Child vs Wild: An Unusual Case of Left-Sided Hemiparesis in a Child Following Leopard Attack

Dear Editor,

Leopard attacks are very commonly noted in the Indian subcontinent due to the proximity of the man to the wild, as many small-scale professionals are dependent on the forest by-products for their livelihood. The face and neck are the commonly injured areas, owing to their location and manipulation during transport, resulting in a higher risk of post-traumatic internal carotid artery dissection (CAD).¹

A pre-morbidly alright developmentally normal 6-year-old male child was brought to the paediatric emergency with a history of acute onset left-sided static limb weakness for the last 4 days. The parents had also noticed a facial deviation to the right side while he was talking and chewing food, which began 12 hours after the limb weakness. The child had sustained a dreadful leopard bite four days prior, on the right thigh and mandibular region, while his parents were working in the sugar-cane field. At presentation, the child was conscious and alert, lying flat on the bed with the lateral border of the left foot touching the mattress [Figure 1a]. Physical examination revealed the presence of a warm, erythematous, and fluctuant swelling in the right parotid swelling (3*3 cm) with healing lacerations (4*4 cm) in the mandible and thigh. Focused neurological examination findings are summarised in Table 1.

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Figure 1:

(a) Posture of the child at admission depicting left-sided hemiparesis, (b) MR-angiography brain of the child showing complete occlusion of the intracranial segment of right-sided internal carotid artery (ICA) (bold black arrow) in contrast to the normal ICA on the left side (thin black arrow), (c) Posture of the child at discharge, completely weight bearing on his limbs

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MRI (magnetic resonance imaging) brain revealed areas of diffusion restriction in the right middle cerebral artery territory -suggestive of acute infarcts. MRA (magnetic resonance angiography) showed complete occlusion of the right internal carotid artery (ICA) after the carotid bifurcation with a flame-shaped abrupt end [Figure 1b], with a normal MRV (magnetic resonance venography). The child was started on broad-spectrum intravenous antibiotics, subcutaneous low-molecular-weight heparin (enoxaparin, 1 mg/kg/dose bd), and aspirin (3 mg/kg/day). He had complete resolution of his neurological status within 7 days of starting anticoagulation therapy, beginning to bear weight on his left lower limb and walk with support at discharge [Figure 1c]. He has been advised to undergo a follow-up MRI after 3 months of anticoagulation to look at ICA recanalisation.

The extra-cranial part of the ICA ( 2-3 cm superior to the common carotid artery bifurcation) is the most frequently involved area in CADs, with an annual incidence rate of 2.6 to 2.9 per 1,00,000 individuals, and accounting for 20-25% of paediatric strokes and 2.5% of all strokes.¹ Risk factors in children include malignant hypertension, hyperhomocysteinemia, Marfan syndrome, Ehler-Danlos syndrome, osteogenesis imperfecta and neck trauma.² Traumatic carotid artery dissection (TCAD) can result either from penetrating injuries to the neck like animal claw bites, a direct blunt force blow to the anterolateral aspect of the neck, or an extreme extension and rotation of the neck. Stroke is common in up to 60-80%% of them, with 80% evolving within 7 days of trauma and having a mortality rate of 40%.³ Our case had an onset of contralateral neurological deficit within 96 hours of the leopard bite injury. Digital subtraction angiography (DSA) is considered the gold standard modality for the diagnosis of CAD. MR angiography is equally sensitive to CT angiography (CTA), and can be used as a first-line screening modality where DSA is not feasible.⁴ Treatment of traumatic CAD comprises antiplatelet and systemic anticoagulation to prevent or mitigate the risk of a future stroke. Therapeutic heparinisation should achieve an aPTT (activated partial thromboplastin time) of 50– 70 seconds, followed by oral treatment with warfarin to target an international normalised ratio of 2–3 for at least 3 months.4 Endovascular stenting may be performed, especially if there are contraindications to anticoagulation or if medical management fails. The cumulative recurrence rate over 10 years is 11.9% in cases of underlying syndromic arteriopathy, and after the first month, the risk of recurrent dissection is approximately 1% per year.⁵

Hence, strong suspicion and prompt identification and treatment of head and neck animal bite injuries improve the overall outcome during stroke-like episodes.