Paediatric Strokes: A Guide for Early Recognition

Paediatric strokes are often misdiagnosed because there are several clinical features which mislead the diagnosis. Hence, identifying potential strokes and management of the patient with early referral to a paediatric neurologist is crucial to minimise the morbidity and mortality.
In Sri Lanka, we are unable to provide the specialised care for Arterial Ischaemic Strokes by Thrombolysis and thrombectomy. The main reason is the inability to come to a specialised centre during the specified timeline for thrombolysis. We also don’t have facilities for interventional radiology-guided thrombectomy for paediatric patients.
The following important points were taken from the RCPCH stroke guideline, which is currently in use in the UK. There are dedicated stroke centres for children in the UK where beds will be offered for any referral with a stroke.
Paediatric stroke would be either,
1. Arterial Ischaemic Stroke
2. Haemorrhagic Stroke
3. Haemorrhagic stroke

Suspect a potential stroke when a child presents with

1. Acute Neurological Focal deficit or
2. New-onset Speech Disturbance or
3. Unexplained, persistent change in the conscious level
   GCS < 12 or AVPU < V
   
   Also, consider if a child presents with
   1. New-onset Focal seizures
   2. New onset of ataxia or
   3. Dizziness
   4. Resolved acute focal neurological deficit
   5. History of sickle cell disease

Initial Management should be focused on

1. Airway Management
2. Administer high-flow O2 if clinically indicated
3. Perform a capillary glucose test at the presentation and treat if CBS is <3 mmol/l by giving 2 ml/kg of 10% dextrose
4. Assess using FAST
5. Transport to the nearest ED with an acute paediatric service and radiology facilities with CT.
6. Priority call/pre-alert the ED regarding the impending arrival of a child with suspected stroke.
7. If Sickle cell disease is suspected, discuss with the haematology team

Initial management at the Emergency Department

1. Intubate if GCS < 8, AVPU =U, if there is loss of airway reflexes, or there is suspected/proven raised intracranial pressure.
2. Administer high-flow oxygen and target saturation > 92%
3. If the circulation is compromised, give a 10ml/kg isotonic fluid bolus.
4. Perform a capillary glucose test at the presentation and treat if CBS is <3 mmol/l by giving 2 ml/kg of 10% dextrose
5. Evaluate the PedNIHSS score

PedNIHSS Assessment

Investigations

1. FBC, PT, APTT
2. CRP
3. BU and electrolytes
4. Group and save
5. Liver function tests
6. CT head and CTA

According to the CT findings, differentiate between the following and plan management accordingly

• Stroke mimic: MRI with stroke-specific sequences should be performed in patients with suspected stroke when there is diagnostic uncertainty.
• Haemorrhagic stroke: Urgent discussion with neurosurgical team regarding need for transfer.
• Arterial Ischaemic Stroke: Consider suitability for other emergency interventions such as thrombectomy or decompressive craniectomy.

Treatment of AIS

Aspirin 5 mg/kg (unless there are any contraindications).

Contraindications for Aspirin
Large infarcts (> 2/3 of the hemisphere involvement)
Infarction with haemorrhagic transformation

Acute thrombolysis
In the UK and Australia, the recommendation for thrombolysis states as below

In children presenting with AIS Thrombolysis, the use of tPA may be considered if 2 – 8 years and could be considered if ≥ 8 years.

IF ALL OF THE FOLLOWING ARE TRUE:

• PedNIHSS ≥4 and ≤24
• tPA can be administered ≤4.5 hours of symptom onset
• CT has excluded intracranial haemorrhage
• CTA demonstrates normal brain parenchyma or minimal early ischaemic change
• CTA demonstrates partial/ complete occlusion of the intracranial artery corresponding to clinical/ radiological deficit
  
  OR
  
  MRI and MRA showing evidence of acute ischaemia on diffusion weighted imaging + partial/ complete occlusion of intracranial artery corresponding to clinical/ radiological deficit
  
  PROVIDING THAT THERE ARE NO CONTRAINDICATIONS

Following early recognition and treatment, the other most important aspect of management is early and continued rehabilitation.

References

RCPCH – Stroke in childhood- Clinical guideline for diagnosis and managementhttps://www.rcpch.ac.uk/resources/stroke-in-childhood-clinical-guideline

Chathurika Weeraratne
Paediatric Neurologist
S B S C H

Reviewed by:
Professor Jithangi Wanigasinghe
Professor in Paediatric Neurology, Faculty of Medicine, University of Colombo.