Cook Mackenzie R, Witt Cordelie E, Bonow Robert H, Bulger Eileen M, Linnau Ken F, Arbabi Saman, Robinson Bryce R H, Cuschieri Joseph
From the Division of Trauma, Burn and Critical Care Surgery (M.R.C., C.E.W., E.M.B., S.A., B.R.H.R., J.C.), Harborview Medical Center, Seattle, Washington; Harborview Injury Prevention Research Center (C.E.W., R.H.B., E.M.B., S.A.), Seattle, Washington; Department of Neurological Surgery (R.H.B.), University of Washington, Seattle, Washington; and Department of Radiology (K.F.L.), Harborview Medical Center, Seattle, Washington.
J Trauma Acute Care Surg. 2018 Jan;84(1):50-57. doi: 10.1097/TA.0000000000001631.
Blunt cerebrovascular injuries (BCVIs) are rare with nonspecific predictors, making optimal screening critical. Radiation concerns magnify these issues in children. The Eastern Association for the Surgery of Trauma (EAST) criteria, the Utah score (US), and the Denver criteria (DC) have been advocated for pediatric BCVI screening, although direct comparison is lacking. We hypothesized that current screening guidelines inaccurately identify pediatric BCVI.
This was a retrospective cohort study of pediatric trauma patients treated from 2005 to 2015 with radiographically confirmed BCVI. Our primary outcome was a false-negative screen, defined as a patient with a BCVI who would not have triggered screening.
We identified 7,440 pediatric trauma admissions, and 96 patients (1.3%) had 128 BCVIs. Median age was 16 years (13, 17 years). A cervical-spine fracture was present in 41%. There were 83 internal carotid injuries, of which 73% were Grade I or II, as well as 45 vertebral injuries, of which 76% were Grade I or II, p = 0.8. More than one vessel was injured in 28% of patients. A cerebrovascular accident (CVA) occurred in 17 patients (18%); eight patients were identified on admission, and nine patients were identified thereafter. The CVA incidence was similar in those with and without aspirin use. The EAST screening missed injuries in 17% of patients, US missed 36%, and DC missed 2%. Significantly fewer injuries would be missed using DC than either EAST or US, p < 0.01.
Blunt cerebrovascular injury does occur in pediatric patients, and a significant proportion of patients develop a CVA. The DC appear to have the lowest false-negative rate, supporting liberal screening of children for BCVI. Optimal pharmacotherapy for pediatric BCVI remains unclear despite a relative high incidence of CVA.
Diagnostic study, level III.
钝性脑血管损伤（BCVI）较为罕见，且预测指标不具特异性，因此优化筛查至关重要。辐射问题在儿童中使这些问题更加突出。尽管缺乏直接比较，但东部创伤外科学会（EAST）标准、犹他评分（US）和丹佛标准（DC）已被推荐用于儿童BCVI筛查。我们推测当前的筛查指南不能准确识别儿童BCVI。
这是一项对2005年至2015年接受影像学确诊的BCVI治疗的儿童创伤患者的回顾性队列研究。我们的主要结局是假阴性筛查，定义为患有BCVI但未触发筛查的患者。
我们确定了7440例儿童创伤入院病例，96例患者（1.3%）有128处BCVI。中位年龄为16岁（13，17岁）。41%的患者存在颈椎骨折。有83处颈内动脉损伤，其中73%为I级或II级，还有45处椎动脉损伤，其中76%为I级或II级，p = 0.8。28%的患者有多支血管受伤。17例患者（18%）发生了脑血管意外（CVA）；8例患者在入院时被确诊，9例患者此后被确诊。使用阿司匹林和未使用阿司匹林的患者中CVA发生率相似。EAST筛查漏诊了17%的患者，US漏诊了36%，DC漏诊了2%。使用DC漏诊的损伤明显少于EAST或US，p < 0.01。
钝性脑血管损伤确实发生在儿童患者中，且相当一部分患者会发生CVA。DC似乎具有最低的假阴性率，支持对儿童进行BCVI的广泛筛查。尽管CVA发生率相对较高，但儿童BCVI的最佳药物治疗仍不明确。
诊断性研究，III级。
