Ischemic Cerebrovascular Disease in Children Homepage

Authors

Zsombor Gal, BA
Nicole Perez, BA
Shahaan Razak, BS, MSEd
Ari Kappel, MD
Brandon Rocque, MD

Section Editors

Edward Smith, MD
Gianpiero Tamburrini, MD
Alfred Pokmeng See, MD

Editor in Chief

Rick Abbott, MD

Introduction

Whereas ischemic cerebrovascular disease is a major source of neurologic morbidity and mortality in the adult population, pediatric ischemic stroke is rare and, as a result, less well understood than ischemic stroke in adults. Nevertheless, if not promptly recognized and appropriately treated, pediatric ischemic stroke may be devastating.

Pediatric ischemic stroke may present as either arterial ischemic stroke or cerebral venous thrombosis. Both are associated with a variety of etiologies, including arteriopathy, sickle cell hemoglobinopathy, CHD, arterial dissection, coagulopathies, and infection. An important cause of cerebral ischemia in children is moyamoya disease. Recognition of pediatric ischemic stroke requires a thorough physical examination and the use of numerous imaging techniques. Treatment is informed by the adult literature, may be variable depending on patient status and resource availability, and includes medical management, a range of adjunctive therapies, and/or endovascular interventions. Appropriate follow-up and secondary stroke prevention are crucial. Trials or registries focused on the pediatric population are needed to improve the management of pediatric ischemic stroke.

Key Points

• Rare but potentially devastating: Pediatric ischemic stroke is estimated to have an incidence rate of fewer than 10 cases per 100,000 children per year. However, ischemic stroke in children may lead to permanent neurological deficits or even death if not swiftly recognized and treated.
• Etiologies vary: Sources of cerebral ischemia in children include arterial ischemic stroke and CVST. Etiologies include, but are not limited to, coagulopathies, sickle cell hemoglobinopathy, CHD, metabolic disorders, infection, craniocervical arterial dissection, and noninfectious vasculitides. Determination of etiology is important for secondary stroke prevention.
• All age groups are affected: Although some etiologies of pediatric ischemic stroke are more common in certain age groups, ischemic stroke may occur in neonates, infants, children, and adolescents.
• Rapid recognition is important: Recognition and treatment of stroke in the pediatric population requires awareness and swift action on the part of the clinician. A thorough history and physical examination are necessary. Imaging modalities used in diagnosis include CT, MRI, and catheter-based cerebral angiography.
• Treatment varies: Depending on the clinical status of the patient and stroke etiology, treatment may include medical management, adjunctive therapies (including thrombolytics, anticoagulant medications, antiplatelet drugs, and drugs indicated for underlying conditions), and/or endovascular interventions (including mechanical thrombectomy and intraarterial thrombolysis). Decompressive craniectomy may be required, but such cases are rare.
• Outcomes are improving: Within the past few decades, more effective stroke care for children has reduced stroke-specific mortality and stroke recurrence.