Case Report

Pediatric Middle Cerebral Artery Occlusion with Dissection Following a Trampoline
Trauma
Nimer Adeeb, Christopher Storey, Alexis J. Vega, Asala Aslan, Bharat Guthikonda, Hugo Cuellar-Saenz

Key words

- BACKGROUND: Owing to the rarity of acute ischemic stroke in the pediatric

- Aspirin

population, evidence supporting the efficacy in children of the various treatments used in adults is scanty. This included mechanical thrombectomy for
acute ischemic stroke.

- Dissection
- Heparin
- Middle cerebral artery
- Pediatric

- CASE

- Stroke
- Thrombectomy

Abbreviations and Acronyms
AIS: Acute ischemic stroke
CT: Computed tomography
ICA: Internal carotid artery
MCA: Middle cerebral artery
TICI: Thrombolysis in Cerebral Infarction
Department of Neurosurgery, Ochsner-Louisiana State
University, Shreveport, Louisiana, USA
To whom correspondence should be addressed:
Nimer Adeeb, M.D.
[E-mail: Nimer_adeeb@hotmail.com]
Citation: World Neurosurg. (2020) 143:428-433.
https://doi.org/10.1016/j.wneu.2020.07.175
Journal homepage: www.journals.elsevier.com/worldneurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2020 Elsevier Inc. All
rights reserved.

INTRODUCTION
The incidence of childhood stroke ranges
from 1.3 to 13 per 100,000, with a mortality of approximately 3%e6% and up to
70% of survivors debilitated with significant deficits.1 Because of this low
incidence, there is a lack of evidence on
the safety and efficacy of various initial
therapies for acute ischemic stroke (AIS)
in the pediatric population.2 Mechanical
thrombectomy, which has become a
standard of care for large-vessel occlusion in adults, has not been included in
guidelines for treating pediatric stroke
owing to the lack of level 1 evidence.3
This has led to long-term management
based on recommendations and expert
opinion, which are typically based on
treatment of the adult population. However, recent retrospective studies and
multiple case reports have shown

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DESCRIPTION: we present the case of an 11-year-old female with
acute left hemiparesis, numbness, and left facial droop occurring after tumbling
on a trampoline. Computed tomography angiography revealed an 11-mm nonfilling defect in the right middle cerebral artery. She underwent thrombectomy
approximately 8.5 hours after the onset of symptoms, and a Thrombolysis in
Cerebral Infarction (TICI) scale score of 2b was achieved. She had an uneventful
postoperative recovery.

- CONCLUSION: Pediatric

patients likely have more reserve and collateral
flow and benefit from a longer therapeutic window following acute ischemic
stroke.

favorable outcomes with high recanalization rates in the pediatric population.2,4,5
Those
previous
studies
evaluated different types of mechanical
thrombectomy, including stent retrievers
and aspiration.
Here we report a patient who underwent
thrombectomy of the right middle cerebral
artery (MCA) as a result of arterial
dissection occurring after jumping on a
trampoline, which was treated with a stent
retriever.

CASE PRESENTATION
Diagnosis
The patient is a 11-year-old female who
was jumping on a trampoline performing her usual tumbles when she felt she
could no longer support herself with her
left leg. She was carried inside for a
bath and began experiencing left hemiparesis and numbness with left facial
droop. She developed slurred speech
and complained of right frontal headache. She was then brought to a
hospital.

A computed tomography (CT) scan of the
head done approximately 90 minutes after
the onset of symptoms did not show any
fracture or intracranial bleeding. The patient was emergently transferred to our
center, where neurosurgery was consulted
for possible spinal cord injury. The left
facial droop noted on examination ruled
out spinal cord injury. Out of concern
for developing ischemic stroke, CT
angiography was performed and showed
an w11-mm nonfilling defect of the M1-M2
segment of the right MCA (Figure 1).
Because of her age, the patient was not a
candidate for tissue plasminogen activator
therapy; therefore, after discussion with
her family, she was taken for
thrombectomy.
Management
A 6 Fr sheath was placed, and a 6 Fr
guide catheter was used to access the
right internal carotid artery. The CT
angiogram showed a delayed arterial
phase indicating retrograde flow through
collateral vessels and a string sign
through the occlusion, suggesting a
dissection with large-vessel occlusion
(Figure 2A and B). The MCA territory

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CASE REPORT
NIMER ADEEB ET AL.

PEDIATRIC MCA OCCLUSION WITH DISSECTION

Figure 1. (A) Preoperative computed tomography (CT)
angiogram, axial maximum intensity projection
reconstruction, showing occlusion of the right middle
cerebral artery (MCA) (arrow) (B) Preoperative CT

was receiving flow from leptomeningeal
branches of the anterior cerebral artery.
The superior M3 MCA branch was
cannulated with a microwire, and the
true lumen was verified on injection.
Using a stent retriever (Trevo; Stryker,
Kalamazoo, MI), we were able to
achieve a Thrombolysis In Cerebral
Infarction (TICI) 2b revascularization at
8.5 hours after the onset of symptoms,
but there appeared to be some
remaining clot along the MCA
(Figure 2C). Thus, 8 mg of tissue
plasminogen activator was pushed
intra-arterially, which revealed an
intimal flap, narrowed lumen, and stagnation of contrast within the false lumen
of the dissection (Figure 2D). No
extracranial dissection was noted that
could have propagated. An immediate
postoperative CT showed an ASPECTS
score of 9 with hypodensity in the right
lenticular nucleus and no signs of
hemorrhage.
The patient was started on a heparin
drip with a target partial thromboplastin
time of 40e60. The patient remained left
hemiplegic immediately after thrombectomy. At w5 hours after thrombectomy,
she remained plegic in the left upper extremity, but had regained strength in left
lower extremity to 4/5. On postoperative

angiogram, coronal maximum intensity projection
reconstruction, showing occlusion of the right MCA
(arrow).

day 2, she returned to 4/5 in her left upper
extremity and 5/5 in her left lower extremity. Magnetic resonance angiography
revealed no stenosis to the right MCA
(Figure 3A). Magnetic resonance imaging
showed a small temporal infarct
(Figure 3B) and an infarct with some
hemorrhagic conversion of the right
corpus striatum. On postoperative day 3,
the heparin drip was stopped, and she
was started on enoxaparin. She was
discharged home on postoperative day 5
on enoxaparin with a target anti-Xa value
of 0.5e1 for 3 months.
Prognosis and Outcomes
The patient did well, progressing with
outpatient physical therapy, but due to
problems with compliance with enoxaparin, she was switched to aspirin 325
mg after her coagulopathy workup was
negative on postoperative day 15. Magnetic resonance angiography performed
at 3 months and 1 year showed no signs
of stenosis or dissection of the right MCA
(Figure 3C). Magnetic resonance imaging
revealed stable old initial infarcts without
new hemorrhage or edema. Connective
tissue disease was ruled out clinically as
a possible etiology, given no family
history and no other signs on physical
examination. She initially had some

WORLD NEUROSURGERY 143: 428-433, NOVEMBER 2020

trouble returning to schoolwork, which
improved with time. At 14 months, she
was changed to aspirin 81 mg in stable
condition with minimal left-sided
deficits.
DISCUSSION
Here we present the case of an 11-yearold female who sustained an AIS. This
was a unique presentation of an MCA
dissection with large vessel occlusion
occurring after trampoline jumping.
Using a stent retriever, we were able to
achieve a TICI score of 2b at 8.5 hours
after the onset of symptoms. For an adult
patient, treatment would have included a
self-expanding stent across the dissection
to prevent propagation of the intimal
flap. However, in pediatric patients, the
required antiplatelet regimen would have
sentenced them to a lifelong risk of
stroke due to lack of compliance.
Instead, we chose to administer an immediate heparin drip followed by a short
course of enoxaparin followed by aspirin.
On follow-up imaging, the flap had
resolved, and the patient has had no
further ischemic events.
A review of the literature identified 20
case reports of pediatric patients with AIS
in the anterior circulation who underwent

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CASE REPORT
NIMER ADEEB ET AL.

PEDIATRIC MCA OCCLUSION WITH DISSECTION

Figure 2. Cerebral angiography, anteroposterior (AP)
view of the right internal carotid artery (ICA) injection in
the early arterial phase, showing occlusion of the right
middle cerebral artery (MCA) (arrow) (A); in the late
arterial phase, showing the string sign across the

thrombectomy with a stent retriever
(Table 1).6-22 Only initial revascularization
attempts were analyzed. Overall, the

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occluded portion of the right MCA (arrow), indicating
dissection (B); after thrombectomy, showing TICI 2b
reperfusion (C); and after intra-arterial tPA
administration postthrombectomy, showing TICI 2b
reperfusion with dissection, the string sign (arrow) (D).

median time from symptom onset to
revascularization was 5 hours; 6 out of 16
patients (37.5%) had recanalization

beyond 6 hours due to delayed diagnosis.
The mean time of reperfusion for TICI
2b or better was 5 hours. Six of the 14

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CASE REPORT
NIMER ADEEB ET AL.

PEDIATRIC MCA OCCLUSION WITH DISSECTION

Figure 3. (A) Magnetic resonance angiography (MRA)
3D reconstruction on postoperative day 2 showing no
right middle cerebral artery (MCA) stenosis. (B)
Diffusion-weighted magnetic resonance imaging on

patients (42.9%) who achieved a TICI of
2b or better were outside of the 6-hour
window suggested for mechanical thrombectomy and without direct complications, likely due to better collateral flow in
the pediatric population. Similarly, our
patient had an impressive outcome after
achieving TICI 2b at 8.5 hours. Hemiplegia
resolving to a pronator drift overnight
validated her good collateral flow. Resolution of the drift and affect changes
demonstrates the remarkable plasticity of
pediatric patients in healing after stroke.

postoperative day 2 showing right basal ganglia stroke.
(C) MRA 3D reconstruction at 1 year
postthrombectomy showing no right MCA stenosis.

The risk of hemorrhagic conversion after
thrombectomy is widely reported in the
literature, with concerns that it might increase with increasing time between
stroke onset and reperfusion; however, a
recent study by Boisseau et al23 showed no
significant correlation.
The current literature suggests that mechanical thrombectomy may be considered
for AIS due to large vessel occlusion (internal carotid artery terminus, M1, basilar
artery) in patients age 1e18 years (level C
evidence; class IIb recommendation).5

WORLD NEUROSURGERY 143: 428-433, NOVEMBER 2020

With continued research and more
evidence, mechanical thrombectomy may
one day become a standard of care.
CONCLUSIONS
As shown in this case, dissection in pediatric patients due to trauma may be
safely treated with enoxaparin and aspirin
after mechanical thrombectomy. Mechanical thrombectomy has been shown to be
beneficial in the adult AIS population with
an extended window. Pediatric patients

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CASE REPORT
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PEDIATRIC MCA OCCLUSION WITH DISSECTION

Table 1. Reports of Pediatric Large Vessel Occlusion Thrombectomy Using Stent Retrievers

Study

NIHSS
Age (years) Score

Vessels

Etiology

Device

TICI Scale

Medications

Time from Symptom
Onset to Intervention
(hours)

Alnaami et al., 20136

8

>9w

MCA

Cardiac

Solitaire

3

Heparin

1.5

Sainz de la
Maza et al., 20147

12

18

ICA

Dissection

Solitaire

2b

NA

8

Hu et al., 20148

9

16

MCA, ICA

Cardiac

Solitaire*

2a

NA

NA

Hu et al., 20148

7

17

MCA, ICA

Infection

Solitaire*,y

2a

NA

NA

Stidd et al., 20149

2

mRS 4z

MCA

Cardiac,
hematologic

Trevo

2b

Heparin, warfarin

7

Bodey et al., 201410

15

21

MCA

Unknown

Solitaire

NA

Heparin, aspirin

6

11

Rhee et al., 2014

9

6

ICA, MCA, ACA

Cardiac

Solitaire

3

Aspirin, dipyridamole,
heparin

7

Van den Wijngaard
et al., 201412

14

21

MCA

Cardiac

Soltaire

2b

NA

5

Vega et al., 201513

11

16

MCA

Cardiac

Trevo*

3

Aspirin

3

14

Mittal et al., 2015

17

12

MCA

Cardiac

Solitaire

2a

NA

NA

Chung et al., 201615

4

16

MCA

Cardiac

Solitaire

3

NA

5

Buompadre et al.,
201716

8

7

ACA/MCA

NA

Trevo

2b

Heparin dipyridamole

5

9

7

MCA

Cardiac

Trevo

3

Dabigatran

8.5

Stowe et al., 2018

9

23

MCA

Cardiac

Trevo

2b

Heparin, warfarin

4.5

Kim et al., 201819

14

2

ICA, MCA

Intracranial
arteriopathy

Trevo

NA

NA

8.4

Bhogal et al., 201820

17

9

ICA

NA

pRESET/Lite

2b

NA

7.4

20

11

2

MCA

NA

Prowler/Solitaire

3

Heparin, aspirin

5.9

Bhogal et al., 201820

16

15

MCA

NA

ReFlex/Solitaire

2b

Aspirin

4

Souto Silva et al.,
201921

4

14

MCA

Cardiac

Trevo

2b

Warfarin

3.5/4

Gervalis et al., 202022

16

13

ICA, MCA, ACA

Cardiac

Solitaire

NA

Aspirin, heparin

NA

Kulhari et al., 201717
18

Bhogal et al., 2018

NIHSS, National Institutes of Health Stroke Scale; TICI, Thrombolysis in Cerebral Infarction; MCA, middle cerebral artery; ICA, internal carotid artery; NA, not applicable; ACA, anterior cerebral
artery.
*Penumbra-assisted.
yBalloon angioplasty performed.
zModified Rankin Scale score.

should be directly incorporated into the
expanded window not only because of
their better collateral flow and fewer
comorbidities, but also because of their
likely delayed diagnosis. In addition,
because pediatric patients have better
neuroplasticity and collateral flow, they
can achieve dramatic improvements from
a TICI 2b reperfusion. The plasticity of the
pediatric brain must also be considered
for thrombectomy treatment, where a
larger core infarct may be a candidate.

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Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 2 July 2020; accepted 26 July 2020
Citation: World Neurosurg. (2020) 143:428-433.
https://doi.org/10.1016/j.wneu.2020.07.175
Journal homepage: www.journals.elsevier.com/worldneurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2020 Elsevier Inc. All
rights reserved.

www.journals.elsevier.com/world-neurosurgery

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