Criteria and Consensus Method for Blunt Cervical Vascular Injury (BCVI) Screening with Imaging

According to the updated Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries (published on March 2013, Neurosurgery 2013;72), 

• Computed tomography is the imaging study of choice for obtunded or un-evaluable patients with potential cervical spine injuries. (Level I)
• Computed tomographic angiography is recommended to assess for vertebral artery injury in selected patients who meet the modified Denver Screening Criteria after blunt cervical trauma. (Level I)

Currently accepted standard used for BCVI screening is that of Modified Denver Criteria applying to acute trauma patients suffering blunt cervical vascular injury with details listed below. In this post, they have been rearranged from the original description.

Injury Mechanisms/Patterns

• High-energy mechanism causing 1) displaced Le Fort II or III, or 2) complex mandible fracture
• Cervical hyperextension/rotation/flexion injury with 1) midface fracture, 2) complex mandible fracture or 3) closed-head injury and diffuse axonal injury

Symptoms

• Massive epistaxis
• Central or lateralizing neurologic deficit that is unexplained or incongruent with CT
• Transient ischemic attack or stroke after blunt neck trauma

Signs

• Expanding neck hematoma
• Honor syndrome
• Cervical vascular bruit in a patient less than 50 years old with blunt neck trauma
• Seat belt abrasion, hanging bruise, or unexplained contusion or hematoma of neck, resulting in significant cervical swelling or altered mental status

Findings on C-spine NCCT

• Upper cervical vertebral fracture (C1-C3)
• Cervical vertebral fracture extending through the transverse foramen
• Cervical vertebral subluxation
• Cervical spine fracture with cervical hyperextension/rotation/flexion injury

Findings on head NCCT

• Acute or subacute cerebral infarction
• Skull base fracture involving foramen lacerum, sphenoid, mastoid, or petrous bones

References: 

1. Biffl WL, Moore EE, Offner PJ, et al. Optimizing screening for blunt cerebrovascular injuries. Am J Surg 1999;178:517–22; 
2. Cothren CC, Moore EE, Biffl WL, et al. Cervical spine fracture patterns predictive of blunt vertebral artery injury. J Trauma 2003;55:811–3.
3. Neurosurgery 2013;72 Supplement 2. Full-text access is FREE