Quick! Which Scanner Should the Patient Go To?

Introduction Rarely does a pediatric patient have a stroke, but when they do what imaging modality is best suited? EMS tele comes in activating a stroke alert. An 11 year old otherwise healthy male presented with 10 hours of left sided sensation changes, waking up with dense left hemiparesis.14 days prior he had been on amusement park rides resulting in headache with vomiting since resolved. On arrival, slight hypertension for age otherwise hemodynamically stable, glucose normal, EKG demonstrated sinus rhythm. No history of genetic blood or clotting disorder. PICU and ER attendings discussion resulted in MRI as the initial imaging study. Methods Case report with topic focused literature review. The patient's legal guardian provided consent using the UMC IRB case report process. Results Initial MRI revealed narrowing of the right ICA and MCA suggestive of acute ischemic stroke. Interventional neurology angiogram revealed dissection of the distal right ICA with collateralized flow improved from MRI, no intervention indicated and started on aspirin. On day two the infarcted tissue swelled causing a mass effect requiring decompressive craniectomy. The patient slowly improved until discharge to rehabilitation facility on day 22 with improving left sided hemiparesis. Hematology and rheumatology workup unrevealing, future consultation with geneticist for possibility of connective tissue disorder recommended. Conclusion Current literature recommends MRI in pediatric stroke cases first due to the higher sensitivity for detection of ischemic stroke, as well as stroke mimics. A negative CT does not place children at a risk high enough to warrant reperfusion therapy.