Pediatric Stroke

What is a stroke?

How did this Happen?

• To date, predictable indicators and risk factors for childhood stroke are much fewer than in adults.  Because an infant or child has not had the time to accumulate the same risky dietary or living habits, i.e. overeating, smoking, medications, etc. of adults, the causes are often very different.  So different in fact, that many dchildhood stroke diagnoses go indefinitely without a cause or source.
• Your doctor will look for known causes should your child be diagnosed with CVA, or infarct (stroke) which may include
  • Existing heart conditions which might be a factor in causing stroke
  • Vascular disorders (where veins, vessels, or capillaries are prone to constriction or rupturing)
  • Blood clots or foreign bodies, which might dislodge and travel to the brain, blocking blood and oxygen flow to a specific area or areas.  This is known to happen during or after surgery to another part of the body, such as a heart surgery.  It is usually listed as a possible complication of surgery to a child or adult
  • Increased blood pressure due to traumatic events (cord wrapping around the neck, difficult and prolonged delivery, rupture of placenta or cord, causing extended lack of nutrient delivery to the baby)
  • Head injury/ Traumatic Brain injury due to falls, automobile accidents, sports injuries, etc.
  • Predisposition to stroke from within the genetic line (congenital)
  • Certain metabolic disorders
  • Sickle Cell Disease
  • Intracranial infection
  • Fat, air, or foreign body embolism
  • Child abuse (trauma), such as Shaken Baby Syndrome
  • Whether or not a cause is found, it is separate from the issue that you’ll need to confront, which is the diagnosis (what has happened) & prognosis, or your doctor’s medical opinion of predicted outcome (what’s going to happen).  That prognosis can differ greatly depending on how quickly treatment can be administered.

Signs/Symptoms of Childhood Stroke

• Severe headache- this is often the first complaint
• Facial droop or salivary drool
• Nausea/vomiting, skin may feel clammy
• Speech difficulties- absent, slurred or inappropriate speech
• Eye movement problems – partial or complete blindness, blurred vision, unequal pupils
• Numbness – paralysis, weakness, or loss of coordination of limbs, usually on one side of the body; loss of balance
• Neck veins extremely prominent
• Urinary incontinence  (wetting oneself during daytime, loss of control of bodily functions)
• Seizures
• Brief loss of consciousness; unconscious ‘snoring’ respirations
• May show signs of rapid recovery (TIA) -- TIA is a mini-stroke, a blockage which dislodges and resolves itself, allowing bloodflow to resume after a short period of time.  It is still very important to see a doctor as the blockage could likely recur temporarily or permanently

What Happens Now?

• There is clinical evidence to suggest that within a very small timeframe (about 2-3 hours) after actual occurrence of stroke, a medical team can administer treatment (usually an IV dose of TPA, a clot buster, which may actually offset the effect.  This is, of course, provided the clot is the cause of stroke and there has been no tear of the vascular wall.  In this instance, some patients had no long-term effects of stroke at all.  TPA is not always recommended for children/ infants due to its possibly long term side effects.  Stroke is often harder to observe in younger infants and children, but parents who knows more about how active their small children and teens are make it easier to notice a loss of use of one side or quadrant of the body, including blurred vision, slurred speech, or sagging of the face.
• There is documented use of aspirin use as a blood thinner or anticoagulant to prevent future strokes if your family is known to have a genetic predisposition to blood clotting, though prolonged use can cause Reye’s syndrome. Talk to your doctor before starting any long term course of medications, even over the counter.  Ask if your child has a risk indicator that causes coagulation of the blood.  Also be sure your child isn't allergic to aspiring or blood thinners, such as ibuprofen and like medications.
• There is a chance your child will leave the hospital with no medical treatment at all, except for stabilization,  a prescribed battery of tests, and a course of therapy alternatives. 

What Do I Do?

• In newborns, a diagnosis of stroke is often a call to action for most parents.  They want to ‘do’ something.  However, the laundry list of things a newborn should be able to accomplish simply isn’t very long.  Consequently, many babies don’t start treatment until a developmental delay is noticed by either the family or doctor during a checkup.  Of the 85% who survive a stroke before, during, or shortly after birth, more than half will experience developmental delays.
• In older children who experience stroke (even those who lived normally only a few months  before the stroke), parents often have a better feel for how cognitively and physically developed the child was before the incident, and can then start comparing and planning a treatment to offset any deficiencies.

1. The biggest thing you can do right now is to start educating yourself (and your child) as best as you can.  As soon as you know of the diagnosis or notice a delay, start working with your doctor and support team to define a wellness plan for your child, including visits, therapy, and surgeries (if needed).  Together you make the difference. Click here for examples.
2. Make lists of things your child cannot do that he is used to (or developmentally should be) doing. Together you can set goals (a little at a time for recovery).  Every state is required to have a version of Early Intervention services (some go by different names).  These are provided from birth to age 3, usually to offset actual or predicted developmental delays, and can include occupational, physical, speech, vision, and other therapies.  These therapies are normally provided in the home or other natural environment, such as preschool, or wherever the child would normally be during the day.
3. Get a hold of your support system.  Make sure your co-workers, boss, and friends know that you need help.  Also consider parental support groups in your area.  Click here for some online support groups. You can also chat with other like parents in support groups, discussion rooms, and e-mail lists. 
4.  If you find a doctor who is unenthusiastic or unconcerned about your child, move quickly toward another direction.  You may need to visit a larger or different metropolitan area just to see a physician who has seen your child’s condition on a more frequent basis.  Some towns are fortunate enough to have one visit small suburban areas once or twice a month.  This is not to say that small town doctors are less knowledgeable or incompetent; however, sometimes the sheer number of cases they see in a year is not enough for them to have the experience in the unique medical needs of children with special needs.  Don’t judge too soon, though.  Some see children from several counties around and can give your child attention a large city physician may not have time to give.

The Good News

• A child’s brain is not done developing, so many times the damage is done to an incomplete product, so to speak.  So even if you never undo the damage caused to the affected areas, the brain most likely will grow and add SOME new function.
• Also, certain activities, therapies, inputs, diet, and other stimuli can cause the brain to react by establishing new connections.  This is the optimal result, secondary to undoing the damage right away if possible (which can only be done by removing the blockage and/or restoring bloodflow before the atrophy occurs).  It is possible, but keep in mind that every child’s result will differ. 
• Many survivors grow up to lead completely normal lives with minimal assistive devices, and some with none at all. 

The Not-so-good News

• A brain which has been deprived of oxygen and nutrients for a specified time (like any other cells in the body), will begin to break down and die.
• The tissue will actually shrink (atrophy) and eventually gets absorbed into the bloodstream, leaving a literal space where there is no brain tissue, only fluid. A CAT scan may reveal a brain image that looks like it has a ‘hole’ in it.
• However, as the child grows, so does the brain, and eventually, much of the space is filled.  This space can be occupied by a portion of the brain that serves a completely different function for the body, so it does not automatically mean that with growth, the function will ever be restored.
• All cases are different and some will be moderate to severe.  Again, use all support systems in place to help you give your child the best care and quality of life possible.

The Light

Secondary Diagnoses

• If the stroke affected the right side of the brain, a general deficit in the left side of the body can be expected.  This is called Left Hemiplegia or Left Hemiparesis, a partial paralysis which affects the left side of the body.
•  Likewise, if the attack happened on the left side, a general deficit on the right side would be expected.  This is called Right Hemiplegia, a partial paralysis which affects the right side of the body.
• Some children display Diplegia (a modification of the word hemiplegia).  This time, half of the limbs are affected, but usually they are like limbs, such as both arms or both legs.  A child may have normal legs, but not be able to fully function with hands and arms or vice versa
• Triplegia happens when three of the four limbs are affected (e.g., two legs and an arm, or two arms and a leg are affected, weak or paralyzed)
• Some children will have limited or no use of all limbs.  This is called quadriplegia
  • Quadriplegic as well as Diplegic & Triplegic (with affected legs) children will often need partial or permanent wheelchair and sometimes advanced handicapped assistance or disability support

The above five categories all fit into the umbrella diagnosis of Cerebral Palsy.  Cerebral means 'of the brain' and Palsy means 'affected ability to move or function.'  These are only physical aspects of Cerebral Palsy (CP).  CP also includes inability to function normally in a mental capacity.  Many people visualize only quadriplegic children when they think of CP, and are surprised to learn that many of them might be able to run, jump, and function normally.  As you are beginning to see, the type and severity of CP depends purely on the location and severity of the stroke, brain injury, or compromise.

• The brain is divided into lobes, which each perform specific groups of job functions.  If the stroke happened in the frontal lobe, a parent might expect a change in or a differentiation in personality, inhibitions, or awareness levels in a child (as compared to that of a 'normal' child) and may need to begin therapies in this area.

• The brain also houses the parietal, temporal, and occipital lobes.

• Loss of a portion of the occipital lobe could result in full or partial blindness, since its function includes vision. However, all other lobes have some involvment in visual processing.

• An attack in the parietal lobe could affect learning, since it determines some intelligence, and also concerns the sensory reception of touch, temperature, and pain.

• The temporal lobe is largely involved with auditory processing, so a stroke in this area could result in partial or profound deafness.

Epilepsy

• Grand mal-  (Also called Tonic Clonic)- This is the most widely recognized, due to its prominent nature and presence, marked by convulsions, loss of consciousness, jerking, salivating, eyes rolled back or stagnant, and sometimes apperance of blue extremeties in the face (from loss of oxygen).
  • Some of these seizures have been called 'completely harmless,' because children under 5 commonly have this type of seizure if a sudden or prolonged high fever is present.  This seizure is called febrile seizure and may not be related to the head injury. The common treatment is to prevent injury during the convulsions, and call for emergency help to stabilize the child, administer oxygen, and check for any brain damage, which would likely occur if the oxygen deprivation lasted too long.
  • Treatment for a typical grand mal, due to stroke or brain injury is much the same.  However, you might be referred to a specialist, such as a pediatric neurologist for follow up.  Your child might also be prescribed an emergency medicine, such as Diastat, a sedative, to help stop or subdue the seizure as you wait for emergency help the next episode.  Obviously, a care plan would be put in place to ensure the diastat remained with the child at all times.
• Petit mal (pronounced petty-mall)- This is also called an absence seizure, because the child will seem distracted or absent from the situation.  He may seem to be daydreaming, 'spaced out,' or in 'la-la' land for a period of time, often coming back to reality and picking up where he may have left off.  Absence seizures might be accompanied by some mild jerking(myoclonic movements), such as those of eyelids or of one arm (which are generally symptoms of partial seizures).  However, they are not partial seizures because there is no aura, absence seizures do not last long, and usually have no confusion or after effects.

• Other seizure types
  • Myoclonic - jerking of one arm or one foot, usually during sleep, no consciousness during seizure
  • Atonic - Partial or complete loss of muscle tone.  Head may drop, arms may lose ability to hold an object, or whole body may drop to the floor.  Dangerous due to the potential for head injury.
  • Simple Partial - Awareness is maintained, child can remember entire episode, but cannot control movements or jerking; may fumble hands, slap self, foot may shake, etc.  Senses are affected.  Child may report a foul odor (burned eggs or smoke), bad taste in their mouths, nausea, or things may look, feel, or sound differently than normal.  Feeling of Deja vu is common.  Seizure lasts a short while.
  • Complex Partial - Awareness is impaired or consciousness is lost.  May be preceded by aura, resembles sleepwalking.  Child is not awake and is not in charge of what he thinks or does.  May have eyes open, be standing, walking, or performing an activity.  Dangerous due to loss of general consciousness and potential for engaging in hazardous activity or injuring others.
  • There are still more seizures and spasms not named here.  Talk to your doctor if your infant or child seems to behave abnormally and you can't explain/control the frequency or activity

Possible therapies for seizure include routine modification, magnetic therapy, medication (reactive or prophylactic), and surgeries.  Some patients have even undergone hemispherectomies (removal of additional portions of the brain), many with great reduction or elimination of seizure altogether.