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Strokes

Pediatric stroke is not as rare as many might believe. In fact, stroke is one of the top 10 causes of death for children, according to the Centers for Disease Control and Prevention.

People rarely think of children as being at risk for stroke. But the truth is, strokes can happen to people of all ages, even to babies in the womb. For children especially, strokes are oftentimes related to bleeding and clotting disorders.

Approximately six in 100,000 children are affected by stroke. Here in the U.S., it is a leading cause of death among children. Nearly 60 percent of childhood strokes occur in boys. Because the causes and symptoms are so different, treating stroke in children requires specialized training.

What is a stroke?

The cells in the body need oxygen and nutrients to be healthy including the cells in the brain. Blood flows through your veins delivering oxygen and nutrients to the cells. There are three types of stroke:

  • An ischemic stroke occurs when a blood clot blocks the flow of blood going into the brain.
  • A hemorrhagic stroke occurs when a blood vessel leaks or bursts causing an interruption to the flow of blood in the brain and hemorrhaging in the brain.
  • Cerebral venous sinus thrombosis (CVST) is a stroke that occurs when a blood clot forms in the brain's venous sinuses, but rather than preventing blood from flowing into the brain, it blocks the blood from flowing out. This may result in blood leaking into the brain and causing a hemorrhagic stroke.

When this happens, the cells in the area of the brain that have been interrupted become damaged. If the flow is interrupted for too long, the cells may die because they don't get the oxygen they need. When this happens, the child is at risk for long-term damage and may even risk losing his or her life.

What causes a stroke?

The causes and types of stroke in children are very different from those in adults. For children, common causes are often related to:

  • Diseases of the arteries
  • Heart Disease – both congenital and acquired
  • Infection in the body or brain
  • Acute or chronic head and neck disorder
  • Blood clotting abnormalities
  • Sickle cell anemia
  • Severe head or neck trauma
  • Dehydration
  • Certain medications, including those used for cancer treatment

Ischemic strokes, the most common type in children, are usually related to:

  • Lack of oxygen during birth
  • A heart defect present at birth
  • Blood disorders such as sickle cell anemia, a disease that destroys blood cells and blocks blood vessels
  • Injury to an artery (a blood vessel that brings oxygen) in the brain
  • dehydration
  • Genetic disorders like Moyamoya, a rare disease that affects arteries in the brain
  • Infection, such as meningitis or chickenpox
  • Certain problems that affect a mother during pregnancy can also cause a baby to have an ischemic stroke before or after birth. Examples include:
  • Preeclampsia (high blood pressure during pregnancy that can cause swelling in the hands, feet, and legs)
  • Premature rupture of the membranes (when the mother's water breaks more than 24 hours before labor starts)
  • Diabetes
  • Drug abuse
  • Placenta problems that decrease the baby's oxygen supply, such as placental abruption

Hemorrhagic strokes can be caused by:

  • A head injury that results in a broken blood vessel
  • Arteriovenous malformation, a condition in which the blood vessels in the brain don't connect properly
  • Aneurysm (weakness in an artery wall)
  • Diseases that affect blood clotting, such as hemophilia

Cerebral venous sinus thrombosis (CVST) is a stroke that occurs when a blood clot forms in the brain's venous sinuses, but rather than preventing blood from flowing into the brain, it blocks the blood from flowing out. This may result in blood leaking into the brain and causing a hemorrhagic stroke. CVST is a rare form of stroke that occurs almost exclusively in children, teens and young adults. Some causes or risk factors include:

  • Sickle cell anemia
  • Iron deficiency anemia
  • Hemolytic anemia
  • Thalassemia
  • Heart disease – both congenital (you are born with it) or acquired (you develop it after birth)
  • Infections
  • Dehydration
  • Head or neck trauma
  • Blood clotting abnormalities
  • Certain medications, including those used for cancer treatment

Over the last 15 years, studies by the National STROKE Association have shown that there has also been an increase in strokes among teens and young adults related to certain disorders normally associated with adult strokes, such as:

  • High blood pressure
  • Diabetes
  • Obesity
  • Cholesterol-related disorders
  • Tobacco use
  • Alcohol abuse

What are the symptoms of a stroke?

While it can be extremely difficult to recognize symptoms of stroke in an adult, it is even more so in children. It is not uncommon for some types of strokes or after effects to go unnoticed. The brain is divided into two parts, the left and the right.

The left side of the brain controls the right side of the body as well as speech and language. If your child has experienced a stroke in the left side of his or her brain you may notice difficulty with speaking or reading or a weakness on the right side of the body.

The right side of the brain controls the left side of the body. If your child has suffered a stroke in the right side of the brain, the left side of the body will be affected along with perception and motor skills, In this case your child may have difficulty with simple tasks such as buttoning a shirt or may suddenly become clumsy due to loss of perception and an inability to judge things like distance.

If your child exhibits any of these same symptoms or warning signs seen in adults, call 911 immediately:

  • Sudden numbness or weakness of face, arm or leg – especially on one side of the body
  • Sudden confusion, trouble speaking or understanding
  • Sudden trouble seeing in one or both eyes
  • Sudden trouble walking, dizziness, loss of balance or coordination
  • Sudden severe headache with no known cause
  • In addition, children may experience the following symptoms and warning signs:
  • Seizures, especially in newborns
  • Worsening or sudden headaches
  • Sudden difficulty speaking, slurring of words or trouble understanding speech
  • Hemiparesis, or a weakness on one side of the body, this may include a "droopy" look on one side of the face
  • Sudden loss of vision or abnormal eye movements
  • Sudden loss of balance or trouble walking

Children, especially little ones, often cannot clearly describe the way they feel. Newborns and infants have no way of expressing their symptoms. If your child has been diagnosed with a disorder, illness or genetic disease or is undergoing certain treatments where stroke could be a possibility, it is very important to discuss a plan of action with your pediatrician and/or specialist. It is also critical to know these signs and take swift action if you believe your child is having a stroke. It could save his or her life.

If at any time you think your child is having a stroke, please call 9-1-1. It is better to not ignore the possibility.

Seizures are closely related to pediatric stroke and can become a continuing issue after a stroke. About 15 percent of seizures in newborns are secondary to stroke. In general, risk of recurrent pediatric stroke is low. However, children who have seizures often have a greater difficulty recovering.

Complications

Strokes are very serious and cause long-term and life-threatening damage. Because the brain is like a "command center" signaling all the functions of our bodies, a stroke affects other parts of the body.

The American Stroke Association reports that between 20 percent and 40 percent of children die after experiencing a stroke, and of those who survive, 50 percent to 80 percent may have permanent neurological deficits. Some of those deficits include:

  • Changes in behavior or personality
  • Cognitive and sensory impairments – bumping into or dropping things due to difficulty judging distance, size, or space
  • Epilepsy or seizures
  • Hemiparesis – weakness on one side of the body
  • Hemiplegia – paralysis of one side of the body
  • Resultant cerebral palsy
  • Difficulty speaking, remembering, solving problems
  • Visual disturbances

Testing and diagnosis

Stroke is diagnosed through several testing techniques. Your doctor will perform a complete physical exam and check for problems with vision, movement, feeling, reflexes, speaking and ability to understand what is being said. Your doctor will also listen for an abnormal sound in the carotid arteries in the neck. This sound, called a bruit, is caused by irregular blood flow.

Neurological examination

Advanced testing will begin with blood tests which may include bleeding time, cholesterol, sugar, clotting, and a complete blood count. Your doctor will also work closely with the neurodiagnostics team who will run one more of the following tests:

How are strokes treated?

Just as the causes for stroke are very different in children than adults, so is treatment. Your child's plan of care will depend on the specific cause of the stroke, as well as other important factors such as age, size and medical issues. Some of the more common treatments stroke in children, teens and young adults include:

  • Supportive care to maintain normal body temperature, proper hydration and normal blood sugar levels
  • Controlling high blood pressure
  • Detecting and treating seizures with EEG monitoring and anticonvulsant medication
  • Managing intracranial pressure
  • Clot-busting drugs
  • Clinical trials
  • Antithrombotic therapy – medications used to prevent blood clots from forming or growing
  • Surgical

For a child with sickle cell disease, blood transfusions may prevent strokes from occurring or recurring. Your doctor will discuss any risks and help to determine if this course of treatment is the right one for your child.

The stroke and thrombosis team at Cook Children's has an outstanding track record in helping patients to recover and to regain as much of their mental and motor skills as possible. An amazing team with extensive knowledge of the types of disorders and issues that can cause stroke and treating those disorders in the tiniest of patients to young adults provides early prevention. And the chance to enjoy childhood and adulthood.

Research

Cook Children's Stroke Program is a proud member of the International Pediatric Stroke Society (IPSS) which is an international network of several large pediatric institutions that are current world leaders in therapy and research in the field of pediatric stroke and thrombosis. Membership in IPSS has allowed Cook Children's to gain access to and participate in an international research trial that offers the most recent advances to treat acute ischemic stroke in children, including the novel use of a "clot busting" medication to reopen the obstructed cerebral artery and offer the best chance for children to have minimal to no neurological deficits.

Our thrombosis program is also a member of the Hemostasis and Thrombosis Research Society (HTRS) which enables us to provide the most up to date thrombosis diagnostics and management to inpatients, as well as outpatients through clinical trials, collaboration and networking with colleagues in this specialized field of hematology. We have also recently become involved in national initiatives for prevention of thrombosis in a variety of clinical situations and disease processes.

The outlook

The American Stroke Association reports that between 20 percent and 40 percent of children die after experiencing a stroke, and of those who survive, 50 percent to 80 percent will have permanent neurological deficits. That means that strokes not only interrupt childhood, but can create challenges well into adulthood and old age, such as:

  • Behavioral issues
  • Cognitive and sensory impairments
  • Epilepsy
  • Hemiparesis, including hemiplegia
  • Resultant cerebral palsy
  • Speech or communication disorders
  • Visual disturbances

The risk of pediatric stroke is greatest within the first year of life. Annually, nearly 11 in 100,000 children from birth to age 18 suffer a stroke. The challenge of pediatric stroke is that stroke aspects–including risk factors, symptoms, prevention efforts and treatment–differ considerably between children and adults. As a result, pediatric stroke is a niche study of medicine that isn't as widely practiced or studied as other specialties, but a dedicated team at Cook Children's is committed to the evaluation and treatment of pediatric stroke patients.

We're here to help.

If your child has been diagnosed, you probably have lots of questions. We can help. If you would like to schedule an appointment, refer a patient or speak to our staff, please call our offices at 682-885-2500.