Balloon angioplasty for paediatric arterial ischemic stroke secondary to presumed focal cerebral arteriopathy: a case report

Focal cerebral arteriopathy (FCA) is one of the most common causes of paediatric arterial ischaemic stroke (AIS) and is characterised by unilateral stenosis or irregularity of the distal internal carotid artery and proximal anterior circulation. Although endovascular treatment has been reported in select cases, the role of balloon angioplasty in young children with FCA-related AIS remains poorly defined. A 21-month-old girl presented with a 30-hour history of progressive right-sided weakness and focal seizures. Neuroimaging demonstrated acute infarction within the left frontoparietal region with an Alberta Stroke Programme Early CT Score (ASPECTS) of 8 and a significant clinical-diffusion mismatch. Vascular imaging revealed severe stenosis (95%) of the ophthalmic (C6) segment of the left internal carotid artery, with reduced blood flow in the left middle cerebral artery and anterior cerebral artery branches. The patient was diagnosed with AIS secondary to presumed FCA. After multidisciplinary evaluation, emergency balloon angioplasty was performed. The procedure successfully relieved the stenosis, restored antegrade blood flow, and improved downstream cerebral perfusion. The patient showed progressive neurological recovery and was able to walk with assistance at discharge. At the 3-month follow-up, she had achieved complete neurological recovery, with a modified Rankin scale(mRS) score of 0 and a Pediatric Stroke Outcome Measure(PSOM) score of 0. Follow-up imaging demonstrated no recurrent stenosis or stroke recurrence. This case suggests that balloon angioplasty is a potential rescue therapy for selected pediatric patients with AIS due to severe intracranial carotid artery stenosis secondary to presumed FCA, even beyond the conventional window. Clinical-diffusion mismatch may help identify candidates who could benefit from delayed intervention. This approach should be reserved for severely symptomatic patients to prevent infarct expansion, pending further validation of its safety and efficacy.