Cause Of Stroke In Children Research Articles

Noninfectious cerebral vasculitis in children

The vasculitides are a heterogeneous group of disorders. Vasculitides secondary to infectious diseases are more common than those attributable to noninfectious causes, especially in developing countries. Cerebral vasculitides might be a primary disorder or complicate a systemic disease. We review the clinical presentation, pathology, and treatment of noninfectious vasculitides in children. Henoch-Schönlein purpura and Kawasaki disease are two of the most common vasculitic disorders in children. Noninfectious cerebral vasculitis is a rare cause of stroke in childhood. Mimics of vasculitis (look-alikes) should be considered whenever cerebral vasculitis is suspected.

Cerebral Venous Thrombosis in Children

Cerebral venous thrombosis is an important cause of stroke in children. Understanding the natural history of the disease is essential for rational application of new interventions. We retrospectively identified 31 children with cerebral venous thrombosis confirmed by head computed tomography (4 patients) or by magnetic resonance imaging (27 patients). Risk factors, clinical and radiographic features, and neurologic outcomes were analyzed. There were 21 males and 10 females aged 1 day to 13 years (median 14 days). Nineteen (61%) were neonates. The most common risk factors included mastoiditis, persistent pulmonary hypertension, cardiac malformation, and dehydration. The chief clinical features were seizures, fever, respiratory distress, and lethargy. Fifteen patients had infarctions (8 hemorrhagic, 7 ischemic). Protein C and antithrombin III deficiency were the most common coagulopathies among 14 tested patients. On discharge, 11 patients were normal, 17 had residual deficits, and 2 patients died. Twenty-seven patients were followed from 1 month to 12 years (mean 22 months). At follow-up, 11 patients were normal, and 13 patients had development delay. One had residual hemiparesis and cortical visual impairment. Two had other deficits. Neonatal cerebral venous thrombosis is probably more common than previously thought, and outcomes are worse in this group. All children with cerebral venous thrombosis should be tested for coagulation disorders.

Strokes in Children

Stroke denotes the sudden onset of a focal neurologic deficit and most often includes the abrupt appearance of weakness. Interruption of blood flow to a part of the central nervous system (CNS) usually underlies the resultant weakness. Because most strokes in children are related to focal cerebral involvement, the most common clinical manifestation is the abrupt appearance of hemiparesis. Less frequently, the cause of stroke involves the brain stem, cerebellum, or spinal cord. The functional consequences always reflect the neuroanatomic features of the affected CNS region. Epidemiology Childhood stroke occurs with an annual incidence of 2.5 cases per 100,000 population and has been reported in all racial and ethnic groups. The sequelae are not trivial. In addition to lasting lateralized weakness, cognitive deficits, disturbances of language, visual deficits, and seizures may persist long after the acute event has concluded. The causes of stroke in children differ from those in adults. Stroke in adults is associated largely with hypertension or atherosclerosis and their respective hemorrhagic and ischemic consequences. Stroke in children more commonly is caused by or related to congenital heart disease, infection, metabolic disorders, hematologic diatheses, and vasculitic disorders, frequently due to autoimmune processes (Table 1). Nonetheless, despite the most thorough of evaluations, etiology escapes detection in approximately 30% of the pediatric patients in whom stroke occurs.

Strokes in children.

Stroke denotes the sudden onset of a focal neurologic deficit and most often includes the abrupt appearance of weakness. Interruption of blood flow to a part of the central nervous system (CNS) usually underlies the resultant weakness. Because most strokes in children are related to focal cerebral involvement, the most common clinical manifestation is the abrupt appearance of hemiparesis. Less frequently, the cause of stroke involves the brain stem, cerebellum, or spinal cord. The functional consequences always reflect the neuroanatomic features of the affected CNS region.EpidemiologyChildhood stroke occurs with an annual incidence of 2.5 cases per 100,000 population and has been reported in all racial and ethnic groups. The sequelae are not trivial. In addition to lasting lateralized weakness, cognitive deficits, disturbances of language, visual deficits, and seizures may persist long after the acute event has concluded.The causes of stroke in children differ from those in adults. Stroke in adults is associated largely with hypertension or atherosclerosis and their respective hemorrhagic and ischemic consequences. Stroke in children more commonly is caused by or related to congenital heart disease, infection, metabolic disorders, hematologic diatheses, and vasculitic disorders, frequently due to autoimmune processes (Table 1). Nonetheless, despite the most thorough of evaluations, etiology escapes detection in approximately 30% of the pediatric patients in whom stroke occurs.

Vertebral artery dissection: Issues in diagnosis and management

Vertebral artery dissection is an uncommon cause of stroke in children. Accuracy of diagnosis by magnetic resonance angiography (MRA) instead of invasive transfemoral angiography (TFA) has been controversial. The need for anticoagulation and duration of such therapy is also arguable. We report 2 boys with vertebral artery dissection: one, aged 7 years, presented with hemiparesis and seizures and the other, aged 4 years, presented with ataxia. Each boy's initial MRA was not interpreted as delineating occlusive lesions to explain the posterior circulation infarcts visualized on computed tomography and magnetic resonance imaging scans. However, subsequent MRAs were suspicious for vertebral artery dissection, which was confirmed by TFA. Both children were treated with anticoagulation therapy. The first patient continued to manifest evidence of new infarcts despite treatment (initially with aspirin alone, followed by anticoagulation with heparin and warfarin), and is now maintained on a combination of high dose warfarin and aspirin. The second patient is now maintained on aspirin alone after initial anticoagulation for 6 months with heparin followed by warfarin. A high index of suspicion for vertebral artery dissection may allow diagnosis on the basis of MRA alone. Previous reports have indicated good outcomes of vertebral artery dissection in children and adults irrespective of anticoagulation treatment. Our experience suggests that anticoagulation may be beneficial in preventing further strokes caused by the dissection.

Childhood stroke associated with familial protein S deficiency

Cerebral infarction is a rare pathology among children and its etiology can be identified in almost two-thirds of cases. The remaining one-third are considered idiopathic. Recently, inherited disorders of blood coagulation predisposing to thrombosis have been taken into account as a possible cause of childhood stroke. We describe here a case of a 6-year-old child presenting with ischemic stroke and protein S (PS) defect. The family study suggested inheritance of the defect. The immunological characterization of PS in the affected family members was consistent with a defect mainly in the free form of PS. In the case here reported no associated predisposing condition to stroke could be identified but familial PS defect was found. No therapy was administered. Nevertheless symptoms disappeared spontaneously and there were no recurrences at the 1 year follow-up. Diagnostic imaging techniques demonstrated that a reduction in the cerebral ischemic area had occurred 2 months after the stroke.