Published in the October 2008 issue of Today’s Hospitalist
According to experts, the No. 1 misconception that physicians have about pediatric stroke is that it is incredibly rare. It’s no surprise, then, that the biggest mistake doctors make is discounting the fact that a stroke has taken place, delaying the onset of urgent care.
“Most child neurologists have long since recognized something a lot of other physicians have not: Stroke isn’t rare in children,” explains E. Steve Roach, MD, neurology chief at Nationwide Children’s Hospital in Columbus, Ohio, and lead author of a new clinical guideline on treating pediatric stroke. “We estimate that various types of stroke in children occur at about twice the rate of brain tumors.”
As a result, hospitalists “both those specializing in pediatric and in adult care “will likely encounter stroke in a child or young adult over the course of their careers. The new guideline, Dr. Roach says, is aimed at them, to help “narrow the gap between the people who know this topic pretty well and everybody else.”
The first-ever clinical guideline to address pediatric stroke, “Management of Stroke in Infants and Children” was published in the September 2008 issue of Stroke. Dr. Roach spoke to Today’s Hospitalist about the guideline’s top recommendations for hospitalists.
Beyond early recognition, what is the most important point for hospitalists to understand about pediatric stroke care?
Many issues in this pediatric guideline parallel those for young adults. You don’t often see in young adults, for instance, atherosclerosis, atrial fibrillation or hypertension as a cause for stroke. Whether you are talking about a 15-year-old or a 30-year-old, the risk factors for stroke will be somewhat similar.
What are these risk factors?
The top two causes of ischemic stroke in children are sickle cell disease and congenital heart disease. We seldom see hemorrhagic stroke in children due to hypertension. Instead, the big risk factor in kids is congenital blood vessel abnormalities.
How is pediatric stroke misdiagnosed?
I have seen kids admitted to the hospital with right-sided weakness and sent home two days later with a diagnosis of transient hemiplegia. I’ve seen weakness in a child not known to have epilepsy and not seen to have a seizure attributed to a seizure when he in fact had had a stroke.
We know now that an acute deficit in a child probably means the same thing most of the time that it means in adults. The take-home message is that stroke in children is not that unusual, so don’t dismiss focal neurologic deficits just because it’s a kid.
How then do you confirm a stroke diagnosis in children?
The diagnostic approach is largely the same: You are going to do a CT and an MRI. The usual shortcoming is that people are convinced that this couldn’t be a stroke so they fail to use those tools. Anybody who gets to first base to consider if this could be stroke is usually OK.
Is treating stroke in children the same as in adults?
Not necessarily. If we have a 75-year-old who has a TIA, we can put that person on aspirin and not worry if we ever need to stop it. Who cares if they take it for the next 10 or 15 years? But if you have a 10-year-old who you put on aspirin and he is doing pretty well, then you are faced with a dilemma: Do we really need to use aspirin in this person for 75 years?
Were you able to find evidence to back up the recommendations?
With the exception of sickle cell disease, there aren’t a lot of pediatric-specific data. There are adult data about what to do, so the guideline piggybacks on those adult data. You approach the person by looking at stroke type and, as best as you can determine, the cause. Then figure out what you are trying to prevent.
Generally speaking, you are going to use anticoagulation if what you are trying to prevent is another embolic stroke. If someone with congenital heart disease has an embolic stroke, the consensus is that the person is at risk for having another. Barring some contraindication, we would use heparin initially and increasingly just warfarin.
If you think the child has a high risk of recurrent stroke but not specifically embolic, it seems reasonable to give aspirin, but we didn’t have enough evidence to make a strong recommendation.
What about concerns over using aspirin in children?
The risk of Reye’s Syndrome at that low a dose (2-3 mg/kg) per day is pretty small. Most children who had Reyes syndrome in days past were not taking small daily doses for its antiplatelet effect but large doses to control fever. Of course, certain infections are more predisposing to Reye’s Syndrome, such as influenza and chicken pox, which is why the guideline says to make sure these kids get a flu and a chicken pox vaccine.
Is there a role for tissue plasminogen activator (tPA) in treating children?
We wrestled with that. The problem is that the drug is approved only for people over age 18. There is no evidence that it wouldn’t work in younger people, but what we have to work with is a handful of case reports where people have tried it.
The big elephant in the room with tPA is the time issue. We certainly don’t have any evidence that it is any safer to use after the time limit in a 10-year-old than in a 40-year-old. However, few children with an ischemic stroke are actually seen by a physician within three hours.
We left some leeway in the guideline, saying that we don’t know of any reason to think there is a physiologic difference between a 14-year-old and a 20-year-old, so it might be reasonable to consider using tPA in a teenager. We wouldn’t want to preclude a physician from deciding to use it.
The guideline recommends against antiseizure medicine for these children.
There is no basis for using antiseizure medicine unless a child has seizures. There are situations where, due to some presumed seizure risk because of scarring, children are sent home on an antiseizure medicine.
Perhaps as many of 15% of kids who have had an ischemic stroke will eventually start to have seizures, but that means 85% don’t. And they presumably would get their coordination back a little quicker if they weren’t on medicine. The 15% of kids who start to have seizures usually don’t begin until eight to 12 months after a stroke.
Once a child has had a stroke, you probably can’t do anything too directly to reverse the damage that has been done. Two things typically determine long-term outlook and function: Does the underlying disease have consequences, and do patients have repeated strokes? Given that many risk factors are to varying degrees treatable, the idea of identifying and treating the risk factor as a means to secondary prevention is a good concept.
Deborah Gesensway is a freelance health care writer based in Sierra Madre, Calif.