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Rare case of childhood stroke

A 12-year-old Asian boy presented to his GP with a 3-month history of four or five episodes of unprovoked right-sided headache, transient blurred vision and photophobia, relieved by vomiting and sleep. There had been no recent trauma and there was no relevant past or family history. Neurological examination was normal and a provisional diagnosis of migraine was made. The patient and parents were advised to maintain a headache diary and use sumatriptan nasal spray for future attacks. When reviewed a month later there had been no further episodes of headache or accompanying symptoms. Three months after the index presentation, while on a family holiday in India, he developed severe dizziness and vomiting associated with reduced hearing in his right ear. Based on the history, right-sided nystagmus and a normal magnetic resonance imaging (MRI) scan, labrynthitis was diagnosed by the paediatrician. Symptoms worsened and an ear, nose and throat specialist in a tertiary hospital confirmed the diagnosis. Symptoms improved transiently with intravenous dexamethasone. Later that day he developed diplopia and encephalopathy. A further MRI showed a large infarct in the right cerebellum and smaller ones in the left cerebellum and occipital lobes, causing obstructive hydrocephalus. A computed tomography angiogram (CTA) showed vertebral artery dissection (VAD). An external ventricular drain was inserted, followed by posterior decompression craniotomy with lax duraplasty. Post-operative neurological recovery was helped by stroke rehabilitation. The patient had residual right lateral rectus palsy and cerebellar features of ataxia, nystagmus, dysarthria and retropulsion. He was discharged 18 days later on an anticoagulant and levetiracetam. Cervical spine X-ray (for atlanto-axial dislocation), thrombophilia screening and echocardiogram were also performed to exclude other causes. On returning to the UK, his GP referred him to a paediatric neurologist, neuro-therapists, an ophthalmologist and a speech therapist. Two months post-discharge the boy had made a remarkable recovery and was able to walk. He had mild dysarthria, incoordination and diplopia. He returned to full time school in a phased manner. There were no cognitive concerns, although there were difficulties with writing secondary to mild problems with coordination. Three months later the visual symptoms had resolved completely. No new changes were found on a magnetic resonance angiogram (MRA) of the head and neck. Antiepileptic and anticoagulant medications were discontinued and long-term aspirin was started. By 10 months, he was doing well academically and back playing cricket.