A Blow to the Neck, Then Hemiplegia

A previously fit and well 14-year-old is taking part in martial arts training when he sustains a blow around the left upper neck and base of the skull.

He stumbles forward and collapses.

Immediately afterwards, he is unable to speak and cannot move his right side.

There is no witnessed seizure.

An urgent non-contrast CT head shows:

No intracranial haemorrhage.

No significant traumatic contusion is identified.

CT angiography demonstrates:

• • attenuation of the left MCA and ACA
• • more marked reduction around the proximal MCA / M1
• • mild attenuation of the distal left internal carotid artery
• • no definite intracranial thrombus

Specialist neuroradiology review considers the appearances suspicious for a left internal carotid artery dissection.

The neurological deficit remains severe.

There is no intracranial haemorrhage, but the neurological deficit followed recent trauma and the vascular abnormality may represent arterial dissection.

The case triggered urgent multidisciplinary discussion involving the local paediatric and adult stroke teams, PICU, retrieval medicine, neuroradiology and specialist stroke clinicians.

Neurosurgical intervention was not indicated because there was no intracranial haemorrhage or other surgical lesion.

No definite targetable intracranial thrombus was identified for mechanical thrombectomy.

The competing risks were therefore considered:

Following multidisciplinary discussion, the balance of benefit and risk was considered to favour reperfusion treatment.

Tenecteplase 0.25 mg/kg was administered as a single IV bolus.

The next question in a disabling arterial ischaemic stroke should be whether there is a large-vessel occlusion that can be mechanically retrieved.

In this case, specialist review did not identify a definite targetable intracranial thrombus.

But the question remains important because paediatric thrombectomy practice is changing rapidly.

Age alone should not prevent discussion with a neurointerventional stroke centre when a child has a disabling stroke and potentially accessible large-vessel occlusion.

Would you intubate?

The patient's GCS is approximately 9-10.

That number understandably makes clinicians uncomfortable.

But much of the reduction in GCS is related to profound aphasia. Meanwhile, the patient is:

• • self-ventilating
• • normally oxygenated
• • haemodynamically stable
• • coughing
• • handling secretions
• • without recurrent seizures

Intubation also introduces induction, sedation, positive-pressure ventilation and the possibility of haemodynamic disturbance in a patient whose cerebral perfusion may already be critically dependent on collateral blood flow.

Reperfusion therapy is only part of stroke management.

Threatened but still viable brain tissue may be dependent on marginal collateral perfusion.

Protect the penumbra.

Following thrombolysis, the patient was transferred urgently to PICU for neurological monitoring and specialist review.

Priorities included:

• • frequent neurological observations
• • serial PedNIHSS assessment
• • maintenance of normal physiology
• • monitoring for haemorrhage
• • urgent CT if neurological deterioration occurred
• • subsequent definitive neurovascular imaging
• • planning secondary stroke prevention

Antiplatelet or anticoagulant therapy requires specialist review, particularly where cervical arterial dissection is suspected.