An 7yM was brought to the ED by his parents complaining of headache, neck pain and dizziness. The prior evening he was playing in a kids league sporting event and was accidentally kicked in the side of the head. He developed a progressive headache and vomiting that evening. The parents chalked it up to a GI issue, as he had been having loose BM’s that morning.
- A systematic review on VAD in adults found the following to be the most common symptoms: dizziness/vertigo (58%), headache (51%), and neck pain (46%); <50% of patients sustained trauma.
- Most centres use heparinization although a systematic review showed no clear benefit of anticoagulation over aspirin, and that rate of infarct recurrence is generally low regardless of treatment modality.
- 7-20% of acute ischemic strokes in children are related to cervical artery dissection.
- Mechanical neck trauma can lead to dissection with strokes occurring seconds to weeks after the initial incident.
- There is substantial delay in presentation with pediatric strokes. Median time to presentation for medical care in one study (24 children) was 9 h for ischemic stroke and 10.5 h for hemorrhagic stroke.
- If CTA/MRI/MRA do not identify cervical artery dissection, some experts recommend four-vessel digital subtraction angiography to make the diagnosis.
- Stroke after traumatic but unrelated to dissection is rare, but can occur.
- VAD is not only a disease of adults.
- CT and CTA are insufficient to rule out posterior circulation stroke, and even MRI/MRA will may occasionally not show the dissection.
- Trust your clinical assessment and treat on clinical grounds – trauma followed by headache, neck pain and dizziness, especially if accompanied by objective signs on physical exam, should probably be considered a VAD until otherwise proven.
Clinical characteristics of symptomatic vertebral artery dissection: a systematic review. Neurologist. 2012 Sep;18(5):245-54. by Dr David Newman-Toker and colleagues (the man behind the HINTS exam).
Athletics, minor trauma, and pediatric arterial ischemic stroke. Eur J Pediatr. 2010 May; 169(5): 557–562. A review and three cases hauntingly similar to this one.
- Antiplatelets vs anticoagulation for dissection: CADISS nonrandomized arm and meta-analysis. Neurology. 2012 Aug 14;79(7):686-9