Cardiovascular

Pediatric stroke

Even if you’ve heard of pediatric stroke, you may not be familiar with its presentation, implications, and treatment. Although rare, strokes in children are potentially catastrophic. What’s worse, many young children are unable to communicate their symptoms to others, which can delay identification. This article helps expand your knowledge base by describing assessment and intervention for pediatric stroke.

Pediatric stroke too often goes unrecognized or overlooked as a primary diagnosis. Yet it ranks among the top 10 killers of children younger than age 14. Many people mistakenly believe stroke occurs only in adults. And many clinicians aren’t aware of the incidence, signs and symptoms, and treatment of pediatric stroke. This unfamiliarity may lead to missed detection or delayed diagnosis. By increasing your knowledge, you can promote better nursing practice—and better patient outcomes.

Sometimes called apoplexy or brain attack, a stroke is an acute event that leads to neurologic injury or interrupted cerebral circulation lasting more than 24 hours. In a stroke, focal neurologic deficits result from an infarction or hemorrhage in the brain. The most notable deficits include loss of motor function, speech, cognition, sensation, and vision.

The most common types of pediatric stroke are hemorrhagic and ischemic, with hemorrhagic strokes representing at least 50%. Other stroke types include arterial and venous thrombus, arterial embolism, and intracranial hemorrhage.

Incidence

Pediatric stroke has an annual incidence of 2.7 per 100,000 and a mortality ranging from 7% to 28%. Incidence in infants from birth to 30 days is 26.4 per 100,000. Perinatal stroke occurs as often as one in every 4,000 live births.

Assessment

Immaturity of the child’s brain can mask abnormalities caused by a stroke, leading to delayed diagnosis. Also, parents and healthcare providers alike may misinterpret upper-extremity hemiparesis (one-sided weakness) for hand dominance, which can be seen as early as 13 months of age by reaching out and side preference. If a child experiences delays in walking or crawling, it may be difficult to diagnosis paralysis because the child may be labeled a “late bloomer.”


Hemiplegia (one-sided paralysis) is the most common presenting manifestation of pediatric stroke. Occurring in 51% of patients, hemiplegia may resolve in a day or may persist for several weeks to months; in some children, it resolves spontaneously. Both choreoathetosis (abnormal body movements) and dystonic movements are typical in pediatric stroke patients. Other common manifestations are seizures (seen in 48% of patients) and speech abnormalities (17%). Seizures commonly are confined to one body area. In many patients, signs and symptoms regress with sleep and recur on awakening.

Other manifestations include hand preference before age 10 months (often mistaken as normal); apnea; poor feeding patterns in newborns; delays in gross motor development, function, and language skills; and constriction or contracture of arm and leg muscles.

On initial assessment, perform a full evaluation of the neurologic system tailored to the child’s age. Be sure to assess childhood milestones. Ask parents or guardians if the child has lost previously acquired skills, which may indicate certain diseases or disorders. Such loss warrants a specialty neurologic assessment. Also ask about difficulties during the mother’s pregnancy, because the neurologic system begins to develop during the third week of fetal life. Note traumas, illnesses, diseases, or disorders of the mother before and during pregnancy. Assess the child’s muscle tone and strength, starting with resting posture. Check for infant reflexes pertinent to the specific age of the child. In children younger than 18 months, check fontanels to ensure closure has taken place.

As appropriate for the child’s age, also evaluate:

  • degree of alertness, including level of consciousness
  • mood
  • affect
  • judgment
  • memory
  • thought
  • communication
  • motor and sensory functions
  • cranial nerves
  • deep and superficial reflexes
  • coordination.

Keep in mind that loss of function in one or more of the above areas reflects the area of potential damage from a stroke.

Finally, review the patient’s history for potential causes of and contributing factors for stroke. (See the box below.)

Causes and contributing factors

The most common causes of pediatric stroke are cardiac disorders, both congenital and acquired. Cardiac disorders include aortic stenosis, mitral stenosis and mitral prolapse, ventricular septal defects, patent ductus arteriosus, and cyanotic congenital heart disease with right to left shunting of blood. Acquired cardiac problems that may precede pediatric stroke include endocarditis, Kawasaki disease, cardiomyopathy, atrial myxoma, rheumatic fever, and arrhythmias. Coagulation disorders that can lead to pediatric stroke include factor V Leiden, antithrombin II deficiency, prothrombin 20210 mutation, and protein C and S deficiency. Sickle cell disease is commonly associated with large-vessel stenosis, which can lead to pediatric stroke.

Vasculopathies, another potential cause of stroke, result from malformation of the normal capillary bed, causing abnormal blood shunting. Children with such malformations commonly present with a history of migraine and seizures.

Infections linked to pediatric stroke include sepsis, bacterial meningitis, otitis media, and mastoiditis. Diabetes is another associated disorder that can potentially lead to pediatric stoke because narrowed arteries can promote the incidence of thrombus or emboli formation and cause ischemia.

Interventions

Interventions include low-molecular-weight heparin for patients with thrombus or emboli. In adults, such thrombolytic therapy is useful when given within 3 hours of symptom onset, but there have been few studies related to effectiveness and timing of administration in children. Children with stroke related to sickle cell anemia should receive blood transfusions. Large clots may be removed surgically.

Many patients need long-term rehabilitation (possibly for decades), which includes physical, speech, and occupational therapies. Psychological services and special education services also may be required. Settings that offer multidisciplinary care and treatment promote optimal outcomes.

Know that follow-up should include consultation with a pediatric hematologist for serial transcranial Doppler studies to evaluate cerebral vessel blood flow, as well as with a pediatric neurologist.

Also, these children may be started on a daily regimen of aspirin (81 mg).

Parents of children who’ve suffered strokes are desperately seeking to increase healthcare providers’ ability to recognize strokes and to educate the public about this debilitating condition. (See the box below.) Earlier recognition and treatment may minimize or avoid damaging effects.

Internet resources on pediatric stroke

Healthcare providers, families, and other interested parties can obtain more information on pediatric stroke by visiting these websites.

American Heart Association Scientific Statement: Management of stroke in infants and children. http://stroke.ahajournals.org/cgi/content/abstract/STROKEAHA.108.189696v1

Children’s Hemiplegia and Stroke Association; Childhood Stroke Awareness Campaign. www.CHASA.org or www.KidsHaveStrokes.org

HemiHelp. www.hemihelp.org.uk

Hemi-Kids. www.HemiKids.org

Regional Infant and Childhood Hemiplegia Stroke Survivors (RICHSS).

Patricia Vanderpool is a nurse practitioner primary care provider who owns a private house call practice in New Castle, Indiana.

Selected references

Behrman RM, Kliegman RE, Jenson HB, Stanton BMD. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: Saunders; 2007.

Berger SE, Friedman R, Polis MC. The role of locomotor posture and experience on handedness and footedness in infancy. Infant Behav Dev. 2011;34(3):472-480. doi:10.1016/j.infbeh.2011.05.003.

Children’s Hemiplegia and Stroke Association. Infant and child pediatric stroke fact sheet. www.chasa.org/wp-content/uploads/2011/06/chasa_pediatric_stroke_fact_sheet_2012.pdf. Accessed June 21, 2012.

Fullerton H, Wu Y, Sidney S, Johnston C. Recurrent hemorrhagic stroke in children: a population-based cohort study. Stroke. 2007;38(10):2658-2662.

Tsze DS, Valente JH. Pediatric stroke: A review. Emerg Med Int. 2011;ID 734506. doi:10.1155/2011/734506.

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