Level 1 Trauma

← All algorithms

Quick reference algorithm

BCVI Screening & Management

Blunt trauma patients · March 2026 edition

Blunt cerebrovascular injury

Expanded Denver screening criteria — obtain CTA

Arterial hemorrhage from neck/nose/mouth
Expanding cervical hematoma
Cervical bruit in patient < 50 years old
Focal neurological deficit (TIA, stroke)
Horner syndrome
GCS ≤ 8 with no CT explanation

Le Fort II or III fracture
Basilar skull fracture into carotid canal
C-spine fracture (subluxation, fracture through foramen transversarium)
DAI with GCS < 6
Near-hanging with anoxia
Seatbelt sign / clothesline injury to neck

BCVI on CTA?

NONo BCVI ↓YESBCVI confirmed ↓

NO

No BCVI

Continue standard care
Reassess if new neuro symptoms

YES

BCVI confirmed

Grade per Biffl scale

Grade I
Irregularity or dissection < 25%
Grade II
Dissection ≥ 25%, intraluminal thrombus, or raised flap
Grade III
Pseudoaneurysm
Grade IV–V
Occlusion (IV) or transection (V)

Next: Antithrombotic contraindicated? ↓

Antithrombotic contraindicated?

ICH, SOI (solid organ injury), recent craniotomy, active bleed

YESHold antithrombotics ↓NOAntithrombotic therapy ↓

YES

Contraindicated

Hold antithrombotics

Reassess daily for eligibility
Consider endovascular/surgical intervention for Grade III–V

Next: Follow-up imaging & monitoring ↓

NO

Not contraindicated

Antithrombotic therapy

Grade I–II: ASA 325 mg daily
Grade III–IV: Heparin drip (consider); or ASA 325 mg daily per institutional protocol

Start ASAP when safe — within 24 h if possible

Next: Follow-up imaging & monitoring ↓

Follow-up imaging & monitoring

Repeat CTA at 7 days — assess for progression or resolution

If Grade I resolved

→ Discontinue antithrombotic

If persistent or worsened

→ Continue therapy, repeat CTA at 3 months

Grade III–V: vascular surgery consult for stent/repair consideration