The Challenge of BCVI in Low-Mechanism Trauma

Blunt cerebrovascular injury (BCVI) represents a serious, nonpenetrating trauma to the carotid or vertebral arteries. Although often associated with high-energy mechanisms, clinicians increasingly encounter BCVI following ground-level falls. Current diagnostic practices remain divided between universal computed tomographic angiography (CTA) and selective screening using the expanded Denver criteria. Consequently, identifying the most resource-efficient strategy is vital for trauma systems operating in high-volume settings.

Yield of CTA and the Expanded Denver Criteria

In a retrospective study at a regional Level I trauma center, researchers evaluated over 1,700 patients who sustained injuries from ground-level falls. Among the 1,045 patients included in the imaging cohort, the team identified BCVI in 67 individuals, representing an incidence of 6.4%. Remarkably, the expanded Denver criteria successfully captured all 67 cases. Furthermore, none of the 446 criteria-negative patients exhibited vascular injury. Therefore, strict adherence to these criteria could have safely avoided nearly 450 unnecessary CTA scans while maintaining diagnostic sensitivity.

Stroke Attribution and Clinical Outcomes

The study also investigated the clinical significance of these injuries by adjudicating 193 stroke cases within the same population. Interestingly, physicians found that none of the strokes were attributable to BCVI. This suggests that while BCVI occurs after minor falls, its role in post-fall stroke may be less prominent than previously feared in this specific demographic. Additionally, the high sensitivity of the screening tool supports a shift away from universal imaging towards a more targeted approach. This selective strategy minimizes radiation exposure and contrast-related risks for elderly patients who frequently present after falls.

Conclusion for Trauma Practitioners

The results strongly advocate for a resource-conscious screening strategy. By utilizing clinical risk factors, hospitals can maintain high diagnostic accuracy while reducing healthcare costs and patient exposure to contrast agents. Clinicians should prioritize the expanded Denver criteria to guide CTA utilization in the ground-level fall population. Therefore, this evidence-based approach ensures that imaging is reserved for those with a high pre-test probability of injury.

What are the expanded Denver criteria for BCVI?

The criteria include specific clinical indicators such as cervical spine fractures, basilar skull fractures, focal neurological deficits, and signs of soft tissue injury to the neck. These markers help identify patients at high risk for vascular injury who require targeted imaging.

Is universal CTA necessary for all fall patients?

No. Research suggests that selective screening using established risk factors is highly sensitive. For ground-level fall patients, this approach effectively identifies all vascular injuries while preventing unnecessary scans in criteria-negative individuals.

Disclaimer: This content is for informational and educational purposes only and does not constitute medical advice or a professional relationship. The information provided is based on clinical research and should be interpreted by qualified healthcare professionals. Refer to the latest local and national guidelines for clinical practice.

References

1. Furtmann A et al. Blunt cerebrovascular injury after ground-level falls: Yield of CT angiography and relevance of the expanded Denver criteria. J Trauma Acute Care Surg. 2026 Jun 10. doi: 10.1097/TA.0000000000005087. PMID: 42268658.


2. Kim DY, et al. Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2020;88(6):875-887.


3. Biffl WL, et al. Diagnosis and management of blunt cerebrovascular injuries: What you need to know. J Trauma Acute Care Surg. 2025;98(1):1-10.