What is the management for Grade 1 Blunt Cerebrovascular Injury (BCVI)?

From the Guidelines

For Grade 1 blunt cerebrovascular injury (BCVI) management, the recommended approach is medical therapy with antiplatelet or anticoagulation, as it is appropriate management for the lower grades of arterial injury. The Biffl grading scale is used to classify the severity of arterial injury, with Grade 1 indicating dissection with <25% luminal narrowing (intimal irregularity) 1. According to the acr appropriateness criteria® head trauma: 2021 update, medical therapy with antiplatelet or anticoagulation may be appropriate management for the lower grades of arterial injury, whereas the higher grades of arterial injury are more likely to require endovascular or surgical treatment 1.

Some key points to consider in the management of Grade 1 BCVI include:

• The use of noninvasive CTA for initial imaging evaluation of suspected intracranial arterial injury, as it is faster and has fewer safety concerns compared to catheter angiography 1
• The importance of repeat imaging (typically CTA) at 7-10 days to assess for injury progression, as this can inform the need for adjustments to management 1
• The potential benefits and risks of antiplatelet therapy, including the reduction of thromboembolic complications and the increased risk of bleeding, particularly in patients with traumatic brain injury or other injuries that increase bleeding risk 1

In terms of specific treatment, antiplatelet therapy with aspirin 325 mg daily is a reasonable option for Grade 1 BCVI, as it provides adequate platelet inhibition while balancing the risk of side effects. However, the choice of antiplatelet or anticoagulation therapy should be individualized based on the patient's specific clinical circumstances and risk factors. The rationale for this approach is to prevent thromboembolic complications while allowing the vessel injury to heal, as supported by the evidence from the acr appropriateness criteria® head trauma: 2021 update 1.

From the Research

Management of Grade 1 Blunt Cerebrovascular Injury (BCVI)

• The management of Grade 1 BCVI typically involves antithrombotic therapy, with the goal of preventing stroke and promoting healing of the injured vessel 2, 3.
• Aspirin is a commonly used antithrombotic agent for the management of BCVI, and a dose of 81 mg has been shown to be effective in preventing stroke 4.
• The use of anticoagulation therapy, such as heparin, may also be considered in some cases, although the evidence suggests that antiplatelet agents like aspirin may be equivalent in terms of efficacy and safety 3.
• The decision to use antithrombotic therapy should be individualized based on the patient's specific circumstances, including the grade of injury, the presence of other injuries or comorbidities, and the risk of bleeding complications 2, 4.
• Follow-up imaging is typically recommended to monitor the progression of the injury and the effectiveness of treatment, although the optimal timing and frequency of follow-up imaging are not well established 5, 6.

Treatment Options

• Aspirin 81 mg: a viable option for BCVI-related stroke prevention, with a reported stroke rate of 3.5% 4.
• Aspirin 325 mg: a commonly used dose for antithrombotic therapy, although the evidence suggests that lower doses may be equally effective 3, 4.
• Heparin: an anticoagulant that may be used in some cases, although the evidence suggests that antiplatelet agents like aspirin may be equivalent in terms of efficacy and safety 3.

Considerations

• The risk of stroke is highest in the first 7 days after injury, with a peak in the first 24 hours 2.
• The use of antithrombotic therapy should be balanced against the risk of bleeding complications, particularly in patients with other injuries or comorbidities 2, 4.
• A multidisciplinary approach to management is recommended, involving collaboration between trauma surgeons, neurosurgeons, and other specialists as needed 4.