What are the Denver criteria for Blunt Cerebrovascular Injury (BCVI)?

From the Guidelines

Patients with suspected blunt cerebrovascular injury (BCVI) should be screened using the Denver criteria, which include risk factors such as cervical spine fractures, LeFort II or III facial fractures, basilar skull fractures, and others, and those meeting these criteria should undergo CT angiography of the neck vessels as the initial screening test. The Denver criteria are screening guidelines used to identify patients at risk for carotid or vertebral artery injuries after blunt trauma 1. Patients should be screened for BCVI if they have any of the following risk factors: cervical spine fractures, especially those involving the transverse foramen or upper cervical spine (C1-C3); LeFort II or III facial fractures; basilar skull fractures involving the carotid canal; diffuse axonal injury with Glasgow Coma Scale score less than 6; near-hanging with anoxic brain injury; or cervical hematoma. Additional criteria include a seat belt sign above the clavicle with significant swelling, pain, or altered mental status; Horner syndrome; or neurological symptoms unexplained by brain imaging 1.

The excellent negative predictive value and high sensitivity of the revised Denver criteria make them an excellent screening tool for BCVI 1. High-velocity maxillofacial trauma and penetrating neck trauma are the most common causes of traumatic vascular injuries, and identification and treatment of these injuries should be swift because irreversible neurologic damage or death may occur 1. CTA has been recommended over digital subtraction angiography for initial vascular evaluation because of its short acquisition time and low complication rate 1.

Some key points to consider when applying the Denver criteria include:

• The importance of swift identification and treatment of BCVI to prevent irreversible neurologic damage or death
• The use of CT angiography as the initial screening test for patients meeting the Denver criteria
• The consideration of additional risk factors, such as complex skull fractures or scalp degloving, which may increase the suspicion of BCVI
• The potential need for endovascular intervention or antithrombotic therapy, depending on the severity of the injury and the presence of contraindications to anticoagulation.

From the Research

Denver Criteria for BCVI

• The Denver criteria are a set of screening criteria used to identify patients at risk for blunt cerebrovascular injury (BCVI) 2, 3, 4, 5, 6.
• The criteria include factors such as cervical spine fracture, basilar skull fracture, and neurological deficits 2, 5.
• The expanded Denver criteria (eDC) have been shown to have a higher sensitivity (74.7%) than the traditional Denver criteria (57.5%) but a lower positive predictive value (14.6% vs 19.6%) 2.
• The use of the Denver criteria has been shown to reduce the unnecessary use of computed tomography angiography (CTA) as a pre-emptive screening tool by 95-97% 3.
• However, the diagnostic performance of the Denver criteria has been shown to be poor, with a high rate of false negatives (42.5% of patients with BCVI not receiving a neck CTA to screen for BCVI) 2.
• The American College of Radiology Appropriateness Criteria recommend using the expanded Denver screening criteria and CTA for the detection of BCVI 5.

Screening for BCVI

• Screening for BCVI is important because delayed detection can have disastrous consequences, including stroke and death 4, 5.
• CTA is a commonly used imaging modality for screening for BCVI, but it is not sensitive enough to reliably detect injuries 6.
• Angiography remains the gold standard for BCVI diagnosis, but it is not always feasible or necessary 6.
• The use of high-risk criteria, such as the Denver criteria, can help identify patients who are at high risk for BCVI and require further imaging or treatment 4, 5.

Treatment and Follow-up

• Early antithrombotic treatment should be commenced as soon as considered safe and continued for at least 3 months in patients with BCVI 5.
• A CTA at 7 days to confirm or discard the diagnosis as well as a final imaging control at 3 months should be performed 5.
• The treatment and follow-up of patients with BCVI should be individualized based on the severity of the injury and the patient's overall condition 5.