Spontaneous carotid and vertebral artery dissection in children

Internal Carotid Dissection as the Cause of Stroke in Childhood

Internal carotid artery (ICA) dissection is a cause of stroke, but it is often underdiagnosed in children. ICAs' risk factors and pathogenic mechanisms are poorly understood, and the treatment is still empirical. We report the case of a previously healthy 9-year-old girl who presented with involuntary hypertonic closure of the right hand associated with transient difficulty for both fine movements of the right arm and speech. She had a history of minor cervical trauma occurring 20 days prior to our observation without other associated risk factors. Magnetic resonance imaging and magnetic resonance angiography showed ischemic lesions due to the left ICA dissection. Treatment with both acetylsalicylic acid and levetiracetam allowed recanalization of the ICA associated with the resolution of clinical signs. Our clinical case suggests that the ICA dissection must be suspected early whenever a child manifests mild neurologic deficits after a cervical trauma, especially if they are associated with headache and/or cervical pain. Moreover, the management of ICA dissection must be improved.

Craniocervical Arterial Dissection in Children: Pathophysiology and Management

BACKGROUND

Craniocervical arterial dissection is a commonly reported arteriopathy associated with stroke in children. It is characterized by a high stroke recurrence rate and variable outcomes. Here we review the pathophysiology, clinical presentation, and diagnostic neuroimaging approaches that are helpful in accurate diagnosis and follow-up of children with arterial dissection.

METHODS

MEDLINE searches (2000 to 2018) for articles that contained patients aged less than 18 years with craniocervical arterial dissection was performed, with the goal of analyzing their presenting features, pathophysiological mechanisms, and imaging characteristics and interventions.

RESULTS

Sixteen articles met the study criteria and reported 182 cases of craniocervical arterial dissection, 68% male, average age 8.6 years. Dissection was associated with head and neck trauma in 56% of the cases and frequently involved the posterior (61%) and extracranial locations (64%); the vertebral artery was the most commonly involved artery (60%). The most common clinical presentation was hemiparesis (80/160, 50%), followed by headache (64/164, 39%). Magnetic resonance imaging was the preferred neuroimaging method, followed by cerebral catheter angiography as a gold standard definitive neurovascular imaging modality when the initial vascular imaging revealed nondiagnostic findings.

CONCLUSIONS

The diagnosis of arterial dissection requires a high index of suspicion and consideration for detailed neurovascular imaging, including both the cranial and cervical regions. Neurovascular imaging challenges, especially visualization of arterial abnormalities, highlight the importance of appropriate and timely use of specific neurovascular imaging techniques. Magnetic resonance imaging appears to be the preferred neurovascular imaging modality in children with arterial dissection and may obviate the need for invasive cerebral catheter angiography.

Imaging Review of Common and Rare Causes of Stroke in Children

Vascular injury is increasingly recognized as an important cause of mortality and morbidity in children (29 days to 18 years of age). Since vascular brain injury in children appears to be less common than in adults, the index of suspicion for vascular brain injury is usually lower. In this review article, we describe frequent and rare conditions underlying pediatric stroke including cardioembolic, viral, autoimmune, post-traumatic, and genetic etiologies. Furthermore, we provide a neuroimaging correlate for clinical mimics of pediatric stroke. This review highlights the role of multimodal noninvasive neuroimaging in the early diagnosis of pediatric stroke, providing a problem-solving approach to the differential diagnosis for the neuroradiologist, emergency room physician, and neurologist.

The Headache and Neck Pain in Ischemic Stroke Patients Caused by Cervicocerebral Artery Dissection. A Case-Control Study

BACKGROUND AND PURPOSE

The symptom of headache and neck pain is common in patients with cervicocerebral artery dissection (CAD). We attempt to screen ischemic stroke patients with CAD based on the characteristics of the pain.

METHODS

Eighty-one consecutive ischemic stroke patients with CAD from 2010 to 2017 and 84 consecutive ischemic stroke patients with large artery atherosclerosis (LAA) were registered prospectively and observed in Zhengzhou, China. Those ischemic stroke patients complained of headache and neck pain were categorized into 2 groups. By analyzing the difference of headache and neck pain in 2 groups, we summarized characteristics of the pain secondary to CAD.

RESULTS

There were 34 patients in CAD group and 19 patients in LAA group. As for patients in CAD group, the pain could be located in the ipsilateral (41.9%), bilateral (41.9%), or contralateral (16.1%) side of the dissected artery, but in LAA group the pain was often in both sides (68.4%). When the dissected artery was involved in anterior circulation, 55.6% of CAD patients had pain in temporal and when involved in posterior circulation, 65.2% of CAD patients had pain in the occipital and neck. Patients with CAD had a higher prevalence of throbbing pain (30.0%), while pulsating pain (43.8%) was more common in LAA group. Patients often presented with severe pain (46.9%) in CAD group, while less frequently (11.8%) in LAA group, with a significant difference (P = .003). And there was a significant difference between the length (≥20 mm) of the involved artery and severity of the pain (P = .028) in CAD group.

CONCLUSIONS

Ischemic stroke patients caused by CAD tend to suffer from headache and neck pain, which may be severe and throbbing, compared with those resulting from LAA. The anterior circulation dissection has a higher prevalence of temporal pain while posterior circulation dissection is typically more associated with occipital and neck pain.

Posttraumatic carotid artery dissection in children: not to be missed!

BACKGROUND

Post-traumatic carotid artery dissection (PTCAD) may result in acute arterial ischemic stroke (AIS). Pediatric PTCAD is rarely diagnosed prior to onset of neurological symptoms. We report on neuroimaging findings in a series of children with PTCAD.

METHODS

Five children with head or neck trauma were included in this study. Clinical histories were reviewed for mechanism of trauma, symptoms, complications, therapy, and outcome. Computed tomography (CT), magnetic resonance imaging (MRI), and CT/MR angiography (CTA, MRA) studies were retrospectively evaluated for signs and complications of PTCAD and presence and extent of skull base fractures.

RESULTS

PTCAD was located at the level of the skull base in all children and was associated with a skull base fracture in two. The diagnosis was made in five children by combined MRI/MRA and in two by CTA. Air in the carotid canal suggested skull base injury with PTCAD in two children. PTCAD was complicated by AIS in three children.

CONCLUSION

PTCAD may result from neck and head trauma. To avoid secondary AIS, radiologists should be familiar with neuroimaging findings in children, especially as acute PTCAD may initially be clinically silent. Consequently, pediatric neuroradiologists should actively exclude PTCAD in children with head and neck trauma.

[Cerebellar infarction]

Cerebellar infarction can be difficult to diagnose because the clinical picture is often dominated by fairly non-specific symptoms, which are more indicative of a benign condition. When cerebellar infarction affects the brainstem, the semiology is richer, and pure cerebellar signs are rendered less important. A perfect knowledge of the organisation of the cerebellar artery territories is required, regardless of the infarct topography. This knowledge is essential for making an accurate diagnosis, understanding the mechanisms and organising a treatment plan. Clinical algorithms for the treatment of dizziness, headaches and vomiting would improve the selection of candidates for brain imaging. Thus, the early identification of patients with a high risk of subsequent deterioration would lead to a better prognosis in cases of cerebellar artery territory infarction.

Endovascular therapy in pediatric intracranial carotid artery dissection

Intracranial carotid dissection is an underrecognized cause of childhood stroke, and, in the face of limited therapeutic experience, its management is controversial. Reported here is the case of a 12-year-old girl who experienced an intracranial carotid artery dissection with progressive and symptomatic occlusion of the middle cerebral artery. Endovascular treatment with intra-arterial thrombolysis and stent reconstruction was successfully performed to recanalize the occluded arterial segment. Current management of intracranial carotid dissection in children is reviewed, with discussion of the reasons for aggressive endovascular intervention.

Low detection rate of craniocervical arterial dissection in children using time-of-flight magnetic resonance angiography: causes and strategies to improve diagnosis

Craniocervical arterial dissection is a frequent cause of childhood arterial ischemic stroke requiring prompt diagnosis and treatment. However, there is no universal guideline for diagnostic cerebrovascular imaging in children. We assessed the role of time-of-flight magnetic resonance angiography in diagnosing craniocervical arterial dissection. We included children (1 month to 18 years) with craniocervical arterial dissection and ischemic stroke from January 1998 to June 2007. Institutional protocol required magnetic resonance imaging (MRI)/ magnetic resonance angiography for all ischemic stroke cases and conventional cerebral angiography if magnetic resonance angiography showed any arteriopathy. Among 233 ischemic stroke cases, craniocervical arterial dissection was diagnosed in 13 patients (5.6%; 10 males), with a mean age of 7.5 years. Initial time-of-flight magnetic resonance angiography missed dissection in 8 patients (61.5%) because the neck vessels were not scanned (n = 2), of suboptimal technique (n = 3), and of diagnostic error (n = 3). T1 fat-saturated MRI and contrast-enhanced magnetic resonance angiography were not performed in 12 patients. If suspicion for arterial dissection is high, T1 fat-saturated neck imaging and contrast-enhanced magnetic resonance angiography should be considered to maximize detection.

An 8-year-old boy with vertebral artery dissection with cerebellar ataxia featuring suspected vertebral artery hypoplasia

We report an 8-year-old boy with left vertebral artery dissection featuring cerebellar ataxia in which congenital vertebral artery hypoplasia was suspected as a predisposing factor in the dissection. The patient suddenly suffered from vertigo and vomiting while swimming, and he was brought to our department. The initial brain Computed Tomography (CT) demonstrated no abnormalities, and his symptoms disappeared the next morning. However, one month after onset, brain Magnetic Resonance Imaging (MRI) revealed ischemic changes (infarction) in the left cerebellum. Transfemoral angiography showed complete occlusion at the C2 portion of the left vertebral artery, suggesting dissection and diffuse narrowing of the proximal segment of the occlusion site. Three-dimensional CT angiography also revealed diffuse narrowing of the left vertebral artery from the bifurcation of the subclavian artery. He has since been living daily life without any difficulties. The detailed etiology of cerebral artery dissection remains unknown, but arterial anomalies should be considered as a predisposing factor.

Vertebral artery dissection in a patient with Wildervanck syndrome

Vertebral artery dissection as a cause of stroke is rarely reported in children. The association between vertebral artery dissection and Klippel-Feil syndrome is also very rare. We report on a case of vertebral artery dissection with posterior circulation involvement in a child with Klippel-Feil syndrome after a hard physical-training lesson. She was also diagnosed with Wildervanck syndrome, with additional clinical findings. Vertebral artery dissection should be considered in patients with Klippel-Feil syndrome who present with acute-onset neurologic signs. Movements such as hyperextension with rotation of the neck should be avoided in these cases.

Multifaceted Dermal Ultrastructural Clues for Ehlers-Danlos Syndrome with Arterial Rupture and Type I Collagen R-to-C Substitution

Type I collagen arginine-to-cysteine (R-to-C) substitutions were found in three middle-aged adults suffering from spontaneous dissection of medium-size arteries. This disorder enters the heterogeneous spectrum of the Ehlers-Danlos syndrome (EDS). Despite similar genetic mutation and arterial alterations, two distinct clinical presentations were identified showing signs of either the EDS classic type or premature osteopenia alone. Ultrastructural changes were found in the dermal collagen fibrils, elastic fibers, and proteoglycan components. The cross-section of most collagen fibrils was rounded, but with diverse diameters. Flower-like outlines of collagen fibrils were rarely disclosed. Large hyaluronic acid globules pushed apart the collagen bundles in the case with EDS classic-type presentation. Elastic fibers contained unusual annular microcalcifications. In conclusion, ultrastructural changes were found in diverse connective-tissue components despite the fact that the mutations were found to be specific for the collagen molecules. In addition, two distinct clinical presentations were found and were correlated with peculiar ultrastructural alterations.

Carotid dissection and stroke after tonsillectomy and adenoidectomy

Carotid dissection and cerebral infarction are extremely rare complications of tonsillectomy and adenoidectomy. We describe a 12-year-old boy who presented with a right internal carotid dissection and right middle cerebral artery infarction, associated with tonsillectomy and adenoidectomy. We discuss the risk factors that may predispose patients to these complications.

Craniocervical arterial dissection in children: clinical and radiographic presentation and outcome

Craniocervical arterial dissection is a recognized cause of arterial ischemic stroke in children. Whether children with craniocervical arterial dissection have dissection characteristics different from those of adults is unclear. A retrospective review of children, 1 month to 18 years of age, with dissection from two Canadian pediatric ischemic stroke registry centers was conducted. From 213 patients with arterial ischemic stroke, 16 (7.5%) were identified with dissection, 37.5% had warning symptoms, and 50% had a history of head or neck trauma. The clinical presentation included headache (44%), altered consciousness (25%), seizures (12.5%), and focal deficits (87.5%). Dissection involved extracranial vessels in 75% and anterior circulation in 56%. Follow-up included complete recovery in 43%, mild to moderate deficits in 44%, and severe deficits in 13%. Fourteen (87.5%) children received antithrombotic treatment. Follow-up angiography showed resolution of abnormalities in 60% of vessels. Total occlusion had the worst outcome for recanalization. In conclusion, the etiology of arterial dissection in the majority of children appears to be either trauma or idiopathic. Long-term angiography shows variable outcomes, depending on the initial findings. The relationship of angiographic outcomes with recurrent strokes requires further study in pediatric dissection. (J Child Neurol 2006;21:8-16).

An Analysis of the Etiology of Cervical Artery Dissections: 1994 to 2003

OBJECTIVE

To provide a literature review of the etiologic breakdown of cervical artery dissections.

METHODS

A literature search of the MEDLINE database was conducted for English-language articles published from 1994 to 2003 using the search terms cervical artery dissection (CAD), vertebral artery dissection, and internal carotid artery dissection. Articles were selected for inclusion only if they incorporated a minimum of 5 case reports of CAD and contained sufficient information to ascertain a plausible etiology.

RESULTS

One thousand fourteen citations were identified; 20 met the selection criteria. There were 606 CAD cases reported in these studies; 321 (54%) were internal carotid artery dissection and 253 (46%) were vertebral artery dissection, not including cases with both. Three hundred seventy-one (61%) were classified as spontaneous, 178 (30%) were associated with trauma/trivial trauma, and 53 (9%) were associated with cervical spinal manipulation. If one apparently biased study is dropped from the data pool, the percentage of CADs related to cervical spinal manipulation drops to approximately 6%.

CONCLUSIONS

The case series that were reviewed in this article indicated that most CADs reported in the previous decade were spontaneous but that some were associated with trauma/trivial trauma, and a minority with cervical spine manipulation. This etiologic breakdown of CAD does not differ significantly from what has been portrayed by most other authors.

Lateral Medullary Infarction Secondary to Vertebral Artery Dissection Presenting as a Trigeminal Autonomic Cephalalgia

A 51-year-old woman had an attack of severe hemifacial pain with autonomic features as the presenting symptom of a lateral medullary infarction. A bilateral vertebral artery dissection was demonstrated. The existence of secondary cases may lead to a better understanding of the pathophysiology of trigeminal autonomic cephalalgias.

Imaging of pediatric head trauma

This article discusses all types of traumatic head injury in infants, children and adolescents. Neuroimaging patterns of injury help to make the precise diagnosis and assists in monitoring responses to therapy.

Stroke and the child's brain: an overview of epidemiology, syndromes and risk factors

Childhood stroke is emerging as a serious and frequent disorder. In contrast to adult stroke, the study of childhood stroke is in a very early stage of research development with no randomized controlled trials conducted to date outside of sickle cell stroke. The results of research in adults have limited applicability to children with stroke due to fundamental age-related differences in the neurological, cerebrovascular and coagulation systems. In recent years clinical and basic research studies have improved our understanding of childhood stroke. Population-based studies have resulted in an increased awareness of the frequencies and features of stroke syndromes in children. Cohort and case-control studies have led to an enhanced understanding of the multiple risk factors underlying childhood stroke. Advances in neuroimaging and in genetic and other laboratory testing approaches have resulted in an increased definition of stroke subtypes and risk factors.