EBQ:Denver Screening Criteria

Background

  • Used to screen for vertebral and carotid artery dissection and/or injury after blunt head and neck trauma (BCVI - blunt cerebrovascular injury)[1][2]
  • 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[3]
  • 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%.[4]
Algorithm for evaluation of BCVI with high risk criteria based on Memphis and Denver Screening Criteria

Clinical Question

  • Can clinical criteria and injury profile and risk factors successfully identify patients at risk for BCVI?

Conclusion

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

The Denver Screening Criteria are divided into risk factors and signs and symptoms

Signs and Symptoms

  • Focal neurologic deficit
  • Arterial Hemorrhage
  • Cervical Bruit or Thrill (<50yo)
  • Infarct on Head CT
  • Expanding Neck Hematoma
  • Neuro exam inconsistent with Head CT

Risk Factors

  • Midface Fractures
  • Cervical Spine Injuries
  • Basilar Skull Fracture
  • GCS<8
  • 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
    • Isolated seatbelt sign without other neurologic symptoms has not been identified as a risk factor[5][6]


  • Kerwin et al: Using the above criteria for both symptomatic and asymptomatic patients, found a 44% positive angiography rate in 1941 patients.[7]
  • Fabian et al: Reported a drop in BCI-associated mortality from 24% to 13% after instituting a broad screening protocol.[8]

Validation

  • 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

See Also

Sources

  1. 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.
  2. 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
  3. Biffl WL, Moore EE, Offner PJ, et al. Optimizing screening for blunt cerebrovascular injuries. Am J Surg. 1999;178:517–522.
  4. 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
  5. 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
  6. 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
  7. 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.
  8. Fabian TC, Patton JH, Croce MA et al. Blunt carotid injury: importance of early diagnosis and anticoagulant therapy. Ann. Surg.1996; 223: 513–25.