Treatment of post-traumatic BCVI

aPTT: activated partial thromboplastin time; BCVI: blunt cerebrovascular injury; CC: common carotid; CT: computed tomography; PSA: pseudoaneurysm; TBI: traumatic brain injury.

* Includes symptoms/signs associated with transient brain ischemia, hemispheric or vertebrobasilar ischemia. Refer to UpToDate topics on the clinical features of stroke.

¶ Refer to UpToDate topics discussing management of cervical hematoma. The choice between open surgical and endovascular treatment is determined by the clinical presentation, accessibility of the injury, comorbities (medical, associated injuries), and surgeon/interventionalist availibility and preference. Post-treatment antithrombotic therapy and follow-up vary based on the specific treatment (eg, endovascular stenting). Refer to UpToDate topics discussing the specific intervention.

Δ Patients without completed stroke; any grade of BCVI (refer to inset). Follow institutional stroke protocols. Medical therapies and options for intervention are individualized and also depend on the nature and severity of associated injuries. Refer to UpToDate topics discussing stroke.

◊ The choice between systemic anticoagulation and antiplatelet therapy includes assessment of bleeding risk, which may contraindicate therapy initially (eg, TBI, pelvic fracture). Initial parenteral infusion (eg, unfractionated heparin at 15 units/kg per hour; no loading dose) is favored for grade II and higher injuries with a lower target aPTT range compared with other indications based on similar efficiacy and reduced bleeding complications.

§ Antiplatelet therapy, typically aspirin, is an alternative to anticoagulation. Aspirin 325 mg orally once daily is preferred to aspirin 81 mg orally once daily due to potential relative resistance to aspirin in the general population. We do not use dual antiplatelet for BCVI because of no additional benefit, but an increased risk of bleeding.

¥ The timing of follow up imaging, typically CT angiography, is individualized. Some clinical scenarios include:

• For patients with intial contraindications to antithrombotic therapy (eg, TBI), consider repeat CT angiography in 48 to 72 hours.
• For grade IV injury, consider delay to 1 to 3 months.
• For asymptomatic CC fistula, reimage with CT angiography at 3 to 4 weeks.
• For symptomatic CC fistula, consider angiography and endovascular therapy.

‡ Initial parenteral anticoagulation in the hospital may be transitioned to outpatient anticoagulation or antiplatelet therapy. The selection varies depending on the Grade of injury (refer to inset), progress in healing, associated injuries and other factors that dictate bleeding risk, as well as institutional practices. Refer to UpToDate topics on BCVI for agent selection and dosing considerations