Diagnosis of vertebral artery dissection in childhood posterior circulation arterial ischaemic stroke

Abstract

AIM Review a series of children with posterior circulation arterial ischaemic stroke (PCAIS) to identify diagnostic modality and associations in cases of vertebral artery dissection (VAD).METHOD Retrospective analysis of 30 cases of childhood PCAIS identified from two tertiary centres over 11 years. Clinical and demographic details were recorded. Brain and cerebrovascular imaging were reviewed. Aetiology was classified using the Childhood Arterial Ischaemic Stroke Standardized Classification and Diagnostic Evaluation criteria. Outcome was evaluated using standardized paediatric stroke outcome scores. Logistic regression was used to explore variables associated with diagnosis.RESULTS Twenty-three patients were male (77%) and 7 were female (23%). VAD was the most commonly identified aetiology, in 15 cases (50%). Aetiology was undetermined in 12 (40%), probable cardioembolism in two, and reversible cerebral vasoconstriction syndrome in one. In those with VAD, diagnosis was made on initial magnetic resonance angiography (MRA) in six (40%). Further cases of VAD were diagnosed with catheter angiography (n=6), computed tomographic angiography (n=1), or follow-up MRA (n=2). Presence of multiple infarcts was associated with a diagnosis of VAD. INTERPRETATION Endoluminal cerebrovascular imaging increases the rate of diagnosis ofVAD in childhood PCAIS and should especially be considered if there are multiple infarcts.Childhood arterial ischaemic stroke (AIS) involves the posterior circulation territory in a third of cases, with distinctive demographic features and risk factors. 1 It is recognized that many cases are secondary to vertebral artery dissection (VAD), usually extracranial. Currently this diagnosis significantly alters management as clinical guidelines recommend anticoagulation -as opposed to antiplatelet therapy for other arteriopathies. Magnetic resonance angiography (MRA) is recommended as the modality of choice for characterizing the cerebrovascular circulation in childhood AIS.2,3 With increasing awareness of the importance of cervical arteriopathies in childhood AIS, it is advocated that MRA includes the cerebral circulation from the aortic arch to the circle of Willis.2 The role of endoluminal cerebrovascular imaging techniques (catheter angiography and computed tomographic angiography [CTA]) in the investigation of childhood AIS remains unclear. This is especially pertinent in cases of posterior circulation AIS (PCAIS), where MRA is known to have limitations in both sensitivity and specificity. 4,5Here we review cases of PCAIS with the aim of describing imaging modality, and clinical and imaging features associated with VAD. METHODThis was a retrospective analysis of a series of sequential children (aged >28d) with PCAIS identified from stroke clinics at Great Ormond Street Hospital NHS Foundation Trust, London, UK, and Addenbrooke's Hospital, Cambridge, UK, between 2003 and. Neonates, children with coexisting anterior circulation AIS, and children without cervical vascular imaging were excluded. Both in...

Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association

“…These children present at a median age of 7 to 8 years, are predominantly male (67% to 77%), and are previously healthy children in the vast majority of cases. 75,76 Presenting signs and symptoms include localizing deficits referable to the posterior circulation in 70% to 100%: hemiparesis, ataxia, dysarthria, visual field deficits, and oculomotor deficits. Nonlocalizing symptoms occur in 60% to 70%, especially headache, vomiting, and altered mental status.…”

Tailored suprainsular partial hemispherotomy: a new functional disconnection technique for stroke-induced refractory epilepsy

“…In addition, patients were evaluated for cerebrovascular abnormalities, cardiac disease, and the presence of any hematological or metabolic risk factors for stroke based on previously reported clinical experience. 1,19,25,28 All patients underwent a comprehensive battery of standardized neuropsychological tests, exploring intelligence and memory (immediate and delayed verbal and visual memory). Patients underwent neuropsychological evaluation when possible.…”

Incidence of Recurrence in Posterior Circulation Childhood Arterial Ischemic Stroke

“…Many centers use catheter angiography safely and effectively to confirm the diagnosis of dissection. 21 Furthermore, we excluded patients with strokes that affected both the carotid and vertebrobasilar systems; hence, more investigation is needed to describe this subgroup. Also, differences between our study and other cohorts might limit the generalizability.…”