- Department of Neurosurgery, Aga Khan University Hospital, Stadium Road, Karachi, Pakistan
- Pakar Neurosurgeri, Neurosurgeri Klinik, Hospital Sultanah Aminah, Jalan Abu Bakar, Johor Bahru Johor, Malaysia
Department of Neurosurgery, Aga Khan University Hospital, Stadium Road, Karachi, Pakistan
DOI:10.4103/2152-7806.80116Copyright: © 2011 Sobani ZA. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Sobani ZA, Ali A. Pediatric traumatic putamenal strokes: Mechanisms and prognosis. Surg Neurol Int 28-Apr-2011;2:51
How to cite this URL: Sobani ZA, Ali A. Pediatric traumatic putamenal strokes: Mechanisms and prognosis. Surg Neurol Int 28-Apr-2011;2:51. Available from: http://sni.wpengine.com/surgicalint_articles/pediatric-traumatic-putamenal-strokes-mechanisms-and-prognosis/
Background:Studies have shown that nearly 3% of closed head injuries result in basal ganglia hemorrhages and that this may be a more frequent occurrence in pediatric patients. Various mechanisms based on shearing forces have been implicated in the injury; however, the underlying mechanism leading to the increased incidence in pediatric patients has not been well described. Angiographic data suggest that putamenal perforators in children are more severely stretched at acute angles compared to those in adults, which may be a contributing factor to the increased incidence.
Case Description:We discuss a series of five relatively benign cases of traumatic putamenal strokes in children and review their presentations, mechanism of injury, neurological deficits, and management with reference to available literature.
Conclusion:Although generally an alarming situation, benign presentations of putamenal strokes may be seen in pediatric populations after closed head injuries. In such cases, conservative management with subsequent rehabilitation and physical therapy is recommended.
Keywords: Pediatrics, putamenal hemorrhages, closed traumatic brain injury, cerebrovascular trauma
Nearly 3% of closed head injuries result in basal ganglia hemorrhages manifesting with the symptoms of severe head injury.[
In this study, we discuss a short series of five cases of relatively benign presentations of traumatic putamenal strokes in children and review their presentations, mechanism of injury, neurological deficits, and management with reference to available literature [
A 5-year-old girl presented to the emergency room (ER) with a history of fall from stairs (approximately 6-feet in height). She had immediate loss of consciousness which lasted for a 5 min. There was also a history of three episodes of vomiting on the way to the hospital, but no history of fits or bleeding from ear or nose after the injury.
On examination, she had a pulse rate of 82 beats per minute with a blood pressure of 115/76 mmHg. Her Pediatric Glasgow Coma Scale (GCS) was assessed to be 11/13, both her pupils were equal in size, and reaction to light. Her movements over the left half of her body were comparatively reduced with a power of 3/5 according to the Medical Research Council (MRC) scale. The rest of the neurological and systemic examination was within normal limits.
The initial brain computed tomography (CT) scan revealed a small ganglionic bleed associated with perifocal edema and a subtle mass effect [
She was managed conservatively and her hemiparesis gradually improved. A_repeat CT scan at 2 weeks showed that the hematoma had almost resolved [
At 6-month follow up, she had improved significantly, and regained a power of 5/5 in the affected limbs. Outcome assessed according to the Glasgow Outcome Scale (GOS) was 5.
A 6-year-old boy was brought to the ER with a history of road traffic accident. He lost consciousness only briefly immediately after the episode and then had repeated episodes of vomiting. His history was negative for any fits or active bleeding from the ear or nose.
On examination, his pulse was 90 beats per minute with a blood pressure of 115/80 mmHg. His pediatric GCS was assessed to be 10/13, both his pupils were equal in size and reaction to light. He had a scalp laceration on the left parietal area, which had been appropriately sutured and dressed in ER. The patient also had left hemiparesis with a power of 3/5 in both upper and lower limb according to the MRC scale. The rest of the neurological and systemic examination was unremarkable.
The initial CT scan of the brain revealed a large hematoma in the left lentiform nucleus with perifocal edema [
He showed clinical improvement on conservative management and became fully alert and conscious within 1 week. A repeat CT scan showed a resolving hematoma and surrounding edema [
An 8-year-old boy was brought to ER with a history of road traffic accident in which he was hit by a motorbike. He had a history of temporary loss of consciousness followed by repeated episodes of nausea and vomiting. There were no complaints of bleeding from ear and nose or seizure like activity after the trauma.
On arrival, his pulse was 87 beats per minute and blood pressure was 115/75 mmHg. His GCS was 12/15, both his pupils were equal in size and reaction to light. There were no other neurological deficits and the rest of the examination was within normal limits.
The CT scan brain done on arrival showed a small hematoma in the area of right putamen with minimal perifocal edema, and no midline shift. The patient was managed conservatively and became fully conscious in 72 h.
He was started on regular physical therapy and discharged after 1 week with regular visits to our rehabilitation unit. At 4 month follow-up, he showed full neurological recovery without any residual deficits, and a GOS score of 5.
A 7-year-old boy was brought to the ER after being involved in a road traffic accident, in which the car he was riding in rolled over. He had a history of loss of consciousness and repeated vomiting. There was no history of fits or bleeding from ear or nose.
On arrival his pulse was 95 beats per minute with a blood pressure of 95/60 mmHg. His GCS was 12/15, and both his pupils were equal in size and reaction to light. There was a 4-cm laceration on the patient's posterior parietal area on the right side. He had a left-sided hemiparesis with power of 3/5. The patient had a deformity of the right upper limb with suspected fracture of the humerus which was stabilized using a long arm back-slab. The rest of the_neurological and systemic examination was unremarkable.
The initial CT scan of the brain showed a large hematoma in right putamenal area with perifocal edema [
The patient was managed nonoperatively with hypertonic saline in Pediatric Neuro-Intensive Care Unit for 24 h after which his imaging was repeated and he was shifted to step down unit, and started on regular limb physiotherapy. He was discharged home after a week on rehabilitation.
At 3-month follow up, he was able to perform basic tasks and was seen comfortably playing with a toy. He was also able to walk with support. A repeat CT scan showed an area of hypodensity with decreasing perifocal edema [
A 14-month male child presented to the ER with a history of fall from a bed (approximate height of 3 feet), after which he lost consciousness. He regained consciousness in about 2-3 min, and started to cry. On his way to the hospital, he had three episodes of vomiting. There was no history of seizure-like activity, or active bleeding from ear or nose.
On examination, his Pediatric GCS was 11/13 and his pupils were equal in size and reaction to light. There was a scalp swelling around the occipital area. He was noticed to have reduced movements over the right side of his body, with a power of 3/5. The rest of the examination was unremarkable.
The CT scan of his brain did not show any brain parenchymal injury 2 h after the incident [
He was managed conservatively with physiotherapy and subjected to regular follow-up. At 3 month follow-up he had a good recovery as he was able to walk with minimal support. His power on the affected side remained 4/5 at 3 months after the incident and his GOS score was 4.
Although the reported incidence is 3% in general population, traumatic putamenal strokes may be more common in the pediatric population. In previously reported studies almost all injuries leading to traumatic basal ganglia hemorrhages occurred in road traffic accidents with significant forces of impact and/or acceleration/deceleration sustained by the patient;[
Several theories have been proposed to explain these injuries seen in this setting including occlusion, vasospasm, arterial emboli, dissection, thrombus formation, and vascular compression secondary to increased intracranial pressure.[
However, traumatic dissection of perforating arteries might better explain underlying mechanism especially in hemorrhagic strokes.[
Following the previously reported data we compared the vascular anatomy of normal pediatric and adult patients undergoing cerebral angiography [
The absence of stretching forces along with the tortuous nature of the perforators [
Although Boto et al. reported that the final outcomes were unfavorable in 84% of their patients, which showed no correlation with volume of the hematoma,[
We recommend that even though the contralateral hemiparesis may be an alarming sign, conservative management with rehabilitative physiotherapy be employed in children with relatively benign traumatic putamenal strokes.
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