Late Complications of Vertebral Artery Dissection in Children: Pseudoaneurysm, Thrombosis, and Recurrent Stroke
Craniocervical arterial dissection is an important cause of childhood arterial ischemic stroke, accounting for 7.5% to 20% of cases. Significant neurologic morbidity and mortality may result and recurrence risk may be higher than in adults. However, the natural history and long-term outcome of pediatric dissection are poorly studied. We report 3 cases of extracranial vertebral artery dissection with complications including pseudoaneurysm formation, recurrent stroke, and late spontaneous thrombosis of the dissected artery. These cases illustrate the dynamic processes involved in vascular injury and healing of vertebral artery dissection in children over years, with potential implications for long-term management and prevention of recurrence.
[Show abstract] [Hide abstract] ABSTRACT: Stroke is a relatively rare but rather significant cause of short- and long-term morbidity and mortality in children. It can be divided into three categories: arterial ischemic stroke (AIS), hemorrhagic stroke (HS) and cerebral sinovenous thrombosis (CSVT). This review focuses on AIS. The etiologies of pediatric AIS are diverse and different from those in adult stroke, chief among these being congenital heart disease, vasculopathies, hematological disorders and prothrombotic states. Additional factors might be related to the age group, ethnicity and geographic factors. Early recognition enables initiation of prompt therapy thereby reducing risk of further recurrence and complications.0Comments 2Citations
- "...12 % and can occur up to a few years post initial presentation and hence may require long term ATT . Thrombophilia Although the frequency of inherited and acquired thrombophilia in pediatric stroke i..."Antithrombotic therapy (ATT) aims to prevent stroke until the dissection has healed or recannalized. The risk of recurrent stroke or transient ischemic attack (TIA) in children with dissection is around 12 % and can occur up to a few years post initial presentation and hence may require long term ATT . Thrombophilia Although the frequency of inherited and acquired thrombophilia in pediatric stroke is being recognized, theFig. 2 Diffusion weighted images on axial view, a demostrate a left MCA infarct in a neonate.
[Show abstract] [Hide abstract] ABSTRACT: Blunt cerebrovascular injury (BCVI) has been well described in the adult trauma literature. The risk factors, proper screening, and treatment options are well known. In pediatric trauma, there has been very little research performed regarding this injury. We hypothesize that the incidence of BCVI in children is lower than the 1% reported incidence in adult studies and that many children at risk are not being screened properly. This is a multi-institutional retrospective cohort study of pediatric patients (<15 years) admitted with blunt trauma to six American College of Surgeons-verified Level 1 pediatric trauma centers between October 2009 and June 2011. All patients with head, neck, or face injuries who were high risk for BCVI based on Memphis criteria were analyzed. Of 5,829 blunt trauma admissions, 538 patients had at least one of the Memphis criteria. Only 89 (16.5%) of these patients were screened (16 patients had more than one test) by angiography (64 by computed tomography angiography, 39 by magnetic resonance angiography, and 2 by conventional angiography), while 459 (83.5%) were not screened. Screened patients differed from unscreened patients in Injury Severity Score (ISS) (22.6 ± 13.3 vs. 13.3 ± 9.9, p < 0.0001) and head and neck Abbreviated Injury Scale (AIS) score (3.7 ± 1.2 vs. 2.8 ± 1.2, p < 0.0001). The incidence of BCVI in our total population was 0.4% (23 patients). Of the 23 patients with BCVI, 3 (13%) had no risk factors for the injury. The odds of having sustained BCVI in a patient with one or more of the risk factors was 4.0 (95% confidence interval, 1.1-14.2). BCVI in Level 1 pediatric trauma centers is diagnosed less frequently than in adult centers. However, screening was performed in a minority of high-risk patients who may explain the reported lower incidence of BCVI in children. Pediatric surgeons need to become more vigilant about screening pediatric patients with high-risk criteria for BCVI. Prognostic/epidemiologic study, level III; therapeutic study, level IV.0Comments 5Citations
- "... of untreated BCVI in the form of vascular dissection , pseudoaneurysm formation, and stroke. 2,20,21,23 The potential morbidity of missed injury is clearly significant. There have been two recent studi..."In contrast, there is a significant amount of data in the literature regarding the devastating consequences of untreated BCVI in the form of vascular dissection , pseudoaneurysm formation, and stroke. 2,20,21,23 The potential morbidity of missed injury is clearly significant. There have been two recent studies on pediatric trauma patients trying to characterize BCVI in children.
- [Show abstract] [Hide abstract] ABSTRACT: Stroke and cerebrovascular disorders in childhood are a cause for significant morbidity in childhood. There is growing emphasis on understanding the mechanisms of stroke so as to inform developments in investigation and management. Advances have been made in the classification of pediatric stroke, aided by clinical and radiological recognition of patterns of injury and differential outcomes dependent on timing of stroke occurrence. Risk factors are multifactorial, with evidence of geographical and national variation. Causality, however, remains difficult to prove. Recent studies highlight a significant association between stroke recurrence and outcome and the presence of steno-occlusive arterial disease, Moyamoya disease and progressive arteriopathy. Focal arteriopathy of childhood is a new term proposed to refine the nomenclature of childhood arteriopathy. The association between infection and childhood stroke is increasingly recognized, with associations with sinovenous thrombosis and childhood arteriopathy. The recommendation to screen for arteriopathy in genetic conditions such as sickle cell disease is now extended to include children with neurofibromatosis type 1. Perfusion and magnetic resonance wall imaging have helped in the determination of the cause of stroke with impact on management in adults. Two new treatment guidelines have been published (American Heart Association and Chest), but barriers remain to the use of thrombolysis in childhood stroke. Continued developments in understanding and practice in childhood stroke are encouraging. However, the absence of clinical trials and evidence-based guidelines is limiting. The conduct of such trials is a goal towards which the International Pediatric Stroke Study is moving.0Comments 9Citations