Idiopathic Intracranial Hypertension Differential Diagnosis

Cerebral ischemia is caused by a reduction in blood fl ow to the brain. Clinical symptoms occur within seconds to minutes due to the lack of gly- cogen storage in neurons, leading to energy fail- ure. If blood fl ow is not restored quickly, infarction or death of brain tissue occurs. A gen- eralized reduction in blood fl ow due to hypoten- sion usually produces syncope. If the blood fl ow is not restored quickly, infarction between the border zones of major cerebral artery distribution occurs, referred to as a “watershed infarct,” pre- senting with proximal arm and leg weakness. Focal ischemia is often due to thrombosis of cerebral vessels or by emboli from other sources e.g., the heart. Hemorrhagic stroke causes symptoms due to mass effect on surrounding brain structures and by direct toxic effect of blood. Pediatric stroke research has mainly focused on ischemic stroke, and therefore our knowledge of pediatric hemorrhagic stroke remains limited Zimmer et al. 2007 . In cases where bleeding occurs within a brain lesion such as a primary brain tumor, pediatric oncologists often refer to this as intratumoral bleeding rather than hemorrhagic stroke. Here, for consistency, intratumoral hemorrhage is included within the category of hemorrhagic stroke.

5.5.1 Presentation of Stroke

in Pediatric Patients The clinical presentation of a CVA depends on the territory of brain involved. Table 5.3 lists key clinical fi ndings based on the vascular territory, mainly attributable to ischemic stroke. In young children focal neurological defi cits can be more subtle and harder to elicit. Hemorrhagic stroke in children, especially the very young, often presents with nonspecifi c signs and symptoms such as AMS or seizures; head- ache is often reported in older children. One study assessed the clinical presentation of 51 children ≥ 6 years of age and found that 73 presented with headache, 57 with AMS, 39 with focal neurological signs, 33 with nauseavomiting, and 16 with seizures or other symptoms such as dysphasia and abnormal gait Lo 2011 .

5.5.2 Differential Diagnosis

of Stroke In the child with acute onset of new neurologic symptoms, the initial differential diagnosis is broad and includes limited focal movement sec- ondary to pain, Todd’s paralysis after seizure, complex migraines, intoxication presenting as AMS or ataxia, medication side effects, and Table 5.3 Symptoms of cerebrovascular accident by vascular territory Artery Key signs and symptoms Anterior circulation Middle cerebral artery Contralateral hemiplegia Contralateral hemianesthesia Contralateral homonymous hemianopia If dominant hemisphere : Global aphasia If nondominant hemisphere : Neglect Anosognosia a Constructional apraxia b Anterior cerebral artery Contralateral paralysis of foot and leg Contralateral sensory loss of leg and toes Urinary incontinence Abulia c Gait apraxia Posterior circulation Posterior cerebral artery Contralateral homonymous hemianopia with macular sparing If thalamus and internal capsule involved: contralateral hemisensory loss and hemiparesis Visual and color agnosias Prosopagnosia d Claude’s syndrome 3rd nerve palsy with contralateral ataxia Weber’s syndrome 3rd nerve palsy with contralateral hemiplegia Basilar artery Bilateral long tract signs sensory and motor Cranial nerve dysfunctions Cerebellar dysfunction a Anosognosia: Unawareness of neurologic defi cit b Construction apraxia: Inability to copy simple line drawings c Abulia: Akinetic mutism d Prosopagnosia: Impairment in facial recognition A. Sabnis et al.