II. Epidemiology

  1. Incidence: 3-15 in 100,000 children per year
    1. Similar Incidence to Pediatric Brain Tumor

IV. Risk Factors

  1. Congenital Heart Disease (most common cause of Pediatric CVA)
  2. Sickle Cell Anemia (6-9% of Pediatric CVA cases)
  3. Cancer
  4. Head Trauma
  5. Vasculopathy or Vasculitis
  6. Coagulopathy
  7. Metabolic Disorders

V. Differential Diagnosis

  1. See Cerebrovascular Accident
  2. Common alternative diagnoses
    1. Complicated Migraine
    2. Hypoglycemia
    3. Seizure (post-ictal paralysis or Todd's Paralysis)
  3. Other alternative diagnoses
    1. Intracranial Hemorrhage
    2. Venous sinus thrombosis
    3. Bell Palsy
    4. Intracranial Mass in Children
    5. CNS Abscess or oither intracranial infection
    6. Alternating Hemiplegia of Childhood
    7. Posterior Reversible Encephalopathy Syndrome (PRES)
    8. Acute Disseminated Encephalomyelitis (ADEM)
    9. Idiopathic Intracranial Hypertension
    10. Acute Cerebellar Ataxia
    11. Moyamoya Disease
  4. References
    1. Kundurti and Bullard-Berent (2022) Crit Dec Emerg Med 36(5): 12-4

VI. Imaging

  1. CT Head
    1. Evaluate for Hemorrhagic Cerebrovascular Accident
  2. MRI/MRA Brain
    1. Discuss indications with neurology stroke team
    2. Do not delay definitive management (i.e. CVA Thrombolysis) if clear CVA findings and no Hemorrhage on CT Head
    3. If used to confirm Ischemic CVA within 3 hour time frame, then obtain stat with TPA ready to infuse

VII. Precautions

  1. Although rare in children, Cerebrovascular Accident is devastating
    1. Longterm morbidity in 75% of cases (Seizures, Hemiparesis, Learning Disorders)
  2. Keep Cerebrovascular Accident on differential diagnosis in children
    1. Do not always assume benign cause (e.g. complicated Migraine Headache or post-seizure Todd's Paralysis)
  3. As with adults presenting with possible CVA, do not delay evaluation and management

VIII. Management

  1. See CVA Management
  2. See CVA Thrombolysis
  3. See CVA in Sickle Cell Disease
  4. Consult neurology stroke team
  5. Consider TPA within 3 hours of Ischemic CVA
    1. Same dose as adults (0.9 mg/kg split dosing with 10% given as bolus and 90% given over 1 hour)
    2. Limited data regarding TPA in CVA under age 18 years old
    3. Amlie-Lefond (2009) Lancet Neurol 8(6): 530-6 [PubMed]
    4. Janjua (2007) Stroke 38(6): 1850-4 [PubMed]
  6. Antiplatelet Therapy following ischemic Cerebrovascular Accident
    1. Aspirin daily

IX. References

  1. Spangler and Sanossian in Herbert (2014) EM:Rap 14(3): 2-4

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