Recovery for Ischemic Cerebrovascular Disease in Children

Postoperative Orders

• PICU admission: Postprocedurally for endovascular treatment and postoperatively for decompressive craniectomy, admit the patient to the PICU or stroke unit for close observation.
• Vital signs: Continuous hemodynamic monitoring is necessary, given the need to closely monitor blood pressure and other vital signs.
• Neurological exam: Perform hourly neurological exams to assess the patient’s neurological status.
• Blood pressure parameters: A U-shaped relationship between the mean postrecanalization systolic blood pressure and mortality has been found in adult patients treated using mechanical thrombectomy (243). Given that normal blood pressure ranges are variable by age and height in the pediatric population, a singular blood pressure range target cannot be defined, but normotension or modest permissive hypertension (adjusted for the patient’s age and height) is likely reasonable. For patients with elevated ICP, maintain the mean arterial pressure (MAP) at least 10 mm Hg above the normal MAP range (adjusted for age and height) to maintain cerebral perfusion pressure (244).
• IV fluids: Maintain euvolemia and normoglycemia. If there is concern for elevated ICP, hyperosmolar therapy may be required and should be made available.
• Ventilator support: Postprocedurally for endovascular treatment, patients who meet standard extubation criteria can likely be extubated safely (229). Ventilation may be required for patients who do not meet these criteria, and ventilation is likely required for postcraniectomy patients given their neurological deficits and hemodynamic instability. Adjust FiO2 to maintain SpO2 >94%.
• ICP parameters: Monitor all patients for signs of elevated ICP via serial neurological exams. ICP targets are poorly defined for postcraniectomy pediatric patients, but findings from adult patients suggest that lower postoperative ICPs are associated with more favorable outcomes, with some authors suggesting a favorable range of 10 to 17 mm Hg (245,246).
• Diet: Maintain normoglycemia, although advancement of diet must be carefully approached on a case-by-case basis, as patients may have dysphagia or altered level of consciousness and may require enteral feeding (247).
• Positioning and activity: After endovascular treatment, the patient should lie flat for at least 2 hours to ensure access-site hemostasis has occurred. Check the dorsalis pedis and posterior tibial pulses frequently to ensure thrombosis has not occurred. Elevate the HOB for patients with an elevated ICP and/or on ventilatory support. Prematurely encouraging patient activity may not be advisable: a trial of adult stroke patients suggested that very early and/or high frequency mobilization may be associated with lower odds of favorable outcomes (248).
• Medications: As described in the Presentation section, ensure antihypertensives are available for use. For critically ill patients, it may be reasonable to consider use of a proton pump inhibitor, bowel regimen, and DVT prophylaxis (247). Initiate or continue use of either antiplatelet (aspirin) or anticoagulation (low-molecular-weight heparin or unfractionated heparin); the latter category of drugs is preferred for patients with pediatric ischemic stroke due to thrombophilic or cardiac etiologies (62).
• Laboratory studies: CBC, urea and electrolytes; PT/INR and PTT; serum glucose; venous or capillary blood gas; and etiology-specific labs may be collected postprocedurally or postoperatively.
• Electroencephalogram: Given the high risk of seizures in children who suffered ischemic stroke, EEG should be initiated (227).
• Imaging: Conduct serial imaging, preferably with MRI to avoid the risk of radiation exposure with CT (227). PWI MRI may be especially useful to reveal persistent perfusion abnormalities in patients who have underwent endovascular treatment (249).
• Consultations: Patients with pediatric ischemic stroke should be evaluated by a team of specialists, including pediatric neurologists, hematologists, rheumatologists, cardiologists, and cardiac surgeons. The precise combination depends on the suspected etiology of the stroke. Some patients may require rehabilitation, so physical, occupational, and/or speech therapy consultation should be considered.

Postoperative Morbidity

• Risk of injury due to absence of bone flap: Decompressive craniotomies inherently involve removal of a bone flap and storage of the flap for future cranioplasty. This places the patient at risk of direct mechanical injury to the decompressed region, which may lead to brain injury (239). The decompressed area should be clearly marked or otherwise indicated in the patient’s room/bed, and both providers and family members should be educated regarding the implications of this morbidity.