Pediatric neurologist and stroke specialist Christine Fox, MD, MAS, presents keys to identifying and treating children with ischemic stroke. In this short video, she covers risk factors, imaging modalities, evolving treatment strategies and secondary stroke prevention.
My name is Christine Fox. I direct the UCSF, pediatric stroke and cerebrovascular Disease Center. And today I'm going to tell you about acute ischemic stroke in Children. I'll start by telling you a little bit about the epidemiology of pediatric stroke. Pediatric stroke essentially breaks down into two age categories. Perinatal stroke and childhood stroke. By definition, perinatal stroke is a stroke that occurs before birth, up to 28 days of life, and this happens in about one in 2500 full term live births. A childhood stroke is a stroke that occurs after 28 days of life through the childhood. The incidence of childhood stroke is about 4.6 per 100,000 Children, and this translates approximately two, Children in the United States annually. And there have been some studies that show that hospitalization for childhood stroke is increasing over time and this may indicate better recognition. These estimates also include both ischemic and hemorrhagic stroke. In adults, approximately 80% of strokes are ischemic, whereas in Children it's probably closer to 5050 ischemic and hemorrhagic stroke. One of the important points about pediatric stroke is that the lifetime costs of care for Children have had a stroke are higher than estimates of costs for similar stroke. In adults, Children who have had a stroke may have a lifetime of disability and epilepsy, and so while it is somewhat less common than stroke in the elderly, or quite a bit less common than stroke in the elderly, it is important both in the individual child and family and um, as a system of health care as well, newborns who have a stroke in the perinatal period may present in a couple of different ways, and the most common is a presentation with neonatal seizures. Some infants also will have encephalopathy and a number of Children who have a stroke in the newborn period do not have any acute presentation but present later as they develop when they develop early handedness or weakness on one side or epilepsy. One of the important points about perinatal stroke is that it's rarely recurrent unless congenital heart disease is present. Epilepsy is one of the important long term outcomes. After a perinatal stroke. And over the first decade of life after perinatal stroke, up to 50% of Children can have a remote seizure or epilepsy and the Children who are really at higher risk for epilepsy are those who present with neonatal seizures. So those who have an acute presentation in the newborn period for the remainder of my talk, I'm really going to focus on childhood ischemic stroke, talking about presentation and um some of the hyper acute and acute treatments that may be available for Children in Children who have a stroke stroke syndromes are often similar to the pattern that you expect to see in adults. They may develop sudden onset, um focal motor deficits, language deficits or altered mental status, but there are some key differences for a stroke that happens in a child that we don't often see in adults. For example, stroke in adults are typically thought to be of to be pain free, but approximately a third of the Children who have an ischemic stroke or old enough to tell us about it to complain of a headache. The other key difference is that seizures are very common in Children who have an acute ischemic stroke, about 5-10%, maybe closer to 5% of adults who who present with an acute ischemic stroke have a seizure at the onset. In Children. This is almost a third and its age dependent, so the younger you are, the more likely you are to present with an acute seizure at the time of the stroke and around school age, around five years of age. This um Uh no longer is that such a steep curve, but somewhere around 20% of Children between the ages of five and 20 will present with a seizure at the time of their acute stroke, and the timing of the deficit onset may also differ from that. In adults, about half have an abrupt onset, like you would expect to see in an adult. Um But a number of other Children can have a progressive weakness that develops over hours or have a waxing and waning course. So what are the most common causes of a childhood stroke? Um Children who have an underlying cardiac disease are certainly at risk and sickle cell disease is also a really important risk factor for childhood stroke. However, it's important to know that a large proportion of the Children that we see with an acute ischemic stroke was previously healthy. Within the previously healthy Children are acquired arterial open. These are the most common causes. These can be either intracranial arterial open these um an inflammatory arterial apathy that's post infectious or can be a more progressive arterial apathy like moya moya or a congenital arterial pithy, extra cranial or cervical artery open. These are also important causes of stroke in a previously healthy child, often after a trauma causing a dissection. And um in many Children who present with an acute ischemic stroke, there are multiple risk factors. So there are for example, maybe a trauma as well as an underlying genetic from ophelia. I'm going to move now to talking about work up for stroke. In the young Children who have an ischemic stroke should have a trans thoracic echo with a bubble study. This is to look for any shunting and if there is shunting then looking for venus clots with Doppler ultrasound, vascular imaging is important both initially and in a delayed fashion. To look for arterial to these arterial wall imaging also may be helpful to look for inflammatory arterial apathy, and conventional angiogram is usually reserved for those who have a suspected Nyamweya syndrome from ophelia work up. Maybe important because there are often multiple risk factors in Children who have an ischemic stroke, identifying a throb. Ophelia is not just helpful in understanding why a stroke occurred but may influence the choice of anti coagulation versus anti platelet, may influence the duration of antibiotic therapy and is important for counseling both for the child in terms of long term risk of other clots, as well as family members in the cases of familial from amelia's, One of the important pieces that I like to emphasis when talking about pediatric stroke is the importance of having being ready when a child presents with a stroke, delays in presentation to medical care are very common. This is for a number of reasons. There is a lack of public awareness of childhood stroke and ischemic stroke often occurs in Children who were previously healthy. So this isn't something that their families are necessarily expecting In the United States. There have been some studies that show that fewer than half present within 24 hours of their scheming stroke, and once Children do come to the hospital, there are oftentimes delays in diagnosis. Um, stroke mimics, for example, are much more common in Children compared to adults and much more common than strokes themselves. So Children are more likely to present um uh to be thought that they had a complex migraine or a seizure um simply because these are more common in Children. So when they're heavy paris is doesn't improve, then they get imaged. But sometimes there is a delay between presentation to medical care and imaging In Australia, only about 6.8% were diagnosed within three hours of onset. And there are similar estimates to this in the United States, Canada and the United Kingdom. So I think one of the important things that we can do for Children with stroke is really public awareness, institutional education and having pediatric stroke guidelines. These are essential in order to minimize delays to diagnosis. Now, when we talk about hyper cute stroke treatment in Children, we really have to start with the treatment that's expected in adults. In adults. We know that um ivy trumbull isis within the 1st 4.5 hours, improves clinical outcomes. And there have been a large number of studies over the past five years that have shown endovascular thrum back to me within six hours after stroke, conducted 24 hours in selected patients. Um also results in better outcomes. And even within these time windows, better outcomes are associated with earlier treatment. Now for the next few minutes, I'd like to address the question of hyper acute stroke therapy and Children, which has been an increasingly prominent topic of discussion nationally and internationally. It's important to know for this discussion that the medications and devices used for thrombosis and thrown back to me in adults with stroke are not FDA approved for use in Children. So I will be presenting the potential risks and benefits of their off label use. So what about hyper acute stroke therapy in Children? Um there are some challenges to think about, and I think one of the big one is the typical delays in both recognition and diagnosis. If we can't get Children in rapidly, then we aren't able to provide hyper cute stroke therapy. And we know that it's likely that in Children, just like adults, the earlier we can reaper fuse the brain, the better the outcome. Most pediatric stroke centers also recommend more stringent diagnostic imaging compared to adults if considering hyper cute stroke treatment. What I mean by this is that a non contrast head cT is sufficient with the appropriate stroke syndrome in an adult in order to treat with crumble ISIS. Most pediatric stroke, um providers would recommend vascular imaging demonstrating an inclusion before recommending considering either through mobile ISIS or thrown back to me. And it's important to know that currently uh ivy thrombosis and endovascular thrown back to me are not considered standard of care in Children. The reason for this is that the risk benefit of an ivy thrombosis or mechanical intellect um er really unknown, there's been limited data and for trumble ISIS there's a lack of dozing and safety data and Children. The last point is that especially with endovascular thrown back to me, I worry that in considering the risk benefit ratio that thrown back to me may not be beneficial in some childhood arterial open these while the risk may be greater. So is there a rationale for hyper acute stroke treatment in Children? I think the largest is the well established efficacy in adults and the path of physiology in path of physiology in Children may also be favorable because Children frequently have large vessel strokes that could benefit from re perfusion. Currently, many pediatric stroke centers in the U. S. May consider hyper cute drug treatment in Children. In some cases some would consider ivy Trumbull IsIS within 4.5 hours using adult criteria other than age and the age criteria varies across pediatric stroke centers. Many pediatric stroke providers would consider and vascular thrum back to me in selected Children within 24 hours, depending on the availability of a neuro interventional radiologist who has pediatric experience and stroke treatment experience. As well as a pick you for post amble ectomy care. And do we have any guidance for this? Well, I'm going to go back a little ways and take you through guidelines for treatment of childhood stroke back to 2008 when the scientific statement for the management of stroke and infants and Children said that until additional safety and efficacy data were available, thrombosis was generally not recommended outside of a clinical trial. However, even in 2008, there was no consensus in the scientific and the writers of the scientific statement about thrombosis and older adults who otherwise meet standard adult eligibility criteria. Then, in 2015, when a number of large multi center adult trials in endovascular thrum Beck to me were completed, there was a focused update of the earlier guidelines for management of patients with acute ischemic stroke regarding endovascular treatment. While this update primarily focused on adults, there was some guidance about Children, and this was the first guideline that suggested that end of vascular thrum Beck to me maybe reasonable in Children in selected patients using adult parameters. Then in 2019, there was another scientific statement again about management of stroke and units and Children that addressed this point In the 2015 guideline. While they suggested it would be reasonable to consider, they didn't necessarily go into much detail about when to consider this. And so the 2019 scientific statement gave a few parameters. They suggested that thrown back to me might be um something to consider if there were persistent disabling neurologic deficits with radiographic lee, confirmed large artery occlusion in larger Children. And when the treatment decision was made in conjunction with neurologists have expertise in the treatment with Children treatment of Children with stroke. And if the intervention can be performed by an endovascular surgeon with experience treating Children and performing from back to me in adult stroke patients. In my experience when I have discussed hyper acute stroke treatment with families, most families would want to have the discussion and have the chance to either opt in or opt out. So, um because hyper cute stroke treatment in Children may be available, it's important to remember that this is an emergency imaging and rapid imaging is as important if you suspect a stroke in a child as it is in adults. I often get asked what kind of imaging should I perform? M. R. I. M. R. A minimizes radiation. It can distinguish stroke from stroke mimics very well. Um and as um imaging has become more readily available across centers, some have developed focused stroke protocols that shorten the sequences so that Children actually can hold still enough in order to get good images. On the other hand, C. T. C. T. A. And C. T. Profusion is typically what we reach for adults who have a acute stroke. Ct is sensitive for blood. This may minimize delay if it's what's available and it might be. And at UCSF, it's our choice for the Children who have underlying cardiac disease in order to minimize delays in which we discussed. Does the child have peace or wires or hardware that may not be MRI compatible? My advice is generally to choose the modality at your institution that minimizes delays with either one. It's important to remember that vascular imaging should be part of the protocol. The reason for this is that looking for a vascular occlusion will influence your decision about hyper cute treatment and down the line even outside of the emergent period. It might be helpful in identifying arterial open these, whatever the cause of the ischemic stroke, meaning whether it is cardio metabolic or there's an underlying from ophelia. An infection is also an additional risk factor that often acts as a trigger. So after the hyper cute treatment, we also are thinking about secondary stroke prevention in Children and choice of anti from biotic treatment. Children who have had a recent stroke are at a relatively high risk for having a recurrent stroke, especially in the early period. The highest risk time for stroke occurrence is over the first year, with some extending up to two years after the initial stroke. So this is the usual time period in which an antibiotic is recommended. Choice of anti platelet versus anticoagulant is dependent on the ideology of the stroke and typically is something that can be discussed between a vascular neurologist and a hematologist. There are few data on direct oral anticoagulants in Children, but this is something that is beginning to be considered in young adults who have underlying congenital heart disease and we know without an antique robotic, the risk of recurrence is much higher. The duration of anti thrombin tick treatment is dependent upon ideology. I often recommendation longer duration if there is a persistent arterial apathy if there's underlying cardiac disease or if we know that there is a severe from ophelia of course in sickle cell disease. The secondary stroke prevention is quite different and involves chronic transfusion and perhaps consideration of stem cell transplant. There is research in the pipeline for some causes of childhood stroke, particularly those that are caused by an inflammatory arterial apathy um with interventions such as steroids or a cycle of fear in order to prevent future strokes. At UCSF we have a great team of neurologists, euro interventional radiologists and neurosurgeons who are experts in treating Children with ischemic or hemorrhagic stroke. Please contact us. If you suspect a stroke in a child 24 7, 365 days a year will be ready. We also take care of outpatients Children who have had a stroke in order to help with their recovery. We lean on our human biology colleagues, geneticists and fizzy interests and psychologists in order to help a child as they're recovering from the stroke. I hope today that this was helpful in learning a little bit about acute ischemic stroke in Children. And thank you for your time, mm.
