The Journal of Emergency Medicine, Vol. 36, No. 1, pp. 30 –33, 2009
Copyright © 2009 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/09 $–see front matter

doi:10.1016/j.jemermed.2007.02.037

Clinical
Communications: Pediatrics

A PRESCHOOL-AGE CHILD WITH FIRST-TIME SEIZURE AND ATAXIA
Joan Papp, MD and Steven T. Dorsey, MD, FACEP
Department of Emergency Medicine, Cleveland Clinic, Cleveland, Ohio
Reprint Address: Steven T. Dorsey, MD, FACEP, Department of Emergency Medicine, E19, Cleveland Clinic, 9500 Euclid Avenue,
Cleveland, OH 44195

e Abstract—We present a case of a 4-year-old previously
healthy child who had a possible first-time seizure at home,
and upon a second Emergency Department evaluation was
found to have gross cerebellar ataxia suggestive of acute
stroke. Initial computed tomography scan and metabolic
work-up were unrevealing. Subsequent neuroimaging demonstrated stroke in the left medulla and cerebellum secondary to left vertebral artery dissection. Cervical artery dissection may cause up to 20% of strokes in childhood and
adolescence. Unlike typical adult presentations, antecedent
or concurrent head and neck pain occurs less often in
pediatric dissections. Symptoms of posterior circulation
ischemia resulting from vertebral artery dissection may
include vertigo, vomiting, ataxia, dysarthria, and seizure.
Willingness to utilize newer, non-invasive imaging modalities may lead to earlier recognition of cervical artery dissection when patients have prodromal symptoms or episodes of transient ischemia. Vertebral artery dissection
should be included in the differential diagnosis when evaluating children with first time seizure, headache, or neck
pain. © 2009 Elsevier Inc.
e Keywords—vertebral artery
stroke; anticoagulation; ataxia

dissection;

sibling because the patient “could not move.” She found
her son awake and lying supine on the floor, sluggish to
respond to verbal and tactile stimuli. The brother reported that the patient had abruptly fallen down and had
been making “choking sounds.” His mother took him to
a local ED, where he was evaluated and discharged home
with a diagnosis of seizure. His symptoms had seemed to
resolve spontaneously by the time of that evaluation, but
one hour before presentation to our ED, his mother
noticed that he was falling to the left while ambulating,
and seemed sleepier than usual. He also had vomited
twice, and was hiccoughing frequently.
On review of systems, the patient had been generally
well. The past medical history was significant for frequent otitis media, seasonal allergies managed with loratadine, and hospitalization at age 1 year for pneumonia.
He was the product of an uncomplicated pregnancy, but
required 5 days of phototherapy after birth for hyperbilirubinemia. The immunizations were up to date.
Vital signs on presentation were: oral temperature
36.9°C, pulse 96 beats/min, respiratory rate 20 breaths/min,
and 97% saturation by pulse oximetry. General appearance,
hydration status, and cardiorespiratory examination were all
normal. On neurologic examination, the child was alert
and oriented, and was watching cartoons. The cranial
nerve examination was normal except for mild dysarthria. The muscle strength was normal. When asked to
ambulate, he was grossly ataxic, began to fall, and had to
be caught to prevent him from falling against the wall of
the examination room.

pediatrics;

CASE REPORT
A 4-year-old child was brought to the Emergency Department (ED) by his mother with a chief complaint of
“he keeps falling down.” Seven hours before presentation, she had been called to her son’s bedroom by a

RECEIVED: 31 August 2005; FINAL SUBMISSION RECEIVED: 18 July 2006;
ACCEPTED: 16 November 2006
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Seizure and Ataxia in a Preschool-Age Child

31

Figure 1. MR image with white arrow demonstrating stroke
in the left medulla.

Electrolytes, complete blood count, and urine toxicology
screen were normal. A non-contrast head computed tomography (CT) scan was interpreted as normal. The child was
subsequently admitted to the general pediatrics service for
neurology consultation and additional neuroimaging.
Upon admission to the pediatric ward, intravenous
heparin was initiated. On hospital day 2, magnetic resonance imaging (MRI) demonstrated posterior inferior
cerbellar artery (PICA) distribution stroke (Figure 1,)
whereas magnetic resonance angiogram (MRA) demonstrated a cut-off of the left vertebral artery (Figure 2.) CT
angiography performed on hospital day 3 confirmed left

Figure 3. CT angiography image demonstrating similar anatomy to Figure 2. White arrow indicates right vertebral artery.
Black arrow indicates terminus of otherwise occluded left
vertebral artery.

vertebral artery occlusion secondary to vertebral artery
dissection (VAD) (Figures 3, 4.) The patient’s ataxia
improved substantially over the next several days, and he
was transitioned from unfractionated heparin to subcutaneous dalteparin. He was discharged home on levetiracetam for seizure prophylaxis. Other than subsequent ED
visits for unrelated complaints, the patient has been lost
to follow-up, but the ED records note that anticoagulants
have been discontinued and the child’s neurologic deficits have resolved.

DISCUSSION
Figure 2. MRA reconstructed image with black arrow indicating terminus of occluded left vertebral artery, visible due
to back-filling with gadolinium.

Stroke is rare in childhood. Limited retrospective data
suggest an incidence of approximately 2.5 to 3.1 cases

32

Figure 4. CT angiography image, coronal reconstruction.
White arrows demonstrate right vertebral artery. Note absence of similar structure on the left side.

per 100,000 children per year (1). Whereas cervical
artery dissection accounts for only 2% of stroke in adults,
it may be responsible for up to 20% of stroke in childhood and adolescence (2). As in adults, carotid artery
dissection is much more common than VAD (1,3,4).
Pediatric cervical artery dissections of both varieties
occur more often in boys than girls (1,3,5). This predilection has been attributed to a higher rate of traumatic
injury in males, but actually persists when cases of
trauma are excluded (5). Although most cases of VAD in
children can be attributed to antecedent traumatic injury,
many cases are labeled as spontaneous or idiopathic
when they occur in a previously healthy child without
underlying congenital defect or vasculopathy. Most dissections occur at the level of the first and second cervical
vertebrae, an area of relative vulnerability due to rotation
at the atlantoaxial junction and lack of bony protection
afforded to lower segments, and thus many cases labeled

J. Papp and S. T. Dorsey

“spontaneous” may be due to insults so trivial that they
are forgotten or go unnoticed (5).
Before uniting at the base of the pons to form the
basilar artery, the vertebral arteries give off anterior and
posterior spinal branches as well as the posterior inferior
cerebellar arteries, which supply the medulla and portions of the cerebellum. The vertebral arteries also supply
perforating vessels to the medulla (6). VAD causes ischemic symptoms either through limiting bloodflow to
branch vessels or through resulting thromboembolic occlusion of distal branch vessels. Patients with VAD may
present with a variety of symptoms including vertigo,
profound nausea and vomiting, dysarthria, hemiparesis,
ataxia, and seizure (4,5,7). A classic Wallenberg syndrome may occur, with loss of temperature and pain
perception on the ipsilateral face and contralateral side of
the body from the neck down, a unilateral Horner’s
syndrome, dysarthria, and vertigo. Prodromal or concurrent occipital headache or ipsilateral neck pain may herald VAD, but occur in less than 50% of affected children;
this is in contrast to VAD in adults, where pain occurs in
the majority of cases (3–5,8).
Conventional angiography remains the gold standard
for diagnosis of cervical artery dissection, and may demonstrate luminal stenosis, aneurysmal dilatation, or the
most specific finding, an intimal flap (2,4). Newer noninvasive imaging modalities are now widely available,
and are particularly preferable in children. MRI and
MRA are most often employed, and were diagnostic in
this case, but may miss lesions in the case of posterior
circulation dissection (1,3,9). Hyperintensity in the vessel wall on axial MRI imaging, the crescenteric hematoma sign, is a pathognomonic finding when corroborated with filling defects on MRA (4). CT angiography
may be more readily available at major centers, and has
the advantage of speed along with the ability to demonstrate precise anatomy through detailed three-dimensional reconstructed images. With regard to additional
work-up beyond diagnosis of the culprit lesion, Ganesan
et al. recommend complete cervical spine evaluation, as
three patients in their series had hypermobility thought to
have contributed to the VAD (3).
Management of VAD in pediatric patients is controversial. Due to the rarity of VAD in the pediatric population, there are very few data available for the practicing
clinician regarding therapeutics; in fact, no randomized
trial regarding management for acute stroke in children
exists (10). Other than anecdotal reports, no investigative
data exist on systemic thrombolytic therapy in the setting
of pediatric ischemic stroke, and most children present
beyond the accepted thrombolytic window (10). Because
most ischemic events related to VAD are thought to be
due to thromboembolic events, systemic anticoagulation
is widely utilized; however, efficacy of anticoagulation

Seizure and Ataxia in a Preschool-Age Child

has not been prospectively validated (1,5). In Fullerton
et al.’s meta-analyis of pediatric cervical artery dissection, none of the 14 VAD patients presenting before 1990
was anticoagulated, and only three patients were treated
with an anti-platelet agent, whereas among 29 VAD
patients who presented after 1990, one-third were treated
with anticoagulants, one-quarter were treated with antiplatelet agents, and one-fifth of patients were treated with
both (5). Mortality and recurrence of dissection were
lower among patients receiving anticoagulation. Two of
29 patients who were anticoagulated had serious bleeding complications. Overall mortality from VAD was 2%,
as opposed to 33% mortality in the group with anterior
circulation dissection (5). In Ganesan et al.’s case series
of posterior circulation stroke, three-quarters of the patients were anticoagulated, and over 50% of patients
recovered without permanent deficit (3). Limited retrospective data suggest that low-molecular-weight heparins, as utilized in the case presented, seem to be as
efficacious as unfractionated heparin in the setting of
non-hemorrhagic stroke in children (11).
The Emergency Physician (EP) must include vascular
dissection in his or her differential diagnosis when evaluating children with first-time seizure. Crucial components of the physical examination, particularly assessment of gait and coordination, must not be omitted.
Although a healthy-appearing child with first-time afebrile
seizure can be discharged home with close follow-up and
additional outpatient testing, a persistent neurologic deficit
requires further investigation (12). Acute frank ataxia is an
infrequent finding in children, and the differential diagnosis
should include VAD as well as acute intoxication or
ingestion. The EP should also consider vascular dissection when evaluating a pediatric patient with a complaint
of posterior headache or neck pain, even when there is no
history of antecedent trauma. All 136 patients in the case
series of Fullerton et al. and Schievink et al. had ischemic signs and symptoms at the time of diagnosis; this
may reflect not only a low awareness of the disease

33

entity, but also a reluctance to obtain neuroimaging studies in afebrile pediatric patients with complaints of head
or neck pain but no measurable neurologic deficit (5,7).
As noted above, such symptoms are not as common in
children as they are in adults with cervical artery dissection, but increased availability of non-invasive imaging
modalities, and a more aggressive approach in obtaining
them might allow for early diagnosis and treatment in
select children with prodromal pain, and might prevent
potentially debilitating stroke.

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