Stroke in Childhood: Report of Two Cases

Contents

• Stroke in an Adolescent: Basilar Artery Dissection
• Stroke in a Child: Carotid Artery Dissection

Stroke in an Adolescent: Basilar Artery Dissection

This was a 15 y.o. w. male previously in good health who was found seizing in the bathtub. On arrival to a local ER he was given ativan and intubated with resolution of his seizures. An initial CT scan and subsequent LP were normal. The patient was extubated but noted to be encephalopathic. Approx. 24 hours later he developed respiratory distress and coma requiring reintubation. An MRI at that time revealed multiple ischemic infarcts of both thalami, R cerebellum, L pons, and R brainstem.

He was transferred to the University Hospital where MRA and arteriography revealed near occlusion of his basilar artery with a question of basilar artery dissection. There was no evidence of aneurysm, AVM, or vasculitis on arteriogram. History and laboratory evaluation failed to reveal causation. Specifically, there was no h/o trauma, previous neurologic events, intravenous drug usage, or other health problems. There was no family history of similar problems. He had a normal cardiac evaluation, no evidence of coagulopathy, and no evidence of genetic, rheumatologic, or other syndromes.

The young man was begun on heparin to maintain his PTT approx. twice normal and received essentially supportive therapy. He gradually improved, was extubated, and was transferred for rehabilitative care. Heparin was discontinued after two weeks and coumadin initiated. At discharge from the Rehabilitation Center he was cognatively appropriate but exhibited mild perceptual problems and had a mild right hemiplegia. He was continued on coumadin for an indeterminate time. All of these have subsequently improved and he is back in his regular class.

His discharge diagnosis was basilar artery dissection of unknown causation with multiple ischemic infarctions.

Stroke in a Child: Carotid Artery Dissection

8 y.o. male admitted in transfer from a community hospital, who was about 24 hrs out from onset of sx's consistent with a L CVA in the MCA distribution. MRI sent with the child had findings consistent with the clinical exam, and an MRA of the neck revealed a left internal carotid dissection, just distal to the bifurcation of the common carotid, with thrombus formation but residual forward flow in the vessel. There was no hx of trauma or hyperextension in the last 4-5 wks; the patient and his family had recently returned from a 7 year assignment in Saudi Arabia.

48hrs out from onset of sx's, neuro deficits were mild and progressively improving. A decision was made to anticoagulate and heparin infusion was started although timing of switch to coumadin and overall length of treatment had not been decided (much less agreed upon by the different services involved in the child's care!). After heparin was initiated, our radiologists requested to be able to duplex ultrasound his carotids, and found that the dissection had progressed, with the resulting intimal flap completely occluding the L internal carotid, and evidence of retrograde flow, presumably via the circle of Willis, in the vessel distal to the occlusion. Heparin was thus stopped, and after documenting normalization of his coagulation studies, he was discharged on the 4th hospital day, having only a mild limp and selective expressive aphasia.

At his 2wk follow-up with the neurologist, his gait was normal and the only residual deficit was an intermittent aphasia for certain letters and numbers.

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