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CASE REPORT
Year : 2020  |  Volume : 15  |  Issue : 3  |  Page : 317-319
 

Ischemic stroke in a 6-month-old child presenting with hemiplegia: A rare case report


1 Department of Pediatrics, University of Health Sciences Turkey, Konya Health Application and Research Center, Konya, Turkey
2 Department of Pediatrics, Mogadishu Somali Turkey Recep Tayyip Erdogan Training and Research Hospital, Mogadıshu, Somalia

Date of Submission24-Feb-2020
Date of Decision29-May-2020
Date of Acceptance30-Jun-2020
Date of Web Publication06-Nov-2020

Correspondence Address:
Dr. Cuneyt Ugur
Department of Pediatrics, University of Health Sciences Turkey, Konya Health Application and Research Center, Konya.
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpn.JPN_38_20

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   Abstract 

Ischemic stroke is a clinical condition resulting from a decrease in blood flow to the brain. It is rare in children, especially more rare in infants. The symptoms in the patients vary according to the age of the patient and the affected vessel. Diagnosis of pediatric stroke is not simple and requires neuroimaging reference. If the diagnosis is delayed and the treatment is not started as soon as possible, the probability of disability or death of the patient increases. In this report, we present a 6-month-old girl with hemiplegia, who was admitted to the emergency department with a complaint of not able to move her left side and who was diagnosed as ischemic stroke. Our case is the youngest ischemic stroke detected in infant period that we know of in the literature. In this case report, we aimed to remind that ischemic stroke is one of the causes of neurological symptoms occurring during infant period.


Keywords: Child, hemiplegia, infant, ischemic stroke


How to cite this article:
Ugur C, Ali NA. Ischemic stroke in a 6-month-old child presenting with hemiplegia: A rare case report. J Pediatr Neurosci 2020;15:317-9

How to cite this URL:
Ugur C, Ali NA. Ischemic stroke in a 6-month-old child presenting with hemiplegia: A rare case report. J Pediatr Neurosci [serial online] 2020 [cited 2020 Nov 24];15:317-9. Available from: https://www.pediatricneurosciences.com/text.asp?2020/15/3/317/300057





   Introduction Top


Stroke is defined as a sudden loss of brain function caused by a decreased cerebral blood flow. It is rare in children, especially more rare in infants. The most common risk factors are hematological problems (most common sickle cell disease), cardiac diseases (congenital or acquired), trauma, and infections. It can occur at all life stages but clinical presentation of pediatric stroke is variable depending on the patient’s age and the involved artery.[1]

They usually present with hemiplegia, hemiparesis, dysphasia/aphasia, hemianopsia, ataxia, nystagmus, and convulsion.[2] Diagnosis of pediatric stroke is not simple and requires neuroimaging reference, which at present is considered essential to confirm the neurovascular origin of symptoms. If the diagnosis is delayed, the probability of disability or death of the patient increases.[3] Our case is that of the youngest ischemic stroke in the literature. In this case report, we aimed to remind that ischemic stroke is one of the causes of neurological symptoms occurring during infant period.


   Case Report Top


A 6-month-old girl was brought to the emergency department as she could not move her left side. She had a history of reduced appetite for 1 week. One morning, her mother noticed no movement in the left arm and leg, and there was no history of trauma. The baby was born term in the hospital with normal spontaneous vaginal delivery. Prenatal, natal, and postnatal history were normal. On physical examination, there was hemiplegia on the left side and mild facial paralysis. Also, the heart sound was heard on the right side, and there was a 2/6 systolic murmur. Her weight was 5.2kg (<3 p), height was 63 cm (3–10 p), and head circumference was 40.5 cm (3–10 p).

In laboratory tests, hemoglobin was 15.5g/dL, white blood cell count was 16.57/mm3, platelet 200.000/mm3, C-reactive protein 3.0 mg/dL, glucose 98 m/dL, urea 12 mg/dL, creatinine 0.18 mg/dL, Na 134 mEq/L, K 5.35 mEq/L, Cl 106 mEq/L, total protein 6.1g/dL, albumin 4.4g/dL, aspartate aminotransferase 55 U/L, alanine aminotransferase 11 U/L, calcium 8.4 mg/dL, magnesium 2.39 mg/dL, prothrombin time 11.8s, international normalized ratio 1.11, and activated partial thromboplastin time 23.5s. Dextrocardia was detected in the posteroanterior chest X-ray [Figure 1].
Figure 1: Dextrocardia was detected in the posteroanterior chest X-ray

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The patient was admitted to pediatric clinic with a preliminary diagnosis of hemiplegia. Echocardiography revealed atrial septal defect, right ventricular hypertrophy, and right atrial dilatation. Abdominal ultrasound showed liver in the left, spleen in the right, and situs inversus totalis. Brain magnetic resonance (MR) diffusion-weighted axial section imaging revealed diffusion limitation consistent with large-scale acute infarction in the right hemisphere of the brain [Figure 2]. In the brain MR angiography, the right middle cerebral artery (MCA) could not be visualized in the axial section, and a signal gap compatible with the thrombus was detected in the proximal part of the right anterior cerebral artery A1 segment [Figure 3].
Figure 2: Brain MR diffusion-weighted axial section imaging revealed diffusion limitation consistent with large-scale acute infarction in the right hemisphere of the brain (A and B)

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Figure 3: In the brain MR angiography, the right MCA could not be visualized in the axial section, and a signal gap compatible with the thrombus was detected in the proximal part of the right anterior cerebral artery A1 segment (A and B)

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As a result of clinical evaluations and examinations, we diagnosed the patient with ischemic stroke caused by thrombus due to congenital heart disease. We started her on low-molecular-weight heparin (LMWH) and exercise therapy. After the follow-up in pediatric clinic, facial paralysis improved, and the left side muscle strength increased to 3/5, the patient was discharged with LMWH and exercise therapy. Her control examination was normal.


   Discussion Top


Although ischemic stroke is common in adults, it is rare in children, especially in infants. The estimated incidence of pediatric stroke is 1–6 per 100,000 children per year.[4] It is an important cause of lifelong disability in a human, and it causes economic impact on families and on the society.[5]

Presumptive risk factors for pediatric stroke differ in children compared with adults. Whereas adult risk factors are primarily related to arrhythmias, obstructive atherosclerotic arteriopathies, and socioeconomic status.[1] In several studies, such as the International Paediatric Stroke Study (IPSS), a wide range of underlying systemic factors were reported in the setting of childhood stroke, in particular, hematological causes, cardiac disorders, trauma, and major infections such as meningitis, encephalitis, and sepsis. However, in the majority of the children, no underlying systemic disease was found.[6]

The clinical presentation varies according to the age of the child and the affected artery. It usually occurs with hemiparesis or hemiplegia in late infants and childhood. Convulsion, fever, headache, and lethargy are more common symptoms in young children. Dystonia can be seen in basal ganglia infarcts. The most frequently affected artery is MCA.[7],[8]

Imaging for diagnosis is performed after the child becomes stable. In the early diagnosis of ischemic stroke, MR imaging is more superior than cranial tomography and is the preferred imaging modality. MR and diffusion MR imaging are primarily performed. If infarct is seen in MR imaging, MR angiography should be performed as a second step.[9]

The main purpose of the treatment of ischemic stroke is to reduce the size of infarct and to prevent complications and recurrence. Its main treatment is antithrombotic therapy and physiotherapy. LMWH in children has become the first choice in acute anticoagulant therapy.[1]

The rate of recurrence in ischemic stroke is 6%–30% in childhood. Recurrences usually occur within the first 6 months. Multiple risk factors, presence of underlying disease such as congenital heart disease and progressive vasculopathy, large infarct area, and convulsion in the early period are determined as poor prognostic factors.[10]


   Conclusion Top


In children with neurological sign and finding, especially in infants, ischemic stroke should be kept in mind, and neuroradiological imaging should be performed. Because if the diagnosis is delayed and the treatment is not started as soon as possible, the probability of disability or death of the patient increases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Rosa M, De Lucia S, Rinaldi VE, Le Gal J, Desmarest M, Veropalumbo C, et al. Paediatric arterial ischemic stroke: acute management, recent advances and remaining issues. Ital J Pediatr 2015;41:95.  Back to cited text no. 1
    
2.
Steinlin MA Clinical approach to arterial ischemic childhood stroke: increasing knowledge over the last decade. Neuropediatrics 2012;43:1-9.  Back to cited text no. 2
    
3.
Srinivasan J, Miller SP, Phan TG, Mackay MT Delayed recognition of initial stroke in children: need for increased awareness. Pediatrics 2009;124:e227-34.  Back to cited text no. 3
    
4.
Agrawal N, Johnston SC, Wu YW, Sidney S, Fullerton HJ Imaging data reveal a higher pediatric stroke incidence than prior US estimates. Stroke 2009;40:3415-21.  Back to cited text no. 4
    
5.
Perkins E, Stephens J, Xiang H, Lo W The cost of pediatric stroke acute care in the United States. Stroke 2009;40:2820-7.  Back to cited text no. 5
    
6.
Catherine AL, Timothy JB, Guillaume S, Neil RF, Geoffrey LH, Norma BL, et al. Predictors of cerebral arteriopathy in children with arterial ischemic stroke: results of the International Pediatric Stroke Study. Circulation 2009;119:1417-23.  Back to cited text no. 6
    
7.
de Veber GA Cerebrovascular disease in children. In: Swaiman KF, Ashwal S, Ferriero DM, editors. Paediatric Neurology-Principles & Practice. 4th ed. St Louis Philadelphia, PA: Mosby Publishers; 2006. pp. 1759-801.  Back to cited text no. 7
    
8.
Andrew M, Monagle PT, Brooker L, editors. Thromboembolic complications during infancy and childhood. Hamilton, ON: B.C. Decker; 2000. pp. 201-29.  Back to cited text no. 8
    
9.
Carlin TM, Chanmugam A Stroke in children. Emerg Med Clin North Am 2002;20:671-85.  Back to cited text no. 9
    
10.
de Veber G Arterial ischemic strokes in infants and children: an overview of current approaches. Semin Thromb Hemost 2003;29:567-73.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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