Pediatric StrokeTarynn Everett

Northern Arizona University

Pediatric Stroke: Abstract• The purpose of this paper is to examine the data published in regards to pediatric stroke. Pediatric stroke has recently received more

attention from the medical community. Pediatric stroke has historically been undiagnosed or misdiagnosed. This may be due to a variety of factors including a low level of suspicion by the clinician and patients who present with subtle symptoms that mimic other diseases. (Tzse, 2011) Stroke was considered a disease which only effected adults and the elderly. This history of misdiagnoses has skewed the data available for reference. Only in the last couple of decades has any specific research been conducted on the topic. Due to the specialized medical equipment and training most cases of pediatric stroke go undiagnosed and untreated in non-industrialized nations. This issue also limits the data available on a global level.

• Keywords: Pediatric Stroke, Infant Stroke, Child Stroke, Perinatal Stroke, cerebral vascular accident, CVA, Stroke, Childhood Mortality

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Pediatric Stroke: Introduction• The medical condition that I chose to examine is cerebral vascular accidents (CVA) which is commonly referred to as a “stroke”. I

will be investigating cerebral vascular accidents in the pediatric patient which will be defined as ages 0-18 years of age. Cerebral vascular accidents are a non-communicable disease which can be described as “a neurological injury caused by the occlusion or rupture of cerebral blood vessels.” (Tsze, 2011) There are two main types of strokes, hemorrhagic and thrombolytic. A hemorrhagic stroke is characterized by the rupture of a cerebral blood vessel while a thrombolytic stroke is caused by an occlusion of a cerebral blood vessel by a thrombus. Because pediatric strokes have only recently garnered attention from the medical community relatively little data is available on the international scale.

• Pediatric stroke is a disease process which has historically gone undiagnosed. Although comparatively uncommon to its manifestation in adults this disease process has begun to garner attention in the medical community. Stroke is relatively rare in children, but can lead to significant morbidity and mortality. (Tzse, 2011) However, pediatric stroke is likely more common than we may realize since it is thought to be frequently undiagnosed or misdiagnosed. (Tzse, 2011) Stroke is one of the top ten killers of children. Of the survivors, over 40% have neurologic deficits that will persist for their lifetime, which for many children will be the better part of a century. One in ten children with ischemic stroke will have a recurrence within 5 years (Roach, 2008)

Pediatric Stroke: Stages of Disease• The risk of stroke in children is greatest in the first year of life, and peaks during the perinatal period (roughly the weeks before and

immediately after birth). Stroke also occurs in about one of every 3,500 live births. (AHA, 2013) The highest incidence occurs in the neonatal period with estimates as high as 20–30/100,000 newborns/y. This is equivalent to approximately 1/4000–5000 live births/y, although a population-based epidemiologic study from Switzerland using MRI confirmation of neonatal AIS showed a higher incidence of 1:2300 live births. Perinatal ischemic stroke (occurring between 20 weeks’ gestation and 28 days’ postnatal life) comprises approximately 25% to 30% of all AISs in children and occurs primarily in term infants. (Friedman, 2009)

• Because strokes are an acute event there is very little time of presymptomatic disease process. Once a cerebral insult has occurred it take only seconds to minutes for symptoms to present.

• AIS most often presents as a focal neurologic deficit. Hemiplegia is the most common focal manifestation, occurring in up to 94% of cases. Hemorrhagic strokes most commonly present as headaches or altered level of consciousness, and are more likely to cause vomiting than in AIS. Seizures are common in both ischemic and hemorrhagic strokes. They occur in up to 50% of children with strokes, are not restricted to any age group, and are not limited to any specific seizure type.(Tzse, 2011)

• Pediatric stroke leads to significant morbidity and mortality. Roughly 10–25% of children with a stroke will die, up to 25% of children will have a recurrence, and up to 66% will have persistent neurological deficits or develop subsequent seizure disorders, learning, or developmental problems. (Tzse, 2011) Of children surviving stroke, about 60% will have permanent neurological deficits, most commonly hemiparesis or hemiplegia. Hemiplegia/hemiparesis (total or partial paralysis on one side of the body) is the most common form of cerebral palsy in children born at term, and stroke is its leading cause. Other long-term disabilities caused by a stroke occurring around the time of birth include cognitive and sensory impairments, epilepsy, speech or communication disorders, visual disturbances, poor attention, behavioral problems, and poor quality of life. (AHA, 2013)

Pediatric Stroke: Rates• Incidence rate. The reported incidence of combined ischemic and hemorrhagic pediatric stroke ranges from 1.2 to 13 cases per

100,000 children under 18 years of age. (Tzse, 2011) However, pediatric stroke is likely more common than we may realize since it is thought to be frequently undiagnosed or misdiagnosed. This may be due to a variety of factors including a low level of suspicion by the clinician and patients who present with subtle symptoms that mimic other diseases. (Tzse, 2011)

• Prevalence rate. I was unable to find data on the prevalence of pediatric stroke worldwide. This may be due to misdiagnoses, poor reporting or improper classifications.

• Mortality rate (number of deaths) worldwide for the past 10 years here. According to the World Health Organizations data on Mortality for the year 2012 no children under the age of 59 months died from having a stroke. The data does show that 7,579 children between the ages of 5 to 14 did die from stroke. (WHO, 2012) I feel that the lack of data in the younger population is a reporting or classification error considering the data the American Heart Association published on U.S. statistics.

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Pediatric Stroke: Patterns of Disease in the U.S.• Childhood mortality from stroke fell by 58% between 1979 and 1998 in the U.S. However, the decline appears to be the result of

decreasing fatalities after stroke, not a decrease in stroke incidence. (AHA, 2013)

• Pediatric stroke presents itself more often in males then females. Stroke is more common in boys than girls, even after controlling for differences in frequency of causes such as trauma. (Tzse, 2011)

• There appears to be a predominance of stroke in black children. This difference remains true even after accounting for sickle cell disease patients with stroke. (Tzse, 2011) This data is supported by data retrieved from the American Heart Association. According to their fact sheet, African American children are at higher risk for stroke, and death from stroke, compared to Caucasian and Asian children. (AHA, 2013)

• The mean age of childhood presentation is 4 to 6 years of age although detailed analysis of 1187 cases from the International Pediatric Stroke Study (IPSS) group showed a slightly older age of 6.8 years for boys and 7.4 years for girls. (Friedman, 2009)

• Epidemiologists have noted an increased incidence in stroke across the southeastern United States which has been dubbed the “Stroke Belt”. A recent investigation has found that this increased incidence is present in the pediatric population as well as the adult population. The greater risk in Stroke Belt states was apparent for ischemic and hemorrhagic stroke, for all age groups and both sexes, and persisted after adjustment for ethnicity. The geographic disparity in children was similar in magnitude to that in adults. (Fullerton, 2004)

• It appears that African American boys are at the highest risk for pediatric stroke even after adjusting for sickle cell disease and trauma. The major concern in my opinion is the incidence rate of this disease. Although small in scale to other diseases pediatric stroke is a severely debilitating disease. With the increased focus on evaluation/treatment the mortality rate of pediatric stroke should decrease.

Pediatric Stroke: Patterns of Disease in Denmark.• The epidemiological data on the incidence rate (IR) of arterial and venous cerebral thrombosis in neonates (< 28 days) and children

(>28 days to 18 years) are sparse. Previous studies have reported IRs of AIS of 1.8–7.8 per 100 000 person-years and of CSVT in the range of 0.25–0.67 per 100 000 person-years. (Tuckuviene, 2010)

• No statistical significant differences in age-specific IRs of AIS (p = 0.14) and CSVT (p = 0.39) were found when comparing boys with girls. (Tuckuviene, 2010)

• No data was found specific to race/ethnicity

• The highest IR of cerebral thrombosis was in infancy with a second peak in the IR of CSVT in adolescence. (Tuckuviene, 2010)

• No data was found specific to geographic region

• The majority of the data found on pediatric stroke was consistent between the United States and Denmark. The one exception was the Denmark data showed minimal difference in incidence between males and females. According to Tuckuviene this may be due to the “possibility that the sample size in our study may have been too small to identify more subtle gender disparities.” (Tuckuviene, 2010)

Pediatric Stroke: Impact• As tragic as pediatric stroke can be there is a positive side to this story. With innovations in medical technology and focus of the

medical community this historically misunderstood disease if finally getting the attention it deserves. If properly diagnosed and treated many children can go on to live fulfilled lives. The child’s brain shows resilience and plasticity which allows these patients to overcome some of the deficits that adult patients struggle with.

• The main effect globalization has on pediatric stroke is in awareness. Being a non-communicable disease there is no concern of transmission. Pediatric stroke is a relatively new topic in the medical community. With the increased awareness pediatric stroke recognition will continue to increase which should correlate to decrease in mortality and morbidity resulting from this disease process.

• The exact costs of childhood stroke to families and society are unknown at this time. However, one study found that the average cost of medical care in the first year after childhood stroke is nearly $43,000, and the subsequent health care needs of these children can last decades, even far into adulthood.4 Another study found that the financial burden of strokes in infants and children is both substantial and long-term, with children costs 15 times higher than children of the same age without stroke. The costs to families and society extend beyond the direct medical costs. Familial and societal impacts include: altered family relationships and home life, lost income and productivity, and educational costs, such as the need for special services and placement. (AHA, 2013)

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Pediatric StrokeReferences

• American Heart Association. (2013). Facts-Knowing no bounds. Stroke in Infants, Children, and Youth.

• Engle, R., Ellis, C. (2012). Pediatric Stroke in the U.S.: Estimates from the Kid’s Inpatient Database. Journal of Allied Health, Fall 2012, Vol 41, No 3

• Friedman, N. (2009). Pediatric Stroke: Past, Present and Future. Advances in Pediatrics. 56 (2009) 271–299

• Fullerton, H., Elkins, J., S. Claiborne Johnston. (2004). Pediatric Stroke Belt: Geographic Variation in Stroke Mortality in US Children. Stroke. 2004; 35: 1570-1573

• Mackay, M. T., Wiznitzer, M., Benedict, S. L., Lee, K. J., deVeber, G. A., Ganesan, V. and on behalf of the International Pediatric Stroke Study Group (2011), Arterial ischemic stroke risk factors: The international pediatric stroke study. Ann Neurol., 69: 130–140. doi: 10.1002/ana.22224

• Roach ES, Golomb MR, Adams R, Biller J, Daniels S, Deveber G, Ferriero D, Jones BV, Kirkham FJ, Scott RM, Smith ER., Management of stroke in infants and children: a scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke. 2008; 39: 2644-2691 Published online before print July 17, 2008, doi:

• Tsze, D., & Valente, J. (2011). Pediatric stroke: a review. Emergency Medicine International, 2011734506. doi:10.1155/2011/734506

Pediatric Stroke: References Continued• Tuckuviene, R. R., Christensen, A. L., Helgestad, J. J., Johnsen, S. P., & Kristensen, S. R. (2011). Paediatric arterial ischaemic

stroke and cerebral sinovenous thrombosis in Denmark 1994-2006: A nationwide population-based study. Acta Paediatrica, 100(4), 543-549. doi:10.1111/j.1651-2227.2010.02100.x

• World Health Organization. (2012). Data. Number of deaths: World. By cause.