Cause Of Arterial Ischemic Stroke Research Articles

Moyamoya Angiopathy: An Underdiagnosed Cause of Ischemic Stroke in a Tunisian Pediatric Cohort

BackgroundMoyamoya angiopathy is a rare cerebral vasculopathy and an underdiagnosed cause of arterial ischemic stroke in children. We aim to report the clinical and radiological presentations in a Tunisian pediatric cohort. MethodsWe identified moyamoya angiopathy in pediatric patients managed at the Child Neurology Department of Hedi Chaker Sfax University Hospital between 2008 and 2020 and reviewed their clinical and radiological data as well as their evolutionary profile. ResultsWe collected 14 patients with median age 40.6 months and a female predominance (sex ratio of 0.75). An arterial ischemic stroke (AIS) revealed the disease in all patients, with the major symptom being a motor deficit. Symptoms related to a transient ischemic attack before the diagnostic consultation were reported in four patients. Carotid territory was, clinically and radiologically, the most frequently involved. Brain magnetic resonance imaging with angiography was performed in 12 patients confirming the diagnosis by revealing the development of collateral vessels. All the investigations concluded to moyamoya disease in 57.2% and moyamoya syndrome in 42.8%. The latter was related to Down syndrome in five patients and neurofibromatosis type 1 in one patient. With a mean follow-up of 2.35 years, two patients had at least two more AISs during the first two years following diagnosis and 42.8% of patients were diagnosed with vascular or poststroke epilepsy. Full recovery was noted in 14.3% of cases. ConclusionsMoyamoya angiopathy in children is a serious condition that needs to be recognized due to the high risk of recurrent ischemic strokes.

Pediatric stroke: a review

Background & Objectives:
 Pediatric stroke is a focal neurological deficit lasting more than 24 hours because of stenosis, occlusion or rupture of cerebral blood vessels. Variable etiological factors are involved ranging from cardiac, haematological, infectious, immune mediated to arteriopathies which is emerging as most important cause of arterial ischemic stroke in children. In this review article we will discuss paediatric stroke with its epidemiology, etiological factors in particular arteriopathies, diagnostic modalities, management protocols and outcome.
 Methods: 
 We searched stroke in Pubmed and found 15315 articles, narrowed down to stroke in children (3814) and selected 45 articles for review.
 Review:
 Stroke in children is defined as a focal neurological deficit that persists for more than 24 hours and is caused by stenosis, occlusion or rupture of cerebral blood vessels. Stroke may be arterial, venous or because of occlusion of venous sinuses. Arterial strokes may be ischemic, haemorrhagic or ischemic-haemorrhagic.
 About half of strokes in children are of arterial ischemic strokes in contrast to adults where about 80-85% strokes are of arterial ischemic strokes. Stroke in children is comparable to brain tumors and is one of top ten common causes of death in children.
 Arterial ischemic stroke in children has significant risk of mortality and morbidity leading to functional disability of patient along with financial burden over family and society. In one study it was estimated that 10-25% of children with stroke die, 25% have recurrence and about 66% of children have neurological deficit after recovery from acute illness or have future epilepsy, behaviour disorder or learning disabilities.
 Early recognition and prompt treatment of paediatric stroke can reduce mortality, morbidity and in return can reduce both social and financial burden over society.
 Conclusion:
 In this review article we will discuss paediatric strokes, epidemiology, risk factors, differential diagnosis, investigations, management protocols, preventive measures and outcome.

Prevalence of Atherosclerotic Risk Factors Among Children and Young Adults With Arterial Ischemic Stroke

Arterial ischemic stroke (AIS) incidence has decreased overall in recent decades yet has increased in young adults. The potential associations with atherosclerotic risk factors (ARFs) remain unknown. To assess the ages at which ARFs may be risk factors associated with AIS. A nested case-control study was conducted within Kaiser Permanente Northern California (KPNC) from January 1, 2000, through December 31, 2014. Data were analyzed from 2019 to 2022. Cases were identified using diagnostic codes and radiology reports. A total of 2 to 3 controls per case, matched on age and enrollment dates, were randomly identified and confirmed as stroke-free by medical record review. Only ARFs documented prior to stroke diagnosis (or the same date in controls) were considered to ensure the same period of observation. Comparisons were stratified by decade of life. Cases and controls were selected from the KPNC population (4.7 million children and 7.5 million young adults). Medical record review was conducted of all children (aged 29 days to 19 years) and a sample of young adults (aged 20-49 years) with International Classification of Diseases, Ninth Revision code or radiology text string search suggestive of AIS. Stroke-free controls were randomly selected. Hypertension, hyperlipidemia, diabetes, obesity, and smoking history. Odds of AIS. In all analyses, cases and controls were compared using logistic regression. A total of 141 pediatric cases (69 [48.9%] aged 29 days to 9 years; 72 [51.1%] aged 10-19 years) and 364 pediatric controls (168 [46.2%] aged 0-9 years; 196 [53.8%] aged 10-19 years) and 455 young adult cases (71 [15.6%] aged 20-29 years; 144 [31.6%] aged 30-39 years; and 240 [52.7%] aged 40-49 years) and 1018 young adult controls (121 [11.9%] aged 20-29 years; 298 [29.3%] aged 30-39 years; and 599 [58.8%] aged 40-49 years) were identified. The percent of the cases that were male or female did not differ from the percent in the control group. The odds ratio (OR) of having any ARFs on AIS was 1.87 (95% CI, 0.72-4.88) for age range 0 to 9 years; OR, 1.00 (95% CI, 0.51-1.99) for age range 10 to 19 years; OR, 2.3 (95% CI, 1.17- 4.51) for age range 20 to 29 years; OR, 3.57 (95% CI, 2.34-5.45) for age range 30 to 39 years; and OR, 4.91 (95% CI, 3.52-6.86) for age range 40 to 49 years. The risk associated with multiple ARFs was OR, 5.29 (95% CI, 0.47-59.4) for age range 0 to 9 years; OR, 2.75 (95% CI, 0.77-9.87) for age range 10 to 19 years; OR, 7.33 (95% CI, 1.92-27.9) for age range 20 to 29 years; OR, 9.86 (95% CI, 4.96-19.6) for age range 30 to 39 years; and OR, 9.35 (95% CI, 6.31-13.8) for age range 40 to 49 years. The ARF findings by both definitions were significant in all young adult groups. Atherosclerosis was the presumed etiology in 0% of cases in the age group 0 to 9 years, 1.4% in the age group 10 to 19 years, 8.5% in the age group 20 to 29 years, 21.5% in the age group 30 to 39 years, and 42.5% in the age group 40 to 49 years. Although atherosclerosis may not be a common cause of AIS in children or in early young adulthood, findings of this study suggest that ARFs associated with stroke in older adults are present in childhood and increase with age. Efforts to reduce these risk factors should begin as early as possible.

Clinical improvement of a toddler with COVID-19 focal cerebral arteriopathy possibly due to intra-arterial nimodipine.

Pediatric stroke is considered an infrequent complication of COVID-19. Focal cerebral arteriopathy (FCA) is one of the most common causes of arterial ischemic stroke in a previously healthy child. The present report describes a toddler with FCA most likely induced by SARS-CoV-2 infection who showed significant clinical improvement that may be related to injection of intra-arterial nimodipine. To our knowledge, this is the first reported use of nimodipine in this setting.

Arterial ischemic stroke in children with congenital heart diseases.

We describe the prevalence, thromboembolic risk factors, and neurologic outcomes in children with congenital heart disease (CHD) and arterial ischemic stroke (AIS). We retrospectively analyzed the clinical data of children with CHD and AIS from 2000 to 2016. Demographics, procedural and postprocedural data, neuroimaging findings, details of antithrombotic treatment, and neurological status at last follow up were evaluated. Patients with cyanotic CHD accounted for 24 of 30 cases with AIS. The majority of AIS (70%) was procedure related, and the mean time from procedure to diagnosis of stroke was 9.7 (range, 1-30) days. At the time of AIS, 14 (46.7%) patients revealed coexistence of additional thromboembolic causes of AIS. Three patients (10.0%) experienced recurrent AIS and six patients (20.0%) were diagnosed with post-stroke epilepsy. The unfavorable outcomes were found in 13 patients (43.3%), including four deaths. The unfavorable outcome was significantly associated with the main branch involvement of middle cerebral artery (OR = 10.296, 95% CI = 1.335-79.439) and hemorrhagic transformation (OR = 16.264, 95% CI = 1.359-194.690). Additional thromboembolic risk factors such as systemic or cardiac thrombus, arrhythmia, and surgical procedures for cyanotic CHD were found in patients with CHD and AIS. The main branch involvement of middle cerebral artery and hemorrhagic transformation were significant predictors of unfavorable outcomes. Further studies are required to identify the target for stroke prevention and develop better prophylactic strategies to minimize AIS in patients with CHD.

Definitive Diagnostic Evaluation of the Child With Arterial Ischemic Stroke and Approaches to Secondary Stroke Prevention.

In children with arterial ischemic stroke (AIS), the definitive diagnosis of stroke subtype and confirmation of stroke etiology is necessary to mitigate stroke morbidity and prevent recurrent stroke. The common causes of AIS in children are sharply differentiated from the common causes of adult AIS. A comprehensive, structured diagnostic approach will identify the etiology of stroke in most children. Adequate diagnostic evaluation relies on advanced brain imaging and vascular imaging studies. A variety of medical and surgical secondary stroke prevention strategies directed at the underlying cause of stroke are available. This review aims to outline strategies for definitive diagnosis and secondary stroke prevention in children with AIS, emphasizing the critical role of neuroimaging.

Vertebral Artery Dissection in a 7-year-old girl: A case report, pictorial review, and review of literature

Vertebral artery dissection (VAD) is a not uncommon cause of arterial ischemic stroke in the pediatric population. Though it is frequently overlooked, and resources help in diagnosis often a concern, the establishment of diagnostic criteria is very crucial for treatment and prognosis. Here, we present a case of VAD with a pictorial and literature review, in addition to imaging recommendations.

Focal Cerebral Arteriopathy in Young Adult Patients With Stroke.

Background and Purpose- Focal cerebral arteriopathy is monophasic inflammatory stenosis of the distal internal carotid artery or the proximal segment of the middle cerebral artery. It is one of the most common causes of acute arterial ischemic stroke in young children but is a less familiar entity for adult neurologists. Methods- We retrospectively reviewed stroke service radiology records at a tertiary referral center from January 2013 to December 2014. Focal cerebral arteriopathy was defined as nonprogressive unifocal and unilateral stenosis/irregularity of the distal internal carotid artery or its proximal branches. Only patients aged 16 to 55 years with stroke were included. Results- There were 5 cases of focal cerebral arteriopathy: 2 males and 3 females. Three cases were from the cohort of 123 acute presentations of young stroke, and 2 cases were outpatient referrals. The mean age (range) was 43 (32-55) years. The majority presented with recurrent transient ischemic attacks/minor strokes within a single vascular territory over days to weeks. All cases had characteristic radiological features. Interval imaging demonstrated resolution in 1 case and improvement in 3 cases. Functional outcome was excellent with discharge modified Rankin Scale score ranging from 0 to 1. Recurrence occurred in 1 case. Conclusions- Focal cerebral arteriopathy is a rare cause of arterial ischemic stroke in young adults. Follow-up intracranial imaging is essential to differentiate from progressive arteriopathies. Evidence-based treatment warrants further investigation. Prognosis is favorable.

Arterial Ischemic Stroke Secondary to Cardiac Disease in Neonates and Children

ObjectiveWe describe the risk factors for peri-procedural and spontaneous arterial ischemic stroke (AIS) in children with cardiac disease. MethodsWe identified children with cardiac causes of AIS enrolled in the International Pediatric Stroke Study registry from January 2003 to July 2014. Isolated patent foramen ovale was excluded. Peri-procedural AIS (those occurring during or within 72 hours of cardiac surgery, cardiac catheterization, or mechanical circulatory support) and spontaneous AIS that occurred outside of these time periods were compared. ResultsWe identified 672 patients with congenital or acquired cardiac disease as the primary risk factor for AIS. Among these, 177 patients (26%) had peri-procedural AIS and 495 patients (74%) had spontaneous AIS. Among non-neonates, spontaneous AIS occurred at older ages (median 4.2 years, interquartile range 0.97 to 12.4) compared with peri-procedural AIS (median 2.4 years, interquartile range 0.35 to 6.1, P < 0.001). About a third of patients in both groups had a systemic illness at the time of AIS. Patients who had spontaneous AIS were more likely to have a preceding thrombotic event (16 % versus 9 %, P = 0.02) and to have a moderate or severe neurological deficit at discharge (67% versus 33%, P = 0.01) compared to those with peri-procedural AIS. ConclusionsChildren with cardiac disease are at risk for AIS at the time of cardiac procedures but also outside of the immediate 72 hours after procedures. Many have acute systemic illness or thrombotic event preceding AIS, suggesting that inflammatory or prothrombotic conditions could act as a stroke trigger in this susceptible population.

Focal Cerebral Arteriopathy of Childhood: Novel Severity Score and Natural History.

Background and Purpose- Focal cerebral arteriopathy (FCA)-a common cause of arterial ischemic stroke in previously healthy children-often progresses over days to weeks, increasing the risk of recurrent stroke. We developed a novel severity scoring system designed to quantify FCA progression and correlate with clinical outcomes. Methods- The VIPS study (Vascular Effects of Infection in Pediatric Stroke) prospectively enrolled 355 children with arterial ischemic stroke (2010-2014), including 41 with centrally confirmed FCA. Two neuroradiologists independently reviewed FCA cerebrovascular imaging, assigning a graded severity score of zero (no involvement) to 4 (occlusion) to individual arterial segments. The FCA severity score (FCASS) was the unweighted sum. In an iterative process, we modeled scores derived from different combinations of arterial segments to identify the model that optimized correlation with clinical outcome, simplicity, and reliability. Results- The optimal FCASS summed scores from 5 arterial segments: supraclinoid internal carotid artery, A1, A2, M1, and M2. The median (interquartile range) baseline FCASS was 4 (2-6). Of 33 children with follow-up imaging, the maximum FCASS (at any time point) was 7 (5-9). Twenty-four (73%) had FCA progression on follow-up with their maximum FCASS at a median of 8 (5-35.5) days poststroke; their median FCASS increase was 4 (2.5-6). FCASS did not correlate with recurrent arterial ischemic stroke. Maximum (but not baseline) FCASS correlated with 1-year pediatric stroke outcome measures ( P=0.037). Conclusions- Our novel scoring system for FCA severity correlates with neurological outcomes in the VIPS cohort and provides a tool for FCA treatment trials under development.

Risk Factors of Pediatric Arterial Ischemic Stroke; A Regional Survey.

Background:Considering that better understanding of the underlying mechanisms and risk factors of arterial ischemic stroke (AIS) would be helpful for better management of stroke and its outcome in children as well as preventing or reducing the occurrence of its related potential disabilities, the aim of this study was to investigate the most common risk factors and causes of AIS in patients referred to the referral hospitals in Tehran and Isfahan cities of Iran.Methods:In this study, medical files of all pediatric patients admitted to the Mofid and Imam Hossein children's hospitals with the diagnosis of AIS from 2001 to 2011 and 2011 to 2016, respectively, were evaluated. Identified risk factors of AIS were categorized as arteriopathies, cardiac disorders (CDs), infection, acute head-and-neck disorders, acute systemic conditions, chronic systemic conditions, prothrombotic states, chronic head-and-neck disorders, atherosclerosis-related RFs, and others.Results:In this study, 61 patients were evaluated. Mean (standard deviation) age of the patients was 5.1 (3.9) years. About 62.3% of the patients were boys while 37.7% were girls (P < 0.01). A total of 36 patients (59%) had at least one risk factor for AIS. About 40.9% of patients had undetermined risk factors. CDs (21.31%) and vascular disease (21.31%) were the most common risk factors of AIS in the studied children. Nearly 11.5% of the patients had moyamoya vascular disease (MMD).Conclusion:The findings of our study indicated that the most common risk factors for AIS in the two studied regions are congenital heart and vascular diseases. The results of the current study could be used for planning more preventive strategies in patients suffering from the mentioned diseases. In addition, the obtained data could be used for conducting targeted education and management of high-risk patients.

Perspectives in neonatal and childhood arterial ischemic stroke

ABSTRACTIntroduction: Over the last decade considerable advances have been made in the identification, understanding and management of pediatric arterial ischemic stroke. Such increasing knowledge has also brought new perspectives and interrogations in the current acute and rehabilitative care of these patients.Areas covered: In developed countries, focal cerebral arteriopathy is one of the most common causes of arterial ischemic stroke in childhood and imaging features are well characterized. However, there are ongoing debates regarding its underlying mechanisms, natural evolution and proper management. The implementation of thrombolytic therapy in acute pediatric stroke has been shown to be efficient in anecdotal cases but is still limited by a number of caveats, even in large tertiary centers. Finally, neonatal stroke represents a unique circumstance of possible early intervention before the onset of any neurological disability but this appears meaningful only in a selective group of neonates.Expert commentary: While perinatal stroke, a leading cause of cerebral palsy, appears to be multifactorial, a large number of childhood ischemic stroke are probably essentially triggered by infectious factors leading to vessel wall damage. Current research is aiming at better identifying risk factors in both conditions, and to define optimal acute and preventive therapeutic strategies in order to reduce significant long-term morbidity.

Etiology and treatment of arterial ischemic stroke in children and young adults.

Stroke is the second leading cause of death worldwide (Go et al. Circulation 129:e28-292, 2014) and is a major cause of morbidity and mortality. Compared with older adults, arterial ischemic stroke (AIS) is relatively uncommon in children and young adults, comprising 5-10% of all stroke (Biller Nat Rev Cardiol 6:395-97, 2009), but is associated with significant cost. In contrast to the declining overall incidence of stroke, some early studies suggest that the rate of stroke hospitalizations in children and young adults is rising (George et al. Ann Neurol 70:713-21, 2011; Kissela et al. Stroke 41:e224, 2010; Nguyen-Huynh et al. Stroke 43, 2012), emphasizing the importance of understanding the similarities and differences in etiology and treatment of AIS across the age spectrum. Among the most common causes of AIS in children are cardioembolism (often related to congenital heart disease), cervicocephalic arterial dissections, focal arteriopathy of childhood and several genetic and metabolic disorders, such as sickle cell disease (SCD). AIS in young adults is less well understood, but likely overlaps in etiology with both children and older adults. Young adults with AIS often have classic atherosclerotic risk factors similar to older adults, but are also more likely to have thrombophilias, cervicocephalic arterial dissections and cardioembolism, similar to children with AIS. Since little evidence exists regarding both acute treatment and secondary prevention after AIS in children and young adults, standard treatment practices are mainly extrapolated from research done in older adults. In most cases we recommend treating young adults per the guidelines published by the American Heart Association for adults with stroke (Jauch et al. Stroke 44:870-947, 2013; Kernan et al. Stroke 45:2160-2236, 2014) and children per the equivalent guidelines regarding pediatric stroke (Roach et al. Stroke 39:2644-91, 2008). It is also important in children and young adults to consider less common structural, metabolic and genetic risk factors for stroke, which may require more specific treatment. Other standard risk factors for stroke, including hypertension, hyperlipidemia and diabetes mellitus should also be addressed, but are less likely in children and young adults. Given the lack of data and possibility of rare underlying etiologies such as Antiphospholipid Antibody Syndrome or Ehlers-Danlos syndrome, we recommend including multiple specialists in the care of these patients, such as hematologists and vascular neurologists.

Association between Hypoxia and Perinatal Arterial Ischemic Stroke: A Meta-Analysis

BackgroundPerinatal arterial ischemic stroke (AIS) occurs in an estimated 17 to 93 per 100000 live births, yet the etiology is poorly understood. Although investigators have implicated hypoxia as a potential cause of AIS, the role of hypoxia in AIS remains controversial. The aim of this study was to estimate the association between perinatal hypoxia factors and perinatal arterial ischemic stroke through a meta-analysis of published observational studies.Patients and methodsA systematic search of electronically available studies published through July 2013 was conducted. Publication bias and heterogeneity across studies were evaluated and summary odds ratios (ORs) and 95% confidence intervals (CIs) were calculated with fixed-effects or random-effects models.ResultsA total of 8 studies describing the association between perinatal hypoxia factors and neonatal arterial ischemic stroke (AIS) met inclusion criteria, and 550 newborns with AIS were enrolled. The associations were found for AIS: preeclampsia (OR 2.14; 95% CI, 1.25 to 3.66), ventouse delivery (OR 2.23; 95% CI, 1.26 to 3.97), fetal heart rate abnormalities (OR 6.30; 95% CI, 3.84 to 10.34), reduced fetal movement (OR 5.35; 95% CI, 2.17 to 13.23), meconium-stained liquor (OR 3.05; 95% CI, 2.02 to 4.60), low Apgar score (OR 5.77; 95% CI, 1.66 to 20.04) and resuscitation at birth (OR 4.59; 95% CI, 3.23 to 6.52). Our data did not show any significant change of the mean risk estimate for oxytocin induction (OR 1.33; 95% CI, 0.84 to 2.11) and low arterial umbilical cord ph (OR 4.63; 95% CI 2.14 to 9.98).ConclusionsThere is a significant association between perinatal hypoxia factors and AIS. The result indicates that perinatal hypoxia maybe one of causes of AIS. Large scale prospective clinical studies are still warranted.

Differential diagnosis of central nervous system vasculopathies: two case reports

Introduction: Arteriopathies usually manifest as a transient focal cerebral angiopathy and are the main cause of arterial ischemic stroke (AIS) in children. In preschool children postvaricella angiopathy is common. Inflammatory etiologies need to be ruled out by imaging and laboratory investigations including cerebrospinal fluid (CSF) analysis. The diagnostic work up should comprise vasculitis mimics and primary central nervous system vasculitis.

Biomarkers of arteriopathy in pediatric stroke

Cerebral arteriopathy is an increasingly recognized cause of arterial ischemic stroke in previously healthy children.1 Focal cerebral arteriopathy (FCA) is a recently coined term for focal cerebral arterial stenosis with no apparent cause, and excludes children with intracranial dissection, moyamoya, sickle cell arteriopathy, postvaricella arteriopathy, vasculitis, or other specific diagnoses.1 Stroke recurrence in children with all types of arteriopathy is high compared to those without arteriopathy, although recurrence risk specifically associated with FCA is unclear. Given the paucity of data, there is no consensus regarding management of childhood stroke associated with FCA.

Fatal Ischemic Stroke Due to Dissecting Aneurysm of the Intracranial Arteries Presenting as Sudden Unexpected Death in Childhood

Sudden unexpected death is any nontraumatic death in healthy individuals with normal activities for age until acute demise. Whereas not uncommon in adults and infants, it is considered a rarity in children, with most cases due to infection or occult cardiovascular abnormalities. Pathologic intracranial findings are rarely found in sudden unexpected death in childhood, with most cases due to occult intracranial neoplasms. Cerebral arterial dissection is an uncommon cause of arterial ischemic stroke in childhood. Outcome is poor, with more than 20% of patients dying. We report 4 cases of sudden unexpected death due to arterial ischemic stroke after cerebral arterial dissection in childhood and present a review of the literature.

Craniocervical Arterial Dissection in Children: Clinical and Radiographic Presentation and Outcome

Craniocervical arterial dissection is a recognized cause of arterial ischemic stroke in children. Whether children with craniocervical arterial dissection have dissection characteristics different from those of adults is unclear. A retrospective review of children, 1 month to 18 years of age, with dissection from two Canadian pediatric ischemic stroke registry centers was conducted. From 213 patients with arterial ischemic stroke, 16 (7.5%) were identified with dissection, 37.5% had warning symptoms, and 50% had a history of head or neck trauma. The clinical presentation included headache (44%), altered consciousness (25%), seizures (12.5%), and focal deficits (87.5%). Dissection involved extracranial vessels in 75% and anterior circulation in 56%. Follow-up included complete recovery in 43%, mild to moderate deficits in 44%, and severe deficits in 13%. Fourteen (87.5%) children received antithrombotic treatment. Follow-up angiography showed resolution of abnormalities in 60% of vessels. Total occlusion had the worst outcome for recanalization. In conclusion, the etiology of arterial dissection in the majority of children appears to be either trauma or idiopathic. Long-term angiography shows variable outcomes, depending on the initial findings. The relationship of angiographic outcomes with recurrent strokes requires further study in pediatric dissection. (J Child Neurol 2006;21:8-16).

Neuroborreliosis Causing Focal Cerebral Arteriopathy in a Child

A 9-year-old girl presented with an acute right-sided hemiparesis. Initially, the clinical presentation and stable vasculopathic abnormalities on MR and conventional angiography were suspicious of a so-called "transient cerebral arteriopathy". Mild but persistent pleocytosis and an elevated CSF IgG index led to an extensive search for infectious and immunological causes of cerebral vasculitis, eventually revealing neuroborreliosis. Although rare, infectious and potentially treatable causes of arterial ischemic stroke should be considered in every child with a documented cerebral arteriopathy.