Vertebral Artery Dissection Masquerading as Concussion in an Adolescent

Area of Science:

• Neurology
• Pediatric Medicine
• Vascular Imaging

Background:

• Traumatic vertebral artery dissection (VAD) is an infrequent but serious cause of ischemic stroke in children.
• VAD diagnosis can be challenging, often presenting with non-specific symptoms that mimic less severe conditions like concussion.
• Delayed diagnosis of VAD can lead to significant morbidity and mortality due to thromboembolic events and secondary complications.

Observation:

• A 16-year-old male presented with confusion post-wrestling, initially diagnosed with concussion despite normal initial neuroimaging.
• Deterioration occurred within 10 hours, marked by altered mental status, hypertension, and decerebrate posturing, necessitating emergent intubation.
• Repeat imaging revealed extensive cerebellar and brainstem infarction secondary to left vertebral artery dissection and near occlusion.

Findings:

• Computed tomography angiography and magnetic resonance imaging confirmed dissection of the left vertebral artery at C2.
• The patient developed acute hydrocephalus due to cerebellar edema and suffered extensive infarcts in the cerebellum and brainstem.
• Despite intensive care, the patient had limited brainstem function, requiring transfer to a rehabilitation facility.

Implications:

• This case underscores the critical need for a high index of suspicion for VAD in pediatric patients with head/neck trauma and neurological deficits.
• Thorough neurological examination and timely, appropriate imaging (CTA/MRA) are essential to differentiate VAD from concussion and prevent catastrophic stroke.
• Early identification and management of pediatric traumatic vertebral artery dissection are vital to improve patient outcomes and reduce long-term disability.