Long Article

Pediatric Stroke Management: Key Takeaways from the AHA

While stroke in children is far less common than in adults, it is also often overlooked as a diagnosis, leading to delays in time-critical treatment. A limited understanding of the mechanisms underlying pediatric stroke complicates matters. Pediatric stroke can lead to lifelong neurologic impairments, neurodevelopmental and learning disabilities, and seizure disorders.1

In January 2019, the American Heart Association published an update to its decade-old scientific statement on pediatric stroke. In it, the AHA focuses on the subtypes of perinatal and childhood stroke, providing considerations for clinical practice for each, as well as addressing current controversies and knowledge gaps in each area.2

Pediatric stroke incidence and risk factors

The new statement estimates that the annualized pediatric stroke incidence rates range from 3 to 25 per 100,000 children in developed countries. These rates include both perinatal (28 weeks’ gestation to 28 postnatal days of life) and later childhood (28 postnatal days to 18 years of age) stroke, and both ischemic and hemorrhagic stroke. Newborns are at the highest risk at 1 in 4,000 live births.2

While most adult strokes can be attributed to risk factors for atherosclerosis, this is not generally a cause of stroke in children. However, dyslipidemia tends to be more prevalent among children who have experienced ischemic stroke. Children who have had a stroke are at increased risk for future strokes.2

Identifying stroke in children

Delays in diagnosis are common with stroke in children, according to the statement. Oftentimes, parents don’t recognize the symptoms of stroke because people generally don’t think about newborns and children having strokes and symptoms such as sleepiness and vomiting may not immediately make parents think of stroke.3

Stroke “mimics” challenge diagnosis by emergency medical technicians and emergency clinicians as well. The authors estimate that roughly 40 percent of pediatric stroke cases receive an incorrect initial diagnosis. The most commonly presenting conditions that may mimic stroke are migraine with aura, Bell’s palsy, or seizure with a Todd’s paresis. But there are also other conditions may also occur that mimic stroke, including brain tumor, demyelinating diseases, syncope, and intoxication. Up to 40 percent of patients who have stroke mimics have time-sensitive treatment implications or serious disease. The diagnostic strategies and tools used in adult populations are of only limited use in children.2

The authors report that other major causes of delays in diagnosis include delays in accessing MRI, often due to the need for anesthesia or sedation, or because of lower staff availability on evenings and weekends.2

Classifying childhood stroke

Dividing perinatal and childhood stroke into subtypes is necessary since diagnosis, treatment, prevention, and management differ by subtype. Ischemic stroke includes arterial ischemic stroke (AIS) as well as venous infarction caused by cerebral sinovenous thrombosis (CSVT) or cortical vein thrombosis.2

Preventing pediatric stroke

The authors discuss primary and secondary stroke prevention in children with sickle cell disease (SCD). Children with abnormal TCD (transcranial doppler) measurements treated with regular blood transfusion therapy had a relative risk reduction of 92 percent for stroke when compared to children who didn’t receive transfusions. Studies have shown that blood transfusion therapy that is then switched to hydroxyurea therapy after 12 months reduces the burden of lifelong blood transfusion therapy without an increase in stroke occurrence.2

For secondary stroke prevention in children with SCD, the authors report that several studies and analyses have shown that blood transfusion therapy is the therapy of choice, compared to observation or hydroxyurea therapy. Other strategies for secondary stroke prevention have not been rigorously assessed, and the authors recommend that clinical trials are conducted with children who undergo any other procedures or treatments aimed at secondary stroke prevention, to determine the best evidence-based approaches.2

Treating pediatric stroke

There is a lack of pediatric clinical trial data to inform hyperacute treatment decisions for AIS, according to the statement. They state the need to “establish systems and pathways for hyperacute pediatric stroke care” in centers who can offer this specialized therapy to children. They also emphasize that safety and efficacy data are lacking for hyperacute stroke therapies in the pediatric population.2

Currently, acute management of childhood stroke relies on data from both pediatric and adult studies to treat hypertension, hypotension, hyperglycemia, and fever. It also employs surveillance to prevent seizures and cerebral swelling and other complications. The statement details how and when each intervention is appropriate given the subtypes and diagnoses that can cause AIS.2

After the acute phase, age-appropriate rehabilitation and therapy programs should be utilized. Psychological assessments are useful for documenting deficits in cognition and language and to plan and monitor therapy and educational programs. For unilateral hand dysfunction after AIS, constraint therapy should be considered. Long-term follow-up is necessary to assess for development of any new concerns in the physical, cognitive, or emotional realms.2

 

Sources

1. Protocols and Guidelines for Stroke in Children: Point and Counterpoint. Pediatric Neurology. doi: 10.1016/j.pediatrneurol.2018.12.008 Last accessed March 19, 2019.

2. Management of Stroke in Neonates and Children: A Scientific Statement from the American Heart Association/American Stroke Association]. Stroke. doi: 10.1161/STR.0000000000000183 Last accessed March 19, 2019.

3. Pediatric Stroke. National Stroke Association.  https://www.stroke.org/understand-stroke/impact-of-stroke/pediatric-stroke/. 2018. Last accessed March 19, 2019.