Childhood Stroke

KEY FACTS

TERMINOLOGY

• Acute alteration of neurologic function due to loss of

vascular integrity

IMAGING

• Best imaging

○ MR with diffusion, perfusion, MRA

○ MRV if MRA negative and DWI positive

○ Can do emergent "limited" MR (FLAIR, DWI, SWI)

• Imaging findings

○ CT

– Insular-ribbon sign = loss of distinction of insular

cortex

– Hyperdense MCA sign = increased density of

thrombosed MCA

– Look for calcified emboli (suggests heart disease)

– ± CTA

○ MR

– DWI is most sensitive imaging sequence for ischemic

injury

– Perfusion studies can identify ischemic penumbra

– FLAIR may show intravascular signal

– Arterial wall imaging may identify vasculopathy

PATHOLOGY

• Etiology

○ Most common: Cardiac disease (25-50%)

○ Other: Sickle cell (200-400x increased risk), trauma

○ No underlying cause discovered in > 33% of cases

CLINICAL ISSUES

• Under-recognized as significant source of morbidity in

pediatric population

○ Can be mistaken for seizure (postictal), migraine

○ Children with stroke often have delayed presentation

○ High risk of recurrence (20-40%), especially with calcified

emboli

(Left) Axial T2WI MR shows

mature encephalomalacia in

the vascular territory of the

left MCA in this 4-month-old

infant with left hand

preference. Handedness

should not be apparent before

12-18 months. (Right) Axial

T1WI C+ MR shows the

characteristic climbing-ivy sign

of enhancing sulcal arteries ﬈

in a child with moyamoya

vasculopathy secondary to

sickle cell disease. Slow flow in

MCA branches distal to the

stenosis allows T1 shortening

from contrast to overcome

flow void effects.

(Left) Axial NECT in 15 year

old with difficulty speaking

and right hand weakness

shows a hyperdense MCA ſt.

The patient presented 12

hours after symptom onset

and was treated with aspirin

only. (Right) Axial ADC in the

same teenager shows reduced

diffusion ſt in the distal left

middle carotid artery territory.

Encephalomalacia developed,

but the patient had a normal

neurologic exam 6 months

later. Children often have a

much greater capacity for

neurologic recovery than

adults, even with similar

imaging findings.

Brain: Pathology-Based Diagnoses: Malformations,

Trauma, and Stroke

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