The necessity of CT/CTA scans on pediatric cerebrovascular injury after blunt trauma - a single center study.

Abstract

Background: Blunt cerebrovascular injury (BCVI) is a rare but potentially devastating complication of pediatric blunt trauma. Delayed or missed diagnosis may result in ischemic stroke, permanent neurological deficits, or death. To avoid missed injuries, many trauma centers apply liberal computed tomography angiography (CTA) screening strategies, although this may expose children to substantial and potentially unnecessary radiation. Several adult- and pediatric-derived screening tools have been proposed, but their applicability in pediatric trauma populations remains controversial. This study aimed to evaluate the incidence of BCVI, imaging utilization, and the diagnostic performance of pediatric BCVI screening approaches in a German Level I trauma center cohort.

Methods: This retrospective observational cohort study included pediatric trauma patients aged 0-15 years who underwent CT imaging following blunt trauma between January 2005 and December 2020 at a Level I trauma center in Germany. Patients were identified through systematic review of electronic medical records and radiological databases. BCVI was defined as traumatic injury to the carotid or vertebral arteries detected by CTA or magnetic resonance imaging (MRI). Demographic, clinical, imaging, and outcome data were collected retrospectively. The McGovern score was calculated for patients with sufficient available data and evaluated using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and receiver operating characteristic (ROC) analysis. Additionally, the theoretical applicability of PECARN and Scandinavian pediatric head trauma guidelines was explored to assess potential reductions in CT utilization.

Results: A total of 956 pediatric trauma patients underwent CT imaging, of whom 668 (70%) additionally received CTA. BCVI was diagnosed in 6 patients, corresponding to an incidence of 0.6%. Five injuries were identified by CTA and one by MRI. All BCVI patients presented with focal neurological deficits at initial evaluation. The McGovern score could be calculated in 896 patients. Using a cutoff value of ≥ 3 points, all BCVI cases were correctly identified, resulting in a sensitivity of 100%, specificity of 83.8%, PPV of 4.0%, and NPV of 100%. ROC analysis demonstrated excellent discriminative ability with an area under the curve of 0.960 (95% CI 0.923-0.989). However, the small number of BCVI cases limited statistical power. Theoretical application of PECARN and Scandinavian guidelines suggested that a substantial proportion of CT examinations may have been avoidable.

Conclusion: BCVI is an uncommon but clinically significant injury in pediatric blunt trauma. Despite its low incidence, CTA utilization was high in our cohort, raising concerns regarding potential overuse of imaging and radiation exposure. Pediatric-specific screening tools such as the McGovern score may help identify low-risk patients while maintaining high sensitivity. However, larger prospective multicenter studies are required to validate pediatric BCVI screening strategies and optimize the balance between early diagnosis and radiation avoidance.