Approach to blunt cerebrovascular injury: Clinical sciences

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.
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.

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.

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.