Posterior Cerebral Artery Stroke in a Pediatric Patient

Pediatric strokes are rare and frequently unrecognized, with diagnostic delays resulting in significant morbidity, mortality, and functional impairments. A challenging case of an ischemic stroke with delayed recognition in a medically complex patient is presented.

A 15-year-old girl with a history of cerebral palsy, intellectual disability, and oral contraceptive use and family history of coagulopathy presented to the emergency department reporting blurry vision, vomiting, fatigue, difficulty ambulating, and lightheadedness. She had experienced self-resolving blurry vision episodes the previous 2 months. The day before, due to an episode of vision loss, she was evaluated, physical examination and head computed tomography were unremarkable, and she was discharged. On the day of presentation, she vomited multiple times and endorsed vision loss. Her initial physical examination and laboratory tests were unremarkable, excepting vision loss, and she was treated with intravenous fluids and antiemetics. Results of magnetic resonance imaging showed no signs of acute intracranial processes. She later became lethargic, prompting a seizure and altered mental status workup and admission to the intensive care unit. A magnetic resonance angiogram obtained the next day showed a left posterior cerebral artery ischemic stroke, which was ineligible for endovascular intervention, given distal location and timing. She improved and was transferred to a rehabilitation hospital, where she subsequently had several additional ischemic strokes while on anticoagulation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although acute neurologic changes in children have widely varying and often nonspecific presentations, pediatric stroke, although rare, should always be considered on the differential, as early recognition and intervention results in improved patient outcomes.