Case report

A 1 year old girl presented to the accident and emergency (A&E) department one hour after a witnessed fall from a sofa. She landed on her left side hitting her head, and afterwards was reluctant to use her left arm and leg. She cried immediately after the fall, had sustained no loss of consciousness and had not vomited or slept since the incident. Her past medical history was unremarkable with a normal delivery and developmental milestones. There was no relevant family history.

On examination she was distressed, crying when moved. There was no obvious limb deformity. There was no spontaneous left arm movement but she could be encouraged to withdraw the limb. She was able to weight bear on both lower limbs but had minimal spontaneous movement of her left leg. She was fully alert with no cranial nerve abnormality detected. After analgesia she settled and full passive movement was achieved in both hips. Radiographs of left shoulder, elbow and wrist were normal. She was discharged home that night to be reviewed the following day at which time there was no change in her condition. On second review her mother described her to be continuously irritable, she had deteriorated in that she was now unable to weight bear, had decreased tone on the left side, flaccid reflexes, an upgoing left plantar and facial asymmetry on crying.

Computed tomography of the head was performed under sedation and showed a low attenuation area in the posterior aspect of the internal capsule (see fig 1). A diagnosis of probable cerebral infarct was made.

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Figure 1

The area of low attenuation (standard orientation) is demonstrated.

She was transferred to Great Ormond Street Hospital for follow up. No cause was found after extensive investigation. She was given aspirin 5 mg/kg/day .

Discussion

Cerebral infarction is uncommon in children (incidence 0.63/100 000/y,¹ 0.58/100 000/y²). The underlying condition remains unknown in as many as half of cases.³ The cause in a sick child may be obvious, for example, severe dehydration in a diarrhoeal illness, diabetic ketoacidosis, severe sepsis or sickle cell disease. Systemic hypertension does not play a major part in children. Higgins² demonstrated aetiology as 21% infection, 18% vascular disorders, 15% haematological disorders, 13% cardiac disorders (a large majority being cyanotic heart disease in children less than 2 years), trauma 8%. Clotting disorders have been further investigated and Baca⁴ demonstrated 7 of 10 cases of infarction to have anticardiolipin antibodies and 2 of the 10 to have a temporary protein C deficiency. This may explain a large proportion of the previously labelled idiopathic cases. Protein S deficiency can be associated with nephrotic syndrome and leukaemia. Other aetiologies includes trauma, for example internal carotid artery damage via the roof of the mouth with a lollipop stick, vasculitides and rare disorders such as Moyamoya.

The major presenting feature (after excluding those related to premature birth, birth trauma and head injury) is acute hemiplegia, which may be associated with seizures and altered consciousness. It is important to obtain any history of trauma, recent infection (55% in a study by Eeg-Olofsson⁵), family history of thrombotic disease or sickle cell disease as it may be the first presentation in a young child. Extensive investigation should be carried out at a specialist centre to identify any treatable cause. Survival is in the region of 80–90%.^{1, 5} Lanska⁶ showed residual disability in 50%, however all were ambulatory, 19% had recurrent seizures. The risk of recurrence is dependent on the cause. Baca's study had no recurrent episodes after 15.7 months while taking aspirin.

Aspirin is used for its anti-platelet action and as in juvenile arthritis is well tolerated. Carers need to be alert for symptoms of salicylism and the serious complication of Reyes syndrome. There is no mention in the literature about the use of dipyridamole specifically for neurological situations.

Conclusion

Our case demonstrates the following points:

• A diagnosis of soft tissue injury should not have been made in a child with upper and lower limb weakness after a fall.

• A history of trauma is important to obtain but in this case may have been misleading.

• Children may need daily review and paediatric advice should be sought if there is no clear diagnosis at presentation.