Top Things to Know: Management of Stroke in Neonates and Children
Published: January 28, 2019
- Annualized pediatric stroke incidence rates, including both neonatal and later childhood stroke and both ischemic hemorrhagic stroke range from 3 -25 per 100,000 children in developed countries. Newborns have the highest risk ratio: 1 in 4,000 live births.
- The standard adult definition of stroke—an acute onset of neurological signs or symptoms attributable to focal brain infarction or hemorrhage—applies to children as reflected by the National Institutes of Health’s (NIH) Common Data Elements definition.
- Pediatric stroke can be characterized by age: Stroke occurring from 28 weeks’ gestation to 28 postnatal days of life is broadly classified as perinatal stroke, and stroke occurring after 28 postnatal days to 18 years of age is classified as childhood stroke.
- Much of adult stroke is related to the traditional risk factors for atherosclerosis, including hypertension, dyslipidemia, obesity, diabetes mellitus, and cigarette smoking. Newer risk factors, including insulin resistance and inflammation, are also important. Atherosclerosis is generally not a cause of stroke in children and adolescence, although it is now clear that the atherosclerotic process that leads to a stroke in adulthood may begin in childhood and that dyslipidemia tends to be more prevalent among children with ischemic stroke than in other children.
- Children and adolescents with stroke may be at particularly increased risk for recurrent strokes in later life related to these processes. This emphasizes the importance of promoting ideal vascular health through good diet, physical activity, and avoidance of tobacco products to protect them from recurrent strokes in adulthood.
- In childhood stroke, the most common symptoms include: hemiparesis and hemi-facial weakness, speech or language disturbances, visual disturbances and ataxia. Children can also present with non-localizing symptoms such as: headache and altered mental status. Seizures at stroke onset are more common in children than in adults.
- This scientific statement discusses perinatal stroke including acute ischemic stroke in neonates. Presentation, risk factors, evaluation, management, rehabilitation and outcomes in the perinatal period are addressed in this paper. Cerebral sinovenous thrombosis (CVST) in neonates is also addressed.
- Identifying stroke in children can be challenging with delays in presentation to medical care and the challenge of “stroke mimics”. The median time from stroke onset to the parent seeking medical attention varies from 1.7 – 21 hours, with the majority usually presenting within 6 hours.
- For the majority of children presenting to the emergency department with an acute neurologic syndrome or “Brain Attack” the most common conditions seen as a stroke mimic are: migraine with aura, Bell’s palsy and seizure with a Todd’s paresis. Other stroke mimics include: brain tumor, demyelinating disease, cerebellitis, encephalitis, epidural abscess, traumatic brain injury, syncope, intoxication, metabolic disease and psychogenic disorders.
- This comprehensive statement provides updates on perinatal and childhood stroke, especially with regards to areas of childhood stroke that have not received close attention such as sickle cell disease (SCD). Acute ischemic stroke is addressed in a comprehensive way in this statement including hyperacute stroke therapies such as the use of thrombolytics and interventional/endovascular treatments in this young group. Each section addressed in this statement provides considerations for clinical practice, current controversies and knowledge gaps.
Citation
Ferriero DM, Fullerton HJ, Bernard TJ, Billinghurst L, Daniels SR, DeBaun MR, deVeber G, Ichord RN, Jordan LC, Massicotte P, Meldau J, Roach ES, Smith ER, on behalf of the American Heart Association Stroke Council and Council on Cardiovascular and Stroke Nursing. Management of stroke in neonates and children: a scientific statement from the American Heart Association/American Stroke Association [published online ahead of print January 28, 2019]. Stroke. doi: 10.1161/STR.0000000000000183.