Craniocervical Arterial Dissection in Children: Clinical and Radiographic Presentation and Outcome

Abstract

Craniocervical arterial dissection is a recognized cause of arterial ischemic stroke in children. Whether children with craniocervical arterial dissection have dissection characteristics different from those of adults is unclear. A retrospective review of children, 1 month to 18 years of age, with dissection from two Canadian pediatric ischemic stroke registry centers was conducted. From 213 patients with arterial ischemic stroke, 16 (7.5%) were identified with dissection, 37.5% had warning symptoms, and 50% had a history of head or neck trauma. The clinical presentation included headache (44%), altered consciousness (25%), seizures (12.5%), and focal deficits (87.5%). Dissection involved extracranial vessels in 75% and anterior circulation in 56%. Follow-up included complete recovery in 43%, mild to moderate deficits in 44%, and severe deficits in 13%. Fourteen (87.5%) children received antithrombotic treatment. Follow-up angiography showed resolution of abnormalities in 60% of vessels. Total occlusion had the worst outcome for recanalization. In conclusion, the etiology of arterial dissection in the majority of children appears to be either trauma or idiopathic. Long-term angiography shows variable outcomes, depending on the initial findings. The relationship of angiographic outcomes with recurrent strokes requires further study in pediatric dissection. (J Child Neurol 2006;21:8-16).

Management of Stroke in Infants and Children

“…[182][183][184] Most dissections occur in the extracranial ICA, typically in the pharyngeal portion of the ICA. In children, the site of dissection is often intracranial.…”

“…184 The main goal of therapy for CCAD is to prevent additional ischemic strokes until the vessel has healed. Potential medical treatments for CCAD, derived largely from adult series, include immediate anticoagulation with intravenous UFH or LMWH followed by a 3-to 6-month course of warfarin designed to maintain a target international normalized ratio of 2.0 to 3.0, continued LMWH, or platelet antiaggregant therapy.…”

Antithrombotic Therapy in Neonates and Children

“…733 In children with cerebral arterial dissection underlying AIS, the risk of recurrent strokes is ‫ف‬ 12%. [733][734][735] Recurrence appears to be reduced by antithrombotic treatment 734 but is still observed during anticoagulation [733][734][735] or antiplatelet treatment. 734 In adults with cerebral artery dissection, a Cochrane meta-analysis that included 327 patients reported no signifi cant difference for initial or recurrent stroke during anticoagulant treatment (fi ve of 414) vs antiplatelet treatment (six of 157).…”

How do we Handle Traumatic Pediatric Carotid Artery Dissection?

“…Conventional angiography is stated to be the diagnostic goldstandard in diagnosing CAD [3,6]. There are specific angiographic findings in CAD: (1) identification of intimal flaps and double lumen, (2) aneurysmal pouch formation, (3) occlusion often tapering with a flame-shape appearance [13].…”

“…These cases also have drawn attention due to concomitant severe damage to the regional vascular structures such as carotid artery [1,2]. In some cases, especially with skull base fractures and cervical vertebral column trauma; carotid artery dissections at the cervical segment can occur [3,4]. The goal of our study is to draw attention to the radiodiagnostics and management of the traumatic pediatric cervical carotid artery dissection with the aid of a case of traumatic cervical carotid artery dissection (CAD).…”