Neuro-Ophthalmology

Recommended Reading – 1. A ripping roller coaster ride & 2. Stroke Due To Extracranial Internal Carotid Artery Dissection After Roller Coaster Rides In A 4-Year-Old Boy

A ripping roller coaster ride
David J. Blacker, Eelco F.M. Wijdicks
Neurology. 2003
NEUROIMAGES

ARTICLE
A 41-year-old woman presented with a right frontotemporal headache and drooping of the right eye. The previous day she rode a violent roller coaster ride twice (figure, left panel) and recalled vigorous jerking of her neck. Examination revealed a right Horner syndrome (figure, middle panel) with ptosis, meiosis, and no anhidrosis. Magnetic resonance angiography (figure, right panel) confirmed the diagnosis of right internal carotid artery dissection.

Figure. (A) The patient on the roller coaster ride. (B) Right Horner syndrome. (C) Magnetic resonance angiography confirmed the diagnosis of right internal carotid artery dissection.

Several other cases of carotid dissection have been reported related to amusement park equipment.

1 Roller coaster rides can generate force in excess of 4 “Gs,”¹ which in combination with neck movements could potentially rip the carotid intima. Distension of the injured arterial wall compresses the adjacent sympathetic fibers,² resulting in a Horner syndrome, which is typically without anhidrosis, in lesions above the bifurcation, where the fibers supplying the face leave to traverse with the external carotid artery.

References:
1. Braksiek R, Roberts D. Amusement park injuries and deaths. Ann Emerg Med . 2002; 39: 65–72.
2.  Mokri B, Sundt T, Houser W, Piepgras D. Spontaneous dissection of the cervical internal carotid artery. Ann Neurol . 1986; 19: 126–138.

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Stroke Due To Extracranial Internal Carotid Artery Dissection After Roller Coaster Rides In A 4-Year-Old Boy
Amre Npuh, Daniel Vela-Duarte, Thomas Grobelny, George Hoganson, David Pasquale, Jose Biller. 
Neurology. 2014; 82 (10 Supplement)  

Abstract
OBJECTIVE: To describe the unusual association of stroke due to an extracranial right internal carotid artery (ICA) dissection following roller-coaster rides in a 4-year old boy. BACKGROUND: Strokes in children should prompt thorough investigations. Strokes associated with roller-coaster rides are unusual.

DESIGN/METHODS: A previously healthy 4-year-old boy frequented many roller coasters with his parents while on vacation at an out of state amusement park. On the flight home the following day, his parents noticed a left facial droop. Upon landing, he was unable to walk due to left sided weakness, prompting immediate evaluation. Magnetic resonance imaging (MRI) of the brain showed an acute right middle cerebral artery (MCA) territory infarction. Magnetic resonance angiography (MRA) showed right M1CA occlusion. Catheter cerebral angiogram performed one week later demonstrated an extracranial right ICA dissection. Transthoracic echocardiogram, extensive hypercoagulable panel, serum autoimmune and inflammatory markers and cerebrospinal fluid (CSF) analysis were unremarkable. Dermatoloical evaluation showed no evidence of connective tissue disease. He received low-dose aspirin.

RESULTS: Neurological function remained stable during his hospital stay, and on a 3 month follow-up he exhibited only mild residual left spastic hemiparesis.

CONCLUSIONS: To our knowledge this is the youngest patient with stroke secondary to ICA dissection following roller-coaster rides. Although the exact mechanism of injury leading to ICA dissection in the setting of sudden linear acceleration, deceleration and rotational forces such as those experienced while riding a roller coaster is not fully understood, these injuries have been attributed to brief sustained excessive gravitational forces likely augmented among predisposed individuals. Children may be at higher risk due to the immature anatomy of their cervical spine. Alterations to roller coaster ride dynamics and use of head restraints may be a reasonable first approach to lower this potential, albeit unusual risk.