CASE REPORT A rare cause of ischemic stroke in childhood: spontaneous long segment intracranial dissection Erdem Simsek 1 & Sanem Yilmaz 1 & Ismail Oran 2 & Gul Aktan 1 & Hasan Tekgul 1 & Sarenur Gokben 1 Received: 14 November 2019 /Accepted: 31 January 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020 Abstract Craniocervical arterial dissection is an important cause of arterial ischemic stroke in children. Recognition of dissections is of particular importance both in determining the risk of recurrence and in bringing about different treatment alternatives. We report a 10-year-old girl who presented with acute ischemic stroke due to spontaneous long segment dissection involving the parasellar internal carotid artery up to the distal M1 portion of the middle cerebral artery. Three-dimensional digital subtraction angiography with flat panel detector revealed the presence of major vessels originating from both true and false lumens and had a critical role in the treatment decision of the case. Keywords Dissection . Intracranial . Pediatric . Spontaneous . Stroke Introduction Ischemic stroke is an important cause of neurological morbid- ity in childhood. Arteriopathy is the most important risk factor for childhood stroke [1, 2]. Dissection among the causes of non-inflammatory arteriopathy is responsible for approxi- mately 7.5–20% of ischemic stroke, but being entirely depen- dent on used imaging modalities, it is estimated to be more frequent than expected [1–4]. The recognition of dissections is important because of the recurrence rate of up to 20% and the possible need for different treatment approaches [1, 5]. Here, we present a case with a long segment spontaneous intracra- nial dissection. To the best of our knowledge, this is the lon- gest spontaneous intracranial dissection in the pediatric age group reported up to date. Another interesting aspect of this case is the lack of any improvement of dissection in the con- trol imaging after 2 years. Case report A 10-year-old girl was admitted to the emergency department with headache and right-sided weakness. No prior history of trauma was reported. Physical examination revealed right hemi- plegia, right central facial palsy, and expressive aphasia. Magnetic resonance imaging was consistent with acute ische- mia in the posterior segment of the basal ganglia and the corona radiata on the left side (Fig. 1). Any finding suggestive for arteriopathy was not detected by carotid Doppler ultrasonogra- phy. Low-molecular-weight heparin therapy was initiated. Genetic panel study for predisposition to thrombosis was found normal. Magnetic resonance angiography (MRA) revealed an intraluminal dissection flap starting from the terminal segment of the left internal carotid artery (ICA) extending to the bifur- cation of the left middle cerebral artery (MCA) (Fig. 2). When evaluated for endovascular intervention with three-dimensional digital subtraction angiography (DSA) with flat panel detector computed tomography, a long intimal dissection flap extending from the parasellar ICA to the distal M1 portion of the MCA was seen (Fig. 3). The imaging also revealed that the posterior communicating artery originated from the true lumen and the lenticulostriate arteries originated from the false lumen as a single trunk (Fig. 3). Since stenting in one lumen would result in squeezing the other lumen with subsequent flow compromise in the side branches, endovascular treatment was deemed un- suitable for this lesion. Low-molecular-weight heparin * Sanem Yilmaz sanem.yilmaz@ege.edu.tr 1 Department of Pediatrics, Division of Child Neurology, Ege University Medical Faculty, 35100 Bornova, Izmir, Turkey 2 Department of Radiology, Division of Interventional Radiology, Ege University Medical Faculty, Izmir, Turkey https://doi.org/10.1007/s00381-020-04530-9 / Published online: 7 February 2020 Child's Nervous System (2020) 36:2871–2875