Basal ganglia stroke due to mild head trauma in pediatric age - clinical and therapeutic management: a case report and 10 year literature review

Mineralizing angiopathy as a rare cause of pediatric stroke: review and report of two cases

In the Indian subcontinent, traumatic brain injury stands as the leading cause of pediatric stroke, whereas in Europe, it is considered a rare or potentially underdiagnosed factor. The etiology of post-traumatic stroke is unknown, although it has been associated with the presence of calcification in the lenticulostriate arteries, a condition known as "mineralizing angiopathy." The theory suggests that calcified lenticulostriate vessels in a brain with inadequate myelination could have an increased vulnerability to mechanical injuries, which may result in their obstruction. This ischemic stroke associated with mineralizing angiopathy usually occurs after mild traumatic brain injury, with an asymptomatic interval following the trauma. The typical age of presentation is between 6 and 24 months. Children with mineralizing lenticulostriate vasculopathy generally experience a favorable outcome after stroke, with the majority achieving complete or nearly complete recovery of their motor functions. Despite aspirin treatment, a small proportion of children may still face stroke recurrence following repeat head trauma. We present the cases of two male patients with clinical features compatible with childhood stroke after a mild traumatic brain injury.

Mineralizing Lenticulostriate Vasculopathy: An Emerging Risk Factor for Basal Ganglia Stroke After Minor Head Trauma in Young Children

Mineralizing lenticulostriate vasculopathy is a well-recognized risk factor for basal ganglia stroke after minor head trauma in infants and young children; it is diagnosed on head computed tomography by the presence of basal ganglia calcification, seen as punctate hyperdensities on axial and linear hyperdensities on reconstructed coronal and sagittal images. In children with anterior fontanel window, its presence is suggested by branching hyperechogenic stripes in the basal ganglia region on cranial ultrasound. Brain magnetic resonance imaging, including susceptibility-weighted sequences and brain magnetic resonance angiography, fail to detect calcification or vascular abnormalities. Although its etiology remains unknown, mineralizing lenticulostriate vasculopathy is considered to represent end-stage pathology of lenticulostriate vasculopathy, a neonatal radiographic condition detected during routine neonatal cranial ultrasonographic examination and represents nonspecific finding associated with a multitude of etiologies. The significance of mineralizing lenticulostriate vasculopathy lies in the fact that it has emerged as one of the most common risk factors for basal ganglia stroke in Indian children, accounting for one-fourth to one-half of all causes of stroke in some studies. The outcome of stroke in children with mineralizing lenticulostriate vasculopathy appears to be favorable with the majority achieving complete or nearly complete recovery of their motor functions. Stroke recurrence following repeat head trauma is seen in a small proportion of children despite aspirin treatment.

Interplay between carotid artery dissection and thrombophilia leading to ischaemic stroke after minor head trauma in an adolescent: a case report

Stroke in children is more common than is often realised; there are numerous potential causes, including carotid artery injury resulting from minor head or neck trauma, as well as genetic conditions associated with thrombophilia. A 13-year-old boy suffered an arterial ischaemic stroke (AIS) secondary to dissection of the left internal carotid artery (ICA) after he headed the ball during a game of football. He presented with generalised tonic-clonic seizure, loss of consciousness, right-sided hemiplegia and aphasia. Neuroradiological imaging showed left caudate, putaminal and posterior insular ischaemic infarct secondary to complete occlusion of the left ICA and accompanying partial left middle cerebral artery occlusion. He was treated with anticoagulant and anti-aggregant agents. Rarely, minor head trauma can result in internal carotid artery dissection, thrombus formation and arterial occlusion, leading to arterial ischaemic stroke. Prompt diagnosis and management are crucial to achieve a good neurological outcome.Abbreviations: AIS: arterial ischaemic stroke; ANA: anti-nuclear antibody; APA: anti-phospholipid antibody; APTT: activated partial thromboplastin time; CAD: carotid artery dissection; CCAD: cranio-cervical artery dissection; CRP: C-reactive protein; CT: computed tomography; CTA: computed tomography angiography; dsDNA: double-stranded DNA; ESR: erythrocyte sedimentation rate; ICA: internal carotid artery; LA: lupus anticoagulant; MCA: middle cerebral artery; MRA: magnetic resonance angiography; MRI: magnetic resonance imaging; MTHFR: methylenetetrahydrofolate reductase; PT INR: prothrombin time international normalised ratio.

Mineralizing angiopathy with basal ganglia stroke after minor head trauma; a clinical profile and follow up study of a large series of paediatric patients from North India

BACKGROUND

There is paucity of published literature on follow-up outcome of mineralizing angiopathy with basal ganglia stroke related to minor head trauma. This retrospective study aims to bridge this knowledge gap.

METHODS

Patients (1 months- 15 years), presenting with acute stroke over a 5-year period were recruited. From this cohort, basal ganglia strokes following minor head trauma were analysed in detail and outcome assessed using the Recovery and Recurrence Questionnaire (RRQ).

RESULTS

A total of 94 patients were eligible, 48 (51%) were basal ganglia stroke following minor head trauma [M: F 2.5:1; mean age 21 ± 8.5 (±SD months]. Further evaluation of this group revealed a median time of 60 min (range 0-96 h) from trauma to stroke onset. Nearly all had acute hemiparesis (45/48). Almost a third of patients (n = 13; 27%) had a transient hemi dystonia on the hemiparetic side after a median of 4 days (range 2-6 days) of symptom onset.Computed tomography (CT) head showed bilateral basal ganglia calcification in all; Most patients (31/48; 64.5%) were anaemic. Magnetic Resonance (MR) angiography, echocardiogram and thrombophilia screen was normal wherever they were performed (6/48).The median follow-up period - 14 months (Range 0-22months). Majority of patients (22/35; 63%) showed complete recovery at 18 months follow up, with maximum recovery occurring between 6 and 12 months.

CONCLUSION

Minor head trauma leading to basal ganglia stroke in children was the most common cause of paediatric stroke in our patients. In follow-up most patients had recovered fully, though a significant minority did not recover completely.

Perinatal Infections: An Important Etiological Risk Factor for Mineralizing Angiopathy

Though mineralizing angiopathy is increasingly being recognised as a cause of ischemic stroke in young children, it's cause is not clear. As congenital infections and perinatal infections have been proposed to be associated with mineralizing angiopathy, the authors studied the prevalence of perinatal infections in children with mineralizing angiopathy and compared it with focal cerebral arteriopathy and non-stroke patients. Sixteen children with mineralizing angiopathy, 14 children with focal cerebral arteriopathy and 40 non-stroke patients were enrolled. Detailed parental interview was conducted to look for perinatal infection [Premature rupture of membranes (PROM) and neonatal sepsis]. Perinatal infection (PROM in 8 and documented neonatal sepsis in 2) was seen in 8 patients (68.2%) with mineralizing angiopathy and none of the children with focal cerebral arteriopathy. Only 3 (7.5%) of non-stroke patients had history of PROM. This difference was statistically significant. Perinatal infections could be an important etiological risk factor seen in children with mineralizing angiopathy.

Current status of infarction in the basal ganglia-internal capsule due to mild head injury in children using PRISMA guidelines

Post-traumatic basal ganglia-internal capsule (BGIC) infarction in pediatric patients is a relatively rare consequence of mild head injury (MHI). To the best of the authors' knowledge, at present, no comprehensive review has been published. To review research on BGIC infarction after MHI, a literature search was performed using the PubMed database and relevant search terms. According to recent data, MHI may cause BGIC infarction due to mechanical vasospasm of the perforating vessels in pediatric patients. The anatomical characteristics of the growing brain in infancy, mineralization of the lenticulostriate arteries and viral infection may all play a part in BGIC infarction after MHI, which often occurs within 24 months. Symptoms are not as severe and tend to disappear in the early period. Computed tomography or magnetic resonance imaging often shows BGIC infarction. There are also children with scattered calcification of the basal ganglia. Neural rehabilitation is a commonly accepted treatment. The prognosis of patients with BGIC infarction after MHI consistently improves.

Right middle cerebral artery infarct after minor head trauma in an infant: Case report and literature review

Ishaemic stroke (IS) in the paediatric population is extremely rare. In this age group, the occurrence of IS often concurs with underlying congenital heart disease, haematological, metabolic or immunological conditions. In contrast, the association between IS and minor head injury in children has been sparse in current literature. The authors report a case of a healthy 9-month-old male who was found to have a right middle cerebral artery territory infarct after a minor head injury. An extensive medical workup was performed, and it was negative for any previously undiagnosed co-morbidities. Given the paucity of such cases, the condition and its management are discussed in corroboration with current literature.

Mineralizing angiopathy presenting with recurrence of basal ganglia stroke following minor head trauma

Basal ganglia stroke secondary to mineralizing angiopathy of lenticulostriate arteries is a well-recognized clinical entity following minor head trauma in children. Recurrences are uncommon, and the majority of these recurrences occur within a few months of initial insult. We report a 2-year-old boy who developed recurrence of basal ganglia stroke after a latency of 18 months from the time of first unrecognized insult at 6 months of age. The case brings forth the need to recognize the condition of basal ganglia stroke secondary to mineralizing angiopathy considering the risk of recurrence to occur as far as 18 months after the first stroke.

A Case of Lenticulostriate Stroke Due to Minor Closed Head Injury in a 2-Year-Old Child: Role of Mineralizing Angiopathy

OBJECTIVE

Cerebral infarction due to minor head injury is rare. Mineralizing angiopathy is considered a predisposing factor for lenticulostriate stroke after minor closed head injury. This entity is characterized by infarction of the basal ganglia and most often occurs in young children, from infancy to 2 years of age. Symptoms usually occur immediately after the injury.

METHODS AND RESULTS

We present the case of a previously healthy 2-year-old female child presenting with right facial hemiparesis and aphasia, along with right arm and leg weakness that occurred immediately after a fall from the couch onto a carpeted floor. A brain computed tomography scan revealed small and linear calcifications of the basal ganglia and subcortical frontoparietal area, in the absence of signs of intracranial hemorrhage. Brain magnetic resonance imaging with stroke protocol revealed restriction of water diffusion in the left basal ganglia on diffusion-weighted imaging sequences as well as apparent diffusion coefficient sequences, suggesting an acute infarct of the left basal ganglia within the distribution of the lenticulostriate vessels. The patient was treated with aspirin and conservative management and had gradual improvement over the next few days, with full recovery of the aphasia, facial nerve function, and arm and leg mobility, within 2 months.

CONCLUSIONS

Some infants can present with the onset of stroke-like symptoms after minor head injuries. Presence of linear calcifications of the basal ganglia noticed on brain computed tomography in many of these patients suggests that mineralizing angiopathy may be a predisposing factor for lenticulostriate stroke after minor closed head injury in infants. Brain magnetic resonance imaging to further delineate possible cerebral infarction is indicated.

Basal Ganglia Infarct following Trivial Trauma in a Child: Case Report and Review of Literature

A 2-year-old boy was presented to us with right-side hemiparesis after trivial fall. Diffusion-weighted magnetic resonance imaging showed an infarct in left basal ganglia and thalamic region. Secondary causes of stroke were ruled out. The child was managed conservatively. Basal ganglia infarct secondary to minor trauma is a rare event. Possible mechanisms leading to such an event and its management are discussed.

Increased Risk of Stroke in Patients of Concussion: A Nationwide Cohort Study

Long-term morbidities can develop after traumatic brain injury (TBI). Some studies have suggested that the risk of stroke is higher after TBI, but the association between concussion and stroke remains unclear. Using a national cohort, the authors analyzed the incidence of both hemorrhagic and ischemic strokes in patients with previous concussion. A representative cohort of approximately one million people was followed up for four years. Patients with new-onset concussion were identified (n = 13,652) as the concussion group. Subsequently, the incidence rates of later stroke events in the concussion group were compared to a sex-, age- and propensity score–matched comparison group (n = 13,652). The overall incidence rate of stroke in the concussion group was higher than that of the comparison group (9.63 versus 6.52 per 1000 person-years, p < 0.001). Significantly higher stroke risk was observed in the concussion group than in the comparison group (crude hazard ratio 1.48, p < 0.001; adjusted HR 1.65, p < 0.001). In the concussion group, the cumulative incidence rates of both ischemic stroke and hemorrhagic stroke were higher than those of the comparison group (8.9% vs. 5.8% and 2.7% vs. 1.6%, respectively, both p < 0.001). Concussion is an independent risk factor for both ischemic and hemorrhagic strokes. Prevention and monitoring strategies of stroke are therefore suggested for patients who have experienced concussion.

Childhood Basal Ganglia Stroke and its Association with Trivial Head Trauma

This study explored the clinical profile, risk factors, neuroimaging and outcome of childhood basal ganglia stroke. Children (6 months-12 years) with basal ganglia stroke registered between 2007-2011 were retrospectively enrolled, while newly diagnosed cases over the 2-year study period were enrolled prospectively. Children with recent trivial head trauma were compared with those without it. Of the 35 children enrolled, trivial head trauma was seen in 74%. The non-trivial head trauma group (n = 9) comprised unidentified etiology (4), Moyamoya syndrome (2), varicella infection (1), homocysteinemia (1), and probable mitochondrial cytopathy (1). Median duration to complete recovery was significantly less in the trivial head trauma group (median = 12, range = 1-72 weeks vs median = 38, range = 20-48 weeks,P= .001). Moreover, these children had increased chances of complete recovery (85% [22/26] vs 44.5% [4/9],P= .029). Basal ganglia stroke can follow trivial head trauma and may have a more favorable outcome.

Posttraumatic cerebral infarction in severe traumatic brain injury: characteristics, risk factors and potential mechanisms

BACKGROUND

Posttraumatic cerebral infarction (PTCI) is a severe secondary insult of traumatic brain injury (TBI). This study aimed to evaluate the characteristics and risk factors of PTCI after severe TBI (sTBI) and explore possible mechanism.

METHODS

This retrospective study included a cohort of 339 patients with sTBI; they were divided into the PTCI and non-PTCI groups. Clinical data and follow-up charts were reviewed for comparison. The logistic regression model was used for multivariate analysis to detect the risk factors of PTCI. The Glasgow Outcome Scale (GOS) and Barthel index (BI) for activities of daily living (ADL) were applied to evaluate their outcome.

RESULTS

PTCI led to an increased mortality (43.5 % vs. 10.7 %, P < 0.001) and days of intensive care unit stay (14.3 days vs. 7.1 days, P < 0.001), decreased GOS (3.1 vs. 4.1, P < 0.001) and BI (25.0 vs. 77.9, P < 0.001). Increased infarction volume led to poor outcome assessed by GOS (r = -0.46, P < 0.0001) and BI for ADL (r = -0.36, P = 0.026) for surviving patients. Compared with non-PTCI patients, PTCI patients had a high incidence of midline shift (36.2 % vs. 20.7 %, P = 0.011) and posttraumatic vasospasm (PTV) (42.0 % vs. 27.4 %, P = 0.027). Daily prevalence of PTCI occurred in two peaks: one (73.9 %) was in the first 24 h after injury, while the other (18.8 %) was in the span of 43 to 60 h postinjury. In multivariate analysis, hyperthermia [adjusted odds ratio (OR), 3.11; P = 0.001] in the first 24 h, thrombocytopenia (OR, 27.08; P < 0.001), abnormal prothrombin time (OR, 7.66; P < 0.001) and traumatic subarachnoid hemorrhage (OR, 2.33; P = 0.022) were independent predictors for PTCI.

CONCLUSIONS

PTCI deteriorates the outcome of sTBI patients. Mechanical compression and hemocoagulative disturbance serve as potential mechanisms mediating this pathophysiological process. PTV may also contribute to PTCI, but its association with PTCI is weak and needs further exploration. Early recognition and intervention of these factors might be beneficial for preventing PTCI.

A Design for Evaluation of the Trauma Apportionment in Cerebral Infarction after Trauma

Objective

Posttraumatic cerebral infarction (CI) is a well-known complication of traumatic brain injury (TBI). However, the causation and apportionment of trauma in patients with CI after TBI is not easy. There is a scoring method, so-called trauma apportionment score (TAS) for CI, consisted with the age, the interval, and the severity of the TBI. We evaluated the reliability of this score.

Methods

We selected two typical cases of traumatic CI. We also selected consecutive 50 patients due to spontaneous CI. We calculated TAS in both patients with traumatic and spontaneous CI. To enhance the reliability, we revised TAS (rTAS) adding three more items, such as systemic illness, bad health habits, and doctor's opinion. We also calculated rTAS in the same patients.

Results

Even in 50 patients with spontaneous CI, the TAS was 4 in 44 patients, and 5 in 6 patients. TAS could not assess the apportionment of trauma efficiently. We recalculated the rTAS in the same patients. The rTAS was not more than 11 in more than 70% of the spontaneous CI. Compared to TAS, rTAS definitely enhanced the discriminating ability. However, there were still significant overlapping areas.

Conclusion

TAS alone is insufficient to differentiate the cause or apportionment of trauma in some obscure cases of CI. Although the rTAS may enhance the reliability, it also should be used with cautions.

Lacunar stroke in a teenager after minor head trauma: case report and literature review

Ischemic strokes in children and young adults are fortunately rare. Contrasted with adult ischemic strokes, pediatric stroke etiologies vary greatly and are often unknown. Childhood lacunar strokes and trauma-induced strokes represent particularly uncommon subsets and have been reported infrequently in the literature. It is unique to find a combination of the 2-a lacunar stroke induced by trauma. Underreporting of these trauma-induced ischemic strokes could be responsible for perpetuating the lack of recognition. Here we present a lacunar stroke in a young woman associated with a water sport accident and explore relevant literature encircling deep brain ischemia coinciding with trauma.

[Childhood cerebral vasculitis]

Central nervous system vasculitides are defined as the invasion of the vascular wall by blood-borne inflammatory cells. In childhood, they may be classified according to their trigger event (infectious vs. non-infectious), their temporal course (time-limited vs. chronic), and the size of the affected vessel. Diseases apparently confined to the central nervous system are also distinguished from secondary forms, associated with infection or rheumatic or systemic inflammatory disorders. Large-vessel vasculitis, the most frequent form, causes stroke and presents with acute focal deficits. MR, or more seldom contrast angiography is required for the positive diagnosis, while the child's medical history conveys the etiological diagnosis. The clinical manifestations of small-vessel vasculitis include headaches, seizures, focal deficits, cognitive decline, and behavior changes that can occur insidiously over a few weeks or a few months. The diagnosis is based on the associated clinical and biological symptoms in secondary forms and on cerebromeningeal biopsy in primary forms. Secondary forms of vasculitides are treated according to the etiology. The injury of large basal arteries is often observed after infection, especially varicella, and is also called transient focal cerebral arteriopathy (TCA) or post-varicella arteriopathy (PVA). This focal, monophasic, and time-limited entity is highly specific of childhood. There are no arguments in the current literature supporting the hypothesis that an aggressive immunomodulatory treatment would be more effective, in terms of recurrence rate or functional outcome, than aspirin alone. In contrast, the diffuse, prolonged, and aggressive course of the rare primary vasculitis of the central nervous system requires a prolonged immunosuppressive treatment. The management of associated symptoms, treatment-related adverse effects, and sequelae is based on a multidisciplinary approach.

Rubiano A, Moscote-Salazar LR. Fatal Massive Cerebral Infarction in a Child after Mild Brain Trauma: A Case Report and Literature Review

Traumatic brain injury is a common entity. However cerebral infarction in infants is a rare entity while the diagnosis of this pathology in the pediatric population is usually difficult. The mild head trauma is rarely accompanied by intracranial injury and even less, with cerebral infarction. We herein report the first case of cerebral infarction after a mild brain trauma in a 2-year-old Latin-American male patient, in which brain computed tomography (CT) scan was performed on the first day of the accident, showed right hemispheric cerebral ischemia compromising the fronto-parieto-occipital region. Conservative management was established. The patient died at day 5. So Brain CT scan may be beneficial to reveal any hemispheric infarction due to a probable mass effect.

Mineralizing angiopathy with infantile basal ganglia stroke after minor trauma

AIMS

The objective of this study was to describe a cohort of infants with basal ganglia stroke associated with mineralization in the lenticulostriate arteries and their clinical outcomes.

METHOD

Subcortical strokes occurring in infants during the study period were categorized as arterial ischaemic, venous, or haemorrhagic. A cohort of infants with basal ganglia infarcts and associated mineralization of lenticulostriate arteries were identified. This group was analysed for possible aetiological factors, clinical course, and recurrence rate of the stroke.

RESULTS

Of 23 infants with basal ganglia arterial ischaemic stroke, 22 (16 males, six females; mean age 11mo [±SD 4.8mo]) were found to have lenticulostriate artery mineralization. Twenty infants presented with hemiparesis and two presented with recurrent episodes of hemidystonia. Eighteen infants had a history of minor trauma before onset of stroke. No other predisposing factors were identified in this cohort. There were no demonstrable causes for vascular and soft tissue calcification. The mean follow-up was 11 months, during which five infants experienced stroke recurrence. Of the 17 infants who did not experience a recurrent stroke, eight exhibited complete neurological recovery, and nine had mild residual hemiparesis.

INTERPRETATION

Acute basal ganglia stroke after minor trauma associated with mineralization of lenticulostriate arteries in infants is a distinct clinicoradiological entity. Investigations for prothrombotic states and vasculopathies are normal. Although neurological outcomes in most children are good, trauma is a risk factor for recurrence of stroke.

Clinical features and risk factors of cerebral infarction after mild head trauma under 18 months of age

Mild head trauma can cause cerebral infarction in children younger than 18 months of age, yet the pathogenesis, clinical characteristics, and risk factors are not fully understood. Data of 16 cases between August 2008 and September 2011, including clinical manifestations and imaging and laboratory findings were collected and analyzed. All patients had the history of mild head trauma. The median age of the cohort was 13.5 months (range 6 months to 18 months). All children developed neurologic symptoms and signs within 72 hours after trauma, 62.5% (10/16) within 30 minutes. The first symptoms included hemiparesis (9/16), facial paresis (4/16), and convulsion (6/16). Overall, 93.75% (15/16) of the lesions were in the basal ganglia region. Two risk factors were identified, basal ganglia calcification in 10 and cytomegalovirus infection in eight. After conservative therapy, the neurologic deficits recovered to some extent. Cerebral infarction after mild head trauma in children younger than 18 months of age may take place, especially under the circumstances of basal ganglia calcification or cytomegalovirus infection.

Does lenticulostriate vasculopathy predipose to ischemic brain infarct? A case report

Lenticulostriate vasculopathy (LSV) is a sonographic finding in infancy with obscure etiology and variable diagnostic and prognostic significance. Ischemic infarct in the territory of the lenticulostriate vessels after mild head trauma is a rare pathology. There are no publications on LSV followed by ischemic infarct. We present the case of an 8-month-old boy who suffered mild head trauma and developed an ischemic brain infarct in the territory of preexisting LSV. It is speculated that LSV might be a predisposing factor for ischemic brain infarct after mild head trauma in infants.

The young brain and concussion: imaging as a biomarker for diagnosis and prognosis

Concussion (mild traumatic brain injury (mTBI)) is a significant pediatric public health concern. Despite increased awareness, a comprehensive understanding of the acute and chronic effects of concussion on central nervous system structure and function remains incomplete. Here we review the definition, epidemiology, and sequelae of concussion within the developing brain, during childhood and adolescence, with current data derived from studies of pathophysiology and neuroimaging. These findings may contribute to a better understanding of the neurological consequences of traumatic brain injuries, which in turn, may lead to the development of brain biomarkers to improve identification, management and prognosis of pediatric patients suffering from concussion.