Blunt CerebroVascular Injuries (BCVI): Management protocol at Canada’s largest trauma center

Discover Sunnybrook, a leading trauma center located in Toronto, Canada, with a dedicated Neurovascular Team managing 80-120 new BCVI cases monthly. Get inspired by their protocol, developed from quality improvement initiatives, which ensures comprehensive patient care and tailored management based on graded BCVI cases. And find out more about future initiatives focus on enhancing diagnostic capabilities and optimizing resource utilization for streamlined patient care.

Case presentation

Sunnybrook
Toronto, Canada

Largest trauma center of Canada
Only accredited Level 1 trauma center outside US.
Neurovascular Team
- Neurosurgeons - Dr. Leodante da Costa, Dr. Ashish Kumar
- Neurologist - Dr. Christine Hawkes
- Radiologist - Dr. Anish Kapadia
- 2 fellows / year

80 -120 new BCVI consults / month. 5 - 15 pages / day.
NVS is the first service consulted for all BCVIs.
Multidisciplinary team approach - CCM, Trauma, TE, Stroke.
Sunnybrook protocol born out of quality improvement initiative.
Intimal injury and endothelial disruption —> Stroke - Higher risk in carotid circulation and high grade BCVI.
Patient’s screened as per expanded Denver Criteria. Other screening criteria - modified Memphis criteria.

Biffl grading classification

Grade	Angiographic characteristics
I	Luminal irregularity or dissection with <25% luminal narrowing
II	Dissection or intramural hematoma with > 25 % luminal narrowing
III	Pseudoaneurysm
IV	Occlusion
V	Transection with extravasation

Intraluminal thrombus

Grade II- Dissection

Grade III - Pseudoaneurysm

Grade I - Irregularity

Grade II- Dissection

Sunnybrook Protocol for BCVI management

PPI - In high risk patient - Oral: Pantoprazole 40 mg PO daily. Feeding Tube: Lansoprazole FasTab 30 mg FT daily. If PPI contraindicated (e.g., allergy): misoprostol 200 mcg PO/FT TID.

High risk patients

Receiving therapeutic anticoagulation
Receiving other antiplatelet medication (e.g., clopidogrel, ticagrelor)
Receiving chronic NSAID therapy (greater than 2 weeks)
Age ≥65 years
Previous history of Peptic Ulcer Disease
Helicobacter pylori infection

CASES

Case - 1 - Vessel sacrifice

49M, fell from 25ft., right paraclinoid ICA irregular with ICA protrudes into the right sphenoid sinus with hemosinus and no active contrast extravasation.

Case - 2 — Flow diverting (FD) stent

40M, Jetski accident, grade IV left ICA, (near occlusion) minimal improvement on serial CTA to grade II, another serial scan showing left cervical pseudoaneurysm, progressed on follow up imaging. Treated with flow diverting stent. Post procedure showed improvement over serial imaging.

Case - 3 - two FD stents for long segment BCVI

45M, MVC, Bilateral ICA grade III BCVI, left ICA has intimal flap and intraluminal thrombus. Evolving bilateral MCA infarcts with progression of the bilateral ICA BCVI with left ICA BCVI progressing to grade IV

Case - 4 - Covered stent

18M, Motorcyclist in MVC, Grade III BCVI with progressively increasing size of pseudoaneurysm

Future initiatives

Implementation of MRI vessel wall imaging will aide in the differentiating between true injury (with wall haemorrhage) versus other entities (e.g. vasospasm, underlying fibromuscular dysplasia and atherosclerosis).

1. minimising resource utilisation
2. reducing unnecessary anti-platelet consumption.
3. Incidence of infarcts can be characterised with concurrent brain DWI imaging.

Studying the role of TCD’s in all high grade anterior circulation BCVIs.

Conclusion

Standardisation streamlines decision-making, particularly beneficial for new trainees, by providing clear guidelines and protocols.
It fosters cohesive team dynamics, enabling everyone to align with management plans and engage in unified discussions among the team, with patients and their relatives.
Provides more consistent and reliable data, prompting comprehensive analysis and insights.