ILLUSTRATIVE CASE

Vertebral Artery Dissection Causing Stroke
After Trampoline Use
Courtney S. Casserly, MD,* Rodrick K. Lim, MD, FRCPC,†
and Asuri Narayan Prasad, MBBS, MD, FRCPE, FRCPC†
Objectives: The aim of this study was to report a case of a 4-year-old boy
who had been playing on the trampoline and presented to the emergency
department (ED) with vomiting and ataxia, and had a vertebral artery dissection with subsequent posterior circulation infarcts.
Methods: This study is a chart review.
Results: The patient presented to the emergency department with a 4-day
history of vomiting and gait unsteadiness. A computed tomography scan of
his head revealed multiple left cerebellar infarcts. Subsequent magnetic resonance imaging/magnetic resonance angiogram of his head and neck demonstrated multiple infarcts involving the left cerebellum, bilateral thalami,
and left occipital lobe. A computed tomography angiogram confirmed
the presence of a left vertebral artery dissection.
Conclusions: Vertebral artery dissection is a relatively common cause of
stroke in the pediatric age group. Trampoline use has been associated with
significant risk of injury to the head and neck. Patients who are small and/or
young are most at risk. In this case, minor trauma secondary to trampoline
use could be a possible mechanism for vertebral artery dissection and subsequent strokes. The association in this case warrants careful consideration because trampoline use could pose a significant risk to pediatric users.
Key Words: stroke, pediatric stroke, vertebral artery dissection, trampoline
(Pediatr Emer Care 2015;31: 771–773)

A

n unwell child with vomiting is a common reason for presentation to the emergency department. In this scenario, a comprehensive history and neurological examination revealed truncal
ataxia. We report the case of a child who presented to the pediatric
emergency department (ED) with vomiting, truncal ataxia, and recent history of trampoline use. In this case, imaging was clearly indicated and identified an unexpected diagnosis.

CASE
A 4-year-old boy presented to the pediatric ED with complaints of gait unsteadiness for 4 days. On day 1, he vomited repeatedly and had taken to bed. His family had assumed that he had the
flu. He stayed in bed for an entire weekend, and the vomiting
persisted. On day 3, his mother suggested that he get out of bed
and go to school. When he attempted this, he was unsteady on
his feet and was stumbling around “as if he was drunk.” He denied
vertigo, tinnitus, or hearing loss. His mother was concerned and
brought him to the ED. On direct questioning, he did report having a low-grade holocephalic headache that had been present for
the last 3 weeks. There was no history of fever, and he had no sick
contacts. There was no neck pain and no known history of head or
neck trauma. However, his family had just purchased a full-size
From the *University of Western Ontario; and †Children's Hospital at London
Health Sciences Centre, Western University, London, Ontario, Canada.
Disclosure: The authors declare no conflict of interest.
Reprints: Courtney S. Casserly, MD, c/o Lisa Baker-Spiller, Department of
Neurological Sciences, Schulich School of Medicine and Dentistry,
University Hospital, 339 Windermere Rd, London, Ontario, N6A 5A5
Canada (e‐mail: courtney.casserly@londonhospitals.ca).
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0749-5161

trampoline, and he and his older siblings, ages 17 and 20 years,
had engaged in play on it on 2 occasions over the preceding
2 days. He was the product of a normal pregnancy and delivery,
was developmentally normal, and had no personal or family history of a neurological disorder, hypercoagulable state, or connective tissue disorder.
On examination on admission, he was alert and appropriate.
On general inspection, the patient was not dysmorphic and had a
normal upper segment to lower segment ratio. His blood pressure
was 130/56 mm Hg, and his heart rate was 88 beats per minute and
regular; he was afebrile and had 99% oxygen saturation on room
air. He had a normal fundoscopic examination with no evidence
of papilledema. Cranial nerve examination was unremarkable. He
had no nystagmus. He had full visual fields to confrontation testing.
He had full strength in the upper and lower extremities. Reflexes
were 2/2 and symmetrical at the biceps, triceps, brachioradialis,
knees, and ankles, and plantar responses were down-going bilaterally. Appendicular coordination was intact (finger-to-nose, heelto-shin), although slightly slower on the left as compared with right.
His gait was remarkable for a slightly wide base of support, and
without support, he fell twice to the left hand side. There was no evidence of excessive joint laxity and no visual, dental, skeletal, dermatological, or cardiac abnormalities.
The patient had a computed tomography head scan that demonstrated multiple small hypodensities in the left cerebellar hemisphere (Fig. 1A). The patient then had a magnetic resonance
imaging (MRI)/magnetic resonance angiogram of the head and
neck, which demonstrated multiple foci of diffusion restriction
on MRI diffusion-weighted imaging within the posterior circulation including the left cerebellum, left brachium pontis, thalami,
and the right medial occipital lobe (Fig. 1B). Magnetic resonance
imaging dissection sequences (fat-saturated images) demonstrated
high signal within the left vertebral artery, which could represent
a dissection. A computed tomography angiogram of the head was
then performed, which confirmed an abnormality of the left vertebral artery at the C1 to C2 level (Fig. 1C). There was a filling defect
within the lumen of the vessel as well as vessel wall thickening.
This abnormality was diagnosed as a dissection with luminal
thrombus. The patient also had a transthoracic echocardiogram,
which was unremarkable.
Over the next several days, his gait improved significantly, and
he was ambulating without any assistance. His nausea and vomiting
also resolved. He was started on therapeutic anticoagulation with
enoxaparin for a planned duration of 3 months, with a plan to
follow-up with the pediatric hematology service. He was discharged
home on day 3 after admission with no clear deficits on neurological examination. To date, formal visual field testing has not been
carried out.

DISCUSSION
Stroke is rare in children, with an estimated incidence of 2.5 to
3.1 cases per 100,000 per year.1 However, although cervical artery
dissection accounts for an estimated 2% of stroke in adults, it accounts for more than 20% of stroke in the pediatric population.1–3

Pediatric Emergency Care • Volume 31, Number 11, November 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

www.pec-online.com

771

Pediatric Emergency Care • Volume 31, Number 11, November 2015

Casserly et al

FIGURE 1. A, Computed tomography head scan showing multiple small hypodensities in the left cerebellar hemisphere. B, Magnetic
resonance imaging (MRI) and angiogram of the head and neck, showing multiple foci of diffusion restriction within the posterior circulation.
C, Computed tomography angiogram of the head confirming an abnormality of the left vertebral artery at the C1 to C2 level.

Dissections occur in the vertebral arteries because the interosseous
portion has limited mobility within the transverse process of the
cervical vertebrae. Abrupt hyperextension and rotation caused by
minimal trauma can tear the vessel wall. Most vertebral artery dissections occur at the level of C1 to C2, where there is rotation of
atlantoaxial joint and minimal bony protection present as compared with the lower cervical column.1 A thrombus forms at the
site of the dissection, leading to downstream artery-to-artery embolism or complete vessel occlusion.4 These dissections may occur secondary to trauma or may be “spontaneous.”
In the pediatric literature, a history of trauma, minor or major,
is reported in approximately 50% to 68% of children with vertebral artery dissection.5,6 This figure is somewhat smaller in adults,
where the incidence of trauma resulting in dissection is estimated
at closer to 25% to 50%.3,7,8 Trauma can be very minor, such as
coughing or sneezing.9 In the remaining spontaneous cases, an
underlying genetic or structural abnormality, such as a connective
tissue disease, is identified in less than 1% to 5% of patients.10 It
remains unclear whether in these “idiopathic cases,” a history of
minor trauma may exist. In the case of a pediatric spontaneous dissection, is it impossible that the insult is so minor that it is forgotten or goes unnoticed?1 Are young children unable to accurately
report the insult? When flexion/extension cervical spine x-rays
were performed on 10 pediatric patients with spontaneous vertebral artery dissections, 8 were found to have subluxation at C2/
C3 at extremes of physiological motion.5 This may represent an

772

underlying mechanical or musculoskeletal laxity that predisposes
some pediatric patients to develop a dissection secondary to minor
trauma. It remains unclear whether this type of cervical ligamentous laxity is more common in children.
Thrombosis of the vertebral artery, or artery-to-downstream
artery embolism, can lead to stroke. The classic Wallenberg or lateral medullary syndrome may be seen (crossed sensory findings,
Horner syndrome, dysarthria, vertigo). This syndrome is uncommonly reported in children.8 However, in both adults and children,
infarcts from vertebral artery dissection with subsequent infarction
can present with any combination of vertigo, nausea and vomiting,
dysarthria, dysphagia, hiccups, hemiparesis, ataxia, and seizure.8,11
Although most adults with vertebral artery dissection will present
with pain, pain is a less common presenting feature in pediatric patients (headache 50%, neck pain <10%).1,5 Finally, both adults and
children seem to do reasonably well after dissection; acute mortality
is higher in adults (10%) as compared with children (3%).9,12
Table 1 contrasts the demographics, location, etiology, clinical
features, and outcome in pediatric versus adult patients with vertebral artery dissection.
With the rise in popularity of the trampoline, the number of
trampoline-related injuries in Canada and the United States has
been increasing. During 2000 to 2005, there were an estimated
500,000 trampoline-related visits to the ED by children younger
than the age 18 years.12 This represents 115 injury-related visits
per 100,000 US children per year and 1.6% of all injury-related

www.pec-online.com

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Pediatric Emergency Care • Volume 31, Number 11, November 2015

Vertebral Artery Dissection Causing Stroke

TABLE 1. Clinical Characteristics of Pediatric Versus Adult Vertebral Artery Dissection
Pediatric

Adult

8

Sex predominance
Male
Male = Female7
8
Mean age
10 y
40–48 y7,9
6
1:36
Ratio intracranial: 1:3 (may be slightly more intracranial cases in
extracranial
pediatric population6)
Etiology
History of trauma 50%–68%5,6,10 (trauma may be slightly
History of trauma 25%–53%7,8
more common)
Symptoms
• Headache and neck pain (neck pain less common)1,5
• Headache, neck pain, or combination of the 2 common1,5
• Ataxia, vertigo, hemiplegia, vomiting11
• Dizziness, vertigo common, lateral medullary
more common in adults7
• Classic lateral medullary syndrome less common in children8
5,6,10
Outcome
• Death 3%, majority with complete or good recovery
• Death 10% acutely, majority with complete or
good recovery9,12

visits.6 In Canada, ED visits for trampoline-related injuries has increased 374% from 1990 to 1998, with a significant increase every year since then, as documented by the Canadian Hospital
Injury Reporting and Prevention Program.13 In a review by Woodward et al,14 98% of these accidents occurred on full-sized trampolines, 48% occurred at home, and 56% occurred with adult
supervision.15 The American Pediatric Society affirmed its policy
on trampolines in 2006, stating that they should never be used in a
home, in an outdoor playground, or at school.16 Similarly, the
Canadian Paediatric Society published a joint statement with
the Canadian Academy of Sport Medicine, recommending that
trampolines should not be used for recreational purposes… by
children or adolescents.12
Head and neck injuries represented approximately 10% of all
injuries related to trampoline use.12,14 Serious injuries, including
spinal cord injury, traumatic brain injury, and 1 case of vertebral
artery dissection, have been reported in the literature.4,12 This case
is similar to the case presented here; it involved an 11-year-old boy
who was using the trampoline with 3 friends and fell off, striking
his head. When he presented to the ED, he was ataxic, and MRI/
magnetic resonance angiogram confirmed a vertebral artery dissection with multiple cerebral infarcts. In 1 review of 114 pediatric
recreational trampoline injuries, injuries are more common with
multiple trampoline users12 and with somersaulting.6 The risk of head
and neck injury seems to be inversely proportional to age.12,14 In all
cases of injury, younger children and lighter children seemed to be at
significantly increased risk of injury (14 times) as compared with
their older, heavier counterparts.14,16 Potentially, in younger children, a relatively weak neck and large head may place them at
an increased risk for neurological injuries such as those seen in
this case. Given the location of most vertebral artery dissections
(C1–C2), the association between dissection and minor trauma,
and the possibility of hypermobility of the cervical spine in some
pediatric patients, children may be uniquely at risk for this type
of injury.
In summary, we present a case of a 4-year-old boy who presented to the ED with vomiting and ataxia, and had a vertebral artery dissection with subsequent posterior circulation infarcts.
Vertebral artery dissection is a relatively common cause of stroke
in the pediatric age group, and in this case, minor trauma secondary to trampoline use was the likely mechanism. It is important for
physicians to be aware of this association as trampoline use could
pose a significant risk to pediatric users.

REFERENCES
1. Papp J, Dorsey T. A preschool-age child with first-time seizure and ataxia.
J Emerg Med. 2007;36:30–33.
2. Tan MA, Armstrong D, MacGregor DL, et al. Late complications of
vertebral artery dissection in children: pseudoaneurysm, thrombosis and
recurrent stroke. J Child Neurol. 2009;24:354–360.
3. Mortazavi MM, Verma K, Tubbs RS, et al. Pediatric traumatic carotid,
vertebral and cerebral artery dissections: a review. Childs Nerv Syst.
2011;27:2045–2056.
4. Hunter KH. Trampolines, children and strokes. Am J Phys Med Rehab.
2000;80:608–613.
5. Ganesan V, Chong WK, Cox TC, et al. Posterior circulation stroke in
childhood: risk factors for recurrence. Neurology. 2002;59:1552–1556.
6. Rafay M, Armstrong D, deVeber G, et al. Craniocervical arterial dissection
in children: clinical and radiographic presentation and outcome. J Child
Neurol. 2006;21:8–16.
7. Saeed AB, Shuaib A, Emery D, et al. Vertebral artery dissection:
warning symptoms, clinical features and prognosis in 26 patients.
Can J Neurol Sci. 2000;27:292–296.
8. Fullerton H, Johnston J, Claiborne S, et al. Arterial dissection and stroke in
children. Neurology. 2001;57:1155–1160.
9. Garry D, Forrest-Hay A. A headache not to be sneezed at. Emerg Med J.
2009;26:384–385.
10. Schievink S, Wouter I. Spontaneous dissection of the carotid and vertebral
artery. N Engl J Med. 2001;344:898–906.
11. Rasalkar DD, Chu WCW. Imaging in children presenting with acute
neurological deficit: stroke. Postgrad Med J. 2012;11:639–648.
12. Linakis JG, Mello MJ, Machan J, et al. Emergency department visits
for paediatric trampoline-related injuries: an update. Acad Emerg Med.
2007;14:539–544.
13. Leonard H, Joffe AR. Children presenting to a Canadian hospital with
trampoline-related cervical spine injury. Paediatr Child Health. 2009;14:84–88.
14. Woodward GA, Furnival R, Schunk JE. Trampolines revisited: a review
of 114 pediatric recreational trampoline related injuries. Paediatrics.
1992;89:849–854.
15. Toth C, McNeil S, Feasby T. Central nervous system injuries in sports
and recreation. Sports Med. 2005;35:685–715.
16. Hurson C, Browne K, Callender O, et al. Pediatric trampoline injuries.
J Pediatr Orthop. 2007;27:729–732.

www.pec-online.com

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

773