Extracranial traumatic carotid artery dissections in children

Field: Medicine (Health Sciences)

Stroke in children as a result of traumatic injury to the extracranial carotid artery (CA) circulation is fortunately a rare event. After an extensive literature search, Chamoun et al. systematically reviewed 19 case reports in small series totaling 34 pediatric patients. There are several important points with regard to children that the authors have pointed out. First and foremost, an extremely high index of suspicion should be entertained given the facts that obtaining a history is difficult and neurological findings can be obscured by injuries to other organ systems.6,7 Appropriate imaging studies should be performed urgently when a neurological finding is obvious and, more importantly, even if one has only a suspicion based on the mechanism of the traumatic event.5 In this review, disease was diagnosed in all 34 patients only after the onset of ischemic symptomatology. In patients involved in accidents resulting in polytrauma, routine imaging of the spine is often performed, and based on this evaluation, MR and/or CT dissection protocols should be part of the evaluation.10 In the older literature, 24 of 34 patients underwent cerebral angiography to confirm the diagnosis but no intervention was performed. Of the 34 patients, 30 were treated with medical therapy, primarily either antiplatelet or warfarin therapy. Even though the number of patients in the series is small, 50% of those treated with observation alone died as a result of a cerebrovascular accident caused by the dissection. As in the adult population, surgical correction of dissection is rarely needed.1 If the dissection heals with significant residual stenosis, then endovascular treatment with or without stenting is currently recommended, although no prospective randomized trials or even a significant number of case reports currently exist in the literature.2 Correction with interposition grafting is usually necessary if surgical intervention is required, and endovascular options do not exist because of anatomical variations or concerns about long-term anticoagulation therapy. I concur with the authors that the issue of the type of anticoagulation utilized is very controversial and debatable.3,4,8,9 The majority of patients in the adult population are treated with warfarin for a period of 3–6 months and thereafter are often converted to antiplatelet therapy depending on imaging studies of the vessel in question. In our experience with 42 dissections of the extracranial CA circulation in adults, 80% of these have healed with anticoagulation therapy, and only 20% have required an intervention related to residual high-grade stenosis or more commonly a residual intimal flap. Although there are no guidelines, as the authors alluded, warfarin anticoagulation in the pediatric population is extremely problematic, and I concur that the first line of treatment should be antiplatelet therapy. In the pediatric population, as in the adult group, an extremely high index of suspicion must be entertained and early imaging must be performed to confirm or refute the diagnosis of dissection, as the resultant mortality rate associated with an undiagnosed or untreated lesion is extremely high. With the newer imaging modalities, I do not believe that intraarterial angiography is necessary, because MR dissection protocols plus or minus CT angiography as a confirmatory test can often eloquently make the diagnosis of dissection and characterize the lesion quite effectively and with significant detail. These tools are also extremely invaluable in follow-up imaging, which is generally performed at 3or 6-month intervals. Ultrasonography alone is usually insufficient to provide the type of anatomical information required but is useful in determining if significant turbulence or hemodynamic stenosis exits. I am grateful to the authors for performing such an extensive review of this extremely uncommon but potentially devastating problem, and the information provided should indeed be in the data bank of knowledge for all individuals taking care of this type of population.