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Answer 36 of 50

Stroke & Vascular

A previously healthy 7 year old suddenly has headache and falls. He is lethargic with left central facial weakness, dense left hemiparesis and conjugate eye deviation to the right. He is afebrile with a supple neck, no head injury and no previous similar attacks.

What is the most likely diagnosis?

Correct answer: A — Acute arterial ischaemic stroke of the right hemisphere, the acute infantile hemiplegia picture

A sudden fixed focal deficit with reduced consciousness in a previously healthy child is stroke until neuroimaging says otherwise.

The eyes deviate toward the side of a destructive hemispheric lesion and away from the hemiparesis, so right gaze deviation with left weakness means a right hemisphere lesion.
Central facial weakness with forehead sparing plus limb weakness on the same side confirms an upper motor neuron hemispheric process.
Urgent magnetic resonance imaging with diffusion weighting is the investigation of choice and distinguishes infarct from haemorrhage and from demyelination.
Aetiology in children is usually arteriopathy, cardiac disease, sickle cell disease or a prothrombotic state rather than atherosclerosis.
Sickle cell disease is a leading cause and its treatment is urgent exchange transfusion, so a haemoglobin electrophoresis belongs in the first set of tests.

★ Clinical pearl

In a child, sudden hemiplegia is stroke until magnetic resonance imaging says otherwise; do not accept migraine at the first attack.

Exam note

Recalls disagree and there is no published answer key. Most recalls give acute infantile hemiplegia, which is arterial ischaemic stroke, while a minority argue for hemiplegic migraine. Migraine only becomes the answer once the child has had repeated stereotyped attacks with full recovery between them and imaging has already excluded infarction, so at a first ever event with a dense deficit and depressed consciousness the answer is stroke.

Go deeper — why the other options fail, and what candidates recalled

Option	Why not
B	Todd paresis follows an observed seizure and resolves within minutes to hours; nothing here suggests convulsive activity and the deficit is dense and persistent.
C	Hemiplegic migraine requires a history of recurrent attacks and usually a family history, and it is a diagnosis of exclusion never made at the first event.
D	Acute disseminated encephalomyelitis follows an infection over days with encephalopathy and multifocal signs, not a deficit that appears in seconds.

What candidates actually recalled: Acute infantile hemiplegia.(Hemiplegic Migraine).ﻉﻝﻱﻩﺍ ﺥﺍﻝﻑ (found in 2 recall sets)

Consistent with AHA scientific statement on stroke in infants and children

Case Complete