896

Bilateral Occlusions In The Cervical Portion of the
Internal Carotid Arteries in a Child

TETSUZO TAGAWA, M . D . ,

TAKASHI MIMAKI, M . D . ,

HYAKUJI YABUUCHI, M . D . ,

AND ATSUFUMI MAKINO,

YOSHIKAZU IWATA, M . D . , *

M.D.t

SUMMARY An 8-year-old boy with a history of recurrent tonsillitis and cervical lymphadenopathy
developed acute hemiplegia. Cerebral angiography revealed bilateral occlusions of the cervical portion of
the internal carotid arteries. Cerebral arterial occlusion in childhood has been attributed to many causes,
e.g., trauma and infections of the neck. In the present case, though not clearly proved, inflammatory
processes may have been related to the occlusion.
Stroke Vol 16, No 5, 1985

A VARIETY OF PATHOLOGICAL PROCESSES
produce acute hemiplegia. Arterial occlusion in adults
occurs frequently in the cervical carotid artery, but
mostly in the intracraniaJ portion in children. Occlusion of the cervical carotid artery is uncommon in
childhod. Bilateral occlusions are very rare. In this
report we describe a child with bilateral occlusions of
the cervical portion of the internal carotid arteries.

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Case Report
An 8-year-old boy was admitted to the Osaka University Hospital on June 8, 1980, with recurrent right
hemiplegia, right facial palsy, aphasia. He was born at
term and his neonatal course was uneventful. His past
medical history was unremarkable except for an episode of fever with lymphadenopathy, suspected of being due to infectious mononucleosis which occurred 4
years prior to admission. He had no history of recent
trauma or cardiac diseases.
Beginning in February 1980, he had recurrent tonsillitis and complained of intermittent ophthalmic
pain. In March 1980 he was admitted to another hospital and was treated with antibiotics for 20 days for a
streptococcal infection. During this hospitalization his
neurological evaluation revealed no abnormality except EEG asymmetry and transient anisocoria.
Ten days before admission to our hospital, he abruptly developed right hemiplegia at school. This improved spontaneously within a few hours. One week
later, when he was taking a bath, the right hemiplegia
reappeared along with right facial palsy and aphasia.
Following this episode a right unilateral convulsion
occurred and continued for about 5 minutes. His clinical symptoms progressed over several days to complete paralysis of his right side.
On admission he was alert and responsive. His pupils were round, equal and reactive to light. Extraocular movements were normal and fundoscopic examination revealed no papilledema or retinal hemorrhage.
No nuchal rigidity or enlargement of the cervical
From the Department of Pediatrics, and from the Department of
Neurosurgery,* Osaka University Medical School, Osaka, Japan; and
the Department of Pediatrics, Kinki Chuo Hospital, Itami, Japan.t
Address correspondence to: Dr. Tetsuzo Tagawa, Osaka University
Medical School, 1-1-50 Fukushima, Osaka, Japan.
Received December 19, 1984; revision # 1 accepted February 28,
1985.

lymph nodes was seen. No bruit was audible in the
neck or skull. Radial and femoral pulses were easily
palpable and equal in both sides. Blood pressure was
110/70 mmHg in both arms. Cardiac sounds were normal. Neurological examination disclosed a right facial
palsy, right hemiplegia with arightBabinski sign, and
exaggerated tendon reflexes in the right arm and leg.
There was a questionable right hemihypesthesia which
was uncertain because of his aphasia.
Numerous laboratory tests were normal including
blood cell counts and differentials, platelet counts,
coagulation tests, serum immunoelectrophoresis, and
CSF. Cardiac examinations including electrocardiogram, echocardiogram and chest films, revealed no
abnormal findings. The erythrocyte sedimentation rate
was 20 mm/hr and CRP was positive. ASO titer wa;
mildly elevated. EEG showed high voltage slow wave
in the left parieto-occipital area. CT scan demonstrates
a low density area in the distribution of the left middlr
cerebral artery, which was markedly enhanced afte>
the contrast infusion, suggesting a cerebral infarction.
Right and left carotid arteriograms demonstrated bilateral internal carotid artery occlusions just above the
carotid bifurcation (fig. 1). In addition, the right carotid angiogram demonstrated retrograde filling of the
right ophthalmic artery. A vertebral angiogram revealed that both anterior cerebral arteries (ACA) and
the right middle cerebral artery (MCA) were filled
through the right posterior communicating artery and
the left MCA filled retrogradely via the anastomosis of
the left posterior cerebral artery (PCA) (fig. 2). These
findings suggested the occlusion of the left internal
carotid artery extended to the origin of the left MCA.
After the angiographic studies, urokinase was administered for one month. The motor disturbance and
aphasia gradually improved. Two months after the onset of the hemiplegia an anastomosis between the left
superficial temporal and middle cerebral arteries was
performed. The postoperative left carotid angiogram
showed excellent filling of the region of the left MCA
via the anastomosis (fig. 3). At the time of this report
the patient can walk unaided and speak fluently. A
mild right hemiparesis remains.
Discussion
Postnatally acquired hemiplegia in a child previously neurologically unimpaired, is not a specific disease

BILATERAL CERVICAL INTERNAL CAROTID ARTERY OCCLUSION/Tagawa et al

R-CAG

L-CAG

897

\

FIGURE 1. Right (R-CAG) and left (L-CAG)
carotid angiograms. Both the right and left
internal carotid arteries occluded just above
the carotid bifurcation. (Double arrow heads)

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but rather the nonspecific response of the central nervous system to injury produced by various etiologies. 12 Using modern neuroradiological diagnostic
techniques, cerebrovascular diseases have been frequently found in hemiplegic children.3 Cerebral arterial occlusions occur commonly extracranially in adults,
while they are principally intracranial in children.4"7
Occlusion in the cervical portion is uncommon in
childhood. Bilateral occlusions are very rare. We have
been unable to find other reported children with bilateral extracranial occlusions of the carotid arteries.
Mymin reported a 2-year-old girl with common carotid
occlusions and congenital heart disease.8 Autopsy
findings revealed coarctation of the aorta, patent ductus arteriosus and bilateral common carotid thrombosis. The author speculated the etiology of the thrombosis might have been aortic dissecting aneurysms. In our
case there were no evidence of dissection on the angiogram and no blunt trauma was reported in the days
prior to the onset of symptoms. Although mitral valve

prolapse has recently been described as a cause of
stroke in childhood,9'10 no evidence of the disease
were found in this boy.
The risk factors for occlusion of the cervical carotid
arteries in children are different from those in adults.
In adults the most important factor is atherosclerosis;
in children trauma to the neck and infections of the
neck or throat are important.4 Spontaneous dissection
and premature atherosclerosis have been reported but
were not apparent in the radiological studies in this
patient. Infection in the neck or throat has long been
implicated as a cause of carotid occlusion from an
arteritis produced by direct extention of the inflammatory process and proximity of the internal carotid system. Our patient had had recurrent tonsillitis with culture proven group A /3-hemolytic streptococci, a
positive CRP and an elevated titer of ASO. Therefore,
in this case, the inflammatory processes may have
been related to the occlusions, as previous authors
suggested.6'IM3

U-

FIGURE 2. The vertebral angiogram. 2a and2b: arterial phase. 2c: venousphase. The anterior cerebral arteries on both sides
and the right middle cerebral artery can be visualized on figure 2a and 2b. Occlusion of the left posterior communicating artery
is demonstrated. (Arrow head) In the venous phase (fig. 2c) the left middle cerebral artery is seen to be filled through the
peripheral anastomosis via the left posterior cerebral artery.

898

STROKE

VOL 16, No 5, SEPTEMBER-OCTOBER

1985

References

R
FIGURE 3.

.
The postoperative angiogram of the left carotid

artery. The region of the left middle cerebral artery is well filled
through the anastomosis by the external carotid artery.

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