106

Vertebral-Artery Dissection Following a Judo Session:
A Case Report
By A. Lannuzezl, T. Moulin 1, D. Amsallem2 , ]. Galmiche1 and L. Rumbach1
lServiee de Neurologie et 2Serviee de Pediatrie, CHU Jean Minjoz, Besanc;on, Franee

A few days after a judo session, an 11-yearold boy presented with an isehemie stroke with dizziness,
aphasia and ataxia. CCT sean revealed a left thalamie
infaret. Angiography showed a fibromuseular dysplasia
(FMD) of the left vertebral artery probably eomplieated by
disseetion. Subsequent evolution was favorable. This observation points out the faet that the assoeiation of a eervieal
pain with neurologieal signs of vertebrobasilar stroke,
espeeially oeeurring after a eervieal trauma or rotatory
motion, should alert to the possibility of vertebral-artery
disseetion. The diagnosis is mainly based on angiographie
eriteria. Aeeurate diagnosis has implieations for prognosis
and probably for aeute medieal treatment.

eervieal eolumn. Immediately he eomplained of a latero-eervieal pain. During the night, he suffered from diffuse headaehes
and vomiting. Similar episodes reeurred the following days. He
also beeame progressively lethargie, developed a dysphasia and
his walking beeame unstable.
On lune 16, 1992 he had left ptosis and
diplopia during one day. He suffered from a reduetion of
speeeh flueney with many perseverations as weIl as axial ataxia
and a left eervieal stiffness. An EEG revealed slow aetivity over
the left temporo-oeeipital region. A CCT sean demonstrated a
low-density lesion in the left thalamus (Fig. 1).

Key words
Disseetion - Extraeranial vertebral artery Thalamie infaret - Child - Fibromuseular dysplasia

Introduction
Vertebral-artery disseetion is the separation of
the layers of the arterial wall by eireulating blood. Sinee the
1980's vertebral artery disseetion in young adults is wellknown, oeeurring most often after eervieal trauma whereas it
is uneommon in ehildren.
This report deseribes an 11-year-old boy with a
thalamie isehemia seeondary to a left vertebral-artery disseetion. Two etiologie faetors were diseovered: a minor eervieal
trauma during a judo session and an FMD of the third segment
of the vertebral artery.

Case report

Fig. 1

Left thalamic infarct involving the tuberothalamic territory (arrowJ,

On admission on lune 18, his neurologieal
status was the same as two days before. Aseleeted 4-axis
angiography performed by transfemoral eatheterization, demonstrated a "string of beads" lesion on the V3 segment of
the left vertebral artery (Fig. 2). No abnormalities were noted in
the other vessels. An MRI eonfirmed the left thalamie infaret, in
the tubero-thalamie territory.

An 11-year-old boy was admitted to our hospital in lune, 1992. His personal and family medieal history
revealed no abnormalities until lune 2, 1992. On this day,
during a judo session, he was vietim of a rotating motion of the

Antieoagulation with heparin was performed
for 15 days and an oral antieoagulation was given for 3 months.
With this treatment, bed rest, and eervieal support with a soft
eollar, the symptoms disappeared and the boy was diseharged
after two weeks, without eomplaints.

Reeeived Getober 11, 1993; aeeepted January 28, 1994

Three months later, the examination was normal. The seleetive angiography performed was unehanged. The
oral antieoagulation was stopped and followed by Aspirin.

Neuropediatrics 25 (1994) 106-108
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Abstract

Neuropediatrics 25 (1994)

Vertebral-Artery Dissection in Childhood

107

Discussion
Children's vertebral-artery dissection is uncommon. The average age for vertebral dissection is about 40 years
with a female preponderance. Dnly a few childhood cases have
been published.

For most patients, the symptoms and signs
have a progressive or stuttering onset, varying from hours to
days, but they were stabilized within 1 or 2 weeks (3).
Transient ischemic attacks are rarely the only
manifestation of vertebro-basilar ischemia. Strokes reveal the
extracranial vertebral disseetion in 87 % of the cases. The most
frequent patterns observed were lateral-medullary infarction
(30 % of the cases) or cerebellar infarction (23 % of the cases)
(4). Thalamic infarcts are rarely described probably because of
the lack of sensitivity of CCT scan in the detection of small
thalamic infaretions. Thalamic infarction was suggested in our
case by lethargia and speech disturbance explained by the
dysfunction of anterior thalamic nucleus (1). The thalamic
infarction in this case is probably due to an embolism, arising
from the site of dissection up to the tubero-thalamic arteries.
In our case it is difficult to ignore the temporal
association between the minor cervical trauma with neck
torsion and the subsequent symptoms. The clinical course
began with a latero-cervical pain occurring just after a necktorsion during a judo session, followed a few days later by
symptoms of brain ischemia.

The traumatic circumstances of vertebral-artery disseetion are extremely variable. It is commonly a minor,
non-penetrating trauma of the neck in connection with ordinary
daily activities like ceiling painting, yoga, gymnastics. It can
also occur after chiropractic manipulations.
The vertebral artery is susceptible to mechanical injury because of its relationship to the neighbouring bony
structures and ligaments, especially in the third atlanto-axial
segment (V3). Anatomical studies have demonstrated that a
flexion or extension of less than 45° along with a tilt of 30° is
needed to produce a decrease in vertebral artery-flow (7).
The diagnosis of vertebral artery dissection is
classically based on angiographic criteria. However, angiographie diagnosis of vertebral artery disseetion cannot always
be made with complete confidence (3). In fact, the most
common angiographic aspects are stenosis or thrombosis.
Pseudoaneurysm is only observed in about 10 % of the cases
occurring in V3 or V4 (2) and the typical feature of double-

Fig. 2

Angiography: Type 1 fibromuscular dysplasia (lIstring of beads"
lesion) (arrow) with arterial dilatations (arrowhead) and strictures on the V3
segment of the lett vertebral artery.

lumen is exceptional. At least 85 % of the stenosis resolve or
substantially improve within 2 or 3 months (2, 3, 4). Regression
of thrombosis of pseudoaneurysm is less frequent.
In our case the arteriography alone does not
allow to make the diagnosis of arterial dissection with certainty.
This can be related to the fact that the arteriography was
realized 16 days after the presumed time of the dissection.
This delay is sufficient for the disappearance of angiographic
signs. However, the typical clinical course, the findings on CCT
scan and the presence of FMD lesions predisposing to arterial
dissection, allows to make with quasi certainty the diagnosis of
traumatic vertebral artery dissection.

FMD is a segmental non-atheromatous stenotic
disease involving small- to medium-sized arteries. The disease
is uncommon, its frequency is estimated to 1 % of cerebral
angiograms. First described in the renal artery, it is now known
to affect other vessels including cervicocerebral ones. The
internal carotid artery is involved most frequently, followed
by the vertebral artery. The involvement of the vertebral artery
is mostly unilateral (70 % of the cases) and associated with
internal carotid artery lesions (85 %). The distribution of the
lesions shows a marked predominance of the involvement of the
V3 segment (5). Pathologically, the lesion reflects a disorganized fibrosis of the intima, media, or occasionally, adventitia.
The involved portions show alternating thick and thin areas of
the vessel wall. The narrowed arterial segments show degeneration of elastic tissue, disruption and loss of the muscular coat,
as weH as an increase in fibrous tissue. The dilatations are due
to atrophy of the vessel wall.

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In 1978, Zimmerman et al reported the case of
a 7-year-old boy who presented a vertebral-artery dissection
occurring after a chiropractic manipulation (10). Perez-Higueras et al in 1988 reported the case of a 9-year-old boy
with cerebellar infarct produced by Type 1 fibromuscular
dysplasia of the vertebral artery complicated by a spontaneous
disseetion (5).
The obvious and inaugural symptom of vertebral-artery disseetion in about 80 % of the cases (2, 4) is a pain
located in the posterior neck or in the occiput and sometimes
accompanied, like in our case, by diffuse headaches and
cervical stiffness.

108 N europediatrics 25 (1994)

Cerebral ischemia is the regular consequence of
the lesion but the cause of ischemia is often unsettled. The FMD
is the principal arteriopathy predisposing to arterial dissection.
Arterial dissections are observed in 15 % of the cases of FMD,
respectively in the series of vertebral arteIY dissections the
percentage of FMD can reach 23 % (4). In these cases the
dissection is classically medial, involving the V3 segment in
70 % of the cases. Vertebral-arteIY dissections have also been
described in association with other arteriopathies such as the
Ehlers-Danlos syndrome Type 4 (7) and the Marfan syndrome
(9).

Dur patient was treated with anticoagulants.
This might, at first, appear contraindicated in a disorder with
bleeding into arterial wall. However, when the dissection is
extracranial, most of the authors agree to prescribe a treatment
with heparin for two weeks followed by oral anticoagulation for
three months. In the same way, when dissection occurs during
unusual activities or minor trauma, it may be advisable to avoid
such potential precipitants in the future.

References
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F. Bonneville: Dissection of the vertebral artery: A study of 23 patients.
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3 Hart, R. G.: Vertebral artery dissection. Neurology 38 (1988) 987-989
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vertebral artery dissections: a review of 13 cases. Stroke 18 (1987)
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1

Prof L. Rumbach
Service de Neurologie
CHU Jean Minjoz
Boulevard Fleming
F-25030 Besanc;on Cedex
France

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The most common radiographic finding is the
so-called "string of beads" (Type 1) created by the formation of
achain of arterial dilatations which are separated from one
another by localized strictures. A second pattern, which is less
common, is unifocal and characterized by tubular stenosis
(Type 2). A third angiographic type of FMD has been called
atypical: one wall of the affected segment is spared, and on the
opposite wall an elongation, ovoid diverticulum, sharply circumscribed at either end by a noncircumferential narrowing,
resembling a localized FMD constriction (8).

A. Lannuzel et al