Vertebral Artery Dissection Leading to Multiple Strokes Presenting as Recurrent Paroxysmal Vertigo

Acute ischemic stroke (AIS) is an uncommon phenomenon in the pediatric population with an annual incidence rate of 1.2-8/100,000 with a marked predominance for the anterior cerebral circulation. Strokes in the posterior (vertebrobasilar) circulations are less common and have higher recurrence rate. The most common underlying etiologies include arteriopathy, cardiac disease, and hematologic conditions.

We present here a case of a nine-years-old boy who presented with recurrent paroxysmal self-resolving vertigo episodes. His physical examination including neurological assessment was unremarkable. Initial laboratory workup and ECG were normal. Given the persistence of his symptoms, he underwent a brain MRI demonstrating multiple cerebellar lesions consistent with acute and subacute ischemic strokes. Full etiologic investigations including hypercoagulability analysis, cardiac and metabolic studies were negative. Subsequent brain CTA was inconclusive for vertebral artery dissection. A week later, despite Enoxaparin and Aspirin treatment, the patient experienced recurrent vertigo episodes correlating with additional strokes in the posterior circulation. Consequently, Enoxaparin dosage was increased and the patient underwent urgent angiography demonstrating cervical left artery dissection with no clear preceding history of trauma. At that point it was decided to pursue conservative management. The patient was free of symptoms and no evidence of AIS on a follow-up MRI ten weeks later.

The diagnosis of stroke in children is challenging and requires a high index of suspicion. Paroxysmal vertigo is a relatively uncommon presentation. Recurrent AIS is more common in arterial dissection and AIS in the posterior circulation within the first three months following the initial episode.