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Chapter 43: Pediatric Stroke

BACKGROUND AND EPIDEMIOLOGY

DIFFERENCES FROM STROKE IN ADULTS

  • Immature neuraxis

    • Causes subtle exam findings, leading to delay in diagnosis

      • Stroke must be considered in any patient with acute neurologic deficit

  • Risk factors for stroke are different compared to adults

    • Atherosclerosis is not common cause of stroke in children

    • There are no randomized, controlled therapeutic trials in children

  • Type of stroke: Arterial ischemic stroke (AIS), hemorrhagic stroke (HS), cerebral venous sinus thrombosis (CVST)

  • Prompt recognition: Allows for optimization of cerebral perfusion and can minimize secondary injury

EPIDEMIOLOGY

  • Pediatric stroke (age 30 days–18 years): annual average incidence of 1.6 to 13/100,0001,2

  • Arterial ischemic stroke (including CVST):

    • 50% to 70% of pediatric strokes

    • Comprises 15% of all ischemic strokes that occur in young adults and adolescents

    • Mortality after AIS ranges from 10% to 15% with 50% of survivors left with a neurologic deficit

    • Risk for recurrence ranges from 1% to 20%3

  • Hemorrhagic stroke:

    • 41% to 49% of pediatric strokes

    • Two to three times the incidence of adults

    • Median age is 5 to 10 years

    • Males are at slightly higher risk (55% to 60%)

    • Mortality is lower in children than adults. While survival is greater, morbidity among survivors is high

RISK FACTORS (TABLE 43-1)

CONSIDERATIONS

  • Many patients have multiple risk factors, whereas 10% to 38% have no risk factor identified2,4

  • Recurrent stroke increased if multiple risk factors identified5

  • Chromosomal mutations (trisomy 21), genetic syndromes (Sturge Weber), and single-gene disorders (sickle cell) may predispose to stroke

TABLE 43-1

Risk Factors Identified in Pediatric Stroke

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TABLE 43-1

Risk Factors Identified in Pediatric Stroke
Risk Factor % Patients Affected
Acute Ischemic Stroke
All arteriopathies 31–60
Moyamoya arteriopathy 4.6–22
Postvaricella arteriopathy 1.5–7
Nontraumatic dissection 1–20
SCD arteriopathy 8–17
CNS lupus arteriopathy 3.1
Nonspecific vasculitides 12
Cardiac etiology 2–27
Infection 2.9–40
Hypercoagulable condition 11.4–25.6
Prothrombotic state Undefined
Trauma 7.7–12
Malignancy 1–2.3
Mitochondrial 2.9–6.4
No identified risk factor 10–38
Cerebral Venous Sinus Thrombosis
Nonspecific infection 40
Chronic otitis media and orbital cellulitis 28
Prothrombotic state 14
Hematologic or metabolic disorder not otherwise specified 60
No factor identified 0–57
Hemorrhagic Stroke
Vascular abnormalities 48–67
Hematologic disorder 10
Bleeding into intracranial tumor 10
Cavernous venous malformation 6.4
Vertebral artery dissection 6.4
No risk factor identified 14–40

Data summarized from references.2,6,8 SCD: Sickle cell disease, CNS: central nervous system.

AIS

  • Arteriopathies: Identified in 31% to 60% of patients6

    • Nontraumatic dissections, vasculitis, moyamoya, postvaricella arteriopathy, primary vascular disorder, sickle cell disease, transient arteriopathies (recent viral infections)

    • Vasculopathy: Increases risk of stroke recurrence, especially in the first 6 months after stroke presentation7

  • Congenital heart disease8...

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