Full text of DOI:10.1177/088307380001501011

Journal of Child Neurology
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Vertebral Artery Dissection and Migraine Headaches in Children
Timothy E. Lotze and Juliann Paolicchi
J Child Neurol 2000 15: 694
DOI: 10.1177/088307380001501011
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694
Dissection
Vertebral
Migraine
and
Artery
Headaches
in
Children
ABSTRACT
ofthe
Strokes
circulation are uncommonin childhood.
posterior
Invertebrobasilar
vertebral
dissectionremainsarare
artery
insults,
the
We
ofan
with a
case
report
boy
history
diagnosis.
8-year-old
presented
of
headacheswho
withacute cerebellar
migraine
signs
infarctions ofbilateralcerebellar
and
agitationfollowingmultiple
Vertebral
dissectionofthe
demonstrated
hemispheres.
angiography
left
basilar
distal
vertebral
withocclusion ofthe
arteryjust
artery
are
toits
with
of
Riskfactorsforvertebral
onassociationwith
dissection
origin.
artery
reviewed,
review
headaches.
A
emphasis
migraine
for
ofdissectionis also
studies
the
presented.
arterial
imaging
diagnosis
the
This
of
case demonstrates
importance
considering
wall
with
a
dissection in
of
history
pediatric patients
withnew
atypical
ChildNeu-
associated
findings. (J
neurologic
migraines
rol 2000;15:694-696).
The
of stroke in
estimated
childhood has been to be
incidence
2.52 cases
Vertebral
dissectionhasbeen
100,000
per
foundtobe
peryear.
artery
1.
Coronal fluid-attenuated
res-
Figure
onance
inversion-recoverymagnetic
increased
a
of
often
traumaticvertebral
consequence
arteryinjury,
both cerebellar
r
imagedemonstrating
the left medial
signal involving
the left medial
in
circulation stroke. There also have been
dissection or dissection associated
spontaneous
l
posterior
on
resulting
case
lobe,
hemispheres,
occipital
temporal
and
left
all consistentwith acute andsub-
thalamus,
the
lobe,
posterior
reports
acute infarcts.
with trivial
involves
of dissection
injuries.2-9
extension
usually
Etiology
flexion,
severeneck
or
butcertainriskfactorscan
dissection. Intheadult
pre-
pop-
an
individualto
dispose
spontaneous
unremarkable. His abdomenwassoft withoutmassor
His
organomegaly.
hasbeen
notedtobe
a
riskfactorfor dissection
ulation, migraine
ofthecranialvessels. 1° Our
he
no
examinationdemonstratedintact cranialnervesand
had
neurologic
be
case
that
reportsuggests
migraine
or
His
motorexamination
weak-
revealed
dysarthria
aphasia.
gross
right-sided
considered as another
in
cases of
sensationwas
intact. His lowerextremities were
possible
etiology
pediatric
ness ;
grossly
hypertonic
plantarresponsebilaterally.
with
reflexesandtherewasan
extensor
brisk
dissection.
Hedemonstratedmarkedright-greater-than-left dysmetria. Hehad
awide-
withnotable ataxia. Hehad
a
based
gait
positive Rombergtest.
Case
Report
A
CTscan revealed
andleftmedial
infarcts
the cerebellar hemi-
multiple
occipital
with
involving
who
R.M. is an
to the
Columbus
8-year-old right-handed boy
Hospital
presented
persistent,
lobe. Therewasnoenhancement. Further
spheres
evaluationwas
of
a
Children’s
with
a
frontal
complaint
Onthe
worsening
resonance
Multi-
performed
proton,
magnetic
imaging(MRI).
andcoronalfluid-atten-
axial,
of
headacheforthe
week.
theheadache
day
presentation,
previous
ple
sagittal,
wasassociatedwiththe acute onset of
Ti weighted
Tz weighted
ataxia, irritability, vomiting, blurry
history
previous year.
obtained of the brain. These
uated
were
inversion-recovery
images
and
medical
was
for
His
vision,
photophobia.
significant
migraine
fociofdiminished
andincreased
involv-
demonstrated
multiple
cerebellar
signal
headacheswithoutauraoverthe
Theseheadaches hadnot
T1
T2
occipital lobe,
(Figure 1).Thesefmdings
wereconsistentwithacuteandsubacuteinfarcts. Thecerebellartonsilswere
both
left medial
the
left
the
ing
medial
hemispheres,
lobe, andthe
beenassociatedwithweaknessorataxia. The
previously
hadbeen
migrainesinitially
ornonsteroidalanti-inflam-
thalamus
temporal
posterior
to
responsive
sleep, acetaminophen,
overthemonth to
theheadaches
presentation,
matorydrugs. However,
hadincreasedin
prior
also
notedtoextend
7
mmbelowtheforamen
resonance
Three-dimensional
magnum.
andintensity. Thepatient’smotheralso
reported
frequency
unexplained
fill-
showed
two
of
2
time-of-flight magnetic
angiogram (MRA)
defects withinthe circulation. The
posterior
mid-aspect
posterior
visualized
multiple
locatedinthe
lossofbalance weeks
to
episodes
prior
presentation.
was
A
scanwas
butwasunremarkable.
ing
largest
computed
tomographic(CT)
was
performed
propranolol
of thebasilar
andthe
artery.
communicating
at
takeoff
of the
second
the
Thevertebral arteries could not be
circulationwasnormal. Aleftvertebral
The
tried on
then
and
artery
largest
patient
initially
cyproheptadine
withoutrelief.
right
Theanterior
adequately.
demonstrated
There
of
was no
neck
history
fever,
stiffness, hypertension, coagu-
of head
a
defect
thrombusatthelevel
or
There
no
was
angiogram
(Figure2). Therewasalso
tothebasilar
filling
representing
lineardefect
lopathy,
trauma,
hemaglobinopathy.
significant history
incidents in which the
a
C2
ofC2
from
his
did
report
mother
two
minor
extendingcephalid
dissection. Therewas
although
arterialwall
slow
very
vessel wasfound
childhadstruckhishead. Neitherof theseinvolvedloss of
tip, representing
the vertebral
consciousness,
at this site.
A
collateral
flowwithin
of
neck
pain.
neck
or
artery
the vertebral
hyperextension,
sequelae
as it left the foramen
at
ofthever-
There
transversarium
On
blood
was
mm
112/57
the
artery
vertebral
reconstituting
admission,
beats
patient’s
pressure
Hg, pulse
exam-
the
The
showednormal
filling
C2 level.
was120
and
was36.2°C. On
physical
right
angiogram
temperature
perminute,
the left
tebral
artery
was occlusion
with
flow down
basilar
arteryjust
vertebral
but
follow
the
wasirritable and
could
commands.
artery.
ination,
Hisheadwas
retrograde
the
patient
agitated
andatraumatic. His
distal
its
There wasfill-
to
were
andreac-
of
origin.
normocephalic
were
pupils
equal
facies. His
Therewasno
of bilat-
filling
tive. Bilateral disc
Hehad
neck
symmetric
examinationwas
cerebellararteries.
sharp.
His
ingof both posteroinferior
margins
range
was
full
anteroinferior
cerebellararteries.
with
of motion.
eral
cerebellararteriesorthe
supple
cardiopulmonary
superior Right
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695
to
brae andmore
withrotation and
prone
injury
hyperextension.
Arterialwalldissectionoccurswhen
bloodextrudesintothemedial
ofthe
a
tearin
the intima. This often results
layer
in
artery
through
orocclusionof
stenosis
thevessel. Distal
cerebrovascular
the
symp-
resul-
toms canresult fromischemia
produced
occlusion,
by
tant
of
extension
thrombus
or
embolization,
formation,
subarachnoid
The
hemorrhage.2,11,12
ofarterial
wall dissection canbe
presentation
variable,
butheadacheis
acommon
Theheadachesare
complaint. 13
usually
described
as
and
withlocalizationnear-
can
sharp,
stabbing,
vessel. The
pulsating
of
estthe
for
onset
dissecting
to
pain
precede
missed
diagnosis
when the
is often
days
weeks; diagnosis
initially
headache
onset
A
of cerebral ischemic
his-
precedes
can further
symptoms.
of
It
be
in
the
delay
should
tory
migraines
diagnosis.
that
headaches due to arterial wall dissection
noted,
however,
areoften
incharacterfromtheusual
migraineurs
Other
atypical
migraine.l4
of arterial
wall dissection include cerebral
presentations
nerve
cranial
Horner’s
and
ischemia,
tinnitus. 13
palsy,
syndrome,
pulsatile
2.
Left vertebral
arrow demonstrates
arteriogram. Large
Figure
thrombusformation at the C2 level.
standard
the
Catheter
is consideredthe
for
angiography
diag-
arrowdemonstrates
large
Single
wall
nosis of
include
arterial
dissection.
double
Typical
cervicocephalic
intimal
fmdings
&dquo;string
have
started
vessel. Double arrowdemonstrates
defect to basilarr
collateral
filling
consistent with
arterial wall dissection.
orthe
lumen,
andMRA
extending
tip
flaps, pseudoaneurysm,
MRI
ofthevessel.
caused
bynarrowing
sign&dquo;
to
an
role in the
diagnosis
visualization of intimal
ofarterial
important
increasingly
play
normal
internalcarotid
demonstrated
ofvessels
sedi-
level, erythrocyte
include
nar-
wall dissection. 15
appearance
arteriography
rightposterior
Findings
clot. Themethod
withfilling ofthe
complete
mentation
cerebral
artery.
whichthe arterial
andthe intramural
by
rowing
A
blood
serum lactic acid
count,
should
depend
have
must
on
a
numberof
walldissection
different
with
is diagnosed
androutine blood chemistries werenormal. His
rate,
coagula-
and
in
The
factors.
radiologist
experience
diagnosis
tion
was normal and
included
profile
counts,
platelet
and antithrombin
prothrombin
in
ver-
diagnosing
dissec-
MRAhasbeenfoundtobeless sensitive
MRA.
III
levels. His antinuclear
His C3andC4pro-
negative.
partial thromboplastin times,
andextractablenuclear
were
as
dissection
to carotid
tebral
antibody
teins were normal. His
antibody
rapid plasma
artery
artery
compared
was
An
nonreactive.
reagin (RPR)
foramen
for
Catheter
alsomuchmoresensitive
the
associ-
iftheclin-
angiographyis
tion.15,16
demonstrated
a
small
ovale
patent
wasotherwise normal.
echocardiogram
(approxi-
in
from
ofsubarachnoid
aneurysm
hemorrhage
diagnosis
2
to
3
mately
The
mm)but
arterialwalldissection.
as inour
Finally, case,
arterial wall dissection
suggest
with
ation
was admittedto the intensive care unit for close obser-
patient
and
MR
the
ical features
Initial
vation.
medical
included maintenance of strict eu-
strongly
indeterminate,
Althoughsonographyis
management
and
of
the
initiation
Over
aspirin.
first 72
are
then catheter
should be
volemia, supine
the
positioning,
angiography
sensitiveinthe
findings
demonstratedslowresolutionofhis
His
hours,
sided
patient
agitation.
right-
fairly
diagnosis
vertebral
performed. 15
arm
becamemore
withthe
moreinvolvedthan
hemiparesis
He
apparent
in
of
arterial wall
its role
carotid
dissection,
diagnosing
the
nerve
VIth
right-sided
a
transient
associatedwith
palsy
leg.
developed
is limited because the dissection is
often distal
dissection
artery
tothe
andesotropia, which
his acute course. The
resolved
diplopia
during
with word
patient
pronunciation.
can
sitethat
bevisualized.
canincludean
Findings
wasalsonotedto have
and
echogenic
or abnormal flow velocities.
difficulty
characterized
fmding
His subacute course
behavior
with
was
intimal
by
impulsive
pronounced
showeddifficulty with
flap, echogenic thrombus,
was
in
his
some
that
more
than
cognitive inflexibility
morbidstate.
pre-
con-
ofarterial wall
of
dissectionshould
sonographysuggestive
Findings
Comprehensivetesting
of
reading,
with
confirmed
the othermethods. 15
be
and
centration,
verbal
complexvisualstimuli, receptiveprocessing,
integration
with
traumais most
in association
Although
dissection
commonlyreported
some
His ataxia
overthe
it
memory.
improved
ambulation. Hehad
hospital course, although
ofthecervicalvertebral
case
with
artery,
reports,
to
wasstill
ofhis
present
independent
MRI and MRAwere
persistence
to dis-
donot
a
oftrauma
history
remainunclearin
clear
dysmetria.
performedjust prior
right-sided
ours,
provide
including
prior
diag-
Thesedemonstratedsubacuteinfarcts ofbilateral cerebellarhemi-
charge.
Theexact
nosis.9,17,18
etiologymight
arterial
manycases.
left medial
and left medial
defectsbut
spheres,
occipital lobe, posterior thalamus,
demonstrated
walldissection
Marfan’s
for
includefibro-
Riskfactors
spontaneous
lobe. The
basilar
temporal
no
artery
injury.
persistentfilling
medial
and
muscular
dysplasia, cystic
necrosis,
syndrome,
evidence ofnew
Onfollow-up
4.9 In
acase-control
Ehlers-Danlos
syndrome
type
study,
the
wasnotedtohavehad
a
dra-
D’Angle-
association
appointments,
in
patient
matic
minimal
headache
He demonstrated
al
et demonstrated
a
improvement
weaknessand
frequency.
onthe affected side withlittle or noataxia.
positive
arterial wall dissection inthe
jan-Chatillon
between
strong
dysmetria
and
spontaneous
migraine
riskfactorof
themean ofthe
age
alsonotedtheadditional
cur-
adult
population. They
Discussion
use. 10
rentoral
included
Because
contraceptive
inthis was42
patients
these
Arterial wall
the
most
dissection of
vertebral
at the
artery
commonly
study
pediatricpopulation.
Theincidenceof strokeintheabsenceofotherrisk
years, it is difficultto
extrapolate
occurs in
level. Theshort
as
Cl to C2
the extradural
vertebral
segment
body
not
datato the
at
arterial
the
theatlantoaxial
junctionis
segment
migraine
hasbeenestimatedto be 1.44
transverse foraminaofthe lower
bony
verte-
protected
by
factors
per 100,000 populationper
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696
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age. P1e9d9i7a;t1r6:N6e7u-r7o0L.
8.
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S,
This
the
is similarto
baseline risk of
Aykut-Bingol
year.
pediatric population’s
dissectionin
young
Mokri
arteries
stroke. Theexact
of
stroke is uncertain. Stroke
etiology
migraine
with auraandhas
D:
dissections of cer-
Schievink
W,
B, Piepgras
Spontaneous
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al,19
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of
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41:55-61.
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dur-
et al: Vertebral
dissection:
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Bonnemann
C,
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cervicocephalic
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canthenleadto significanttrauma
vessel. 15
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the cause ofstroke
migraine. Angiography
D,
diagnosisandmP19ea9d6ni;aa1tg4re:2mN5ee5-un2rt5o8.l.
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more
likely.
Arterial wall dissectionis the causeofstrokein 5%to 20%of
In addition to
for
a
patients.2°
the
history
possible
young
eliciting
also should be screened for risk factors of
trauma,
patient
headaches.
arterialwall
spontaneous
dissection,
migraine
including
if
a
with an
Conversely,
in
patientpresents
atypical migraine, espe-
the
Early-Onset
Syndrome
Moyamoya
with
in
a
PatientWithDown
cially
conjunction
pos-
and
persistentneurologic findings,
Syndrome:
of arterial wall dissection should be considered
Case
andReviewofthe Literature
sibility
additional
Report
explored.
imaging
neuroloradiologic
ABSTRACT
E.
MD
Timothy
Juliann
Lotze,
MD
Paolicchi,
disease is
a
chronic occlusive cerebrovascular disor-
Moyamoya
Department of Pediatric
Columbus Children’s
Neurology
It can
a
associated
der.
occuras
disease orasa
primary
syndrome
Hospital
with
a
ofconditions.
takes
a
1
to
2
to
variety
Usuallyit
years
develop
Ohio
Columbus,
We
a
classic
20-month-old
with
report
moyamoyapattern.
and
girl
whopresented
Down
seizure
case
with
syndrome
and
moyamoya syndrome
To our
ReceivedJune
lication
Receivedrevised
1999.
for
21, 1999.
Sept21, 1999.
Sept20,
Accepted
pub-
is
this
the
hemiparesis.
youngest
knowledge,
with
and Down
moyamoya syndrome
syndrome.
and
reported
Address
to DrJuliann
Section of
correspondence
Paolicchi,
700Children’s
Neurology,
OH
ColumbusChildren’s
fax:
43205. Tel:
The
treatment
andcurrent
ofmoyamoyasyndrome
Columbus,
Hospital,
614-722-4670;
Dr,
jpaolicc@chi.osu.edu.
prognosis
e-mail:
614-722-4605;
is some
reason
its relationtoDown
arereviewed. There
syndrome
that the abnormalities associated with Down
to
speculate
syn-
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a
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