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Sainz DB, Howell EC, Grayeb DR, Barlas Y, Gonzalez D, Miskimins R. Analyzing computed tomography Modalities for screening pediatric patients for traumatic blunt cerebrovascular injury. Am J Surg 2024; 238:115859. [PMID: 39059338 DOI: 10.1016/j.amjsurg.2024.115859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 07/16/2024] [Accepted: 07/18/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Optimal screening for BCVI in pediatric trauma patients remains debated. We hypothesized screening with CTAN would decrease the number of duplicate CT scans per patient and increase BCVI detection rate. METHODS Local BCVI screening institutional protocol changed May 2022 to include Computed Tomography angiography neck (CTAN). We performed a retrospective review of pediatric blunt trauma patients presenting at our Level 1 trauma center between 2019 and 2023. Patients before and after implementation of universal screening were compared for demographic, clinical, radiographic, and outcome data. RESULTS Six-hundred-eight patients were included with 368 before and 240 after the protocol change. Screening with CTAN decreased the number of duplicate neck scans (5.7%vs.2.1 %,p = 0.03) and increased BCVI detection rate (0.27%v.2.5 %,p = 0.01). Of the seven patients diagnosed with BCVI 2019-2023, no patients suffered any stroke-related morbidity. CONCLUSION Universal screening for BCVI in pediatric patients with CTAN resulted in fewer scans and an increased BCVI detection rate.
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Affiliation(s)
- Dylan B Sainz
- University of New Mexico School of Medicine, UNM School of Medicine, MSC08 4720 1, UNM, Albuquerque, NM, 87131-0001, USA.
| | - Erin C Howell
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA.
| | - Dominique R Grayeb
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA.
| | - Yalda Barlas
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA.
| | - Deanna Gonzalez
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA.
| | - Richard Miskimins
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA.
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Najar DA, Cardenas-Turanzas M, King J, Shah MN, Cox CS, Ugalde IT. Risk Factors for Blunt Cerebrovascular Injury in a Cohort of Pediatric Patients With Cervical Seat Belt Sign. Pediatr Emerg Care 2024; 40:359-363. [PMID: 38447283 DOI: 10.1097/pec.0000000000003091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
BACKGROUND Blunt cerebrovascular injury (BVCI), injury to the carotid or vertebral arteries, may result from forces involving seatbelts. Although previous studies have not found a seat belt sign to be a significant predictor for BCVI, it is still used to screen patients for BCVI. OBJECTIVE This study aims to determine risk factors for BCVI within a cohort of patients with seat belt signs. METHODS We conducted a retrospective cohort study using our institutional trauma registry and included patients younger than 18 years with blunt trauma who both had a computed tomography angiography (CTA) of the neck performed and had evidence of a seat belt sign per the medical record. We reported frequencies, proportions, and measures of central tendency and conducted univariate analysis to evaluate factors associated with BCVI. We estimated the magnitude of the effect of each variable associated with the study outcome by conducting logistic regression and reporting odds ratios and 95% confidence intervals. RESULTS Among all study patients, BCVI injuries were associated with Injury Severity Score higher than 15 ( P = 0.04), cervical spinal fractures ( P = 0.007), or basilar skull fractures ( P = 0.01). We observed higher proportions of children with BCVI when other motorized and other blunt mechanisms were reported as the mechanisms of injury ( P = 0.002) versus motor vehicle collision. CONCLUSIONS Significant risk factors for BCVI in the presence of seat belt sign are: Injury severity score greater than 15, cervical spinal fracture, basilar skull fracture, and the other motorized mechanism of injury, similar to those in all children at risk of BCVI.
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Affiliation(s)
- Daniel A Najar
- From the McGovern Medical School, UTHealth Houston, Houston, TX
| | - Marylou Cardenas-Turanzas
- The University of Texas Health Science Center at Houston School of Biomedical Informatics, Houston, TX
| | - Jadeyn King
- From the McGovern Medical School, UTHealth Houston, Houston, TX
| | - Manish N Shah
- Departments of Pediatric Surgery and Neurosurgery, McGovern Medical School, UTHealth Houston, Houston, TX
| | - Charles S Cox
- Department of Pediatric Surgery, McGovern Medical School, UTHealth Houston, Houston, TX
| | - Irma T Ugalde
- Department of Emergency Medicine, McGovern Medical School, UTHealth Houston, Houston, TX
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El Tawil C, Nemeth J, Al Sawafi M. Pediatric Blunt Cerebrovascular Injuries: Approach and Management. Pediatr Emerg Care 2024; 40:319-322. [PMID: 37159384 DOI: 10.1097/pec.0000000000002967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
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.
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Affiliation(s)
- Chady El Tawil
- From the Department of Emergency Medicine, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Joe Nemeth
- McGill University Health Center, Montreal General Hospital, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Muzna Al Sawafi
- Montreal General Hospital, McGill University, Montreal, Quebec, Canada
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Nickoles TA, Lewit RA, Notrica DM, Ryan M, Johnson J, Maxson RT, Naiditch JA, Lawson KA, Temkit M, Padilla B, Eubanks JW. Diagnostic accuracy of screening tools for pediatric blunt cerebrovascular injury: An ATOMAC multicenter study. J Trauma Acute Care Surg 2023; 95:327-333. [PMID: 36693233 DOI: 10.1097/ta.0000000000003888] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Todd A Nickoles
- From 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
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Schulz M, Weihing V, Shah MN, Cox CS, Ugalde I. Risk factors for blunt cerebrovascular injury in the pediatric patient: A systematic review. Am J Emerg Med 2023; 71:37-46. [PMID: 37327710 DOI: 10.1016/j.ajem.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/25/2023] [Accepted: 06/03/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND While blunt cerebrovascular injury (BCVI) is a rare complication of blunt trauma, it is associated with significant morbidity and mortality. In the pediatric population, unique anatomy and development require screening criteria that accurately diagnose these injuries while limiting unwarranted radiation. METHODS We searched Medline OVID, EMBASE, and Cochrane Library databases for studies that investigated the risk factors of BCVI in individuals younger than 18 years of age. We adhered to the Preferred Reporting Items in Systematic Reviews and Meta-Analyses (PRISMA) guidelines and assessed the quality of each study using the Newcastle-Ottawa Scale. We compared key characteristics of the papers, including incidence of BCVI, incidence of risk factors, and statistical significance of risk factors. RESULTS Of 1304 studies, 16 met the inclusion criteria. Of these, 15 were retrospective cohort studies and one was a retrospective case control study. Most of the studies included all pediatric blunt trauma admissions, but four only included those which underwent imaging, one only included those with cervical seatbelt sign, and one excluded those who did not survive 24-h post-admission. The ages included as pediatric varied between papers. Papers examined different risk factors and reported differing statistical significances. Though no single risk factor was found to be statistically significant in every study, cervical spine and skull fractures were found to be significant by most. Maxillofacial fractures, depressed GCS score, and stroke were found to be statistically significant by multiple studies. Twelve studies examined cervical soft tissue injury, and none found it to be statistically significant. CONCLUSIONS The risk factors most found to be statistically significant for BCVI were cervical spine fracture (10/16 studies), skull fracture (9/16), maxillofacial fractures (7/16), depressed GCS score (5/16), and stroke (5/16). There is a need for prospective studies on this topic. LEVEL OF EVIDENCE Level III, Systematic Review.
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Affiliation(s)
- Madison Schulz
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 361-947-1354, USA.
| | - Veronica Weihing
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - Manish N Shah
- Division of Pediatric Neurosurgery, Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center, Houston, Houston, TX, USA.
| | - Charles S Cox
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center, Houston, Houston, TX, USA.
| | - Irma Ugalde
- Department of Emergency Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA.
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Dunn CL, Burjonrappa S. Pediatric cerebrovascular trauma: Incidence, management, and outcomes. J Pediatr Surg 2023; 58:310-314. [PMID: 36404185 DOI: 10.1016/j.jpedsurg.2022.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Pediatric cerebrovascular trauma (CVT) is rare. There is an increasing use of endovascular management in vascular trauma. We studied the incidence, management, and outcomes of CVT in the pediatric population using the NTDB (National Trauma Data Bank). METHODS The NTDB was queried for CVT in patients less than 18 years of age over a recent three-year period (2017-2019). Demographics, injury mechanism, type and location, Glasgow Coma Score (GCS), length of stay (LOS), surgical approach (open vs endovascular), and morbidity/mortality were evaluated. Statistical analysis included χ2 and student's t-tests or Fisher's exact tests where appropriate. RESULTS Of 386,918 pediatric trauma cases, 1536 (0.4%) suffered 1821 CVT. Blunt trauma accounted for 69.3%. Patients were predominantly male (65.4%) and white (57.5%), with an mean age of 14 years. There were 998 (55%) carotid artery injuries, including 846 common/internal carotid and 145 external carotid. Other vessel injuries included 141 (11%) intracranial carotid, 571 (31%) vertebral artery and 252 (14%) jugular vein. Mean number of vessels injured was 1.2. Motor vehicle trauma was most common (49.3%) followed by firearm injury (21%). The mean GCS was 11, and mean total LOS was 11.3 days. Majority of interventions were performed in an open fashion (65.7%), whereas 29.7% were performed endovascularly. Stroke rate was 3.1%. Patients with multiple vascular injuries had an overall mortality of 29% (p<0.0001). CONCLUSION While not accorded as much importance as blunt injury, penetrating CVT comprises of 30% of injuries. Nearly 1/3rd of all cases needing surgical intervention were managed with endovascular techniques. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Candice L Dunn
- Rutgers Robert Wood Johnson Medical School, 503 Medical Education Building, New Brunswick, NJ 08901, United States
| | - Sathyaprasad Burjonrappa
- Department of Pediatric Surgery, Section Chief Adolescent Obesity Program, Director Pediatric MIS, RWJUH, Rutgers Robert Wood Johnson Medical School, 503 Medical Education Building, New Brunswick, NJ 08901, United States.
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Development and validation of machine learning models for the prediction of blunt cerebrovascular injury in children. J Pediatr Surg 2022; 57:732-738. [PMID: 34872731 DOI: 10.1016/j.jpedsurg.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 11/05/2021] [Accepted: 11/10/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Blunt cerebrovascular injury (BCVI) is a rare finding in trauma patients. The previously validated BCVI (Denver and Memphis) prediction model in adult patients was shown to be inadequate as a screening option in injured children. We sought to improve the detection of BCVI by developing a prediction model specific to the pediatric population. METHODS The National Trauma Databank (NTDB) was queried from 2007 to 2015. Test and training datasets of the total number of patients (885,100) with complete ICD data were used to build a random forest model predicting BCVI. All ICD features not used to define BCVI (2268) were included within the random forest model, a machine learning method. A random forest model of 1000 decision trees trying 7 variables at each node was applied to training data (50% of the dataset, 442,600 patients) and validated with test data in the remaining 50% of the dataset. In addition, Denver and Memphis model variables were re-validated and compared to our new model. RESULTS A total of 885,100 pediatric patients were identified in the NTDB to have experienced blunt pediatric trauma, with 1,998 (0.2%) having a diagnosis of BCVI. Skull fractures (OR 1.004, 95% CI 1.003-1.004), extremity fractures (OR 1.001, 95% 1.0006-1.002), and vertebral injuries (OR 1.004, 95% CI 1.003-1.004) were associated with increased risk for BCVI. The BCVI prediction model identified 94.4% of BCVI patients and 76.1% of non-BCVI patients within the NTDB. This study identified ICD9/ICD10 codes with strong association to BCVI. The Denver and Memphis criteria were re-applied to NTDB data to compare validity and only correctly identified 13.4% of total BCVI patients and 99.1% of non BCVI patients. CONCLUSION The prediction model developed in this study is able to better identify pediatric patients who should be screened with further imaging to identify BCVI. LEVEL OF EVIDENCE Retrospective diagnostic study-level III evidence.
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8
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McCollum N, Guse S. Neck Trauma: Cervical Spine, Seatbelt Sign, and Penetrating Palate Injuries. Emerg Med Clin North Am 2021; 39:573-588. [PMID: 34215403 DOI: 10.1016/j.emc.2021.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Pediatric cervical spine, blunt cerebrovascular, and penetrating palate injuries are rare but potentially life-threatening injuries that demand immediate stabilization and treatment. Balancing the risk of a missed injury with radiation exposure and the need for sedation is critical in evaluating children for these injuries. Unfortunately, effective clinical decision tools used in adult trauma cannot be uniformly applied to children. Careful risk stratification based on history, mechanism and examination is imperative to evaluate these injuries judiciously in the pediatric population. This article presents a review of the most up-to-date literature on pediatric neck trauma.
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Affiliation(s)
- Nichole McCollum
- Division of Emergency Medicine, Children's National Hospital, 111 Michigan Ave NW, Washington, DC 20010, USA.
| | - Sabrina Guse
- Division of Emergency Medicine, Children's National Hospital, 111 Michigan Ave NW, Washington, DC 20010, USA; George Washington School of Medicine and Health Sciences, 2300 I St NW, Washington, DC 20052, USA
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9
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Schonenberg Llach M, Fishe JN, Yorkgitis BK. Implementation of a dual cervical spine and blunt cerebrovascular injury assessment pathway for pediatric trauma patients. Am J Emerg Med 2021; 47:74-79. [PMID: 33780736 DOI: 10.1016/j.ajem.2021.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/05/2021] [Accepted: 03/06/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Pediatric cervical spine (CSI) and blunt cerebrovascular injuries (BCVI) are challenging to evaluate as they are rare but carry high morbidity and mortality. CT scans are the traditional imaging modality to evaluate for CSI/BCVI, but involve radiation exposure and potential future increased risk of malignancy. Therefore, we present results from the implementation of a combined CSI/BCVI pediatric trauma clinical pathway to aid clinicians in their decision-making. METHODS We conducted a 2-year retrospective cohort study analyzing data pre and post implementation of the combined CSI/BCVI pathway. Data was obtained from a level 1 pediatric trauma center and included blunt trauma patients under the age of 14. We evaluated the use of cervical spine computed tomography (CT), CT angiography, and plain radiographs, as well as missed injuries and provider pathway adherence. RESULTS We included 358 patients: 209 pre-pathway and 149 post-pathway implementation. Patient mean age was 8.9 years and 61% were male (61% males). There were no significant differences in GCS, AIS, and ISS between pre and post pathway groups. Post pathway implementation saw reduced use of cervical spine CT, although this was not clinically significant (33% vs 31%, p = 0.74). However, cervical spine radiography use increased (9% vs 16%, p = 0.03), and there was also an increase in screening for BCVI injuries with higher use of CTA (5% vs 7%, p = 0.52). A total of 12 CSI and 3 BCVI were identified with no missed injuries. Provider adherence to the pathway was modest (54%). Conclusion Implementation of a combined CSI/BCVI clinical pathway for pediatric trauma patients increased screening radiography and did not miss any injuries. However, CT use did not significantly decrease and provider adherence was modest, supporting the need for further implementation analysis and larger studies to validate the pathway's sensitivity and specificity for CSI/BCVI.
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Affiliation(s)
- Maria Schonenberg Llach
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, USA.
| | - Jennifer N Fishe
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, USA.
| | - Brian K Yorkgitis
- Department of Surgery, University of Florida College of Medicine - Jacksonville, USA.
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Affiliation(s)
| | - Jan O Jansen
- 2Center for Injury Science, University of Alabama, Birmingham, Alabama; and
| | - Zane Schnurman
- 3Department of Neurosurgery, NYU Langone Medical Center, New York, New York
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Cerebrovascular Complications of Pediatric Blunt Trauma. Pediatr Neurol 2020; 108:5-12. [PMID: 32111560 PMCID: PMC7306436 DOI: 10.1016/j.pediatrneurol.2019.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 12/02/2019] [Accepted: 12/08/2019] [Indexed: 12/13/2022]
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.
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12
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Savoie KB, Shi J, Wheeler K, Xiang H, Kenney BD. Pediatric blunt cerebrovascular injuries: A national trauma database study. J Pediatr Surg 2020; 55:917-920. [PMID: 32089272 DOI: 10.1016/j.jpedsurg.2020.01.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 01/25/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The incidence of blunt cerebrovascular injuries (BCVIs) in children is unknown. We aimed to determine the rate and consequences of BCVIs in pediatric blunt trauma patients. METHODS We queried the National Trauma Data Bank (NTDB) for all blunt trauma patients between 2007 and 2014. BCVI patients were identified by ICD-9 codes. Demographic, emergency room, and concomitant injury data were analyzed. RESULTS There were 732,702 blunt trauma patients, and 1682 BCVIs were identified (0.23%). 791 (47%) sustained carotid artery injuries (CAIs), 957 (57%) had vertebral artery injuries (VAIs), and 4% of patients sustained both. A majority of the injuries occurred in white patients (61%) and in motor vehicle accidents (53%). The average age was 12.1 ± 5.4 years. CAIs had more skull base fractures (55% vs 35%, p < 0.0001), and cervical spine fractures were more common in VAIs (26 vs 11%, p < 0.0001). Intensive care length of stay was longer in the CAI patients (9.2 vs 7.9 days, p = 0.03), as was length of stay (12.5 vs 9.7 days, p = 0.0002). 5% of CAI patients were coded for stroke, versus 2% of VAIs (p = 0.002). CONCLUSIONS BCVIs are rare in children. Vertebral injuries are more common. Carotid injuries are associated with a longer length of stay and higher stroke rates. TYPE OF STUDY Retrospective cohort study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kate B Savoie
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH
| | - Junxin Shi
- Center for Injury Research and Policy at the Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Krista Wheeler
- Center for Injury Research and Policy at the Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Henry Xiang
- Center for Injury Research and Policy at the Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Brian D Kenney
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH.
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Transcranial Doppler Ultrasound During Critical Illness in Children: Survey of Practices in Pediatric Neurocritical Care Centers. Pediatr Crit Care Med 2020; 21:67-74. [PMID: 31568242 DOI: 10.1097/pcc.0000000000002118] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The scope of transcranial Doppler ultrasound in the practice of pediatric neurocritical care is unknown. We have surveyed pediatric neurocritical care centers on their use of transcranial Doppler and analyzed clinical management practices. DESIGN Electronic-mail recruitment with survey of expert centers using web-based questionnaire. SETTING Survey of 43 hospitals (31 United States, 12 international) belonging to the Pediatric Neurocritical Care Research Group. PATIENTS None. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A 67% (29/43) hospital-response rate. Of these centers, 27 reported using transcranial Doppler in the PICU; two hospitals opted out due to lack of transcranial Doppler availability/use. The most common diagnoses for using transcranial Doppler in clinical care were intracranial/subarachnoid hemorrhage (20 hospitals), arterial ischemic stroke (14 hospitals), and traumatic brain injury (10 hospitals). Clinical studies were carried out and interpreted by credentialed individuals in 93% (25/27) and 78% (21/27) of the centers, respectively. A written protocol for performance of transcranial Doppler in the PICU was available in 30% (8/27 hospitals); of these, two of eight hospitals routinely performed correlation studies to validate results. In 74% of the centers (20/27), transcranial Doppler results were used to guide clinical care: that is, when to obtain a neuroimaging study (18 hospitals); how to manipulate cerebral perfusion pressure with fluids/vasopressors (13 hospitals); and whether to perform a surgical intervention (six hospitals). Research studies were also commonly performed for a range of diagnoses. CONCLUSIONS At least 27 pediatric neurocritical care centers use transcranial Doppler during clinical care. In the majority of centers, studies are performed and interpreted by credentialed personnel, and findings are used to guide clinical management. Further studies are needed to standardize these practices.
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Harris DA, Sorte DE, Lam SK, Carlson AP. Blunt cerebrovascular injury in pediatric trauma: a national database study. J Neurosurg Pediatr 2019; 24:451-460. [PMID: 31323625 DOI: 10.3171/2019.5.peds18765] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 05/09/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The incidence of blunt cerebrovascular injury (BCVI) has not been well characterized in the pediatric population. The goal of this study was to describe the incidence, patient characteristics, and risk factors for pediatric patients with cerebrovascular injuries. METHODS The authors collected data from the Kids' Inpatient Database (KID), a nationally representative database of pediatric admissions, for years 2000, 2003, 2006, 2009, and 2012. RESULTS Among an estimated 646,549 admissions for blunt trauma, 2150 were associated with BCVI, an overall incidence of 0.33%. The incidence of BCVI nearly doubled from 0.24% in 2000 to 0.49% in 2012. Patients 4 to 13 years of age were less likely to have BCVI than those in the youngest (0-3 years) and oldest age groups comprising adolescents (14-17 years) and young adults (18-20 years). BCVIs were associated with cervical (adjusted OR [aOR] 4.6, 95% CI 3.8-5.5), skull base (aOR 3.0, 95% CI 2.5-3.6), clavicular (aOR 1.4, 95% CI 1.1-1.8), and facial (aOR 1.2, 95% CI 1.0-1.5) fractures, as well as intracranial hemorrhage (aOR 2.7, 95% CI 2.2-3.2) and traumatic brain injury (aOR 2.0, 95% CI 1.7-2.3). Mechanism of injury was also independently associated with BCVI: motor vehicle collision (aOR 1.7, 95% CI 1.3-2.2) and struck pedestrian (aOR 1.4, 95% CI 1.0-1.9). Among pediatric patients with BCVI, 37.4% had cerebral ischemic infarction with an in-hospital mortality of 12.7%, and patients with stroke had 20% mortality. CONCLUSIONS The incidence of pediatric BCVI is increasing, likely due to increased use of screening, but remains lower than that in the adult population. Risk factors include the presence of cervical, facial, clavicular, and skull base fractures, similar to that of the adult population. Diagnosed BCVI is associated with a relatively high incidence of stroke with increased morbidity and mortality. The use of adult screening criteria is likely reasonable given the similarity in the risk factors identified in this study. Further studies are needed to investigate the role of treatment with antiplatelet agents or anticoagulation.
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Affiliation(s)
- Dominic A Harris
- 1Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico; and
| | - Danielle E Sorte
- 1Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico; and
| | - Sandi K Lam
- 2Division of Pediatric Neurosurgery, Texas Children's Hospital Baylor College of Medicine, Houston, Texas
| | - Andrew P Carlson
- 1Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico; and
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Screening for blunt cerebrovascular injuries in pediatric trauma patients. J Pediatr Surg 2019; 54:1861-1865. [PMID: 31101425 DOI: 10.1016/j.jpedsurg.2019.04.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 04/02/2019] [Accepted: 04/19/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Adult imaging for blunt cerebrovascular injuries (BCVI) is based on the Denver and Memphis screening criteria where CT angiogram (CTA) is performed for any one of the criteria being positive. These guidelines have been extrapolated to the pediatric population. We hypothesize that the current adult criteria applied to pediatrics lead to unnecessary CTA in pediatric trauma patients. STUDY DESIGN At our center, a 9-year retrospective study revealed that strict adherence to the Denver and Memphis criteria would have resulted in 332 unnecessary CTAs out of 2795 trauma patients with only 0.3% positive for BCVI. We also conducted a retrospective chart review of 776,355 pediatric trauma patients in the National Trauma Data Bank (NTDB) from 2007 to 2014. Data collection included children between ages 0 and 18, ICD-9 search for blunt cerebrovascular injury, and ICD-9 codes that applied to both Denver and Memphis criteria. RESULTS Of 776,355 pediatric trauma activations, 81,294 pediatric patients in the NTDB fit the Denver/Memphis criteria for screening CTA neck or angiography based on ICD-9 codes, while only 2136 patients suffered BCVI. Strict utilization of the Denver/Memphis criteria would have led to a negative CTA in 79,158 (97.4%) patients. Multivariate regression analysis indicates that patients with skull base fracture, cervical spine fractures, cervical spine fracture with cervical cord injury, traumatic jugular venous injury, and cranial nerve injury should be considered part of the screening criteria for BCVI. CONCLUSION Our study suggests the Denver and Memphis criteria are inadequate screening criteria for CTA looking for BCVI in the pediatric blunt trauma population. New criteria are needed to adequately indicate the need for CT angiography in the pediatric trauma population. LEVEL OF EVIDENCE IV.
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Big problems in little patients: Nationwide blunt cerebrovascular injury outcomes in the pediatric population. J Trauma Acute Care Surg 2019; 87:1088-1095. [DOI: 10.1097/ta.0000000000002428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Long MK, Arevalo O, Ugalde IT. Case Series of Adolescents With Stroke-Like Symptoms Following Head Trauma. J Emerg Med 2019; 56:554-559. [PMID: 30890373 DOI: 10.1016/j.jemermed.2019.01.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 01/16/2019] [Accepted: 01/25/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Studies cite the incidence of pediatric blunt cerebrovascular injuries (BCVI) ranges from 0.03% to 1.3%. While motor vehicle incidents are a known high-risk mechanism, we are the first to report on football injuries resulting in BCVI. CASE REPORT Case 1 is a 14-year-old male football player who presented with slurred speech and facial droop 16 h after injury that had resulted in unilateral stinger on the field. The patient had a negative brain computed tomography (CT) at the onset of symptoms. Given progression of symptoms over the next 24 h, re-evaluation with CT angiography (CTA) of brain and neck showed left internal carotid artery (ICA) dissection, and magnetic resonance imaging of the brain showed left middle cerebral artery infarct. Case 2 is a 16-year-old male football player who presented with headache and right hemiparesis immediately following a tackle injury. CT brain and neck were negative at an outside hospital, but he was transferred to us for progressive symptoms, and then CTA showed a left ICA dissection with distal emboli, including occlusive involvement of the intracranial left ICA. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The diagnosis of BCVI requires a high level of suspicion. Focal neurologic deficits are consistently a risk factor across all screening criteria, including the Denver, Utah, Memphis, and Eastern Association for the Surgery of Trauma. These current screening criteria, however, may not be sufficient to diagnosis BCVI in children. The addition of the mechanism of injury and attention to the patient's clinical presentation and examination are important to prevent missed diagnosis and poor neurologic outcomes.
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Affiliation(s)
- Megan K Long
- McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Octavio Arevalo
- McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Irma T Ugalde
- McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
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Authors Response to Commentary on our Manuscript. J Trauma Acute Care Surg 2018; 86:554-555. [PMID: 30444860 DOI: 10.1097/ta.0000000000002131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Time to stroke: A Western Trauma Association multicenter study of blunt cerebrovascular injuries. J Trauma Acute Care Surg 2018; 85:858-866. [DOI: 10.1097/ta.0000000000001989] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Judicious angiographic imaging and conservative management should be the standard for pediatric patients at risk for blunt cerebrovascular injury. J Trauma Acute Care Surg 2018; 85:651-652. [PMID: 30148460 DOI: 10.1097/ta.0000000000001948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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