Pediatric Stroke

Last Updated by Lindsay Pagano

Summer 2013
 Epidemiology of Childhood Stroke
Childhood
Stroke
2-3/100,000*

Hemorrhagic
Ischemic Stroke
Stroke
1.2/100,000
1.1/100,000

ICH SAH
0.8/100,000 0.3/100,000

*Incidence rate is per 100,000 child-years

Overall, childhood stroke is as common as brain tumor in childhood !!
Numbers from: Fullerton et al. Neurology 2003.
 Signs, Symptoms and Differential
Symptoms/Signs
Hemiparesis/focal motor 60%
Aphasia 10-15%
Seizure 25% (vs. 5% in adults)
Headache 32%
Altered mental status 21%

Differential
Complex Migraine: eg focal aura, hemiplegic migraine
Focal seizure with postictal focal weakness (Todds paralysis/plegia)
Stroke Ischemic/Hemorrhagic
Other focal brain pathology
Stroke Mimics can include:
Encephalopathy related to hypertension, intracranial infection, tumor, drug toxicity,
pseudotumor cerebri, inflammatory disease, epilepsy
 Etiology of Ischemic Stroke in Older Kids:
Think Embolic or Arteriopathy

Arteriopathy present in 60-80% of Children

Arterial Dissection in 25% , also Focal cerebral arteriopathy,
Moyamoya, post-infectious, HIV, Varicella, etc.
Cardioembolism 25-35%
Sickle Cell Anemia
10% will have a clinical stroke by age 20
20% more will have a silent infarct
Hypercoaguable state
More unusual causes: vasculitis, pregnancy, metabolic disorders, cerebral
sinus venous thrombosis
Idiopathic 5-30%
 Acute Management of Child with Possible
Stroke: The First 15 Minutes!
Goals:
1. cerebral perfusion
2. oxygenation
3. minimize demands for cerebral blood flow
Head of Bed Flat if alert, or 30 degrees if not alert/aspiration risk.
IV Fluids: isotonic, at maintenance+, no dextrose as want to avoid
hyperglycemia. Check sugars
Oxygen only if needed to keep sats > 95%
Acetaminophen if temp > 37.0
Get a neuro exam you can follow serially
Peds NIHSS- Peds Stroke Cards
 Diagnostic Evaluation
Ischemic Stroke: Head, Neck, Heart, Blood
Acutely
MRIbrain, MRA head,neck
At VCH: Order emergent peds stroke protocol brain MRI in all kids with symptoms <
48 hours or if stroke will change management dramatically
Protocol takes 10 minutes and includes:
DWI bright and ADC dark = acute stroke (within the last 10 days)
FFE/GRE: sequence for blood
No MRA if MRI shows stroke
+/- MR Venogram (especially consider with sickle cell disease)

Note: Head CT will miss 60% of acute stroke within 12 hours of symptom onset.
Need MRI.
Note: Neck vessel imaging - MR or CT Angiography, NOT ultrasound

After initial head imaging

Echo Transthoracic Echo with bubble study to eval for PFO, thrombus source
Coagulation evaluation
 Treatment
Aspirin
For all older children with ischemic stroke except kids with sickle cell disease
Typical dose is 3-5 mg/kg/day
Risk of Reyes syndrome is very low. Still we strongly recommend annual flu vaccine
and some will hold aspirin with high fever or flu-like symptoms (I dont).

Anticoagulation
Consider if suspicion high for cardioembolic stroke, arterial dissection, posterior
circulation stroke, stuttering deficits suggestive of thrombosis.
Risk of hemorrhagic transformation of ischemic stroke is less after 48 hours.
May prevent further strokes, but wont help this one improve.

**Sickle Cell Disease/HbSS

Treatment is Transfusion (usually, pRBC in ED, exchange transfusion in PICU)
Regular transfusions through heme/onc as indicated in the future
 PREP Question
A 6 year old right handed girl with no significant past medical history presents
to the emergency department for concerns of new onset right sided weakness that was
first noted when she tried to get out of bed that morning. Her speech was also slurred.
Her symptoms seemed to improve throughout the morning but did not completely
resolve. There were no witnessed convulsions or associated loss of consciousness. Her
birth history was uncomplicated, and her development has been appropriate.
PE is significant for slurred speech with short sentences, difficulty following
commands, and flattening of the right nasolabial fold. She also has a slight decrease in
right sided tone and 4/5 strength on the right. There is a right plantar extensor response.
Of the following, the MOST accurate statement is:
A. The most likely vascular territory involved is the right middle cerebral artery.
B. The most likely lesion producing these symptoms is one involving the left internal
capsule.
C. Angiogram could show abnormal collateral arterial networks.
D. The most likely diagnosis is complicated migraine, and the family can be reassured
and the patient discharged.
E. The best characterization of her speech deficit is dysarthria.
 C. Angiogram could show abnormal collateral arterial
networks
Moyamoya Vasculopathy
Idiopathic versus associated with other disease states
NF1, fibromuscular dysplasia, Marfan syndrome, Down syndrome, radiation vasculitis,
vasculitis, infectious/postinfectious vasculopathy, congenital heart disease, sickle cell
disease, Fanconi anemia, atherosclerosis, head trauma
Noninflammatory, progressive cerebrovascular occlusive disease slowly causing stenosis
and occlusion of cerebral arteries, especially those surrounding or feeding the Circle of
Willis
puff of smoke
Regarding the other choices:
A. The most likely vascular territory involved is the right MCA: left MCA is most likely
since she is right handed, and her cortical language and left motor areas are involved
B. The most likely lesion producing these symptoms is one involving the right internal
capsule: as above
D. The most likely diagnosis is complicated migraine, and the family can be reassured
and the patient discharged: this may be the diagnosis, but need to rule out acute stroke
E. The best characterization of her speech deficit is dysarthria: dysarthria AND aphasia
(both receptive and expressive)