Vertebral Artery Dissection in Children: A Comprehensive Review

Abstract

Vertebral artery dissection (VAD) has been infrequently recognized in children. The authors have reviewed 68 reported cases of VAD in children in the existing literature. An association between routine types of neck movement in sports and the evolution of VAD was recognized in half of the reported cases. Boys outnumbered girls by a ratio of 6.6 to 1, in contrast to adults, for whom the male to female ratio is approximately equal (1.3 to 1). Neck pain, one of the hallmark symptoms of VAD in adults, was infrequently noted in this young population (12%). Most children presented with various combinations of symptoms and signs, including ataxia (53%), headache (38%) and vomiting (34%). Eye signs or symptoms were noted in 72% of patients, and paresis/paralysis of one or more extremity occurred in 54%. Angiography was the method most frequently used to diagnose VAD (63/68; 93%). Magnetic resonance angiography (MRA) revealed pathognomonic signs of VAD in only 3 out of 13 patients evaluated (23%). In this series of 68 patients, 48 reports failed to indicate whether or not a cervical X-ray was performed, but in the 20 patients for whom such information was recorded, half had skeletal abnormalities in the occipital/atlas/axis region. The most common treatments were antiplatelet therapy (n = 15) and anticoagulation with (n = 8) or without (n = 7) supplemental antiplatelet therapy. Asymptomatic recovery occurred in 12 of the 15 patients (80%) who received antiplatelet therapy compared with 4 of the 15 patients (27%) who received anticoagulation therapy with or without antiplatelet therapy. There is a very high incidence of associated cervical anomalies in children with VAD. Further studies are required to determine if noninvasive examinations such as magnetic resonance imaging, ultrasonography, computed tomography angiography and MRA could replace angiography as the modality of choice in establishing the diagnosis of VAD in children. The role of different therapies for children presenting with symptoms related to VAD is unclear.

Traumatic Vertebral Artery Dissection in a Child with Brachial Plexus Injury

“…Ouvrier and Hopkins [9] first reported angiographically confirmed TVAD in two children in 1970. The overall incidence of stroke in children has been estimated at about 2.5 per 100,000 and stroke after TVAD is rarely reported [3, 6, 7, 13]; however, TVAD is an important cause of brain stem stroke in children.…”

“…There is a very high prevalence of associated cervical anomaly in children with TVAD [3]. Giacobetti et al [2] reported flexion/distraction-type injuries to be the most common mechanism in nonpenetrating vertebral artery injuries, followed by flexion compression mechanism.…”

“…No guidelines have yet been established as to the time and means of anticoagulation or antiplatelet therapy: intravenous heparin followed by 6 weeks to 6 months of warfarin has been used [1, 5]. Then, the therapeutic regimen may be changed to an antiplatelet drug [3]. …”

Blunt traumatic vertebral artery injury: a clinical review

“…The V2 segment is the most commonly affected in adult TVAI [9,16]. In infants and children, the V3 and upper V2 segment are more commonly affected [17,53]. This may be related to the higher laxity of ligaments at the craniocervical junction in children associated with lower velocity trauma, while in the adult population most of the injuries relate to highimpact trauma with forced flexion/extension and lateral rotation involving the whole of the cervical spine.…”

Extracranial vertebral artery dissection in children: natural history and management

“…Only limited data are available concerning this type of dissection [4,8,9]. A review of the literature [10] revealed 68 paediatric cases of vertebral artery dissection, but few details have been reported concerning their clinical and radiological outcome.…”