2. Agenda
Introduction
Pediatric Stroke Risk Factors
Imaging In Acute Ischemic Stroke.
Hyperacute Treatment For Pediatric Stroke
Early Management .
Secondary Stroke Prevention, Outcomes, And Recovery.
Perinatal Stroke
3. 13 years old girl, aphasia , right side weakness
present to ER one hour from the onset ,
recentaly she had upper respiratory infection
MRI and MRA done (apatchy left basal ganglia infarction irregular
left middle cerebral artery without dissection.
Your approach?
Case 1
5. Case 2
12 years boy, right handed, exercise intolerance due
to complex congenital heart disease, was admitted for
a cardiac catheterization
12 hours post procedure he appeared confused and
had not recovered from the procedure and anesthesia
as expected.
7. Introduction
stroke is uncommon in children but can be a major cause of childhood mortality and morbidity
when it occurs
result in long-term neurologic sequelae and disabilities over many years
costly care
The burden on mental and emotional health is often high for children and caregivers
a stroke that occurs in children after the first 28 days of life is considered a childhood stroke.
A stroke that occurs during the first 28 days of life is considered a perinatal stroke (1/3000 live
full-term births)
8. presumed perinatal stroke: when imaging demonstrates a
chronic infarct in an older child who begins to show focal
deficits during development.
Childhood and perinatal strokes are categorized as distinct
entities they differ in (management, workup, risk factors,
and secondary stroke prevention)
9. How pediatric ischmic stroke differ from
adult ischmic stroke
stuttering rather than an abrupt symptom onset
Headache
acute symptomatic seizure (1/3 of patients more at younger ages)
initially attributed to a stroke mimic(seizure, migraine, functional neurologic
deficit, infection, demyelinating disease, methotrexate toxicity, or posterior
reversible encephalopathy syndrome -PRES)
Challenges in young patient (determining time of stroke onset-assessing
neurologic deficit-posterior circulation strokes-initial stroke in healthy child )
10. PEDIATRIC STROKE RISK FACTORS
Multifactorial rather than related to a single etiology,
Overlapping genetic predisposition and acquired risk factors.
11. Young SCD patients with a PFO are more susceptible to developing RLS
and PE, further increasing their susceptibility to stroke
12. Complex Cardiac Disease
Congenital heart disease or acquired heart disease are major risk factors
for perinatal or childhood stroke, together accounting for almost one-
third of arterial ischemic strokes in children.
Atrial or ventricular dilation and dysfunction, right to left shunting, or
alteration in blood flow patterns that increase risk for embolic disease
Disruptions in the balance of hemostasis, alteration in blood composition,
or loss of endothelial integrity may result in thrombosis, bleeding, or
both.
13. Many cardioembolic strokes in children occur in perioperative phase
for correction of cardic defects (Barriers to early diagnosis are common,
including sedating or paralytic medications in critically ill children,
emergence from anesthesia after a procedure)
14. Patent foramin ovale
children with otherwise cryptogenic stroke may benefit from PFO closure for
secondary stroke prevention.
The Risk of Paradoxical Embolism (RoPE) score is used to select adult
patients.
In the presence of other pediatric stroke risk factors, a paradoxical embolism
through a PFO is less likely to be the causative etiology
When a PFO is identified during a childhood stroke assessment, venous
ultrasound of the extremities and laboratory testing for thrombophilia risk
factors should be performed
15. Clinical features that suggest stroke is due to a paradoxical embolus include
1)Echocardiogram demonstrating a large PFO
2) PFO with aneurysm
3)Significant right-to-left shunting,
4)Stroke onset after a Valsalva maneuver,
5)An identified deep venous thrombosis.
16. 1)AHA consensus statement does not provide a recommendation for PFO closure in preventing
recurrent stroke in children due to insufficient evidence. For healthy children with an incidental
discovery of isolated PFO, no further treatment or follow-up is advised as there is currently no evidence
of future complications associated with isolated PFO in children
2)PFO is more prevalent in children with migraine with aura. However, there is still a lack of
evidence from RCTs to support medical treatment or PFO closure in children with migraines
3)an observational study in children with migraine with aura did observe symptomatic
improvement after PFO closure
17. Arteriopathy
Cerebral arteriopathy is present in at least half of all children with
ischemic stroke and is a risk factor for initial stroke and stroke
recurrence.
The most common cause of ischemic stroke in a previously healthy
child is a cervicocephalic dissection or a presumed inflammatory
intracranial focal cerebral arteriopathy.
20. Inflammatory arteriopathy
The definitive etiology of inflammatory type focal cerebral arteriopathy(FCA)
remains unknown( varicella zoster-SARS-CoV-2)
Distal carotid terminus, proximal middle cerebral artery, proximal anterior
cerebral artery, lenticulostriates, or a combination of these.
The natural history is monophasic(progression of the stenosis in the first
days to weeks)
25% risk of recurrence due to (progressive lenticulostriate involvement,
artery-to-artery emboli, or flow-related ischemia)
23. The FOCAS (Focal Cerebral
Arteriopathy Steroid)50
comparative effectiveness study of
early versus late corticosteroid
started in USA 2023
24. Cervicocephalic arterial dissection
accounts for approximately 10% of childhood arterial ischemic stroke and
half of posterior circulation childhood arterial ischemic stroke
spontaneously or following trauma.
collagenopathies or elastinopathies such as Ehlers-Danlos syndrome,
Marfan syndrome, Loeys-Dietz syndrome, and arterial tortuosity
syndrome
28. Moyamoya disease
a progressive steno-occlusive arteriopathy, may be the
most prevalent risk factor for childhood stroke in Asian
countries
Adults experience hemorrhage more commonly;
cerebral ischemic events are more common in children
Watershed infarcts are also very commonly identified
29. Cerebral angiography is the criterion standard for the diagnosis of moyamoya
disease. The following findings support the diagnosis:
1. Stenosis or occlusion at the terminal portion of the internal carotid artery or the
proximal portion of the anterior or middle cerebral arteries
2. Abnormal vascular networks in the vicinity of the occlusive or stenotic areas
3. Bilaterality of the described findings (although some patients may present with
unilateral involvement and then progress)
32. Studies(not randomized) have suggested that revascularization
surgery is superior to medical management alone to decrease risk of
ischemic injury
33. Sickle Cell Disease
Without intervention, about 10% of people with sickle cell
disease will sustain an ischemic stroke during childhood.
About 20% of children with sickle cell disease who have had a
stroke go on to have a recurrent stroke, even if chronic red
blood cell transfusion is started.
Sickle cell disease can lead to a moyamoya-like syndrome,
with progressive steno-occlusive arteriopathy and collateral
formation
35. STOP (Stroke Prevention Trial in Sickle Cell Anemia) The Stroke Prevention Trial in Sickle Cell Anemia
(STOP) was a randomized trial to evaluate whether chronic transfusion could prevent initial stroke
in children with sickle-cell anemia at high risk as determined by transcranial Doppler (TCD)
36. TWiTCH (TCD With Transfusions Changing to Hydroxyurea) trial found that children without severe arteriopathy
whose TCDs had normalized after a period of transfusion therapy could safely transition to hydroxyurea
37. American Society of Hematologys
recommended algorithm for
management of acute ischemic
stroke in sca patient
IV fluids
38. A transfusion should be performed for
all children with sickle cell disease who
present with focal neurologic symptoms,
even if symptoms are resolving or have
resolved
39. Exhange transfusion vs Simple
transfusion
Exchange transfusion is preferred when it can be done
quickly, but a simple transfusion is acceptable if exchange
transfusion cannot be provided quickly.
40. Infectious disorder
activation of the coagulation cascade, thrombosis from a systemic inflammatory
response, septic emboli, and direct invasion of the endothelium
37% of children with bacterial meningitis
one study in South Africa 71% of patient with TB meningitis
Focal cerebral arteriopathy
SARS-CoV2 virus
41. Imaging in acute ischemic stroke
Brain MRI with magnetic resonance angiography (MRA) is the optimal study for diagnosis of
acute childhood arterial ischemic stroke because it readily differentiates an ischemic infarct from
more common childhood stroke mimics.
Head CT with CT angiography is a reasonable alternative because it is more readily available and
may be easier to obtain quickly. Head CT and CT angiography may also be the preferred initial
study in children with known heart disease to avoid imaging delays while assessing whether
cardiac hardware is present and magnetic resonanceconditional
42. Vascular imaging is crucial to identify a large vessel occlusion or an arteriopathy that
influences management
In cases with moyamoya, DSA is typically performed to delineate anatomy before surgery.
When sedation is required for neuroimaging, blood pressure should be maintained to optimize
brain perfusion, particularly in the setting of arteriopathy or dependency on collateral
circulation
44. Hyperacute Treatment For Pediatric
Stroke
Although guidelines support consideration of IV thrombolysis or
thrombectomy in children in specific circumstances on a case-
by-case basis, these treatments are not considered a
requirement. using weight-based dosing similar to that in adults.
Hyperacute treatment decisions should be made in conjunction
with neurologists with expertise in the treatment of children
with stroke.
the estimated risk of symptomatic intracranial hemorrhage after
thrombolysis is low
45. Cerebral arteries do not approximate adult size until
around the age of 5 years, so the size and age of a child
should be considered for device selection.
In systems of care without availability of providers
experienced in pediatric stroke treatment, the priority
should instead be stabilization and transfer to the
appropriate centers.
46. Children have an increased tendency to form early
collaterals, so the selection criteria for children likely to
benefit from mechanical thrombectomy during this
extended time window are especially uncertain.
If durable collateral circulation is already well established,
recanalization may not improve outcomes.
47. The Pediatric National Institutes of
Health Stroke Scale (PedNIHSS)
Pediatric NIH Stroke Scale (NIHSS) (mdcalc.com)
A modification of the adult scale
Use in children aged 2 years and older
48. International muti center cohort study
Stopped due to failure in enrollment
54% of patient was stroke mimics
49. provide considerations in which it may be reasonable or appropriate to consider
hyperacute reperfusion treatment in children based on evidence extrapolated
from adults
50. In the absence of pediatric clinical trial data to guide treatment
decisions, hyperacute therapies for childhood AIS remain
controversial ?.
It would be reasonable to limit consideration of this intervention to
children meeting these criteria:
Persistent disabling neurological deficits (eg, Pediatric NIH Stroke Scale
score 6 at the time of intervention or higher)
Radiographically confirmed cerebral large artery occlusion
Larger children.
51. Treatment decision made in conjunction with neurologists with
expertise in the treatment of children with stroke
Intervention performed by an endovascular surgeon with
experience in both treating children and performing thrombectomy
in adult stroke patients
52. The findings of this cohort study suggest that use of
EVT and/or IVT is safe in children with AIS.
53. This cross-sectional evaluation of the clinical course and short-term
outcomes of pediatric patients with ischemic stroke treated with EVT
demonstrates that EVT is likely a safe modality which confers high rates
of favorable functional outcomes.
54. Adjunctive IVT may not provide benefit to MT in patients with AIS
caused by distal and medium vessel occlusion.
55. Early Management
The goals of acute care
1. Limiting injury by rescuing penumbra
2. Preventing stroke extension or early recurrence
3. Treating complications
56. Because of the prevalence of arteriopathies in childhood stroke with subsequent
cerebrovascular narrowing or loss of normal hemodynamic compensatory mechanisms,
collateral cerebral flow should be supported by initial fluid resuscitation if needed ,keeping the
head of bed flat, instituting bed rest, and avoiding hypotension.
57. In Hypertensive crisis ,blood pressure should be lowered cautiously top prevent stroke
extension
Electroencephalography monitoring maybe needed to detect subclinical seizures.
Mechanical deep vein thrombosis prevention or anticoagulation)may be indicated in older
children
58. Early assessment of progressive intracranial hypertension and need for urgent decompressive
hemicraniectomy maybe lifesaving in children with malignant middle cerebral artery infarction
or large cerebellar infarcts.
59. Workup for Acute Childhood Stroke
Urgent labs: complete blood count with differential,
screening coagulation laboratory tests, and a metabolic panel
with renal function.
The traditional cardiovascular risk factors of diabetes,
hypertension, and hyperlipidemia are less frequently a
concern in children than in adults, but screening laboratory
tests could be considered in older teens or when strongly
suggested by family history.
60. An echocardiogram should be obtained urgently to evaluate for possible cardiac thrombus or
vegetation and should include a bubble study or color flow Doppler study to evaluate for a right-to-
left shunt
When a right-to-left shunt is identified, venous Doppler of the extremities should then be
performed to evaluate for venous thrombosis.
61. Although arrhythmias are less common in children than in adults, a screening
electrocardiogram is recommended
62. Secondary Stroke Prevention, Outcomes,
And Recovery
In children with ischemic stroke who do not have sickle cell disease or cardioembolic stroke -
aspirin (1 mg/kg/dose to 5 mg/kg/dose orally once daily)
The optimal duration of aspirin use following childhood stroke is not known, but guidelines
recommend a minimum of 2 years. and it is sometimes used indefinitely.
In children with presumed cardioembolic stroke and significant thrombophilic states -
Anticoagulation
cervical artery dissection the choise of anticoagulation or antiplatelets is controversial.
63. prevention
This prospective multicenter follow-up study has provided evidence that low-
dose LMWH is not superior to aspirin and vice versa in preventing recurrent
stroke in white pediatric stroke patients. However, further adequately sized
randomized trials are required to obtain reliable information on safety and
efficacy with respect to the antithrombotic medications used.
64. Perinatal Stroke
Risk factors (chorioamnionitis or other systemic or central nervous system infections, inherited
thrombophilia, and complex congenital heart disease
Presentation:
Usually late in infancy period with( focal motor fits, encephalopathy)
In newborn period(early handedness or fail to meet developmental milestones)
Acute treatment ( treatment of infection or dehydration, optimization of oxygenation, and cerebral
perfusion with normalization of systemic blood pressure)
Neonatal seizures due to a stroke may require multiple loads of antiseizure medicines to end status
epilepticus.
66. Case 1
She was diagnosed with an inflammatory focal cerebral arteriopathy. She was treated with a
course of corticosteroids and a daily aspirin .After her acute stay ,she completed 2months of
inpatient rehabilitation. Duringth at time,her speech recovered ,and she regained power in her
right arm and leg. Two years following the stroke, she was able to run and was back to playing
sports despite mild residual weakness of her right arm
67. Case 2
Neurologist agreed to proceed with thrombectomy. The procedure wassuccessful, with
recanalization and complete reperfusion of all distal branches. She recovered slowly during
several monthsof inpatient pediatric rehabilitation.
