Posttraumatic Pontomedullary Infarction - Rare Complication after Mild Craniocerebral Trauma

Background: In childhood, brain trauma is very common with an incidence of 185 per 100,000 children. Posttraumatic infarction due to secondary perfusion disturbances are mostly found in severe traumas, mainly in the area of the basal ganglia. In the brain stem infarcts have rarely been described yet.

Case History: 4-year-old girl, presenting with mild headache, dizziness and vomiting after a fall from the bathtub. Within a few hours: repeated vomiting, abdominal pain, feeling of pressure in the eyes. The following day: gait abnormalities and double vision. Patient history: Passages of stuttering at the age of three. Family history: Mother migraine, allergies and asthma, father myocarditis at the age of six after angina tonsillaris. Grandmother (paternal) five heart attacks since the age of 48, grandfather (paternal) several strokes since the age of 60. Grand cousin perinatal stroke.

Clinical Status: initially slightly reduced general condition, frontal haematoma, no neurological deficits. Two days after trauma: reduced general condition, mood depressed. Covers right eye frequently, paresis to the left. Sitting with support, free standing or walking not possible.

Diagnostic Approach: MRI: solitary lesion in the right pontomedullary junction, most likely infarct. Control after 7 days: constant sized solitary lesion with focal barrier disorder; after 3 months: small residual defect. No evidence of tumorous, inflammatory or demyelinating process.

Coagulation Analysis: Antithrombin (129%) slightly increased. Thrombophilia screening: heterozygous variant of MTHFR. Basic laboratory, blood lipids, basal autoimmune diagnostics inconspicuous.

Diagnoses: Post-traumatic infarction of the right pontomedullary region with disturbance of the abducens and vestibular function. MTHFR variant.

Therapy: ASS 1.5 mg/kg over 3 months, intensive physiotherapy including three-week neurorehabilitation.

Course: Improvement within a few days, inconspicuous bulbomotor activity after 6 weeks, unsteady gait pattern and one-legged stand, no tendency to fall after three months, slight staggering in the case of fatigue and double images when looking into the distance.

Conclusion and Discussion: Within the observation period, the patient had shown a significant deterioration regarding the mild brain trauma, which required further diagnosis. The reported infarct in the area of the brainstem, is a rare finding in childhood. As possible risk factors apart from the fall and the possibly associated hemodynamic changes, only a heterozygous variant of MTHFR was found in the patient, which can be proven in 40% of the population and thus has only a questionable pathogenic value.