Tag Archives: carotid

How Common Is BCVI, Really?

Blunt carotid and vertebral artery injuries (BCVI) are an under-appreciated problem after blunt trauma. Several screening tools have been published over the years, but they tend to be unevenly applied at individual trauma centers. I will discuss them in detail in the next section.

For the longest time, the overall incidence of BCVI was thought to be low, on the order of 1-2%. This is the number I learned years ago, and it has not really changed over time.

But how do we know for sure? Well, the group at Birmingham retrospectively reviewed every CT angiogram (CTA) of the neck they did in a recent two-year period. They did this after adopting a policy of imaging each and every one of their major blunt trauma patients for BCVI. Each patient chart was also evaluated to see if the patient met any of the criteria for the three commonly used screening systems.

During the study period, a total of 6,287 of 6,800 blunt trauma patients underwent BCVI screening with CTA of the neck. They discovered that 480 patients (7.6%) were positive for BCVI!

This is a shocking 8x higher than we expected! Why hasn’t this been obvious until now? Most likely because we were previously only aware of patients who became symptomatic. Luckily, many of these patients dodge the proverbial bullet and never exhibit any symptoms at all.

So why should we be worried? This is one of those clinical entities like blunt thoracic aortic disruption that potentially has terrible consequences if ignored. Although the number of patients who develop sequelae from their BCVI is small, suffering a stroke can be catastrophic.

Should we perform a screening study for all blunt trauma patients? Seems like overkill, or is it? Is there any way we be more selective about it?

In the next post, I’ll review the three current screening tools  used to determine which patients should receive CTA, and how good they are.

Reference: Universal screening for blunt cerebrovascular injury. J Trauma 90(2):224-231, 2021.

It’s BCVI Week!

This post will kick off a series of posts on BCVI. What is that, you ask? There seems to be some confusion as to what the acronym BCVI actually stands for. Some people believe that it means blunt cerebrovascular injury. This is not correct, because that term refers to injury to just about any vessel inside the skull.

The correct interpretation is blunt carotid and vertebral artery injury. This term refers to any portion and any combination of injury to those two pairs of vessels, from where they arise on the great vessels, all the way up into the base of the skull. Here’s a nice diagram:

Note that we will be excluding the external carotid arteries from this discussion, since injuries to them do not have any impact on the brain. They can cause troublesome bleeding, though.

These arteries are relatively protected from harm during blunt trauma. But given enough energy, bad things can happen. Fortunately, injuries to these structures are not very common, but unfortunately many trauma professionals under-appreciate their frequency and severity.

Over the next four posts, I’m going to provide an update on what we know about BCVI. I will try to tease out the true incidence, review the (multiple) screening systems, and discuss various ways to manage these injuries.

In the next post, we’ll explore the incidence of this injury. Is it truly as uncommon as we think?

The October 2020 Trauma MedEd Newsletter: Blunt Carotid and Vertebral Artery Injury

This issue is devoted to an uncommon yet potentially devastating problem, blunt carotid and vertebral artery injury.

In this issue, you will learn about:

  • What BCVI is
  • How common it is
  • The various screening systems and how good they are
  • How to grade it
  • And most importantly, how to treat it

To download the current issue, just click here!

Or copy this link into your browser: https://traumameded.com/courses/blunt-carotid-and-vertebral-artery-injury/

This newsletter was released to subscribers over a week ago. If you would like to be the first to get your hands on future newsletters, just click here to subscribe!

In The Next Trauma MedEd Newsletter: Blunt Carotid And Vertebral Injury

The next issue of Trauma MedEd will be sent out to subscribers this week, and will provide some interesting information on fblunt carotid and vertebral artery injury (BCVI).

This issue is being released to subscribers at 9am Central time on Tuesday. If you sign up any time before then, you will receive it, too. Otherwise, you’ll have to wait until it goes out to the general public next week. Click this link right away to sign up now and/or download back issues.

BCVI is not something trauma professionals see often. Or is it?

In this issue, learn about:

  • What BCVI is
  • How common it is
  • The various screening systems and how good they are
  • How to grade it
  • And most importantly, how to treat it

As always, this month’s issue will go to all of my subscribers first. If you are not yet one of them, click this link right away to sign up now and/or download back issues.

Best Of AAST #9: Blunt Carotid And Vertebral Injuries

Blunt carotid and vertebral artery injuries (BCVI) are an under-appreciated problem after blunt trauma. Several screening tools have been published over the years, but they tend to be unevenly applied at individual trauma centers. For an unfortunate few, the only indication of BCVI is a stroke while in hospital.

The overall incidence of BCVI is thought to be small, on the order of 1-2%. But how do we know? Well, the group at Birmingham retrospectively reviewed every CT angiogram (CTA) of they did in a recent two year period. They did this after adopting a policy of screening all their major blunt trauma patients. Each patient chart was also evaluated to see if they met any of the criteria for the three commonly used screening systems.

Here are the factoids:

  • 5,634 of 6,800 blunt trauma patients underwent BCVI screening with CTA of the neck
  • 471 patients (8.4%) were found to have BCVI
  • Here are the accuracy statistics for the three screening systems

Here are my comments: The authors found that the incidence of BCVI is about 8x what we previously thought. What we don’t know is the percentage of these patients that go on to cause stroke or other neurologic deficits. But this is somewhat frightening.

Even more frightening is that the screening systems that we rely on fare so poorly. The Denver and Modified Memphis criteria have a true positive rate that is the same as a coin toss. And even if the patient meets none of the criteria in any system, about 5% BCVI will sneak through (NPV 95%).

So the question becomes, do we all perform universal screening for blunt trauma? Or do we still use one of the three systems and keep our fingers crossed that the ones we miss will not progress? Or maybe just give everybody an aspirin a day for a while. And still keep our fingers crossed!

Here are some questions for the presenter and authors:

  • Why did you decide to implement a universal screening protocol in the first place? Bad experience(s)?
  • Do you have any screening recommendations other than to screen everybody? How do you decide which blunt trauma patients to screen? Every car crash? What level of fall? The devil is in the details!

This is an easy to follow paper with a solid analysis and real world implications. Excellent work!