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Trauma to the Nervous System

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Stroke in Neonates and Children

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INTRODUCTION

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Stroke in the pediatric population is a rare yet devastating occurrence. Ischemic and hemorrhagic strokes result in the loss of neurologic function of the corresponding injured regions of the brain. It is a common cause of neonatal seizures and cerebral palsy, and stroke often leads to permanent cognitive and motor deficits. Stroke is often underrecognized in children, particularly during the acute period. Prompt recognition and treatment may potentially reduce morbidity and mortality rates. Research on this disease in areas of treatment and management is necessary to improve outcomes in children afflicted with stroke. This chapter reviews the clinical manifestations of stroke in neonates and children, and it describes diagnostic and therapeutic interventions to aid in establishing the etiology of stroke and to potentially decrease the risk of morbidity and risk of stroke recurrence.

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PATHOGENESIS AND EPIDEMIOLOGY

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Stroke is classified broadly into 2 types: ischemic and hemorrhagic stroke. Ischemic stroke occurs when a thrombotic or embolic occlusion creates loss of perfusion to an area of the central nervous system. Bleeding occurring directly into brain parenchyma is classified as hemorrhagic stroke. Ischemic stroke occurs more commonly than does hemorrhagic stroke.

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In pediatric patients, strokes are additionally classified based on age. Perinatal strokes, sometimes referred to as neonatal strokes, occur in infants up to 28 days of age. In older infants and children up to age 18 years, this disease is referred to as childhood stroke. This distinction is important because risk factors, treatments, and outcomes are different in these 2 groups of pediatric patients.

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The incidence of stroke in childhood ranges from 2 to 13 per 100,000 children per year. For unclear reasons, childhood arterial ischemic stroke is more common in boys than girls. In neonates, the occurrence of stroke is greater than that of childhood stroke and occurs in approximately 1 in 4000 births. Neonatal nontraumatic hemorrhagic stroke has an estimated incidence of 1.1 per 1000 live births.

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Despite its rarity, stroke has a large impact on society and on the affected children, as a serious cause of death and disability. Persistent neurologic deficits are reported in as many as 70% of children with stroke. Cerebral palsy as a consequence of perinatal stroke is reported in as many as 88% of these infants. In children with perinatal stroke, the incidence of epilepsy has been reported in as many as 46%. Epileptic encephalopathies such as infantile spasms are reported after perinatal stroke, and some children develop intractable epilepsy. Mortality rates associated with childhood stroke are reported to be between 20% and 40%. Stroke recurrence in childhood stroke is reported to be up to 15%, further increasing the risk of mortality in this group. The highest risk group includes children with underlying congenital heart disease or coagulopathies. While ...

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