Stroke in Children and Young Adults E-Book

Read "Stroke in Children and Young Adults E-Book" by José Biller with Rakuten Kobo. The revised and updated second edition of this comprehensive text.
Table of contents

Pediatric Stroke and Cerebrovascular Disorders. Anesthesia and Perioperative Care for Aortic Surgery.

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Pediatric Head and Neck Tumors. Paediatrics, Psychiatry and Psychoanalysis. How to write a great review. However, CA should be strongly considered in cases with equivocal or negative findings on MR vascular imaging or where no other explanation for stroke is identified. CT angiography CTA is another option for assessing vascular anatomy and relative cerebral blood flow.

It may be used to identify arterial dissection causing AIS, and facilitates rapid assessment of vascular lesions requiring immediate surgery. The contrast required may also limit the volume of contrast that can be safely administered for subsequent, more definitive delineation by CA. Other investigations to consider include ultrasound to evaluate the extracranial carotid circulation. Since cardiac anomalies are a significant risk factor for stroke in children, an ECG, chest radiograph, and transthoracic or transesophageal echocardiography may be useful.

There are no clearly established laboratory testing guidelines for the assessment of pediatric stroke. Laboratory assessment may include a variety of nonspecific blood tests and more specific laboratory tests looking for specific causes of stroke such as coagulopathies, hematological disorders, or vasculitides. Table 2 provides a suggested list of laboratory and imaging tests to consider. One should also keep in mind that many thrombophilias are familial, and that other family members may also be affected and require evaluation.

Laboratory and diagnostic testing considerations for the acute pediatric stroke patient. Adapted from Younkin [ 23 ] and Deveber [ 92 ]. Once the type of stroke is identified, treatment depends on the etiology. Hemorrhagic strokes may require medical management beyond supportive measures.

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Prevention of rebleeding includes correction of coagulation defects and hematologic disorders. Recombinant factor VIIa rFVIIa promotes hemostasis and has been shown to stabilize intracerebral hematomas and reduce hemorrhage volume. However, adult studies have not demonstrated improved survival or functional outcome at this time [ 94 ]. Further prospective studies in adults are still needed to determine if subsets of patients may benefit from this therapy, so it is likely too early to extrapolate this data to the pediatric population.

Surgical management of hemorrhagic strokes is controversial. There may be benefit of early surgical evacuation in patients with clinical deterioration due to mass effect. Children may warrant more aggressive intervention given their lack of cerebral atrophy which, in older adults, could potentially accommodate some degree of hematoma expansion. Although a recent prospective, multicenter trial suggested that surgical evacuation of a supratentorial intraparenchymal hemorrhage does not improve chances of good recovery or moderate disability beyond best medical management, a recent meta-analysis does suggest that surgical evacuation is associated with a reduction in the odds of being dead or dependent [ 92 , 95 ].

Other surgical options include stereotactic radiosurgery, microsurgical or endovascular techniques, and endoscopic surgical evacuation of the intracerebral hematoma or obliteration of aneurysms and AVMs [ 96 — 98 ]. Another surgical consideration is emergent splenectomy for intraparenchymal bleeding associated with idiopathic thrombocytopenic purpura [ 99 ]. Another goal specific to AIS management includes preventing a subsequent ischemic event. Although LMWH has reproducible pharmacokinetics and requires fewer monitoring tests, it cannot be reliably reversed with protamine, like UFH.

Adapted from Roach et al. Although the practice of initiating short-term anticoagulation pending evaluation of stroke etiology in the adult population is no longer applied, recent guidelines have suggested that it may be prudent to start anticoagulation in children. This is because the likelihood of a child having an underlying condition that would benefit from anticoagulation e.

Anticoagulation is also often used in children with arterial dissection, dural sinus thrombosis, coagulation disorders, high risk of embolism, or progressive deterioration during the initial evaluation of a new cerebral infarction. Long-term anticoagulation beyond the acute phase can be provided in the form of antiplatelet agents such as aspirin, clopidogrel, oral vitamin K antagonists like warfarin, or weekly subcutaneous LMWH injections.

However, these measures can be initiated in consultation with the appropriate specialists after the initial management and stabilization are carried out in the emergency department setting. Thrombolytic therapy in children with ischemic strokes must be carried out in a guarded and judicious manner. Published guidelines suggest that tPA may be considered in a select group of children with CVST, but could not make any further recommendations, including whether adult guidelines could be applied to adolescents who met adult eligibility criteria [ 88 ].

Although there are case reports and case series of IV recombinant tPA for children with strokes, there is little else upon which to base thrombolytic recommendations [ — ]. Despite anecdotal reports of successful endovascular thrombolysis and IV tPA use in children, there are other reports of high risks of hemorrhagic complication rates in children with systemic thrombolysis who receive IV tPA and inadequate evidence for deciding which patients are the best candidates [ — , , ].

Management of stroke in children with sickle cell disease deserves special mention. Evaluation for a structural vascular lesion in children with sickle cell disease and a hemorrhagic stroke is reasonable. This is because there is often an underlying aneurysm with potential for rebleeding in adolescents with SCD who present with a SAH [ ].

However, evaluation with CA to identify such aneurysms should be deferred until after reduction of the percentage of sickle hemoglobin because of concerns that CA might facilitate sickling [ 88 ]. Surgical revascularization procedures may be considered as a last resort in children with sickle cell disease who have persisting cerebrovascular dysfunction despite optimal medical management [ 88 ].

Rapid transfer to a tertiary pediatric center is indicated. In situations where further information or guidance is desired, a call to a pediatric stroke telephone consultation service like NOCLOTS may be useful. Calling this service is not only a means of obtaining assistance, but helps with the collection of information for future study [ ].

Strokes in children are being recognized more frequently as diagnostic aids develop and clinician recognition improves. However, because the incidence is still low relative to adult strokes, and children are distinctly different from adults, it remains a challenge to create evidence based diagnostic and treatment guidelines. Due to the low incidence of this disease, future stroke research needs to be pursued with a collaborative effort both nationally and internationally.

RCTs specific to children are clearly needed to better establish the safety and efficacy of both acute and preventative treatments.


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The long-awaited and highly anticipated TIPS trial will lead the way with other studies to improve care for children [ ]. Until then, stroke should remain a strong consideration in children with concerning signs and symptoms and significant risk factors, and the best available evidence should be utilized in providing optimal medical care. National Center for Biotechnology Information , U. Journal List Emerg Med Int v. Published online Dec Received Jul 3; Accepted Sep This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This article has been cited by other articles in PMC. Abstract Stroke is relatively rare in children, but can lead to significant morbidity and mortality. Background Stroke is a neurological injury caused by the occlusion or rupture of cerebral blood vessels. Epidemiology A stroke or cerebral vascular accident CVA in children is typically considered to be a rare event.

Clinical Presentation There are some generalizations that can be made as to how strokes present in children Table 1. Table 1 Clinical presentation of pediatric ischemic and hemorrhagic strokes. Ischemic Hemorrhagic Earley et al. Open in a separate window. Differential Diagnosis There are many other diseases that may mimic a stroke.

Strokes in young adults: epidemiology and prevention

Risk Factors and Causes The majority of signs and symptoms of stroke are nonspecific, and can be easily attributed to other causes. Cardiac Cardiac disease is the most common cause of stroke in childhood, accounting for up to a third of all AIS [ 4 ]. Hematologic Sickle cell disease SCD is a very common cause of pediatric stroke, occurring in cases per , affected children [ 1 ].

Infection Varicella infection within the past year can result in basal ganglia infarction [ 56 , 57 ]. Vascular Arteriovenous malformations AVM are the most common cause of hemorrhagic stroke after infancy, but can also cause thrombotic stroke [ 8 , 10 , 62 ]. Syndromic and Metabolic Disorders Although rare, children with Marfan syndrome are at risk of ischemic neurovascular complications [ 63 ].

Vasculitis Cerebral vasculitis is a less common cause of stroke in children, and is more common in children older than 14 years of age [ 8 ]. Oncologic Children with cancer are at increased risk for AIS as a result of their disease, subsequent treatment, and susceptibility to infection. Trauma Children who have experienced head and neck trauma are at risk of developing an ischemic event subsequent to dissection of the carotid or vertebral arteries. Drugs Drug use, both illicit and prescribed, are a concern in the adolescent population. Management The management of stroke in children is less-studied and largely extrapolated from the adult literature with the only randomized controlled trials for the treatment of acute stroke in children in the setting of SCD.

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Imaging and Testing Noncontrast head computed tomography CT is sensitive for acute bleeding and should be obtained emergently to exclude a hemorrhagic cause of stroke. Table 2 Laboratory and diagnostic testing considerations for the acute pediatric stroke patient. Treatment Once the type of stroke is identified, treatment depends on the etiology. Table 4 Protocol for systemic heparin administration and adjustment in children. Conclusions Strokes in children are being recognized more frequently as diagnostic aids develop and clinician recognition improves.

Stroke in children and sickle-cell disease: Baltimore-Washington cooperative young stroke study. Arterial strokes in children. Etiology of stroke in children. Journal of Child Neurology. Neurologic outcome in survivors of childhood arterial ischemic stroke and sinovenous thrombosis. In pursuit of evidence-based treatments for paediatric stroke: Chung B, Wong V. Pediatric stroke among Hong Kong Chinese subjects. Cerebrovascular disease in infants and children: Stroke in children within a major metropolitan area: Eeg-Olofsson O, Ringheim Y.

Clinical characteristics and prognosis. Report of the national institute of neurological disorders and stroke workshop on perinatal and childhood stroke. Cerebrovascular disorders in children.

Pediatric Stroke: A Review

Current Neurology and Neuroscience Reports. Cerebrovascular disease in children under 16 years of age in the city of Dijon, France: Journal of Clinical Epidemiology. Is it time for a large, collaborative study of pediatric stroke? Risk of stroke in children: Diagnostic pitfalls in paediatric ischaemic stroke. Developmental Medicine and Child Neurology. Time lag to diagnosis of stroke in children.

Seminars in Pediatric Neurology. Clinical survey of ischemic cerebrovascular disease in children in a district of Japan. Cerebrovascular disease in children. Factor V Leiden and prothrombin gene G a variant in children with ischemic stroke. Ischemic strokes in children. Diagnosis and treatment of ischemic pediatric stroke. Investigation of risk factors in children with arterial ischemic stroke. Evolution of early hemiplegic signs in full-term infants with unilateral brain lesions in the neonatal period: Spontaneous intracranial haemorrhage in children: Prehospital delay and emergency department management of ischemic stroke patients in Taiwan, R.

Especially for these young stroke patients, evaluation for the etiology of uncontrollable hypertension such as renal artery stenosis, pheochromocytoma, hyperaldosteronism, or systemic vasculitis may be indicated in some cases. The benefit of statins in young stroke patients with predominantly nonatherosclerotic stroke etiologies remains controversial; however, in young patients with cryptogenic stroke, statin therapy was associated with fewer recurrent vascular events.

Diabetic stroke patients, both young adults and the elderly, have higher mortality, a less favorable outcome, more severe disability, and slower recovery after a stroke, as well as higher rates of stroke recurrence within 6 months. Therefore, more aggressive treatment of these comorbidities is required.

In stroke patients with defined large-artery atherosclerosis or small-vessel disease, risk factors should be modified and antiplatelet drugs are recommended, along with carotid endarterectomy or percutaneous transluminal angioplasty in selected patients. According to the guidelines, acetylsalicylic acid ASA should be a first-choice antiplatelet drug in secondary prevention.

In patients with cardioembolic stroke due to atrial fibrillation or other cardioembolism, warfarin International Normalized Ratio [INR] 2—3 is indicated for secondary prevention. Clinical studies have demonstrated noninferiority of all NOAC tested in comparison with warfarin, with better safety and a reduced risk of intracerebral hemorrhage. NOAC can be also used for secondary prevention of cardioembolic stroke in patients with stroke recurrence despite appropriate treatment with warfarin.

For lack of results from clinical trials on stroke prevention in patients with PFO, antiplatelet treatment is considered appropriate for stroke patients with isolated PFO and percutaneous closure of PFO is not recommended. Anticoagulant therapy is normally indicated in the event of a proven deficiency of antithrombin III, protein C, or protein S, as well as resistance to activated protein C factor V Leiden.

ASA may be considered as a preventive treatment in patients with antiphospholipid antibody positivity after a first ischemic stroke. Oral anticoagulants for an INR of 2—3 are recommended for patients who meet the criteria for antiphospholipid syndrome. Pregnant women with stroke or transient ischemic attack may be considered for treatment with unfractionated or low molecular weight heparin throughout the first trimester, followed by low-dose ASA for the remainder of the pregnancy, if a high-risk thromboembolic condition is ruled out.

One of the main problems in secondary stroke prevention is long-term use of secondary prevention medications following stroke, because up to one third of stroke patients discontinued one or more such medications within 1 year of hospital discharge. Stroke in young adults is a major public health problem, and further research using standardized methodology is needed. These studies will provide clarity by enabling comparison of incidence rates between countries and trends over time, along with insights into underlying etiologic mechanisms.

Prevention is the primary treatment strategy, aimed at reducing morbidity and mortality related to young stroke, but there are no specific recommendations or guidelines. In the near future, organizations such as the World Stroke Organization, the European Stroke Organization, and the American Heart and Stroke Association should make an effort to publish recommendations or a guideline for the prevention and treatment of stroke in young adults. National Center for Biotechnology Information , U.

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Published online Feb The full terms of the License are available at http: Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. This article has been cited by other articles in PMC. Introduction Despite considerable improvement in primary prevention, diagnostic workup, and treatment, stroke is in second or third place on a mortality list, and projections indicate that it will remain so in the year Epidemiology of stroke in young adults There are many published series concerning stroke in young patients, but the data are conflicting.

Risk factors Modifiable risk factors are the same for both younger and older age groups. Etiology The etiology of ischemic stroke in young adults and adolescents is diverse and varies according to age and geographic region. Open in a separate window. All numbers are percentages. Table 2 Uncommon causes of stroke in young adults. Table 3 Cardiac sources of embolism. Primary stroke prevention Primary prevention aims to reduce the risk of stroke in asymptomatic subjects.

Conclusion Stroke in young adults is a major public health problem, and further research using standardized methodology is needed. Footnotes Disclosure The author reports no conflicts of interest in this work. Ischaemic stroke in young adults: J Neurol Neurosurg Psychiatry. Causes of ischemic stroke in young adults, and evolution of the etiological diagnosis over the long term. Trends in stroke hospitalizations and associated risk factors among children and young adults, — Incidence of stroke in young adults: Characteristics of stroke in young adults in Tuzla Canton, Bosnia and Herzegovina.

Analysis of consecutive patients aged 15 to 49 with first-ever ischemic stroke: Incidence and prognosis of stroke in young adults: Stroke in the young in the Northern Manhattan Stroke Study. Trends in stroke incidence and acute case fatality in a Japanese rural area: Stroke in a biracial population: Incidence and prognosis of stroke in the Belluno Province, Italy: The third stroke registry in Tartu, Estonia: A case series of young stroke in Rome.

Demographic and geographic vascular risk factor differences in European young adults with ischemic stroke: How does number of risk factors affect prognosis in young patients with ischemic stroke? Zhang YN, He L. Risk factors study of ischemic stroke in young adults in Southwest China. Young ischaemic stroke in South Auckland: Stroke in young patients: Etiology of ischemic stroke among young adults of Serbia.

Spengos K, Vemmos K. Risk factors, etiology, and outcome of first-ever ischemic stroke in young adults aged 15 to 45 — the Athens Young Stroke Registry. Stroke care in young patients. Etiology of first ever ischaemic stroke in European young adults: Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. Trial of Org in Acute Stroke Treatment. New approach to stroke subtyping: Evaluation and management of stroke in young adults.

Continuum Minneap Minn ; Relation between migraine and stroke.