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
- Congenital Heart Disease (most common cause of Pediatric CVA)
- Sickle Cell Anemia (6-9% of Pediatric CVA cases)
- Cancer
- Head Trauma
- Vasculopathy or Vasculitis
- Coagulopathy
- Metabolic Disorders
V. Differential Diagnosis
- See Cerebrovacular Accident
- Common alternative diagnoses
- Complicated Migraine
- Hypoglycemia
- Seizure (post-ictal paralysis or Todd's Paralysis)
- 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
- References
- Kundurti and Bullard-Berent (2022) Crit Dec Emerg Med 36(5): 12-4
VI. 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
VII. 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
VIII. 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
IX. References
- Spangler and Sanossian in Herbert (2014) EM:Rap 14(3): 2-4
