儿童钝性脑血管损伤：漏报还是漏诊？：一项多中心 ATOMAC 研究。
Blunt cerebrovascular injury in children: underreported or underrecognized?: A multicenter ATOMAC study.
机构信息
From the Division of Pediatric Surgery (N.A., J.W.E.), and Department of Preventive Medicine (J.Y.W.), University of Tennessee Health Science Center; and Division of Pediatric Surgery (S.G.), Lebonheur Children's Hospital, Memphis, Tennessee; Division of Pediatric Surgery (P.G.F.) and Level I Pediatric Trauma Center (D.M.N.), Department of Surgery, Phoenix Children's Hospital, College of Medicine, University of Arizona; and Department of Surgery (D.M.N.), Mayo Clinic, Phoenix, Arizona; Section of Pediatric Surgery (A.R., D.W.T.), Department of Surgery, The Children's Hospital at OU Medical Center, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma; Division of Pediatric Surgery (N.M.G., K.A.L.), Department of Surgery, Dell Children's Medical Center of Central Texas, University of Texas Southwestern Medical School, Austin; and Division of Pediatric Surgery (A.C.A.), Department of Surgery, and Trauma Services (C.G.), Children's Medical Center Dallas, UT Southwestern, Dallas, Texas; and Division of Pediatric Surgery/Trauma (R.T.M., J.R.), Department of Surgery, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
出版信息
J Trauma Acute Care Surg. 2013 Dec;75(6):1006-11; discussion 1011-2. doi: 10.1097/TA.0b013e31829d3526.
BACKGROUND
Blunt cerebrovascular injury (BCVI) has been well described in the adult trauma literature. The risk factors, proper screening, and treatment options are well known. In pediatric trauma, there has been very little research performed regarding this injury. We hypothesize that the incidence of BCVI in children is lower than the 1% reported incidence in adult studies and that many children at risk are not being screened properly.
METHODS
This is a multi-institutional retrospective cohort study of pediatric patients (<15 years) admitted with blunt trauma to six American College of Surgeons-verified Level 1 pediatric trauma centers between October 2009 and June 2011. All patients with head, neck, or face injuries who were high risk for BCVI based on Memphis criteria were analyzed.
RESULTS
Of 5,829 blunt trauma admissions, 538 patients had at least one of the Memphis criteria. Only 89 (16.5%) of these patients were screened (16 patients had more than one test) by angiography (64 by computed tomography angiography, 39 by magnetic resonance angiography, and 2 by conventional angiography), while 459 (83.5%) were not screened. Screened patients differed from unscreened patients in Injury Severity Score (ISS) (22.6 ± 13.3 vs. 13.3 ± 9.9, p < 0.0001) and head and neck Abbreviated Injury Scale (AIS) score (3.7 ± 1.2 vs. 2.8 ± 1.2, p < 0.0001). The incidence of BCVI in our total population was 0.4% (23 patients). Of the 23 patients with BCVI, 3 (13%) had no risk factors for the injury. The odds of having sustained BCVI in a patient with one or more of the risk factors was 4.0 (95% confidence interval, 1.1-14.2).
CONCLUSION
BCVI in Level 1 pediatric trauma centers is diagnosed less frequently than in adult centers. However, screening was performed in a minority of high-risk patients who may explain the reported lower incidence of BCVI in children. Pediatric surgeons need to become more vigilant about screening pediatric patients with high-risk criteria for BCVI.
LEVEL OF EVIDENCE
Prognostic/epidemiologic study, level III; therapeutic study, level IV.
背景
钝性脑血管损伤（BCVI）在成人创伤文献中已有详细描述。其风险因素、适当的筛查和治疗选择已广为人知。然而，在儿科创伤中，对此类损伤的研究却很少。我们假设儿童中 BCVI 的发生率低于成人研究报告的 1%，并且许多有风险的儿童没有得到适当的筛查。
方法
这是一项多机构回顾性队列研究，纳入了 2009 年 10 月至 2011 年 6 月期间在六家美国外科医师学会认证的 1 级儿科创伤中心因钝性创伤住院的<15 岁的儿科患者。所有头颈部或面部受伤且根据孟菲斯标准存在 BCVI 高风险的患者均进行分析。
结果
在 5829 例钝性创伤患者中，有 538 例患者至少有一项孟菲斯标准。仅有 89 例（16.5%）（16 例患者接受了超过一项检查）接受了血管造影筛查（64 例行 CT 血管造影，39 例行磁共振血管造影，2 例行常规血管造影），而 459 例（83.5%）未接受筛查。与未筛查患者相比，筛查患者的损伤严重程度评分（ISS）（22.6±13.3 比 13.3±9.9，p<0.0001）和头颈部简明损伤评分（AIS）（3.7±1.2 比 2.8±1.2，p<0.0001）更高。在我们的总人群中，BCVI 的发生率为 0.4%（23 例）。在 23 例 BCVI 患者中，有 3 例（13%）无该损伤的风险因素。在有 1 项或多项风险因素的患者中，发生 BCVI 的可能性为 4.0（95%置信区间，1.1-14.2）。
结论
1 级儿科创伤中心诊断 BCVI 的频率低于成人中心。然而，在高危患者中，仅有少数患者进行了筛查，这可能解释了儿童中报告的 BCVI 发生率较低的原因。儿科外科医生需要更加警惕筛查有 BCVI 高危标准的儿科患者。
证据水平
预后/流行病学研究，III 级；治疗研究，IV 级。
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