Management of Ischemic Cerebrovascular Disease in Children

Initial Management at Presentation

• Urgent evaluation and workup: Any child presenting with suspected ischemic stroke, regardless of etiology, should be urgently evaluated (see Evaluation at Presentation).
• Stabilization and preparation for definitive intervention: As described in Intervention at Presentation, stabilization may be achieved via the ABCDE approach. Decisions regarding further management are informed by the exam, laboratory studies, and imaging (see Evaluation at Presentation).
• Management is variable: The goal of pediatric ischemic stroke management is preservation of brain tissue and prevention of future stroke (62). The urgency of intervention is largely determined by the clinical picture and the patient’s stability. The etiology may inform specific management decisions, which are highly variable.

Adjunctive Therapies

• Adjunctive therapies vary by presentation and etiology: Adjunctive therapies for pediatric stroke are highly variable and are discussed in greater detail in Adjuvant Therapies for Ischemic Cerebrovascular Disease in Children). Their selection depends on the patient’s clinical status and the etiology of their stroke.
• Medication-based treatments: Adjunctive therapies include the use of thrombolytics, anticoagulant medications, antiplatelet drugs, and drugs indicated for underlying conditions such as sickle cell hemoglobinopathy and vasculitis.
• Surgical interventions: Neurosurgical expertise is required for patients who require endovascular intervention such as thrombectomy. Consultation with cardiac surgery may be required for patients with CHD.

Follow-up

• Variable by etiology and patient status: Follow-up schedules are variable by institution and may be informed by stroke etiology and patient status upon recovery.
• Specialist consultations: Patients may be referred to additional specialists, including stroke neurologists, cardiac surgeons, hematologists, and rheumatologists. Patients with persistent neurological deficits and/or developmental delay may require follow-up with physical, occupational, and/or speech therapists, in addition to developmental-behavioral pediatricians and/or neuropsychologists.
• Imaging: Early interval imaging during initiation of secondary stroke prevention may range from a few days to a week, followed by interval clinical and radiological evaluation every few months for the first year and annually thereafter.