What is a stroke? A stroke is a condition in which blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients resulting in focal neurological deficit.
Types of Strokes
Ischemic Stroke: Is due to the blockage in the blood supply to the brain.
Hemorrhagic Stroke: occurs when the blood vessels in the brain leak or rupture.
Transient Ischemic Attack (TIA): AKA Mini stroke, occurs when the brain blood supply is interrupted for a very brief time. The symptoms usually last for a few minutes to hours and usually disappear within 24 hours.
Prevalence:
Pediatric stroke is a rare condition but it is still the sixth leading cause of death in children, affecting one in every 4,000 newborns (defined as age 0 to 28 days) and an additional 2,000 older children each year. Both types of strokes are equally common in children.
Risk factors:
Arteriovenous malformations (AVMs) is an abnormal tangling of blood vessels inside the brain which can easily get ruptured causing brain hemorrhage. 30 and 50 percent of hemorrhagic strokes are due to AVM
Cerebral Cavernous malformations is a collection of small blood vessels in the central nervous system that are enlarged and irregular in structure and account for 25 percent of hemorrhagic stroke in children.
Aneurysm is the ballooning of an artery due to weakness of the artery wall which may continue to weaken, ruptures and bleed into the brain.
Heart diseases including congenital and acquired heart diseases, patent foramen ovale (PFO), Atrial fibrillation (AF).
Hypercoagulable state
Blood disorders, like sickle cell disease (SCD)
Infections like bacterial meningitis , encephalitis and brain abscess.
Moya Moya disease which is very common in Japan. Here brain arteries narrow down to cause strokes.
Head and neck Trauma
Genetic and metabolic
Perinatal stroke is a disease where an infant has a stroke between the 140th day of the gestation period and the 28thpostpartum day. Within perinatal stroke, mode of presentation distinguishes 2 varieties.
1-Acute perinatal stroke occurs in newborn infants at or near birth and typically presents shortly after onset with focal seizures or encephalopathy.
2-Presumed perinatal stroke refers to chronic infarcts, diagnosed in later infancy, that are presumed to have occurred in the perinatal period, typically with recognition of congenital hemiparesis (usually diagnosed as out-patient).
Childhood stroke:
There are 3 types of stroke in children between 28 days to 18 year.
Arterial ischemic stroke(AIS) occurs when the blood vessels of the brain are partly or completely blocked.
The majority of infants who were later diagnosed with presumed perinatal stroke were free of symptoms and do not have any significance in neurological examination during the neonatal period. The diagnosis is usually in later infancy, typically with recognition of congenital hemiparesis.
Cerebral sinovenous ischemic stroke(CSVT) is a disease in the cerebral venous system caused by thrombosis. Thrombosis in this region will hinder outflow from the venous system, causing a surge in the central venous pressure. This will lead to intracranial hypertension, cerebral ischemia or wide spreading hemorrhage which may result in a permanent neurologic deficit or mortality.
Hemorrhagic stroke is due to bleeding in the brain that leads to brain injury. Arteries and other small blood vessels create pathways throughout the brain that bring blood from the heart. If these arteries or blood vessels weaken and burst, they can cause a hemorrhagic stroke.
Symptoms of stroke:
Symptoms of stroke in children depend on the age of the child and the cause of the stroke.
In newborns you might see:
Seizures
Extreme sleepiness or altered mental status
A tendency to use only one side of their body
In children and teenagers the most common signs and symptoms of stroke include the sudden appearance of:
Weakness or numbness of the face, arm or leg, usually on one side of the body
Trouble walking due to weakness or trouble moving one side of the body, or due to loss of coordination
Problems speaking or understanding language, including slurred speech, trouble trying to speak, inability to speak at all, or difficulty in understanding simple directions
Severe headache especially with vomiting and sleepiness
Trouble seeing clearly in one or both eyes
Severe dizziness or loss of coordination that may lead to losing balance or falling
New appearance of seizures, especially if affecting one side of the body and followed by paralysis on the side of the seizure activity
Combination of progressively worsening non-stop headache, drowsiness and repetitive vomiting, lasting days without relief
Diagnosis of stroke:
Neuro imaging techniques such as Diffusion-weighted magnetic resonance imaging (DW-MRI) is effective for early diagnosis of perinatal stroke.
Magnetic resonance angiography (MRA) may also be done as part of the MRI.
Computed Tomography (CT) scans are a good option if MRI is not available.
Transcranial doppler (TCD) or ultrasound of the brain may be done to look for abnormalities of brain blood vessels.
Electroencephalogram or EEG. This is done to look for seizures.
Electrocardiogram or ECG to check for irregular heartbeat
Echocardiogram to look for possible causes of embolism and thrombus.
Lumbar puncture is done to check the CSF (fluid surrounding the brain and spinal cord) for blood or signs of infection.
Blood is tested for signs of infection, sickle cell disease, inflammation of blood vessels, and blood clotting abnormalities.
Treatment of Stroke:
Neuro protection: The main target of treatment of pediatric stroke is the protection of the developing brain by minimizing acute brain injury, preventing neurodevelopmental impairment and disability. For instance:
correcting dehydration
maintaining normal blood sugars
avoiding increased body temperatures
treating infections
recognizing and treating seizures
maintaining good blood pressure (this optimizes blood flow to the brain)
Other early management methods vary based on the type and cause of stroke.
Antibiotics. Strokes related to infection usually require antibiotics.
Corticosteroids. Strokes related to inflammation may be treated with steroids.
Blood transfusion Strokes related to sickle cell disease may require blood transfusion.
Blood thinners help prevent the growth or development of new blood clots. The two primary blood thinner types prescribed after a childhood stroke are:
those that affect the coagulation system (such as heparin)
those that affect the platelets (such as aspirin)
Surgeries The type of surgery needed depends on the cause of the stroke.
Direct and indirect bypass surgery for Moyamoya syndrome and major arterial occlusion
Endovascular thrombectomy for venous sinus thrombosis
Craniotomy for evacuation of a hemorrhage, arteriovenous malformation resection, or aneurysm clipping
Endovascular aneurysm coiling.
Rehabilitation for children following stroke can likely lead to vast improvements in long-term outcomes, with a favorable impact in long-term morbidity, quality of life and emotional health for the child and the family . A multidisciplinary team should be involved in pediatric stroke rehabilitation such as clinicians with expertise in developmental pediatrics and pediatric stroke rehabilitation, including physicians (such as physiatrists and specialized pediatricians), occupational therapists, physical therapists, speech language pathologists, nurses, social workers, psychologists, and dietitians. Overall, a child’s growing brain has a better chance of recovering from stroke than an adult’s brain.