Joey Wahler (Host): They can affect children from infants to teens. So, we're discussing pediatric strokes. Our guest is Dr. Kevin O'Connor. He's a vascular neurologist for UK HealthCare. This is UK HealthCast, a podcast from UK HealthCare. Thanks so much for joining us. I'm Joey Wahler. Hi, Dr. O'Connor. Welcome.

Dr. Kevin O'Connor: Thanks for having me.

Host: Great to have you aboard. So first, just how common are pediatric strokes and what exactly are they?

Dr. Kevin O'Connor: So, pediatric strokes are less common than adult strokes. And we know by the numbers, about one in three out of every 100,000 children or so will have an ischemic stroke every year. And from there, since pediatric strokes are about 50/50 ischemic and hemorrhagic, then that tells us that for pretty much all strokes, it's somewhere around the range of one to three per a hundred thousand every year. So overall, not all that common, but common enough that we should be concerned about it.

Host: Understood. Pediatric strokes can actually strike kids of any age, starting with newborns, right?

Dr. Kevin O'Connor: That's correct. And we like to divide pediatric stroke into sort of two groups. We have our perinatal or neonatal strokes. And that's everyone up to about 30 days of life. And then, between 30 days of life up until you're about 18 is a separate set of pediatric stroke. And we like to distinguish those two because a lot of times the causes of the stroke and some of the treatments that are available are going to be different between those two groups.

Host: And so, tell us what you mean by that.

Dr. Kevin O'Connor: So when we think of perinatal or neonatal strokes, a lot of times those happen while the child is still in the womb, so in utero. And a lot of those causes are going to be things like you can have hemorrhages or bleeds into the brain or, for some reason, something obstructs the blood flow and you develop an ischemic stroke. A lot of times, there aren't a lot of specific treatments for those because when you're still in the womb, there's not a lot of things that can be done. And we only discover these strokes once the baby is born. But when you're 30 days and older, we have a lot more options, and some of those options will be similar to the ones that we have for adult strokes.

Host: I was going to ask you that next. You led me in beautifully. How do pediatric strokes differ from the ones suffered by adults?

Dr. Kevin O'Connor: So for the most part, the potential for devastating consequences is the same. We know that about 40-70% or so of children that have strokes end up with some degree of deficit. Whether that is weakness on one side, language trouble, vision trouble. And so, children can have the same types of long-term problems from their stroke that adults do, but the causes of their strokes are going to be different.

In adults, the majority of strokes are ischemic, where something causes not enough blood flow to get to the brain. And a smaller proportion of strokes in adults are the bleeding type of strokes. But in children, it's about a 50-50 split. And in adults we tend to think of some of the more chronic medical risk factors like smoking, blood pressure problems, diabetes. You might have an abnormal heart rhythm, like atrial fibrillation. And we don't generally see those risk factors in children. So in children, a lot of times, we'll be thinking of congenital heart problems or the heart problems that you were sort of born with as being a risk factor, or you might have sickle cell disease, or you may have a really bad ear or throat infection that can cause nearby issues with the blood vessels.

Host: So, these can be caused in children even before birth, by things going on at that time, as opposed to lifestyle factors and other conditions that often affect adults, right?

Dr. Kevin O'Connor: That's correct. So, we don't see quite as many lifestyle factors affecting stroke in children because we don't tend to see a lot of children smoking a whole lot, having really bad uncontrolled hypertension or blood pressure problems.

Host: How about the signs of a stroke in a child, and do they differ by age?

Dr. Kevin O'Connor: So, a lot of times the same sort of signs and clues that somebody's having a stroke are going to be very similar whether you are a child or an adult. But what tends to differ is how we perceive those. So, we like to use a mnemonic device called BEFAST to kind of highlight the most common symptoms of a stroke. And this will broadly apply to any age.

So, the BEFAST covers balance, so if you're having walking trouble. Eyes, so if your eyes start going in different directions or you start losing vision in your eye, or both eyes. F is face. So if you start having facial weakness or drooping, we sometimes notice an unequal smile or smile asymmetry. The arms and legs, so if you start having weakness in one arm or one leg, or in both the arm and the leg on one side, or if you lose sensation in the arm and the leg on one side. And then, S is your speech. So if you start having any sort of communication or language trouble where you can't understand people or people can't understand you. And then, the T in BEFAST emphasizes the importance of time and acting as quickly as possible.

And so in adults and children, we can sometimes see the same pattern of you might have balance or walking trouble, eye trouble, face, arm, leg weakness, and then speech trouble. But you can imagine that in a 50-year-old or a 15-year-old, they may notice I'm having trouble with my arm and leg, and then they can tell us, "I'm having trouble with my arm and leg." But in a two-year-old or maybe a one-year-old, they can't really communicate that well. So, what you may notice instead is that they just don't use their left side or their right side very well, or they don't make as many noises or verbalizations as they normally would.

Host: And so, what are the actions that a parent should take if they notice any of these signs? Because you mentioned a moment ago that for one thing, time is of the essence. We always hear that when it comes to adult strokes, of course. Why is that so important?

Dr. Kevin O'Connor: So, that's so important because every minute that the brain or part of the brain doesn't get enough blood flow, the brain cells in that region may have a lot of damage and may eventually die. And so, every minute that goes by, that's another however many brain cells that we may not be able to save. So, the sooner you get to a hospital, the sooner we can try to figure out what's going on and what treatments are available, the more of your brain that we can save and the more long-term deficits or problems we can try to avoid.

Host: And so if a parent notices one of these things you mention is amiss, what's their first move?

Dr. Kevin O'Connor: So, the first thing to do would be to call 911 and get to a hospital as quickly as possible. And then once at that hospital, that's where we'll try to figure out what might be going on. Now in the pediatric population, unlike the adult population when we have the sudden onset of neurologic problems, again, balance, eyes, weakness, sensation loss, language, trouble, in adults, more often than not, that could be a stroke. But in the pediatric population, that's less likely to be a stroke. And that's one of the problems with pediatric stroke in general, is that most of those children presenting with that type of problem might be having a migraine attack. They could have had a seizure and they're having post-seizure symptoms. And that really emphasizes the importance of getting to the hospital so we can figure out is what's going on a stroke or not, because we're going to treat a migraine attack a lot differently than we would a stroke.

Host: And so, it begs the question, when you're dealing with younger kids, let's say, those, oh, maybe three years old, give or take a year or so, that are not as able to communicate what they're feeling, et cetera. How much of a challenge is that for you and yours in order to diagnose and treat?

Dr. Kevin O'Connor: Yeah. So, that can be a big challenge because a lot of what we do in Neurology requires communication. And you can imagine it, it's hard to have a really thorough conversation with a three-year-old, but that's where we also try to rely on our examination. And even if we can't get a child to fully participate in an exam the same way we would be able to for let's say even a 10-year-old, there are ways that we can assess and test their abilities in terms of movement, sensation, vision that can kind of clue us into what might be going on.

Host: So, especially as kids get older, is there anything, Doctor, that parents can do to try to prevent pediatric strokes?

Dr. Kevin O'Connor: Yeah. So, a lot of the emphasis on pediatric stroke prevention is going to be recognizing that if you have a congenital heart problem, for example, or if you have sickle cell disease, that you're getting that monitored appropriately. Because we know that there are ways for sickle cell in particular that we watch the disease itself to make sure that you're not getting to the point where you're at an increased risk of stroke. It's going to also be things like if you're having an infection, that you're getting that evaluated and treated because we know that infections, particularly in the ear or elsewhere in the head and the neck, can be a contributing factor to pediatric stroke risk. And then, in general, it's being healthy and taking care of your medical conditions.

Host: Gotcha. A couple of other things. So, how are pediatric strokes typically treated?

Dr. Kevin O'Connor: So for the most part, we're going to try to treat pediatric strokes similarly to adult strokes when applicable. So in the adult population, you'll often hear that if you get to the hospital soon enough, you can receive what we call the clot-busting medicine, which is the term we'll use commonly for a fibrinolytic medication called alteplase or tenecteplase, which helps break up clots. And if a child shows up to the emergency department, we'll go through as much workup and evaluation as we can to determine: are you having a stroke? And if you are, do we think you're going to benefit from this medication? And then if we do, we'll discuss that and, potentially, offer it. Similarly, in adults where if we do blood vessel imaging and we find a clot in a blood vessel and it's blocking flow, we can go in and perform a thrombectomy to try to remove that clot. Similar situation in a child, if we figure out that you are having a stroke and we take pictures and see a clot blocking a blood vessel, we'll talk to you about attempting a thrombectomy to try to remove that clock.

Host: How about recovery from a stroke? How would you compare how that works typically for kids as opposed to adults? Does one group recover any "better" than the other?

Dr. Kevin O'Connor: So, in the pediatric population, much like the adult population, a lot of the recovery is going to depend on where in the brain the stroke was, how big the stroke was, whether or not we were able to perform any of those acute treatments to try to reduce the damage. But in general, the pediatric population, because the brains are still developing, have the potential for a bit more recovery because that continuing development of the brain goes on until about the mid-20s. So, a lot of that brain's ability to continue to develop and grow, that we call it neuroplasticity, does offer the potential for better recovery in the pediatric population than the adult population.

Host: And then, we hear that with adult strokes, once you get one, it leaves you more vulnerable to a second at some point down the road. Is the same true in kids?

Dr. Kevin O'Connor: It can be. But oftentimes in the pediatric population, it's going to depend more on what the underlying cause for that stroke was. A lot of times in the adult population when you have your first stroke, we do our best to try to figure out why. And more often than not in adults, it's because we're finding that there are medical conditions we may not have known about that we now need to start treatments for.

So for example, you may not have known you had high blood pressure or diabetes or sleep apnea. But now that we've found them, we try to get you on treatments to reduce the risk of those in the future. In children, however, if we know that you have, for example, congenital heart disease, that those heart problems that you're sort of born with, if we find that that led to a stroke, then it's going to be the heart disease itself that leaves you with an ongoing risk for stroke rather than having had the stroke to begin with. Similar situation with sickle cell disease. Now, if we think of the children that have those ear or those head and neck infections that lead to a stroke, I wouldn't expect a child like that to have an increased risk of stroke in the future necessarily because they already had a stroke, because their risk came from an infection. And so as long as they don't get another infection, they should have a future stroke risk very close to any other child that never had that.

Host: Okay. And in summary, Doctor, what unique care would you say UKHC provides to stroke patients? What do you really hang your hat on?

Dr. Kevin O'Connor: So at UK, we offer a comprehensive team that helps provide care to stroke patients. In particular, we helped develop, along with University of Louisville and Norton Children's Hospital, an algorithm or sort of triage process for any hospital in the state of Kentucky. If a child comes to any hospital in this state and they have any of those acute onset neurologic problems. We help guide that hospital through the workup process to determine: is this a pediatric stroke? And if it is, do we need to consider any acute intervention? And if we do, then, we try to bring that child to Lexington as soon as we can so that we can help guide those treatments and offer those treatments. And then, once you get to the University of Kentucky, we have a robust team that is multiple specialties, Neurology, Neurosurgery, the Pediatric team that all can provide a nice, comprehensive care plan for a pediatric stroke patient.

Host: So, those kids are in great hands indeed. Well, folks, we trust you are now more familiar with pediatric strokes. Dr. Kevin O'Connor, keep up all your great work and thanks so much again.

Dr. Kevin O'Connor: Thanks for having me.

Host: Absolutely. And for more information, please do visit ukhealthcare.uk.edu. Now, if you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. And thanks again for being a part of UK HealthCast, a podcast from UK HealthCare.