Rare Pediatric Posterior Stroke Case Report with Discussion of Brainstem Lesions

<b>Introduction:</b> The rates of pediatric ischemic stroke incidence have more than doubled over the past 3-4 decades; however, pediatric posterior circulation strokes are even more uncommon. These rising incidence rates have led to increasing awareness of pediatric strokes and the development of institutional guidelines regarding these patients to optimize outcomes when possible. <b>Case Report:</b> We describe a rare case of acute ischemic posterior circulation stroke in a 14-year-old previously healthy adolescent boy who presented with right-sided facial droop, dysarthria, and right-sided hemiplegia. An MRI of the brain demonstrated an acute infarct in the brainstem, and an echocardiogram demonstrated a patent foramen ovale (PFO). We also discuss how to localize brainstem lesions to a specific location within the brainstem and associated blood supply using symptomatology. <b>Conclusions:</b> All stroke patients require evaluation for possible etiologies of stroke and possible underlying risk factors. Nearly half of patients who suffer from cryptogenic stroke are found to have a PFO, and adult studies have shown that PFO closure is associated with reduced recurrent cryptogenic strokes, although pediatric-specific data is lacking. If a posterior stroke is suspected, specifically in the brainstem, then the Brainstem Rules of Four may be utilized to localize these lesions and identify blood supply using simplified knowledge of the brainstem anatomy.