Pediatric Stroke 101

Defining Pediatric Stroke

Perinatal Stroke: Last 18 weeks of gestation through 1-month old
Childhood Stroke: 1-month old to 18 years

Pediatric Stroke Statistics

There is no universal surveillance for this population

  • The prevalence of Perinatal Stroke is 1 in 4,000 live births (AHA 2019 Journal)
  • Incidence of Perinatal Stroke may be as high as 1 in 1,000 live births (Canada)
  • The annual incidence of Childhood Stroke ranges from 3 to 25 per 100,000 children (AHA 2019 Journal)
  • Affects 5 out of 100,000 children per year in the UK (combines perinatal with childhood stroke)
  • In Canada there are more than 10,000 children (0 – 18 years) living with stroke
  • Annual estimated incidence rates for Australia: Perinatal Stroke bet. 76 and 122 newborns; Childhood Stroke – bet. 58 and 390 children

The majority of pediatric strokes occur in the perinatal period.

Pediatric Stroke Facts

  • An estimated 10% to 25% of children with stroke will die
  • Ischemic stroke is highest in infants and children <5 years of age and higher in boys than girls
  • Black and Asian children have a higher incidence than white children (Most of the increased ischemic stroke risk in black children is explained by sickle cell disease (SCD)
  • Hemorrhagic stroke makes up about half of pediatric stroke
  • Rate of recurrence after an initial childhood stroke: 6.8% at 1 month; 12% at one year (The strongest predictor of stroke recurrence was the presence of an arteriopathy (disease of an artery), which resulted in a 5-fold increased recurrence risk)
  • The likelihood of recurrence after a perinatal stroke is low except in those with congenital heart disease
  • Average adjusted 5-year costs for pediatric stroke are substantial:
    • $51,719 for neonatal strokes, $131,161 for childhood strokes
    • $81,869 for childhood stroke admission, $39,613 for neonatal admission
    • Chronic costs were highest in the first year post stroke, but continued to exceed control costs even in the fifth year by an average of $2,016

What Are the Effects of Pediatric Stroke?

Of children surviving stroke, over 75% are left with long-term neurological deficits. These include:

  • Hemiplegia/Hemiparesis − paralysis or weakness on one side of the body (most common deficit)
  • Learning and memory problems
  • Difficulty with speech and language
  • Different types of impaired vision
  • Behavioral or personality changes
  • Development of epilepsy (not typically seen in adults)

Family, Medical and Educational Needs

  • Affects the entire family – parental guilt is common
  • Parents of children who had suffered a stroke showed signs of PTSD while children showed signs of anxiety
  • Parents’ PTSD and children’s anxiety could have a negative effect on the children’s stroke recovery
  • Educational rehab needed to re-integrate into school
  • Comprehensive, multidisciplinary team needed: neurologist, neuropsychologist, physiatrist, orthopedic surgeon, developmental pediatrician, hematologist, therapists, neonatologist, etc.

Risk Factors for Pediatric Stroke

Perinatal

  • Congenital heart disease
  • Disorders of the placenta
  • Blood clotting disorders
  • Infections
  • Maternal disorders

In most perinatal strokes, no risk factors are ever found.

Childhood

  • Congenital heart disease
  • Cardiac disorders
  • Cerebral vascular disorders
  • Infections
  • Head or neck trauma
  • Sickle cell disease
  • Autoimmune disorders

No previous risk factors are identified in about half of childhood stroke cases.

Risk Factors and Causation

  • A risk factor implies an association with stroke, but not necessarily the cause.
  • Many children possess multiple risk factors which may have to combine in order for stroke to occur.
  • The causes of strokes in children are not well understood.
  • Genetic problems are responsible for a very small number of known causes.
  • A significant number of children will have no risk factors identified despite extensive investigation.

Acute Stroke Treatment

  • Because an initial stroke is often the first sign of a problem in a child, preventing a first childhood stroke can be difficult.
  • There is a battery of tests that need to be done if no cause or risk factor is evident.
  • Treatments for acute stroke in adults have not been tested for safety and efficacy in children.
    • New generation clot-removal devices
    • Intravenous Tissue Plasminogen Activator (IV-tPA)

Knowledge Gaps

  • An incomplete understanding of the causes of all forms of perinatal stroke limits the ability to develop preventative strategies
  • Safety and efficacy data for hyperacute stroke therapies in children are lacking. Children treated with such therapies should be enrolled in existing registries, for example, the Swiss NeuroPediatric Stroke Registry and the International Pediatric Stroke Study Registry
  • There is no evidence to guide how young or how small a child may safely undergo thrombectomy
  • Although there is evidence that antithrombotic agents can benefit adults with ischemic stroke, controlled clinical trial data in children are lacking
  • Outside the setting of Sickle Cell Disease, there have been no stroke prevention trials in children
  • Emotional health and mental health in children with a history of stroke are important outcomes and need further study

List of Specialists

Hematologist – a blood specialist who helps with testing for blood clotting disorders or occasional rare causes of stroke in children
Neonatologist – a pediatrician expert in newborn care is usually involved early in the care of children diagnosed with acute neonatal strokes
Neuropsychologist – for assessment and help with learning and education needs
Neurosurgeon – occasionally involved when certain types of stroke can be helped with surgical procedures Occupational Therapist – works with the child to enhance participation in everyday activities, play and sports, and return to home or school
Orthopedic Surgeon – expert in the “mechanical” complications of stroke such as tightness in the arm or leg that might be helped by surgery
Pediatrician – a community-based child health specialist, can often help coordinate multiple issues with child’s general health
Physical Therapist – assists in reaching the child’s maximum potential to function, facilitates motor development, improves strength and endurance
Psychologist – can assist with the psychological stresses in both child and family that are common in perinatal stroke
Rehabilitation Specialists – includes doctors such as physiatrists and developmental pediatricians with expertise in child rehabilitation
Speech Language Pathologist – for assessment and help with speech or language challenges

Definitions and FAQs

Glossary of Pediatric Stroke Terms from Children’s Hospital of Philadelphia
Summary of pediatric stroke terms and signs and symptoms. Includes fact sheet and video. 2019

Pediatric Stroke: Definitions and Terminology
From the University of Calgary, Calgary Pediatric Stroke Program. 2019

Frequently Asked Questions on Perinatal Stroke
From the University of Calgary, Calgary Pediatric Stroke Program