Journal of the American Academy of Physician Associates (JAAPA)What is Causing This Teenager’s Neurologic Symptoms?

🧩 Diagnostic Reasoning Exercise / Teaching Case

A previously healthy 16-year-old girl developed sudden expressive aphasia, dysarthria, and right-sided weakness while playing video games. Emergency stroke evaluation demonstrated a left MCA occlusion with an NIHSS score of 11. Following thrombolytic therapy and thrombectomy, rapid neurologic improvement occurred, but the source of the embolus remained unexplained.

Diagnostic Considerations

• Acute focal deficits and vascular imaging strongly supported acute ischemic stroke despite the patient’s young age.
• Differential considerations included postictal neurologic deficit, functional neurologic disorder, demyelinating disease, and embolic stroke.
• Transthoracic and transesophageal echocardiography identified structural cardiac abnormalities including mitral valve pathology and a small PFO.
• Pathology from the retrieved embolus revealed gram-positive cocci, directing attention toward an infectious source.
• Subsequent history uncovered recent dental work followed by fatigue, sweats, chills, and joint symptoms.
• Blood-culture and imaging findings ultimately connected the neurologic presentation to a systemic process rather than a primary neurologic disorder.

Practice Pearls

• Recognize that ischemic stroke can occur in adolescents despite its rarity.
• Maintain a broad etiologic workup in young patients with cerebrovascular events.
• Consider infective endocarditis when stroke accompanies constitutional or embolic clues.
• Obtain detailed recent procedural and infectious histories during stroke evaluation.
• Remember pediatric stroke risk factors differ substantially from adult populations.
• Coordinate multidisciplinary evaluation when cardiac, neurologic, and infectious etiologies intersect.