Recurrent arterial ischemic stroke with good response to mycophenolate mofetil

Background

Arterial ischemic stroke is rare in childhood. Often, the diagnosis is made after considerable delay. A thorough workup to pinpoint the underlying etiology is necessary, as a correct diagnosis is the determining factor in treatment decision. In case of primary angiitis of the central nervous system, treatment with corticosteroids and immunosuppressive agents is indicated.

Case study

We described an eleven-year-old boy who presented at the age of six years with left hemiparesis and hemianopia. Cerebral imaging showed acute ischemia in the right posterior cerebral artery territory. Extensive workup was negative. In the following eight months, he had recurrent strokes on three separate occasions due to progressive arteriopathy involving multiple large- and medium-sized vessels. A presumed diagnosis of primary angiitis of the central nervous system was made. Pulse intravenous methylprednisolone therapy was started followed by oral prednisolone. After the fourth stroke, a six-month treatment with cyclophosphamide was given which was followed by maintenance treatment with azathioprine. Shortly after cessation of corticosteroids and cyclophosphamide the subject relapsed. Cyclophosphamide was restarted in combination with corticosteroids and subsequently replaced by mycophenolate mofetil. Under mycophenolate mofetil maintenance treatment combined with low-dose corticosteroids, the patient achieved disease control with a relapse-free period of more than four years.

Conclusion

A guideline for current treatment of relapsing central nervous system angiitis in childhood is missing in the literature. We describe a subject with multiple relapses despite treatment with corticosteroids and immunosuppressive agents, and stabilization of his clinical condition and of the radiological signs under mycophenolate mofetil treatment.