Vertebral Artery Dissection After A Water Slide Ride

Presentation:

A previously healthy 15 years old boy, presented to ER with headache, vertigo, nausea, vomiting and blurred-vision, symptoms started 6 days ago after head trauma while riding a water slide during school trip with subsequent loss of consciousness, he was admitted for further evaluation.

Vital signs were normal, physical examination revealed ataxia, photophobia, no motor or sensory deficits and intact cranial nerves.

Blood workup included CBC, chemistry, hormones, electrolytes and coagulation which were normal, toxicology tests negative.

EKG show sinus rhythm, normal funduscopy.

Head-CT showed No pathologic findings.

Discussion:

Differential diagnosis included head concussion, autoimmune disease, blood disorders, CVA, bleeding, SOL, ICP, hypertension& toxicology.

History of recent head trauma narrowed the differential diagnosis and it thought to be the main contributing factor for his symptoms.

Head-CT &neck-CTA show no-pathological findings, due to aggravation of symptoms, head-neck MRI &MRA ordered which revealed Sub-acute infarction at the right posterior Medulla Oblongata, changes in right vertebral artery with intramural hematoma these findings were concerning for vertebral artery Dissection(VAD) , Neurosurgeoan and hematologist were consulted which recommended medical management with anticoagulant medication(LMWH).

Ultimately, it was thought that head trauma form the water slide caused the dissection, while neurologic symptoms were attributed to ischemic changes from VAD

The patient referred to neurological rehabilitation center, with improving in his symptoms.

Conclusion:

VAD is a rare pediatric finding, should be considered as cause of stroke.

CT is first performed to exclude brain hemorrhage, followed by CTA to identify VAD. MRI &MRA more sensitive in children.