Neurosurgery notes/Trauma/Primary head Injury/Blunt cerebrovascular injury (BCVI)

Blunt cerebrovascular injury (BCVI)

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Parent item
Primary head Injury
Sub-item
Traumatic cervical artery dissections
Carotid artery blunt injuries
Vertebral artery blunt injuries

Numbers

  • A 13% mortality rate is considered low.
  • Nearly one-third of patients are not treatable.
  • Incidence: 1–2% of blunt trauma patients
    • Among those who stayed >24 hrs in a trauma hospital the incidence was 2.4%
  • In paediatric patients identified with blunt cerebrovascular injury (BCVI),
    • 69% were located in the intracranial ICA,
    • 23% in the extracranial ICA
    • 6% in the VA.

Denver screen criteria-Geddes 2016

The Denver Health Medical Center BCVI screening guideline
The Denver Health Medical Center BCVI screening guideline

Evaluation of patients with risk factors or signs/symptoms of BCVI

  • The following is an adaptation of the guidelines of the Western Trauma Association flow chart.
    • CTA on scanners with ≥ 16 detectors (16-slice multidetector CT angiography (16MD-CTA))
      • Have an accuracy near 99%
      • Equivalent predictive value to catheter cerebral angiogram.
    • MRA and U/S are not considered adequate for BCVI screening.
    • If 16MD-CTA is not available, then catheter angiography is recommended.
    • 16MD-CTA should be obtained as follows:
      • Emergently in patients with signs/symptoms of BCVI
      • Asymptomatic patients with risk factors for BCVI:
        • If the presence of BCVI would alter therapy (e.g. no contraindication to heparin) then 16MD-CTA should be done within 12 hours if possible
        • If heparin is contraindicated due to associated injuries, timing of 16MD-CTA is determined by patient stability
    • If the 16MD-CTA is equivocal, or if it is negative but clinical suspicion remains high:
      • A catheter arteriogram should be done (otherwise, if negative: stop)
    • Grading
      • If the 16MD-CTA or catheter arteriogram shows positive findings:
        • Determine the BCVI grade (AKA the “Denver grading scale”)
            • Grade
            Description
            I
            Luminal irregularity with <25% stenosis
            II
            ≥ 25% luminal stenosis or intraluminal thrombus or raised intimal flap
            III
            Pseudoaneurysm
            IV
            Occlusion
            V
            Transection with free extravasation
            notion image

Management of documented BCVI

  • Antiplatelet therapy is as effective in preventing stroke as anticoagulation for cerebrovascular dissection.
  • For paediatric patients (i.e., age < 18 years), see below.
  • Grade specific therapy

      • Grade I & II

      • Most resolve on their own
      • Even though there might be a slight benefit of heparin over aspirin for low grade injuries, due to the low overall risk the general trend is to treat these with aspirin

      Grade III

      Anti-coagulate with heparin

      • Rationale: heparin & aspirin are roughly equivalent for Grade III;
        • However, most will need to be restudied in 7–10 days and heparin is easier to stop for an angio
      • Heparinization:
        • When anticoagulation is employed, perform a baseline PTT and then begin heparin drip 15U/kg/hr IV.
        • Repeat PTT after 6 hours, and titrate to PTT= 40–50 seconds.
        • Trauma contraindications to anticoagulation:
          • Patient that are actively bleeding,
          • Patient have potential for bleeding
          • Patient whom the consequences of bleeding are severe.
            • Specific examples include:
              • Liver and spleen injuries, major pelvic fractures, and intracranial haemorrhage.
        • Dissection-related anticoagulation risks include:
          • Extension of the Intracerebral haemorrhage (with possible SAH)
          • Intracerebral haemorrhage (conversion of pale infarct to haemorrhagic).
      • CADISS trial
        • For dissection only hence between Grade 1-3. (did not mention how many had complete occlusion
        • Showed no difference in anticoag or anti platelet in terms of recanalization of vessel, stroke and death outcomes
        • Age of patient and whether a vessel was stenosed are the predicting factors if a vessel will recanulate

      Repeat angiogram or 16MD-CTA 7–10 days post-injury

      • To assess healing if:
        • Lesion healed: discontinue anticoagulation
        • Non-healed lesions:
          • Consider endovascular stenting “with caution” for severe luminal narrowing or expanding pseudoaneurysm
            • Controversial: results have been mixed
          • Transition from heparin to aspirin (75–150mg/d) alone
          • Repeat 16MD-CTA or catheter angiography 3 months post injury
            • Rationale: most heal with canalization in 6 wks.
            • Results:
              • Healed lesion: consider discontinuing aspirin
              • Non-healed:
                • Optimal drug and duration is not known.
                • Recommendation: lifelong antiplatelet therapy with either aspirin or clopidogrel.
                  • Dual therapy is used for acute coronary syndromes and following angioplasty (± stenting) but is not recommended in patients who have had a stroke or TIA

      Grade IV

      • Endovascular occlusion to prevent embolization

      Grade V: highly lethal injury

      • Accessible lesions
        • Consider for urgent surgical repair (anecdotal)
      • Inaccessible lesions (the majority):
        • Incomplete transection may be amenable to endovascular stenting with concurrent antithrombotics;
        • Complete transections should be ligated (or occluded endovascularly)