Traumatic Ataxia in a Child

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.

The morning of his ED presentation, the patient was unable to walk, complaining of dizziness and double vision. He was otherwise healthy.

On exam, his vitals were within normal limits. He was in no distress. The patient’s head was tilted a few degrees to the left, which he explained made things appear more normal. He had nystagmus at rest. Finger-to-nose was dysmetric. He could sit up straight but could not walk, showing truncal ataxia. There was no dysarthria. There was no sign of basal skull fracture or other head injury. His neck was supple with normal ROM and no bruits.

What’s your diagnosis?

Because of rapid accessibility, the patient was sent for STAT head CT followed by CT angiography to rule out cervical artery (specifically vertebral artery) dissection. Both were normal. Images not shown.

What’s your diagnosis? Has it changed?

If you are thinking that you are done with the workup you are wrong. CT is insufficient for ruling out posterior circulation infarct, and normal CTA means MRI/MRA is needed. The patient was then referred for MRI and MRA. The MRI, shown below, showed a right medullary infarct. The MRA failed to show a dissection flap.

The patient was admitted for presumed vertebral artery dissection (despite no documented dissection on imaging) secondary to neck trauma. He was placed on heparin. Several weeks later he was transferred to a rehab centre and was walking on his own again.

A little more on VAD:

• 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.

 VAD in children:

• 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.

Learning points from this case:

• 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.

Resources/References:

• 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