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. Background Stroke is a pediatrics in review 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. Pediatric stroke leads to significant morbidity and mortality. 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, pediatrics in review management of pediatric stroke. Neonatal stroke will not be discussed in this paper. The reported incidence of combined ischemic and hemorrhagic pediatric stroke ranges from 1. However, pediatrics in review 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. Another study demonstrated up to a 28-hour delay in seeking medical attention from the onset of symptoms and a 7. Stroke is more common in boys than girls, even after controlling for differences in frequency of causes such as trauma. Clinical Presentation There are some generalizations that can be made as to how strokes present in children. Seizures are common in both ischemic and hemorrhagic strokes. Ischemic Hemorrhagic Earley et al. The younger the child, the more nonspecific their symptoms may be. Older children demonstrate more specific neurological defects similar to adults. These include hemiparesis, language e. Older children may even be able to report prior episodes of suspicious signs or symptoms. Specific types of stroke will also present differently in each age group. The clinical presentation is also useful for localizing the lesion. The majority of pediatric ischemic strokes occur in the distribution of the middle cerebral artery, which results in hemiplegia with upper limb predominance, hemianopsia, or dysphasia. Bulbar dysfunction and dysarthria points towards lower brainstem involvement whereas aphasia suggests involvement of the basal ganglia, thalamus, or cerebral hemispheres. If the hemispheres are involved, then the eyes will look towards the lesion, rather than away as if the brainstem were involved. Differential Diagnosis There are many other diseases that may mimic a stroke. Focal seizures can result in subsequent transient postictal hemiparesis Todd's Paresisbut stroke should be considered if the duration of the deficit is prolonged relative to the duration of the preceding seizure. Risk Factors and Causes The majority of signs and symptoms of stroke are nonspecific, and can be easily attributed to other causes. One way to avoid delays or misdiagnoses would be to identify risk factors for stroke that would prompt more aggressive and timely investigation. In children with a cardiac repair or catheterization, nearly 50% of strokes occur within 72 hours. Trauma Children who have experienced head and neck trauma are at risk of developing an ischemic event subsequent to dissection of the carotid or vertebral arteries. Drugs Drug use, both illicit and prescribed, are a concern in the adolescent population. However, generalizations and recommendations can still be made based on what is available and consensus statements. The emergency department management of stroke can be categorized into general supportive measures, diagnostic modalities, and treatment appropriate to the type of stroke identified. Recommended universal supportive measures include the following: fever control, normalization of serum glucose, and maintenance of normal oxygenation as there is no evidence that supplemental oxygen is useful in nonhypoxic patients. Control of systemic hypertension is recommended, but caution should be used as pediatrics in review reduction of blood pressure has been associated with worse neurological outcomes and larger infarcts in adults. Some experts do allow for mild permissive hypertension. Other investigations to consider include ultrasound to evaluate the extracranial carotid circulation. There are no clearly established laboratory testing guidelines for the assessment of pediatric stroke. Laboratory assessment may include a variety of nonspecific blood tests and more specific laboratory tests looking for specific causes of stroke such as coagulopathies, hematological disorders, or vasculitides. One should also keep in mind that many thrombophilias are familial, and that other family members may also be affected and require evaluation. Treatment Once the type of stroke is identified, pediatrics in review depends on the etiology. Hemorrhagic strokes may require medical management beyond supportive measures. Prevention of rebleeding includes correction of coagulation defects and hematologic disorders. Further prospective studies in adults are still needed to determine if subsets of patients may benefit pediatrics in review this therapy, so it is likely too early to extrapolate this data to the pediatric population. Surgical management of hemorrhagic strokes is controversial. There may be benefit of early surgical evacuation in patients with clinical deterioration due to mass effect. Children may warrant more aggressive intervention given their lack of cerebral atrophy which, in older adults, could potentially accommodate some degree of hematoma expansion. This is because the likelihood of a child having an underlying condition that would benefit from anticoagulation e. Anticoagulation is also often used in children with arterial dissection, dural sinus thrombosis, coagulation disorders, high risk of embolism, or progressive deterioration during the initial evaluation of a new cerebral infarction. However, these measures can be initiated in consultation with the appropriate specialists after the initial management and stabilization are carried out in the emergency department setting. Thrombolytic therapy in children with ischemic strokes must be carried out in a guarded and judicious manner. Management of stroke in children with sickle cell disease deserves special mention. Evaluation for a structural vascular lesion in children with sickle cell disease and a hemorrhagic stroke is reasonable. Rapid transfer to a tertiary pediatric center is indicated. Conclusions Strokes in children are being recognized more frequently as diagnostic aids develop and clinician recognition improves. However, because the incidence is still low relative to adult strokes, and children are distinctly different from adults, it remains a challenge to create evidence based diagnostic and treatment guidelines. Due to the low incidence of this disease, future stroke research needs to be pursued with a collaborative effort both nationally and internationally. Until then, stroke should remain a strong consideration in children with concerning signs and symptoms and significant risk factors, and the best available evidence should be utilized in providing optimal medical care. Uszynski M, Osinska M, Zekanowska E, Ziolkowska E. Children with acute lymphoblastic leukemia: is there any subgroup of children without elevated thrombin generation?.
