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Summer 2012

Case Study — Diagnosing Pediatric Stroke

In January 2008, 7-year-old James T. Syring got violently ill while on a family vacation. "He was nauseous, vomiting, and had severe headache and dizziness," says his father, also James Syring.

When the family returned home to Portland, Ore., emergency room physicians there ran standard tests and sent the boy home, prescribing rest for his flulike symptoms.

But the symptoms quickly worsened. A CT scan, ordered by the Syring's pediatrician, sent the family scrambling back to the hospital, where an MRI revealed a stroke.

Insight but Continued Mystery

Doctors put James T. on a blood thinner, monitored him closely in the ICU — and suggested the Syrings contact UCSF. A week later, the family met with UCSF pediatric neurologist Heather Fullerton, M.D..

Dr. Heather Fullerton and patient James T. Syring

Dr. Heather Fullerton and James

One of the world's leading experts on pediatric stroke, Fullerton ordered imaging of the head and the neck — the neck had not been part of the previous imaging. "We found a cerebellar stroke that was attributable to a vertebral artery dissection," she says.

After a comprehensive exam, she sent James T. home on an aspirin a day and prescribed regular follow-ups.

"Over time, we noticed that the vessel didn't heal as we expected," says Fullerton. Still, James T. seemed fine, with no recurrent strokes, so Fullerton continued him on aspirin therapy.

Second Stroke Leads to Complex Surgery

Then, nearly four years to the day after his first stroke, James T. collapsed at school, landing him back in the Portland hospital. There, a consulting neurologist ordered an immediate MRI, which confirmed another stroke.

The neurologist phoned Fullerton, who suggested a rotational neck CT scan, a special study that examines the vertebral artery in different positions as the head rotates. A phone collaboration between the Portland radiologists and a UCSF neuroradiologist led to the missing link: when James T. turned his head 60 degrees to the left, there was 100 percent closure of the vertebral artery.

This rare condition — compression of the vertebral artery with head turning — likely was the cause of the chronic injury to the vertebral artery that increased the risk of stroke-causing clots. As soon as they could, the Syrings rushed back to UCSF to meet with a team that included Fullerton, pediatric neurosurgeon Nalin Gupta, M.D., Ph.D., vascular neurosurgeon Michael Lawton, M.D., and interventional neuroradiologist Randall Higashida, M.D..

Higashida's angiogram precisely identified the causes of the compression; the surgery to alleviate the problem would take almost the entire next day.

"We knew it was risky, cutting around that artery, but we trusted them," says Syring, who was impressed with the surgical team's experience.

"To ease the external compression, we drilled away the bone adjacent to the artery and removed soft tissue at the level of cervical vertebrae C1 and C2," Gupta says. "Imaging immediately afterwards showed some improvement in the occlusion."

Dr. Nalin Gupta

Dr. Nalin Gupta

But only time would tell if the surgery had truly diminished the risk of another stroke.

In the ensuing weeks, James T. returned to normal activities. His headaches went away.

The week of March 25, 2012, he returned to UCSF for testing, which revealed the surgery was a success.

There was no more occlusion of the vertebral artery when James T. turned his head.

"We are very appreciative of UCSF's expertise and the way the two hospitals worked together," says Syring. "People need to know that kids really do have strokes."

For more information, contact Dr. Heather Fullerton at (415) 353-3681 or Dr. Nalin Gupta at (415) 353-7500.

 

Neurosciences — Summer 2012 Index

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