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Diagnostic accuracy of screening tools for pediatric blunt cerebrovascular injury: An ATOMAC multicenter study
Todd A Nickoles1, Ruth A Lewit, David M Notrica
1From the Phoenix Children's Center for Trauma Care, Phoenix Children's (T.A.N., D.M.N., M.T., B.P.), Phoenix, Arizona; Department of Pediatric Surgery, Le Bonheur Children's Hospital (R.A.L., J.W.E.) Memphis, Tennessee; Division of Pediatric Surgery, Department of Surgery (R.A.L., J.W.E.), College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (D.M.N., B.P.), College of Medicine, University of Arizona Phoenix, Arizona; Trauma Services, Children's Medical Center (M.R.), Dallas, Texas; Division of Pediatric Surgery (M.R.), University of Texas Southwestern Medical Center Dallas, Texas; Trauma Services, Oklahoma Children's Hospital (J.J.), OU Health, Oklahoma City, Oklahoma; Department of Surgery (J.J.), University of Oklahoma Health Science Center Oklahoma City, Oklahoma; Trauma Services, Arkansas Children's Hospital (R.T.M.), Little Rock, Arkansas; Department of Surgery (R.T.M.), University of Arkansas for Medical Sciences Little Rock, Arkansas; Department of Surgery, Dell Medical School (J.A.N., K.A.L.), University of Texas at Austin Austin, Texas; and Trauma and Injury Research Center, Dell Children's Medical Center of Central Texas (J.A.N.), Austin, Texas.
Insights
The Memphis criteria best identify blunt cerebrovascular injury (BCVI) in children, showing high sensitivity. However, a more refined tool is needed to balance sensitivity and specificity for pediatric BCVI screening.
Area of Science:
- Pediatric Trauma Surgery
- Diagnostic Accuracy
- Cerebrovascular Imaging
Background:
- Blunt cerebrovascular injury (BCVI) is a rare but serious complication in pediatric blunt trauma patients.
- Existing BCVI screening criteria for adults and pediatrics were developed from retrospective, single-center data.
- There is a need to evaluate the diagnostic accuracy of these criteria in a contemporary, multicenter pediatric cohort.
Purpose of the Study:
- To prospectively assess the diagnostic accuracy of five established BCVI screening criteria in children.
- To compare the sensitivity and specificity of Denver, Memphis, Eastern Association for the Surgery of Trauma, Utah, and McGovern criteria in a pediatric population.
Main Methods:
- A prospective, multi-institutional observational study included children (<15 years) with blunt head, face, or neck trauma.
- Five BCVI screening criteria (Denver, Memphis, EAST, Utah, McGovern) were collected for analysis.
- Patients underwent CT angiography or clinical follow-up based on Memphis criteria or neurological findings.
Main Results:
- Of 1,461 analyzed cases, 24 (1.6%) had BCVI.
- Memphis criteria showed the highest sensitivity (91.7%), while Utah score had the highest specificity (95.8%).
- The Denver, EAST, and McGovern criteria demonstrated moderate sensitivity and specificity.
Conclusions:
- The Memphis criteria are most effective in identifying pediatric BCVI due to high sensitivity.
- The Utah score, while highly specific, misses a significant proportion of injuries.
- A refined screening tool is necessary to optimize BCVI detection in pediatric trauma patients.
Background:
Blunt cerebrovascular injury (BCVI) is rare but significant among children. There are three sets of BCVI screening criteria validated for adults (Denver, Memphis, and Eastern Association for the Surgery of Trauma criteria) and two that have been validated for use in pediatrics (Utah score and McGovern score), all of which were developed using retrospective, single-center data sets. The purpose of this study was to determine the diagnostic accuracy of each set of screening criteria in children using a prospective, multicenter pediatric data set.
Methods:
A prospective, multi-institutional observational study of children younger than 15 years who sustained blunt trauma to the head, face, or neck and presented at one of six level I pediatric trauma centers from 2017 to 2020 was conducted. All patients were screened for BCVI using the Memphis criteria, but criteria for all five were collected for analysis. Patients underwent computed tomography angiography of the head or neck if the Memphis criteria were met at presentation or neurological abnormalities were detected at 2-week follow-up.
Results:
A total of 2,284 patients at the 6 trauma centers met the inclusion criteria. After excluding cases with incomplete data, 1,461 cases had computed tomography angiography and/or 2-week clinical follow-up and were analyzed, including 24 cases (1.6%) with BCVI. Sensitivity, specificity, positive predictive value, and negative predictive value for each set of criteria were respectively 75.0, 87.5, 9.1, and 99.5 for Denver; 91.7, 71.1, 5.0, and 99.8 for Memphis; 79.2, 82.7, 7.1, and 99.6 for Eastern Association for the Surgery of Trauma; 45.8, 95.8, 15.5, and 99.1 for Utah; and 75.0, 89.5, 10.7, and 99.5 for McGovern.
Conclusion:
In this large multicenter pediatric cohort, the Memphis criteria demonstrated the highest sensitivity at 91.7% and would have missed the fewest BCVI, while the Utah score had the highest specificity at 95.8% but would have missed more than half of the injuries. Development of a tool, which narrows the Memphis criteria while maintaining its sensitivity, is needed for application in pediatric patients.
Level Of Evidence:
Diagnostic Test/Criteria; Level II.
