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Cervical internal carotid artery occlusion and stroke in a toddler: A rare complication of blunt intraoral trauma due to “pencil poke” injury

1 Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
2 Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Mangalagiri, Andhra Pradesh, India

Date of Submission30-Oct-2020
Date of Decision20-Dec-2020
Date of Acceptance26-Jan-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Chinnaiah Govindhareddy Delhikumar,
Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpn.JPN_293_20


How to cite this URL:
Sugumar K, Delhikumar CG, Arun Babu T. Cervical internal carotid artery occlusion and stroke in a toddler: A rare complication of blunt intraoral trauma due to “pencil poke” injury. J Pediatr Neurosci [Epub ahead of print] [cited 2023 May 30]. Available from: https://www.pediatricneurosciences.com/preprintarticle.asp?id=320389

Habitual mouthing or oral sensory seeking behavior is commonly found in infants and toddlers.[1] This apparently innocuous habit however carries a risk of blunt intraoral trauma involving palate or oropharynx if they fall down with objects in their mouth. We report an extremely rare complication of such injury resulting in internal carotid artery occlusion and stroke in a toddler.

An 18-month-old male child was brought to our pediatric emergency department with complaints of weakness of the left side of the body for 2 days. There was a significant history of trauma to the right peritonsillar area due to fall with pencil in his mouth, with the pointed end facing inside. There was transient, self-limiting bleeding from the site which subsided within minutes. One day following the event, child was noticed to have weakness of the left side of his body. On examination, there was a contusion over the right peritonsillar region. Neurological examination revealed left hemiparesis with left upper motor type of facial palsy. There were no seizures and sensorium was normal. Magnetic resonance imaging with angiography (MRI with MRA) was done which showed infarction of the right fronto-parietal region and anterior temporal region [Figure 1]A. Right internal carotid artery was not visualized along its entire course, and right middle cerebral artery was diffusely narrowed [Figure 1]B. Cardiothoracic vascular surgery and interventional radiology opinion were sought regarding surgical intervention, but a conservative line of management was favored in view of non-progression of symptoms. The child was started on aspirin and low molecular weight heparin which is planned to be continued till complete resolution of the thrombus. Physiotherapy exercises were taught to the mother. As there was improvement in weakness within a week of hospital stay, the child was discharged and advised to follow up. He is doing well at 3 months of follow-up with minimal residual weakness.
Figure 1: (A) MRI showing T2 hyperintensity in the parietal region (white arrow). (B)
MR angiogram showing complete non-visualization of right internal carotid artery (white arrow)

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Intraoral traumas by common objects like pens and pencils are one of the rarest causes of stroke in children. There seems to be no correlation between the severity of injury and the neurovascular sequelae. The proposed mechanism is that the intraoral injury causes intimal tear in the carotid vessels resulting in dissection, thrombus formation, occlusion, and embolization from the initial site.[2],[3],[4] However, a latent period is observed between the injury and the onset of neurological symptoms, which has been hypothesized that collateral circulation via circle of Willis compensates for the circulatory pause on the affected side.[2] MRI brain with angiography is the gold standard for diagnosis of carotid dissection and occlusion due to thrombus.[5] High suspicion with early detection is extremely crucial as surgical interventions like thrombectomy and intimal repair, if decided, are to be performed in the early stages. Conservative management is an option for stable patients with non-progression of symptoms and late presentation. There are reports of few similar cases with intra-oral trauma, resulting in carotid injury and stroke in Indian children.[3],[4]

Clinicians should be aware of this rare complication of stroke that can follow even after a trivial intraoral injury. Parents, caretakers, and school teachers should be sensitized regarding the risk of children mouthing long sharp objects.

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There are no conflicts of interest.

   References Top

Kwong LH, Ercumen A, Pickering AJ, Unicomb L, Davis J, Luby SP. Hand- and object-mouthing of rural Bangladeshi children 3–18 months old. Int J Environ Res Public Health 2016;13:563.  Back to cited text no. 1
Bent C, Shen P, Dahlin B, Coulter K. Blunt intraoral trauma resulting in internal carotid artery dissection and infarction in a child. Pediatr Emerg Care 2016;32:534-5.  Back to cited text no. 2
Aggarwal A, Gupta D, Dhandapani SS. “Stroke by pencil”: A friend turned fiend. Neurol India 2017;65:206-7.  Back to cited text no. 3
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Bhaisora KS, Behari S, Godbole C, Phadke RV. Traumatic aneurysms of the intracranial and cervical vessels: A review. Neurol India 2016;64(Suppl):S14-23.  Back to cited text no. 4
Jordan LC, Hillis AE. Challenges in the diagnosis and treatment of pediatric stroke. Nat Rev Neurol 2011;7:199-208.  Back to cited text no. 5


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