Stroke

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Suspecting or learning that your child has had a stroke can be overwhelming. The neuroscience experts at CHOC help every step of the way, from evaluation and diagnosis to treatment and recovery.

What is a Stroke?

A stroke is a brain injury caused by the interruption of blood flow to part of the brain. Blood carries oxygen, nutrients and other important substances to the body’s cells and organs, including the brain.

There are two different types of stroke: ischemic and hemorrhagic. Ischemic strokes occur when the blood supply is disrupted due to a clot or narrowing of the blood vessels. Hemorrhagic strokes occur when the bloody supply is disrupted due to bleeding in the brain. In children, approximately 50% of strokes are ischemic and 50% are hemorrhagic. A transient ischemic attack (TIA) is a temporary disruption of blood flow that does not cause permanent damage to the brain tissue or permanent disability.

What Causes Strokes in Children?

Finding the cause of a pediatric stroke in children can be difficult. Common causes of stroke in children differ from those in adults.

Some common causes of ischemic stroke in children include:

  • Congenital heart disease: patients with congenital heart disease have a higher risk of developing blood clots in the heart that may then travel to the brain, causing a stroke.
  • Problems with blood vessels in the brain (also called arteriopathies): this may be caused by an infection, the reaction of the body to an infection, trauma or an underlying disease of the blood vessels such as moyamoya disease.
  • Sickle Cell Disease or other blood disorders.
  • Autoimmune diseases.

Common causes of hemorrhagic strokes in children include:

  • Head injuries/trauma.
  • Blood vessel abnormalities (dissection, vasculitis, abnormally formed blood vessels).
  • Blood clotting diseases.

Risk of Stroke in Kids

The risk of stroke in kids is highest before the age of 1. A stroke is much more common in adults than in children. Because strokes aren’t as common in children as they are in adults, a diagnosis may be delayed. Children, however, often recover more easily than adults because their brains are still developing and are more adaptable to change.

Symptoms of Stroke in Children

Symptoms of strokes in children depend on the age of the child and the cause of the stroke. Below are some common signs of a stroke in infants, kids and teens.

Common Signs of a Stroke in Infants

Perinatal strokes may occur from the middle of the pregnancy, through the birth period and up until 28 days after the baby is born. In some cases, infants with perinatal stroke develop normally but at a slower pace than other kids. They also might tend to use one hand more than the other. In other cases, there are symptoms of stroke that occur during the newborn period. Symptoms in infants and newborns could include:
  • Seizures: this can manifest as repetitive involuntary jerking of the face, arm or leg, staring spells or periods in which baby stops breathing and turns blue.
  • Extreme fatigue, difficulty waking up or poor feeding.
  • Often there are no signs in the newborn period, but around 4-6 months old, parents or the primary care doctor may notice the baby is weaker on one side of the body, has a major hand preference before 1 year of age or is not meeting developmental milestones as expected.

Common Signs of a Stroke in Kids and Teens

Signs of stroke in children usually start suddenly. They may include:
  • Weakness or loss of sensation on one side of the body or face
  • Vision changes
  • Inability to speak clearly or understand
  • Balance problems
  • Severe headache (especially with vomiting or sleepiness)
  • New seizures (usually affecting one side of the body)
If your child has symptoms of a stroke, call 9-1-1 or your local emergency number.

How to Remember Signs of a Stroke

F.A.S.T. is an easy way to remember the signs of a stroke. If you spot any of the signs, call 9-1-1 immediately. FAST chart for stroke symptoms F.A.S.T. stands for:
  • F is for face drooping – One side of the face is drooping or numb. When the person smiles, the smile is uneven.
  • A is for arm weakness – One arm is weak or numb. When the person lifts both arms at the same time, one arm may drift downward.
  • S is for speech difficulty – You may notice slurred speech or difficulty speaking. The person can’t repeat a simple sentence correctly when asked.
  • T is for time to call 9-1-1 – If someone shows any of these symptoms, even if they go away, call 9-1-1 immediately. Make note of the time the symptoms first appeared.

Diagnosis of Stroke in Children

Diagnosis of stroke in children begins with a review of the child’s current symptoms and health history. Your child’s provider will then examine the child, looking for any signs of weakness, numbness or other signs of a stroke. Several tests may be done to help make the diagnosis. These tests could include:

  • Brain imaging such as an Magnetic Resonance Imaging (MRI), MRA (magnetic resonance angiogram) to look at the arteries or MRV (magnetic resonance venogram) to look at the veins.
  • CT (computed tomography), a fast imaging test of the brain. This type of images uses radiation to look at the bones and a simple view of the brain structure and vessels.
  • Blood work looking for possible blood disorders or infection.
  • Heart and blood vessel studies: Heart rhythm is checked with an Electrocardiogram (ECG). A special ultrasound of the heart may be done to look for the heart for possible causes of air embolism or blood clot. A special monitor may also be worn to look for heart rhythm abnormalities over a period of time.
  • Lumbar Puncture: Fluid surrounding the brain and spinal cord may be checked for blood or signs of infection.
  • Electroencephalogram (EEG) to measure electrical activity in the brain and to look for any signs the child may have had a previous seizure.

Stroke Treatment in Children

It is important to call 9-1-1 at the first sign of a stroke. Treatment works best if it is as close as possible to when the stroke occurs. Treatment depends on:

  • The cause of the stroke
  • The child’s age
  • The area of the brain affected
  • How much brain tissue was damaged

Treatment for Perinatal Stroke

  • Treatment for perinatal stroke depends on the cause and type of stroke.
  • If a cause is found, such as increased risk for blood clots, infection or seizures, your child’s doctor will discuss additional treatments or medications.
  • If your baby has trouble moving, developing or speaking, therapies can help improve their strength and retrain the brain.

Treatment for Childhood Ischemic Stroke

Acute (immediate) treatment may include:

  • Tissue Plasminogen Activator (tPA), a clot-dissolving medication.
  • Thrombectomy, a minimally-invasive surgical procedure where a specialist removes a blood clot from the blood vessel, under image guidance, to allow the return of normal blood flow.
  • Treatment of fever, high or low blood pressure, high or low blood sugar, seizures and infection.

Long-term and preventative treatments may include:

  • Blood-thinning or anti-clotting medications to prevent future strokes.
  • Medications to control seizures, high blood pressure or high cholesterol.
  • Treatment of any co-occurring infection or other underlying cause for stroke.
  • Rehabilitation program that may include physical therapy, occupational therapy, speech therapy or psychology.

Treatment for Hemorrhagic Stroke

Treatments may include:

  • Surgery or close monitoring in the intensive care unit.
  • Medications to control or prevent seizures, manage elevated blood pressure or fluid in the brain.
  • Rehabilitation programs such as physical therapy, occupational therapy, speech therapy or psychology.

Stroke Prevention in Children

In children, the first symptom of a stroke is usually the first warning, so there may be no way to prevent the first stroke. Some children may have a second stroke. Your child’s healthcare provider will treat the condition that may have led to the stroke. Medicines, tests, procedures and surgery may be part of that treatment.

The chance of your child having another stroke depends on the underlying cause and should be discussed with your doctors. Overall, most children do not have additional strokes after an initial stroke.

Things you can do to reduce to the risk of your child having another stroke include:

  • Follow up regularly with your child’s primary care provider and specialists.
  • Take all medications as prescribed. If your child has difficulty with any medications, notify your medical provider before discontinuing.
  • Decrease sodium and eats lots of fruits and vegetables.
  • Exercise for at least one hour every day.
  • Avoid smoking and exposure to second-hand smoke. Have open discussions with your teenager about risks of smoking and how to resist peer pressure.
  • High blood pressure, high cholesterol and uncontrolled diabetes increase the risk of stroke. Make sure your child’s primary care doctor checks for these regularly. If your child is diagnosed with any of these, make sure they take their medications and follow any prescribed dietary guidelines. These conditions should be monitored on a regular basis.

Stroke Recovery in Children

Each child recovers from stroke differently. The impact of the stroke on your child also depends on the location in the brain and size of the stroke. Overall, studies have found that about one-third of children recover completely after stroke, and two-thirds have some sort of on-going neurological problems. Among the two-thirds with on-going problems, about half are mild and half are moderate or severe. Persistent problems after stroke may include:

  • Weakness
  • Loss of sensation
  • Vision problems
  • Favoring one side of the body (ignoring the weaker side)
  • Problems with speaking or understanding language
  • Swallowing problems
  • Balance/coordination difficulty
  • Learning problems (may include attention, memory, judgment, problem-solving)
  • Emotional or behavioral problems

The number one thing you can do to optimize your child’s recovery is to have them engage in an active rehabilitation program. Your medical team will advise what types are appropriate for your child, such as physical, occupational or rehabilitation therapy.

The experts at CHOC can help with the diagnosis, treatment and recovery associated with pediatric stroke.