- Define the guideline based on published observational studies and expert opinion of the Western Trauma Association and East Trauma Association.
- The algorithm and guideline represent a safe and sensible approach.
- We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm.
Blunt injury to the carotid or vertebral vessels (blunt cerebrovascular injury [BCVI]) is diagnosed in approximately 1 of 1,000 (0.1%) patients hospitalized for trauma in the United States unless a screening program has been initiated. However, the majority of these injuries are diagnosed after the development of symptoms secondary to central nervous system ischemia, with a resultant neurologic morbidity of up to 80% and associated mortality of up to 40%. When asymptomatic patients are screened for BCVI, the incidence rises to 1% of all blunt trauma patients and as high as 2.7% in patients with an Injury Severity Score ≥16. Key issues that need to be addressed in the diagnosis and management of BCVI include what population (if any) merits screening for asymptomatic injury, what screening modality is best, what is the appropriate treatment for BCVI (both symptomatic and asymptomatic), and what constitutes appropriate follow-up for these injuries.
1. Trauma patients with any of the following signs or symptoms should be considered to have BCVI until proven otherwise:
- Focal neurological deficit, including evidence of cerebral infarction on CT or MRI scan or neurologic deficit that is incongruous with CT or MRI findings.
- Arterial hemorrhage from neck, mouth, nose, ears
- Cervical bruit in a patient less than 50 years of age
- Expanding neck hematoma
- Neurological exam inconsistent with head CT scan
- Cerebrovascular accident on follow-up head CT not seen on initial head CT
2. The Denver screening criteria lists the following risk factors for blunt cerebrovascular injury (BCVI)
- Presence of Lefort II or III fractures
- Cervical spine fractures involving subluxation
- Any Cervical spine fractures involving C1-C3
- Cervical vertebral body or transverse foramen fracture, subluxation, or ligamentous injury at any level.
- Basilar skull fractures with carotid canal involvement
- Diffuse axonal injury with a Glasgow Coma Scale of 6 or less
- Near hanging injuries with anoxic brain injury
- Clothesline type injury or seatbelt abrasion with significant swelling, pain, or altered mental status
Bromberg, William et. al, Eastern Association for the Surgery of Trauma Blunt Cerebrovascular injury. https://www.east.org/education/practice-management-guidelines/blunt-cerebrovascular-injury (2010)
Biffl, Walter. Western Trauma Association. http://westerntrauma.org/algorithms/WTAAlgorithms_files/gif_4.htm (2014)