Severe ischemic stroke with progressive edema development is frequently life-threatening and associated with a poor prognosis due to limited expandability within the cranial cavity. This chapter describes the relevant aspects of supra- and infratentorial space-occupying strokes with particular emphasis on the role of decompressive surgery. Large ischemic infarction of the middle cerebral artery (MCA) territory can lead to a clinical syndrome called malignant MCA stroke. Cranial computed tomography (CT) is still the most widely used radiological modality to diagnose and monitor malignant MCA infarction. The only specific treatment option for this type of stroke with a solid base of evidence and major impact on the clinical course to date is decompressive surgery, that is, hemicraniectomy. Swelling of a large space-occupying cerebellar infarct appears within a few days from symptom onset and can lead to compression of the brainstem and midbrain or cause a hydrocephalus.

Henoch-Schönlein purpura (HSP), the most common vasculitis that affects children, is an acute, small-vessel leukocytoclastic process. HSP is a systemic vasculitis involving vascular wall deposits of predominantly immunoglobulin (Ig) A within the small vessels of the gut, skin, joints, and kidneys, and in the mesangium of the renal glomeruli. The most frequent laboratory abnormalities are high erythrocyte sedimentation rates, microscopic hematuria, proteinuria, and elevated levels of IgA. HSP is known to cause neurological complications including seizure, chorea, encephalopathy, focal neurological signs, cortical blindness, as well as cranial and peripheral neuropathies and intracerebral hemorrhage. Ischemic infarction and strokes also occur in HSP. Pulse steroids have been shown to be effective, but sometimes plasmapheresis has been used to arrest disease progressio. Patients with severe nephritis, especially with the nephritic syndrome, have often been treated with corticosteroids and cyclophosphamide, cyclosporine, or azathioprine.

The childhood stroke is classified as either hemorrhagic or ischemic. Hemorrhagic infarctions are either subarachnoid or intraparenchymal. No historical feature distinguishes ischemic from hemorrhagic stroke. However, nausea, vomiting, headache, and a depressed level of consciousness are more common in hemorrhagic strokes. Subarachnoid hemorrhage (SAH) generally presents with a sudden onset of severe headache, nausea, vomiting, meningismus, and photophobia. Ischemic infarctions are thrombotic (arterial or venous) or embolic (arterial). Seizures are a presenting symptom of ischemic stroke in approximately 20% of patients. The sudden development of focal neurological deficits, headache, seizure, and altered consciousness are typical manifestations of childhood stroke. Selected historical information helps to determine the etiology of stroke. An emergent head computerized tomography (CT) scan may help to determine whether the stroke is hemorrhagic or ischemic and to guide further diagnostic evaluations. Aspirin is used especially in children who are at risk of developing recurrent stroke.