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 and 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. Peri natal, 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 23 to 5000 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. Thes estimates also include both ischemic and hemorrhagic stroke. In adults, approximately 80% of strokes are ischemic, whereas in Children it's probably closer to 50 50 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. Um, 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 theme 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 ah, presentation with neonatal seizures. Some infants also will have encephalopathy, and a number of Children who have a stroke of 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 Peri Natal 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 haven't 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 syndrome zehr often similar to the pattern that you expect to see in adults, um, 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 court old enough to tell us about it do complain of a headache. The other key difference is that seizures are very common in Children who have an acute ischemic stroke about 5 to 10% maybe closer to 5% of adults who who present with an acute ischemic stroke, have a seizure at the onset and Children. This is almost a third, and it's age dependent. So the younger you are, um, 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 having 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 a childhood stroke. However, it's important to know that ah, large proportion of the Children that we see with an acute ischemic stroke was previously healthy within the previously healthy Children are acquired. Arterial Path These are the most common causes. These could be either intracranial arterial apathy. These, um, and inflammatory arterial pithy that's post infectious or can be a more progressive arterial pithy like Moya Moya or a congenital arterial, pithy extra Crennel or cervical artery apathy czar. 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. Um, 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 with ease. Arterial wall imaging also may be helpful to look for inflammatory artery aapa thes and conventional angiogram is usually reserved for those who have a suspected Nyamweya syndrome from Ophelia work up. Maybe important because, um, 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 antique robotic 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 Ophelia's. One of the important pieces that I like to emphasize when talking about pediatric stroke is the importance of having of 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, Um, 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 scheme IQ stroke, and once Children do come to the hospital there. 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, uh, to be thought that they have 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 in 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 thrum Bill Isis 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 acute stroke therapy, and we know that it's likely that in Children just like adults, the earlier we can reap refuse the brain, the better the outcome. Most pediatric stroke centers also recommend more stringent diagnostic imaging compared to adults if considering hyper acute stroke treatment. What I mean by this is that, um, a non contrast head C T 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 thrum Bill Isis or thrown back to me. And it's important to know that currently Ivy, Trumbull, Isis and Endovascular thrown back to me are not considered standard of care in Children. The reason for this is that the risk benefit of on the throat I've crumble Isis or mechanical and elect me are really unknown. There's been limited data, Um, and for thrum Bill Isis, there's a lack of dozing and safety data and Children. Um, the last point is that especially with endovascular thrown back to me, um, I worry that in considering the risk benefit ratio that thrown back to me may not be beneficial in some childhood arterial path ease while the risk may be greater, So is there a rationale for hyper acute stroke treatment and Children? I think the largest is the well established efficacy in adults. And the path of physiology and path of physiology in Children may also be favorable because Children frequently have large vessel strokes that could benefit from re profusion. Currently, many pediatric stroke centers in the U. S. They consider hyper acute stroke treatment in Children. In some cases, some would consider, I Vaeth Rumble Isis within 4.5 hours using UM, 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 2000 and eight, when the scientific Statement for the Management of Stroke and Infants and Children said that until additional safety and efficacy data were available from Bill, Isis was generally not recommended outside of a clinical trial However, even in 2000 and eight, there was no consensus in the scientific in the writers of the scientific statement about crumble Isis and older adults who otherwise meet standard adult eligibility criteria. Then, in 2000 and 15, when a number of large multi center adult trials and endovascular thrum back 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 thrown back 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 in 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 on DSO, the 2019 scientific statement gave a few parameters. They suggested that throwing back to me might be, um, something to consider if there were persistent disabling neurologic deficits with radiographic. Lee confirmed large artery occlusion enlarger Children and when the treatment decision was made in conjunction with Neurologist of expertise in the treatment with Children, treatment of Children with stroke and if the intervention could be performed by an Endo vascular 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 acute stroke treatment and Children may be available, it's important to remember that this is an emergency image ing. 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 image ing should I perform? And M R I M R A minimizes radiation. It could distinguish stroke from stroke mimics very well. Um, and as um, imaging has become more readily available across centers. Some have, um, developed focused stroke protocols that shortened 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 CT perfusion is typically what we reach for adults who have a acute stroke. SETI 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 discuss, does the child have peace or wires or hardware that may not be Emery compatible? My advice is generally to, um, 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 oppa thes whatever the cause of the ischemic stroke meaning, whether it is cardio, metabolic or there's an underlying throb. 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 and Children and choice of anti thematic 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, Um, with some extending up to two years after the, uh, the initial stroke. So this is the usual time period in which an anti from biotic is recommended. Choice of anti platelet versus anticoagulants is depended on the ideology of the stroke. And, um, typically is something, um, that can be discussed between a vascular neurologist and 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 anti from biotic, the risk of recurrence is much higher. The duration of anti thrum Batic treatment is dependent upon ideology. I often recommendation longer duration if there is a persistent artery apathy, if there's underlying cardiac disease, or if we know that there is a severe throwem Ophelia, Of course, in sickle cell disease, um, 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 pithy 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, neuro, 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, we'll 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 he mythology 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 and learning a little bit about acute ischemic stroke in Children. Thank you for your time
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