Algorithm for diagnosis and management of blunt cerebrovascular injury

BCVI: blunt cerebrovascular injury; TIA: transient ischemic attack; CT: computed tomography; MRI: magnetic resonance imaging; TBI: traumatic brain injury; GCS: Glasgow coma scale; MS: mental status; CTA: computed tomographic angiography; PTT: partial thromboplastin time; DSA: digital subtraction angiography.
* CTA with multidetector-row CT; 64-channel is optimal. If fewer than 16 channels, interpret CT angiogram with caution; DSA is the gold standard.
¶ Patient has not suffered completed stroke.
Δ If signs/symptoms or high clinical suspicion and negative CTA, consider DSA.
◊ For positive arteriogram (DSA), follow treatment algorithm per multislice CTA results.
§ Heparin is preferred in the acute setting as it is reversible and may be more effective than antiplatelet agents. Anticoagulation may be contraindicated due to other injuries. Antiplatelet therapy is typically aspirin 325 mg daily.
¥ Stenting should be performed with caution and appropriate antithrombotic therapy administered concurrently.
‡ If symptomatic common carotid fistula, consider arteriography and endovascular therapy. If asymptomatic common carotid fistula, reimage with CTA at three to four weeks.
† Aspirin alone (325 mg daily) is adequate and should be considered lifelong as its risk profile is superior to warfarin.