Vascular Anomaly as a Probable Cause of Acute Ischemical Stroke in a 13-yr Old Girl

Background: Acute ischemic stroke (AIS) is a rare condition in children (0.6-7.9 / 100.000 year), more common in boys (~60%), associated with heart conditions, hematologic changes, vasculopathies, metabolic disorders and drugs. In infants, AIS typically presents with seizures and altered mental status, while older children present with focal deficits, hemiparesis, visual disturbance or cerebellar signs. Anamnesis and neuroimaging, CT-angiography or MRI, are essential for timely diagnosis and intervention. Further investigation includes blood tests, ECG, and echocardiography.

Objective: We report a case of AIS in a 13-yr old girl previously diagnosed with arteriovenous malformation (AVM). We discuss etiologies for AIS including its association with AVM.

Case Study: M.D.G., complained of ocular pain 2 days prior to admission and presented with headache and vomiting, followed by facial asymmetry and slowed speech. Past medical history of an AVM in left sub-scapular region. On examination a right hemiparesis with homolateral facial involvement, past pointing on the right, and ataxia. Full blood count, biochemistry screen and CSF results were normal. CT scan was normal but cranial MRI revealed a left anterolateral pons lesion, confirming early stage AIS. Echocardiogram was normal. Prothrombotic factors were not identified. LMW-heparin and acetylsalicylic acid were initiated promptly as well as a rehabilitation program. Cranial MRA revealed occlusion of the distal 1/3 of the basilar artery and no other evidence of a vasculopathy. On cervical MRA the vertebrobasilar circulation was not directly related to the AVM. Clinical and angiographic course were favorable.

Discussion and Conclusion: Diagnosis of AIS in children is difficult and requires a high level of suspicion. In this age group etiological investigation is essential to identify treatable causes. In our patient we could not identify usual causes, nor syndromes associating AIS with AVM. We question if the AVM could be responsible for a “steal” syndrome resulting in AIS.