VASCULARDenver Criteria (BCVI Screening)
High-Risk Signs
Horner's Syndrome
Cervical Bruit
Neurologic Deficit / TIA
Expanding Neck Hematoma
Arterial Bleed (Mouth/Nose)
Risk Factors
LeFort II or III Fracture
C-Spine Fracture (C1-C3)
Basilar Skull Fracture
Diffuse Axonal Injury
Direct Neck Trauma
Near-side Impact (Seatbelt sign)
Awaiting Trauma Data
Select the patient's clinical signs and injury risk factors to evaluate the need for BCVI screening.
Guidelines & Evidence
Verified
Last Review: 2026
When to Use
When to Screen
Any blunt trauma patient meeting one or more Denver screening criteria — initiate CTA of the neck (carotid and vertebral arteries) as the diagnostic study of choice
High-energy mechanisms with clinical or radiographic risk signs: motor vehicle collision (MVC), motorcycle crash (MCC), pedestrian struck, fall from height, direct neck or craniofacial blow
Signs or symptoms neurologically unexplained by intracranial CT findings — focal deficit, Horner syndrome, amaurosis fugax, transient ischemic attack (TIA)
Cervical spine fractures extending into or near the transverse foramen (vertebral artery territory) or involving C1–C3 (carotid territory)
LeFort II or III facial fractures — association with carotid canal injury is well established
Basilar skull fractures involving the carotid canal
Diffuse axonal injury (DAI) as confirmed or suspected on CT/MRI — associated with high-energy deceleration forces sufficient to injure cervical vessels
Near-hanging or strangulation mechanism
Seat belt sign or significant soft tissue cervical injury
Denver Screening Criteria — Signs & Symptoms
| Category | Specific Finding | Vascular Territory Implicated |
|---|---|---|
| Neurologic | Focal neurologic deficit unexplained by head CT | Carotid (anterior circulation) or vertebral (posterior) |
| Neurologic | Horner syndrome (ptosis, miosis, anhidrosis) | Carotid artery (sympathetic plexus disruption) |
| Neurologic | Transient ischemic attack (TIA) or stroke symptoms | Carotid or vertebral, territory-dependent |
| Vascular | Cervical bruit in patient <50 years | Carotid artery injury with turbulent flow |
| Vascular | Expanding cervical hematoma | Carotid artery pseudoaneurysm or laceration |
| Imaging | Basilar skull fracture involving carotid canal | Internal carotid artery (ICA) |
| Imaging | LeFort II or III fracture pattern | ICA (pterygoid/carotid canal trajectory) |
| Imaging | Cervical spine fracture (C1–C3) or subluxation | ICA or vertebral artery (VA) |
| Imaging | Fracture through transverse foramen (any level) | Vertebral artery |
| Imaging | Diffuse axonal injury (DAI) on CT/MRI | Either territory (mechanism-based) |
| Mechanism | Near-hanging / strangulation | Carotid artery (direct compression/stretch) |
| Mechanism | Seat belt sign or clothesline injury to neck | Carotid or vertebral depending on trajectory |
Comparison: Denver vs. Memphis (Expanded) Criteria
| Criterion | Denver | Memphis (Expanded) | Clinical Relevance |
|---|---|---|---|
| Basilar skull # (carotid canal) | Yes | Yes | High-yield ICA injury predictor |
| LeFort II/III fracture | Yes | Yes | Strong carotid association |
| Cervical spine fracture (C1–C3) | Yes | Yes | Carotid and VA risk |
| Transverse foramen fracture | Yes | Yes | VA-specific predictor |
| Diffuse axonal injury | Yes | Yes | Mechanism-based, not anatomic |
| Near-hanging/strangulation | Yes | Yes | Direct vessel compression |
| Seat belt sign on neck | Yes | Yes | Soft tissue surrogate of vessel stretch |
| Horner syndrome | Yes | Yes | Carotid sympathetic plexus sign |
| GCS <6 | No | Yes | Memphis adds physiologic threshold |
| Petrous bone fracture | No | Yes | ICA canal proximity |
| Any C-spine fracture (not just C1–C3) | No | Yes | Memphis broader — higher sensitivity, lower specificity |
| Facial fractures (any) | No | Yes | Memphis more inclusive |
| Screening yield (BCVI detection) | ~1–2% | ~2–3% | Memphis screens more, finds marginally more injury |
Epidemiology & Incidence
BCVI occurs in approximately 1–2% of all blunt trauma patients admitted to Level I trauma centers.
Among high-risk patients meeting Denver screening criteria, BCVI incidence rises to 6–10%.
Carotid artery injuries account for approximately 50–60% of BCVI; vertebral artery injuries account for 40–50%.
Bilateral injuries occur in 20–30% of BCVI cases — mandates bilateral vascular imaging.
Untreated BCVI carries a stroke risk of 20–40% — stroke is typically delayed 10–72 hours after injury, often while the patient is neurologically intact.
With antithrombotic treatment, stroke risk is reduced to approximately 0.5–3%.
Stroke from untreated BCVI carries a neurologic morbidity rate of 50–80% and a mortality rate of 25–30%.
Explicit Limitations
Denver Criteria were developed for blunt trauma and do not apply to penetrating neck injuries (zone-based assessment used instead). The criteria identify patients for screening CTA — they do not diagnose BCVI or determine antithrombotic eligibility. A negative screen does not exclude BCVI if high clinical suspicion exists. Patients with contraindications to CTA (contrast allergy, severe renal impairment) require alternative imaging (MRA) — formal DSA is reserved for therapeutic planning or equivocal CTA. The Denver Criteria do not specify antithrombotic agent or duration — see Biffl grading for treatment stratification.
Last Comprehensive Review: 2026