A previously healthy 2‐year‐old Asian girl presented on day of admission with left upper‐ and lower‐extremity weakness and facial droop. On arrival to ER her exam was benign except for: HR 260. dysarthria, left facial droop, positive Babinski, and MS 3/5 in LUL and 4/5 in LLL. Her ECG showed NCT with HR 260. She received a dose of IV adenosine without termination of narrow‐complex tachycardia (NCT). While having an echocardiogram in the ER, she spontaneously converted back to SR 100‐120. In the PICU, she had another episode of NCT, which was terminated with IV labetalol. She was started on PO propranolol, which was later changed to amiodarone. Her head CT showed large an acute non‐hemorrhagic right middle cerebral artery (MCA) infarct that was confirmed by MRI. Her MRA showed occlusion of right MCA just proximal to bifurcation. She had serial echocardiogram evaluations during her hospital stay, which showed mild to moderate dilatation of the LV with decreased contractility, with an EF of 58%, small PFO. and mild dilatation of the LA without clear thrombus. Her Echo before discharge showed improved dilated cardiomyopathy with an EF of 72% and normal biventricular systolic function. She was evaluated by a cardiologist, a neurologist, a hemetologist, and physialrists. She had an extensive workup for hypercoagulable state, which showed low functional protein C and high factor VIII. She was started on warfarin, which was adjusted to maintain the INR at 2‐2.5. During a 2‐week stay, her left‐sided weakness improved significantly with joint intervention of neurology and rehabilitation medicine. She was discharged on amiodarone and warfarin and recommended to follow‐up with appropriate sub‐specialists.
Unlike adults, a cardiac illness resulting in arterial ischemic stroke (AIS) is unusuai in an otherwise healthy child. A variety of causes of MCA occlusion can be postulated in our patient. First. NCT may have resulted in CHF with poor myocardial contraction and mural thrombus formation followed by embolism to the cerebral circulation. Regardless of the cause. CHF with reduced EF increases the risk of embolism. Paradoxical embolism with PFO and right to left shunt‐associated transient increase in RA pressure is more common in young adults than in children. Second, this child may have had a transient focal cerebral arteriopathy of childhood that involves the proximal part of MCA secondary to inflammation and vasculitis due to autoimmune diseases and varicella infection. Third, a hypercoagulable or prothrombotic state has been associated with AIS. Last, a systemic vasculitis affecting both cerebral and cardiac vessels may result in AIS and NCT.
Cardiac illness is not the most common cause of childhood AIS. After having extensive evaluation for hypercoagulable state and vasculitis, our patient's presentation was most likely a result of underlying cardiac sequelae of NCT.
D. Patel, Inova Fairfax Hospital for Children, employer; K. Carpenter, Inova Fairfax Hospital for Children, hospilalist.