II. Epidemiology
-
Incidence: 3-15 in 100,000 children per year
- Similar Incidence to Pediatric Brain Tumor
III. Types
- Acute ischemic Cerebrovascular Accident (55%)
- Hemorrhagic Cerebrovascular Accident
- Cerebral Venous Thrombosis
IV. Risk Factors
- Cardiac Causes (15 to 30% Pediatric CVA cases)
-
Hypercoagulable or Thrombotic Disorders (20 to 50% of cases)
- Sickle Cell Anemia (6-9% of Pediatric CVA cases, RR 200)
- Cancer
- Polycythemia
- Vasculopathy or Vasculitis
- Coagulopathy
- Other Causes
- Head Trauma
- Metabolic Disorders
- Acute Infections
V. Findings: Acute Ischemic Stroke Presentations
- Perinatal Ischemic Stroke
- Focal and unilateral Seizure
- Cardiovascular Signs
- Altered Level of Consciousness
- Failure to Thrive
- Feeding intolerance
- Childhood Ischemic Stroke
- Hemiparesis
- Unilateral facial weakness
- Altered Speech
- Vision changes
- Altered Level of Consciousness
VI. Differential Diagnosis
- See Cerebrovascular Accident
- Common alternative diagnoses
- Complicated Migraine
- Hypoglycemia
- Seizure (post-ictal paralysis or Todd's Paralysis)
- However acute strokes may also present with unilateral Focal Seizure
- Other alternative diagnoses
- Intracranial Hemorrhage
- Venous sinus thrombosis
- Bell Palsy
- Intracranial Mass in Children
- CNS Abscess or oither intracranial infection
- Alternating Hemiplegia of Childhood
- Posterior Reversible Encephalopathy Syndrome (PRES)
- Acute Disseminated Encephalomyelitis (ADEM)
- Idiopathic Intracranial Hypertension
- Acute Cerebellar Ataxia
- Moyamoya Disease
- References
- Kundurti and Bullard-Berent (2022) Crit Dec Emerg Med 36(5): 12-4
VII. Imaging
-
CT Head
- Evaluate for Hemorrhagic Cerebrovascular Accident
- MRI/MRA Brain
- Discuss indications with neurology stroke team
- Do not delay definitive management (i.e. CVA Thrombolysis) if clear CVA findings and no Hemorrhage on CT Head
- If used to confirm Ischemic CVA within 3 hour time frame, then obtain stat with TPA ready to infuse
VIII. Precautions
- Although rare in children, Cerebrovascular Accident is devastating
- Longterm morbidity in 75% of cases (Seizures, Hemiparesis, Learning Disorders)
- Keep Cerebrovascular Accident on differential diagnosis in children
- Do not always assume benign cause (e.g. complicated Migraine Headache or post-seizure Todd's Paralysis)
- As with adults presenting with possible CVA, do not delay evaluation and management
IX. Management
- See CVA Management
- See CVA Thrombolysis
- See CVA in Sickle Cell Disease
- Consult neurology stroke team
- Consider TPA within 3 hours of Ischemic CVA
- Same dose as adults (0.9 mg/kg split dosing with 10% given as bolus and 90% given over 1 hour)
- Limited data regarding TPA in CVA under age 18 years old
- Amlie-Lefond (2009) Lancet Neurol 8(6): 530-6 [PubMed]
- Janjua (2007) Stroke 38(6): 1850-4 [PubMed]
-
Antiplatelet Therapy following ischemic Cerebrovascular Accident
- Aspirin daily
X. References
- Chan and Mann (2023) Crit Dec Emerg Med 37(5): 14-5
- Spangler and Sanossian in Herbert (2014) EM:Rap 14(3): 2-4
- Tsze (2011) Emerg Med Int +PMID: 22254140 [PubMed]