Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association

Abstract

Purpose-Much has transpired since the last scientific statement on pediatric stroke was published 10 years ago. Although stroke has long been recognized as an adult health problem causing substantial morbidity and mortality, it is also an important cause of acquired brain injury in young patients, occurring most commonly in the neonate and throughout childhood. This scientific statement represents a synthesis of data and a consensus of the leading experts in childhood cardiovascular disease and stroke. Methods-Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and the American Heart Association's Manuscript Oversight Committee and were chosen to reflect the expertise of the subject matter. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge. This scientific statement is based on expert consensus considerations for clinical practice. Results-Annualized pediatric stroke incidence rates, including both neonatal and later childhood stroke and both ischemic and hemorrhagic stroke, range from 3 to 25 per 100 000 children in developed countries. Newborns have the highest risk ratio: 1 in 4000 live births. Stroke is a clinical syndrome. Delays in diagnosis are common in both perinatal and childhood stroke but for different reasons. To develop new strategies for prevention and treatment, disease processes and risk factors that lead to pediatric stroke are discussed here to aid the clinician in rapid diagnosis and treatment. The many important differences that affect the pathophysiology and treatment of childhood stroke are discussed in each section. Conclusions-Here we provide updates on perinatal and childhood stroke with a focus on the subtypes, including arterial ischemic, venous thrombotic, and hemorrhagic stroke, and updates in regard to areas of childhood stroke that have not received close attention such as sickle cell disease. Each section is highlighted with considerations for clinical practice, attendant controversies, and knowledge gaps. This statement provides the practicing provider with much-needed updated information in this field. (Stroke. 2019;50:e00-e00.

Arterial Ischemic Stroke Secondary to Cardiac Disease in Neonates and Children

“…The American Heart Association (AHA) Guidelines on Management of Stroke in Infants and Children suggests reasonable evaluation for the more common prothrombotic states even when another stroke risk factor has been identified (Class IIa, Level of Evidence C). 29 The updated 2019 AHA guidelines for Management of Stroke in Neonates and Children 30 and the AHA Guidelines on Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease concur with these recommendations and suggest considering evaluation for inherited or acquired prothrombotic risk factors in children with heart disease who have a stroke (Class IIa, Level of Evidence B). 6 Although routine testing for hypercoaguability after neonatal stroke may not be indicated in the absence of cardiac disease, 31 in neonates and children with CHD, a thrombophilia evaluation may be appropriate.…”

A Stroke Alert Protocol Decreases the Time to Diagnosis of Brain Attack Symptoms in a Pediatric Emergency Department

“…[1][2][3][4][5][6] This requires enhanced community education and an organized system of evaluation and management once a patient presents for medical care. 20 We have shown that the establishment of a stroke alert system at a tertiary children's hospital, coupled with extensive internal educational efforts, significantly decreases the median time to diagnosis by neuroimaging of patients presenting to the ED with brain attack symptoms. This finding represents an important first step in ensuring that a greater proportion of children with AIS are diagnosed within a time frame that enables treatment with acute interventions.…”

Hemoglobin Southampton complicated by cerebral ischemia, moyamoya, and hydroxyurea‐induced methemoglobinemia

“…Aspirin therapy is given for thromboprophylaxis prior to surgery and to promote patency of the graft vessels. 25 There has been a historical reluctance to use aspirin in SCD patients with moyamoya due to a concern that its use may precipitate intracranial hemorrhage. However, this increased risk generally occurs well into adulthood and is not exclusive to SCD-associated moyamoya, so clinical practice trends are starting to change.…”

“…25 There has been a historical reluctance to use aspirin in SCD patients with moyamoya due to a concern that its use may precipitate intracranial hemorrhage. Aspirin therapy is given for thromboprophylaxis prior to surgery and to promote patency of the graft vessels.…”