Cerebrovascular Disorders
What to know
Pediatric arterial ischemic stroke often presents with hemiparesis, aphasia, or seizure; seizures at onset are more common in children than adults. Causes differ from adults: arteriopathy (focal cerebral arteriopathy, arterial dissection, moyamoya), congenital heart disease, sickle cell disease, and prothrombotic states. Perinatal stroke typically involves the left middle cerebral artery, presents with neonatal seizures, and later yields hemiparesis.
Sickle cell disease is the highest-yield association: annual transcranial Doppler screening from ages 2–16; a mean velocity above 200 cm/s prompts chronic transfusion, and acute stroke is treated with exchange transfusion.
Moyamoya is progressive stenosis of the distal internal carotid and proximal middle cerebral arteries with a "puff of smoke" collateral pattern; treat with revascularization such as encephaloduroarteriosynangiosis rather than observation. It is bilateral in idiopathic forms and unilateral in NF1.
Cerebral sinovenous thrombosis presents with headache, seizures, and papilledema; risk factors are dehydration, mastoiditis, and prothrombotic states; anticoagulation is used even with hemorrhagic infarction.
Hemorrhagic stroke: arteriovenous malformations carry roughly 2–4% annual rupture risk; cavernomas appear as popcorn lesions with hemosiderin rings; aneurysms are rare in children and often large.
Traps
Stroke mimics are common - postictal Todd paresis, hemiplegic migraine, hypoglycemia, ADEM, and MELAS. Do not miss basilar artery thrombosis in a child with headache, vomiting, and altered consciousness. Adult thrombolysis criteria are not established in children.
Rule of thumb
Any child with sickle cell disease and sudden focal deficit gets urgent imaging and exchange transfusion without waiting for a complete stroke workup.