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]

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

Denver screening criteria for blunt cerebrovascular injury

Algorithm for evaluation of BCVI with high risk criteria based on Memphis and Denver Screening Criteria

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


  • Kerwin et al: Using the above criteria for both symptomatic and asymptomatic patients, found a 44% positive angiography rate in 1941 patients.[5]
  • Fabian et al: Reported a drop in BCI-associated mortality from 24% to 13% after instituting a broad screening protocol.[6]

Major Points

  • The Denver Screening Criteria identify trauma patients at risk for blunt cerebrovascular injury (BCVI)
  • Screening 5% of all trauma patients using clinical criteria captured 18% with confirmed vascular injury
  • Early identification of BCVI allows initiation of antithrombotic therapy to prevent devastating stroke
  • Implementation of screening protocols has been associated with reduced BCVI-related mortality

Study Design

  • Prospective, single-center observational study
  • Denver Health Medical Center, Level I Trauma Center
  • Screening criteria applied to all blunt trauma patients presenting to the ED
  • Positive screening triggered 4-vessel cerebral angiography

Population

Inclusion Criteria

  • All blunt trauma patients presenting to the trauma center
  • Patients meeting one or more Denver screening criteria

Exclusion Criteria

  • Penetrating trauma
  • Patients who died before screening could be completed

Interventions

  • No therapeutic intervention; this was a screening accuracy study
  • Patients meeting Denver criteria underwent 4-vessel cerebral angiography
  • Positive patients received antithrombotic therapy (heparin or antiplatelet agents)

Outcomes

  • 5% of all trauma patients met screening criteria
  • 18% of screened patients had confirmed vascular injury on angiography
  • Kerwin et al validation: 44% positive angiography rate in 1,941 patients using liberalized criteria
  • Fabian et al: BCVI-associated mortality decreased from 24% to 13% after instituting screening

Criticisms

  • The Denver Criteria have not been externally validated in a large multicenter study
  • CTA has largely replaced conventional angiography for screening, and the criteria were developed in the angiography era
  • Sensitivity of the criteria is unknown; some BCVI may be missed in patients not meeting screening criteria
  • Optimal antithrombotic treatment protocol for identified BCVI remains debated
  • The Memphis criteria provide an alternative screening tool with similar variables

Funding

  • None reported

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. ↑ 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.
  6. ↑ Fabian TC, Patton JH, Croce MA et al. Blunt carotid injury: importance of early diagnosis and anticoagulant therapy. Ann. Surg.1996; 223: 513–25.
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