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Published on: April 1, 2019
Cerebrovascular Complications of Pediatric Blunt Trauma
Maria M Galardi1, Jennifer M Strahle2, Alex Skidmore2
1Department of Neurology, Washington University School of Medicine, St. Louis, Missouri.
Insights
Pediatric trauma, especially head or neck injuries, increases stroke risk within two weeks. Managing stroke in trauma patients requires individualized care due to complex injuries and competing priorities.
Area of Science:
- Pediatric neurology
- Trauma surgery
- Neurocritical care
Background:
- Stroke, both ischemic and hemorrhagic, is a potential complication of pediatric trauma, particularly with head/neck injuries.
- The highest risk period for stroke post-trauma is within the initial two weeks.
- Diagnosis and management are complicated by concurrent injuries and competing medical priorities.
Purpose of the Study:
- To review the epidemiology, clinical presentation, and diagnostic strategies for various types of stroke in pediatric trauma patients.
- To highlight the complexities and heterogeneity of managing cerebrovascular injuries in this population.
- To provide a framework for individualized, multidisciplinary care by discussing physiological principles and evidence-based considerations.
Main Methods:
- Review of literature on pediatric trauma-associated stroke.
- Discussion of blunt arterial injuries, cerebral sinovenous thrombosis, mineralizing angiopathy, abusive head trauma, and traumatic hemorrhagic stroke.
- Analysis of physiological principles of cerebral perfusion and oxygen delivery.
- Consideration of ventilator strategies in the context of co-existing lung injury.
- Evaluation of current evidence on anticoagulation risks and benefits.
Main Results:
- Stroke risk is elevated post-pediatric trauma, peaking in the first two weeks.
- Diagnostic challenges arise from limited neurological assessment and competing injury management.
- A "one-size-fits-all" management pathway is impractical due to injury heterogeneity.
- Individualized care requires understanding the goals and consequences of management decisions.
Conclusions:
- Effective management of stroke in pediatric trauma necessitates a tailored, multidisciplinary approach.
- Understanding cerebral perfusion, oxygenation, and anticoagulation risks is crucial for optimizing patient outcomes.
- Providers must weigh competing priorities to individualize cerebrovascular injury management in trauma patients.
Abstract:
Ischemic and hemorrhagic stroke can occur in the setting of pediatric trauma, particularly those with head or neck injuries. The risk of stroke appears highest within the first two weeks after trauma. Stroke diagnosis may be challenging due to lack of awareness or concurrent injuries limiting detailed neurological assessment. Other injuries may also complicate stroke management, with competing priorities for blood pressure, ventilator management, or antithrombotic timing. Here we review epidemiology, clinical presentation, and diagnostic approach to blunt arterial injuries including dissection, cerebral sinovenous thrombosis, mineralizing angiopathy, stroke from abusive head trauma, and traumatic hemorrhagic stroke. Owing to the complexities and heterogeneity of concomitant injuries in stroke related to trauma, a single pathway for stroke management is impractical. Therefore providers must understand the goals and possible costs or consequences of stroke management decisions to individualize patient care. We discuss the physiological principles of cerebral perfusion and oxygen delivery, considerations for ventilator strategy when stroke and lung injury are present, and current available evidence of the risks and benefits of anticoagulation to provide a framework for multidisciplinary discussions of cerebrovascular injury management in pediatric patients with trauma.
