Screening Indications (Denver Criteria)
Screen with CTA neck when any of the following are present:
- Cervical spine fracture (especially C1–C3, or fracture involving the foramen transversarium)
- Skull base fracture
- Severe facial fractures
- Seatbelt sign to the neck
- GCS <6 with facial fractures
Denver Grading Scale
| Grade | Findings |
|---|---|
| I | Luminal irregularity or dissection with <25% narrowing |
| II | Dissection or intramural hematoma with ≥25% narrowing; intraluminal thrombus; or raised intimal flap |
| III | Pseudoaneurysm |
| IV | Occlusion |
| V | Transection with free extravasation — surgical emergency |
Antithrombotic Management by Grade
| Grade | Preferred Treatment | Notes |
|---|---|---|
| I | Antiplatelet — aspirin 81 mg daily | First-line; escalate to aspirin 325 mg or dual antiplatelet if injury progresses on follow-up |
| II | Antiplatelet (aspirin 81–325 mg) or anticoagulation (heparin → warfarin/NOAC) | Decision driven by hemorrhagic risk (TBI, solid organ injury); anticoagulation preferred when tolerated |
| III | Antiplatelet or anticoagulation + repeat CTA at 7–10 days | Enlarging or symptomatic pseudoaneurysm → endovascular repair (stent / coil); carotid pseudoaneurysms more often require intervention than vertebral |
| IV | Anticoagulation (heparin bridge); low recanalization yield | Continue imaging follow-up; delayed revascularization occasionally possible for symptomatic occlusion |
| V | Surgical or endovascular emergency — antithrombotics have no acute role | Free extravasation; damage control; neurovascular surgery or covered stent |
Antithrombotic decisions must be made in conjunction with trauma surgery given competing hemorrhagic risks (TBI, solid organ, pelvic fractures). Initiation timing varies by institution protocol. BCVI is a common cause of stroke in young trauma patients — treatment is not elective.
Follow-Up Imaging
| Grade | Repeat CTA Timing | Goal |
|---|---|---|
| I | 7–10 days | Most Grade I injuries heal; confirm resolution vs. progression |
| II | 7–10 days, then 3 months if stable | Confirm no pseudoaneurysm formation; regression of intramural hematoma |
| III | 7–10 days; 3 and 6 months | Assess pseudoaneurysm size stability; enlargement or new symptoms → intervention |
| IV | 7–10 days | Confirm stability; rare recanalization in delayed setting |
| V | Post-intervention per surgeon/interventionalist |
CTA Technique
| Parameter | Recommendation |
|---|---|
| Coverage | Aortic arch to vertex — must include full course of carotid arteries (including petrous and cavernous segments) and vertebral arteries (V1–V4) |
| Collimation | ≤1 mm; multiplanar reformats in axial, coronal, and sagittal; curved reformats along vessel long axis |
| Contrast | 60–100 mL nonionic IV contrast at 3–4 mL/s; bolus-track trigger at aortic arch |
| Key structures | Carotid canal walls (ICA injury); transverse foramina (vertebral artery injury); foramen lacerum; jugular foramen |
| Reporting pitfalls | Venous contamination may mimic intraluminal thrombus — compare to contralateral side and arterial phase timing; motion artifact at C3–C6 is common and may obscure dissection |
Reporting Checklist — BCVI
- Denver grade: I / II / III / IV / V
- Vessel(s) involved: ICA (specify segment: petrous / cavernous / supraclinoid) / VA (V1–V4)
- Bilateral involvement: yes / no
- Pseudoaneurysm: size (mm), location
- Dissection extent: proximal and distal limits
- Luminal reduction: estimate % stenosis
- Intraluminal thrombus: present / absent
- Associated injury: skull base fracture (ICA canal) / cervical spine fracture (transverse foramen)
- Ischemic changes: present / absent on CT or CTP (territory at risk)
References
Biffl WL, et al. The devastating potential of blunt vertebral arterial injuries. Ann Surg. 2000;231(5):672–681. (Denver grading system)
Burlew CC, et al. Blunt cerebrovascular injuries: Redefining screening criteria in the era of noninvasive diagnosis. J Trauma Acute Care Surg. 2012;72(2):330–337.
Shahan CP, et al. The impact of continuous antiplatelet therapy on blunt cerebrovascular injury outcomes. J Trauma Acute Care Surg. 2017;82(5):863–867.