Stroke in children tend to have different causes than in adults. The most common cause of stroke in a child is a heart problem. Other causes for children include sickle cell disease (a type of blood disease passed down through families), infection, trauma, dehydration, blood clotting problems, and birth defects. In many cases, however, no cause can be found.
While strokes in children can be devastating, children appear to have a better ability to heal because of the greater flexibility and plasticity of their nervous system and brain. With physical?and speech therapy, many childhood stroke survivors recover?most or all the use of their arms, legs and speech.
In this segment, Kristin Guilliams, MD, Washington University pediatric neurologist at St. Louis Children's Hospital, discusses causes and treatment for stroke in children and when to refer to a specialist.
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Pediatric Stroke
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Learn more about Kristin Guilliams, MD
Kristin Guilliams, MD
Kristin Guilliams, MD, is a Washington University pediatric neurologist at St. Louis Children’s Hospital.Learn more about Kristin Guilliams, MD
Transcription:
Pediatric Stroke
Melanie Cole (Host): Stroke in children tends to have different causes than in adults. However, while strokes in children can be devastating, children appear to have a better ability to heal because of the greater flexibility and plasticity of their nervous system and brain. My guest today is Dr. Kristin Guilliams. She’s a Washington University Pediatric Neurologist and Intensivist at Saint Louis Children’s Hospital. Dr. Guilliams has disclosed that she will be discussing off-label use of therapeutics for the acute management of stroke in today’s podcast. Welcome to the show, Dr. Guilliams. What is a pediatric stroke?
Dr. Kristin Guilliams (Guest): Thank you, Melanie. Pediatric stroke is a disease caused by a lack of blood flow to a part of the brain. We think of this as two different reasons why this can happen. Commonly it’s from an ischemic stroke or when there’s a blood clot and stoppage of blood flow to the brain, but also can include hemorrhagic stroke, when a blood vessel breaks, and there’s leakage of blood out of the blood vessel into the surrounding tissue, and it doesn’t get to its intended tissue downstream.
When we think about pediatric stroke, we really think about it also divided up by age group as well. There can be a perinatal or neonatal stroke, and this is when the stroke occurs any time before the baby’s born up until the first month of life. Childhood stroke, which includes anyone who’s a month old or older, up to 18 years of age.
Melanie: Is there any warning sign, Dr. Guilliams? Is there anything that would alert the obstetrician/gynecologist, or in the case of childhood stroke, would alert the pediatrician?
Dr. Guilliams: Sure, commonly children who have a neonatal or perinatal stroke are not moving both sides equally as well after they’re born. Sometimes the children can have seizures right at stroke onset, and this can occur in either the neonatal or the childhood stroke, as well. For the neonatal stroke, the other things that often clues us in is when a child shows early hand preference. Hand preference, being right-handed or left-handed typically shouldn’t develop until somewhere between two to three years of age, so if a child is clearly right-handed or left-handed before their first birthday, that is something that would warrant further workup and investigation.
For childhood stroke, we look at the same signs and symptoms as adults. This is commonly put together by the acronym FAST. F - for facial droop. A - for arm weakness. S - for speaking difficulty and T – Time to call 9-1-1. This can be somewhat complicated in children because also it can be accompanied by a seizure as I mentioned earlier, and sometimes can also have a headache in addition to the stroke symptoms.
Melanie: Let’s start with a diagnosis of neonatal stroke. How is that made? What are the clinical indications for even making that diagnosis?
Dr. Guilliams: It’s most commonly made by imaging, most often by an MRI. In the case of neonatal stroke that we either -- sometimes we’re able to catch the acute stroke if it’s happened shortly after birth, but sometimes, even months later, we can have the imaging, which shows that there is the encephalomalacia or the evidence that the brain tissue has died and been reabsorbed in a clear vascular territory -- that’s a sign of a chronic stroke -- and the child has been previously well, and we don’t know exactly when it occurred.
Melanie: And what about in childhood stroke? You mentioned the moniker, FAST – if this is noticed by a pediatrician or by the parents and they get to the Emergency Room, is the treatment similar to an adult? What happens there?
Dr. Guilliams: At pediatric stroke specialty centers, such as Saint Louis Children’s Hospital, but other Children’s Hospitals around the country that have dedicated stroke teams, then we can offer treatment to some children similarly to adults. Specifically, the two types of treatment are – one is tPA or the clot-busting medication. What’s important about this is it’s only effective if it’s administered within the first four and a half hours after the symptoms occurred, so it really requires a rapid diagnosis in order to be available. The other therapy is mechanical thrombectomy or clot retrieval. This one has a slightly longer window but still is very important and time-sensitive for removal of the clot.
We actually had our first case last month where we were able to successfully remove a clot from a teenager’s brain a few hours after he had sudden weakness on one side and difficulty talking. We were able to restore the blood flow, and thankfully, he had rapid improvement of his symptoms afterward and is doing much better today.
Melanie: In adults, we hear about prevention and things that you can do, lifestyle modification, but what about for children, Dr. Guilliams, is there anything that you’d like pediatricians to be aware of, or even parents when they’re hearing this and saying, “Well, is there anything I can do?”
Dr. Guilliams: You’re right in that the causes of pediatric stroke are different than adults. Children who have strokes haven’t had years of smoking, high blood pressure, and all of the things we commonly think of with adult strokes. We’re still learning a lot about what causes stroke in children, particularly those who don’t have clearly identifiable risk factors, such a congenital heart disease, or sickle cell disease – which are two populations known to be at high-risk.
Interestingly, we’re finding that infection is likely playing some role in the idiopathic childhood stroke. There was a recent study that was specifically looking at the role of infection in childhood ischemic strokes, and looked at children who were diagnosed in the hospital with an acute ischemic stroke, and also looked at two types of control populations. One was trauma patients also admitted to the hospital, as well as children who were coming to the pediatric neurologist or an outpatient clinic just for a routine visit, such as a follow-up on a headache diagnosis. The goal was trying to see that because we know that infections are common in children, was there any reason that the stroke population was different?
And what was interesting was – two things from that study, one being that the children who had strokes were more likely to have infectious symptoms, and upper respiratory tract symptoms in the two to three weeks preceding their stroke diagnosis, as well as to have antibodies specifically for the herpes complex viruses in their blood compared to the other children. And also, very interestingly, was that the children who had strokes were much less likely than the other children to be fully vaccinated. We don’t know exactly what that direct relationship is, but it does look like vaccines – just the routine, scheduled childhood vaccinations, may be protective for childhood stroke.
Melanie: In summary, Doctor, what would you like other pediatricians to know about pediatric stroke, and when to refer to a specialist?
Dr. Guilliams: Stroke does occur in children, and it is important to refer immediately – in fact, call 9-1-1 if a child is having acute symptoms of facial weakness, arm weakness or speaking difficulties. Time is Brain, and rapid diagnosis and assessment may offer the possibility for treatment, but if they’re seeing a patient who they either think had a neonatal stroke, or may even have stroke risk factors, such as vascular abnormalities in the brain, or congenital heart disease, or other things that they think put them at risk for stroke, that would also be an appropriate referral to a Pediatric Stroke Clinic to discuss risk factors and possible modifications.
Melanie: And what can a referring physician expect from the stroke team at Saint Louis Children’s Hospital?
Dr. Guilliams: When a child arrives at Saint Louis Children’s Hospital with concern for stroke or with high stroke risk factors, they will be rapidly assessed and diagnosed and work to either diagnose the stroke or whatever is underlying their acute symptoms and offered specialized multidisciplinary care.
Melanie: Thank you, so much, for being with us today. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678-4357. You’re listening to Radio Rounds with Saint Louis Children’s Hospital. For more information on resources available at Saint Louis Children’s Hospital, you can go to SaintLouisChildrens.org, that’s SaintLouisChildrens.org. This is Melanie Cole. Thanks, so much for listening.
Pediatric Stroke
Melanie Cole (Host): Stroke in children tends to have different causes than in adults. However, while strokes in children can be devastating, children appear to have a better ability to heal because of the greater flexibility and plasticity of their nervous system and brain. My guest today is Dr. Kristin Guilliams. She’s a Washington University Pediatric Neurologist and Intensivist at Saint Louis Children’s Hospital. Dr. Guilliams has disclosed that she will be discussing off-label use of therapeutics for the acute management of stroke in today’s podcast. Welcome to the show, Dr. Guilliams. What is a pediatric stroke?
Dr. Kristin Guilliams (Guest): Thank you, Melanie. Pediatric stroke is a disease caused by a lack of blood flow to a part of the brain. We think of this as two different reasons why this can happen. Commonly it’s from an ischemic stroke or when there’s a blood clot and stoppage of blood flow to the brain, but also can include hemorrhagic stroke, when a blood vessel breaks, and there’s leakage of blood out of the blood vessel into the surrounding tissue, and it doesn’t get to its intended tissue downstream.
When we think about pediatric stroke, we really think about it also divided up by age group as well. There can be a perinatal or neonatal stroke, and this is when the stroke occurs any time before the baby’s born up until the first month of life. Childhood stroke, which includes anyone who’s a month old or older, up to 18 years of age.
Melanie: Is there any warning sign, Dr. Guilliams? Is there anything that would alert the obstetrician/gynecologist, or in the case of childhood stroke, would alert the pediatrician?
Dr. Guilliams: Sure, commonly children who have a neonatal or perinatal stroke are not moving both sides equally as well after they’re born. Sometimes the children can have seizures right at stroke onset, and this can occur in either the neonatal or the childhood stroke, as well. For the neonatal stroke, the other things that often clues us in is when a child shows early hand preference. Hand preference, being right-handed or left-handed typically shouldn’t develop until somewhere between two to three years of age, so if a child is clearly right-handed or left-handed before their first birthday, that is something that would warrant further workup and investigation.
For childhood stroke, we look at the same signs and symptoms as adults. This is commonly put together by the acronym FAST. F - for facial droop. A - for arm weakness. S - for speaking difficulty and T – Time to call 9-1-1. This can be somewhat complicated in children because also it can be accompanied by a seizure as I mentioned earlier, and sometimes can also have a headache in addition to the stroke symptoms.
Melanie: Let’s start with a diagnosis of neonatal stroke. How is that made? What are the clinical indications for even making that diagnosis?
Dr. Guilliams: It’s most commonly made by imaging, most often by an MRI. In the case of neonatal stroke that we either -- sometimes we’re able to catch the acute stroke if it’s happened shortly after birth, but sometimes, even months later, we can have the imaging, which shows that there is the encephalomalacia or the evidence that the brain tissue has died and been reabsorbed in a clear vascular territory -- that’s a sign of a chronic stroke -- and the child has been previously well, and we don’t know exactly when it occurred.
Melanie: And what about in childhood stroke? You mentioned the moniker, FAST – if this is noticed by a pediatrician or by the parents and they get to the Emergency Room, is the treatment similar to an adult? What happens there?
Dr. Guilliams: At pediatric stroke specialty centers, such as Saint Louis Children’s Hospital, but other Children’s Hospitals around the country that have dedicated stroke teams, then we can offer treatment to some children similarly to adults. Specifically, the two types of treatment are – one is tPA or the clot-busting medication. What’s important about this is it’s only effective if it’s administered within the first four and a half hours after the symptoms occurred, so it really requires a rapid diagnosis in order to be available. The other therapy is mechanical thrombectomy or clot retrieval. This one has a slightly longer window but still is very important and time-sensitive for removal of the clot.
We actually had our first case last month where we were able to successfully remove a clot from a teenager’s brain a few hours after he had sudden weakness on one side and difficulty talking. We were able to restore the blood flow, and thankfully, he had rapid improvement of his symptoms afterward and is doing much better today.
Melanie: In adults, we hear about prevention and things that you can do, lifestyle modification, but what about for children, Dr. Guilliams, is there anything that you’d like pediatricians to be aware of, or even parents when they’re hearing this and saying, “Well, is there anything I can do?”
Dr. Guilliams: You’re right in that the causes of pediatric stroke are different than adults. Children who have strokes haven’t had years of smoking, high blood pressure, and all of the things we commonly think of with adult strokes. We’re still learning a lot about what causes stroke in children, particularly those who don’t have clearly identifiable risk factors, such a congenital heart disease, or sickle cell disease – which are two populations known to be at high-risk.
Interestingly, we’re finding that infection is likely playing some role in the idiopathic childhood stroke. There was a recent study that was specifically looking at the role of infection in childhood ischemic strokes, and looked at children who were diagnosed in the hospital with an acute ischemic stroke, and also looked at two types of control populations. One was trauma patients also admitted to the hospital, as well as children who were coming to the pediatric neurologist or an outpatient clinic just for a routine visit, such as a follow-up on a headache diagnosis. The goal was trying to see that because we know that infections are common in children, was there any reason that the stroke population was different?
And what was interesting was – two things from that study, one being that the children who had strokes were more likely to have infectious symptoms, and upper respiratory tract symptoms in the two to three weeks preceding their stroke diagnosis, as well as to have antibodies specifically for the herpes complex viruses in their blood compared to the other children. And also, very interestingly, was that the children who had strokes were much less likely than the other children to be fully vaccinated. We don’t know exactly what that direct relationship is, but it does look like vaccines – just the routine, scheduled childhood vaccinations, may be protective for childhood stroke.
Melanie: In summary, Doctor, what would you like other pediatricians to know about pediatric stroke, and when to refer to a specialist?
Dr. Guilliams: Stroke does occur in children, and it is important to refer immediately – in fact, call 9-1-1 if a child is having acute symptoms of facial weakness, arm weakness or speaking difficulties. Time is Brain, and rapid diagnosis and assessment may offer the possibility for treatment, but if they’re seeing a patient who they either think had a neonatal stroke, or may even have stroke risk factors, such as vascular abnormalities in the brain, or congenital heart disease, or other things that they think put them at risk for stroke, that would also be an appropriate referral to a Pediatric Stroke Clinic to discuss risk factors and possible modifications.
Melanie: And what can a referring physician expect from the stroke team at Saint Louis Children’s Hospital?
Dr. Guilliams: When a child arrives at Saint Louis Children’s Hospital with concern for stroke or with high stroke risk factors, they will be rapidly assessed and diagnosed and work to either diagnose the stroke or whatever is underlying their acute symptoms and offered specialized multidisciplinary care.
Melanie: Thank you, so much, for being with us today. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678-4357. You’re listening to Radio Rounds with Saint Louis Children’s Hospital. For more information on resources available at Saint Louis Children’s Hospital, you can go to SaintLouisChildrens.org, that’s SaintLouisChildrens.org. This is Melanie Cole. Thanks, so much for listening.