Stroke is a neurological injury caused by the occlusion or rupture of cerebral blood vessels. Strokes are primarily classified as ischemic, hemorrhagic or combination (e.g. thrombotic stroke with hemorrhagic transformation)
Pediatric stroke was reported in the earliest medical literature as ‘cerebral apoplexy’ ‘acute infantile hemiplegia’ ‘acute hemiplegia of childhood’ ‘congenital hemiplegia’ and ‘hemiplegic cerebral palsy’.
The first documented case of pediatric stroke in the medical literature was presented by Thomas Willis (1621–1675) in the 17th century.
Giovanni Battista Morgagni’s (1682–1771) proposed that lesions occur in the brain opposite the site of hemiplegia.
Matthew Baillie (1761–1823), first described cerebral hemorrhage as the consequence of disease of the blood vessels of the brain.
Hemorrhagic stroke occurs when intracranial vessels rupture and bleed into cerebral tissues due to malformation, traumatic injury, and/or bleeding diathesis, or coagulopathies. Cerebral venous sinus thrombosis results in back pressure and leakage of blood into brain tissue, or loss of flow into areas of the brain due to the higher pressure.
Ischemic strokes result from an interruption in blood flow due to inadequate systolic cardiac function, inappropriate vasoconstriction, or thromboembolic occlusion of a vessel.
Epidemiology including risk factors and primary prevention
The estimated incidence of stroke in children ranges from 2 to 13 per 100,000 children per year.1
Incidence of pediatric stroke can be categorized by age at onset, etiology, and ethnicity.
Pediatric Stroke based on age is subgrouped into:
- Perinatal stroke: A stroke which occurs before 29 days of life.2 The incidence of perinatal stroke is 1 in 2300 to 5000 births.3
- Childhood stroke: A stroke which occurs between 29 days and 18 years of age.2 Childhood stroke has an incidence of 2-13 per 100,000.4
Pediatric Stroke by etiology:
- Hemorrhagic Stroke: A retrospective cohort study of 2.3 million children (age <20 years) followed for more than a decade revealed an average annual incidence rate of 1.4 per 100,000 children for hemorrhagic stroke. Among hemorrhagic stroke subtypes, the estimated annual incidence of intra cerebral hemorrhage in developed countries ranges from 1.1 to 5.2 per 100,000 children, while the estimated annual incidence of subarachnoid hemorrhage is 0.4 per 100,000 children. Hemorrhagic strokes occur more frequently in older children.5 Around 40% of pediatric stroke hospitalizations are due to hemorrhagic stroke.6
- Ischemic Stroke: Annual incidence rates of arterial ischemic stroke (AIS) in infants and children range from 0.6 to 7.9/100,000 children per year. AIS is more common in the younger age group and in males.5 Approximately 55% of pediatric strokes are ischemic, (in adults, greater than 80%). Basilar artery stroke: 0.037 per 100,000 children per year.7 Around 60% of pediatric stroke hospitalizations are due to ischemic strokes.6
Pediatric Stroke by ethnicity:
- Asians and African American have higher risk of Arterial Ischemic Stroke (AIS).8
- African Americans are affected more commonly than Caucasian or Hispanics even when corrected for sickle cell disease. Sickle cell disease (SCD) is a very common cause of pediatric stroke. 11% of patients with Sickle cell disease will have a clinically apparent stroke by age of 20 years. Strokes may occur as early as 18 months of age, but most children present after five years of age. 25% of patients with Sickle cell disease will have a stroke by age 45.9
Risk factors include1,5
Ischemic Stroke: (Pediatric Stroke: Current Diagnostic and Management Challenges)10
- Hypoxia or Acidosis
- Arteriopathies (Focal Cerebral Arteriopathy, Arterial Dissection, Vasculitides and Moyamoya)
- Cardiac Disease (Arrhythmia, Congenital Conditions, Cardiac Surgeries)
- Prothrombic Disorders
- Sickle Cell Disease
- Infection or Sepsis
- Asians and African Americans
- Male Sex
- Vascular Disorders (AV Malformations, Aneurysms, Moyamoya)
- Clotting Disorders (Platelet Disorders, Inherited Bleeding Coagulopathies, Anticoagulant Therapy)
- Sickle Cell Disease
- Drug Use (Cocaine and Methamphetamines)
- African Americans
- Male Sex
In the case of pediatric AIS2., predisposing factors include mineralizing angiopathy and mild trauma immediately or shortly preceding stroke onset.5
Predisposing factors for hemorrhagic stroke include vascular and coagulopathy abnormalities like arteriovenous malformation, and trauma.11,12
Primary prevention in select populations:
- Sickle cell disease: Periodic blood transfusion is recommended to reduce risk of first stroke if two transcranial Doppler studies demonstrate high velocity flow in the middle cerebral artery or distal internal carotid artery.7,13 Use of hydroxyurea is indicated to prevent sickling.
- Administering folic acid, niacin and B12 in an effort to normalize homocysteine levels is beneficial.
- Cardiac: Aspirin and anti-coagulants have been used to reduce the risk of cardiac origin stroke. Surgical repair can reduce risk of embolic stroke.13
- Activity precautions in patients with stroke resulting from bleeding diathesis, or coagulopathies, especially resistive exercises
- Routine vaccines have been shown to protect against pediatric stroke. This is thought to be due to the direct protective effects of vaccination against infections. One reason why infection may lead to increased risk of pediatric stroke is due to the increase in systemic inflammation and activation of the coagulation cascade, so vaccinations decrease the risk of systemic inflammation due to infections. The study was unable to show if any one vaccine was more protective, rather it is thought that overall vaccinations are protective.14
The middle cerebral artery is the most commonly affected distribution in ischemic strokes. Hemorrhagic strokes are typically supratentorial. Cerebral venous sinus thrombosis occurs more often in the superficial venous system than within the deep veins.1
On a cellular level, ischemic changes precipitate a series of events that result in tissue necrosis. Cell injury leads to activation of enzymes that degrade the cell’s proteins, genetic material, and lipids. The injured cells also trigger further cellular injury through activation of N-methyl-D-aspartate receptors and formation of reactive oxygen species. Soon after the initial insult, there is an influx of inflammatory cells to the site of injury. Further changes take place in the area surrounding the ischemic focus over subsequent hours to days.1
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
New onset/acute 1,6
- Abrupt onset of focal neurologic signs or rapid decline in neurologic function.
- Altered mental status or seizure may be the only presenting symptom. In Intracranial hemorrhage: nausea, vomiting, and headache.
- One study found seizures to be present in 94% of neonatal AIS and in 17% of childhood AIS.15
- Signs and symptoms may be subtle, especially in infants. Nonspecific symptoms seen in pediatric stroke, include decreased level of consciousness, headache, and vomiting. 8 However, hemiparesis and facial weakness, similar to adult presentation, is often seen. Despite this, the diagnosis of Pediatric Stroke is commonly delayed. 8 This is in part due to poor awareness among professionals about pediatric strokes because of low prevalence, keeping pediatric stroke lower on the differential, and the risk factors for children are very different than that of adults.8 One study showed that the median time from symptom onset to diagnosis of AIS was around 23 hours.16
- FAST (“Face, Arms, Speech Time) criteria is a method to screen for stroke (Royal College of Pediatrics and Child Health Full Recommendations for Childhood Stroke).17
- Patients who have had previously unrecognized or misdiagnosed strokes may present in the subacute period with a history of stepwise or progressive decline in function over time.
Most studies estimate that over 50% of pediatric stroke patients will have long-lasting or permanent neurologic sequelae.13
In one study, the majority of pediatric stroke patients achieved independence with activities of daily living (ADL). However, children were more likely to regain function in a previously learned domain than achieve a new skill. Thus, younger age is a risk factor which may limit progress in ADL independence. 9
In the chronic phase, regression in function is rare.9 Recurrent stroke should be suspected if a child develops new deficits.
Morbidity and Mortality: Pediatric stroke leads to significant morbidity and mortality. Roughly 10–25% of children with a stroke will succumb to death. Up to 25% of children may have recurrence, mostly due to an underlying etiology, and up to 66% will have persistent neurological deficits or develop subsequent seizure disorders, learning, or developmental problems.
Specific secondary or associated conditions and complications
Sequelae of pediatric stroke may include:
- Seizure disorder
- Epilepsy-Can be as high as 50% 18
- Infantile Spasm-around 25% 18
- Cerebral Palsy19
- Muscle contractures.
- Visual deficits.
- Speech and language impairment.
- Dysphagia-around 40% in neonates and children20
- Oral motor-around 25% in children and neonates20
- Motor speech-around 25% in children and neonates20
- Cognitive impairment.
- Head Growth Deceleration-associated with poor outcomes19
- Obstructive Sleep Apnea21
All the above may impact a child’s mobility and/or independence with activities of daily living.
Essentials of Assessment
A thorough history in a child with suspected stroke should include:
- Time of symptom onset.
- Specific sensory or motor deficits, vision changes, dysphagia.
- Seizure activity.
- Screening for potential risk factors, including recent infections.
- Birth and developmental history
- Family history of clots, miscarriages, drug exposure
- Closely monitor vital signs acutely.
- Document seizure activity.
- Look for signs of increased intracranial pressure, such as papilledema.
- A full neurologic exam should be completed, including mental status, cranial nerves, motor function, sensory testing, reflexes, and coordination. Later stages: assess ADL skills, transfer skills, other functional mobility.
The Pediatric NIH Stroke Scale (PedNIHSS) can be used to quantitate stroke severity in the short-term and is adapted for the pediatric population. A guide to using the scale is available online.22
The Pediatric Stoke Outcome Measure (PSOM) is a validated tool used specifically for the pediatric stroke population.23 PSOM is used to predict future long-term functional outcomes after a stroke.24 Poor PSOM scores at 1 month has correlated with decreased functional motor and gross motor function and adaptive skills at 12 months after the stroke.25
Laboratory studies that may facilitate the evaluation of a patient with suspected stroke include:
- A complete blood count (anemia, platelet disorders). If abnormal, peripheral blood smear to further characterize.
- A metabolic panel (electrolyte abnormalities, dehydration).
- Coagulation panel (APTT, PT, lupus anticoagulant, anti-cardiolipin antibodies, ANA, anti-B2GP1 antibodies, platelet aggregation, factor VIII activity, d-dimers, thrombin time, factor V Leiden, Protein C antigen, Protein S antigen, Plasminogen activator inhibitor, homocysteine, coagulation factor assays)
- Inflammatory markers including sedimentation rate and C-reactive protein (inflammatory or infectious conditions).
- Maternal labs for syphilis testing (VDRL, toxicology screen)
MRI, when available, is preferred for first line imaging study for a child with stroke like symptoms.26 If MRI is not available, then CT or head ultrasound can be used.27
The optimal imaging study is somewhat dependent on the child’s clinical stability.
Cranial ultrasound is safe and readily available, but it may miss superficial and ischemic lesions and cannot be done after the fontanelles are closed. It is primarily used to evaluate extra cranial blood vessels.
CT brain quickly and accurately depicts superficial or hemorrhagic lesions and confirms the lesion location. However, venous thrombosis and early acute ischemic stroke (AIS) are easily missed with CT. Reports have shown CT can miss up to 47% of acute ischemic strokes. 26
MRI, magnetic resonance angiography (MRA), and magnetic venography (MRV) may more accurately define the site of an arterial or venous occlusion. Additionally, MR studies often demonstrate associated parenchymal abnormalities more clearly, including non-ischemic lesions that clinically mimic arterial or venous stroke.
CT/MRI differentiates hemorrhagic verses ischemic lesions which also guide in formulating plan for using thrombolytics which are contra-indicated in hemorrhagic strokes
Diffusion-weighted imaging (DWI) can confirm the presence and location of an infarction earlier than other MRA sequences or CT. This DWI study can be performs in around 30 seconds. 26
Other advancing MRI techniques include pH-weighted arterial spin labeling (AST), amide proton transfer (APT), vessel wall imaging, bold oxygen level-dependent (BOLD), T2-relaxation-under-spin lagging, asymmetrical spin echo and edited spectroscopy.26
CT angiography (CTA) is an accurate means of identifying primary vascular abnormalities when there is an unexplained hemorrhagic lesion. CTA can fail to differentiate between a stroke and a stroke mimic, like hemiplegic migraine and seizure with postictal paralysis. CTA requires a correctly time contrast injection through a small intravenous line while exposing a child to increased radiation making it not recommended as the first line approach.26
Catheter angiography (CA) is technically more difficult in babies and tends to be done only when endovascular surgical intervention is anticipated.
Vascular imaging by MRI or CTA is done either at the same time or after the initial imaging study due to the high likelihood of an arteriopathy, which is a poor prognostic factor and has a higher chance of stroke recurrence. Follow-up imaging 6 to 12 weeks after the initial stroke is recommended to monitor arteriopathy changes or to find previously missed arteriopathy and/or new infarcts.2
Supplemental assessment tools
EKG and echocardiogram should be obtained after acute ischemic stroke (arrhythmia, thrombus, or congenital cardiac defects).1
Generalized activity suppression or subtle presentation of focal seizure activity can be seen on EEG.
Neuropsychology testing plays an important role in assessing cognitive and memory deficits.
Early predictions of outcomes
For ischemic strokes, a low PedNIHSS is the best predictor of having no symptoms or mild symptoms in 3-6 months.28
Hemorrhagic strokes cause higher mortality in the acute phase. Most studies have found an in-hospital mortality rate of 6-9% for pediatric hemorrhagic strokes.28 Larger volume of hemorrhage correlates to worse 30-day outcomes.29
Prior to discharge, consider the physical accessibility of the child’s discharge destination. A thorough discussion with caregivers may help to identify additional equipment or home adaptation needs.30
Social role and social support system
After assessing the child’s mobility, independence with activities of daily living, speech, and cognitive changes, caregivers may find that the child will need more frequent assistance or more intensive care than they previously required. Functional parenting styles, positive discipline practices, and autonomy-supportive strategies for task engagement should be encouraged when intervening with these children. Parents should be supported to engage in these practices in all aspects of daily activities.31
Mentoring support groups such as hemi-kids and CHASA are available in the community.
Mental health illnesses are a concern in both the child and the family members. In the child post stroke depression, anxiety and Post-traumatic stress disorder (PTSD) are common. PTSD, depression and anxiety are common in the mothers, while PTSD and depression are seen in fathers of children after a stroke.32
Rehabilitation Management and Treatments
Available or current treatment guidelines
Meta-analysis of peer-reviewed research is limited in the pediatric stroke population.
In 2019 the American Heart Associate released their “Considerations for Clinical Practice” for pediatric rehabilitation which states:
- “Age-appropriate rehabilitation and therapy programs are appropriate for children after a stroke.”
- “Psychological assessment to document cognitive and language deficits is useful for planning therapy and educational programs after a child’s stroke.”
- “Constraint therapy should be considered in children with unilateral hand dysfunction after AIS.”
- “Long-term follow-up is required for children with stroke to assess for development of new cognitive, physical, and emotional concerns that may occur over time as children grow into deficits.”33
Other recommendations by the AHA include:
- Use constraint therapy for upper extremity strength
- Long-term antithrombotic therapy can be used to prevent recurrent strokes
- Perform a physiological assessment for cognitive and language deficits
- Follow-up long term for new concerns as children grow into their deficits
In 2015 the Canadian Stroke Best Practice Recommendations: Stroke Rehabilitation Practice Guidelines released recommendations care in the pediatric population, as listed below.34
|Pediatric Stroke Recommendations|
|Arm and Hand Rehabilitation||Use Constraint-Induced Movement Therapy for upper limb impairment|
|Pediatric Stroke Recommendations Level B|
|Rehabilitation Assessment||An initial assessment by medical professionals should be done quickly to determine stroke severity and rehabilitation needs|
|Provide acute and rehabilitation stroke care on a specialized pediatric unit|
|Offer outpatient support to children who have a change in functional status and would benefit from more rehabilitation services at any time during their recovery|
|Rehabilitation Team||Care should be given by health professionals who have experience in pediatric stroke care, regardless of the location of services to decrease complication risk|
|Teams should have experts in pediatrics, pediatric stroke rehabilitation, including physicians, occupational therapists, physical therapists, speech-language pathologists, nurses, social workers, psychologists, and dietitians|
|Family Wellness||Provide educational interventions to reduce maternal guilt or parental blame|
|Educate parents, particularly mothers, about causes of pediatric stroke and that it almost impossible to prevent|
|Tell mother directly and repeatedly “This is not your fault”|
|Offer families support and information relating to changes in physical needs and dependency of the child|
|Other changes that should be addressed include family members social roles, leisure activities, impact on family members, and issues that may arise with resources|
|Pediatric Stroke Recommendations Level C|
|Rehabilitation Assessment||Use standardized, valid assessment tools relating to functional activity limitations, impairment due to the stroke, restrictions in role participation, changes in mood and behavior, and environmental restriction|
|Develop individualized rehabilitation plans and update as patient progresses developmentally. This should be done yearly.|
|Determine the appropriate setting for rehabilitation after the initial assessment|
|Rehabilitation Team||Include family members as part of the team|
|Other members of the team can include, but not limited to, recreation therapists, educational therapist, and orthotists|
|General Rehabilitation Principles||To enhance motor control and return sensorimotor function, children should have rehabilitation that is meaningful, engaging, repetitive and progressively adapted, age appropriate, task-specific and goal oriented|
|Children should participate in training that encourages use of the affected limb undergoing functional tasks and that mimic daily life activities appropriate for the child’s developmental stage|
|Use objective, functional outcome measure before and after to determine benefit for the child|
|Use functionally relevant goals determined by the child and the family with the help of a therapist|
|Arm and Hand Rehabilitation||Include range of motion exercises that place the upper limb in a wide range of positions that are safe in the child’s visual field|
|Hand and wrist splints can be used and customized for the child along with a plan to monitoring the splints|
|Other rehabilitation interventions that can be used for the upper limbs include Functional Electric Stimulation, Mirror Therapy, Botulinum Toxin Type A, Repetitive Transcranial Magnetic Stimulation or Surgical Interventions.|
|Lower Limb Rehabilitation||Provide lower limb range of motion exercises, gait training, and physical activity|
|Other rehabilitation therapies that can be used for the lower limbs include Ankle-Foot Orthoses, Botulinum Toxin Type A, or Surgical Interventions|
|Devices for Adaption and Assistance||Adaptive devices, like splints and orthoses, can be used|
|Special equipment, like wheelchair trays, should be used on an individual basis. Evaluate as the child grows|
|School||Continue to evaluate need for educational and vocational needs during development|
|Resume education when the child is ready|
|School-aged children should receive educational rehabilitation and support services, along with an individualized educational plan|
|Leisure||Offer treatment that relates to specific play and leisure skills|
|Provide information related to leisure skills and adaptive programs in the community|
Adult Level Canadian Recommendations: A list of Level A guidelines from the Canadian Stroke Best Practice Recommendations: Stroke Rehabilitation Practice Guidelines, update 2015 is listed below. A more complete list of recommendations can be found online.
|Adult Stroke Recommendations Level A|
|Initial Assessment||Perform initial assessment as soon as possible for all patients admitted to the hospital for acute stroke|
|Core Rehabilitation team include physiatrists, other physicians, occupational therapists, physiotherapists, speech-language pathologists, nurses, social workers and dietitians|
|Rehabilitation Unit Care||Treat on a specialized stroke rehabilitation unit|
|Allow all patients to engage in inpatient stroke rehabilitation who are ready for rehab and can have their goals changed by rehabilitation|
|Delivery of Rehabilitation||Patients should receive rehabilitation as soon as possible and are medically able|
|Therapy should be individualized to each patient, appropriate to their level of intensity and duration|
|Therapy skills should be incorporated into the patient’s daily life|
|Include repetitive and novel tasks that challenge the patient|
|Outpatient Rehabilitation||Stroke survivors should have access to stroke services even after leaving the hospital or an outpatient service|
|Early Supported Discharge (ESD)||ESD is acceptable when available|
|Criteria include mild to moderate disability, ability to participate in rehabilitation after discharge, having medically available care|
|Provided by the same team that provided inpatient rehabilitation when possible|
|Upper Extremity Rehabilitation||Training is meaningful and goal oriented to improve motor control and restore sensorimotor function|
|Training should simulate everyday tasks|
|Functional Electrical Stimulation should be considered that targets the wrist and forearm|
|Constraint-induced movement therapy should be considered for certain patients|
|Mirror Therapy can be used along with motor therapy|
|Virtual Reality can be used along with other therapy|
|Strength training is considered for mild to moderate upper extremity function in subacute and chronic recovery phases|
|Routine use of splints is not recommended|
|Can use botulinum toxin to increase range of motion and decrease pain|
|Do not use overhead pulleys for shoulder pain|
|Do not move arm beyond 90 degrees of shoulder flexion or abduction in most cases|
|Educate staff members, family and the patient about how to handle the arm|
|Lower Extremity||Tone and pain are not impacted by strength training|
|Use task and goal training to improve tasks like walking distance|
|Treadmill-based gait training can be used|
|Electromechanical assisted gait training can be used|
|Rhythmic auditory stimulation can be used|
|Virtual reality training can be used|
|Mental Practice can be used|
|Offer balance training|
|Trunk training, task specific interventions and force platform biofeedback are effective|
|Add specific aerobic training of large muscle groups while monitoring heart rate and blood pressure|
|Have a planned transition from structured activity to self-directed activity|
|Can use ankle-foot orthoses|
|Functional Electrical Stimulation can be used|
|Can used botulinum toxin|
|Dysphagia and Nutrition||No Level A recommendations|
|Visual Field Deficits||No Level A recommendations|
|Central Pain||No Level A recommendations|
|Language and Communication||Supported Conversation techniques should be taught to potential communication partners|
|Resumption of Life Roles||Give targeted therapy for patients struggling with leisure activities|
At different disease stages
- Supportive care, including hydration and management of hypoxia or hypotension. Seizure activity should be treated. Monitor for signs of increased intracranial pressure.
- Neurology and Pediatric Hematology or a stroke consult service should be involved as early as possible in the acute setting for making timely decisions for thrombolytic therapies for eligible patients.30 In 2010, the National Institute of Neurological disorders and stroke (NINDS) funded the first prospective treatment trial in acute pediatric stroke, the Thrombolysis in Pediatric Stroke (TIPS) trial. This study was defunded because it was unable to recruit enough pediatric ischemic strokes patients.35 The former TIPS sites have continued to identify patients who would have been eligible for TIPS and have treated children with tissue-type plasminogen activator (tPA) using the TIPS protocol. Heparin is not used widely in children with perinatal AIS, although children with severe pro-thrombotic disorders or with cardiac or multiple systemic thrombi may benefit.30
- Surgical evacuation of hemorrhage is not typically indicated but may be useful in select patients with persistently increased intracranial pressure refractory to medical management.
- IV thrombolysis within 4.5 hours in >2 years and a PedNIHSS score between 4 and 24. Imaging must show lack of hemorrhage and normal or minimally ischemic parenchyma on CT or acute ischemia on MRI. There also must be arterial occlusion or severe stenosis on CTA or MRA.10
- IV tPA has been shown to be low risk in children at doses of 0.9 mg/kg with a max dose of 90 mg.36
- Mechanical thrombectomy is being looked at as treatment for ischemic stroke due to a large vessel occlusion in patients aged 1-18 years.37
- Markedly low platelet counts and factor deficiencies should be corrected. Vitamin K deficiency may be an issue in areas of the world where vitamin K is not routinely administered to newborns, in infants with biliary atresia, or in babies whose mothers ingested warfarin, phenytoin, or barbiturates during pregnancy.
- Thorough documentation of deficits will facilitate involvement of appropriate members of the rehabilitation team.
- Secondary prevention and disease management strategies
- Sickle cell patients with confirmed infarct will require a long-term red blood cell transfusion program for secondary prevention. Those who cannot receive ongoing transfusions may receive hydroxyurea.
- Even though chronic transfusions carry risk, stopping chronic transfusions lead to increased risk of stroke.38
- Revascularization is useful in patients with Moyamoya (a congenital syndrome of cerebral arterial malformation).
- Consult Neurosurgery in determining whether to undergo revascularization in a patient with Moyamoya.33
- Patients with extra cranial arterial dissection or cardio embolism can be started on heparin therapy and transitioned to warfarin. The duration of therapy is 3-6 months for dissection, and one year or longer for cardio embolic causes (depending on whether the causative lesion can be corrected).
- Congenital vascular abnormalities should be treated with surgery, endovascular repair, or radiosurgery when possible.
- Patients may wish to discontinue oral contraceptives, consider other forms of birth control.
- Oral contraceptives are associated with cerebral sinovenous thrombosis.33
- In patients with elevated homocysteine levels, diet changes and/or folate, vitamin B6, and vitamin B12 supplementation may be used in attempt to decrease homocysteine.
- Use of folic acid can decrease risk of sequelae in those with elevated homocysteine levels.33
- Aspirin and anticoagulation with LMWH is not indicated due to the low recurrent risk for stroke in neonates. Can be used if there is a high risk of recurrent AIS, such as thrombophilia or congenital heart disease.33
- There is little information about the long-term use of prophylactic therapies such as LMWH in neonates.33 Although recurrent stroke is uncommon in these patients, individuals with prothrombotic conditions plus other risk factors including complex congenital heart disease, dehydration, or prolonged bed rest may have a higher likelihood of recurrent venous and arterial thrombosis, and prophylaxis may be considered in these individuals.33 It is reasonable to supplement folate and B vitamins for children with a methylene tetra hydro-folate reductase (MTHFR) mutation in an effort to normalize homocysteine levels
- Planning a child’s individualized therapy and educational programs may involve multiple team members. Plans must include a thorough assessment of deficits
- Promote function and safety in a classroom setting through educational rehabilitation and support services. An Individualized Education Plan (IEP) should be made when required. 34
- Provide information about resources available through school, and how to request a 504 plan or an Individual Education Plan (IEP). This plan should specify educational adaptations, educationally related therapy services, and nursing services to be provided by the school.
- Orthotics, adaptive equipment, and medical management of spasticity can all be used to facilitate a child’s recovery. 34
- Parental guilt or blame can be seen, so it is important to consider entire family when starting rehabilitation program.34
- Goals include education and vocational rehabilitation as well as goals similar to that of an adult.34
Coordination of care
Multidisciplinary teams remain the standard of care for pediatric stroke patients.
In acute care setting: The critical care team, neurology, hematology, trauma service, neurosurgery, care co-ordination, and physiatry may be involved.
In Rehabilitation setting: physiatry, pediatrics, physical therapy, occupational therapy, speech therapy, neuropsychology, dietician, child life therapies, recreational therapies, care-coordinators, social worker, nursing staff, and services that had evaluated the patient during acute management (to follow-up on any pending health concerns) may be involved.
Patient & family education
Most sources do indicate cautious optimism is warranted; a good balance of honesty about probable long-term deficits but also overall strong potential for recovery that is possible should be provided.
The Children’s Hemiplegia and Stroke Association (http://www.chasa.org/) is an excellent starting point for families to meet others with similar experiences, learn about stroke rehabilitation, and find events and activities for children who have had a stroke.
Several validated measures have been used to document outcomes, but not all are specific to pediatric stroke. The Pediatric Stroke Outcomes Measure, Pediatric Stroke Recurrence and Recovery Questionnaire, and the PedNIHSS were developed specifically for this population.17
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
Remember to keep stroke in the differential diagnosis for children with neurologic complaints, headache, or vomiting. Misdiagnosis or delayed diagnosis is common.18
Inpatient Rehabilitation has been shown to significantly improve functional outcomes, with hemorrhagic strokes having better outcomes than ischemic strokes.39
Children who had a stroke were found to have worse academic achievement in the future, specifically in mathematics.40 It is important to have a neuropsychologist screen these children because they may have difficulties with higher level learning that are overlooked early on.41 It is recommended that children receive an individualized education plan to meet the needs of that child. 34
Children were more likely to regain function in a previously learned domain than achieve a new skill. Thus, younger age is a risk factor which may limit progress in ADL independence.9
If a child develops new deficits, it is important to consider a recurrent stroke.9
A recent study of Cerebral Palsy patients suggest that children are able to choose functional and developmentally appropriate goals for themselves. This study suggest children should be able to define their own goals in rehabilitation and may be useful when treating pediatric stroke patients.42
Cutting Edge/ Emerging and Unique Concepts and Practice
Robotic therapies to improve upper extremity function have been tested in adult stroke patients and in children with cerebral palsy. Expansion to the pediatric stroke population is a logical next step.30
Newer robotic therapies like virtual reality and electromechanical assisted gait training, can be useful in children. 34
Early studies have shown noninvasive brain stimulation with other therapies, like CIMT, may lead to improved upper extremity outcomes.4
Transcranial magnetic stimulation (TMS) and transcranial direct-current stimulation (tDCS) are being shown to be safe in the pediatric stroke population.43
A recent review showed most effective methods are CIMT, forced use therapy, repetitive transcranial magnetic stimulation, functional electrical stimulation, and robotics.44
Implanted brain-computer interface is an emerging technology in adults and a recent pilot study showed benefit in improving limb function.45
Other interventions that are being examined in the adult populations include stem-cell based treatment and the use of pharmacologic interventions, like Fluoxetine (Pediatric Stroke: Unique implications of the immature brain on injury and recovery).4
Gaps in the Evidence- Based Knowledge
Extensive pediatric research in the field of pediatric stroke is lacking due to relative low incidence of stroke in pediatric population. Some of the reasons these reasons include the difference in clinical presentation based on symptoms and age, making the diagnosis more challenging, the various risk factors that can lead to pediatric stroke, and the low prevalence making it difficult to perform large studies.10, 35
Mechanical thrombectomy reports have some inconsistency and may not be as beneficial as some reports imply.46
The gene ADAMTS encodes for parts of the extracellular matrix and recent evidence suggests that some of the genes, like ADAMTS12, can lead to increased risk of pediatric stroke.47Other genes that may affect pediatric stroke include: ANCC6 and COL4A1. These studies suggest that there are a number of genetic variances that can increase likelihood of pediatric stroke.48
Rehabilitation has focused mostly on the upper limbs, while fewer focus on the lower limbs or cognitive impairment.44
Early studies showed Pediatric Stroke is an infrequent, but important, complication of COVID-19. 49 Case reports have described pediatric strokes 3-4 weeks after a COVID-19 infection, but the overall effect is unknown.50
- Advances in pediatrics in Pediatric stroke: past, present and future. Neil Friedman MBChB. DOI 10:1016/j.yapad.2009.08.003.
- Khalaf A, Iv M, Fullerton H, Wintermark M. Pediatric Stroke Imaging. Pediatr Neurol. 2018 Sep;86:5-18. doi: 10.1016/j.pediatrneurol.2018.05.008. Epub 2018 Jul 9. PMID: 30122281; PMCID: PMC6215731.
- Raju TN, Nelson KB, Ferriero D, Lynch JK; NICHD-NINDS Perinatal Stroke Workshop Participants. Ischemic perinatal stroke: summary of a workshop sponsored by the National Institute of Child Health and Human Development and the National Institute of Neurological Disorders and Stroke. Pediatrics. 2007 Sep;120(3):609-16. doi: 10.1542/peds.2007-0336. PMID: 17766535.
- Malone LA, Felling RJ. Pediatric Stroke: Unique Implications of the Immature Brain on Injury and Recovery. Pediatr Neurol. 2020 Jan;102:3-9. doi: 10.1016/j.pediatrneurol.2019.06.016. Epub 2019 Jul 3. PMID: 31371122; PMCID: PMC6959511.
- Stroke in infancy: a convergence of causes. GABRIELLE DEVEBER doi: 10.1111/dmcn.12296
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Original Version of the Topic
Edward Hurvitz, MD and Alecia Daunter, MD. Pediatric stroke. Published9/20/2013
Previous Revision(s) of the Topic
Rajashree Srinivasan, MD and Saylee Dhamdhere MD, UTSW. Pediatric stroke. Published 8/8/2017
Sathya Vadivelu, DO
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Joshua Kaseff, MS
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