Transition from classic to expanded Denver screening criteria for blunt cerebrovascular injury: lessons from a high-volume level I trauma center.

Abstract

Objective: Blunt cerebrovascular injuries (BCVIs) are associated with significant morbidity and mortality. To identify patients with BCVI who were undetected using the classic criteria, researchers designed the expanded Denver screening criteria. The aim of this study was to evaluate adherence to the classic and expanded screening protocols. The authors then assessed the impact of this transition on the identification of BCVI and the development of ischemic brain injuries.

Methods: Patients with moderate to severe traumatic brain injury (TBI) admitted to the authors' center between 2014 and 2021 were retrospectively reviewed. Patient characteristics, adherence to the screening protocol, the incidence of BCVI detected by CT angiography (CTA) or digital subtraction angiography, and the development of ischemia in patients admitted before (2014-2018) and after (2019-2021) the implementation of the expanded Denver criteria were compared. Comparisons in qualitative and quantitative variables between periods were performed using the chi-square test and Mann-Whitney U-test, respectively. Which individual criterion was most associated with adherence to the protocol and incidence of BCVI according to multivariate logistic regression analysis was also determined. The performance of each screening protocol was determined using the C-statistic.

Results: Of the 648 patients with TBI identified during the study period, 397 were recruited in the classic period (2014-2018) and 251 in the expanded period (2019-2021). The rate of adherence to the screening protocol was 58.9% in the classic period and 78.1% in the expanded period (p < 0.001). BCVIs were detected in 38 patients (9.6% incidence) in the classic period and 20 patients (8% incidence) in the expanded period. If the classic criteria had been used in the 2019-2021 period, 14 CT angiograms would not have been performed. During the classic period, 27 patients (6.8%) developed ischemia. In 5 (18.5%) of these 27 patients, ischemia could not be prevented because they were not screened through CTA despite fulfilling the criteria. In the expanded period, 24 patients (9.6%) developed ischemia, with no CTA performed in just 1 patient (4.2%), despite meeting the criteria for screening (p = 0.125).

Conclusions: Despite the improvement in adherence and the enhanced diagnosis of BCVI following training and the implementation of the expanded Denver criteria, the study failed to find a significant reduction in delayed ischemia, while acknowledging the potential for other contributing factors. Further endeavors should be conducted to ensure protocol adherence and early diagnosis of patients at risk of BCVI.