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New Guidelines For Treatment and Prevention of Stroke in Children

Posted Sep 22 2008 11:02am

Most people have the preconception that cerebrovascular disease or stroke only occurs in the elderly, or in the middle-aged adults.  However, even with lack of clinical studies, it is documented that children can also have this disease.  I do not have the local statistics but, in the U.K., there are 5 out of 100,00 children who gets CVD every year.  Not as common as people dying from complications of hypertension or diabetes, but still the fact is that children can also get this disease.  I’ve personally seen one during my internship and the patient was just 3-years old, with a weakness in one side of the body as the beginning symptom, her parents having noted that she wasn’t able to play like her usual.  She was able to survive the stroke, but I haven’t seen her in follow-up consults to know whether she’s able to regain back all her normal functions.

Stroke in children are commonly caused by congenital diseases like sickle-cell anemia and heart diseases.

The American Heart Association Stroke Council issued guidelines for the prevention and treatment of stroke in children in the July 17 Online First Issue of Stroke and will be reported in the September print of Circulation.  The purpose was to review the literature on childhood stroke and to recommend optimum diagnosis and treatment.

Vascular imaging is recommended for all cases of stroke in children.  Conventional arteriography (CA) is most accurate to image lesions of the distal arterial branches and lesions of the intracranial internal carotid artery but magnetic resonance angiography (MRA) may be an alternative.  Fat-saturated T1 imaging of the neck and/or venous imaging may improve the yield of MRA.  CA can be used for extracranial arterial dissections, particularly for those in the posterior circulation, and for small vessel vasculitis.  For hemorrhagic and ischemic stroke, emergency vascular imaging should include magnetic venography (MRV).  Cranial ultrasound, Doppler ultrasound, computed tomography, computed tomographic angiography, computed tomographic perfusion, magnetic resonance imaging, magnetic resonance perfusion, and nuclear medicine should be utilized depending on the clinical situation.

Here are the other recommendations (as quoted from Medscape):

Class I recommendations for children with SCD are as follows:

  • Acute management of ischemic stroke from SCD should include optimal hydration and correction of hypoxemia and systemic hypotension (class I, level of evidence C).
  • To lower stroke risk in children 2 to 16 years of age with abnormal transcranial Doppler (TCD), periodic transfusions to reduce the percentage of sickle hemoglobin are effective and are recommended (class I, level of evidence A).
  • A regular program of red cell transfusion, along with measures to prevent iron overload, are indicated for children with SCD and confirmed cerebral infarction (class I, level of evidence B).
  • Before performing CA in a patient with SCD, the percentage of sickle hemoglobin should be reduced with transfusions (class I, level of evidence C).

Class I recommendations for children with stroke and heart disease are as follows:

  • Treatment for congestive heart failure is recommended and may lower the risk for cardiogenic embolism (level I, level of evidence C).
  • To improve cardiac function and to lower subsequent risk for stroke, congenital heart lesions should be repaired when feasible, especially complex heart lesions with high risk for stroke (class I, level of evidence C). However, this recommendation does not yet apply to patent foramen ovale.
  • In light of ongoing risk for cerebrovascular complications associated with atrial myxoma, resection is indicated (class I, level of evidence C).

Class I recommendations for evaluation and treatment of hemorrhagic stroke in children are as follows:

  • To identify treatable risk factors before another hemorrhage occurs, children with nontraumatic brain hemorrhage should undergo a thorough risk factor evaluation, including standard cerebral angiography, when noninvasive tests have not been diagnostic (class I, level of evidence C).
  • Appropriate factor replacement therapy is indicated for children with a severe coagulation factor deficiency. Factor replacement after trauma is indicated for children with less severe factor deficiency (class I, level of evidence A).
  • Because congenital vascular anomalies are associated with risk for repeat hemorrhage, these lesions should be identified and corrected whenever it is clinically feasible, as should other treatable risk factors for hemorrhage (class I, level of evidence C).
  • In children with brain hemorrhage, stabilizing measures should include optimization of respiratory effort, controlling systemic hypertension and epileptic seizures, and managing increased intracranial pressure (class I, level of evidence C).
  • It is important that the first stroke should be treated optimally, as to prevent the recurrence ( second stroke occurs in 10%-25% of children with stroke ).

    For other stroke-related guidelines, please see AHA Stroke Council’s site.

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