I believe the pathology in this case was lenticulostriate vasculopathy – not uncommon. According to one report, the incidence varies from 0.3% to 32% depending on the population studied. It suggests some prior insult to the brain. A variety of associations with other conditions, both infectious (CMV) and others have been suggested. The condition may make the blood vessels that supply this area of the brain more rigid and vulnerable to stretching injury compared with normal vessels. So, relatively mild trauma may cause injury to the arteries (vasospasm or clot formation) that may have led to a stroke. Apparently, the initiating event was the child having a 'mild' fall backwards bumping its head.
To Helen's initial observation, there is certainly a reluctance to perform CT on young children...the highest risk for subsequent head and neck cancers following ionizing radiation exposure is in children < 1 y/o. Indeed, I have to have repeated conversations with residents in my pediatric ER about balancing risks and benefits of CT for evaluating for very real life-threatening conditions versus unnecessary imaging. However, there are some important considerations beyond that contribute to the decision to obtain axial neuro-imaging in young children.
In general, this child's experience, while certainly influenced by a general reluctance to expose infants and young children to ionizing radiation, has a lot more to do with how health care (and research including dx error research) for children is prioritized, funded and taught. In the US, Emergency Medicine residency requires that only 20% of patients are pediatric. General EM physicians are excellent at managing pediatric trauma, minor illness, and resuscitations in otherwise healthy kids presenting with life-threatening conditions that are clear cut (sepsis, cardiac and pulmonary arrests, DKA, seizures). But identifying focal neurologic deficits in a child just learning to crawl is an immense challenge; more so when you're not as comfortable with fussy infants and toddlers with stranger anxiety. Indeed, even when seen at Sick Kids in Toronto, the diagnosis was missed. Was this due to time pressures, the experience of the examiner, the patience of the examiner, the thoroughness of the neurologic exam, cognitive biases? Probably a combination of several, I would suspect.
We (health care professionals and lay society) have put a lot of faith in technology to reduce these errors – perhaps we think it is cheaper and more reliable. But, I would posit the solution lies partly in teaching better physical exam skills, history taking skills (i.e., listening) and critical thinking skills and promoting improvements that allow clinicians time to examine and think about their patients.
Joe Grubenhoff, MD, MSCS (he/him/his) | Associate Professor of Pediatrics
Section of Emergency Medicine | University of Colorado
Medical Director – Diagnostic Safety Program
Children's Hospital Colorado
This is Quality Management information relating to the evaluation or improvement of health care services, and is part of a Quality Management program as described in 42 U.S.C.A 299, et seq., 42 C.F.R. 3.206 et seq., C.R.S. § 25-3-109 et seq., and C.R.S. § 12-30-204 et seq.. It is confidential and protected under C.R.S. § 12-30-204 et seq., C.R.S. § 25-3-109 et seq., 42 U.S.C.A. 299, et seq., and 42 C.F.R. 3.206 et seq., and is to be used for Children's Hospital Colorado purposes only. It is confidential, privileged and protected under the same references.
Region of US for risk of tick borne illness?
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