EBQ:Denver Screening Criteria
- Used to screen for vertebral and carotid artery dissection and/or injury after blunt head and neck trauma (BCVI - blunt cerebrovascular injury)
- A CTA to evaluate for VAI should be obtained in those meeting the modified Denver Criteria
- BCVI has the highest association with cervical hyperextension and rotation, hyperflexion, or direct blunt force to head and neck
- Most injuries are diagnosed after the development of symptoms secondary to central nervous system ischemia resulting in neurologic morbidity of up to 80% and associated mortality of up to 40%.
- Can clinical criteria and injury profile and risk factors successfully identify patients at risk for BCVI?
Denver criteria can successfully identify trauma patients at risk for vascular injury.
- 5% of trauma patients were screened
- 18% of screened patients had a vascular injury
Denver screening criteria for blunt cerebrovascular injury
The Denver Screening Criteria are divided into risk factors and signs and symptoms
Signs and Symptoms
- Arterial hemorrhage
- Cervical bruit
- Expanding neck hematoma
- Focal neurologic deficit
- Neuro exam inconsistent with head CT
- Stroke on head CT
- Midface Fractures (Le Fort II or III)
- Basilar Skull Fracture with carotid canal involvement
- Diffuse axonal injury with GCS<6
- Cervical spine fracture
- Hanging with anoxic brain injury
- Seat belt abrasion or other soft tissue injury of the anterior neck resulting in significant swelling or altered mental status
- Kerwin et al: Using the above criteria for both symptomatic and asymptomatic patients, found a 44% positive angiography rate in 1941 patients.
- Fabian et al: Reported a drop in BCI-associated mortality from 24% to 13% after instituting a broad screening protocol.
- The Denver Criteria has not been externally validated
- The Memphis Criteria which includes many of the same criteria screened 3.9% of patients and found an incidence of 29% vascular injury in screened patients.
- Cervical Spine Fracture
- Neuro deficit not explained by brain imaging
- Horner's Syndrome
- Leforte 2 or 3 fracture
- Basilar Skull Fracture involving the carotid Canal
- Seatbelt Sign
- Neck Hematoma
- Hanging Mechanism
- Bromberg, William. et al. Blunt Cerebrovascular Injury Practice Management Guidelines: The Eastern Association for the Surgery of Trauma. J Trauma. 68 (2): 471-7, Feb 2010.
- Cothren CC, Moore EE, Biffl WL, et al. Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg. 2004;139:540–545; discussion 545–546. PDF
- Biffl WL, Moore EE, Offner PJ, et al. Optimizing screening for blunt cerebrovascular injuries. Am J Surg. 1999;178:517–522.
- Davis JW, Holbrook TL, Hoyt DB, Mackersie RC, Field TO Jr, Shackford SR. Blunt carotid artery dissection: incidence, associated injuries, screening, and treatment. J Trauma. 1990;30:1514–1517
- DiPerna CA, Rowe VL, Terramani TT, et al. Clinical importance of the “seat belt sign” in blunt trauma to the neck. Am Surg. 2002;68:441–445
- Rozycki GS, Tremblay L, Feliciano DV, et al. A prospective study for the detection of vascular injury in adult and pediatric patients with cervicothoracic seat belt signs. J Trauma. 2002;52:618–623; discussion 623–624
- Kerwin AJ, Bynoe RP, Murray J et al. Liberalized screening for blunt carotid and vertebral artery injuries is justified. J. Trauma 2001; 51: 308–14.
- Fabian TC, Patton JH, Croce MA et al. Blunt carotid injury: importance of early diagnosis and anticoagulant therapy. Ann. Surg.1996; 223: 513–25.