title: Blunt cerebrovascular injury in children: underreported or underrecognized?: A multicenter ATOMAC study.
abstract: 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).
  
  
  CONCLUSIONS
  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.
  
  
  METHODS
  Prognostic/epidemiologic study, level III; therapeutic study, level IV.
authors.affiliation: 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.
authors.forename: Nima
authors.initials: N
authors.lastname: Azarakhsh
authors.forename: Sandra
authors.initials: S
authors.lastname: Grimes
authors.forename: David M
authors.initials: DM
authors.lastname: Notrica
authors.forename: Alexander
authors.initials: A
authors.lastname: Raines
authors.forename: Nilda M
authors.initials: NM
authors.lastname: Garcia
authors.forename: David W
authors.initials: DW
authors.lastname: Tuggle
authors.forename: Robert Todd
authors.initials: RT
authors.lastname: Maxson
authors.forename: Adam C
authors.initials: AC
authors.lastname: Alder
authors.forename: John
authors.initials: J
authors.lastname: Recicar
authors.forename: Pamela
authors.initials: P
authors.lastname: Garcia-Filion
authors.forename: Cynthia
authors.initials: C
authors.lastname: Greenwell
authors.forename: Karla A
authors.initials: KA
authors.lastname: Lawson
authors.forename: Jim Y
authors.initials: JY
authors.lastname: Wan
authors.forename: James Wallace
authors.initials: JW
authors.lastname: Eubanks
mesh_terms: D002533:Cerebral Angiography / Q000379:methods*; D020214:Cerebrovascular Trauma / Q000175:diagnosis* / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D015601:Injury Severity Score; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D012189:Retrospective Studies; D013714:Tennessee / Q000453:epidemiology; D014057:Tomography, X-Ray Computed / Q000379:methods*; D014193:Trauma Centers; D014949:Wounds, Nonpenetrating / Q000175:diagnosis* / Q000453:epidemiology