Title: Pediatric stroke<br/>Author: Jenny Guyther<br/><a href='http://umem.org/profiles/faculty/314/'>[Click to email author]</a><hr/><div style="font-family: Arial, Helvetica, sans-serif; font-size: small;">
<font color="#212121" face="BlinkMacSystemFont, -apple-system, Segoe UI, Roboto, Oxygen, Ubuntu, Cantarell, Fira Sans, Droid Sans, Helvetica Neue, sans-serif"><span style="font-size: 16px;">Stroke diagnosis is often delayed in pediatric patients due to delay in seeking care, misdiagnosis and lack of stroke being included in the initial differential diagnosis. </span></font></div>
<div style="font-family: Arial, Helvetica, sans-serif; font-size: small;">
<font color="#212121" face="BlinkMacSystemFont, -apple-system, Segoe UI, Roboto, Oxygen, Ubuntu, Cantarell, Fira Sans, Droid Sans, Helvetica Neue, sans-serif"><span style="font-size: 16px;">Perinatal strokes (occurring between 20 weeks gestation and 28 days of life) are more common than strokes in ages 29 days to 18 years. The incidence of perinatal stroke is 37/100,000 births and 2.3/100,000 children after 29 days. Infants age 29 days to < 1 year had the highest rate of stroke outside of perinatal strokes, followed by 15-19 year olds.</span></font></div>
<div style="font-family: Arial, Helvetica, sans-serif; font-size: small;">
<font color="#212121" face="BlinkMacSystemFont, -apple-system, Segoe UI, Roboto, Oxygen, Ubuntu, Cantarell, Fira Sans, Droid Sans, Helvetica Neue, sans-serif"><span style="font-size: 16px;">The most common risk factors for pediatric strokes include: arteriopathies (such as arterial dissection, moyamoya and vasculitis), cardiac disorders (single ventricle physiology have the highest risk) and infections. Sickle cell disease and cerebral venous thrombosis are other risk factors for acute ischemic stroke.</span></font></div>
<div style="font-family: Arial, Helvetica, sans-serif; font-size: small;">
<font color="#212121" face="BlinkMacSystemFont, -apple-system, Segoe UI, Roboto, Oxygen, Ubuntu, Cantarell, Fira Sans, Droid Sans, Helvetica Neue, sans-serif"><span style="font-size: 16px;">Children younger than 6 years were more likely to present with altered mental status or seizures. Other presentations included facial weakness, speech disturbances, hemiparesis, headache, nausea and vomiting.</span></font></div>
<div style="font-family: Arial, Helvetica, sans-serif; font-size: small;">
<font color="#212121" face="BlinkMacSystemFont, -apple-system, Segoe UI, Roboto, Oxygen, Ubuntu, Cantarell, Fira Sans, Droid Sans, Helvetica Neue, sans-serif"><span style="font-size: 16px;">There is a pediatric NIH stroke scale that can be used in children at least 2 years old that accounts for developmental differences.</span></font></div>
<div style="font-family: Arial, Helvetica, sans-serif; font-size: small;">
<font color="#212121" face="BlinkMacSystemFont, -apple-system, Segoe UI, Roboto, Oxygen, Ubuntu, Cantarell, Fira Sans, Droid Sans, Helvetica Neue, sans-serif"><span style="font-size: 16px;">Differential Diagnosis includes (most to least common): migraines, seizures, Bell's palsy, conversion disorder and syncope. Once study found that up to 63% of patients that were suspected of having a stroke, but did not, had another significant disease process that required further evaluation. These other processes included vascular anomalies, seizures, inflammatory disease, metabolic anomalies and drug ingestions.</span></font></div>
<div style="font-family: Arial, Helvetica, sans-serif; font-size: small;">
<font color="#212121" face="BlinkMacSystemFont, -apple-system, Segoe UI, Roboto, Oxygen, Ubuntu, Cantarell, Fira Sans, Droid Sans, Helvetica Neue, sans-serif"><span style="font-size: 16px;">MRI brain and MRA of the head and neck are gold standard for diagnosis. If this is not obtainable or would be delayed, then head CT followed by CTA of the head and neck should be obtained.</span></font></div>
<div style="font-family: Arial, Helvetica, sans-serif; font-size: small;">
<font color="#212121" face="BlinkMacSystemFont, -apple-system, Segoe UI, Roboto, Oxygen, Ubuntu, Cantarell, Fira Sans, Droid Sans, Helvetica Neue, sans-serif"><span style="font-size: 16px;">The treatment of acute ischemic stroke is still not fully researched and much is adopted from adult protocols. TPA and endovascular thrombectomy are not well established. There has been a small study of patients treated with TPA, but a subsequent NIH funded trial could not recruit enough patients. Adult dosing guidelines for TPA have been adopted if TPA is going to be used and should be given within 4.5 hours of symptom onset. Endovascular therapy should be considered only in patients with persistent, disabling neurological defects and a confirmed large vessel occlusion. Patient selection is limited by the side of the catheter used. Patients with confirmed ischemic stroke who do not receive TPA or endovascular therapy should receive antiplatelet therapy.</span></font></div>
<div style="font-family: Arial, Helvetica, sans-serif; font-size: small;">
<font color="#212121" face="BlinkMacSystemFont, -apple-system, Segoe UI, Roboto, Oxygen, Ubuntu, Cantarell, Fira Sans, Droid Sans, Helvetica Neue, sans-serif"><span style="font-size: 16px;">Cerebral venous thrombosis is treated with anticoagulation. Hemorrhagic strokes in children are treated similar to adults.</span></font></div>
<div style="font-family: Arial, Helvetica, sans-serif; font-size: small;">
<font color="#212121" face="BlinkMacSystemFont, -apple-system, Segoe UI, Roboto, Oxygen, Ubuntu, Cantarell, Fira Sans, Droid Sans, Helvetica Neue, sans-serif"><span style="font-size: 16px;">Exchange transfusion is the mainstay of treatment for sickle cell patients with a goal to decrease HbS to < 30%.</span></font></div>
<fieldset><legend>References</legend>
<p>
<span style="color: rgb(33, 33, 33); font-family: BlinkMacSystemFont, -apple-system, "Segoe UI", Roboto, Oxygen, Ubuntu, Cantarell, "Fira Sans", "Droid Sans", "Helvetica Neue", sans-serif; font-size: 16px;">Baldovsky MD, Okada PJ. Pediatric stroke in the emergency department. J Am Coll Emerg Physicians Open. 2020 Oct 6;1(6):1578-1586. doi: 10.1002/emp2.12275. PMID: 33392566; PMCID: PMC7771757.</span></p>
</fieldset>