Stroke, Arterial Ischemic

Key Features

Essentials of Diagnosis

• Perinatal ischemic stroke is defined as strokes occurring in neonates younger than 28 days old

• Childhood ischemic stroke occurs in children between 28 days to 18 years old

• Neuroimaging is required to make the diagnosis of stroke

General Considerations

• Perinatal arterial ischemic stroke

  • More common than childhood ischemic stroke, affecting 1:3500 children

  • Has two distinct presentations: acute and delayed

  • In acute presentation, neonatal seizures develop during the first week of life, usually in association with a perinatal event

• Childhood arterial ischemic stroke

  • Affects 1.6 per 100,000 children per year

  • Previously diagnosed congenital heart disease is the most common predisposing illness, followed by hematologic and neoplastic disorders

  • Arteriopathy is seen in as many as 80% of "idiopathic" patients and likely confers an increased recurrence risk

Clinical Findings

Symptoms and Signs

• Perinatal arterial ischemic stroke

  • Seizures in acute cases are often focal motor seizures of the contralateral arm and sometimes leg

  • Presentation is stereotypical because of the predilection of the ischemic stroke to occur in the middle cerebral artery

  • An evolving hemiparesis is typically seen in patients present with delayed symptoms

• Childhood arterial ischemic stroke

  • Manifestations vary according to the vascular distribution to the brain structure that is involved

  • Children may present with acute hemiplegia

  • Unilateral weakness, sensory disturbance, dysarthria, and dysphagia may develop over minutes, but may evolve over several hours

  • Bilateral hemispheric involvement may lead to a depressed level of consciousness

  • Disturbances of mood and behavior and focal or multifocal seizures may occur

  • Retinal hemorrhages, splinter hemorrhages in the nail beds, cardiac murmurs, rash, fever, neurocutaneous stigmata, and signs of trauma are especially important findings

  • A thorough history of prior illnesses, especially those associated with varicella (even in the prior 1–2 years) should be taken as well as history of minor head or neck trauma and familial clotting tendencies

Differential Diagnosis

• Hypoglycemia

• Prolonged focal seizures or prolonged postictal paresis (Todd paralysis)

• Acute disseminated encephalomyelitis

• Meningitis

• Hemorrhagic stroke

• Encephalitis

• Hemiplegic migraine

• Brain abscess

• Neurodegenerative disorder (eg, adrenoleukodystrophy or mitochondrial disorder)

• Drug abuse (particularly cocaine) and other toxic exposures must be investigated diligently in any patient with acute mental status changes.

Diagnosis

Laboratory Findings and Ancillary Testing

• In the acute phase, following tests should be carried out emergently

  • Complete blood cell count

  • Complete metabolic panel

  • Serum or urine pregnancy test

  • Disseminated intravascular coagulation (DIC) panel

  • Fibrin split products

  • Erythrocyte sedimentation rate, C-reactive protein

  • Prothrombin time/partial thromboplastin time

  • Anti-factor Xa activity

  • Chest radiography

  • ECG

  • Urine toxicology

• Examination of CSF is indicated in patients with

  • Fever

  • Nuchal rigidity

  • Obtundation

• Lumbar puncture may be deferred until a neuroimaging scan has excluded brain abscess or a space-occupying lesion

• EEG may help in patients with severely depressed ...