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Strokes in Children Not the Same as in Adults

For the first time ever, the American Heart Association and the American Stroke Association have issued guidelines for dealing with strokes in infants and children, an event once thought so rare that such guidelines were not warranted.  New diagnostic tools and in-depth studies of the children who experience strokes, however, reveal the event is still uncommon but not so rare that similarities and specific characteristics cannot be documented.  And one very important factor in children’s strokes is that they are quite different from the strokes adults suffer; so different, in fact, that treatment and prevention measures are most effective when handled in an age-appropriate manner.

As recently as 20 years ago, strokes were considered so unlikely in children that they were rarely diagnosed.  With today’s improved diagnostic tools, including vascular ultrasound and magnetic resonance imaging (MRI), evidence reveals the risk of a child having a stroke before his or her 19th birthday is 10.7 for every 100,000 children every year.

Often the first symptom of stroke in a newborn is seizure, usually involving just one arm or leg.  Seizures are such a common symptom of stroke in newborn babies, even full-term babies, that about 10% of all seizures are now attributed to strokes.  Experts today consider strokes immediately before or immediately after birth to be a leading cause of cerebral palsy.  Although not unheard of, seizures are rarely associated with strokes in adulthood.

When children have strokes, one or more risk factors is known before the event in more than 50% of cases.  In other cases, risk factors are discovered during thorough evaluation after the event.  The first year of life is the most risky for childhood strokes, with the first two months considered the most critical.  The risk of neonatal strokes, those occurring during the first month after birth, has been established at one for every 4,000 live births.  A child’s risk of having a stroke generally diminishes with age.

Just like strokes in adults, however, it is equally as important to diagnose and treat strokes in children of all ages as quickly as possible to minimize any brain damage or risk of death or disability that might be caused by the event.  Recommended treatment and rehabilitation therapies differ with age, though.

When treating adult stroke patients, a drug called tissue plasminogen activator (t-PA) is almost always used when the stroke is ischemic, or caused by a clot in the brain.  In the Western world, about 80% to 85% of all adult strokes are ischemic and t-PA is a powerful clot-busting agent.  Strokes in children are ischemic only about 55% of the time, with the remaining 45% of them hemorrhagic, or caused by bleeding in the brain, a situation for which t-PA is ineffective.

Atherosclerosis, a build-up of fats, cholesterol, and other substances along the lining of the arteries that are generally referred to as plaque, is the main cause of strokes in adults but children and infants rarely develop this condition.  Instead, strokes in children are caused by a number of risk factors, with sickle cell disease and heart disease, both congenital and acquired, being the most common causes.  Other risk factors include:

• Dehydration
• Infection in the head and neck
• Trauma to the head
• Systemic issues such as disorders to the autoimmune system and inflammatory bowel disease.

Infants are also at risk of stroke due to situations that affect their mothers and their pregnancies, such as:

• A woman’s history of infertility
• Infection of the fluid surrounding a developing fetus, a condition called chorioamnionitis
• Membranes rupturing prematurely
• High blood pressure related to pregnancy, called preeclampsia

Other conditions that cause strokes in adults but not children are cigarette smoking, diabetes, atrial fibrillation, hypertension, artery disease, and being 55 or older.

The one risk factor shared by both adults and children of all ages is sickle cell disease.

To prevent adult strokes, patients are urged to change behaviors or medications known to increase the risk of stroke.  Risk factors are not always known in infants and children, with the stroke itself often being the first sign of illness, so prevention measures most often involve preventing a second, or subsequent, stroke.  In children, treatment of the underlying cause is considered the most effective preventive measure.

Once a child has had a stroke, measures recommended to prevent future strokes include:

• Treating migraine headaches, since migraines in children, especially those with aura, are thought to increase the child’s risk of ischemic stroke
• Stroke-prevention education that stresses the importance of a lifestyle based on a healthy diet and ample exercise, as well as the avoidance of all tobacco-related products
• Alternatives to oral contraceptives for girls who’ve had strokes or have been treated for cerebral venous sinus thrombosis (CVST)
• Thorough evaluation of all possible risk factors when trauma to the head has occurred

Since the just-released guidelines are the first of their kind, the writing committee urges continued research into the diagnosis, risk factors, and treatment of childhood strokes, with updates to be issued as more information is gathered and improved technologies are developed.

Source: American Heart Association

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