A 5-year-old boy is brought to the emergency department due to right-sided hemiplegia. His parents say that he has been having increasing difficulty moving his right arm and leg over the past 3 hours. This morning, approximately 10 hours prior, the child tripped on a toy while brushing his teeth and fell forward with the toothbrush in his mouth. He cried immediately, but his parents did not note any oral bleeding. The boy did say, "My throat hurts" throughout the day but was able to eat his lunch. The child has a history of attention deficit hyperactivity disorder for which he takes methylphenidate. The boy's mother has a history of migraines, and his grandfather had a stroke at age 62. Neurologic examination shows right hemiplegia, right hemianesthesia, and mild motor aphasia. Which of the following is the most likely cause of this patient's condition?

Question

A 5-year-old boy is brought to the emergency department due to right-sided hemiplegia.  His parents say that he has been having increasing difficulty moving his right arm and leg over the past 3 hours.  This morning, approximately 10 hours prior, the child tripped on a toy while brushing his teeth and fell forward with the toothbrush in his mouth.  He cried immediately, but his parents did not note any oral bleeding.  The boy did say, "My throat hurts" throughout the day but was able to eat his lunch.  The child has a history of attention deficit hyperactivity disorder for which he takes methylphenidate.  The boy's mother has a history of migraines, and his grandfather had a stroke at age 62.  Neurologic examination shows right hemiplegia, right hemianesthesia, and mild motor aphasia.  Which of the following is the most likely cause of this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d826_f03c_bc81_1fd7e8d008a6_MD0003_00 This patient's symptoms of hemiparesis and aphasia after injury to the posterior pharynx are suspicious for an injury to the cervical internal carotid artery, which is located directly lateral and posterior to the tonsillar pillars. Carotid artery dissection is a rare but potentially severe complication of penetrating trauma, seemingly minor oropharyngeal trauma (eg, a fall with object in mouth), or neck strain/manipulation (eg, yoga, sports). oropharyngeal trauma neck strain/manipulation Intimal injury to the internal carotid artery can result in dissection or thrombus formation, which occurs over hours to days and can extend into the middle and anterior cerebral arteries. Patients may develop neck pain, "thunderclap" headache, and symptoms of an ischemic stroke (eg, hemiparesis, facial droop, aphasia). The diagnosis of a carotid artery dissection is confirmed with CT or MR angiography. dissection (Choices A and D) Cerebral thromboses can also present with hemiparesis, facial droop, and aphasia. Antithrombin III deficiency is a hypercoagulable state with an increased risk of spontaneous venous thromboembolism, particularly of the femoral and mesenteric veins; cerebral thromboses are less common. Certain cardiac defects (eg, atrial septal defect) can cause right-to-left shunting of venous emboli into the cerebral arterial circulation causing stroke ("paradoxical emboli"). The history of trauma in an otherwise healthy child makes these diagnoses much less likely. (Choice B) Cerebral arteriovenous malformations are a rare but often fatal cause of intracranial hemorrhage. Arteriovenous malformation rupture is usually spontaneous without antecedent trauma. Patients typically experience acute headache, vomiting, and altered mental status. (Choice E) Todd paralysis is a transient hemiplegia following a seizure. There was no witnessed seizure activity or loss of consciousness in this patient, making this diagnosis unlikely. (Choice F) Hemiplegic migraines are most common in adolescents and present with headache, visual aura, and a self-resolving hemiplegia, none of which are present in this patient. (Choice G) Homocystinuria presents with lens dislocation, intellectual disability, marfanoid features, and an increased risk of arterial and venous thrombi. This diagnosis is unlikely in a healthy child with symptoms starting shortly after trauma to the posterior oropharynx. (Choice H) Penetrating oropharyngeal trauma increases the risk of retropharyngeal abscess. Symptoms include fever and severe neck pain rather than hemiplegia, and presentation typically occurs several days after initial injury. Educational objective: Posterior oropharyngeal injuries can result in internal carotid artery dissection or thrombus formation, which can present with hemiplegia, facial droop, and aphasia. References: Blunt intraoral trauma resulting in internal carotid artery dissection and infarction in a child. (http://www.ncbi.nlm.nih.gov/pubmed/25695844) Current management of penetrating injuries of the soft palate. (http://www.ncbi.nlm.nih.gov/pubmed/16949964) An impalement injury to the oropharynx in a paediatric patient--a case report. (http://www.ncbi.nlm.nih.gov/pubmed/20727632)

A 5-Year-Old Boy Is Brought to the Emergency Department Due