Paediatric stroke

Stroke in children (Paediatric stroke)

Stroke can happen at any point in a person’s lifetime, from infancy and childhood to adulthood. A stroke is caused by the interruption of normal flow of blood to the brain, either by a blockage or a rupture in the blood vessels. When a part of the brain doesn’t receive its regular flow of blood that carries vital nutrients and oxygen, brain cells die, causing a loss of brain function.

The age of the child at the time of stroke makes a difference in how doctors identify and treat the problem. Stroke can occur in these three different age groups:

* The prenatal phase, or in the womb.
* The first 28 days of life, or newborn phase.
* The infant years up to 18 years of age.

Stroke is relatively more common in the first two age groups, occurring in up to one in every 4,000 live births. In the third age group, stroke is more rare, only affecting about five out of every 100,000 children each year in Canada.

The location in the brain the stroke takes place will determine the extent of the damage and the after-effects, if any.

Children may experience two types of stroke: hemorrhagic stroke (rupturing of blood vessels), or ischemic stroke (blockage caused by a blood clot).

The causes of stroke in children

The reasons why stroke occurs in children are varied and include malformations of the blood vessels and rare diseases. Here are the most common causes:

Causes of hemorrhagic stroke

Hemorrhagic stroke occurs when a blood vessel ruptures in the brain. In children, it may be due to a weakened or malformed artery. If an artery wall is weak, blood can collect in the wall causing it to balloon (aneurysm). If the pressure builds, the aneurysm can rupture. When this happens, two problems arise. The first occurs when blood flows into areas of the brain where it doesn’t belong, and second, when blood fails to reach its destination, depriving that part of the brain of oxygen and nutrients.

The causes of hemorrhagic stroke in children include:

* An artery malformation or disorder.
* A brain tumour.
* Drug or alcohol abuse by the mother (rare).

Causes of ischemic stroke

Ischemic stroke is usually caused by a blood clot in the brain. The leading risk factors for ischemic stroke in children include:

* Heart disease. When children are born with a heart defect (congenital heart disease), their risk of having a stroke is increased. Heart disease, such as rheumatic heart disease, can also be acquired later in childhood. Stroke is not usually the first sign of heart disease. Often heart disease has been diagnosed before the child has a stroke.
* Blood-clotting disorders. Blood-clotting disorders, also known as prothrombotic disorders, cause the blood to thicken and clot faster. These disorders can be present at birth or acquired later on. A child can be born with a genetic mutation that makes the blood clot faster. Stroke is often the first sign of a blood-clotting disorder. Some illnesses, such as meningitis, sepsis, diarrhea, dehydration or an iron deficiency, can also lead to a blood clotting disorder.
* Irregular arteries A child can have a stroke because the arteries in the brain are irregular or narrowed. This is called arteriopathy. Often, children are born with this problem, but it often goes undetected. In these cases, stroke is the first sign of an irregular artery problem. Children with irregular arteries need to be monitored very closely by their stroke clinic team because 25 per cent of them will experience another stroke.
* Viruses Stroke can also be indirectly caused by a virus. One of the culprits is the chicken pox virus. Once a child is infected, the virus can lie dormant in the body. When the virus is triggered, it can attack an artery in the brain.
* Other risk factors Children are also at higher risk of having a stroke if they have any of the following risk factors:
o heart or brain surgery.
o moyamoya disease.
o sickle cell disease.
o autoimmune disease that attacks arteries in the brain.
o trauma to the brain or neck.
o leukemia.
o migraine headaches with aura.
o metabolic illness.

Up to 20 per cent of paediatric stroke cases have no known cause. This is an area of active medical research.

Diagnosis of paediatric stroke

A quick diagnosis is important to minimize risk for brain damage. Doctors rely on imaging machines and other tests to see what has happened in a child’s brain.

* Computed Tomography (CT) scan uses X-rays to take a detailed picture of the affected area of the brain. A CT scan will confirm whether or not the child has had a stroke, what kind of stroke it is and where in the brain it occurred.
* Magnetic Resonance Imaging (MRI) uses magnetic radio waves to create an image of the brain. It provides greater visual details than a CT scan.
* Cerebral Arteriogram uses a special dye injected into the arteries of the brain and an X-ray is then taken.
* Echocardiogram uses sound waves to take pictures of the heart to see whether there are problems with the heart valves or other heart functions that may be creating blood clots.
* Blood tests may also be ordered to find out whether your child has a blood-clotting disorder.
* Lumbar puncture (also known as a spinal tap) to find out if there are signs of infection or inflammation in the nervous system.

Treatments of stroke in children

In children who have had a hemorrhagic stroke, treatment focuses on stabilizing the child (controlling blood pressure and body temperature, and helping them breathe), and treating the hemorrhage itself. Children who have had an ischemic stroke may need to go on blood thinners.

Treatment for hemorrhagic stroke Kids who have had a hemorrhagic stroke will be looked after by the vascular neurosurgery team. Surgical options may include microsurgery to clip the aneurysm or remove the abnormal vessels.

Treatments for ischemic stroke The goal of treatment in ischemic stroke is to reduce damage to the brain and prevent another stroke. If your child has been diagnosed with an ischemic stroke, doctors will most likely prescribe a blood thinner. These include:

* Warfarin (Coumadin), given by mouth.
* Heparin, given by injection into a vein.
* Low molecular weight heparin, given by injection under the skin.
* Acetylsalicylic acid (Aspirin or ASA), given by mouth.
* Clopidogrel (Plavix), given by mouth.

Once a child has been treated for their initial stroke symptoms, they will be assessed to see how the stroke may affect them in the longer term. The healthcare team will monitor reflexes, eye movements, speech skills, swallowing and other body functions. The team may also administer tests to find out how well your child is doing in processing and reacting to light, pictures, sound and touch.

Newborns generally don’t require treatment for stroke, although they may be treated for heart problems, if that is the source of their illness.

What are the possible effects of a stroke?

Stroke often causes after-effects in children. They include:

* Weakness on one side of the body (hemiparesis).
* Paralysis on one side of the body (hemiplegia).
* One-sided neglect, where the child ignores the weaker side (unilateral neglect).
* Difficulty with speech and language (aphasia).
* Trouble swallowing (dysphagia).
* Vision problems (decreased field of vision or perception).
* Loss of emotional control and mood changes.
* Problems with memory, judgment or problem-solving (cognitive changes).
* Behavioural or personality changes.

Physical effects usually occur on the opposite side of the body from where the stroke occurred. For instance, children who have had a stroke affecting the left side of their brain may have weakness or paralysis on the right side of their body. The left side of the brain controls reading, talking, thinking and mathematics, so these skills could be affected.

On the other hand, children who have had a stroke affecting the right side of their brain, may have paralysis or weakness on the left hand side of their body. The right side of the brain controls skills such as buttoning a shirt or tying shoes, as well as memory.

In children who have experienced a stroke, changes in physical abilities may be immediately apparent, but changes in cognition and behaviour tend to be discovered over time. Often children do recover faster than adults because their brains are still growing. This is called plasticity. If children are quite young when they have a stroke, the extent of their deficits may not become apparent until they are older. For example, a reading problem may not be discovered until your child is in grade one.

You and your child may feel overwhelmed, angry, depressed or frightened, which are all normal reactions. Speak to your hospital’s healthcare team about counselling options for yourself and your child.

What rehabilitation programs are available?

Rehabilitation will allow your child to recover physical functions such as walking or reading. Getting help as soon as possible after the stroke maximizes recovery in children. Children are likely to regain the most function in the first six months. They may continue to improve for two years or more. Speak to your hospital’s healthcare team about rehabilitation options.


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