Pediatric Homonymous Superior Quadrantanopia in the Presence of Acute Vertebral Artery Dissection

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Abstract

Objective

Spontaneous dissection of the vertebral artery is a dangerous and often underdiagnosed cause of posterior circulation and occipital lobe stroke in the young. Vertebral artery dissection should be considered in young patients with a history of minor, nontraumatic changes in head position and visual disturbances.

Methods

Clinical records for this patient were retrospectively reviewed at Miami Children's Hospital and associated pediatric ophthalmology clinic.

Results

A previously healthy 8-year-old boy presented to the emergency department with a 2-day history of headache and blurred vision that developed after going on a high-velocity amusement park ride. Confrontation visual field testing showed a subtle superior visual field deficit superiorly. Computer topography scan of the head without contrast was performed and showed bilateral occipital hypodense lesions consistent with ischemic infarction. A filling defect was seen in the transverse portion of the right vertebral artery at the level of C2 as it exited the right transverse foramen, consistent with an acute arterial dissection at this level. Automated visual field testing showed macular sparing left homonymous superior quadrantanopia.

Conclusions

Most patients with vertebral artery dissection present with signs of posterior circulation ischemia consisting of neurological deficits, headaches, or neck pain. This case report highlights the unique clinical features and diagnostic imaging seen in the work-up of this rare disease process and exemplifies the importance of identifying acute visual symptoms in an emergency situation.

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