Clinical Neurology and Neurosurgery 109 (2007) 876–879

Case report

Ischemic stroke in a child mistaken as functional disorder
Amit Agrawal a,∗ , S.R. Joharapurkar b , Pankaj Gharde a
a Department of Surgery, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha 442005, Maharashtra, India
b Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha, India

Received 21 May 2007; received in revised form 3 July 2007; accepted 13 July 2007

Abstract
Stroke is a rare but increasingly recognized disorder in children. Lack of published clinical trials and experience in most institutions has
resulted in significant challenges for clinicians who manage children with stroke. We report a case of 16-year-old male child who was presented
with history of sudden onset of weakness 2 months back and before he could consult the physician, the weakness improved significantly and
a misdiagnosis of functional disorder was made at a peripheral hospital. Children with stroke may have subtle manifestations and to make an
early diagnosis of stroke in children there is need of awareness about this entity in children.
© 2007 Elsevier B.V. All rights reserved.
Keywords: Child; Stroke; Ischemic; Functional disorder

1. Introduction
Stroke is a rare but increasingly recognized disorder in
children [1]. It is under diagnosed because physicians do
not usually include it in differential diagnoses [2], and lack
of published clinical trials and experience in most institutions has resulted in significant challenges for clinicians who
manage children with stroke [3]. We report a case of male
child whose initial presentation was mistaken as functional
disorder and review the relevant literature.

2. Case report
Sixteen-year-old male child presented with history of
sudden onset of weakness and mild slurring of speech 2
months back that significantly improved over next few hours.
When parents consulted the physician child had only mild
residual weakness of right hand. The child was investigated
with a CT scan and it was apparently normal (Fig. 1). This
episode was dismissed as functional disorder and child was
started on anti-anxiety medication. However child was con∗ Corresponding author. Tel.: + 91 7152 3956552; fax: +91 7152 2245318.

E-mail address: dramitagrawal@gmail.com (A. Agrawal).
0303-8467/$ – see front matter © 2007 Elsevier B.V. All rights reserved.
doi:10.1016/j.clineuro.2007.07.007

tinuously complaining of hand weakness and had minimal
slurring of speech. The child was most of the time irritable and short of temper. The child attended our outpatient
clinic and on examination there was mild grip weakness of
right hand with mild slurring of speech. The child underwent
contrast-enhanced magnetic resonance imaging (MRI) and it
showed a chronic infarct in the territory of left middle cerebral
artery (Figs. 2 and 3). Monitoring for heart rhythm including
ECG and blood pressure were normal. Blood investigations
including complete blood count, coagulation profile and erythrocyte sedimentation rate were within normal limits. Colour
Doppler of the neck vessels, transoesphageal echocardiography and CT angiography of brain were normal. Lumbar
puncture showed two cells all lymphocytes, sugar-45 mg%,
protein-30 mg% and culture was sterile. Skin biopsy was not
performed. Child was started on low dose aspirin and doing
well at follow up.

3. Discussion
Stroke in children may present as decline in cognitive
performance causing delay in the diagnosis [4]. The initial diagnosis of stroke can be reached after inexpensive
tests: history, examination, and head CT [5,6]. Computed

A. Agrawal et al. / Clinical Neurology and Neurosurgery 109 (2007) 876–879

877

Table 1
Summary of risk factors for stroke in children
Thrombophilia
Protein C and S deficiencies
Leiden’s factor-V and factor-XII deficiency
Sickle cell anemia and polycythemia
Infections
AIDS
Varicella
Meningitis
Acquired or congenital emboligenic heart diseases
Prosthetic heart valve
Ventricular septal defects
Unidentified (cryptogenic stroke)
Genetic predisposition
Homocystinuria
Fabry’s disease
Fibromuscular dysplasia
Neurofibromatosis
Down’s syndrome

Fig. 1. In acute stage CT scan may be normal.

tomography (CT) is still considered to be the initial imaging study of choice as it is rapid, widely available, and
clearly distinguishes hemorrhagic and ischemic stroke [7].
However CT scan may be normal in acute stroke as in
present case and can delay the diagnosis [8,9]. MRI with
MR angiography and MR venography is more effective
for detection of acute ischaemia, and can detect acute and
chronic haemorrhage as well and is the preferred investigation in patients with suspected stroke [10,11]. Regarding
the radiological findings there is predominant involvement
of the left MCA among children (as in the present case)
with ischemic stroke leading to right hemiparesis (or hemiplegia) [2,8,12–14]. The workup for the final diagnosis is
long and expensive and investigations of children with stroke
should be selective and should be guided by clinical suspicion [5,6,9]. Based on clinical features there should be a
vigorous search for possible risk factors in pediatric stroke
patients (Table 1) [4,8,9,12,15–17]. Cardiovascular and
cerebrovascular investigations include electro-cardiogram,
echocardiogram, carotid and transcranial Doppler ultrasound
[4,8,9,12,15–17]. Assays for factor-V Leiden, prothrombin G20210A, and methylenetetrahydrofolate reductase
C677T gene mutations, levels of anticardiolipin antibodies
immunoglobulin G and M, homocysteine, protein C, protein
S, antithrombin III, antinuclear antibodies, rheumatoid factor, serum complement, and lipoprotein A can be performed
where necessary [4,8,9,12,15–17]. A metabolic screening
includes: blood glucose, lactate and electrolytes levels, a
lipid profile, and renal and liver function tests. Tests for
HIV infection (ELISA), syphilis (VDRL), sickle cell anemia (hemoglobin electrophoresis), and iron deficiency may
be performed based on clinical suspicion [4,8,9,12,15–17].

Trauma
Drugs
Metabolic and nutritional disorders
Moyamoya disease

Because of the high prevalence and importance of multiple
risk factors, a complete investigation, including hematologic and metabolic studies and angiography, should be
considered in children with ischemic stroke [9,12]. Diagnosing ischaemic stroke and determining its cause, both
are important for selection of treatment and prediction of
outcome [8,18]. Data from animal and adult stroke studies
have demonstrated a benefit for the aggressive treatment of
underlying cause [19]. An international study is currently
in progress to formally study the incidence, risk factors,
treatment strategies and outcomes of stroke in children
[1]. Current therapies for arterial ischemic stroke include
thrombolytic, antithrombotic and antiplatelet agents, blood
transfusion and surgery [1,19]. Blood transfusion in acute
ischemic stroke is done for an underlying hypovolemic shock.
Prophylactic transfusion prevents strokes in children with
sickle cell anemia who have abnormalities on transcranial
Doppler ultrasonographic examination [20]. Thrombolysis,
though not indicated for patients <18 years of age, is currently being administered to children, with unclear benefit.
Larger studies are needed to evaluate the safety and efficacy of this treatment for children [21]. Stroke in children
is associated with high recurrence rate, mortality and those
who survived experienced long-term neurological or cognitive sequelae [8,9,22,23]. Because of the low incidence,
the paucity of information about the best approach to the
diagnosis and management of stroke in children and lack
of general awareness of cerebrovascular disorders in children all are probably contributors to delay in their diagnosis
[5]. Children with stroke require immediate, special attention and preferably managed at an institution that can offer

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A. Agrawal et al. / Clinical Neurology and Neurosurgery 109 (2007) 876–879

Fig. 2. MRI (done 1 month later) showing ischemic stroke involving left middle cerebral artery territory (A) T1 image, (B) T2 image, (C) FLAIR image and
(D) diffusion weighted image.

Fig. 3. The lesion was enhancing after contrast administration.

A. Agrawal et al. / Clinical Neurology and Neurosurgery 109 (2007) 876–879

pediatric neurovascular expertise and the care of paediatric
neurologist [9]. To conclude early management of ischemic
stroke certainly deserves more attention from physicians and
from the general public, regardless of patient’s age. Recognition of stroke is indeed the very first step in this process.

Acknowledgement
I would like to acknowledge Ms. Jayashree PR who helped
me in writing and assisting in editing English style and grammar and offered suggestions for improvement in this paper.

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