Pediatric Stroke: Diagnosis and Management in the Emergency Department

Points and Pearls Excerpt

• Consider cervicocephalic arterial dissection as a cause of stroke, particularly in boys aged 6 to 10 years with a preceding trauma within the past week.
• Infants may present with nonfocal signs such as altered mental status and seizures. Other reported findings include a full fontanelle, lethargy, vomiting, increasing head circumference, and hemiparesis.
• Consider cerebral sinus venous thrombosis (CSVT) in patients who present with focal neurologic symptoms as well as signs and symptoms of increased intracranial pressure.
• The most common stroke mimics include migraines, seizures, Bell palsy, conversion disorder, and syncope.
• Neurologic symptoms of migraines commonly resolve within 30 minutes. In contrast, children with arterial ischemic stroke (AIS) present with sudden-onset focal weakness (more often than numbness), speech or language changes, ataxia, and/or seizures.

Most Important References

• * Ferriero DM, Fullerton HJ, Bernard TJ, et al. Management of stroke in neonates and children: a scientific statement from the American Heart Association/American Stroke Association. Stroke. 2019;50(3):e51-e96. (Review article, AHA guidelines)
• * Monagle P, Chan AKC, Goldenberg NA, et al. Antithrombotic therapy in neonates and children: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e737S-e801S. (Review article, American College of Chest Physicians guidelines)
• * Roach ES, Golomb MR, Adams R, et al. Management of stroke in infants and children: a scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke. 2008;39(9):2644-2691. (Review article, AHA guidelines)
• Elbers J, Wainwright MS, Amlie-Lefond C. The pediatric stroke code: early management of the child with stroke. J Pediatr. 2015;167(1):19-24. (Expert recommendations) 
• * Amlie-Lefond C, deVeber G, Chan AK, et al. Use of alteplase in childhood arterial ischaemic stroke: a multicentre, observational, cohort study. Lancet Neurol. 2009;8(6):530-536. (Descriptive study of tPA use in the International Pediatric Stroke Study and case reports; 15 children)