Introduction   Prognostication with unilateral large territory anterior circulation arterial ischaemic stroke (LAIS) in the critical care setting is challenging. Perceptions that active medical management is futile present a potential barrier to acute stroke therapies for such children.

Objective   To determine positive outcomes in children requiring critical care unit support following LAIS.  To highlight limitations in using diffusion weighted imaging (DWI) findings for LAIS prognostication.

Methods   We report prospectively collected clinical and radiological findings of 5 children admitted Nov 2008-Jan 2010 to critical care following LAIS.   Outcome data including video recordings and Paediatric Stroke Outcome measures at follow-up were obtained in all. 

Results   Among 5 children with LAIS (2 male; median age 0.58 yrs, range 2 days – 6.33 yrs) arterial territories involved were middle cerebral artery alone (two), middle and anterior cerebral artery (one) and middle and posterior cerebral artery (one).  Based on history and LAIS extent critical care staff withdrew active medical support (one), and proposed futility of active treatment or prognostication of profound neurological disability (four).  All survived and at median of.8 years (1.0-2.9 years) follow-up.  Both previously ambulant children and both neonates attained/regained ambulation by 18 months.  The 7 month-old infant at stroke sat independently at two years.

Conclusion  Predicting outcome and decision making following large territory arterial ischaemic stroke in the critical care setting is challenging.  We suggest caution in the interpretation of the significance and prognostic value of history and extent of DWI in this setting.