Head and Neck Trauma Increase the Risk of Stroke in Children

LOUISVILLE—Head or neck trauma is a significant risk factor for stroke in children, according to results of a study presented at the 38th National Meeting of the Child Neurology Society. Children with loss of consciousness accompanying the trauma had the highest risk of stroke, reported Brandon A. Zielinski, MD, PhD, and colleagues.

“Although suspected on the basis of various case studies, as well as secondary analyses, trauma has been cited as a risk factor for acute ischemic stroke in children but has not been formally evaluated,” stated Dr. Zielinski, a Resident in Child Neurology at the University of California, San Francisco. “Despite sometimes clearly extensive workups, the majority of cases of childhood stroke remains idiopathic in etiology, so the hunt is on to identify risk factors, or targets for both primary and secondary prevention.”

Dr. Zielinski’s group conducted a case-control study within a cohort of 2.4 million children who were enrolled in the Kaiser Permanente Medical Health Care Program in Northern California for a mean of four years. Non-neonatal arterial ischemic stroke cases were identified by inpatient and outpatient records searches and confirmed through independent chart review; three controls were randomly selected per case and pair-matched on birth year and primary care facility. Any documented medical encounter specifically for head or neck trauma within 12 weeks preceding the stroke date was defined a priori as head or neck trauma.

Children with retrospective trauma history first elicited at the time of stroke diagnosis were excluded from the study. Conditional logistic regression was used to evaluate trauma as a risk factor for arterial ischemic stroke.

Preceding Traumatic Events

“Of 97 cases of acute ischemic stroke in children, 10.3% had a history of head or neck trauma within 12 weeks preceding their stroke date, versus 1.4% of controls, [yielding] an odds ratio of 7.5,” Dr. Zielinski stated. “A particularly high risk was seen in children who lost consciousness.” Documented loss of consciousness at the time of the trauma occurred in 5.2% of the cases and 0.3% of controls, for an odds ratio of 15.0, Dr. Zielinski continued.

A total of 8.2% of the cases had trauma admission, compared with zero controls. Skull fracture occurred in 1% of cases, and no controls. “Interestingly, male gender was not significant in this study,” Dr. Zielinski noted. “Qualitative assessment of traumatic mechanism reveals that although the majority of trauma involves motor vehicle accidents, or blunt trauma, mechanisms of trauma vary significantly, and included penetration injury as well as sports-related injuries in our stroke cases.”

Imaging Analysis

Imaging reports, as well as secondary analysis, indicated that two cases were diagnosed with arterial dissection. Notably, neurovascular imaging was incomplete, suggesting that cases of arterial dissection may have been missed.

“Of the 10 cases with documented trauma history, two received a diagnosis of arterial dissection, despite the finding that two had no vascular imaging, and three had cerebral (but not cervical) vascular imaging,” he stated. “Although 100% of the cases received a head CT, none had CT angiography, only two received magnetic resonance angiography of the neck, and one received a conventional angiogram.”

“We conclude that head or neck trauma is a strong risk factor for pediatric arterial ischemic stroke,” Dr. Zielinski said. “Although we are limited by a small sample size, factors reflective of greater trauma severity such as loss of consciousness may involve greater risk.” He noted that more studies are needed to determine indications for vascular imaging in childhood victims of head or neck trauma. However, “comprehensive vascular imaging in children with stroke would likely increase the diagnosis of arterial dissection, possibly affecting management,” Dr. Zielinski commented.

Suggested Reading
Golomb MR, Fullerton HJ, Nowak-Gottl U, et al. Male predominance in childhood ischemic stroke: findings from the international pediatric stroke study. Stroke. 2009;40(1): 52-57.

Sepelyak K, Gailloud P, Jordan LC. Athletics, minor trauma, and pediatric arterial ischemic stroke. Eur J Pediatr. 2009; Sep 17 [Epub ahead of print].