Authors: Bruno Perocco Braga, MD; Muhammad Janjua, MD; Nancy Rollins, MD; Amy Hogge, MD; Dowling Michael, MD (Dallas, TX)
Pediatric ischemic stroke is rare and difficult to diagnose. Vertebral artery dissection has a high recurrence rate and morbidity. Therefore, identifying a cause and establishing a protocol for diagnosis and treatment may improve outcome in children. We present a prospective case series of patients with dynamic compression of the vertebral artery at the site of dissection who underwent treatment by posterior C1C2 fusion.
From September 2014 to April 2018, nine patients presented with either cerebellar and/or occipital stroke and were found to have unilateral or bilateral dissection at the V3 segment of the vertebral artery. After a period of anticoagulation therapy while on cervical collar and an extensive hematological work-up negative to justify the stroke, they underwent angiogram with rotational maneuver and were found to have total or partial occlusion of the vertebral artery at the site of previous dissection. They all underwent C1C2 posterior fusion as part of their treatment. Other treatment options such as decompression or prolonged anticoagulation with cervical immobilization were not effective or considered but not feasible.
There were 6 male and 3 female patients. Median age was 65.6 months (range 22-121 months). Posterior rib was used as autograft on all patients. On C1, there were 18 lateral mass screws. On C2, there were 12 pedicle screws and 6 pars screws. Median follow-up was 15.5 months (range 3-25 months) and there has been no ischemic event after surgery. Median blood loss was 41.8 mL. Only complication was a superficial wound infection treated with oral antibiotics alone in one patient. There was no need for transfusion, no repositioning of screws, no vascular or neurologic injury.
After following a strict diagnostic and treatment protocol, posterior C1C2 fusion is a safe and effective option for treatment of dynamic compression in vertebral artery dissection in children.