Stroke in Pediatric Patients: Occurrence, Intervention and Beyond

By Dr. Sharief Taraman

Many might picture a stroke patient as middle aged or elderly, but

Dr. Sharief Taraman, CHOC Children's pediatric neurologist
Dr. Sharief Taraman, CHOC Children’s pediatric neurologist

the reality is that the ailment occurs across the lifespan.

A stroke affects one in every 3,500 live births and six to 13 per 100,000 children per year.  At CHOC Children’s, that translates to one or two patients per month outside the newborn period.

Among many risk factors, the largest for stroke in children include cardiac disease (19 percent); coagulation disorders (14 percent); and dehydration (11 percent). Multiple risk factors are present in up to 25 percent of pediatric stroke patients.

Atherosclerosis and modifiable risk factors that dominate adult stroke mechanism and treatment were nearly non-existent in pediatric stroke. However, in the past decade and a half, traditional cardiovascular risk factors for stroke in people ages 15 to 34 have been steadily increasing.

Placental diseases can cause perinatal arterial stroke, and perinatal stroke accounts for a large proportion of pediatric stroke morbidity. The first week of life carries the most risk for stroke and the majority of survivors have lifelong morbidity, most typically, hemiparetic cerebral palsy. Cognitive or behavioral disorders and epilepsy are also common.

Acute ischemic stroke (AIS) lesions are often multifocal, even in the absence of overt cardiac disease, which lends support to proximal embolic source. Many neonates with AIS have risk factors and presentations that overlap with hypoxic ischemic encephalopathy, and the two can co-occur.

Delayed diagnosis

Despite these occurrences and the inherent dangers, a lack of awareness prevails and diagnosis of childhood stroke is often significantly delayed. One study found up to a 28-hour delay in seeking medical attention from the onset of symptoms and a 7.2 hour delay after presentation before any brain imaging occurred (Lenn, et al, 2002).

Further complicating matters is that presentation can be subtle, varied and non-specific, and often occurs in the setting of a systemic illness. One study found the median time to diagnose AIS in neonates was 87.9 hours and 24.8 hours in children (Mackay, et al 2009). Another study saw that 19 of 45 children with a stroke did not receive a correct diagnosis until 15 hours after initial presentation, and in some cases, up to three months afterward (DeVeber, et all 2006).

Also, many other diseases mimic a stroke: A fifth of children presenting for evaluation of suspected acute stroke have a “stroke mimic,” rather than an actual stroke (Shelhaas, Pediatrics, 2006). Stroke mimics include migraines and delirium, as well as seizure and tumor.

Intervention

High-powered clinical trials that guide adult stroke management – including antiplatelet and anticoagulant strategies; chemical and mechanical thrombolysis; stroke unit care; and many others – do not yet exist for children.

Of 687 children enrolled in the International Pediatric Stroke Study (2011), 15 patients received tissue plasminogen activator (tPA): nine underwent intravenous tPA and six underwent intra-arterial tPA. The median time to treatment from onset was 3.3 hours for intravenous alteplase and 4.5 hours for intra-arterial alteplase.

Of those patients, four had intracranial hemorrhage (non-symptomatic); one died from brainstem stroke; one died from massive stroke with herniation; one was discharged without deficits; and 12 were discharged with neurological deficits.

Intravenous tissue plasminogen activator (tPA) needs more study for safety, dosing and efficacy before it can be fully applied to pediatric patients. Dosing in children cannot be extrapolated from adult data or existing pediatric data.

Limited pediatric safety and effectiveness data also exists around neurointerventional techniques like intra-arterial tPA and mechanical thromboectomy. Early intervention results in better outcomes, though success rates depend heavily on the operator’s experience.

Rehabilitation, recurrence

Similar to the adult stroke population, rehabilitation is multifaceted and comprises neuropsychology; developmental monitoring; educational intervention; and physical, occupational, and speech therapies. Most of the functional recovery occurs in the first two to three months. The quality of functional recovery is better in the pediatric population; however, the prognosis worsens as the lesion size increases.

The risk of recurrence following a stroke is up to 25 percent and highest in the first three months of onset. The lowest risk of recurrence is in perinatal and cryptogenic stroke.

Like any other condition, prevention of pediatric stroke is important and many patients will be placed on antiplatelet or anticoagulation. Interestingly, children with some, few or no vaccinations are shown to be at risk of stroke seven times higher than those who received all or most vaccinations.

CHOC has a collaborative team with protocols in place to recognize and treat pediatric stroke aggressively. Learn more about the CHOC Children’s Neuroscience Institute.

CHOC Children’s Grand Rounds Video: Bringing Palliative Care to Your Pediatric Practice

Palliative care in infants and children is a critical and evolving field. In this grand rounds video presentation, Dr. Sirisha Perugu, CHOC Children’s neonatologist, and Meg Mohr, FNP-BC, MSN, coordinator of CHOC’s pediatric advanced care team, provide valuable insight. More specifically, they:

  • define palliative care and provide a brief history of its development;
  • highlight the ways palliative care adds value to culturally sensitive and family- centered care;
  • examine the health care provider’s role in end-of- life care and patient management decisions;
  • and suggest how the health care provider can assist a family whose child requires the added layer of support of palliative care.

Learn more about CHOC’s palliative care services.

View previous grand rounds videos.

CHOC Children’s Hospital Earns National Distinction for Safe, Quality Care

The Leapfrog Group has once again named CHOC Children’s Hospital to its annual list of Top Hospitals, distinguishing CHOC’s commitment to providing the safest, highest quality health care.  CHOC is one of only 12 children’s hospitals in the nation and only two in the state to earn the respected award.

The selection is based on results of The Leapfrog Group’s annual hospital survey, which measures hospitals’ performance on patient safety and quality, focusing on three critical areas:

  • How patients fare
  • Resource utilization
  • Management structures established to prevent errors

Performance across many facets of hospital care, including survival rates for high-risk procedures and ability to prevent medication errors, is considered in establishing the qualifications for the award.

“Leapfrog’s Top Hospital award is widely acknowledged as one of the most prestigious distinctions any hospital can achieve in the United States,” said Leah Binder, president and CEO of The Leapfrog Group.  “Top Hospitals have lower infection rates, better outcomes, decreased length of stay and fewer readmissions.  By achieving Top Hospital status, CHOC has proven it prioritizes the safety of its patients, is committed to transparency, and provides exemplary care for children and families in Orange County.  I congratulate the hospital’s board, staff and clinicians whose efforts achieved these results.”

See the full list of 2015 Top Hospital honorees. 

CHOC Children’s Grand Rounds Video: Insufficient Sleep is a Public Health Concern

The Centers for Disease Control and Prevention has recognized insufficient sleep as a public health concern, says CHOC Children’s pulmonologist Dr. John Saito.

In this grand rounds video, Dr. Saito addresses the problem, which is often rooted in childhood. Disorders and disruptions of sleep in a developing brain may have short- term neurocognitive effects, as well as long- term consequences, especially in children who are medically fragile.

Healthcare providers, educators and parents all need to update their level of understanding sleep and sleep disorders in children in order to identify, diagnose, and reduce the negative health consequences of sleep disruption to the child, to the family and to society.

View previous grand rounds videos.

November is Prematurity Awareness Month – CHOC Offers Innovative and Life-Saving Neonatal Care

In recognition of National Prematurity Awareness month, we’re highlighting the innovative life-saving treatment provided to some of the tiniest and most fragile babies through our neonatology services.

Premature birth is the leading cause of newborn death in the United States. While California has one of the lowest premature birth rates in the nation, almost 9 percent of infants born in 2013 in the state were premature, according to the March of Dimes. Pre-term newborns often need immediate specialized care not available at birthing centers, and CHOC Children’s is ready to help if the baby needs to be transferred.

CHOC uses the latest in life-saving technology and trained neonatal specialists to provide the best possible outcomes for both pre- and full-term newborns. While many hospitals offer neonatal intensive care units (NICUs), the CHOC NICU is rated by the American Academy of Pediatrics as a Level 4 NICU – the highest rating available – and is among the top 25 in the nation, according to U.S. News & World Report.

“Because of our innovation and advanced protocols, our survival of low-birth-weight babies, and the long term quality of health of such babies, admitted to the CHOC NICU are the best in California according to the California Perinatal Quality Care Collaborative,” said Dr. Vijay Dhar, medical director, CHOC NICU. “Coordinated care across multiple specialties ensures that these fragile newborns receive treatment from a full medical team.”

With access to a full range of CHOC pediatric subspecialists, the NICU offers a number of life-saving technologies and advanced respiratory support such as high-frequency ventilation and inhaled nitric oxide; advanced brain and body cooling; the only extracorporeal membrane oxygenation (ECMO) unit in Orange County; and innovative procedures including mandibular distraction and epidural anesthesia.

For babies born as young as 24 weeks, or who weigh less than 1,000 grams, the CHOC NICU has a Small Baby Unit (SBU) — the only one of its kind — to focus on caring for the unique needs of these newborns. We also have the only Surgical NICU on the West Coast, which cares for babies needing complex surgery; the only Cardiac NICU in Orange County that performs open heart surgery on newborns; and a Neurocritical NICU to treat babies with neurological issues such as seizures, asphyxiation and brain damage. All four areas provide the highly specialized care needed for fragile newborns.

CHOC has three NICUs, serving CHOC Children’s Hospital, St. Joseph Hospital and CHOC Children’s at Mission Hospital. In addition, our neonatologists have privileges at more than a dozen hospitals across Southern California. And, we are currently building 36 private, state-of-the-art rooms at CHOC Children’s Hospital, which will further advance the quality, safety and outcomes of our neonatology program.

Neonatal Intensive Care Unit (NICU) Referrals:

When a baby is born, the CHOC Children’s Transport Team is ready and waiting to transport newborns to CHOC from other hospitals in Southern California. Our neonatologists and surgeons are available for consultations with other hospitals around the clock and can collaborate with referring physicians via phone, telemedicine and secure text messaging.

For any questions, to request a consultation with an on-call neonatologist, or to schedule a transport, referring hospitals may call the CHOC Children’s NICU 24/7 at 714-509-8540.