Pediatric Clinics of North America - CIPERJ

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Pediatr Clin N Am 55 (2008) 323–338 Pediatric Arterial Ischemic Stroke Timothy J. Bernard, MD a,b,c, *, Neil A. Goldenberg, MD a,b a Mountain States Regional Hemophilia and Thrombosis Center, P.O. Box 6507, Mail-Stop F-416, Aurora, CO 80045-0507, USA b Pediatric Stroke Program, University of Colorado and The Children’s Hospital, 13123 East 16th Avenue, Aurora, CO 80045, USA c Department of Child Neurology, University of Colorado and The Children’s Hospital, 13123 East 16th Avenue, Aurora, CO 80045-0507, USA Arterial ischemic stroke (AIS) is a rare, but increasingly recognized, disorder in children. Research in this area suggests that risk factors, outcomes, and even presentation are different from those of adult stroke. In particular, prothrombotic abnormalities and large vessel arteriopathies that are nonatherosclerotic seem to play a large role in the pathogenesis of childhood AIS. The purpose of this review is first to examine the epidemiology and etiologies of neonatal and childhood AIS and then provide a detailed discussion of approaches to the clinical characterization, diagnostic evaluation, and management of this disorder in pediatric patients. Long-term outcomes of recurrent AIS and neuromotor, speech, cognitive, and behavioral deficits are considered. Emphasis is on available evidence underlying current knowledge and key questions for further investigation. Characterization AIS is characterized by a clinical presentation consistent with stroke combined with radiographic evidence of ischemia or infarction in a known arterial distribution. Unless otherwise specified, throughout this article the term, ‘‘stroke,’’ is used synonymously with AIS. AIS in pediatrics is divided into two main categories: neonatal AIS and childhood (non-neonatal) AIS. Neonatal AIS is defined as any ischemic stroke occurring within the first 28 days of life and is subdivided further into prenatal, perinatal, and * Corresponding author. Department of Child Neurology, University of Colorado and The Children’s Hospital, P.O. Box 6507, Mail Stop F-416, Aurora, CO 80045-0507. E-mail address: timothy.bernard@uchsc.edu (T.J. Bernard). 0031-3955/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.pcl.2008.01.002 pediatric.theclinics.com
324 BERNARD & GOLDENBERG postnatal. Acute perinatal stroke usually presents with neonatal seizures during the first week of life. This differs from a presumed prenatal stroke, which typically presents at 4 to 8 months of life with an evolving hemiparesis [1]. Because of the difficulty in determining the exact timing of presumed prenatal AIS, some investigators combine the two classifications as presumed prenatal/perinatal AIS. In contrast to neonatal stroke, childhood AIS typically presents with sudden onset of focal neurologic symptoms and signs and (given the broad differential diagnosis) requires an MRI of the brain with diffusion-weighted images to confirm the diagnosis of AIS (AIS presentation discussed later). Epidemiology The incidence of neonatal AIS recently is estimated at approximately 1 in 4000 live births annually [2]. Similar estimates are provided by the United States National Hospital Discharge Survey, which recently published an incidence of 18 neonatal strokes per 100,000 births per year [3]. Childhood AIS is less common than neonatal stroke, occurring one third to one tenth as often. The incidence of childhood stroke is approximately 2 to 8 in 100,000 per year in North America [4,5]. Before the advent of MRI techniques, a Mayo Clinic retrospective analysis of cases in Rochester, Minnesota, in the late 1970s yielded an incidence of 2.5 strokes per 100,000 children per year [6]. Although pre-MRI data likely underestimate the incidence of AIS because of the low sensitivity of CT for ischemia, more recent retrospective analyses using medical record review are subject to well-documented inaccuracies engendered by the International Statistical Classification of Diseases, 9th Revision coding [7]. In addition, given the low index of suspicion for cerebrovascular events in children, the true incidence of pediatric AIS likely remains underdiagnosed. Etiology The etiology of neonatal and childhood AIS is in many instances poorly understood, largely owing to the low incidence of the disease in the pediatric population and the lack of sufficient multicenter data on causal factors. The traditional ischemic stroke risk factors in adults, such as hypertension, atherosclerosis, diabetes, smoking, obesity, and hypercholesterolemia, are infrequent among neonates and older children who have AIS. In some instances of childhood AIS, such as congenital heart disease, sickle cell disease, and arterial dissection, the etiology readily is understood. For instance, with regard to cardiac risk factors, the Canadian Pediatric Stroke Registry found heart disease in 25% of patients who had pediatric AIS [8], whereas the prevalence of patent foramen ovale (PFO) in patients who had cryptogenic stroke was 40% to 50% compared with 10% to 27% in the general population [9,10]. Some additional important risk factors for childhood AIS are
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Pediatr Clin N Am 55 (2008) 447-460
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