Pediatric stroke poses a diagnostic challenge, and this often causes delay in management. We emphasize the importance of early consideration of ischemia as a diagnosis. We also emphasize the collaborative approach between pediatric and adult neurologists.

Case report

A 15-year-old male presented for new onset seizure. The patient had difficulty writing the morning of the seizure. Initial blood work, CBC, CMP, urine analysis and toxicology were unremarkable. He had a second seizure while in the ED. CT of the head revealed a subtle area of decreased attenuation in the left frontal lobe, felt to be artifact. Patient was transferred to our hospital for higher level of care. MRI of the brain showed gyriform signal abnormality within the left frontal lobe with restricted diffusion, no abnormal enhancement. Serum MOG, NMDA, LGI1, NMO antibodies were negative. LP showed no evidence of infection. Spine MRIs were unremarkable. CTA/CTV were unremarkable. Patient was started on high dose steroids for possible autoimmune etiology on hospital day 2. On Hospital Day 3, the case was re-evaluated, and the possibility of infarction was proposed. CT Perfusion revealed a subacute left frontal infarct and possible dural AVF. A diagnostic cerebral angiography revealed enhanced capillary blush and early draining vein consistent with shunt in region of left peri-Sylvian infarct. Patient was discharged on Vimpat and aspirin. Echo revealed a PFO on Valsalva maneuver. MRI spectroscopy findings were consistent with an evolving infarct with increased choline due to gliosis. He is currently planned for PFO closure.

Pediatric stroke incidence is 0.6 to 7.9 per 100,000 children per year. 60% of patients will end up with disability and half will have a decreased quality of life. Collaborative approaches could avoid significant delays in diagnosis and treatment in pediatric patients.