Denver criteria for blunt cerebrovascular injury
The Denver criteria are a set of screening criteria used to determine when CT angiography of the neck is indicated to detect blunt cerebrovascular injury (BCVI) in trauma patients.
The Denver criteria were initially developed in 1996 1, modified in 2005 to limit the types of cervical spine injuries that qualify 2, and expanded in 2012 to include additional craniofacial, brain, and thoracic injuries 3. Subsequently, the Denver criteria have been further expanded to include again all cervical spine fractures 4,5.
The current screening protocol criteria are divided into signs/symptoms of blunt cerebrovascular injury and risk factors:
Signs and symptoms
- potential arterial hemorrhage from the neck, nose, or mouth
- cervical bruit in patients <50 years of age
- expanding cervical hematoma
- focal neurologic deficit (transient ischemic attack, hemiparesis, vertebrobasilar symptoms, Horner syndrome)
- neurologic deficit incongruous with head CT findings
- stroke on CT or MRI
High-energy transfer mechanism plus any of the following 4:
- Le Fort II or III displaced midface fracture
- mandible fracture
- complex skull fracture (e.g., involving frontal bone and orbit)
- base of skull fracture (sphenoid, petrous temporal, clivus, and occipital condyle fractures)
- scalp degloving
- cervical spine fracture, subluxation, or ligamentous injury at any level
- severe traumatic brain injury with Glasgow coma scale <6
- near hanging with hypoxic-ischemic (anoxic) brain injury
- clothesline type injury or seat belt abrasion with significant swelling, pain, or altered mental status
- traumatic brain injury with thoracic injuries
- upper rib fractures
- thoracic vascular injuries
- blunt cardiac rupture
If a trauma patient meets any of these criteria, the possibility of blunt cerebrovascular injury should be evaluated with multidetector-row, 64-channel CTA 4.
Patients diagnosed with blunt cerebrovascular injury should receive antithrombotic therapy (aspirin or heparin) to decrease the risk of stroke and stroke-related mortality 5.
History and etymology
The Denver criteria were developed by trauma surgeon Walter Biffl and surgical colleagues at Denver Health Medical Center in Colorado. Dr Biffl subsequently moved institutions, but the criteria have continued to be refined by colleagues in the Denver group and are featured in practice guidelines by various professional societies 5.
- modified Memphis criteria of blunt cerebrovascular injury
- 1. Biffl WL, Moore EE, Offner PJ, Brega KE, Franciose RJ, Elliott JP, Burch JM. Optimizing screening for blunt cerebrovascular injuries. (1999) American journal of surgery. 178 (6): 517-22. doi:10.1016/s0002-9610(99)00245-7 - Pubmed
- 2. Cothren CC, Moore EE, Ray CE, Johnson JL, Moore JB, Burch JM. Cervical spine fracture patterns mandating screening to rule out blunt cerebrovascular injury. (2007) Surgery. 141 (1): 76-82. doi:10.1016/j.surg.2006.04.005 - Pubmed
- 3. Burlew CC, Biffl WL, Moore EE, Barnett CC, Johnson JL, Bensard DD. Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis. (2012) The journal of trauma and acute care surgery. 72 (2): 330-5; discussion 336-7, quiz 539. doi:10.1097/TA.0b013e31823de8a0 - Pubmed
- 4. Geddes AE, Burlew CC, Wagenaar AE, Biffl WL, Johnson JL, Pieracci FM, Campion EM, Moore EE. Expanded screening criteria for blunt cerebrovascular injury: a bigger impact than anticipated. (2016) American journal of surgery. 212 (6): 1167-1174. doi:10.1016/j.amjsurg.2016.09.016 - Pubmed
- 5. Kim DY, Biffl W, Bokhari F, Brakenridge S, Chao E, Claridge JA, Fraser D, Jawa R, Kasotakis G, Kerwin A, Khan U, Kurek S, Plurad D, Robinson BRH, Stassen N, Tesoriero R, Yorkgitis B, Como JJ. Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma. (2020) The journal of trauma and acute care surgery. 88 (6): 875-887. doi:10.1097/TA.0000000000002668 - Pubmed