UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Ischemic stroke in children: Evaluation, initial management, and prognosis

Authors
Sabrina E Smith, MD, PhD
Christine Fox, MD, MAS
Section Editors
Scott E Kasner, MD
Douglas R Nordli, Jr, MD
Deputy Editor
John F Dashe, MD, PhD

INTRODUCTION

While more common in older adults, stroke also occurs in neonates, infants, children, and young adults, resulting in significant morbidity and mortality.

An overview of the evaluation, initial management, and prognosis of arterial ischemic stroke in children one month of age or older is provided here. Other aspects of ischemic stroke in children and young adults are reviewed elsewhere. (See "Ischemic stroke in children and young adults: Etiology and clinical features" and "Ischemic stroke in children: Secondary prevention" and "Stroke in the newborn" and "Etiology, clinical features, and diagnosis of cerebral venous thrombosis".)

EVALUATION

Urgent evaluation and neuroimaging is important for confirming the diagnosis of acute arterial ischemic stroke (algorithm 1) because there are numerous conditions that can mimic ischemic stroke, particularly with regard to children [1].

Because the causes of stroke in children and young adults are varied, and because the presence of multiple risk factors for stroke increases recurrence risk [2], clinicians should conduct a thorough investigation for possible cardiac, vascular, and hematologic risk factors in all patients.

Stroke in children is a multifactorial disease, so the full diagnostic evaluation should be completed even if one risk factor is identified. In support of this, a case-control study of 38 children with underlying cardiac disease and ischemic stroke found more than one hemostatic abnormality consistent with a prothrombotic state in 10.5 percent of cases and in none of the 100 age-matched controls [3].

               

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Fri Jul 15 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Shellhaas RA, Smith SE, O'Tool E, et al. Mimics of childhood stroke: characteristics of a prospective cohort. Pediatrics 2006; 118:704.
  2. Lanthier S, Carmant L, David M, et al. Stroke in children: the coexistence of multiple risk factors predicts poor outcome. Neurology 2000; 54:371.
  3. Sträter R, Vielhaber H, Kassenböhmer R, et al. Genetic risk factors of thrombophilia in ischaemic childhood stroke of cardiac origin. A prospective ESPED survey. Eur J Pediatr 1999; 158 Suppl 3:S122.
  4. Paediatric Stroke Working Group. Stroke in childhood: Clinical guidelines for diagnosis, management and rehabilitation. November 2004. www.rcplondon.ac.uk/pubs/books/childstroke/ (Accessed on January 14, 2011).
  5. Elbers J, Wainwright MS, Amlie-Lefond C. The Pediatric Stroke Code: Early Management of the Child with Stroke. J Pediatr 2015; 167:19.
  6. Mallick AA, Ganesan V, Kirkham FJ, et al. Diagnostic delays in paediatric stroke. J Neurol Neurosurg Psychiatry 2015; 86:917.
  7. Bernard TJ, Friedman NR, Stence NV, et al. Preparing for a "Pediatric Stroke Alert". Pediatr Neurol 2016; 56:18.
  8. Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44:870.
  9. Hemphill JC 3rd, Greenberg SM, Anderson CS, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015; 46:2032.
  10. Roach ES, Golomb MR, Adams R, et al. Management of stroke in infants and children: a scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke 2008; 39:2644.
  11. Monagle P, Chan AK, Goldenberg NA, et al. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e737S.
  12. Thirumalai SS, Shubin RA. Successful treatment for stroke in a child using recombinant tissue plasminogen activator. J Child Neurol 2000; 15:558.
  13. Gruber A, Nasel C, Lang W, et al. Intra-arterial thrombolysis for the treatment of perioperative childhood cardioembolic stroke. Neurology 2000; 54:1684.
  14. Carlson MD, Leber S, Deveikis J, Silverstein FS. Successful use of rt-PA in pediatric stroke. Neurology 2001; 57:157.
  15. Kirton A, Wong JH, Mah J, et al. Successful endovascular therapy for acute basilar thrombosis in an adolescent. Pediatrics 2003; 112:e248.
  16. Ortiz GA, Koch S, Wallace DM, Lopez-Alberola R. Successful intravenous thrombolysis for acute stroke in a child. J Child Neurol 2007; 22:749.
  17. Tan M, Armstrong D, Birken C, et al. Bacterial endocarditis in a child presenting with acute arterial ischemic stroke: should thrombolytic therapy be absolutely contraindicated? Dev Med Child Neurol 2009; 51:151.
  18. Janmaat M, Gravendeel JP, Uyttenboogaart M, et al. Local intra-arterial thrombolysis in a 4-year-old male with vertebrobasilar artery thrombosis. Dev Med Child Neurol 2009; 51:155.
  19. Arnold M, Steinlin M, Baumann A, et al. Thrombolysis in childhood stroke: report of 2 cases and review of the literature. Stroke 2009; 40:801.
  20. Alshekhlee A, Geller T, Mehta S, et al. Thrombolysis for children with acute ischemic stroke: a perspective from the kids' inpatient database. Pediatr Neurol 2013; 49:313.
  21. Nasr DM, Biller J, Rabinstein AA. Use and in-hospital outcomes of recombinant tissue plasminogen activator in pediatric arterial ischemic stroke patients. Pediatr Neurol 2014; 51:624.
  22. Amlie-Lefond C, deVeber G, Chan AK, et al. Use of alteplase in childhood arterial ischaemic stroke: a multicentre, observational, cohort study. Lancet Neurol 2009; 8:530.
  23. Demaerschalk BM, Kleindorfer DO, Adeoye OM, et al. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2016; 47:581.
  24. Powers WJ, Derdeyn CP, Biller J, et al. 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015; 46:3020.
  25. Rivkin MJ, Bernard TJ, Dowling MM, Amlie-Lefond C. Guidelines for Urgent Management of Stroke in Children. Pediatr Neurol 2016; 56:8.
  26. Amlie-Lefond C, Chan AK, Kirton A, et al. Thrombolysis in acute childhood stroke: design and challenges of the thrombolysis in pediatric stroke clinical trial. Neuroepidemiology 2009; 32:279.
  27. Rivkin MJ, deVeber G, Ichord RN, et al. Thrombolysis in pediatric stroke study. Stroke 2015; 46:880.
  28. Bernard TJ, Rivkin MJ, Scholz K, et al. Emergence of the primary pediatric stroke center: impact of the thrombolysis in pediatric stroke trial. Stroke 2014; 45:2018.
  29. Schechter T, Kirton A, Laughlin S, et al. Safety of anticoagulants in children with arterial ischemic stroke. Blood 2012; 119:949.
  30. Sträter R, Kurnik K, Heller C, et al. Aspirin versus low-dose low-molecular-weight heparin: antithrombotic therapy in pediatric ischemic stroke patients: a prospective follow-up study. Stroke 2001; 32:2554.
  31. deVeber G, Chan A. Aspirin versus low-molecular-weight heparin for ischemic stroke in children: an unanswered question. Stroke 2002; 33:1947.
  32. Yawn BP, Buchanan GR, Afenyi-Annan AN, et al. Management of sickle cell disease: summary of the 2014 evidence-based report by expert panel members. JAMA 2014; 312:1033.
  33. Ramaswamy V, Mehta V, Bauman M, et al. Decompressive hemicraniectomy in children with severe ischemic stroke and life-threatening cerebral edema. J Child Neurol 2008; 23:889.
  34. Smith SE, Kirkham FJ, Deveber G, et al. Outcome following decompressive craniectomy for malignant middle cerebral artery infarction in children. Dev Med Child Neurol 2011; 53:29.
  35. Goldenberg NA, Bernard TJ, Fullerton HJ, et al. Antithrombotic treatments, outcomes, and prognostic factors in acute childhood-onset arterial ischaemic stroke: a multicentre, observational, cohort study. Lancet Neurol 2009; 8:1120.
  36. Marini C, Totaro R, Carolei A. Long-term prognosis of cerebral ischemia in young adults. National Research Council Study Group on Stroke in the Young. Stroke 1999; 30:2320.
  37. Leys D, Bandu L, Hénon H, et al. Clinical outcome in 287 consecutive young adults (15 to 45 years) with ischemic stroke. Neurology 2002; 59:26.
  38. Greenham M, Gordon A, Anderson V, Mackay MT. Outcome in Childhood Stroke. Stroke 2016; 47:1159.
  39. Ganesan V, Hogan A, Shack N, et al. Outcome after ischaemic stroke in childhood. Dev Med Child Neurol 2000; 42:455.
  40. Cnossen MH, Aarsen FK, Akker SLj, et al. Paediatric arterial ischaemic stroke: functional outcome and risk factors. Dev Med Child Neurol 2010; 52:394.
  41. deVeber GA, MacGregor D, Curtis R, Mayank S. Neurologic outcome in survivors of childhood arterial ischemic stroke and sinovenous thrombosis. J Child Neurol 2000; 15:316.
  42. Lo W, Gordon A, Hajek C, et al. Social competence following neonatal and childhood stroke. Int J Stroke 2014; 9:1037.
  43. Fox CK, Glass HC, Sidney S, et al. Acute seizures predict epilepsy after childhood stroke. Ann Neurol 2013; 74:249.
  44. Smith SE, Vargas G, Cucchiara AJ, et al. Hemiparesis and epilepsy are associated with worse reported health status following unilateral stroke in children. Pediatr Neurol 2015; 52:428.
  45. Goeggel Simonetti B, Cavelti A, Arnold M, et al. Long-term outcome after arterial ischemic stroke in children and young adults. Neurology 2015; 84:1941.
  46. Ganesan V, Ng V, Chong WK, et al. Lesion volume, lesion location, and outcome after middle cerebral artery territory stroke. Arch Dis Child 1999; 81:295.
  47. Grelli KN, Gindville MC, Walker CH, Jordan LC. Association of Blood Pressure, Blood Glucose, and Temperature With Neurological Outcome After Childhood Stroke. JAMA Neurol 2016; 73:829.
  48. Keidan I, Shahar E, Barzilay Z, et al. Predictors of outcome of stroke in infants and children based on clinical data and radiologic correlates. Acta Paediatr 1994; 83:762.
  49. Delsing BJ, Catsman-Berrevoets CE, Appel IM. Early prognostic indicators of outcome in ischemic childhood stroke. Pediatr Neurol 2001; 24:283.
  50. Mallick AA, Ganesan V, Kirkham FJ, et al. Outcome and recurrence one year after paediatric arterial ischaemic stroke in a population-based cohort. Ann Neurol 2016.
  51. Goldenberg NA, Jenkins S, Jack J, et al. Arteriopathy, D-dimer, and risk of poor neurologic outcome in childhood-onset arterial ischemic stroke. J Pediatr 2013; 162:1041.
  52. Elbers J, deVeber G, Pontigon AM, Moharir M. Long-term outcomes of pediatric ischemic stroke in adulthood. J Child Neurol 2014; 29:782.
  53. Domi T, deVeber G, Shroff M, et al. Corticospinal tract pre-wallerian degeneration: a novel outcome predictor for pediatric stroke on acute MRI. Stroke 2009; 40:780.
  54. Sträter R, Becker S, von Eckardstein A, et al. Prospective assessment of risk factors for recurrent stroke during childhood--a 5-year follow-up study. Lancet 2002; 360:1540.
  55. Ganesan V, Prengler M, Wade A, Kirkham FJ. Clinical and radiological recurrence after childhood arterial ischemic stroke. Circulation 2006; 114:2170.
  56. Fullerton HJ, Wu YW, Sidney S, Johnston SC. Risk of recurrent childhood arterial ischemic stroke in a population-based cohort: the importance of cerebrovascular imaging. Pediatrics 2007; 119:495.
  57. Fullerton HJ, Wintermark M, Hills NK, et al. Risk of Recurrent Arterial Ischemic Stroke in Childhood: A Prospective International Study. Stroke 2016; 47:53.