Stroke-Like Cerebral Injury Following Mild Traumatic Brain Injury and Early Posttraumatic Seizures in an Infant: A Diagnostic Dilemma with Negative Vascular Imaging

Abstract

Abstract Stroke-like cerebral injury following mild traumatic brain injury (TBI) in infants is exceedingly rare. We report a 10-month-old male infant who sustained mild TBI in a road traffic accident, presenting with a pediatric Glasgow Coma Scale of E4V4M6 and a brain computed tomography (CT) scan showing only a thin left frontotemporal subdural hygroma. Despite intravenous levetiracetam, he developed recurrent focal seizures over 2 days followed by progressive left hemiparesis. Repeat CT on day 3 revealed extensive hypodensity in the right internal carotid artery territory and patchy hypodensities in the contralateral left middle cerebral artery (MCA) territory—a distribution atypical for single-vessel occlusion—necessitating emergency right-sided decompressive craniectomy. Both CT angiography and digital subtraction angiography were negative for vascular pathology. Magnetic resonance imaging at day 15 demonstrated right hemispheric cortical laminar necrosis with focal hemorrhages, without established structural injury in the left MCA territory. At 2-month follow-up, the infant was alert and active with normal power (5/5) in all four limbs. The negative vascular imaging, combined with recurrent pre-infarction seizures and a multi-territorial infarct distribution, raises the possibility of seizure-mediated cerebral injury as a contributing mechanism. This case underscores the diagnostic uncertainty inherent in angiographically negative stroke-like injury following mild pediatric TBI and the role of early decompressive surgery.