ED Acute Pediatric Stroke (2 - 18 years) - Curbside
ED Acute Pediatric Stroke (2 - 18 years)
Editors: Dan Imler, MD, Sarah Lee, Jorina Elbers
Inclusion Criteria  (All criteria are present)
  • Clinical signs of stroke: Weakness or sensory change on one side of the body, vision loss, speech difficulty, dizziness/imbalance/problem with coordination
  • Sudden/Acute onset < 6 hours prior
Exclusion Criteria
  • Unknown last seen normal, or symptom onset > 6 hours prior to presentation

Consult pediatric neurology, institute neuroprotective measures

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Evidence
Total Notes: 7
Evidence

1 Acute stroke in children and adolecents

Stroke is a very uncommon (incidence in infants and children 0.6 to 7.9/100,000 per year), but devastating illness in children and young adults. Stroke does have a male predominance in children of which the cause is unknown. A high clinical suspicion of stroke in patients presenting with concerning symptoms is key to the diagnosis of this disease process.



References:
  1. Cerebrovascular disease in children under 16 years of age in the city of Dijon, France: a study of incidence and clinical features from 1985 to 1993.
    Giroud M, Lemesle M, Gouyon JB, Nivelon JL, Milan C, Dumas R,
    J Clin Epidemiol 1995 Nov;48(11):1343-8.
  2. Stroke in children and sickle-cell disease: Baltimore-Washington Cooperative Young Stroke Study.
    Earley CJ, Kittner SJ, Feeser BR, Gardner J, Epstein A, Wozniak MA, Wityk R, Stern BJ, Price TR, Macko RF, Johnson C, Sloan MA, Buchholz D,
    Neurology 1998 Jul;51(1):169-76.
  3. Paediatric arterial ischaemic stroke and cerebral sinovenous thrombosis in Denmark 1994-2006: a nationwide population-based study.
    Tuckuviene R, Christensen AL, Helgestad J, Johnsen SP, Kristensen SR,
    Acta Paediatr. 2011 Apr;100(4):543-9.
  4. Incidence of stroke in young adults in Florence, Italy.
    Nencini P, Inzitari D, Baruffi MC, Fratiglioni L, Gagliardi R, Benvenuti L, Buccheri AM, Cecchi L, Passigli A, Rosselli A,
    Stroke 1988 Aug;19(8):977-81.
  5. Epidemiology and etiology of ischemic stroke in young adults aged 18 to 44 years in northern Sweden.
    Kristensen B, Malm J, Carlberg B, Stegmayr B, Backman C, Fagerlund M, Olsson T,
    Stroke 1997 Sep;28(9):1702-9.
  6. Black-white differences in stroke risk among young adults.
    Kittner SJ, McCarter RJ, Sherwin RW, Sloan MA, Stern BJ, Johnson CJ, Buchholz D, Seipp MJ, Price TR,
    Stroke 1993 Dec;24(12 Suppl):I13-5; discussion I20-1.
  7. Prospective assessment of risk factors for recurrent stroke during childhood--a 5-year follow-up study.
    Sträter R, Becker S, von Eckardstein A, Heinecke A, Gutsche S, Junker R, Kurnik K, Schobess R, Nowak-Göttl U,
    Lancet 2002 Nov;360(9345):1540-5.
  8. Risk of stroke in children: ethnic and gender disparities.
    Fullerton HJ, Wu YW, Zhao S, Johnston SC,
    Neurology 2003 Jul;61(2):189-94.
  9. Male predominance in childhood ischemic stroke: findings from the international pediatric stroke study.
    Golomb MR, Fullerton HJ, Nowak-Gottl U, Deveber G, Deveber G,
    Stroke 2009 Jan;40(1):52-7.

2 Risk factors for stroke

The etiologies for stroke in children and adolescents vary greatly from the adult population. More than have of patients are previously healthy with no known risk factors. The most prevalent independent risk factor for stroke the week prior to the event is recent infection.



References:
  1. Predictors of cerebral arteriopathy in children with arterial ischemic stroke: results of the International Pediatric Stroke Study.
    Amlie-Lefond C, Bernard TJ, Sébire G, Friedman NR, Heyer GL, Lerner NB, DeVeber G, Fullerton HJ, Fullerton HJ,
    Circulation 2009 Mar;119(10):1417-23.
  2. Arterial ischemic stroke risk factors: the International Pediatric Stroke Study.
    Mackay MT, Wiznitzer M, Benedict SL, Lee KJ, Deveber GA, Ganesan V, Ganesan V,
    Ann. Neurol. 2011 Jan;69(1):130-40.
  3. Investigation of risk factors in children with arterial ischemic stroke.
    Ganesan V, Prengler M, McShane MA, Wade AM, Kirkham FJ,
    Ann. Neurol. 2003 Feb;53(2):167-73.
  4. Prospective assessment of risk factors for recurrent stroke during childhood--a 5-year follow-up study.
    Sträter R, Becker S, von Eckardstein A, Heinecke A, Gutsche S, Junker R, Kurnik K, Schobess R, Nowak-Göttl U,
    Lancet 2002 Nov;360(9345):1540-5.
  5. Recent trauma and acute infection as risk factors for childhood arterial ischemic stroke.
    Hills NK, Johnston SC, Sidney S, Zielinski BA, Fullerton HJ,
    Ann. Neurol. 2012 Dec;72(6):850-8.
  6. Infection, vaccination, and childhood arterial ischemic stroke: Results of the VIPS study.
    Fullerton HJ, Hills NK, Elkind MS, Dowling MM, Wintermark M, Glaser CA, Tan M, Rivkin MJ, Titomanlio L, Barkovich AJ, deVeber GA, deVeber GA,
    Neurology 2015 Oct;85(17):1459-66.

3 Stroke Code

One of the key drives of outcomes in acute stroke management is early evaluation and treatment of stroke with supportive and reversible therapies. In the adult literature rapid assessment measures ("Stroke Codes") have been shown to improve outcomes in patients. The pediatric literature has shown that the median time from presentation to diagnosis of stroke in children is almost 24 hours, with in-hospital delays accounting
for the largest proportion of this time. Pediatric patients would likely benefit from similar systems of early, rapid assessment and care as adults.



References:
  1. The Pediatric Stroke Code: Early Management of the Child with Stroke.
    Elbers J, Wainwright MS, Amlie-Lefond C,
    J. Pediatr. 2015 Jul;167(1):19-24.e1-4.
  2. Stroke units, tissue plasminogen activator, aspirin and neuroprotection: which stroke intervention could provide the greatest community benefit?
    Gilligan AK, Thrift AG, Sturm JW, Dewey HM, Macdonell RA, Donnan GA,
    Cerebrovasc. Dis. 2005;20(4):239-44.
  3. Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. Stroke Unit Trialists' Collaboration.

    BMJ 1997 Apr;314(7088):1151-9.
  4. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
    Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H, Yonas H, Yonas H, Yonas H, Yonas H,
    Stroke 2013 Mar;44(3):870-947.
  5. The effect of a stroke unit: reductions in mortality, discharge rate to nursing home, length of hospital stay, and cost. A community-based study.
    Jřrgensen HS, Nakayama H, Raaschou HO, Larsen K, Hübbe P, Olsen TS,
    Stroke 1995 Jul;26(7):1178-82.
  6. Stroke unit treatment. Long-term effects.
    Indredavik B, Slřrdahl SA, Bakke F, Rokseth R, Hĺheim LL,
    Stroke 1997 Oct;28(10):1861-6.
  7. Treatment and rehabilitation on a stroke unit improves 5-year survival. A community-based study.
    Jřrgensen HS, Kammersgaard LP, Nakayama H, Raaschou HO, Larsen K, Hübbe P, Olsen TS,
    Stroke 1999 May;30(5):930-3.
  8. Delay to diagnosis in acute pediatric arterial ischemic stroke.
    Rafay MF, Pontigon AM, Chiang J, Adams M, Jarvis DA, Silver F, Macgregor D, Deveber GA,
    Stroke 2009 Jan;40(1):58-64.
  9. Influence of the stroke code activation source on the outcome of acute ischemic stroke patients.
    de la Ossa NP, Sánchez-Ojanguren J, Palomeras E, Millán M, Arenillas JF, Dorado L, Guerrero C, Abilleira S, Dávalos A,
    Neurology 2008 Apr;70(15):1238-43.




  10. Code stroke. An attempt to shorten inhospital therapeutic delays.
    Gomez CR, Malkoff MD, Sauer CM, Tulyapronchote R, Burch CM, Banet GA,
    Stroke 1994 Oct;25(10):1920-3.
  11. "Code stroke": hospitalized versus emergency department patients.
    El Husseini N, Goldstein LB,
    J Stroke Cerebrovasc Dis 2013 May;22(4):345-8.
  12. The "DeyeCOM Sign": Predictive Value in Acute Stroke Code Evaluations.
    Coffman CR, Raman R, Ernstrom K, Herial NA, Schlick KH, Rapp K, Modir RF, Meyer DM, Hemmen TM, Meyer BC,
    J Stroke Cerebrovasc Dis 2015 Jun;24(6):1299-304.
  13. Call a stroke code!
    Miller J, Elmore S,
    Nursing 2005 Mar;35(3):58-63; quiz 63-4.

4 Neuroprotective measures

Besides initial resuscitation measures, there are specific issues related to stroke that should be immediately implemented in patients where stroke is of concern. Many of these measures are brought from the adult literatures as there have been few studies in the pediatric literature.

  • Fluids: Patients with stroke are often hypovolemic which may impair cerebral blood flow. isotonic saline without dextrose is the fluid of choice. Hypotonic fluids may exacerbate cerebral edema.
  • Hypoglycemia/Hyperglycemia: Should be avoided in patients. Either case may exacerbate neuronal injury. Normoglycemia is the goal.
  • Head and body position: Elevation of the head of bed may decrease intracranial pressure and decrease the risk of aspiration, but during acute stroke, cerebral bloodflow is of utmost importance and the patient should remain flat if possible.
  • Temperature: Hyperthermia may worsen cerebral ischemia and the use of NSAIDs may be useful. Induced hypothermia is not currently recommended.


References:
  1. 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.
    Roach ES, Golomb MR, Adams R, Biller J, Daniels S, Deveber G, Ferriero D, Jones BV, Kirkham FJ, Scott RM, Smith ER, Smith ER, Smith ER,
    Stroke 2008 Sep;39(9):2644-91.
  2. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
    Monagle P, Chan AK, Goldenberg NA, Ichord RN, Journeycake JM, Nowak-Göttl U, Vesely SK, Vesely SK,
    Chest 2012 Feb;141(2 Suppl):e737S-801S.
  3. The Pediatric Stroke Code: Early Management of the Child with Stroke.
    Elbers J, Wainwright MS, Amlie-Lefond C,
    J. Pediatr. 2015 Jul;167(1):19-24.e1-4.
  4. The hydration influence on the risk of stroke (THIRST) study.
    Rodriguez GJ, Cordina SM, Vazquez G, Suri MF, Kirmani JF, Ezzeddine MA, Qureshi AI,
    Neurocrit Care 2009;10(2):187-94.
  5. Intensive care management of acute ischemic stroke.
    Burns JD, Green DM, Metivier K, DeFusco C,
    Emerg. Med. Clin. North Am. 2012 Aug;30(3):713-44.
  6. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
    Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H, Yonas H, Yonas H, Yonas H, Yonas H,
    Stroke 2013 Mar;44(3):870-947.
  7. Is hyperglycaemia an independent predictor of poor outcome after acute stroke? Results of a long-term follow up study.
    Weir CJ, Murray GD, Dyker AG, Lees KR,
    BMJ 1997 May;314(7090):1303-6.
  8. Acute blood glucose level and outcome from ischemic stroke. Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators.
    Bruno A, Biller J, Adams HP, Clarke WR, Woolson RF, Williams LS, Hansen MD,
    Neurology 1999 Jan;52(2):280-4.
  9. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview.
    Capes SE, Hunt D, Malmberg K, Pathak P, Gerstein HC,
    Stroke 2001 Oct;32(10):2426-32.
  10. Abnormal glucose metabolism in non-diabetic patients presenting with an acute stroke: prospective study and systematic review.
    Dave JA, Engel ME, Freercks R, Peter J, May W, Badri M, Van Niekerk L, Levitt NS,
    QJM 2010 Jul;103(7):495-503.
  11. The deleterious effect of admission hyperglycemia on survival and functional outcome in patients with intracerebral hemorrhage.
    Béjot Y, Aboa-Eboulé C, Hervieu M, Jacquin A, Osseby GV, Rouaud O, Giroud M,
    Stroke 2012 Jan;43(1):243-5.
  12. Hyperglycemia in acute stroke.
    Lindsberg PJ, Roine RO,
    Stroke 2004 Feb;35(2):363-4.
  13. Acute hyperglycemia adversely affects stroke outcome: a magnetic resonance imaging and spectroscopy study.
    Parsons MW, Barber PA, Desmond PM, Baird TA, Darby DG, Byrnes G, Tress BM, Davis SM,
    Ann. Neurol. 2002 Jul;52(1):20-8.
  14. European Stroke Initiative Recommendations for Stroke Management-update 2003.
    Olsen TS, Langhorne P, Diener HC, Hennerici M, Ferro J, Sivenius J, Wahlgren NG, Bath P,
    Cerebrovasc. Dis. 2003;16(4):311-37.
  15. Effects of body position on intracranial pressure and cerebral perfusion in patients with large hemispheric stroke.
    Schwarz S, Georgiadis D, Aschoff A, Schwab S,
    Stroke 2002 Feb;33(2):497-501.
  16. Heads down: flat positioning improves blood flow velocity in acute ischemic stroke.
    Wojner-Alexander AW, Garami Z, Chernyshev OY, Alexandrov AV,
    Neurology 2005 Apr;64(8):1354-7.
  17. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: a scientific statement from the American Heart Association.
    Summers D, Leonard A, Wentworth D, Saver JL, Simpson J, Spilker JA, Hock N, Miller E, Mitchell PH, Mitchell PH,
    Stroke 2009 Aug;40(8):2911-44.
  18. Combating hyperthermia in acute stroke: a significant clinical concern.
    Ginsberg MD, Busto R,
    Stroke 1998 Feb;29(2):529-34.
  19. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.
    Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN, Macdonald RL, Mitchell PH, Scott PA, Selim MH, Woo D, Woo D, Woo D, Woo D,
    Stroke 2015 Jul;46(7):2032-60.
  20. The Paracetamol (Acetaminophen) In Stroke (PAIS) trial: a multicentre, randomised, placebo-controlled, phase III trial.
    den Hertog HM, van der Worp HB, van Gemert HM, Algra A, Kappelle LJ, van Gijn J, Koudstaal PJ, Dippel DW, Dippel DW,
    Lancet Neurol 2009 May;8(5):434-40.
  21. Cooling therapy for acute stroke.
    Den Hertog HM, van der Worp HB, Tseng MC, Dippel DW,
    Cochrane Database Syst Rev 2009(1):CD001247.

5 IV thrombolysis

There have been very few studies on using IV thrombolysis for the treatment of stroke in children. The decision to use thrombolysis should be done in close consultation with a pediatric neurologist.



References:
  1. Successful treatment for stroke in a child using recombinant tissue plasminogen activator.
    Thirumalai SS, Shubin RA,
    J. Child Neurol. 2000 Aug;15(8):558.
  2. Intra-arterial thrombolysis for the treatment of perioperative childhood cardioembolic stroke.
    Gruber A, Nasel C, Lang W, Kitzmüller E, Bavinzski G, Czech T,
    Neurology 2000 Apr;54(8):1684-6.
  3. Successful use of rt-PA in pediatric stroke.
    Carlson MD, Leber S, Deveikis J, Silverstein FS,
    Neurology 2001 Jul;57(1):157-8.
  4. Successful endovascular therapy for acute basilar thrombosis in an adolescent.
    Kirton A, Wong JH, Mah J, Ross BC, Kennedy J, Bell K, Hill MD,
    Pediatrics 2003 Sep;112(3 Pt 1):e248-51.
  5. Successful intravenous thrombolysis for acute stroke in a child.
    Ortiz GA, Koch S, Wallace DM, Lopez-Alberola R,
    J. Child Neurol. 2007 Jun;22(6):749-52.
  6. Bacterial endocarditis in a child presenting with acute arterial ischemic stroke: should thrombolytic therapy be absolutely contraindicated?
    Tan M, Armstrong D, Birken C, Bitnun A, Caldarone CA, Cox P, Kahr W, Macgregor D, Askalan R,
    Dev Med Child Neurol 2009 Feb;51(2):151-4.
  7. Local intra-arterial thrombolysis in a 4-year-old male with vertebrobasilar artery thrombosis.
    Janmaat M, Gravendeel JP, Uyttenboogaart M, Vroomen PC, Brouwer OF, Luijckx GJ,
    Dev Med Child Neurol 2009 Feb;51(2):155-8.
  8. Thrombolysis in childhood stroke: report of 2 cases and review of the literature.
    Arnold M, Steinlin M, Baumann A, Nedeltchev K, Remonda L, Moser SJ, Mono ML, Schroth G, Mattle HP, Baumgartner RW,
    Stroke 2009 Mar;40(3):801-7.
  9. The Pediatric Stroke Code: Early Management of the Child with Stroke.
    Elbers J, Wainwright MS, Amlie-Lefond C,
    J. Pediatr. 2015 Jul;167(1):19-24.e1-4.
  10. A randomized trial of intraarterial treatment for acute ischemic stroke.
    Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJ, van Walderveen MA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama ŕ Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach HZ, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YB, van der Lugt A, van Oostenbrugge RJ, Majoie CB, Dippel DW, Dippel DW,
    N. Engl. J. Med. 2015 Jan;372(1):11-20.
  11. Thrombolysis for children with acute ischemic stroke: a perspective from the kids' inpatient database.
    Alshekhlee A, Geller T, Mehta S, Storkan M, Al Khalili Y, Cruz-Flores S,
    Pediatr. Neurol. 2013 Nov;49(5):313-8.
  12. Use and in-hospital outcomes of recombinant tissue plasminogen activator in pediatric arterial ischemic stroke patients.
    Nasr DM, Biller J, Rabinstein AA,
    Pediatr. Neurol. 2014 Nov;51(5):624-31.
  13. Use of alteplase in childhood arterial ischaemic stroke: a multicentre, observational, cohort study.
    Amlie-Lefond C, deVeber G, Chan AK, Benedict S, Bernard T, Carpenter J, Dowling MM, Fullerton H, Hovinga C, Kirton A, Lo W, Zamel K, Ichord R, Ichord R,
    Lancet Neurol 2009 Jun;8(6):530-6.
  14. Emergence of the primary pediatric stroke center: impact of the thrombolysis in pediatric stroke trial.
    Bernard TJ, Rivkin MJ, Scholz K, deVeber G, Kirton A, Gill JC, Chan AK, Hovinga CA, Ichord RN, Grotta JC, Jordan LC, Benedict S, Friedman NR, Dowling MM, Elbers J, Torres M, Sultan S, Cummings DD, Grabowski EF, McMillan HJ, Beslow LA, Amlie-Lefond C, Amlie-Lefond C,
    Stroke 2014 Jul;45(7):2018-23.

6 Thrombectomy

There is little literature about the use of mechanical thrombectomy in the treatment of pediatric stroke. Close consultation with pediatric neurology and interventional radiology should be considered in cases where thrombectomy may be useful.



References:
  1. 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.
    Powers WJ, Derdeyn CP, Biller J, Coffey CS, Hoh BL, Jauch EC, Johnston KC, Johnston SC, Khalessi AA, Kidwell CS, Meschia JF, Ovbiagele B, Yavagal DR, Yavagal DR,
    Stroke 2015 Oct;46(10):3020-35.


  2. The Pediatric Stroke Code: Early Management of the Child with Stroke.
    Elbers J, Wainwright MS, Amlie-Lefond C,
    J. Pediatr. 2015 Jul;167(1):19-24.e1-4.

7 Clinical findings

The clinical presentation of acute stroke may be subtle and sometimes confusing. Patients with unexplained seizures, altered mental status and focal weakness should be strongly considered for acute stroke. Younger children are more likely to present with global findings (seizures, altered mental status) rather than older children who more often present with focal findings. In patients with subtle findings, emergent consultation with a pediatric neurologist may be useful.



References:
  1. The Pediatric Stroke Code: Early Management of the Child with Stroke.
    Elbers J, Wainwright MS, Amlie-Lefond C,
    J. Pediatr. 2015 Jul;167(1):19-24.e1-4.
  2. Age-related variation in presenting signs of childhood arterial ischemic stroke.
    Zimmer JA, Garg BP, Williams LS, Golomb MR,
    Pediatr. Neurol. 2007 Sep;37(3):171-5.
  3. Arterial ischemic strokes in infants and children: an overview of current approaches.
    deVeber G,
    Semin. Thromb. Hemost. 2003 Dec;29(6):567-73.
  4. Seizures are common in the acute setting of childhood stroke: a population-based study.
    Chadehumbe MA, Khatri P, Khoury JC, Alwell K, Szaflarski JP, Broderick JP, Kissela BM, Kleindorfer DO,
    J. Child Neurol. 2009 Jan;24(1):9-12.
  5. Seizures as a presenting symptom of acute arterial ischemic stroke in childhood.
    Abend NS, Beslow LA, Smith SE, Kessler SK, Vossough A, Mason S, Agner S, Licht DJ, Ichord RN,
    J. Pediatr. 2011 Sep;159(3):479-83.
  6. Acute childhood arterial ischemic and hemorrhagic stroke in the emergency department.
    Yock-Corrales A, Mackay MT, Mosley I, Maixner W, Babl FE,
    Ann Emerg Med 2011 Aug;58(2):156-63.