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E1959. Double Trouble: The “Unholy Alliance” Between Blunt Cerebrovascular Injuries (BCVI) and Bone Trauma
Authors
  1. Emilio Supsupin; University of Texas Health Science Center Houston McGovern Medical School Department of Diagnostic and Interventional Imaging
  2. Miguel Fabrega; University of Texas Health Science Center Houston McGovern Medical School Department of Diagnostic and Interventional Imaging
Background
Injuries to the vasculature supplying the cerebral circulation (the carotid and vertebral arteries) from blunt trauma are collectively termed blunt cerebrovascular injuries (BCVI). These injuries are potentially devastating and are significantly associated with cervical spine and/or skull base fractures.

Educational Goals / Teaching Points
1. Illustrate the association between BCVI and cervical spine and/or skull base fractures 2. Review the most relevant screening criteria for BCVI in adults (Modified Denver criteria) and children (Utah score) 3. Describe the value and limitations of CT angiogram in the screening and diagnosis of BCVI in the acute trauma setting 4. Analyze patterns of bony injuries most associated with BCVI 5. Review the proposed mechanisms for blunt vascular injury 6. Describe the imaging findings in BCVI using the Denver grading scale 7. Review current imaging and grade-based treatment recommendations for BCVI, including pertinent issues that compound management

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
BCVI can have a high morbidity and mortality. Isolated BCVI related death could be as high as 38% in earlier studies in which the diagnosis was made because of symptoms and not screening. Stroke is one of the most feared outcomes of BCVI and multiple screening criteria have been proposed. Screening is based on early diagnosis and treatment in a relatively asymptomatic stage, potentially preventing permanent neurologic symptoms. The Modified Denver criteria are the most studied and most widely accepted in identifying high-risk patients for BCVI. An injury grading has been proposed based on the imaging appearance of these injuries, with increasing risk of stroke and worse prognosis with increasing grade. BCVI is associated with complex cervical spine fractures that include subluxation, extension into the foramen transversarium, or C1 to C3 fractures. The extracranial segments of the carotid and vertebral arteries are more vulnerable to injuries because they are more superficial and mobile and run near bony structures. Carotid injuries are most common at its distal extracranial segment, with injuries relating to stretching over the lateral masses of C1-C3 vertebrae. The vertebral artery is most frequently injured in the pars transversaria (V2) or the atlas loop (V3) due to laceration from fracture fragments or stretching. Because of its widespread availability and time efficiency, CT angiogram (CTA) has widely replaced conventional digital subtraction angiography (DSA). It is now considered the imaging technique of choice, with a sensitivity and specificity of nearly 98% and 100%, respectively. The treatment of BCVI depends on the extent of vessel injury and patient symptoms. In cases of concurrent BCVI and unstable cervical spine trauma, the timing and sequence of intervention for both the vessel injury and unstable fracture can be complicated.

Conclusion
BCVI can have a high morbidity and mortality. CTA is now the imaging of choice in the screening and diagnosis of BCVI. The Modified Denver criteria are the most widely accepted screening criteria in the identification of patients at high-risk for BCVI.