Chief Complaint: 3 year old male with
refusal to bear weight on his leg
Amanda Conti, MD
Melody Brewer, MD
Brendan Kelly, MD
Baystate Medical Center, Springfield, MA
Case Presentation
• 3 year old Caucasian male with autism
• Presented to the Emergency Department with a
reluctance to bear weight on his right leg
• While at school earlier on the day, he suddenly
jumped up, started crying, and would not bear
weight on his right leg
• This was not associated with changes in mental
status, seizure like activity, vomiting, or headache
• The patient had no known trauma
Case Presentation
• On initial evaluation, patient seemed to be in pain and
preferred to keep his eyes closed, stating that he was
dizzy
• Physical exam and x-rays of his right leg were
unrevealing
• It was thought that perhaps the patient had iliopsoas
irritation accounting for the reason that he would not
stand, therefore an abdominal x-ray and ultrasound
were completed, and both of these were normal
• Given the unusual story and the fact that the patient
refused to walk, he was admitted to the hospital for
further work-up and management
Hospital Course
• Patient’s pain and dizziness improved over
twenty-four hours and he slowly started to
bear weight on his leg
• He was asked to walk down the hallway and
was noted to veer to the right and walk into
the wall
• Repeat neurological exams revealed persistent
ataxia
Hospital Course
• Patient had an MRI …
• Images on next 4 slides
Hospital Course
• MRI that demonstrated acute and subacute
infarcts in the left PCA territory
• Chronic infarcts were also present within the
right inferior cerebellum in the distribution of
the right PICA
• MRA of the neck revealed dissection of the
right vertebral artery at the level of C2
• Pt was started on anticoagulation
Learning Objectives
• Review incidence of ischemic stroke in
children
• Review key aspects of vertebral artery
dissection
• Review the differences and similarities of
cerebral artery dissection in adult and
pediatric patients
• Discuss the management of craniocervical
dissection
Case Discussion
• The risk of ischemic stroke in childhood is 7.8
per 100,000.
• Craniocervical artery dissection [CAD] is the
cause of ischemic stroke in 7.5% of childhood
cases.
• The risk is higher for males and African
American children.
Case Discussion
• Vertebral artery dissection usually occurs in the upper
part of the vertebral artery at the C1–C2 level of the
vertebrae.
• This most likely occurs because of the rotation of the
head at the atlanto-axial joint.
• Dissection may be precipitated by fibromuscular
dysplasia, connective tissue disorder, trauma, or may
be classified as spontaneous.
• Spontaneous dissection of the cervical arteries is a rare
cause of stroke in the general population, but in the
young, it is a major cause, accounting for about 10%–
25% of ischemic events.
Case Discussion
• Both adults and children with CAD most commonly
have intracranial dissections and these are more
common in males.
• CAD differs in adults and children as the most common
symptom(s) for adults is unilateral occipital headache
and/or posterior neck pain. In children, pain is not a
principal symptom, with only half of children
complaining of head or neck pain.
• Adults commonly have vertigo, diplopia, or nausea and
vomiting, whereas children commonly experience
hemiparesis.
Case Discussion
• Treatment in children with CAD is similar to that
in adults.
• Both adults and children should be treated with
LMWH or coumadin for at least 6 weeks, with
ongoing treatment dependent on radiologic
assessment.
• Head injury is common in children and we
recommended restricting activity and wearing a
helmet for our patient while being treated with
Coumadin.
Case Discussion
• It should be noted that our patient had a full
thrombophilic and cardiac work-up that was
negative for abnormalities.
• His bilateral infarcts were thought to be
secondary to his unilateral vertebral
dissection.
Question #1
• Spontaneous dissection in the young accounts for
about ………of ischemic events
A) 1-3%
B) 5%
C) 10-25%
D) 30%
E) 40-50%
Answer - C
• Spontaneous dissection in the young accounts for
about ………of ischemic events
A) 1-3%
B) 5%
C) 10-25%
D) 30%
E) 40-50%
Question #2
• Craniocervical artery dissection in children
often presents with:
A)
B)
C)
D)
E)
Amaurosis Fugax
Vertigo
Diplopia
Nausea and Vomiting
Hemiparesis
Answer - E
• Craniocervical artery dissection in children
often presents with:
A)
B)
C)
D)
E)
Amaurosis Fugax
Vertigo
Diplopia
Nausea and Vomiting
Hemiparesis
References
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Rayfay, MF. et al. Craniocervical arterial dissection in children: clinical and
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Fullerton, H. Arterial Dissection and Stroke in Children. Neurology 2001. 57: 11551160.
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