Sociodemographic profile and clinical presentation of young children unintentionally exposed to marijuana: A single site retrospective cohort.

BACKGROUND AND OBJECTIVES: Legalization of medical marijuana has increased unintentional exposure to marijuana in young children. We aim to explore the sociodemographic disadvantage profile, prevalence, and clinical presentation of children diagnosed with unintentional exposure to marijuana. METHODS: We conducted a retrospective chart abstraction of 121 children (aged 0-6) seen at the Emergency Department (ED) at a single tertiary hospital center in Dayton, Ohio between January 01, 2010 and January 09, 2022. RESULTS: Majority were female (62.8%), white (50.4%), and with Medicaid as their primary insurance (84.3%). The median age at exposure was 1.8 years. There was a 14-fold increase in unintentional marijuana cases pre-2017 (7 cases) versus post-2017 (114 cases), the year of legalization of medical marijuana in the state of Ohio. Majority of the patients were using public assistance (66.4%). 26.7% of the cases had a prior social work consultation and 38.1% had a prior children services consultation. 51.3% of the children had a social disadvantage index score of 3 or greater (range 0-5) with higher scores indicating greater disadvantage. DISCUSSION AND CONCLUSIONS: The number of patients presenting to the ED at the hospital has increased 14-fold since the legalization of medical marijuana in Ohio. Half of the children displayed a higher sociodemographic disadvantage index score. SCIENTIFIC SIGNIFICANCE: Our study is the first study investigating the sociodemographic profile of children exposed to marijuana. The findings of this study may be utilized to inform policy for safely dispensing recreational and medicinal marijuana products and focus the efforts on families with sociodemographic disadvantage.

Reducing Discharge Medication Reconciliation Errors at a Pediatric Neurology Inpatient Unit.

Background and Objectives: Medication reconciliation errors are a common problem in health care, particularly during transitions of care. Discharge medication reconciliation (DMR) errors in a pediatric setting can range from 26% to 42.2%. We conducted a quality improvement project to decrease DMR error rate at Dayton Children's Hospital in Dayton, Ohio. Methods: We conducted 2 interventions, each with 3 Plan-Do-Study-Act cycles from September 2021 through February 2023. The first intervention focused on using current specialty neurology nurses as scribes and creating a template note to include the plan of care and review of DMR before discharge. Our second intervention consisted of standardizing the seizure rescue medication order by creating an order panel within our electronic medical record system for all the rescue medications presently available. Medication errors were documented by the specialty neurology nurse during a phone conversation on the next business day post discharge. DMR error rates were calculated for each week using a control chart. Medication errors and patient harm were classified according to the National Coordinating Council for Medication Error Reporting and Prevention Index. Results: One hundred six errors were noted. Of these, 98 (92%) occurred in patients with seizure and 64 (60%) were related to prescription of seizure rescue medication specifically. The baseline error rate was calculated at 15.7% or 7 errors per month (January 2021 through June 2021). The average error rate dropped from 15.7% to 5.3% (2 errors per month) after initiation of our first intervention (September 2021). Twelve weeks after initiation of the second intervention, a 2.9% (1 error per month) was noted. Afterward, there was a ten-week period of 0% errors. Discussion: Sustainable reduction of DMR errors in pediatric patients with epilepsy was achieved by using specialty neurology nurses to scribe the care plan and creating order panels to facilitate accuracy of discharge medication orders without additional cost to the hospital.

Intracranial arachnoid cyst in children: Clinical presentation and risk factors for surgical intervention.

INTRODUCTION: Intracranial Arachnoid Cysts (IAC) in children are a common incidental finding on imaging. Most IACs are asymptomatic and can be monitored, however, a small percentage may enlarge and require surgical intervention. This study aimed to identify clinical risk factors in patients with IAC who underwent surgery versus those who did not. METHODS: We conducted a retrospective chart review from 2009 to 2021 at a free-standing children's hospital. A total of 230 patients diagnosed with an IAC aged 0 to 21 years of age were included in the study. Data on demographics, imaging and neurological follow-up were analyzed. RESULTS: Out of 230 patients, 45 (19.6%) underwent surgery. At time of IAC diagnosis, the surgical patients were younger (median age 1.1 years), and their median cyst volume was larger (41.7cm3), compared to non-surgical patients (median age 5.9 years, volume 11.8cm3, respectively). Headache was the most common reason for initial imaging in non-surgical patients (54/185, 29.2%) while prenatal ultrasound (11/45, 24.4%) and macrocephaly (11/45, 24.4%) were the most common reasons for surgical patients. The majority of both surgical and non-surgical patients had the IAC incidentally found (41/45, 91.1% and 181/185, 97.8%, respectively). Surgery relieved symptoms in 38/45 (84.4%) patients. Cyst volume and age were predictors of increased odds of having surgery. DISCUSSION/CONCLUSION: Patients who underwent surgery were younger and had larger cyst volumes at time of diagnosis. The majority of the IAC were found incidentally and remained stable over prolonged follow up. The majority of the patients experienced relief of symptoms post-surgical intervention. There is a greater odds of having surgical treatment with decreased age and greater cyst volume at diagnosis and therefore these patients should be monitored closely for development of symptoms indicating need for surgical intervention.

Demographic and geographic variations in the access time of pediatric patients presenting with staring spells.

OBJECTIVE: To assess the demographic and geographic variations in access time - defined as years between the date of symptom onset and initial date of neurological care - in pediatric patients presenting with staring spells. MATERIALS AND METHODS: We conducted a secondary analysis of a retrospective chart review study from 2011 to 2021. A total of 1,353 staring spell patients, aged 0 to 17.9 years, were analyzed for age, sex, race/ethnicity, insurance, county, average county annual per capita personal income, and access time. RESULTS: Patients aged 0-2.9 years had the shortest median access time of 0.3 years, compared to 1.2 years in patients aged 3-12.9 years and 1.0 year in patients aged 13-17.9 years. Statistically significant differences were seen based on race/ethnicity and insurance with White patients having shorter access time of 0.5 years compared to Black patients with 1.0 year and self-pay patients having the shortest access time of 0.4 years compared to patients with private insurance (0.7 years). Warren County had the largest annual per capita personal income of $65,855 and access time of 0.5 years compared to Preble county with the least annual per capita personal income of $45,016 and access time of 1.1 years. CONCLUSION: Demographic parameters of age, race/ethnicity, insurance, and annual county per capita personal income appeared to be associated with access time to initial neurological care in patients with staring spells. These associations need to be investigated further to ensure timely access to neurological care and to ensure equity in health care.

Staring spells in children with autism spectrum disorder: A clinical dilemma.

LAY ABSTRACT: It is a common occurrence for children with autism spectrum disorder to be diagnosed with staring spells. Staring spells are defined as periods of time when children "space out" and are subcategorized as either "absence seizures" (brain activity resembling a seizure but with no physical seizure symptoms) or "non-epileptic spells" (inattentiveness or daydreaming). Due to the subtle characteristics of staring spells, they are usually diagnosed via long-term video electroencephalogram. The child is monitored for 3-5 days with an electroencephalogram which records brain waves. An electroencephalogram may be difficult to perform in children with autism spectrum disorder due to behavior, cognitive, or sensory concerns. Therefore, we wanted to investigate other clinical characteristics that may help us differentiate between epileptic seizures versus non-epileptic spells in children with autism spectrum disorder presenting with staring spells. We reviewed 140 charts retrospectively from the years of 2010-2021. We abstracted demographic and clinical information from the electronic medical record system and reviewed electroencephalogram videos to group the 140 children into epileptic seizure diagnosis group versus non-epileptic spell group. Of the 140 children in this study, 22 were diagnosed with epileptic seizures and the remaining were diagnosed with non-epileptic spells. We found that the two groups differed in certain clinical characteristics such as how long the staring spells lasted, how many staring spells the child had in 1 week, and whether they responded to verbal commands. We believe that clinical features may be helpful in differentiating epileptic seizures from non-epileptic spells in children with autism spectrum disorder.

Peripheral Nerve Blocks: A Tool for Inpatient Pediatric Status Migrainosus.

BACKGROUND: To assess the efficacy and safety of peripheral nerve blocks in the inpatient settings for pediatric patients presenting with status migrainosus. METHODS: An analysis of a retrospective cohort of patients aged 13 to 18 years, admitted for status migrainosus from 2017 to 2022, was performed. Among the 1805 patients who presented with status migrainosus, 265 required hospital admission. A total of 177 patients failed the first- and second-line intravenous therapy and were treated with either peripheral nerve block (PNB) or dihydroergotamine (DHE) intravenous infusions. The primary outcome of the study was pain score level reduction by 50%, and the secondary outcome was duration of hospital stay. Visual analog scale score was used for pain assessment. RESULTS: Among the 177 patients, 100 patients were treated with DHE and 77 were treated with PNB. Target pain control was achieved in 59 of 100 patients receiving DHE and 38 of 77 patients receiving PNB. The average hospital stay of patients who responded to PNB was significantly lower compared with that of patients receiving DHE (3.6 days vs 4.9 days). Among the 41 patients who were refractory to DHE, 30 patients received PNB, of which 12 responded to nerve blocks. The most common side effects for PNBs were pain at injection site in 39% of patients and nausea/vomiting for DHE in 50% of patients. CONCLUSIONS: PNB can be safely administered in the hospital setting to pediatric patients with status migrainosus. PNB treatment helped achieve target pain control with minimal side effects and reduced the hospital stay duration.

Staring Spells: An Age-based Approach Toward Differential Diagnosis.

Evaluations to rule out epileptic vs nonepileptic staring spells may entail unnecessary evaluations that can be costly and time consuming. Our study aims to identify common etiologies for staring spells across 3 different pediatric age groups and to propose an age-based clinical guidance to help determine which patients warrant further workup. Methods: This was a single-center retrospective chart analysis of 1496 patients aged 0.0-17.9 years presenting with confirmed staring spell diagnosis from January 2011 to January 2021. The patients were divided into 3 groups based on their age: 0.0-2.9, 3.0-12.9, and 13.0-17.9 years. Patient information collected included demographics, clinical presentation, comorbidities, and final diagnosis. Multilevel likelihood ratios and a receiver operating characteristic curve were determined using 8 of the 11 clinical variables. A total of 1142 patients who met the inclusion criteria were included for the final analysis. The most common final diagnosis was attention-deficit hyperactivity disorder (ADHD) (35%), followed by normal behavior (33%). Generalized and focal epilepsy were diagnosed in 8% and 4% of the patients, respectively. In the 0.0-2.9-year age group, normal behavior was the final diagnosis in 72% patients. In the 3.0-12.9-year and 13.0-17.9-year age groups, ADHD was the most frequent final diagnosis in 46% and 60%, respectively. Overall, ADHD and normal behaviors remain the most common final diagnoses. Multilevel likelihood ratios can be used to develop an age-based guidance to differentiate between epileptic and nonepileptic staring spell diagnoses.

Health Disparities in Pediatric Epilepsy: Methods and Lessons Learned.

Epilepsy affects 1% of youth and is associated with neurocognitive and psychosocial comorbidities, increased risk of mortality, and poor health-related outcomes. Health disparities in children and youth with epilepsy (CYE) have been understudied. A Special Interest Group (SIG) within the Pediatric Epilepsy Research Consortium is conducting a scoping review to systematically assess the literature and highlight the gaps in access to clinical care and management of pediatric epilepsy. The methodology for this review is presented. In conducting a peer-reviewed assessment of the scope of health disparities in pediatric epilepsy, we learned that developing the methodology for and conducting a comprehensive scoping review with multiple contributors resulted in a time-intensive process. While there is an evidence to suggest that health disparities do exist in CYE, very few studies have focused on these disparities. Disparity results are often not included in key elements of articles, lending them to be underemphasized and underrecognized. Preliminary conclusions inform several important research considerations.

Reduction of No-Show Rate for New Patients in a Pediatric Neurology Clinic.

BACKGROUND: The rate of patients not keeping their appointments at our children's hospital outpatient pediatric neurology clinic (no-shows) was high. We conducted a quality improvement project to reduce no-show rates and improve operational efficiency. Specifically, we aimed to decrease the new patient no-show mean rate from 7% to 4% at the main campus and from 17% to 12% at the south campus. METHODS: After reviewing the previous literature on this topic and institutional data, we used the simplified failure mode and effects analysis (sFMEA) to identify the key drivers. Of the patients at the main campus who failed to keep their appointment, 84% had not confirmed their appointment. Errors in inpatient/family contact information, limited use of the electronic patient portal, and miscommunication were other key drivers identified. Three Plan-Do-Study-Act (PDSA) cycles were completed over seven months. The key interventions we implemented were bidirectional text triage, telephone reminders, and promoting the use of the electronic patient portal. A run chart was used to assess the results of these interventions. RESULTS: A statistically significant shift was noted in the run chart for the median rate of no-shows, which declined from 7% to 4% at the main campus and 17% to 10% at the south campus. CONCLUSION: We were able to successfully reduce no-shows among new patients in the neurology clinic. The limitations of our study include unknown external factors, the potential impact of COVID-19, and the brief length of the study.

Post COVID-19 Lymphocytic Hypophysitis: A Rare Presentation.

Introduction: Lymphocytic hypophysitis (LH) is a rare autoimmune disorder involving the destruction of the anterior pituitary due to lymphocytic infiltration. The disease shows a female predominance, commonly affecting women during late pregnancy into the postpartum period. The etiology of LH has not been well established and is presumed to be autoimmune based on the histopathological findings of lymphocytic infiltration and postpartum cases. Lymphocytic hypophysitis has yet to be studied in the context of a patient status post-recovery from COVID-19. Since the initial outbreak, additional information regarding the symptoms and outcomes has emerged on the virus's effects on the nervous system. Case: We present a novel case of post-COVID lymphocytic hypophysitis in a pediatric patient at Dayton Children's Hospital. An 18-year-old previously healthy girl presented to the emergency department (ED) with acute onset headache and dizziness for 5 days. She had a history of symptomatic COVID-19 three weeks prior to the onset of current symptoms. Contrast enhanced magnetic resonance imaging (MRI) of the brain revealed diffuse thickening and enlargement of the infundibulum with homogenous contrast enhancement of the hypophyseal axis. Based on the suspicion for lymphocytic hypophysitis, she was started on Methylprednisolone 250 mg IV Q6hrs on day 1-3. Symptomatic clinical improvement was seen on day 3 with a significant decrease in the intensity of the headache. Conclusion: The case illustrates the varied presentation and neurological sequalae associated with the COVID-19 virus. The case described here is the first ever reported post-COVID manifestation of lymphocytic hypophysitis.

Is Botox Right for Me: When to Assess the Efficacy of the Botox Injection for Chronic Migraine in Pediatric Population.

Botulinum toxin type A (BoNT-A) has shown to be a safe and effective treatment for children with chronic migraines. Our study was to assess the efficacy of the Onabotulinum toxin type A at different intervals after initiation of therapy. We conducted a retrospective and prospective analysis of 34 patients at a children's hospital where children received four rounds of the BoNT-A therapy for the treatment of chronic migraine. Among the 34 patients, 25 patients (age range: 13-21 years), who responded to the BoNT-A therapy, were included in the analysis. Patients received standard 31 injection, 155 unit's protocol. Patients were assessed every 3 months after their initial injection. Reasons for discontinuation of therapy were analyzed. After the first two BoNT-A sessions, significant improvement was observed with a decrease in headache frequency and intensity (p < 0.001). There was further reduction in headache frequency and intensity with the fourth round of BoNT-A therapy, with comparative analysis between the second and fourth round showing a p-value of <0.001. In terms of reduction of emergency room visits and hospitalization, a significant improvement was seen after the third round of BoNT-A therapy (p < 0.01). A significant decrease in the number of abortive and preventive medications was seen after the second round of BoNT-A therapy (p < 0.001). The efficacy of BoNT-A treatment in decreasing headache frequency, intensity, and the number of abortive and preventive medications can be assessed effectively after two treatment sessions. This trend continued to be observed with additional third and fourth sessions.

Generalized Anxiety Disorder: A Predictor for Poor Responsiveness to Botulinum Toxin Type A Therapy for Pediatric Migraine.

BACKGROUND: To assess the efficacy, safety, and predictors for poor responsiveness of botulinum toxin type A (BoNT-A) for chronic migraine in the adolescent and young adult population. METHODS: A retrospective analysis of 56 patients who received BoNT-A for chronic migraine with an age range from 13 to 21 years was performed. Of 56 patients, 34 were enrolled in the study based on the inclusion criterion. Patients who received three dosages of BoNT-A were assessed at nine months from the first injection. Variables including age, body mass index, headache intensity, frequency, character, and side effects were assessed. The patients were divided into two groups based on response to BoNT-A therapy, responders and nonresponders. RESULTS: Overall among the 34 patients enrolled in the study, the average headache frequency decreased from 18.6 of 28 to 9.9 of 28 days, P value, <0.001 from baseline. There was significant decrease in the average headache intensity, 8.1 to 4.3. Of 34 patients, 25 (73%) patients responded to treatment with decrease in headache frequency by ≥ 50% from the baseline. Among the nonresponder patients, a significant number of patients (six of nine, 67%) had generalized anxiety disorder with Generalized Anxiety Disorder-7 score greater than 15 versus the responder group (six of 25, 24%, P value 0.040). CONCLUSIONS: BoNT-A remains a safe and effective therapy for adolescent and young adult patients with chronic migraines at nine months of follow-up. Generalized anxiety disorder with Generalized Anxiety Disorder-7 score greater than 15 can be a major predictor of poor response to this therapy.

Utility of electroencephalogram in the pediatric emergency department.

INTRODUCTION: Electroencephalograms (EEG) can be helpful in evaluating patients presenting to the emergency department (ED). METHODS: We reviewed the charts of patients who had an EEG done in the ED at Dayton Children's Hospital in Dayton, Ohio from 2010 to 2018. We divided the indication for EEG into 6 categories, 1) suspected new onset seizures, 2) recurrent seizures, 3) altered mental status, 4) death, 5) non-convulsive status epilepticus, and 6) psychogenic seizures. We collected data on age, gender, suspected diagnosis, EEG result, outcome of the visit in terms of discharge versus inpatient admission, follow up of the patient with respect to a) diagnosis, b) medication, c) recurrent visit to the ED, and d) clinical outcome over a two-year follow up. We also collected data on the results of the subsequent video EEG in patients who had an EEG in the ED and determined whether the video EEG had the same results and/or added any additional information. RESULTS: We studied 162 patients (mean ± SD age 7.8 ± 5.8 years, 42.6% females) with routine EEG in the ED from 2010 to 2018. In 142 patients (87.7%), the EEG was helpful in confirming or ruling out the suspected diagnosis. For the indications of new onset seizures (n = 90), recurrent seizures (n = 48), acute mental status change (n = 22), and psychogenic seizures (n = 5), the EEG was useful in 91.1%, 81.3%, 81.8%, and 100% respectively. Of the 162 patients, 58 were discharged and 104 were admitted. For the 142 patients in whom the routine EEG was diagnostically useful, 59.9% were admitted, compared to 95.0% of the 20 patients in whom the EEG did not help in clarifying the diagnosis (p = 0.002). In 31 of the admitted patients, a video EEG was done. In the 31 patients who obtained video EEG, it did not add any additional information in 23 patients while in 8 patients (25.8%) the video EEG provided additional information that was useful for diagnosis and management. CONCLUSIONS: EEG done in the ED is a useful diagnostic tool that may prevent admission to the hospital. Video EEGs should be considered in patients where the diagnosis is uncertain despite obtaining a routine EEG in the ED.

Bilateral Ptosis, Zosteriform Rash and Flaccid Bladder in a 10-Year-old boy.

We present a case report of a 10-year-old completely immunized boy presenting with a 2-week history of bilateral eyelid drooping, fatigue followed by bladder and bowel paralysis. This was followed by the appearance of a vesicular painful and itchy rash which directed further diagnosis and treatment as it was consistent with a varicella reactivation rash. This case is a very important addition to the current body of literature on varicella-related neurological complications. It outlines that varicella reactivation can present in completely vaccinated, immunocompetent young children as a neurological syndrome affecting the autonomic nervous system primarily and the rash can occur a few weeks later after presentation of the neurological symptoms.

Evaluation and management of drug resistant epilepsy in children.

Epilepsy is one of the most common neurological conditions in children. Most children with epilepsy respond to anti- epileptic drugs (AEDs) but approximately 30% of children develop drug resistant epilepsy (DRE) defined as 'the failure of adequate trials of two tolerated, appropriately chosen and used anti-epileptic drugs (AEDs)'. DRE is associated with serious consequences including higher mortality and worse cognitive outcomes. DRE impacts several aspects of the child's and the caregiver's life.

Pediatric auto-immune encephalitis.

Pediatric Auto-Immune Encephalitis (PAE) is a neuro-inflammatory disorder with a varied presentation. The discovery of the Anti NMDA receptor and other antibodies as the causative agents of PAE, has led to an increased need for guidelines for diagnosis and management of these disorders. PAE remains a challenging group of disorders due to their varying presentations and etiology with a prolonged clinical course. The wide spectrum of clinical symptoms involves altered mental status, movement disorders, acute behavioral changes, psychosis, delirium, seizures, and insomnia. This group of disorders was recently recognized in the children. This review provides clinicians with information on the most common PAE disorders, the spectrum of their clinical presentation, diagnostic tests and treatment protocols based on the current literature.

Efficacy of a pediatric headache infusion center: A single-center experience.

OBJECTIVE: To evaluate the efficacy of a pediatric headache infusion center (HIC) in alleviating the symptoms and preventing future visits to the emergency department (ED). BACKGROUND: Headache is a common reason for visits to the pediatric ED. ED visits are associated with inordinate costs of care and are conceived by parents to be avoidable if adequate alternatives are available. An infusion center for acute treatment of intractable headache in children with chronic migraine may be an effective alternative to an ED visit. METHODS: This was a retrospective analysis of data from a single-center cohort of patients with a known history of chronic migraine, presenting to Dayton Children's HIC with an acute migraine from June 1, 2017 to June 1, 2020. Patients were treated according to established protocols divided into two pathways. Patient demographics, clinical characteristics, pre- and postinfusion pain scores, ED visits and inpatient admissions within 2 weeks of HIC visit, and ED visits 1 year prior and 1 year after the HIC visit were noted. RESULTS: A total of 297 HIC visits were analyzed from 201 patients. The HIC was effective in controlling symptoms with a significant reduction in pain score (median [interquartile range; IQR] 7.0 [2.0] preinfusion vs. 1.0 [2.0] postinfusion, p < 0.001). Only 25/297 (8.4%) patients came to the ED within 2 weeks of the HIC visit, and an even smaller number of patients (20/297, 6.7%) were admitted as inpatients within 2 weeks of the HIC visit. The number of ED visits was significantly reduced in the year after the HIC visit compared with the year prior (median [IQR] 1.0 [2.0] before vs. 0.0 [1.0] after, p < 0.001). CONCLUSION: A pediatric HIC is effective in alleviating the symptoms and preventing ED visits. These centers should be considered as standard of care at children's hospitals.

Measuring the Barriers to Adherence With Neurology Clinic Appointments for Children With Epilepsy: A Pilot Study.

INTRODUCTION: Epilepsy is one of the most common neurological disorders in children. Missed appointments reflect missed opportunity to provide care for children with epilepsy. The objective of this study was to identify social determinants of health (SDH) and other factors associated with missed appointments in children with epilepsy and measure the relation between missed appointments and frequency of emergency room (ER) visits and inpatient admissions. METHODS: This was a prospective study conducted in the neurology division at a level 4 epilepsy center. Children (0 to < 18 years of age) with a diagnosis of epilepsy were included and a semi-structured questionnaire was provided to the families. Patients with 2 or more missed neurology clinic appointments in the previous year ("study group", n = 36) were compared to those with 1 or zero missed appointments ("control group", n = 49). A comparison of the clinical characteristics, emergency room visits and hospitalizations in the past year as well as SDH was performed. Statistical analysis was performed using SPSS and p < 0.05 was considered significant. RESULTS: The mean age, gender distribution and presence of medical refractoriness were comparable between the 2 groups. Families in the study group reported a higher likelihood of having to make special work arrangements for clinic appointments. Children in the study group were noted to have a significantly higher frequency of single mother households, presence of public insurance, father not graduating from high school and household income less than 50,000 dollars. Within the preceding year, children in the study group were noted to have a higher frequency of visits to the emergency department as well as 6 times higher likelihood of inpatient hospitalization for seizures. CONCLUSIONS: Social determinants of health play an important role in determining adherence with neurology clinic visits in children with epilepsy. Children with more missed appointments are likely to have a higher frequency of visits to the emergency department as well as a higher incidence of hospitalization for seizures. Identification of high-risk families and implementation of early interventions may improve adherence to office visits and decrease emergency room visits and hospitalization for seizures.

Vertebral Artery Dissection Masquerading as Concussion in an Adolescent.

OBJECTIVE: Educate providers about the clinical presentation and consequences of delaying diagnosis of traumatic vertebral artery dissection with thromboembolic ischemic strokes in the pediatric population. Vertebral artery dissection is often difficult to diagnose and can be a potentially devastating cause of ischemic stroke. METHODS: Review of the chart, peer review/discussion, and imaging interpretation. RESULTS: A 16-year-old boy was admitted with confusion after a head and neck trauma was sustained while wrestling. (Glasgow Coma Scale=15, NIHSS = 0). Investigations including computed tomography (CT) head and cervical spine were normal. He then developed severe nausea, vomiting, dizziness, and headaches and was admitted for symptoms of concussion. Ten hours later, patient declined (hypertensive and unresponsive) and was noted to have decerebrate posturing. After emergent intubation, he was transferred to the pediatric intensive care unit. Repeat CT head showed an acute left cerebellar infarct with associated cerebellar edema resulting in effacement of the fourth ventricle/basilar cisterns and acute hydrocephalus. The CT angiography and magnetic resonance imaging of brain confirmed arterial dissection and near occlusion of the left vertebral artery at the C2 level. Extensive infarct was seen in the left cerebellum, brainstem, and right cerebellum. During a prolonged hospital stay, the family opted to continue care, and he was transferred to an inpatient rehabilitation facility because of limited brainstem activity, being nonverbal, and not demonstrating purposeful spontaneous movements. CONCLUSIONS: Detailed history and thorough neurological examination in conjunction with appropriate imaging are necessary to distinguish between brainstem/cerebellar ischemia from vertebral artery dissection and concussion.