12 year old female with a history of Heterotaxy Syndrome and cardiac surgery presents to your ED with sudden onset of right arm and leg weakness. She has a history of being on Warfarin for a “clot” in her heart and her symptoms suddenly came on about 1 hour PTA in your ED. The weakness is still present on exam. You are concerned about a stroke… but children actually get strokes?
Pediatric Stroke
Some numbers. . .
- Incidence of combined Ischemic and hemorrhagic stroke ranges from 1.2-13/100,000 cases per year under age 18
- Incidence of ischemic Stroke in children 7.8/100,000
- Incidence of hemorrhagic stroke in children 2.9/100,000
- For pediatric patients, 40 % of stroke cases under 1 year of age
Because its so rare… physicians take a while to diagnose a stroke…
Pediatrics 2009 study showed median hours to diagnose a neonatal stroke >87 hours and non-neonate 25 hours!
Some more numbers. . .
About 45% of pediatric strokes are hemorrhagic!!! (much more than adults!)
Causes of Strokes:
Cardiac #1—make up 1/3 of all ischemic strokes in children (like our patient)
Sickle Cell
Prothombotic Disorders
Infections, ie Varicella- leads to basal infarcts
Vascular, ie Arteriovenous malformation (number 1 cause of hemorrhagic strokes after infancy)
Trauma
Drugs
Clinical Presentation
Similar to adults… check out the table below to see some reviews
Tsze DS, Valente JH. Pediatric Stroke: A Review. Emergency Medicine International. 2011; 1-10
To CT or not to CT
No published guidelines in the US. Below are some benefits of each
- CT Positives
- No sedation
- Easy to obtain and in most Emergency Departments
- Sensitive for hemorrhage
- CT Negatives
- Radiation
- Can miss ischemic strokes and other stroke mimics
- Will likely eventually need MRI
- MRI
- Positive:
- Can pick up stroke mimics
- Good for ischemia and hemorrhage in pediatric patients
- No radiation
- Negatives
- Not easy to obtain in certain institutions
- May require sedation
- Positive:
Royal College of Physicians: “Brain MRI should be undertaken as soon as possible after presentation. If brain MRI will not be available within 48 hour, CT is an acceptable initial alternative”
But. . .
Yock-Corrales A, Barnett P. The Role of Imaging Studies for Evaluation of Stroke in Children. Pediatric Emergency Care. 2011. CT is still considered modality of choice in ED to detect presence of hemorrhage and mass effectIf immediately available, MRI with DW has advantage over CT as venous and arterial pathology can usually be identified
Management
- Supportive Measures:
- Ensure patients are have good O2 sat, normoglycemic and normothermic. Monitor BPs and neurologic checks frequently. OxygenationFS, EKG, CBC, BMP with glucose, Coags, O2 sat, Echo of the heart + additional studies as needed
- Admit, neurology evaluation
- TPA?
- The Thrombolysis in Pediatric Stroke (TIPS) study (looking at TP use in children with strokes) was halted in 2013 due lack of recruitment
- No support in acute management of childhood stroke
Hope you enjoy! And look up Heterotaxy Syndrome- it’s REAL!
References:
Tsze DS, Valente JH. Pediatric Stroke: A Review. Emergency Medicine International. 2011; 1-10
Lynch JK, Hirtz DG, et Al. Report of the National Institute of Neurological Disorders and Stroke Workshop on Perinatal and Childhood Stroke. Pediatrics. 2002; 109: 116-123
Srinivasan J, Miller SP, et Al. Delayed Recognition of Initial Stroke in Children: Need for Increased Awareness. Pediatrics. 2009; 124: 227-234
Beslow LA, Jordan LC. Pediatric Stroke: The Importance of Cerebral Arteriopathy and Vascular Malformations. Childrens Nervous System. 2010. 26(10): 1263-1273
Pappachan J, Kirkham F. Cerebrovascular disease and stroke. Arch Dis child 2008; 93: 890-898
Shellhaas RA, Smith SE, et Al. Mimics of Childhood Stroke: Characteristics of a Prospective Cohort. Pediatrics. 2006; 118: 704-09
Stroke in childhood Clinical guidelines for diagnosis, management and rehabilitation. Paediatric Stroke Working Group November 2004. Royal College of Physicians London
Roach ES, Golomb MR, et Al. Management of Stroke in Infants and Children. Stroke. Journal of the American Heart Association. 2008;39:2644-2691
Yock-Corrales A, Barnett P. The Role of Imaging Studies for Evaluation of Stroke in Children. Pediatric Emergency Care. 2011; 27: 966-977
Singhal AB, Biller J, et Al. Recognition and Management of Stroke in young adults and adolescents. Neurology. 2013.
PEM Fellows
Latest posts by PEM Fellows (see all)
- When Orange is the New Black – “Blurry Eyes” - May 11, 2016
- A Pediatric Neurology Case. . . you will get one of these at some point! - April 14, 2016
- Think outside the box- It can be exotically toxic! – the Perspective of a Newbie Doctor - March 14, 2016
0 Comments