Blunt Cerebrovascular Injuries

Author: Michelle Lin, MD
Updated: 7/1/2011

Blunt Cerebrovascular Injuries (BCVI)

Classic mechanisms of injury

  • Carotid artery injury (CAI): Hyperextension of neck resulting in stretching of carotid artery over lateral processes of C1-C3
  • Vertebral artery injury (VAI): Fracture through transverse process of C-spine, or hyperextension-stretch injury


  • Antithrombotic agent (heparin vs aspirin)

Denver Screening Criteria for BCVI

Signs / symptoms of BCVI

  • Arterial hemorrhage from neck, nose, or mouth
  • Cervical bruit in patients <50 years old
  • Expanding cervical hematoma
  • Focal neurologic deficit (TIA, hemiparesis, vertebrobasilar symptoms, Horner’s)
  • Neurologic exam incongruous with head CT findings
  • CVA on CT or MRI

Risk factors for BCVI

  • LeFort II or III facial fracture
  • C-spine fracture patterns: subluxation, fx extending into transverse foramen, fracture involving C1-C3
  • Basilar skull fracture with carotid canal involvement
  • Petrous bone fracture
  • Diffuse axonal injury with GCS <6
  • Near-hanging with anoxic brain injury
  • Clothesline type injury or seat belt abrasion with significant swelling, pain, or altered mental status

Imaging Choice

  • Gold standard: Digital subtraction angiography
  • Accepted first-line imaging: CT angiography (at least 16-slice scanner)
  • Alternative: MRI (does not need contrast), may be less sensitive and less specific than CT
  • NOTE: A simple seat-belt sign along the neck does not warrant a CT angiogram. Patients with higher risk findings such as significant pain, tenderness, swelling, and/or a bruit may need imaging.

BCVI Grading and Incidence of CVA complication

Grade Definition CVA Rate Carotid CVA Rate Vertebral
1 Irregularity of vessel wall, or dissection/intramural hematoma with <25% luminal stenosis 3% 6%
2 Intraluminal thrombus or raised intimal flap is visualized, or dissection/intramural hematoma with ≥25% luminal narrowing 14% 38%
3 Pseudoaneurysm 26% 27%
4 Vessel occlusion 50% 28%
5 Vessel transection 100% 100%

Risk of undiagnosed BVCI: Delayed CVA

  • May occur hours to 14 years later
  • Majority develop CVA symptoms in 10-72 hours


  • Burlew CC, Biffl WL. Imaging for blunt carotid and vertebral artery injuries. Surg Clin N Amer. 2011, 91(1), 217-31 [PubMed]