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Table of Contents    
LETTER TO EDITOR
Year : 2020  |  Volume : 68  |  Issue : 6  |  Page : 1500-1501

Natural Prognosis of Pediatric Rotational Vertebral Artery Occlusion: A Reversible Case Report


1 Department of Stroke Center, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
2 Department of Imaging, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
3 Department of Ultrasonography, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China

Date of Web Publication19-Dec-2020

Correspondence Address:
Dr. Jingxin Zhong
Department of Stroke Center, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, NO.111, Dade Road, Yuexiu District, Guangzhou - 510 120, Guangdong
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.304095

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How to cite this article:
Mo X, Huang W, Li R, Lin H, Zhong J. Natural Prognosis of Pediatric Rotational Vertebral Artery Occlusion: A Reversible Case Report. Neurol India 2020;68:1500-1

How to cite this URL:
Mo X, Huang W, Li R, Lin H, Zhong J. Natural Prognosis of Pediatric Rotational Vertebral Artery Occlusion: A Reversible Case Report. Neurol India [serial online] 2020 [cited 2021 Jan 19];68:1500-1. Available from: https://www.neurologyindia.com/text.asp?2020/68/6/1500/304095




Sir,

Rotational vertebral artery occlusion (RVAO) is defined as dynamic occlusion of the vertebral artery (VA) induced by head rotation. Pediatric cases are rare and may be under-recognized. Here, we present a self-limited pediatric case with vertigo and syncope. Repeated dynamic assessments showed normal results, and no symptoms recurred after two years. This first assessment of the natural history of RVAO may draw attention to the recognition and management strategy of pediatric case.

A 6-year-old girl had experienced vertigo and syncope during rapid head rotation to the right when dancing, but she recovered after a few seconds. After admission, she experienced tension and tenderness in her cervical muscles. Dynamic color Doppler ultrasonography (CDU) showed the C2-3 section of the dominant LVA to be significantly compressed upon turning the head 90° rightward, with increased blood flow velocity and vascular resistance [Figure 1]. Correspondingly, transcranial Doppler (TCD) showed that the peak of systolic velocity of LVA decelerated from the basic value of 102 to 51 cm/s while the counterpart of RVA accelerated from 71 to 98 cm/s as compensation. Further rotational three-dimensional time of flight magnetic resonance angiography confirmed that significant compression at C2-3 section of LVA during head rotation to the right [Figure 1]. The girl was instructed to limit rapid and excessive head rotation. After two years of follow-up, her second rotational CDU and TCD results turned out to be normal [Figure 2], without symptoms or signs of recurrence.
Figure 1: Dynamic MRA, CDU and TCD findings

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Figure 2: Normal dynamic CDU and TCD after 2 years

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The incidence of RVAO is unknown, but it is thought to be rare, as most people are asymptomatic due to compensating contralateral circulation.[1] Most children present with vertigo but no syncope. Because pediatric cases are even rarer and may be under-recognized, the case we reported may arouse enough attention for pediatric clinicians to make a differential diagnosis for children complaining of vertigo or syncope. Detailed assessments are crucial to precise therapy. In this case, rotational CDU combined with TCD can offer reliable, real-time, and noninvasive assessments of both morphology and hemodynamics of the extra- and intracranial VAs.

RVAO treatment is debatable. A 2-year-old girl had a transient left-side weakness due to the atlanto-occipital ligament calcification. She was managed with anticoagulation and a rigid neck collar.[2] She had no further infarction after 1 year, but her RVA remained occluded when she turned her head to the left. Similarly, a RVAO teenager with cranio-vertebral junction anomalies had recovered from posterior fossa stroke, but the stroke only ceased to recur when his neck movement was restricted.[3] In our case, the symptoms might be caused by muscle tension and rapid head rotation.[4] Nonrecurrence might be partially caused by neck restriction and self-limiting process. Based on the initial assessment of the naturally reversible pediatric case, neurologists should be cautious when making a surgical therapeutic strategy for children with RVAO. Furthermore, which conservative management, such as medicine and neck immobilization, is appropriate for pediatric cases is worth exploring.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gregory FJ, Andrew TD. Bow hunter's syndrome revisited: 2 new cases and literature review of 124 cases. Neurosurg Focus 2015;38:1-15.  Back to cited text no. 1
    
2.
Nathan TC, Dana BH, Yaser AD, Monica SP, Jonathan GM. Atlanto-occipital ligament calcification: A novel imaging finding in pediatric rotational vertebral artery occlusion. Pediatr Radiol 2020;50:137-41.  Back to cited text no. 2
    
3.
Sathwik RS, Banuprakash AS, Thimappa H, Rajesh KN. Bow hunter's stroke – A rare presentation of CV junction anomaly: Case report. Neurology India 2012;60:520-1.  Back to cited text no. 3
    
4.
Choi KD, Choi JH, Kim JS, Kim HJ, Kim MJ, Lee TH, et al. Rotational vertebral artery occlusion mechanisms and long-term outcome. Stroke 2013;44:1817-24.  Back to cited text no. 4
    


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