Challenges in the diagnosis and treatment of pediatric stroke

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Abstract

Stroke in children is rarely due to traditional stroke risk factors such as hypertension and diabetes. Rather, stroke in this patient group typically results from the simultaneous occurrence of multiple stroke risk factors, the presence of which necessitates a thorough evaluation to determine the cause of this disorder. Several challenges exist in the care of children with stroke. Of note, recognition of pediatric stroke onset by parents and caregivers is often delayed, highlighting the need for increased awareness of and education regarding this condition. Moreover, various neurological conditions resemble stroke in pediatric patients and a definite diagnosis of this disorder requires MRI; adding to the diagnostic challenge, young children may need to be sedated to undergo acute MRI. Perhaps the most significant challenge is the need for clinical research studies focusing on pediatric stroke treatment, so as to allow evidence-based treatment decision-making. A final challenge is the standardization of outcome assessment after stroke for a wide range of ages and developmental levels. In this Review, we examine recent findings and diagnostic issues pertaining to both arterial ischemic stroke and hemorrhagic stroke in children.

Key Points

  • Common risk factors for pediatric arterial ischemic stroke include cerebral arteriopathies, congenital or acquired cardiac disease, and sickle cell disease

  • Cerebral vascular abnormalities are the most common causes of hemorrhagic stroke in children

  • A combination of multiple, seemingly minor risk factors may lead to stroke in childhood

  • Delayed recognition of stroke in children by families and health-care providers is a significant issue for both medical care and clinical trials

  • Clinical trials of treatment strategies—particularly trials of antithrombotic medications (aspirin versus anticoagulants) and rehabilitation methods—are needed for pediatric stroke

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Figure 1: Arteriopathy in pediatric stroke.
Figure 2: Acute hemorrhagic stroke and susceptibility-weighted imaging.
Figure 3: Idiopathic moyamoya disease.
Figure 4: Acute arterial ischemic stroke with diffusion–perfusion mismatch.

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Acknowledgements

L. C. Jordan (grant K23NS062110) and A. E. Hillis (grants RO1 NS047691 and RO1 DC05375) receive funding from the NIH.

L. Barclay, freelance writer and reviewer, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the MedscapeCME-accredited continuing medical education activity associated with this article.

Author information

L. C. Jordan researched the data for the article, provided a substantial contribution to discussions of the content, wrote the article and contributed to review and editing of the manuscript before submission. A. E. Hillis provided a substantial contribution to discussions of the content and contributed to review and editing of the manuscript before submission.

Correspondence to Lori C. Jordan.

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Competing interests

L. C. Jordan has acted as a consultant for Berlin Heart. A. E. Hillis declares no competing interests.

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