Imaging in childhood arterial ischaemic stroke

There remains a misconception that arterial ischaemic stroke (AIS) is a rare childhood disorder. Approximately 2–6/100,000 children are affected annually, and it is one of the top ten causes of childhood death. Following the ictus, up to 25% of children will have a recurrence, and two thirds of children will have a long-term disability with considerable socio-economic burden. The established vascular risk factors seen in adult stroke are rare in children. Instead, childhood AIS is associated with a variety of underlying aetiologies, including cerebral arteriopathies, sickle cell disease, cardio-embolic disease, infection, head and neck trauma, genetic/metabolic disease and prothrombotic abnormalities. Approximately 50% of children will have another recognised medical condition, and many children will have multiple risk factors. Given the complexity of the presentation and the potential ambiguity of the clinical findings, imaging is often the most revealing aspect of the diagnostic workup during both an acute and chronic presentation. This review considers the practical issues related to imaging children and looks at some of the controversies pertaining to aetiology and its implication for stroke management. It aims to give an overview of childhood arterial ischaemic stroke and to highlight the importance of both acute and delayed vascular imaging in the diagnosis, management and stratification of further stroke risk.