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Neurologic Symptoms Set the Tone In Blunt Extracranial Cerebro-Vascular Injuries In Children

Saturday, October 20, 2012: 8:26 AM
Versailles Ballroom (Hilton Riverside)
Offir Ben-Ishay, MD, Department of Surgery, Boston Children's Hospital, Boston, MA and David P. Mooney, MD, MPH, FAAP, Department of Surgery, Boston's Children Hospital, Boston, MA

Purpose

Blunt extracranial cerebrovascular injuries (BECVI) in children are rarely reported and screening criteria, management and outcome remain ill defined. Limited data exists in the pediatric population for this rare injury. Our study describes BECVI in a single institution over 15 years.  

Methods

A retrospective review was conducted to identify children with blunt injuries from January 1996 - October 2011. Patients with BECVI were identified and further scrutinized. Data collected included demographics, mechanism of injury, management and outcome. 

Results

In the period of the study 14,772 blunt trauma patients were admitted.  Thirteen (0.08%) patients suffered 15 BECVI, which involved: 4 vertebral artery, 4 internal carotid artery, 4 common carotid artery, and 3 internal jugular vein. Six (46.1%) patients sought medical attention when neurological symptoms occurred due to cerebral ischemia and had no recent associated injury. In 7 (53.8%) patients their neurologic signs and symptoms such as headache, nausea and vomiting, hemiparesis or seizures were in association with a known recent injury. All patients underwent magnetic resonance angiography (MRA) and 10 (76.7%) also underwent computerized tomographic angiography (CTA).  No diagnostic disagreements were observed between the two imaging modalities. Treatment with low molecular weight heparin was initiated in 6 (53.8%) and 4 (30.8%) were started on aspirin. Follow-up imaging was performed after a mean of 53.6 days, with MRA in 12 and CTA in 1. Complete vascular re-canalization was demonstrated in 10 of 16 injured vessels (62.5%), with 89.9% of these patients demonstrating no neurological signs or symptoms.  Partial re-canalization was seen in 25% of injured vessels and 75% of these patients demonstrated no neurological signs or symptoms. Only 1 patient was found to have had a complete occlusion on follow-up.  They had ongoing neurologic deficits due to an accompanying cervical spinal cord injury. There were no deaths in this cohort.

Conclusion

BECVI are rare in children and neurological signs and symptoms raise suspicion for vascular injury. Our results reveal that BECVI may occur even with relatively minor or remote head or neck trauma regardless of the mechanism of injury or associated injuries, making the development of a decision rule for screening difficult in children.  MRA was able to accurately diagnose these injuries and should be used liberally when clinical suspicion arises.  Despite the range of management strategies utilized, most vessels at least partially re-canalized and most neurologic deficits resolved. 

 

n-13

Age (y)

8.58

Gender, male (%)

69.2

GCS, median (IQR)

 

       12-15 (%)

69.2 (n-9)

        8-11 (%)

15.4 (n-2)

        <8 (%)

15.4 (n-2)

Time to Dx (h)

25.15

Time to Tx (h)

27.09

Type of Tx

 

        Medical (%)

76.9 (n-10)

        Observation (%)

15.4 (n-2)

        Endovascular (%)

7.7 (n-1)

LOS in ICU (d)

4.9

LOS in Hospital (d)

10.54

Survival (%)

100 (n-13)