFort fracture.
As for the CT of the cervical spine, you might see a cervical spine fracture or a facet dislocation. These findings should lead you to consider stroke from blunt cerebrovascular injury, which is a medical emergency.
Your next step will depend on the CTA findings. Here’s a high-yield fact!
If your patient sustained a high-impact injury and has a focal neurological deficit that is not apparent on the head CT, be sure to order CTA of the neck to evaluate for BCVI.
Okay, if on CTA you see vertebral or carotid artery occlusion, you are dealing with a grade IV BCVI. A complete occlusion of either artery poses a high risk of brain ischemia and stroke.

Grade IV and V BCVI 3:45–5:18

On the other hand, CTA showing a transection of the vertebral or carotid artery with contrast extravasation means your patient has a grade V BCVI, which is rapidly fatal and therefore a surgical emergency.
Here’s a clinical pearl! Sometimes, when the patient has multiple traumatic injuries, the signs of BCVI are not obvious.
In these cases, the extended Denver criteria can be used to screen those at risk for blunt cerebrovascular injury to decide if they need adjunctive imaging like a CTA of the head and neck.
The criteria include the presence of nasal, oral, or cervical arterial hemorrhage, carotid bruit in a patient under 50 years of age, or an expanding neck hematoma, as well as the presence of a focal neurological deficit, ischemic stroke on initial imaging, GCS less than 6, degloving injury of the scalp, or anoxic brain injury from hanging.
Additionally, fractures of the face, mandible, skull, upper ribs, or cervical spine, as well as cervical spine ligamentous injury or high-impact thoracic injury, should lead you to consider getting additional imaging to assess for concomitant BCVI.
Okay, now that the unstable patients are taken care of, let’s move on to the stable ones, who unlike unstable patients, don’t have obvious signs of neurologic deficits.

Stable Patient 5:18–6:40

Your next step here is to quickly perform a secondary survey, which means a detailed history and head-to-toe physical exam.
Then, get some basic trauma labs like a CBC, CMP, coag studies, as well as adjunctive imaging including a CT scan of the head, maxillofacial region, and cervical spine.
History might reveal motor vehicle collision, fall, assault, or strangulation. When it comes to physical exam, you might find facial deformity, swelling, bruising, or tenderness; epistaxis; neck tenderness, swelling, bruising, lacerations, or hematoma of the neck.
Sometimes, you might see bony step-off or tenderness along the cervical spine; or delayed-onset Horner syndrome. As before, head CT might reveal skull base fracture, while CT of the maxillofacial region might show mandibular fracture or LeFort fracture.
Lastly, CT of cervical spine might reveal cervical spine fracture or facet dislocation. In this case, consider blunt cerebrovascular injury and order a CTA scan of the head and neck.
If the CTA shows vertebral or carotid artery injury with less than 25 percent luminal narrowing, you can make your diagnosis of a grade I blunt cerebrovascular injury.

Grade I BCVI 6:40–6:57

This type of BCVI refers to minimal vascular injury. Alternatively, on CTA, you might see a vertebral or carotid artery dissection or an intramural hematoma causing greater than 25 percent luminal narrowing.

Grade II BCVI 6:57–7:19

You might also find an intraluminal thrombus, or a raised intimal flap. These findings are consistent with a grade II blunt cerebrovascular injury.
Lastly, CTA might reveal the presence of a pseudoaneurysm of the vertebral or carotid artery. This means that there is some damage to the arterial wall causing it to weaken, so you’re dealing with grade III blunt cerebrovascular injury.

Grade III BCVI 7:19–7:35

Alright, as a quick recap… When a patient presents with a blunt cerebrovascular injury, first perform a primary survey to determine if they are stable or unstable.

Review 7:35–8:00

In both stable and unstable patients you will need to get CT of the head, maxillofacial region, and cervical spine as part of your adjunctive tests.
However, CTA of the head and neck will definitely tell you if you are dealing with BCVI and help you