Advances in the diagnosis of pediatric arterial ischemic stroke - imaging and beyond.

Introduction: Arterial ischemic stroke (AIS) represents a significant cause of neurological morbidity and mortality in the pediatric population, with reported mortality rates ranging from 2% to 9%. The growing evidence supporting the efficacy and safety of reperfusion therapies in pediatric AIS underscores the critical importance of timely and accurate diagnosis. There are many barriers to achieving this, including a lack of clinical recognition and diagnostic imaging delays.

Areas covered: This narrative review highlights key advances in reperfusion therapies, acute neuroimaging, advanced imaging, and the development of stroke pathways. It explores the growing understanding of the etiology and genetics of childhood AIS. A comprehensive literature search was performed using PubMed, Medline, and EMBASE for relevant studies and reports, as well as reviewing published guidelines available through March 2025.

Expert opinion: Pediatric AIS remains challenging due to its infrequent occurrence, diagnostic complexity, and system-level barriers. Advances in imaging and development of streamlined pediatric stroke pathways are shortening the time to diagnosis, but future advances will rely on integration within established adult systems of care, the use of telemedicine and the development of pediatric perfusion imaging expertise. Evolving knowledge of pediatric neurovascular genetics and secondary imaging modalities will lead to tailored management of conditions with stroke risk.