SHARE @ Advocate Health - Midwest - Scientific Day: Strokes of Bad Luck: A Pediatric Case Series of Acute Onset Lower Extremity Neurological Changes
 

Affiliations

Advocate Children's Hospital

Abstract

Introduction/Background:

Acute onset focal neurological change of the lower extremity is a medical emergency with a broad differential including stroke, transverse myelitis, acute inflammatory demyelinating polyneuropathy, acute flaccid paralysis, spinal tumor, epidural abscess, and tick paralysis. In this case series, we describe two pediatric cases of spinal cord ischemia (SCI) of which there are limited reports in the literature.

Description:

Case 1: An 11-year-old female with a history of autism spectrum disorder presented with acute onset ataxia, lower extremity weakness, loss of lower extremity deep tendon reflexes and urinary incontinence. She had a viral illness the week prior and a suspected allergic reaction the day prior. Initial work up for stroke, including magnetic resonance imaging (MRI) of the brain and spinal cord and lumbar puncture were negative. 96 hours later, with no clinical improvement, subsequent MRI with diffusion weighted sequence (DWI) revealed a stroke of the spinal artery territory from C3/C4 to T3/T4, along with a tear in the posterior annulus fibrosis of the C6-C7 disc. This was suggestive of fibrocartilaginous embolism (FCE). Case 2: A 13-year-old healthy male presented with acute onset right lower extremity weakness, numbness, and inability to urinate. The day prior, he felt a few minutes of right foot numbness while gardening. On exam, he had complete paralysis and hyperreflexia of his right lower extremity, numbness in both legs, and a loss of sharp/ cold sensation and areflexia in the left lower extremity. Initial MRI was normal; subsequent MRI with DWI identified an acute infarction in the spinal cord from C6-T4 and a small central disc protrusion with an annular fissure at C6-C7.

Discussion:

SCI occurs due to disrupted blood supply to the spinal cord, due to generalized hypotension, vascular injury/compression, thrombosis, or embolization to the spinal arteries. In both cases, the likely etiology for these patients’ SCI was an FCE. The first case had no known inciting event, but the second case was likely precipitated by increased intradiscal pressure associated with gardening maneuvers. As it is not always evident on typical MRI spine sequences, a high index of suspicion is needed to ensure DWI sequencing is obtained. Once diagnosed, treatment is supportive, focusing on intensive rehabilitation. Valsalva maneuvers should be avoided in the first 48 hours to limit extension of the stroke. The degree of recovery is variable.

Presentation Notes

Presented at Scientific Day; May 21, 2025; Park Ridge, IL.

Full Text of Presentation

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Document Type

Poster


 

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May 21st, 11:41 AM May 21st, 1:15 PM

Strokes of Bad Luck: A Pediatric Case Series of Acute Onset Lower Extremity Neurological Changes

Introduction/Background:

Acute onset focal neurological change of the lower extremity is a medical emergency with a broad differential including stroke, transverse myelitis, acute inflammatory demyelinating polyneuropathy, acute flaccid paralysis, spinal tumor, epidural abscess, and tick paralysis. In this case series, we describe two pediatric cases of spinal cord ischemia (SCI) of which there are limited reports in the literature.

Description:

Case 1: An 11-year-old female with a history of autism spectrum disorder presented with acute onset ataxia, lower extremity weakness, loss of lower extremity deep tendon reflexes and urinary incontinence. She had a viral illness the week prior and a suspected allergic reaction the day prior. Initial work up for stroke, including magnetic resonance imaging (MRI) of the brain and spinal cord and lumbar puncture were negative. 96 hours later, with no clinical improvement, subsequent MRI with diffusion weighted sequence (DWI) revealed a stroke of the spinal artery territory from C3/C4 to T3/T4, along with a tear in the posterior annulus fibrosis of the C6-C7 disc. This was suggestive of fibrocartilaginous embolism (FCE). Case 2: A 13-year-old healthy male presented with acute onset right lower extremity weakness, numbness, and inability to urinate. The day prior, he felt a few minutes of right foot numbness while gardening. On exam, he had complete paralysis and hyperreflexia of his right lower extremity, numbness in both legs, and a loss of sharp/ cold sensation and areflexia in the left lower extremity. Initial MRI was normal; subsequent MRI with DWI identified an acute infarction in the spinal cord from C6-T4 and a small central disc protrusion with an annular fissure at C6-C7.

Discussion:

SCI occurs due to disrupted blood supply to the spinal cord, due to generalized hypotension, vascular injury/compression, thrombosis, or embolization to the spinal arteries. In both cases, the likely etiology for these patients’ SCI was an FCE. The first case had no known inciting event, but the second case was likely precipitated by increased intradiscal pressure associated with gardening maneuvers. As it is not always evident on typical MRI spine sequences, a high index of suspicion is needed to ensure DWI sequencing is obtained. Once diagnosed, treatment is supportive, focusing on intensive rehabilitation. Valsalva maneuvers should be avoided in the first 48 hours to limit extension of the stroke. The degree of recovery is variable.

 

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