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Screening for blunt cerebrovascular injuries in pediatric trauma patients
Michael U Mallicote1, Mubina A Isani1, Jamie Golden1
1Children's Hospital Los Angeles, Los Angeles, CA.
Insights
Current adult screening criteria for blunt cerebrovascular injuries (BCVI) lead to many unnecessary CT angiograms (CTA) in pediatric trauma patients. New, more accurate criteria are needed for this population.
Area of Science:
- Pediatric Traumatology
- Vascular Imaging
- Emergency Medicine
Background:
- Adult screening criteria for blunt cerebrovascular injuries (BCVI), the Denver and Memphis criteria, are routinely applied to pediatric trauma patients.
- These guidelines recommend CT angiogram (CTA) for patients meeting any positive screening criterion.
- The extrapolation of adult criteria to children may result in unnecessary imaging and associated risks.
Purpose of the Study:
- To evaluate the effectiveness of the Denver and Memphis criteria for screening pediatric blunt trauma patients for BCVI.
- To determine the rate of unnecessary CTAs performed in pediatric trauma patients based on current screening guidelines.
- To identify potential new criteria for BCVI screening in children.
Main Methods:
- A retrospective study at a single center analyzed 2795 trauma patients over 9 years.
- A large-scale retrospective chart review of 776,355 pediatric trauma patients from the National Trauma Data Bank (NTDB) (2007-2014) was conducted.
- Data included patients aged 0-18, utilizing ICD-9 codes for BCVI and screening criteria.
Main Results:
- In the NTDB cohort, 81,294 pediatric patients met Denver/Memphis criteria, but only 2136 had BCVI.
- Strict adherence to these criteria would have resulted in 79,158 (97.4%) negative CTAs.
- Multivariate analysis identified skull base fracture, cervical spine fractures (with or without cord injury), traumatic jugular venous injury, and cranial nerve injury as significant indicators for BCVI screening.
Conclusions:
- The Denver and Memphis criteria are inadequate for screening pediatric blunt trauma patients for BCVI.
- A significant number of pediatric patients undergo unnecessary CTAs when these adult-derived criteria are strictly applied.
- Revised screening criteria, incorporating specific injury patterns, are necessary to improve the diagnostic yield of CTA in pediatric BCVI evaluation.
Background:
Adult imaging for blunt cerebrovascular injuries (BCVI) is based on the Denver and Memphis screening criteria where CT angiogram (CTA) is performed for any one of the criteria being positive. These guidelines have been extrapolated to the pediatric population. We hypothesize that the current adult criteria applied to pediatrics lead to unnecessary CTA in pediatric trauma patients.
Study Design:
At our center, a 9-year retrospective study revealed that strict adherence to the Denver and Memphis criteria would have resulted in 332 unnecessary CTAs out of 2795 trauma patients with only 0.3% positive for BCVI. We also conducted a retrospective chart review of 776,355 pediatric trauma patients in the National Trauma Data Bank (NTDB) from 2007 to 2014. Data collection included children between ages 0 and 18, ICD-9 search for blunt cerebrovascular injury, and ICD-9 codes that applied to both Denver and Memphis criteria.
Results:
Of 776,355 pediatric trauma activations, 81,294 pediatric patients in the NTDB fit the Denver/Memphis criteria for screening CTA neck or angiography based on ICD-9 codes, while only 2136 patients suffered BCVI. Strict utilization of the Denver/Memphis criteria would have led to a negative CTA in 79,158 (97.4%) patients. Multivariate regression analysis indicates that patients with skull base fracture, cervical spine fractures, cervical spine fracture with cervical cord injury, traumatic jugular venous injury, and cranial nerve injury should be considered part of the screening criteria for BCVI.
Conclusion:
Our study suggests the Denver and Memphis criteria are inadequate screening criteria for CTA looking for BCVI in the pediatric blunt trauma population. New criteria are needed to adequately indicate the need for CT angiography in the pediatric trauma population.
Level Of Evidence:
IV.
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