Knowledge Questions

A previously healthy 10-year-old girl presents to her pediatrician’s urgent care with severe headache, eyes forcibly deviated to the left, and slurred speech. Which of the following conditions are on the differential? [select all that apply]

A 15-year-old girl presents to the ED 45 minutes after the onset of a headache with associated right hand weakness, paresthesias (“pins and needles” sensation), aphasia (difficulty producing speech), and nausea with vomiting. She has no significant past medical history except for occasional headaches over the past year that were associated with nausea. An MRI/A brain is ordered, and an intravenous fluid bolus and antiemetic are administered given the vomiting. While awaiting MRI, there is resolution of the right hand weakness, paresthesia, and aphasia. Which answer best explains this patient’s symptoms?

Stroke occurs in children of any age. Which age group among children has the highest rate of occurrence of arterial ischemic stroke?

A 7-year-old previously healthy boy presents after he suddenly had a witnessed fall on the playground after school. He was very lethargic and EMS was activated rapidly. On assessment in the ED he was found to have difficulty speaking, right sided hemiparesis, and a left gaze preference. MRI and MRA 1 hour and 15 minutes after onset of symptoms showed an acute left MCA stroke involving the frontal lobe, with thrombus occluding the middle cerebral artery. It is now 2 hours after the onset of symptoms. What will you consider for initial treatment of his stroke? [select all that apply]

A 2-year-old child is admitted to the PICU after an arterial ischemic stroke that presented with face and hand weakness. The next day the child develops episodes of decreased level of consciousness, eye deviation, and inability to speak each lasting several minutes. What is the most likely explanation?

A teenager with no prior neurological history undergoes cardiac catheterization for evaluation of his congenital heart disease and recovers fully from anesthesia. In the PACU he develops sudden onset focal weakness of his right face and hand and inability to speak. A rapid response is called and a CT scan 15 minutes later shows no abnormalities, but his clinical symptoms persist. Which of the following diagnoses are you most concerned about?

Which of the following conditions confer an increased risk of moyamoya (or “moyamoya-like”) arteriopathy, a disorder of progressive narrowing of the major intracranial arteries that leads to recurrent stroke or transient ischemic attack? [select all that apply]

Which of the following are part of the standard evaluation for underlying etiologies of pediatric (non-neonatal) arterial ischemic stroke based on current consensus recommendations? [select all that apply]

Which of the following are part of the standard evaluation for underlying etiologies of pediatric hemorrhagic stroke based on current consensus recommendations? [select all that apply]

An 11-year old boy who recently immigrated to the United States from Nigeria presents to the ER with a 2-hour history of right sided hemiparesis. Brain MRI confirms a left MCA territory ischemic stroke. Parents report that the patient and his 6-year old sister have a history of a blood disorder that typically manifests as pain crisis in the arms and legs which required frequent hospitalizations in Nigeria. Hematology reviews a peripheral blood smear which shows “sickle shaped red blood cells”. A presumptive diagnosis of sickle cell anemia is made and the parents want to know the relationship between this disease and his current neurological symptoms. What is the incidence of stroke in children with sickle cell anemia?

The patient described in the previous question is admitted to the intensive care unit. Hemoglobin electropheresis confirms a diagnosis of HbSS sickle cell anemia. The most appropriate next step(s) in the management for this patient are [select all that apply]

You have just diagnosed a child with an arterial ischemic stroke and are counseling the family. Which of the following is accurate? [select all that apply]

A 17-year-old boy with known Marfan syndrome (a connective tissue disorder) develops severe nausea and vomiting, incoordination, and balance problems several hours after a motor vehicle accident in which he was the restrained driver. He has no memory of a head strike and no visible bruising or other skull findings. What is the most likely explanation?

Which of the following should be instituted for neuroprotective care in a child with an acute stroke? [select all that apply]

A mother walks into the living room of the family home to find her 7 year old otherwise healthy son laying on the floor, incontinent of urine, head and eyes deviated to the right, and unresponsive to verbal and tactile stimulus. EMS was activated. Upon arrival 5 minutes later, he is more alert though lethargic. During an IV placement in his left arm, he briskly moves and the placement is unsuccessful. There is no movement noted of his right arm when his IV is placed on that side. Upon arrival to the ED, he is alert, following simple commands, but unable to move his right arm actively or to painful stimulus. He has not recently been ill and there are no known sick contacts. Three hours after the child was initially found by his mother, he has improved movement of his right arm. The decision is made to send him for MRI/A head and neck, which is negative for ischemic or hemorrhagic stroke. Which of the following answer choices is the most likely cause of this hemiparesis?

A 10-year-old girl with a history of surgically repaired cyanotic congenital heart disease not on anticoagulation has suddenly developed headache, loss of vision in the right side of the world, and right-sided weakness. You strongly suspect acute ischemic stroke. Which of the following will hasten her medical evaluation and increase her chance of receiving brain-saving hyperacute treatment? [select all that apply]

A 2-day-old infant born at 41-weeks of gestation after a relatively uncomplicated pregnancy to a 28-year old G1P0A0 woman develops episodic right arm shaking and apneic events confirmed on EEG to be seizures. Neuroimaging confirms a left MCA territory stroke. The patient is admitted to the neonatal intensive care unit. Institution of neuroprotective measures in addition to anti-seizure management is initiated, and the infant stabilizes over the next few days. There is no family history of venous thromboembolism, recurrent miscarriages, or early onset stroke/myocardial infarction. Patient’s father is a physician and requests thrombophilia testing. The most appropriate thrombophilia testing strategy for this patient is which of the following? [select all that apply]

An 11-year-old boy presents to a pediatric stroke center with the sudden onset of headache and left-sided weakness. He arrives to the ED 5 hrs after the onset of symptoms. MRI/MRA imaging of the brain is consistent with stroke, with an abrupt loss of flow in the proximal right middle cerebral artery (large vessel occlusion), but only a small portion of the corresponding MCA territory is currently infarcted (small infarct core). Which of the following is true regarding treatment options for this patient? [select all that apply]

A 5-year-old comes to his mother limping on his right leg and demonstrates right hand and arm weakness. Over the next few hours those motor symptoms come and go finally to stay. The child is brought to the hospital emergency room and persistent weakness on the right side is confirmed. The child is awake and irritable but has no fever or neck rigidity. A cranial CT shows some hypodensity in the left basal ganglia. A subsequently obtained MRI with MRA of head and neck show stroke in the left putamen and a segment of smooth narrowing of the supraclinoid portion of the left internal carotid artery and proximal half of the middle cerebral artery. There is no evidence of vascular proliferation or vessel wall enhancement in the circle of Willis. This child’s stroke is most likely due to which of the following?

A 14-year-old boy presents to a pediatric stroke center with the sudden onset of headache and left-sided weakness. He was recently discharged from the hospital after a one-week admission for orthopedic surgery on his leg. During the admission, he was on low molecular weight heparin, which was discontinued 18 hrs ago. He arrives to the ED 3 hours after the onset of symptoms. MRI/MRA imaging of the brain is consistent with stroke with a large vessel occlusion and small infarct core. His NIH Stroke Scale (NIHSS) is 6. Which of the following is true regarding treatment options for this patient? [select all that apply]