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Childhood Stroke
Childhood Stroke
TERMINOLOGY
TOP DIFFERENTIAL DIAGNOSES
• Acute alteration of neurologic function due to loss of vascular integrity
• Seizure-related injury, acute encephalitis, mitochondrial disorders, posterior reversible encephalopathy
IMAGING
PATHOLOGY
• NECT: ↓ attenuation of affected gray matter • NECT: Insular ribbon sign: Loss of distinct insular cortex • NECT: Hyperdense middle cerebral artery (MCA) sign: Clot in MCA • MR: ↓ diffusion within ~ 30 minutes of arterial occlusion • MR: Cytotoxic edema evident in affected territory on FLAIR/T2 by 4-6 hours after arterial occlusion • MR: Enhancement of infarct typically occurs after 5-7 days • CTA/MRA: Critical for early evaluation & identification of possible etiology (e.g., dissection, arteriopathy) • MR perfusion imaging can provide valuable information regarding region at risk in setting of acute stroke
• Major causes: Cardiac disease (~ 25%), moyamoya-type arteriopathy, arterial dissection, CNS vasculitis, hematologic/metabolic • No underlying cause discovered in ~ 25% of cases
Brain
KEY FACTS
CLINICAL ISSUES • Incidence: 2-3/100,000 per year in USA ○ Mortality: 0.6/100,000 • Children typically present later than adults (> 24 hours) • Focal deficit may be masked by lethargy, coma, irritability • Treatment in pediatric acute stroke usually conservative: Thrombolysis/thrombectomy not well studied in children • Capacity for recovery in children much > adults
(Left) Axial NECT in a 15-yearold girl with dilated cardiomyopathy shows a large area of low attenuation in the right middle cerebral artery (MCA) territory . Note the sulcal effacement & loss of the gray-white matter differentiation. (Right) Axial DWI MR in the same patient confirms restricted diffusion in the right MCA territory . Also note the focus of restricted diffusion in the left periventricular region . Infarcts in multiple vascular territories should raise suspicion of a proximal embolic source.
(Left) Axial FLAIR MR in a 2year-old girl shows multiple areas of cytotoxic edema in both cerebral hemispheres due to a moyamoya-type vasculopathy (which is predominantly a terminal internal carotid artery occlusion leading to "puff of smoke" collateral vessels). (Right) Axial DWI MR in the same girl shows diffusion restriction in the right frontoparietal hemisphere , suggesting an acute/subacute infarct. However, there is no diffusion restriction in the left parietal region , suggesting this infarct is of an older age.
317
TERMINOLOGY
TOP DIFFERENTIAL DIAGNOSES
• Acute alteration of neurologic function due to loss of vascular integrity
• Seizure-related injury, acute encephalitis, mitochondrial disorders, posterior reversible encephalopathy
IMAGING
PATHOLOGY
• NECT: ↓ attenuation of affected gray matter • NECT: Insular ribbon sign: Loss of distinct insular cortex • NECT: Hyperdense middle cerebral artery (MCA) sign: Clot in MCA • MR: ↓ diffusion within ~ 30 minutes of arterial occlusion • MR: Cytotoxic edema evident in affected territory on FLAIR/T2 by 4-6 hours after arterial occlusion • MR: Enhancement of infarct typically occurs after 5-7 days • CTA/MRA: Critical for early evaluation & identification of possible etiology (e.g., dissection, arteriopathy) • MR perfusion imaging can provide valuable information regarding region at risk in setting of acute stroke
• Major causes: Cardiac disease (~ 25%), moyamoya-type arteriopathy, arterial dissection, CNS vasculitis, hematologic/metabolic • No underlying cause discovered in ~ 25% of cases
Brain
KEY FACTS
CLINICAL ISSUES • Incidence: 2-3/100,000 per year in USA ○ Mortality: 0.6/100,000 • Children typically present later than adults (> 24 hours) • Focal deficit may be masked by lethargy, coma, irritability • Treatment in pediatric acute stroke usually conservative: Thrombolysis/thrombectomy not well studied in children • Capacity for recovery in children much > adults
(Left) Axial NECT in a 15-yearold girl with dilated cardiomyopathy shows a large area of low attenuation in the right middle cerebral artery (MCA) territory . Note the sulcal effacement & loss of the gray-white matter differentiation. (Right) Axial DWI MR in the same patient confirms restricted diffusion in the right MCA territory . Also note the focus of restricted diffusion in the left periventricular region . Infarcts in multiple vascular territories should raise suspicion of a proximal embolic source.
(Left) Axial FLAIR MR in a 2year-old girl shows multiple areas of cytotoxic edema in both cerebral hemispheres due to a moyamoya-type vasculopathy (which is predominantly a terminal internal carotid artery occlusion leading to "puff of smoke" collateral vessels). (Right) Axial DWI MR in the same girl shows diffusion restriction in the right frontoparietal hemisphere , suggesting an acute/subacute infarct. However, there is no diffusion restriction in the left parietal region , suggesting this infarct is of an older age.
317