Healthy wealth: Pediatric Stroke: A Review

The kids are not sick , they are dehydrated overtime. They NEED constant supply of water .

Stroke is relatively rare in children, but can lead to significant morbidity and mortality.

Understanding that children with strokes present differently than adults and often present with unique risk factors will optimize outcomes in children. Despite an increased incidence of pediatric stroke, there is often a delay in diagnosis, and cases may still remain under- or misdiagnosed. Clinical presentation will vary based on the child's age, and children will have risk factors for stroke that are less common than in adults. Management strategies in children are extrapolated primarily from adult studies, but with different considerations regarding short-term anticoagulation and guarded recommendations regarding thrombolytics. Although most recommendations for management are extrapolated from adult populations, they still remain useful, in conjunction with pediatric-specific considerations.

1. Background

Stroke is a neurological injury caused by the occlusion or rupture of cerebral blood vessels. Stroke can be ischemic, hemorrhagic, or both. Ischemic stroke is more frequently caused by arterial occlusion, but it may also be caused by venous occlusion of cerebral veins or sinuses. Hemorrhagic stroke is the result of bleeding from a ruptured cerebral artery or from bleeding into the site of an acute ischemic stroke (AIS).

AIS accounts for about half of all strokes in children, in contrast to adults in whom 80–85% of all strokes are ischemic [1, 2].

Children also have a more diverse and larger number of risk factors for stroke that differ significantly from adults which are predominated by hypertension, diabetes, and atherosclerosis [3, 4].

Pediatric stroke leads to significant morbidity and mortality. Roughly 10–25% of children with a stroke will die, up to 25% of children will have a recurrence, and up to 66% will have persistent neurological deficits or develop subsequent seizure disorders, learning, or developmental problems [3, 5, 6]. Given the onset of impairment during childhood and the effect on quality of life for the child and family, the economic and emotional costs to society are amplified.

Early recognition of pediatric stroke should lead to more rapid neurological consultation, imaging, treatment, and improved outcomes. In this article, we will review the epidemiology, clinical presentation, differential diagnosis, risk factors and causes, and management of pediatric stroke. Neonatal stroke will not be discussed in this paper.

2. Epidemiology

A stroke or cerebral vascular accident (CVA) in children is typically considered to be a rare event. The reported incidence of combined ischemic and hemorrhagic pediatric stroke ranges from 1.2 to 13 cases per 100,000 children under 18 years of age [1, 7–15]. However, pediatric stroke is likely more common than we may realize since it is thought to be frequently undiagnosed or misdiagnosed. This may be due to a variety of factors including a low level of suspicion by the clinician and patients who present with subtle symptoms that mimic other diseases. This, in turn, can lead to a delay in the diagnosis of stroke. In one report, 19 out of 45 children with a stroke did not receive a correct diagnosis until 15 hours to 3 months after initial presentation [16]. Another study demonstrated up to a 28-hour delay in seeking medical attention from the onset of symptoms and a 7.2-hour average delay after presentation before any brain imaging was done [17]. However, the reported incidence of pediatric stroke has more than doubled from prior decade estimates [18]. This may be due to a combination of increased survival in children with risk factors for stroke, such as congenital heart disease, sickle cell disease, and leukemia, and increased awareness [4, 6, 18].

Stroke is more common in boys than girls, even after controlling for differences in frequency of causes such as trauma. There appears to be a predominance of stroke in black children [9]. This difference remains true even after accounting for sickle cell disease patients with stroke [15].

3. Clinical Presentation

There are some generalizations that can be made as to how strokes present in children (Table 1). AIS most often presents as a focal neurologic deficit. Hemiplegia is the most common focal manifestation, occurring in up to 94% of cases [1, 10, 19–21]. Hemorrhagic strokes most commonly present as headaches or altered level of consciousness, and are more likely to cause vomiting than in AIS [1, 10, 22]. Seizures are common in both ischemic and hemorrhagic strokes. They occur in up to 50% of children with strokes, are not restricted to any age group, and are not limited to any specific seizure type [23].