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Pediatric Cerebrovascular Disease and Stroke

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Summary

Cerebrovascular disease is a group of conditions that can lead to a cerebrovascular (brain and blood vessel) event, such as a stroke.

Expanded Overview

A stroke is an unexpected interruption of blood flow to the brain which can affect how you move, talk, and think. The underlying causes of stroke in children are different from those in adults. In children, strokes are more often due to blood clotting problems, congenital heart disease, infections or other long term conditions like Sickle Cell Disease. The underlying causes of stroke in children are different from those in adults.

Causes

These conditions have multiple causes, including deep vein thrombosis (blood clot in a deep vein, usually in a leg) and atherosclerosis (when dangerous plaque builds up in the arteries and causes a blockage).

Types

  • Aneurysm - This is an enlargement of an artery caused by weakness in the arterial wall, which can cause serious problems and even death.
  • Arterial Ischemic Stroke (AIS) - An Arterial Ischemic Stroke or AIS is a lack of oxygen and blood supply to an area of the brain. This is usually due to a blood clot in the artery.
  • Cerebral Sinovenous Stroke (CSVT) - A CSVT is a blood clot in the vein(s) or sinuses of the brain which can sometimes lead to a stroke.
  • Hemorrhagic Stroke - Intracranial hemorrhage is a leaking of blood vessels. This leaking causes too much pressure in the brain which leads to a stop of blood supply to an area of the brain.
  • Stenosis - This is a narrowing or blockage in the arteries.
  • Stroke - This occurs when blood supply to the brain is cut off. A stroke is a serious condition, and immediate treatment is critical.
  • Transient Ischemic Attack (TIA): TIA is a term used to define symptoms of a stroke which last a short period of time. These symptoms usually resolve without medical help.

Our Program

Treatment for stroke in children can be quite complex and it is critical that patients be managed and treated in a center of excellence with extensive cerebrovascular and stroke experience.

The Center for Cerebrovascular Disorders in Children at Children’s Health offers children and parents a collaborative group of experts that comprehensively diagnose and treat your child’s cerebrovascular condition, including stroke. We are among the very best in the region at performing the most advanced procedures and therapies for the treatment of pediatric cerebrovascular disease. Each of our primary team members works solely in the pediatric setting with a clinical interest in disorders of cerebrovascular system.

The Center is the only one of its kind in Texas, and our Comprehensive Stroke Program brings together a multidisciplinary team dedicated to providing timely, personalized care to children suffering from a stroke or other cerebrovascular disorders. We treat and care for children of all ages and see every stage of stroke, from acute care in the emergency department through long-term follow-up care and rehabilitation. The Stroke team includes specialized experts in pediatric neurology, neurosurgery, neuroradiology, interventional radiology, hematology, neuropsychology, physical and occupational therapy, speech and language therapy and physical medicine and rehabilitation. 

Symptoms

Symptoms

Many signs that would automatically make a doctor think of stroke in an adult can go unrecognized as the signs of stroke in a child.
How can you tell if your child is having a stroke?
Common warning signs include:

  • Confusion
  • Difficulty balancing
  • Difficulty communicating, including slurred speech
  • Dizziness
  • Loss of consciousness
  • Loss of half vision
  • Memory loss or confusion
  • Nausea, vomiting
  • Paralysis of one side of body
  • Seizures, especially in newborns
  • Severe, sudden headaches
  • Trouble seeing and even loss of vision

There is an acronym that can help people recognize and respond to the signs of stroke. It’s called FAST, and it can apply as much to your child as to an adult:

  • Face – One side of the face gets frozen (so the child can’t smile) or droopy, in which case an eye and the mouth sag on one side.
  • Arms – They  can’t raise both arms at the same time and keep them up
  • Speech – Slurred speech
  • Time –  Call 911 immediately if you see anything like this happening

Quick action can spare your child from suffering a significant, permanent disability. It can even save your child’s life.  It is important that your child be treated by a team that is specialized in the management of stroke in the pediatric population.​

Tests & Diagnosis

Tests & Diagnosis

If your doctor suspects your child has a stroke the doctor will do a complete exam of your child and one or more of the following tests:

  • CT and CT Angiogram – This test uses X-rays to produce multiple images of the inside of the body.  These three-dimensional pictures of the brain can be used to further evaluate conditions that affect blood vessels within the brain.
  • Magnetic Resonance Imaging (MRI) and Angiography (MRA) – This test uses radiofrequency to create accurate two- and three-dimensional images of the arteries in the neck and brain.
  • Cerebral Angiogram – This test is performed by an interventional radiologist who specializes in the care of children. This is extremely important as children have smaller blood vessels, limitations on dye administration, and specific radiation recommendations. The cerebral angiogram is a minimally invasive procedure which uses a special contrast, or dye, to observe blood flow in the brain. During the procedure, the radiologist places a small IV or catheter in a blood vessel in the groin, which he or she then uses to reach the blood vessels that supply the brain. With the help of the special contrast or dye, an X-ray machine moves in different angles and takes pictures of the blood vessels. A team – consisting of a radiologist, anesthesiologist, radiology technologists, and nurses – will care for your child throughout the procedure. Following the procedure, your child will have to lie flat for approximately four hours due to puncture of a large blood vessel in the groin, as this decreases the risk of bleeding.  If needed, your child will receive medication to help him or her relax and rest during this time.
  • Echocardiogram (ECHO) – An ECHO is an ultrasound of the heart that can determine if there are any defect within the heart that can make a child more susceptible to stroke.
  • Transcranial Doppler (TCD) – A TCD is an ultrasound on the blood vessels of the brain that can measure velocity of blood flow to determine if there is narrowing or blockage within a blood vessel.
  • Electroencephalogram (EEG) – An EEG is a test that uses sensors or electrodes that will be connected to your child’s head and these sensors will detect electrical activity of the brain.  This test is especially helpful in identifying if your child is experiencing seizures. 
  • Blood tests to detect clotting disorders – There are specific blood tests that can be performed to identify if your child is likely to form blood clots that can cause stroke or other health care problems.
Treatments

Treatments

Treatment varies based on the onset of stroke, time of presentation, severity, location and symptoms. Our team offers a comprehensive approach with multiple possible treatments, interventions or combination of treatments. These can include, but are not limited to, medical management, interventional radiographic techniques such as thrombectomy or thrombolysis, and in severe cases an operation to alleviate pressure on the brain due to swelling.

  • Medical Management – Most children that present with stroke require medical management that consists of medication to either break up a blood clot that is blocking blood flow to the brain or to decrease the ability of blood to clot further and cause additional blockage.  Our team of specialists will work together to determine an individualized regimen for your child.  These medications can include:
    • tPA – This medication is only given in acute stroke and not all patients will be candidates for the medication as it is time sensitive to the onset of symptoms and patient presentation. This medication is a potent “clot buster” that will help to dissolve the blood clot that is blocking blood flow to the brain.
    • Heparin
    • Lovenox
    • Aspirin
    • Coumadin
  • Thrombectomy is performed in conjunction with a conventional cerebral angiogram. This procedure is dependent on the artery that is blocked within the brain as well as the length of the time that a child has been experiencing symptoms.  Not all stroke patients will be candidates for this procedure.  During this procedure, a specialized interventional neuro-radiologist inserts a thin plastic catheter into an artery in your child’s groin. The catheter is guided into the blocked artery and a special catheter is used to remove a blood clot from the artery to restore blood flow to the brain.
  • Neurosurgery – Children with a stroke that need surgical intervention requires a highly specialized and meticulous approach.  In this surgery, the goal is to reduce pressure within the skull caused by swelling.  This approach requires a craniectomy or a removal of a piece of the skull to relieve the pressure.

Almost all children that present to the hospital with a stroke will require observation in the Intensive Care Unit for close monitoring and evaluation.  The duration of hospitalization is patient dependent and our team of specialists will collaborate to determine an individualized treatment plan for the care of your child.

Resources

Resources

For more information about cerebrovascular disease and strokes, please visit these sites:

FAQs

FAQs

What caused this to happen to my child?

There are a number of causes of stroke and they are very different in children than in adults.  Your child will be evaluated by our pediatric hematologists to determine if they have any blood clotting disorders that could predispose your child to the risks of future strokes.  Stroke can also be caused by trauma to the arteries in the head and neck and there are many times that a clear cause of the stroke is not identified in children.

What is the treatment for stroke?

Treatment can vary from child to child and our team of specialists will collaborate to determine an individualized approach to the treatment and care of your child.  We offer resources that will span the initial phase of stroke as well as long term care including follow-up in our comprehensive stroke clinic and therapies to help your child recover.

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