Hemorrhagic stroke in children
- Evelyn Shih, MD, PhD
Evelyn Shih, MD, PhD
- Fellow Physician, Division of Neurology
- The Children's Hospital of Philadelphia
- Lauren Beslow, MD, MSCE
Lauren Beslow, MD, MSCE
- Assistant Professor of Pediatrics and Neurology
- Director, Pediatric and Neonatal Stroke Program
- Yale School of Medicine
- Section Editors
- Scott E Kasner, MD
Scott E Kasner, MD
- Section Editor — Stroke
- Professor of Neurology
- University of Pennsylvania School of Medicine
- Douglas R Nordli, Jr, MD
Douglas R Nordli, Jr, MD
- Section Editor — Pediatric Neurology
- Chief of Neurology
- Children’s Hospital Los Angeles
- Vice Chair of Neurology
- USC Keck School of Medicine
Although less common than in adults, hemorrhagic stroke can affect children, resulting in significant morbidity and mortality.
An overview of hemorrhagic stroke in children beyond the newborn period is provided here. Other clinical aspects of stroke in neonates and children are reviewed elsewhere. (See "Stroke in the newborn: Classification, manifestations, and diagnosis" and "Ischemic stroke in children and young adults: Etiology and clinical features" and "Ischemic stroke in children: Evaluation, initial management, and prognosis" and "Ischemic stroke in children: Secondary prevention" and "Etiology, clinical features, and diagnosis of cerebral venous thrombosis".)
Hemorrhagic stroke encompasses spontaneous intracerebral hemorrhage, isolated intraventricular hemorrhage, and nontraumatic subarachnoid hemorrhage . Intracerebral hemorrhage is defined by intraparenchymal hemorrhage or a combination of intraparenchymal and intraventricular hemorrhage (image 1).
Despite its common usage, the term hemorrhagic stroke remains confusing. It has been used to denote hemorrhagic transformation of arterial ischemic stroke or of cerebral venous sinus thrombosis, but it does not encompass those entities, strictly speaking.
Although stroke in children is relatively rare compared with adults, it is a significant cause of childhood death and lifelong disability. A stroke suffered within the first decade may cause functional sequelae for multiple decades to follow. Hemorrhagic stroke is a notable contributor to childhood morbidity and mortality, as it accounts for about half of all childhood strokes, compared with <20 percent of adult strokes [2,3].To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Saver JL, Warach S, Janis S, et al. Standardizing the structure of stroke clinical and epidemiologic research data: the National Institute of Neurological Disorders and Stroke (NINDS) Stroke Common Data Element (CDE) project. Stroke 2012; 43:967.
- Broderick JP, Phillips SJ, Whisnant JP, et al. Incidence rates of stroke in the eighties: the end of the decline in stroke? Stroke 1989; 20:577.
- Broderick J, Talbot GT, Prenger E, et al. Stroke in children within a major metropolitan area: the surprising importance of intracerebral hemorrhage. J Child Neurol 1993; 8:250.
- Fullerton HJ, Wu YW, Zhao S, Johnston SC. Risk of stroke in children: ethnic and gender disparities. Neurology 2003; 61:189.
- Giroud M, Lemesle M, Gouyon JB, et al. Cerebrovascular disease in children under 16 years of age in the city of Dijon, France: a study of incidence and clinical features from 1985 to 1993. J Clin Epidemiol 1995; 48:1343.
- Jordan LC, Johnston SC, Wu YW, et al. The importance of cerebral aneurysms in childhood hemorrhagic stroke: a population-based study. Stroke 2009; 40:400.
- Al-Jarallah A, Al-Rifai MT, Riela AR, Roach ES. Nontraumatic brain hemorrhage in children: etiology and presentation. J Child Neurol 2000; 15:284.
- Liu J, Wang D, Lei C, et al. Etiology, clinical characteristics and prognosis of spontaneous intracerebral hemorrhage in children: A prospective cohort study in China. J Neurol Sci 2015; 358:367.
- Al-Shahi R, Warlow C. A systematic review of the frequency and prognosis of arteriovenous malformations of the brain in adults. Brain 2001; 124:1900.
- Zhao J, Wang S, Li J, et al. Clinical characteristics and surgical results of patients with cerebral arteriovenous malformations. Surg Neurol 2005; 63:156.
- Di Rocco C, Tamburrini G, Rollo M. Cerebral arteriovenous malformations in children. Acta Neurochir (Wien) 2000; 142:145.
- Fullerton HJ, Achrol AS, Johnston SC, et al. Long-term hemorrhage risk in children versus adults with brain arteriovenous malformations. Stroke 2005; 36:2099.
- Chung B, Wong V. Pediatric stroke among Hong Kong Chinese subjects. Pediatrics 2004; 114:e206.
- Giroud M, Lemesle M, Madinier G, et al. Stroke in children under 16 years of age. Clinical and etiological difference with adults. Acta Neurol Scand 1997; 96:401.
- Meyer-Heim AD, Boltshauser E. Spontaneous intracranial haemorrhage in children: aetiology, presentation and outcome. Brain Dev 2003; 25:416.
- Tomlinson FH, Rüfenacht DA, Sundt TM Jr, et al. Arteriovenous fistulas of the brain and the spinal cord. J Neurosurg 1993; 79:16.
- Cooke D, Tatum J, Farid H, et al. Transvenous embolization of a pediatric pial arteriovenous fistula. J Neurointerv Surg 2012; 4:e14.
- Al-Shahi R, Bhattacharya JJ, Currie DG, et al. Prospective, population-based detection of intracranial vascular malformations in adults: the Scottish Intracranial Vascular Malformation Study (SIVMS). Stroke 2003; 34:1163.
- Gross BA, Smith ER, Goumnerova L, et al. Resection of supratentorial lobar cavernous malformations in children: clinical article.. J Neurosurg Pediatr 2013; 12:367.
- Gault J, Sarin H, Awadallah NA, et al. Pathobiology of human cerebrovascular malformations: basic mechanisms and clinical relevance. Neurosurgery 2004; 55:1.
- Lanthier S, Carmant L, David M, et al. Stroke in children: the coexistence of multiple risk factors predicts poor outcome. Neurology 2000; 54:371.
- Mottolese C, Hermier M, Stan H, et al. Central nervous system cavernomas in the pediatric age group. Neurosurg Rev 2001; 24:55.
- Fortuna A, Ferrante L, Mastronardi L, et al. Cerebral cavernous angioma in children. Childs Nerv Syst 1989; 5:201.
- Gerosa M, Licata C, Fiore DL, Iraci G. Intracranial aneurysms of childhood. Childs Brain 1980; 6:295.
- Meyer FB, Sundt TM Jr, Fode NC, et al. Cerebral aneurysms in childhood and adolescence. J Neurosurg 1989; 70:420.
- Patel AN, Richardson AE. Ruptured intracranial aneurysms in the first two decades of life. A study of 58 patients. J Neurosurg 1971; 35:571.
- Roche JL, Choux M, Czorny A, et al. [Intracranial arterial aneurysm in children. A cooperative study. Apropos of 43 cases]. Neurochirurgie 1988; 34:243.
- Sedzimir CB, Robinson J. Intracranial hemorrhage in children and adolescents. J Neurosurg 1973; 38:269.
- Locksley HB, Sahs AL, Knowler L. Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage. Section II. General survey of cases in the central registry and characteristics of the sample population. J Neurosurg 1966; 24:922.
- Locksley HB. Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations. Based on 6368 cases in the cooperative study. J Neurosurg 1966; 25:219.
- Gemmete JJ, Toma AK, Davagnanam I, et al. Pediatric cerebral aneurysms. Neuroimaging Clin N Am 2013; 23:771.
- Alawi A, Edgell RC, Elbabaa SK, et al. Treatment of cerebral aneurysms in children: analysis of the Kids' Inpatient Database. J Neurosurg Pediatr 2014; 14:23.
- Huang J, McGirt MJ, Gailloud P, Tamargo RJ. Intracranial aneurysms in the pediatric population: case series and literature review. Surg Neurol 2005; 63:424.
- Jordan LC, Hillis AE. Hemorrhagic stroke in children. Pediatr Neurol 2007; 36:73.
- Abbas Q, Merchant QU, Nasir B, et al. Spectrum of Intracerebral Hemorrhage in Children: A Report from PICU of a Resource Limited Country. Crit Care Res Pract 2016; 2016:9124245.
- Wang JJ, Shi KL, Li JW, et al. Risk factors for arterial ischemic and hemorrhagic stroke in childhood. Pediatr Neurol 2009; 40:277.
- Klinge J, Auberger K, Auerswald G, et al. Prevalence and outcome of intracranial haemorrhage in haemophiliacs--a survey of the paediatric group of the German Society of Thrombosis and Haemostasis (GTH). Eur J Pediatr 1999; 158 Suppl 3:S162.
- Revel-Vilk S, Golomb MR, Achonu C, et al. Effect of intracranial bleeds on the health and quality of life of boys with hemophilia. J Pediatr 2004; 144:490.
- Yoffe G, Buchanan GR. Intracranial hemorrhage in newborn and young infants with hemophilia. J Pediatr 1988; 113:333.
- Earley CJ, Kittner SJ, Feeser BR, et al. Stroke in children and sickle-cell disease: Baltimore-Washington Cooperative Young Stroke Study. Neurology 1998; 51:169.
- Strouse JJ, Hulbert ML, DeBaun MR, et al. Primary hemorrhagic stroke in children with sickle cell disease is associated with recent transfusion and use of corticosteroids. Pediatrics 2006; 118:1916.
- Ohene-Frempong K, Weiner SJ, Sleeper LA, et al. Cerebrovascular accidents in sickle cell disease: rates and risk factors. Blood 1998; 91:288.
- Dobson SR, Holden KR, Nietert PJ, et al. Moyamoya syndrome in childhood sickle cell disease: a predictive factor for recurrent cerebrovascular events. Blood 2002; 99:3144.
- Kyrnetskiy EE, Kun LE, Boop FA, et al. Types, causes, and outcome of intracranial hemorrhage in children with cancer. J Neurosurg 2005; 102:31.
- Lo WD, Lee J, Rusin J, et al. Intracranial hemorrhage in children: an evolving spectrum. Arch Neurol 2008; 65:1629.
- Jordan LC, Kleinman JT, Hillis AE. Intracerebral hemorrhage volume predicts poor neurologic outcome in children. Stroke 2009; 40:1666.
- Gumer LB, Del Vecchio M, Aronoff S. Strokes in children: a systematic review. Pediatr Emerg Care 2014; 30:660.
- Beslow LA, Licht DJ, Smith SE, et al. Predictors of outcome in childhood intracerebral hemorrhage: a prospective consecutive cohort study. Stroke 2010; 41:313.
- Beslow LA, Heuer GG, Jordan LC. Nontraumatic Intracerebral Hemorrhage and Subarachnoid Hemorrhage. In: Pediatric Neurocritical Care, Abend NS, Helfaer MA (Eds), Demos Medical, New York 2012. p.195.
- Beslow LA, Abend NS, Gindville MC, et al. Pediatric intracerebral hemorrhage: acute symptomatic seizures and epilepsy. JAMA Neurol 2013; 70:448.
- Abend NS, Beslow LA, Smith SE, et al. Seizures as a presenting symptom of acute arterial ischemic stroke in childhood. J Pediatr 2011; 159:479.
- Beghi E, D'Alessandro R, Beretta S, et al. Incidence and predictors of acute symptomatic seizures after stroke. Neurology 2011; 77:1785.
- De Herdt V, Dumont F, Hénon H, et al. Early seizures in intracerebral hemorrhage: incidence, associated factors, and outcome. Neurology 2011; 77:1794.
- Fullerton HJ, Wu YW, Sidney S, Johnston SC. Recurrent hemorrhagic stroke in children: a population-based cohort study. Stroke 2007; 38:2658.
- Morgenstern LB, Hemphill JC 3rd, Anderson C, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2010; 41:2108.
- Kidwell CS, Chalela JA, Saver JL, et al. Comparison of MRI and CT for detection of acute intracerebral hemorrhage. JAMA 2004; 292:1823.
- 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.
- Schwarz S, Häfner K, Aschoff A, Schwab S. Incidence and prognostic significance of fever following intracerebral hemorrhage. Neurology 2000; 54:354.
- Poungvarin N, Bhoopat W, Viriyavejakul A, et al. Effects of dexamethasone in primary supratentorial intracerebral hemorrhage. N Engl J Med 1987; 316:1229.
- Tellez H, Bauer RB. Dexamethasone as treatment in cerebrovascular disease. 1. A controlled study in intracerebral hemorrhage. Stroke 1973; 4:541.
- Passero S, Ciacci G, Ulivelli M. The influence of diabetes and hyperglycemia on clinical course after intracerebral hemorrhage. Neurology 2003; 61:1351.
- Weir CJ, Murray GD, Dyker AG, Lees KR. Is hyperglycaemia an independent predictor of poor outcome after acute stroke? Results of a long-term follow up study. BMJ 1997; 314:1303.
- 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.
- Omay SB, Carrión-Grant GM, Kuzmik GA, et al. Decompressive hemicraniectomy for ischemic stroke in the pediatric population. Neurosurg Rev 2013; 36:21.
- Liu AC, Segaren N, Cox TS, et al. Is there a role for magnetic resonance imaging in the evaluation of non-traumatic intraparenchymal haemorrhage in children? Pediatr Radiol 2006; 36:940.
- Truwit CL. CT angiography versus MR angiography in the evaluation of acute neurovascular disease. Radiology 2007; 245:362.
- Kondziolka D, McLaughlin MR, Kestle JR. Simple risk predictions for arteriovenous malformation hemorrhage. Neurosurgery 1995; 37:851.
- Graf CJ, Perret GE, Torner JC. Bleeding from cerebral arteriovenous malformations as part of their natural history. J Neurosurg 1983; 58:331.
- Ondra SL, Troupp H, George ED, Schwab K. The natural history of symptomatic arteriovenous malformations of the brain: a 24-year follow-up assessment. J Neurosurg 1990; 73:387.
- Winn HR, Richardson AE, Jane JA. The long-term prognosis in untreated cerebral aneurysms: I. The incidence of late hemorrhage in cerebral aneurysm: a 10-year evaluation of 364 patients. Ann Neurol 1977; 1:358.
- Lang SS, Beslow LA, Bailey RL, et al. Follow-up imaging to detect recurrence of surgically treated pediatric arteriovenous malformations. J Neurosurg Pediatr 2012; 9:497.
- Schoenberg BS, Mellinger JF, Schoenberg DG. Cerebrovascular disease in infants and children: a study of incidence, clinical features, and survival. Neurology 1978; 28:763.
- Livingston JH, Brown JK. Intracerebral haemorrhage after the neonatal period. Arch Dis Child 1986; 61:538.
- Qureshi AI, Tuhrim S, Broderick JP, et al. Spontaneous intracerebral hemorrhage. N Engl J Med 2001; 344:1450.
- Lynch JK, Han CJ. Pediatric stroke: what do we know and what do we need to know? Semin Neurol 2005; 25:410.
- Fox CK, Johnston SC, Sidney S, Fullerton HJ. High critical care usage due to pediatric stroke: results of a population-based study. Neurology 2012; 79:420.
- Lo WD, Hajek C, Pappa C, et al. Outcomes in children with hemorrhagic stroke. JAMA Neurol 2013; 70:66.
- Greenham M, Gordon A, Anderson V, Mackay MT. Outcome in Childhood Stroke. Stroke 2016; 47:1159.
- Blom I, De Schryver EL, Kappelle LJ, et al. Prognosis of haemorrhagic stroke in childhood: a long-term follow-up study. Dev Med Child Neurol 2003; 45:233.
- Hawks C, Jordan LC, Gindville M, et al. Educational Placement After Pediatric Intracerebral Hemorrhage. Pediatr Neurol 2016; 61:46.
- 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.
- Broderick JP, Brott TG, Duldner JE, et al. Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality. Stroke 1993; 24:987.
- Adil MM, Qureshi AI, Beslow LA, et al. Factors Associated With Increased In-Hospital Mortality Among Children With Intracerebral Hemorrhage. J Child Neurol 2015; 30:1024.
- Kleinman JT, Beslow LA, Engelmann K, et al. Evaluation of intraventricular hemorrhage in pediatric intracerebral hemorrhage. J Child Neurol 2012; 27:526.
- Hemphill JC 3rd, Bonovich DC, Besmertis L, et al. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 2001; 32:891.
- Beslow LA, Ichord RN, Gindville MC, et al. Pediatric intracerebral hemorrhage score: a simple grading scale for intracerebral hemorrhage in children. Stroke 2014; 45:66.
- Nelson MD Jr, Maeder MA, Usner D, et al. Prevalence and incidence of intracranial haemorrhage in a population of children with haemophilia. The Hemophilia Growth and Development Study. Haemophilia 1999; 5:306.
- ETIOLOGY AND RISK FACTORS
- Vascular malformations
- CLINICAL FEATURES AND PRESENTATION
- INITIAL EVALUATION AND DIAGNOSIS
- Urgent neuroimaging
- Laboratory studies
- DIFFERENTIAL DIAGNOSIS
- Supportive measures
- Intracranial pressure
- Identifying the etiology
- Treatment of vascular lesions
- Follow-up imaging
- Neurologic outcome
- Outcome predictors
- Hemorrhagic stroke recurrence
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS