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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.
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.
