Wafaa Abougabal: Differential Diagnosis of Acute Neurologic Deficits and Stroke in PICU
Wafaa Abougabal, Head of Pediatrics and PICU department at Ministry of Health and Population of Egypt, shared on LinkedIn:
”Is It Truly Stroke in PICU?
A 9-year-old girl presented with acute right hemiparesis, aphasia, and focal seizure.
MRI: cortical diffusion restriction in the temporo-parietal region.
MRA/MRV: patent vessels.
No thrombocytopenia. No major inflammatory markers.
At first glance: acute arterial ischemic stroke.
But careful analysis showed:
Lesion not confined to a single vascular territory
Mixed ADC pattern
Relative cortical hyperperfusion
Elevated serum lactate
Maternal history of early sensorineural hearing loss
Differential considerations included: Arterial stroke, CVST, TTP, CNS vasculitis, ADEM, CNS infection.
However, absence of vascular occlusion, systemic inflammation, thrombocytopenia, and venous thrombosis shifted the probability.
Final diagnosis: Mitochondrial stroke-like episode (MELAS).
Key learning point:
In pediatric acute focal deficits, diffusion restriction alone does not confirm thromboembolic stroke.
Non-territorial lesions with preserved vessels and metabolic abnormalities mandate consideration of mitochondrial cytopathy.
Avoiding inappropriate thrombolysis can be life-saving.”
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