Paediatric Stroke

Epidemiology

  • 1.2-13 cases per 100000 (really rare), but it is frequently misdiagnosed/underdiagnosed.

Clinical presentations

  • Focal neurological signs (similar to adult, and therefore not hard to make a dx if you consider it)
  • Non specific symptoms, especially in infants: sleepiness, irritability, feeding difficulty, hypotonia
    – The younger the children, the more non-specific the symptoms are.\

Causes: in children with stroke, there is often an underlying disorder

  • Cardiac: most common
    – Cyanotic lesion –> polycythemia which increases risk of thromboembolism
    – Embolic stroke from infective endocarditis
    – PFO
  • Hematologic
    – Sickle cell disease
    – Prothrombotic disorder
    – Leukemia causing hyperviscous state
  • Trauma
    – Carotid and vertebral artery dissection
  • Vascular
    – AVM
    – Moya-moya disease
  • Vasculitis
    – septic vasculitis, viral induced vasculitis
    – autoimmune vasculitis eg Kawasaki, PAN; more common in older children (adolescent)
  • Metabolic
    – Hyperhomocystenemia (not only hereditary type, but also from folate and vitamin b12 deficiency)
  • Drugs
    – Cocaine, heroine

However, also need to remember that it is not infrequent for kids to get hypertension (primary and secondary) that is undiagnosed for years before they present with hemorrhagic stroke.

Differential diagnosis

  • Hemiplegic migraine
    – Normally there is aura before migraine or positive family history
  • Different kinds of encephalopathies
  • Postictal hemiplegia (Todd’s paresis)
  • Intracranial space occupying lesions eg abscess and tumour
    – A non contrast CT would demonstrate any other intracranial lesions
  • Metabolic: hypoglycemia
    – Do not forget to check the blood glucose level !
  • Rare: MELAS (mitochondrial encephalopathy, lactic acidosis with stroke like episodes) (and any other weird mitochondrial diseases), some inborn error of metabolism  may also present with neurological symptoms mimicking stroke
    – Most likely these metabolic diseases will present with AGMA (eg lactic acidosis in MELAS) and in addition hypoglycemia and hyperammonemia will present in many IEMs.

Mnemonic for stroke mimic in kids: ABCDEFGHI

  • Abscess
  • Bleed (hematoma)
  • Cancer
  • Dural sinus thrombosis
  • Encephalopathies
  • Fit (postictal hemiparesis)
  • Glucose low
  • Hemiplegia migraine
  • Inborn error of metabolism

Diagnosis

  • Similar to adults, non contrast head CT to rule out intracranial bleeding or any other intracranial pathologies.
  • MRI if the facility is available.
  • The more important thing is paediatric stroke can often be missed because it is not considered as the diagnosis.

Treatment

General approach

  • Supportive care eg maintenance of normal oxygenation, fever control, maintenance of euglycemia could be done.
  • BP control: AHA guidelines suggest control of systemic hypertension in children with AIS (anterior ischemic stroke) & hemorrhagic stroke but no specific guidelines of BP values.
  • Prophylactic anticonvulsant is NOT recommended (as in adults) in ischemic stroke acccording to AHA, but no recommendation in hemorrhagic stroke.
    – But there are no studies to support tx vs no tx in children.
  • Management of ICP
    – Look for acute deterioration of mental status (early sign)
    – Treatment is similar to in adult

Specific treatment

  • Well, most of te treatments are extrapolated from trials evaluating treatment in adult’s stroke.
  • First, should we give tPA?
    – Short answer, no. as evidence is very limited.
  • Antiplatelets and anticoagulation for 2ndary prevention:
    – Non SCD vs SCD group

RCP recommendation:

  1. Non SCD group: ASA 1-3 mg/kg/day
    – Anticoagulation is considered if there is
    a) Recurrence despite aspirin
    b) dissection
    c) dural venous thrombosis
    d) embolism from distal side (eg heart)
  2. SCD group: No ASA
    – Regular blood transfusion (every 3-6 weeks i.e every month) to reduce HbS level < 30% and Hb 10-12 g/dL.
    ** Evidence for acute transfusion in the setting of first-ever AIS is not as strong, although acute transfusions are
    commonly performed in clinical practice
    – if cannot receive blood transfusion eg allo-immunization, hydroxyurea maybe considered

Role of surgical therapy

  • Hemicraniectomy: in high ICP or large infarction
  • Surgical evacuation of hematoma ?
    – In adults is not proven better than medical tx, but in children who are at risk of more acute rise in ICP due to smaller cranial cavity, whether this result applies as well is unknown

Take home messages

  1. Stroke in kids can be non specific, so at least consider the diagnosis.
  2. Basically, for treatment, only supportive care + antiplatelets with or without anticoagulation for non-SCD group. No role of anticonvulsant but this is not evidence based.
  3. For SCD group, immediate transfusion to lower HbS. No aspirin should be given.
  4. No tPA; for massive infarction hemicraniectomy can be life saving.
  5. Unsure for hematoma surgical evacuation in children with hemorrhagic stroke.

References:

  1. L. C. Jordan and A. E. Hillis. Challenges in the diagnosis and treatment of pediatric stroke. Nat Rev Neurol. 2011 Apr; 7(4): 199–208
  2. Daniel S. Tsze and Jonathan H. Valente. Pediatric Stroke: A Review. Emerg Med Int. 2011; 2011: 734506.
  3. Stroke in childhood. Clinical guidelines for diagnosis, management and rehabilitation.
    https://www.rcplondon.ac.uk/sites/default/files/documents/stroke-in-childhood-guideline.pdf
  4. Management of Stroke in Infants and Children. A Scientific Statement From a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young.
    http://stroke.ahajournals.org/content/39/9/2644.full
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