Cerebrovascular complications are being frequently recognized in the pediatric intensive care unit in the recent few years. The epidemiology and risk factors for pediatric stroke are different from that of the adults. The incidence of ischemic stroke is almost slightly more than that of hemorrhagic stroke. The list of diagnostic causes is increasing with the availability of newer imaging modalities and laboratory tests. The diagnostic work up depends on the age of the child and the rapidity of presentation. Magnetic resonance imaging, computerized tomography and arteriography and venography are the mainstay of diagnosis and to differentiate between ischemic and hemorrhagic events. Very sophisticated molecular diagnostic tests are required in a very few patients. There are very few pediatric studies on the management of stroke. General supportive management is as important as the specific treatment. Most of the treatment guidelines and suggestions are extrapolated from the adult studies. Few guidelines are available for the use of anticoagulants and thrombolytic agents in pediatric patients. So, our objective was to review the available literature on the childhood stroke and to provide an insight into the subject for the pediatricians and critical care providers.
Schoenberg BS, Mellinger JF, Schoenberg DG. Cerebrovascular disease in infants and children: A study of incidence, clinical features, and survival. Neurology 1978;28:763-8.
Broderick J, Talbot T, Prenger E, Leach A, Brott T. Stroke in children within a major metropolitan area: The surprising importance of intracerebral hemorrhage. J Child Neurol 1993;8:250-5.
Deveber GA, Adams M, Andrew M. Canadian pediatric ischemic stroke registry. Can J Neurol Sci 1995;22:S24.
Nicolaides P, Appleton RE. Stroke in children. Dev Med Child Neurol 1996;38:172-180.
Mancini J, Girard N, Chabrol B. Ischemic cerebrovascular disease in children: Retrospective study of 35 patients. J Child Neurol 1997;12:193-9.
Kerr LM, Anderson DM, Thompson JA, Lyver SM, Call GK. Ischemic stroke in the young: Evaluation and age comparison of patients six months to thirty-nine years. J Child Neurol 1993;8:266-70.
Roach ES, Riela AR. Pediatric Cerebrovascular Disorders. 2nd ed. New York: Futura; 1995. p. 359.
Johnston IH, Whittle IR, Besser M, Morgan MK. Vein of galen malformation: Diagnosis and management. Neurosurgery 1987;20:747-58.
Menezes AH, Graf CJ, Jacoby CG, Cornell SH. Management of veinof Galen aneurysms: Report of two cases. J Neurosurg 1981;55:457-62.
Portnoy BA, Herion JC. Neurological manifestations in sickle-cell disease - with a review of the literature and emphasis on the prevalence of hemiplegia. Ann Intern Med 1972;76:643-52.
Balkaran B, Char G, Morris JS, Thomas PW, Serjeant BE, Serjeant GR. Stroke in a cohort of patients with homozygous sickle cell disease. J Pediatr 1992;120:360-6.
Vomberg PP, Breederveld C, Fleury P, Arts WF. Cerebral thromboembolism due to antithrombin III deficiency in two children. Neuropediatrics 1987;18:42-4.
Koh S, Chen LS. Protein C and S deficiency in children with ischemic cerebrovascular accident. Pediatr Neurol 1997;17:319-21.
Montes de Oca MA, Babron MC, Bletry O, Broyer M, Courtecuisse V, Fontaine JL, et al. Thrombosis in systemic lupus erythematosus: A French collaborative study. Arch Dis Child 1991;66:713-7.
Selhub J, Jaques PF, Bostom AG, D′Agostino RB, Wilson PW, Belanger AJ, et al. Association between plasma homocysteine concentrations and extracranial carotid-artery stenosis. N Engl J Med 1995;268:877-81.
Schoffner JM. Mitochondrial myopathy diagnosis. Neurol Clin 2000;18:105-23.
Suzuki J, Kodama N. Moyamoya disease: A review. Stroke 1983;14:104-9.
Golden G. Cerebrovascular disease. In. Pediatric neurological diseases. Ed. Swaiman K. CV Mosby, St Louis. 1989, pp 603-617.
Deveber G, Andrew M. Cerebral sinovenous thrombosis in children. N Engl J Med 2001;345:417-23.
Lin CC, Lui CC, Tain YL. Thalamic stroke secondary to straight sinus thrombosis in a nephrotic child. Pediatr Nephrol 2002;17:184-6.
Keane S, Gallagher A, Ackroyd S, McShane MA, Edge JA. Cerebral venous thrombosis during diabetic ketoacidosis. Arch Dis Child 2002;86:204-5.
Garcia JH, Ho Khang-Loon, Pantoni L. Pathology in Barnett. In: Henry JM, Mohr JP, Stein BM, Yatsu FM, editors. Stroke Pathophysiology, Diagnosis and Management. 3rd ed. Philadelphia, PA: Churchill Livingston; 1998.
Tresher WH. Ischemic stroke syndromes in childhood. Pediatr Ann 1992;21:374-83.
Yamamoto H, Bogousslavsky J, van Melle G. Different predictors of neurological worsening in different causes of stroke. Arch Neurol 1998;55:481-6.
Hakim AM. Ischemic penumbra, the therapeutic window. Neurology 1998;51:S44-6.
Becker KJ. Inflammation and acute stroke. Curr Opin Neurol 1998;11:45-9.
Hademenos GJ, Massoud TF. Biophysical mechanisms of stroke. Stroke 1997;28:2067-77.
Abram HS. Vascular Disease. In: David B, editor. Child and Adolescent Neurology. St. Louis: Mosby; 1998. p. 271-93.
Yang JS, Park YD, Hartlage PL. Seizures associated with stroke in childhood. Pediatr Neurol 1995;12:136-8.
Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R. Malignant middle cerebral artery territory infarction: Clinical course and prognostic signs. Arch Neurol 1996;53:309-15.
Brust CM, Chamorro A. Anterior cerebral artery diseases. In: Mohr JP, Choi DW, Grotta JC, Weir B, Wolf PA, editors. Stroke Pathophysiology, Diagnosis and Management. 4th ed. Philadelphia, PA: Churchill Livingston; 2004. p. 101-11.
Sean I, Savitz MD, Louis R, Caplan MD. Verterbrobasilar disease. N Engl J Med 2005;352:2618-26.
Rosman NP, Wu JK, Caplan LR. Cerebellar infarction in the young. Stroke 1992;23:763-6.
Baumgartner RW, Sidler C, Mosso M, Georgiadis D. Ischemic lacunar stroke in patients with and without potential mechanism other than small-artery disease. Stroke 2003;34:653-9.
Samuel J, Fernandes CM. Lateral sinus thrombosis (a review of 45 cases). J Laryngol Otol 1987;101:1227-9.
Leker RR, Steiner I. Features of dural sinus thrombosis simulating pseudotumor cerebri. Eur J Neurol 1999;6:601-4.
Roach ES, Meredith R, Golomb MR, Adams R, Biller J, Daniels S, et al. Management of stroke in infants and children. Stroke 2008;39:2644-691.
Castillo J. Deteriorating stroke: Diagnostic criteria, predictors, mechanisms and treatment. Cerebrovasc Dis 1999;9:1-8.
Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al. Guidelines for the early management of adults with ischemic stroke: A guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Circulation 2007;115:e478-534.
Treib J, Grauer MT, Woessner R, Morgenthaler M. Treatment of stroke on an intensive stroke unit: a novel concept. Intensive Care Med 2000;26:1598-611.
Castillo J, Leira R, Garcia MM, Serena J, Blanco M, Davalos A. Blood pressure decrease during the acute phase of ischemic stroke is associated with brain injury and poor stroke outcome. Stroke 2004;35:520-6.
Konstantinos Spengos K, Tsivgoulis G, Zakopoulos N. Blood pressure management in acute stroke. Eur Neurol 2006;55:123-35.
Ginsberg MD, Busto R. Combating hyperthermia in acute stroke: A significant clinical concern. Stroke 1998;29:529-34.
Correia M, Silva M, Veloso M. Cooling therapy for acute stroke. Cochrane Database Syst Rev 2000;CD001247.
Thoresen M, Whitelaw A. Therapeutic hypothermia for hypoxic-ischaemic encephalopathy in the newborn infant. Curr Opin Neurol 2005;18:111-6.
Baird TA, Parsons MW, Phanh T, Butcher KS, Desmond PM, Tress BM, et al. Persistent poststroke hyperglycemia is independently associated with infarct expansion and worse clinical outcome. Stroke 2003;34:2208-14.
Monagle P, Chan KC, Deveber G, Malmberg K. Pediatric thromboembolism and stroke. 1st ed. Hamilton, ON: B.C. Decker; 2006.
Lee MC, Frank JI, Kahana M, Tonsgard JM, Frim DM. Decompressive hemicraniectomy in a 6-year-old male after unilateral hemispheric stroke: Case report and review. Pediatr Neurosurg 2003;38:181-5.
Stroke and central nervous system disease: The management of sickle cell disease. National Institute of Health. Bethesda, MD: Publication No. 02-2117. 2002.
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581-7.
Browne M, Newall F, Campbell J, Savoia HF, Monagle P. Thrombolytic therapy with tissue plasminogen activator (tPA), analysis of safety and outcome in children. J Thromb Haemost 2003;1:P1488.
Zenz W, Muntean W, Beitzke A, Zobel G, Riccabona M, Gamillscheg A. Tissue plasminogen activator (alteplase) treatment for femoral artery thrombosis after cardiac catheterisation in infants and children. Br Heart J 1993;70:382-5.
Monagle P, Phelan E, Downie P, Kaufman SL, Martin LG, Gilarsky BP Local thrombolytic therapy in children. Thromb Haemost 1997;78:504.
Gupta AA, Leaker M, Andrew M, Massicotte P, Liu L, Benson LN, et al. Safety and outcomes of thrombolysis with tissue plasminogen activator for treatment of intravascular thrombosis in children. J Pediatr 2001;139:682-8.
Coull BM, Williams LS, Goldstein LB, Meschia JF, Heitzman D, Chaturvedi S, et al. Anticoagulants and antiplatelet agents in acute ischemic stroke. Stroke 2002;33:1934-42.
Lecompte TP, Lecrubier C, Bouloux C. Antiplatelet effects of the addition of acetylsalicylic acid 40 mg daily to ticlopidine in human healthy volunteers. Clin Appl Thromb Hemost 1997;3:245-50.
Monagle P, Chan A, Massicotte P, Chalmers E, Michelson AD. Antithrombotic therapy in children: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:645S-87S.
Sherman DG. Antithrombotic and hypofibrinogenetic therapy in acute ischemic stroke: What is the next step? Cerebrovasc Dis 2004;17:138-43.
Schmugge M, Risch L, Huber AR, Benn A, Fisher JE. Heparin-induced thrombocytopenia-associated thrombosis in pediatric intensive care patients. Pediatrics 2002;109:E10.
Burak CR, Bowen MD, Barron TF. The use of enoxaparin in children with acute, nonhemorrhagic ischemic stroke. Pediatr Neurol 2003;29:295-8.
Royal college of physicians, Pediatric stroke Working group. Stroke in childhood: Clinic guidelines for diagnosis, management and rehabilitation; 2004.
Sacco RL, Adams R, Albers G, Alberts MJ, Benavente O, Furie K, et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: A statement for healthcare professionals from American Heart Association /American Stroke Association council on stroke: Co-sponsored by the council on cardiovascular radiology and intervention: The American Academy of neurology affirms the value of this guideline. Circulation 2006;113:e409-49.
Paediatric Stroke Working Group, Royal College of Physicians of London. Stroke in childhood: clinical guidelines for diagnosis management and rehabilitation.
Willis JK, Morello A, Davie A, Rice JC, Bennett JT. Forced use treatment of childhood hemiparesis. Pediatrics 2002;110:94-6.
Charles JR, Wolf SL, Schneider JA, Gordon AM. Efficacy of a childfriendly form of constraint-induced movement therapy in hemiplegic cerebral palsy: A randomized control trial. Dev Med Child Neurol 2006;48:635-42.
Lanska MJ, Lanska DJ, Horwitz SJ, Aram DM. Presentation, clinical course, and outcome of childhood stroke. Pediatr Neurol 1991;7:333-41.
Higgins JJ, Kammerman LA, Fitz CR. Predictors of survival and characteristics of childhood stroke. Neuropediatrics 1991;22:190-3.
Keidan I, Shahar E, Barzilay Z, Passwell J, Brand N. Predictors of outcome of stroke in infants and children based on clinical data and radiologic correlates. Acta Paediatr 1994;83:762-5.
Eeg-Olofsson O, Ringheim Y. Stroke in children: Clinical characteristics and prognosis. Acta Paediatr Scand 1983;72:391-5.
Lanthier S, Carmant L, David M, Larbrisseau A, de Veber G. Stroke in children: The coexistence of multiple risk factors predicts poor outcome. Neurology 2000;54:371-8.
Blom I, De Schryver EL, Kappelle LJ, Rinkel GJ, Jennekens-Schinkel A, Peters AC. Prognosis of haemorrhagic stroke in childhood: Along-term follow-up study. Dev Med Child Neurol 2003;45:233-9.
Strδter R, Becker S, von Eckardstein A, Heinecke A, Gutsche S, Junker R, et al. Prospective assessment of risk factors for recurrent stroke during childhood-a 5-year follow-up study. Lancet 2002;360:1540-5.
Ganesan V, Prengler M, Wade A, Kirkham FJ. Clinical and radiological recurrence after childhood arterial ischemic stroke. Circulation 2006;114:2170-7.
DeVeber GA, MacGregor D, Curtis R, Mayank S. Neurologic outcome in survivors of childhood arterial ischemic stroke and sinovenous thrombosis. J Child Neurol 2000;15:316-24.
Chabrier S, Husson B, Lasjaunias P, Landrieu P, Tardieu M. Stroke in childhood: Outcome and recurrence risk by mechanism in 59 patients. J Child Neurol 2000;15:290-4.
Ganesan V, Hogan A, Shack N, Gordon A, Isaacs E, Kirkham FJ. Outcome after ischaemic stroke in childhood. Dev Med Child Neurol 2000;42:455-61.
Pavlovic J, Kaufmann F, Boltshauser E, Capone Mori A, GubserMercati D, Haenggeli CA, et al. Neuropsychological problems after paediatric stroke: Two year follow-up of Swiss children. Neuropediatrics 2006;37:13-9.
Salih MA, Abdel-Gader AG, Al-Jarallah AA, Kentab AY, Al-Nasser MN. Outcome of stroke in Saudi children. Saudi Med J 2006;27:S91-6.
De Schryver EL, Blom I, Braun KP, Kappelle LJ, Rinkel GJ, Peters AC, et al. Long-term prognosis of cerebral venous sinus thrombosis in childhood. Dev Med Child Neurol 2004;46:514-9.
Ganesan V, Chong WK, Cox TC, Chawda SJ, Prengler M, Kirkham FJ. Posterior circulation stroke in childhood: Risk factors and recurrence. Neurology 2002;59:1552-6.
Hogan AM, Kirkham FJ, Isaacs EB. Intelligence after stroke in childhood: Review of the literature and suggestions for future research. J Child Neurol 2000;15:325-32.
Max JE, Mathews K, Manes FF, Robertson BA, Fox PT, Lancaster JL, et al. Attention deficit hyperactivity disorder and neurocognitive correlates after childhood stroke. J Int Neuropsychol Soc 2003;9:815-29.
Max JE, Mathews K, Lansing AE, Robertson BA, Fox PT, Lancaster JL, et al. Psychiatric disorders after childhood stroke. J Am Acad Child Adolesc Psychiatry 2002;41:555-62.
Friefeld S, Yeboah O, Jones JE, deVeber G. Health-related quality of life and its relationship to neurological outcome in child survivors of stroke. CNS Spectr 2004;9:465-75.
Delsing BJ, Catsman-Berrevoets CE, Appel IM. Early prognostic indicators of outcome in ischemic childhood stroke. Pediatr Neurol 2001;24:283-9.
Ganesan V, Ng V, Chong WK, Kirkham FJ, Connelly A. Lesion volume, lesion location, and outcome after middle cerebral artery territory stroke. Arch Dis Child 1999;81:295-300.
Boardman JP, Ganesan V, Rutherford MA, Saunders DE, Mercuri E, Cowan F. Magnetic resonance image correlates of hemiparesis after neonatal and childhood middle cerebral artery stroke. Pediatrics 2005;115:321-6.
Hurvitz EA, Beale L, Ried S, Nelson VS. Functional outcome of paediatric stroke survivors. Pediatr Rehabil 1999;3:43-51.