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Table of Contents    
CASE REPORT
Year : 2021  |  Volume : 69  |  Issue : 2  |  Page : 478-479

Isolated Cervical Pain Revealing a Common Carotid Artery Dissection in a Child Following a Minor Trauma: A First Pediatric Case Report and a Review of the Literature


Department of Neurology, Military Hospital of Tunis, Monfleury, Tunis, Tunisia

Date of Submission18-Feb-2020
Date of Decision10-Jun-2020
Date of Acceptance08-Jul-2020
Date of Web Publication24-Apr-2021

Correspondence Address:
Dr. Manel Akkari
Cleopathre Residency, APT C3-3, Menzah 7 bis, Ariana 2037
Tunisia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.314524

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 » Abstract 


Background: Cervical artery dissections are not exceptional in the pediatric population. Typically, it affects the internal carotid artery or the vertebral artery. To our knowledge, this is the first case of common carotid artery (CCA) dissection in a child.
Case: We present a case of a 7-year-old-boy admitted to our neurology department complaining of cervical pain after a minor neck trauma. The neurological examination was normal. The ultrasound showed a mural hematoma with an intimal flap. The magnetic resonance angiography revealed an irregular segment of the left CCA just before its bifurcation. The diagnosis of an acute dissection on the left CCA was confirmed and antiplatelet therapy was started.
Conclusion: The diagnosis of cervical artery dissections remains a challenge because of its variable clinical presentation. It should be suspected in the context of neck trauma and treatment should be initiated rapidly to reduce the risk of ischemic stroke.


Keywords: Cervical artery dissection, common carotid artery, isolated cervical pain, pediatric case
Key Message: In the pediatric population, a cervical artery dissection may complicate a minor trauma, and it should be suspected even in the absence of ischemic symptoms. Here, we present the first pediatric case of a common carotid artery dissection.


How to cite this article:
Messelmani M, Akkari M, Souissi W, Mrissa R. Isolated Cervical Pain Revealing a Common Carotid Artery Dissection in a Child Following a Minor Trauma: A First Pediatric Case Report and a Review of the Literature. Neurol India 2021;69:478-9

How to cite this URL:
Messelmani M, Akkari M, Souissi W, Mrissa R. Isolated Cervical Pain Revealing a Common Carotid Artery Dissection in a Child Following a Minor Trauma: A First Pediatric Case Report and a Review of the Literature. Neurol India [serial online] 2021 [cited 2021 May 15];69:478-9. Available from: https://www.neurologyindia.com/text.asp?2021/69/2/478/314524




Craniocervical artery dissection (CCAD) is a frequent cause of acute ischemic stroke in children, causing around 10% of all cases of arterial ischemic stroke (AIS).[1] Typically, CCAD affects the internal carotid artery or the vertebral artery. Here, we report the first pediatric case of a common carotid artery (CCA) dissection revealed by isolated cervical pain after a minor trauma without ischemic stroke.


 » Case History Top


A 7-year-old boy, with no medical history, was admitted to our department with new onset cervicalgia. His mother reported a preceding history of trauma with an acute movement of hyperextension of the neck. The pain was moderate and predominantly in the left anterior side of the neck. It was continued without headache, vomiting, heaviness, vertigo, or visual disturbance. The neurological examination was normal. The ultrasound visualized mural hematoma with an echogenic intimal flap [Figure 1]. His magnetic resonance imaging scan of the brain revealed no ischemic lesions. MR angiography (MRA) showed an irregular segment of the left CCA just before its bifurcation with a linear filling defect. The diagnosis of Craniocervical artery dissection (CCAD) without brain ischemia was made. Antiplatelet therapy was introduced. Within a few days, the cervical pain had disappeared. Our patients remained asymptomatic after three years of follow-up.
Figure 1: Cervical ultrasound showed an intimal flap with pericarotid hematoma

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 » Discussion Top


Our observation highlights the particularity of the clinical presentation of pediatric CCAD, leading sometimes to diagnostic delay. Clinically, the context of post-traumatic neck pain was highly suggestive of cervical artery dissection. In the pediatric population, AIS because of CCAD can be preceded by prodromal signs, such as dysarthria, vision loss, hemiparesis, or any other focal neurologic deficit.[2] The diagnosis of CCAD in children is challenging for clinicians as clinical signs are general rather than specific with an isolated headache or cervical pain.[3] So far, our case is the first one that reported an isolated cervical pain as the only clinical presentation of pediatric CCAD.

In most centers, MRI/MRA has become the first-line complementary exam in cases with suspected dissection.[2] Although MRI is reported to be more sensitive, transcranial doppler ultrasound has been increasingly used in children with suspected CCAD. This noninvasive modality is easy and available 24/7 and could make an important contribution to the diagnosis of critically ill patients.[4] The International Pediatric Stroke Study defines CCAD as angiographic double-lumen separated by an intimal flap with pseudoaneurysm. Hence, no recommendations concerning imaging modalities are currently available.

In the pediatric population, just like adults, the treatment of CAD is still controversial. Although anticoagulation is the advocated and the most commonly used treatment in children with dissection, there are no randomized trials comparing the efficacy of antiplatelet therapy versus anticoagulation in pediatric CCAD.[5] In patients who are refractory to medical treatment, endovascular treatment with intra-arterial thrombolysis and stent reconstruction is considered.[6] In our patient, treatment with antiplatelet drugs was successful with a good outcome after a follow-up reaching more than three years.

We suggest then that CAD should be considered as a potential diagnosis in all children who present with a new onset of cervical pain even without a history of violent trauma.[7] Early diagnosis and treatment are important, as they can reduce the risk of propagation of the clot from the dissection site, prevent ischemic lesions, and, subsequently, prevent focal neurological symptoms that could be irreversible.[2]


 » Conclusion Top


CAD in children is not rare, and when it is not diagnosed on time, it can cause ischemic brain lesions. Besides the context of severe head or neck traumas and neurological focal symptoms, isolated cervical pain after a minor trauma should suspect the diagnosis of CAD. To confirm the diagnosis, many imaging modalities, such as MRI/MRA and cervical ultrasound, are available. There is no consensus treatment for pediatric CAD. Whatever is the medication chosen, treatment should be initiated rapidly to reduce the risk of acute ischemic stroke

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Fuerte A. Craniocervical arterial dissection: A common cause of stroke in childhood [Internet]. Available from: https://journals.heart.org/bloggingstroke/2019/05/10/craniocervical-arterial-dissection-a-common-cause-of-stroke-in-childhood/. [Cited 2020 Jun 10].  Back to cited text no. 1
    
2.
Nash M, Rafay MF. Craniocervical arterial dissection in children: Pathophysiology and management. Pediatr Neurol 2019;95:9-18.  Back to cited text no. 2
    
3.
Orman G, Tekes A, Poretti A, Robertson C, Huisman TAGM. Posttraumatic carotid artery dissection in children: Not to be missed! J Neuroimaging 2014;24:467-72.  Back to cited text no. 3
    
4.
Chamoun RB, Mawad ME, Whitehead WE, Luerssen TG, Jea A. Extracranial traumatic carotid artery dissections in children: A review of current diagnosis and treatment options. J Neurosurg Pediatr 2008;2:101-8.  Back to cited text no. 4
    
5.
Basso A, Desrumaux A, Lametery E, Bouzat P, Mortamet G. Transcranial doppler as a useful tool in the detection of cervical steno-occlusive arteriopathy in infants. Arch Pediatr 2019;26:415-8.  Back to cited text no. 5
    
6.
Roach ES, Golomb MR, Adams R, Biller J, Daniels S, Deveber G, et al. Management of stroke in infants and children: A scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke 2008;39:2644-91.  Back to cited text no. 6
    
7.
Lai YJ, Chang FC, Lin C-J, Hsieh TC, Wang KL. Endovascular therapy in pediatric intracranial carotid artery dissection. Pediatr Neurol 2010;42:291-4.  Back to cited text no. 7
    


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