Biffl scale for blunt cerebrovascular injury

The Biffl scale or grade illustrates the spectrum of blunt cerebrovascular injury (BCVI) seen on angiography (both CTA and DSA). Some authors refer to the grading scale as the Denver scale, which is not to be confused with the Denver criteria, a series of clinical indications and risk factors for BCVI. 


  • grade I:  mild intimal injury or irregular intima
  • grade II: dissection with raised intimal flap / intramural hematoma with luminal narrowing >25% / intraluminal thrombosis
  • grade III: pseudoaneurysm
  • grade IV: vessel occlusion/thrombosis
  • grade V: vessel transection

Treatment and prognosis

This grading system has prognostic and therapeutic implications. Stroke risk increases with injury grade and therefore the lower the grade, the better the prognosis 1.

  • grade I: heals regardless of therapy
  • grade II: 70% of dissections or hematomas with luminal stenosis progress while on heparin therapy
  • grade III: only ~8% of pseudoaneurysms heal with heparin and ~90% resolve after stenting
  • grade IV: occluded carotid arteries do not recanalize in the early post-injury period
  • grade V: transections are lethal and refractory to therapy
Share article

Article information

rID: 13710
Synonyms or Alternate Spellings:
  • Biffl scale
  • BCVI criteria
  • BCVI scale
  • Biffl grade
  • Denver scale
  • Denver scale for direct cerebrovascular injury

Support Radiopaedia and see fewer ads

Cases and figures

  • Case 1: grade II right vertebral artery
    Drag here to reorder.
  • Updating… Please wait.

     Unable to process the form. Check for errors and try again.

     Thank you for updating your details.