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  • In U.S. children, hemorrhagic strokes are more common than ischemic strokes, with a hemorrhagic incidence of 7.8/100 000 per year versus 2.9/100 000 per year for ischemic strokes.
  • Ischemic strokes are caused by vascular occlusion of an artery, usually because of thromboembolism (arterial ischemic stroke) or occlusion of venous sinuses or cerebral veins (sinovenous thrombosis).
  • A history of complex congenital heart disease, prosthetic heart valve, recent cardiac surgery, or ECMO should raise suspicion of an embolic phenomenon. Twenty-five percent of patients with sickle cell disease will develop cerebrovascular problems.
  • Magnetic resonance imaging (MRI) is more sensitive in detecting small infarcts, infarcts of the brain stem and cerebellum, and hemorrhagic conversion of infarcts than a CT scan.
  • A computed tomography (CT) scan will show a tumor and abscess, and may show loss of gray/white differentiation and dense triangle sign (hyperdense thrombus in posterior part of superior sagittal sinus), but may not detect an acute hemorrhage.
  • Magnetic resonance angiography can be done at the time of the MRI to visualize the flow through the cerebral arteries. MRI can also be used with magnetic resonance venography (MRV) to diagnose sinovenous thrombosis.
  • For patients in whom a hemorrhagic stroke is suspected and in whom the CT scan is negative, a lumbar puncture is indicated. Particularly with a small subarachnoid hemorrhage, the CT scan may not reveal blood.
  • The key function of the emergency department is stabilization of the patient's respiratory and cardiovascular status, especially the blood pressure. In the event of an ischemic infarct, a precipitous decline in blood pressure is avoided, since it can worsen cerebral ischemia, but if hypotension is present, careful fluid resuscitation and inotropic support may be needed.
  • Serum glucose should be monitored closely as hypoglycemia can worsen the effect of the stroke, and hyperglycemia can increase infarct size.
  • Specific therapy is directed at the etiology of the stroke, such as correction of clotting abnormalities, antibiotics for infections, antiepileptic medication for seizures, and surgery for evacuation of a hematoma. For patients with sickle cell disease, exchange transfusion is indicated for ischemic stroke.


Although they are uncommon in children when compared to adults, both ischemic and hemorrhagic strokes occur. In U.S. children, hemorrhagic strokes are more common than ischemic strokes, with an incidence of 7.8/100 000 per year for hemorrhagic events versus 2.9/100 000 per year for ischemic events.1 Ischemic strokes can be categorized as arterial ischemic strokes (AIS) and cerebral sinovenous thrombosis (CSVT). In the pediatric population, arterial ischemic stroke usually results from a thromboembolism. Occlusion of venous sinuses or cerebral veins can result in cerebral sinovenous thrombosis. The peak age of AIS is neonatal and childhood2, whereas the peak age of CSVT is neonatal and adolescence.3 This chapter will focus on the older age group.


The signs of AIS vary with age and the area of the brain affected by ischemia; they include focal neurologic findings such as hemiparesis, cranial nerve palsies, visual field deficits, and aphasia. Seizures may or ...

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