Denver Criteria for Blunt Cerebrovascular Injuries (BCVI) in Trauma Surgery

Denver Criteria for Blunt Cerebrovascular Injuries (BCVI)

Purpose: To identify BCVI (injuries to the carotid and vertebral arteries) in trauma patients.

Background

Blunt cerebrovascular injuries can occur from trauma and lead to strokes or other serious complications. The Denver Criteria were developed to screen and diagnose these injuries early to provide appropriate treatment.

Screening Criteria

1. Neurologic Deficit: Any new, unexplained neurological symptoms after trauma.

2. Ischemic Stroke: Signs of a stroke following trauma.

3. Glasgow Coma Scale <6: Severe brain injury indicating potential vascular injury.

4. Basilar Skull Fracture: Fractures at the base of the skull.

5. LeFort II/III Fractures: Severe fractures of the midface.

6. Cervical Hematoma: Expanding bruising in the neck area.

7. Cervical Bruit: Abnormal sound heard over the carotid artery.

8. Cervical Fracture: High cervical spine fractures (C1-C3) or fractures involving the foramen transversarium.

9. Hanging/Anoxia: Trauma from hanging or significant oxygen deprivation.

Diagnosis

• CT Angiography (CTA): First choice for imaging to identify BCVI.

• Digital Subtraction Angiography (DSA): The gold standard but more invasive, used if CTA is inconclusive.

Management

1. Antithrombotic Therapy:

   • Use antiplatelet drugs like aspirin or anticoagulants like heparin to prevent clots.

   • Monitor for bleeding, especially if other injuries are present.

2. Endovascular Intervention:

   • Stenting may be necessary for severe injuries.

   • Angioplasty can be used depending on the situation.

3. Surgical Repair:

   • Required if endovascular methods are not suitable or if there is active bleeding.

   • Direct repair of the artery may be necessary.

Why Use the Denver Criteria?

• Early Detection: Helps identify BCVI early in trauma patients.

• Prevention of Complications: Reduces the risk of strokes and other complications.

• Guided Treatment: Provides a structured approach for managing vascular injuries.

Key Takeaways

• Early Identification: Look for signs and symptoms of BCVI using the Denver Criteria.

• Prompt Imaging: Use CTA for initial diagnosis; follow with DSA if necessary.

• Effective Management: Start antithrombotic therapy and consider endovascular or surgical options based on the severity of the injury.

By following the Denver Criteria, medical professionals can ensure timely and appropriate care for trauma patients with suspected BCVI, improving outcomes and preventing serious complications.

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Introduction

Blunt cerebrovascular injuries (BCVI) involve damage to the carotid or vertebral arteries as a result of blunt trauma. The Denver Criteria are a set of guidelines used to screen patients for these potentially life-threatening injuries. Understanding these criteria and the appropriate management strategies is crucial for trauma surgeons.

Criteria for Screening

1. Neurologic Deficit: Any new or unexplained neurological deficits following trauma should raise suspicion for BCVI.

2. Ischemic Stroke: Signs of stroke, such as hemiparesis, aphasia, or visual disturbances, in a trauma patient.

3. Glasgow Coma Scale Score <6: Indicates severe brain injury and warrants further investigation for BCVI.

4. Basilar Skull Fracture: Fractures involving the base of the skull, especially if the fracture crosses the carotid canal.

5. LeFort II/III Fractures: Severe midface fractures can disrupt the carotid arteries.

6. Cervical Hematoma: Expanding hematoma in the neck, which can indicate vascular injury.

7. Cervical Bruit: An audible bruit over the carotid artery, suggesting turbulent blood flow due to a possible tear or dissection.

8. Cervical Fracture: High cervical spine fractures (C1-C3), fractures involving the foramen transversarium, or severe ligamentous injury/subluxation.

9. Hanging/Anoxia: Trauma leading to hanging or significant anoxic events that may disrupt the cervical vasculature.
   

Clinical Application of Denver Criteria

Initial Assessment and Resuscitation:

1. Overt Symptoms:

   • Immediate standard ABC (Airway, Breathing, Circulation) resuscitation is crucial.

   • Urgent surgical or endovascular intervention as indicated based on initial findings.

2. Moderate/Modest Symptoms:

   • Conduct diagnostic tests to confirm the presence of BCVI.

   • Early heparinization with continuous dosage (10 U/kg/hr) is recommended for Grades I-IV injuries.
     

Imaging and Diagnosis:

• CT Angiography (CTA): The primary imaging modality for evaluating BCVI due to its non-invasiveness and high sensitivity.

• Digital Subtraction Angiography (DSA): Considered the gold standard but is less commonly used due to its invasive nature. It is reserved for cases where CTA results are inconclusive or when therapeutic intervention is anticipated.
  

Management of BCVI

Treatment Approach:

1. Antithrombotic Therapy:

   • Initiate antiplatelet (aspirin or clopidogrel) or anticoagulation therapy (heparin) in confirmed cases of BCVI to prevent thromboembolic complications.

   • Monitor for signs of bleeding, especially in patients with associated injuries that might contraindicate anticoagulation.

2. Endovascular Intervention:

   • Consider stenting for severe vascular injuries, particularly in high-grade lesions (Grade III and IV).

   • Angioplasty may be used for selected cases, depending on the lesion's location and severity.

3. Surgical Repair:

   • Indicated for cases where endovascular treatment is not feasible or in the presence of active bleeding.

   • Direct repair of the injured vessel may be required, particularly in cases of penetrating trauma.
     

Additional Insights

Injury to Carotid Artery:

1. Hard Signs:

   • Immediate cervical exploration is indicated for external hemorrhage from Zone II injuries, internal hemorrhage into trachea/esophagus, or a pulsating/expanding hematoma in the anterior triangle.

   • Loss of pulse without neurological deficit should prompt a CTA to evaluate the vascular status.

2. Soft Signs:

   • Any suggestive signs of carotid injury warrant a CTA to rule out or confirm vascular injury.
     

Management Considerations:

1. Temporary Intraluminal Shunt:

   • Used only with poor backflow or when prolonged complex repair is anticipated. This is a bridge to definitive repair.

2. Avoid Antiplatelet Therapy:

   • Contraindicated in cases of intracranial hemorrhage, solid organ injuries, and complex pelvic fractures.

   • Alternative anticoagulants may be used if heparin is contraindicated, such as aspirin (ASA 325 mg/day) or clopidogrel (Plavix 75 mg/day).
     

Key Messages from the Presentation

Screening Criteria:

1. Neurologic Deficit

2. Ischemic Stroke

3. Glasgow Coma Scale Score <6

4. Basilar Skull Fracture

5. LeFort II/III Fractures

6. Cervical Hematoma

7. Cervical Bruit

8. Cervical Fracture

9. Hanging/Anoxia
   

Take Home Messages:

1. Overt Symptoms: Follow standard ABC resuscitation protocols.

2. Moderate Symptoms: Perform diagnostic tests promptly to confirm BCVI.

3. Carotid Artery Repair: Essential for appropriate cases to prevent further complications.

4. Temporary Intraluminal Shunt: Utilize only with poor backflow or for prolonged complex repairs.

5. BCVI Management: Heparinization for Grades I-IV, stent for Grade V injuries.

6. Esophagostomy: Necessary for significant tissue loss or delayed repair.
   

Conclusion

The Denver Criteria provides a structured approach for trauma surgeons to identify and manage blunt cerebrovascular injuries in trauma patients. By applying these criteria, surgeons can ensure prompt diagnosis and appropriate treatment, significantly reducing the risk of complications such as stroke. Comprehensive management includes the use of imaging techniques, appropriate antithrombotic therapy, and surgical or endovascular interventions when necessary.