Acute ischemic stroke in pediatric patients.

A 17-year-old boy with Down's syndrome was last known normal at 11 pm and found with right-sided weakness and facial droop at 1 Am. In the local hospital, stroke was suspected and he was flown to a tertiary care center with mRI and neuro-logical expertise available 24 hours a day. On arrival, his National Institutes of Health Stroke Scale was 12. He had a right partial hemianopia, severe right hemiparesis, moderate dysarthria and aphasia. Emergent mRI demonstrated diffusion restriction in the left lentiform nucleus and a small area in the anterior temporal lobe with apparent diffusion coefficient correlate suggestive of acute ischemia. magnetic resonance angiography (mRA) revealed left middle cerebral artery bifurcation occlusion, and a perfusion scan showed a large perfusion/diffusion mismatch (Figure [A] and [B]). Consent was obtained from the parents and intravenous tissue-type plasminogen activator (tpA) administered. In addition, the patient was immediately taken for endovas-cular thrombectomy. Conventional angiogram confirmed distal middle cerebral artery occlusion, and a Solitaire stent retriever was used to recanalize the left middle cerebral artery (Figure [C] and [D]). The patient improved dramatically over the next few hours and was discharged with an National Institutes of Health Stroke Scale of 4. The patient had an atrial septal defect, which had previously been repaired. Echocardiography showed a right to left shunt on bubble study, and he subsequently had this closed using the Amplatzer device. The rest of his work-up was negative. Note: for the purposes of this discussion, we define pediat-ric patients as aged <18 years although in some countries this might be defined differently. Although not as prevalent in pediatric populations as in adults, stroke is an important cause of mortality and disability in children. It is among the top 10 causes of mortality in children aged 5 to 25 years. Improved neuroimaging has led to increased detection of childhood ischemic stroke, and the current estimated incidence of childhood arterial ischemic stroke is 1.6 per 100 000 children/y. Causes of stroke in children are varied and differ from those seen in adults. One or more risk factors can be identified in up to three fourths of children with ischemic stroke and an even greater percentage in children with hemorrhagic stroke. Only 10% to 25% of childhood strokes remain cryptogenic. Although high rates of childhood obesity and associated traditional stroke risk factors, such as hypertension, diabetes melli-tus, and hyperlipidemia, have led to increased pediatric stroke …