Background and Aims:

Pediatric arterial ischemic stroke (AIS) has different etiologies compared with adults. Strokes in children are rarer, but not less serious. We discuss three different cases of AIS.

Methods:

Case 1. A 15-year-old patient was admitted with new onset refractory status epilepticus (NORSE). Brain MRI showed left cortical and lenticulostriatal ischemic stroke and angiogram showed focal irregularity of left middle cerebral artery (MCA). Vessel wall MRI sequences displayed diffuse thickening of right MCA wall (figure A), up to the terminal branches, leading to diagnosis of focal cerebral arteriopathy (FCA). Steroids and aspirin were started, but NORSE required 12 days of sedation. Case 2. A 12-year-old child experienced acute right hemiparesis and aphasia, due to left basal ganglia ischemia, detected by MRI. The patient was successfully treated by systemic thrombolysis. Cerebral angiography showed left MCA duplication and M1 branch occlusion caused by probable dissection (figure B), not treated by mechanical thrombectomy because of high risk of complications. Case 3. A 5-year-old child with autistic spectrum disorder presented with right frontal ischemic stroke. Cerebral angiogram showed very poor right cortical perfusion (figure C), with smoke like effect of the vertebral territory, due to collaterals. A diagnosis of moyamoya syndrome was made and the patient underwent surgical revascularization.

Results:

Figure A.

Figure B.

Figure C.

Conclusions:

Diagnosis of pediatric AIS are often delayed, because of many different chameleons. Compared with CT scan, brain MRI should be preferred in acute phase, adding peculiar sequences, as vessel wall that could guide diagnosis and treatment, as fibrinolysis or mechanical thrombectomy.