Ischaemic stroke in children

Stroke in children is uncommon. Atherosclerosis is not a cause, unlike in adults. However, localised forms of vasculitis and other forms of cerebral vasculopathy, congenital heart disease, arterial dissection and metabolic diseases are common causes. Always consider stroke mimics (eg Todd paresis, migraine).

Ischaemic stroke most commonly presents in children as acute hemiparesis, due to involvement of the carotid distribution. Vertebrobasilar stroke is unusual—look for a dissection of the vertebrobasilar arteries when it occurs. Neurological signs in childhood stroke can be subtle.

On presentation, start neuroprotective measures (ie normalise blood pressure, fluid volume, blood glucose concentration, body temperature and blood gases; control seizures). Perform urgent brain imaging (preferably magnetic resonance imaging, otherwise computed tomography) within 1 hour of arrival at hospital, and preferably within 4 hours of onset of symptoms.

The harms and benefits of thrombolytic therapy in children have not been fully assessed—at the time of writing, thrombolytic therapy should only be given in paediatric stroke centres. The efficacy of thrombectomy has not been fully assessed in young children. It is recommended that a tertiary paediatric centre be contacted for urgent neurological advice.

Perform imaging of the cervical and proximal intracranial arterial vasculature in all children with arterial ischaemic stroke, ideally within 24 hours of presentation. Also perform transthoracic echocardiography in this time frame.

Investigate all children with ischaemic stroke for a prothrombotic tendency (eg protein C or protein S deficiency, activated protein C resistance, increased lipoprotein (a), factor V Leiden, prothrombin gene mutation, antithrombin III, antiphospholipid antibodies). Measure serum homocysteine and urine homocystine concentrations. Exclude sickle cell disease. Measure the blood lactate concentration (raised in mitochondrial disease).

In acute arterial ischaemic stroke in a child, after brain imaging has excluded intracranial haemorrhage, and within 48 hours of onset, give aspirin. Use:

Anticoagulation with unfractionated heparin or low molecular weight heparin is used as an alternative to aspirin in some centres.

Although secondary prevention of ischaemic stroke with aspirin is established in adults, good evidence for its efficacy is not available in children. Nevertheless, aspirin is widely used for childhood ischaemic stroke. For secondary prevention, use:

To prevent recurrent cardiogenic embolism, seek expert advice.