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Blunt cerebrovascular injury in children: A prospective multicenter ATOMAC+ study
Ruth A Lewit1, Todd A Nickoles, Regan Williams
1From the Le Bonheur Children's Hospital, Division of Pediatric Surgery (R.A.L., R.W., S.G., J.W.E.); Division of Pediatric Surgery, Department of Surgery (R.A.L., R.W., S.G., J.W.E.), College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee; Phoenix Children's Hospital (T.A.N., D.M.N., R.L.S.); University of Arizona College of Medicine-Phoenix (D.M.N.), Phoenix, Arizona; Children's Health, Dallas, Texas (M.R.); Division of Pediatric Surgery (M.R.), University of Texas Southwestern Medical Center; Oklahoma Children's Hospital (J.J.J.), OU Health; Department of Surgery (J.J.J.), University of Oklahoma Health Science Center, Oklahoma City, Oklahoma; Dell Children's Medical Center of Central Texas (J.A.N., K.A.L.), Austin, Texas; Dell Medical School (J.A.N., K.A.L.), University of Texas at Austin; Arkansas Children's Hospital (R.T.M.); Department of Surgery (R.T.M.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and Department of Surgery (R.T.M.), College of Medicine, University of Arizona, Phoenix, Arizona.
Insights
Blunt cerebrovascular injury (BCVI) screening in children identified a 1% incidence, with a significant stroke risk. Treatment application was inconsistent, and stroke occurred even after diagnosis.
Area of Science:
- Pediatric Trauma Surgery
- Vascular Surgery
- Emergency Medicine
Background:
- Blunt cerebrovascular injury (BCVI) incidence in children is poorly understood.
- Current screening rates for pediatric BCVI are low (16.5%).
- A standardized screening guideline's impact on pediatric BCVI detection and outcomes is needed.
Purpose of the Study:
- To evaluate the effectiveness of the Memphis criteria for screening pediatric blunt trauma patients for BCVI.
- To determine the incidence and outcomes of BCVI in children.
- To assess the application of treatment and occurrence of stroke in pediatric BCVI patients.
Main Methods:
- Prospective, multi-institutional observational study of children (<15 years) with blunt head, face, or neck trauma.
- Screening using the Memphis criteria; CT angiogram recommended for positive screens.
- Treatment guided by trauma burden, with 7-10 day follow-up imaging.
Main Results:
- 2,285 patients included; 520 (23%) met Memphis criteria, 222 (42.5%) received imaging.
- 30 BCVIs identified in 25 patients (1.05% incidence).
- Six children (24%) with BCVI suffered a stroke, regardless of treatment status.
Conclusions:
- Pediatric BCVI has a 1% incidence and carries a substantial stroke risk.
- The Memphis criteria demonstrated 88% sensitivity for BCVI detection.
- Inconsistent treatment application and post-diagnosis stroke highlight the need for improved management protocols.
Background:
The incidence of blunt cerebrovascular injury (BCVI) in children remains largely unknown, with only 16.5% of children receiving appropriate screening. This study sought to determine the impact of a screening guideline on injury detection and outcomes in children with BCVI.
Methods:
This was a prospective, multi-institutional observational study of children younger than 15 years with blunt trauma to the head, face, or neck (Abbreviated Injury Scale score, >0) at any of six level 1 pediatric trauma centers. All patients were screened using the Memphis criteria. Head/neck computed tomography angiogram was recommended for those meeting the criteria. Treatment for BCVI was recommended based on overall trauma burden, with 7- to 10-day follow-up imaging.
Results:
A total of 2,285 patients met the inclusion criteria. Of those, 520 (23%) (median age, 7.9 years) met the Memphis screening criteria, and 222 (42.5%) received appropriate imaging. A total of 30 BCVIs were identified in 25 patients (1.05%); 22 (88%) had a carotid injury, and 6 (24%) had a vertebral artery injury. Motor vehicle collision was the most common mechanism (42%). Those with BCVIs were older (8.01 years, p = 0.03), with a lower median Glasgow Coma Scale (7.8 vs. 15, p < 0.0001). All but three met the Memphis screening criteria (sensitivity, 88%). Eight (32%) underwent treatment. Six children with BCVI suffered a stroke (24%): two untreated and one treated patient developed a stroke after diagnosis.
Conclusion:
Similar to adults, BCVI in children screened has an incidence of 1% (overall incidence of 0.33% in all blunt trauma) and carries a significant risk of stroke. Treatment of BCVI in children in this study is inconsistently applied even after diagnosis, and stroke may still occur with treatment.
Level Of Evidence:
Prognostic and Epidemiological; Level II.
