Imaging Approach for Pediatric Stroke

Introduction to Pediatric Stroke Imaging

The American College of Radiology recommends MRI with diffusion-weighted imaging (DWI) and MR angiography (MRA) of the head and neck as the definitive imaging study for pediatric stroke patients beyond the acute treatment window, to evaluate both the infarct and underlying arteriopathy 1, 2.

In the subacute phase (1 week after symptom onset), the patient is not a candidate for emergent intervention, which is the primary indication where CTA offers speed advantages over MRI, according to the American College of Radiology 1, 2, 3.
MRI with DWI is the imaging procedure of choice for pediatric stroke detection, demonstrating 77% sensitivity within 3 hours versus only 16% for CT, and remaining superior to CT for up to 12 hours and beyond, as stated by the American College of Radiology 1, 2, 3.

Arteriopathies account for 53% of pediatric ischemic strokes, making them the single most common etiology in children, and include moyamoya (22%), arterial dissection (15-20%), vasculitis (12%), and sickle cell disease arteriopathy (8%), according to the American College of Radiology 2, 4, 5.
Arteriopathies confer a 66% risk of recurrent stroke, making their identification critical for prognosis and secondary prevention, as stated by the American College of Radiology 5.

The American College of Radiology recommends the following core MRI sequences: DWI to confirm infarct location and extent, FLAIR to assess for additional lesions and stroke age, SWI/Gradient echo to detect hemorrhagic transformation, blood products, and intravascular thrombus, and MRA of head and neck to identify arteriopathy, dissection, stenosis, or moyamoya pattern 1, 2.

Cerebral angiography remains the most definitive means of imaging cerebral vasculature abnormalities in children, with low complication rates (0-1% neurologic complications) in experienced centers, according to the American College of Radiology 1, 2, 3.