Guidelines Highlight Key Differences Between Child And Adult Stroke

The “Management of Stroke in Children” statement provides healthcare professionals with evidence-based guidelines for prevention, evaluation and treatment.

“Children and adolescents with stroke have remarkable differences in presentation compared with adults,” said E. Steve Roach, M.D., chair of the statement writing group and professor of pediatric neurology at the Ohio State University College of Medicine. “In newborns, the first symptoms of stroke are often seizures that involve only one arm or one leg. That symptom is so common that stroke is thought to account for about 10 percent of seizures in full-term newborns. Seizure is a much less common stroke symptom in adults.”

Roach emphasized, however, that while stroke symptoms may differ between children and adults, speedy diagnosis and treatment are still very important to minimize the risk for brain damage, disability and death. In addition to prompt treatment, age-appropriate rehabilitation and therapy is indicated for children after a stroke.

A major treatment difference between adult and child stroke is the use of the drug tissue plasminogen activator (t-PA). The clot-busting agent is the cornerstone of treating adult ischemic stroke but, in the new statement it’s not generally recommended for treating young children, especially newborns, outside of a clinical trial until additional safety and efficacy data are published. In general, the statement recommends that if any treatable risk factor is discovered in a child who has had a stroke, the condition should be treated.

“Stroke in children is uncommon but not as rare as we used to think,” said Roach, who is also chief of neurology at Nationwide Children’s Hospital in Columbus, Ohio. “Even as recently as 20 years ago, stroke was an unlikely diagnosis in a child because it was so strongly associated with adults with atherosclerosis.” The risk of stroke from birth through 18 years is 10.7 per 100,000 children per year.

He added that improvements in diagnostic techniques such as magnetic resonance imaging (MRI) and vascular ultrasound have made it possible to confirm that a stroke has occurred when it was only suspected before. Research has also helped to better define treatment protocols. Because of these advances, experts now believe that a significant number of cerebral palsy cases may be due to strokes before or right after birth.

The most common underlying risk factors for childhood stroke are sickle cell disease and congenital or acquired heart disease. However, the list of associated conditions include:

• head and neck infections;
• systemic conditions such as inflammatory bowel disease and autoimmune disorders;
• head trauma; and
• dehydration.

Suspected maternal risk factors for infant stroke include a history of infertility, chorioamnionitis (infection in the fluid surrounding an unborn baby), premature rupture of membranes, and preeclampsia (pregnancy-related high blood pressure).

According to the statement, more than half of children who have a stroke have a known risk factor, and one or more risk factors are often discovered in others after a thorough evaluation. The risk of stroke in children is greatest in the first year of life, particularly in the first two months. It decreases after that. Data from the statement shows that stroke in the first month of life (neonatal stroke) occurs in about one of every 4,000 live births. Stroke also can occur before birth.

In adults, stroke risk factors are much different, and include high blood pressure, cigarette smoking, age (over 55), artery disease, diabetes, and atrial fibrillation. Sickle cell disease is a risk factor common to both children and adults.

Prevention efforts are different for children as well. For adults, prevention often means adopting behaviors or medication to prevent a first stroke. Prevention in children is focused on reducing the likelihood of second or additional strokes.

“Primary prevention – stopping the first stroke from occurring – is sometimes possible in children when we know of an underlying risk factor such as a heart problem or sickle cell disease. Aside from those conditions, an initial stroke is difficult to prevent because the stroke is often the first sign of a problem,” Roach said. “That’s why it’s critical to promptly recognize and diagnose a stroke, because treating the cause reduces the likelihood of additional strokes.”

Recommendations for preventing a second or subsequent stroke in children include:

• Children with ischemic stroke who also have migraines may be evaluated for other stroke risks. Common migraine isn’t likely linked to stroke, but migraine with aura seems to increase risk.
• It is reasonable to counsel children with stroke and their families about the benefits of a healthy diet, exercise and avoiding tobacco products.
• It is reasonable to suggest an alternative to oral contraceptives after a stroke or cerebral venous sinus thrombosis (CVST).
• Children with brain hemorrhage not caused by trauma should undergo a thorough risk factor evaluation, including standard cerebral angiography when noninvasive tests have failed to establish a cause to identify treatable risk factors before another hemorrhage occurs.

The incidence of the two main types of stroke (ischemic and hemorrhagic) is different in adults and children. According to the statement, 80–85 percent of adult strokes in Western countries are ischemic (caused by a blood clot). In contrast, in children about 55 percent of strokes are ischemic and the other 45 percent are hemorrhagic (bleeding in the brain).

The writing committee said the new guidelines will need to be updated as new information and technology becomes available. It urged continued research to better understand the unique diagnosis and treatment of stroke in children.

Co-writers are Meredith R. Golomb, M.D., M.Sc.; Robert Adams, M.D., M.S.; Jose Biller, M.D.; Stephen Daniels, M.D., Ph.D.; Gabrielle deVeber, M.D., MSc; Donna Ferriero, M.D.; Blaise V. Jones, M.D.; Fenella J. Kirkham, M.B., M.D.; R. Michael Scott, M.D.; and Edward R. Smith, M.D. Author disclosures are available on the manuscript.