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Pediatric Blunt Cerebrovascular Injuries: Approach and Management
Chady El Tawil1, Joe Nemeth2, Muzna Al Sawafi3
1From the Department of Emergency Medicine, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
Insights
Pediatric blunt cerebrovascular injury (BCVI) may be underdiagnosed due to lack of guidelines. Vertebral artery injuries show the highest stroke risk, and current screening tools have low sensitivity in children.
Area of Science:
- Trauma Surgery
- Pediatric Neurology
- Vascular Imaging
Background:
- Blunt cerebrovascular injury (BCVI) is underreported in pediatric populations, potentially due to inadequate screening and imaging.
- Existing screening guidelines show low sensitivity when applied to children, highlighting a critical gap in diagnosis.
- Vertebral artery injuries present a significant stroke risk (27.6%) in pediatric BCVI cases.
Conclusions:
- Pediatric BCVI requires improved diagnostic strategies due to the limitations of current screening guidelines and imaging techniques.
- Early identification and management of pediatric BCVI are crucial to mitigate stroke risk, particularly in cases of vertebral artery injury.
- The optimal antithrombotic therapy for pediatric BCVI remains controversial, with studies suggesting comparable efficacy between systemic heparinization and antiplatelet agents.
Abstract:
The low incidence of blunt cerebrovascular injury (BCVI) reported in pediatric studies (<1%) might be related to an underreporting due to both the absence of current screening guidelines and the use of inadequate imaging techniques. This research is a review of the literature limited to the last 5 years (2017-2022) about the approach and management of BCVI in pediatrics. The strongest predictors for BCVI were the presence of basal skull fracture, cervical spine fracture, intracranial hemorrhage, Glasgow Coma Scale score less than 8, mandible fracture, and injury severity score more than 15. Vertebral artery injuries had the highest associated stroke rate of any injury type at 27.6% (vs 20.1% in carotid injury). The sensitivity of the well-established screening guidelines of BCVI varies when applied to the pediatric population (Utah score - 36%, 17%, Eastern Association for the Surgery of Trauma (EAST) guideline - 17%, and Denver criteria - 2%). A recent metaanalysis of 8 studies comparing early computed tomographic angiogram (CTA) to digital subtraction angiography for BCVI detection in adult trauma patients demonstrated high variability in the sensitivity and specificity of CTA across centers. Overall, CTA was found to have a high specificity but low sensitivity for BCVI. The role of antithrombotic as well as the type and duration of therapy remain controversial. Studies suggest that systemic heparinization and antiplatelet therapy are equally effective.
