LAUSR

A previously healthy 14-year-old female was unwell for a few days with vomiting associated with mild unilateral neck pain. Whilst on the phone, she developed left sided limb weakness, slurred speech and double vision over a matter of few minutes. She was transferred to Accident and Emergency (A and E) where she had ongoing focal neurology with a left side ataxic hemiparesis and a right internuclear ophthalmoplegia. Although she was in Paediatric age-group, there was a strong suspicion of a stroke and she underwent CT imaging which showed a normal brain parenchyma. However, CT angiogram confirmed a pseudo-aneurysm in the left vertebral artery suggestive of dissection and a filling defect at the tip of the basilar artery in keeping with occlusion (likely embolus). As she was within the 4.5 hour window for thrombolysis, she was treated with Alteplase, a tissue plasminogen activator (tPA) by the on-call stroke consultant and was started on high dose Aspirin before being transferred to a tertiary Paediatric Neurology centre for ongoing care. MRI scan later confirmed bilateral pontine infarcts. At follow-up, she has a minor left sided ataxia but otherwise has recovered well. This patient presented before the publication of recent RCPCH stroke guidelines but a pragmatic decision by the A and E team ensured appropriate acute treatment. Childhood arterial ischaemic stroke is rare, with an incidence of 1.6 per 100,000.1 As demonstrated in our patient, early recognition is key for thrombolysis to be effective. The publication of the Stroke in Childhood: Clinical guideline for diagnosis, management and rehabilitation (2017)2 advocates the importance FAST (Face, Arms, Legs and Time) which has already proved to be successful for early diagnosis in adult patients. Effective collaboration with our adult counterparts is vital to share resources and implement guidance locally. References 1. Mallick AA, Ganesan V, Kirkham FJ, et al. Childhood arterial ischaemic stroke incidence, presenting features, and risk factors: A prospective population-based study. The Lancet Neurology2014;13(1):35–43. 2. Stroke in childhood: Clinical guideline for diagnosis, management and rehabilitation. Royal College of Paediatrics and Child Health2017.