We talked to Cinzia Auriti, Lecturer in General and Specialist Paediatrics at UniCamillus University.
When people talk about strokes, they do not think about children. But strokes can affect the very young, even the foetus in the last weeks of gestation.
One of the most serious neurological emergencies, a stroke is a sudden change in brain function caused by a vascular problem. Defined by the World Health Organisation (WHO) as a clinical syndrome characterised by a focal neurological deficit, strokes can be caused by either ischaemic or haemorrhagic factors.
In children, diagnosis is usually delayed, both because young children cannot communicate symptoms well and because symptoms may be more subtle and less clear. Therefore, awareness of the severity of a paediatric stroke is fundamental (indeed, vital!) to its management.
What happens in a stroke?
A stroke occurs when a blood clot temporarily blocks a blood vessel in the brain (arterial ischaemic stroke (AIS)) or when a vessel ruptures, blocking the flow of blood and oxygen to a part of the brain (haemorrhagic stroke). The lack of oxygen causes brain cells to die, with serious consequences, including partial or total disability, depending on the severity and area of the brain affected. Early diagnosis and targeted therapy can significantly improve the patient’s prognosis and quality of life.
Warning signs: how can you identify a stroke in children?
Although the symptoms of a stroke in children can be different from those in adults, it is important to identify the warning signs in order to act quickly as children may not be able to communicate what they are feeling, so parents need to know what can happen.
Here are the main symptoms:
- Seizures
- Partial or complete paralysis of a part of the body
- Sudden, projectile vomiting
- Headache that comes on suddenly and gets worse quickly
- Coma
- Problems with balance or walking
- Difficulty speaking
- Visual problems
These signs can appear suddenly and require immediate medical attention. “The first thing to do is to go urgently to A&E, where neuroimaging will be carried out for diagnosis”, explains Cinzia Auriti, Lecturer in General and Specialised Paediatrics at UniCamillus. “When neurological symptoms are observed, it is important to minimise the time between symptom onset and admission to hospital. Early notification of the hospital by the person taking the child to the emergency department is also useful to speed up specialist assessment and treatment. The management of the newborn/infant with stroke is always multidisciplinary. Therefore, it is advisable to go to appropriately equipped care centres in the first instance whenever possible”.
Risk factors
Paediatric strokes are classified according to the age at which they occur.
- Perinatal stroke is a focal vascular brain injury that occurs between the 28th week of pregnancy and the first 28 days after birth.
- Paediatric stroke is also called ‘childhood stroke’ and occurs between 1 month of age and 18 years of age.
- Juvenile stroke occurs between the ages of 18 and 35.
Most strokes happen in the first week of life. “The few days before and the week after birth are a high-risk period for stroke in both mother and child, probably because the coagulation mechanisms are activated during this critical period”, says Auriti. “The characteristics of the perinatal period that influence the state of coagulation include the presence of foetal haemoglobin, a high haematocrit and a high viscosity of the blood, which makes it easier to clot”.
The most common causes of stroke in babies and children are heart disease, blood vessel abnormalities and blood clotting disorders.
However, when perinatal stroke occurs during or immediately after birth, it can be associated with placental disorders, premature birth, infection, severe hypoglycaemia and complications during childbirth.
In older children and adolescents, other risk factors include head trauma, autoimmune diseases, sickle cell disease (SCD), leukaemia and brain tumours.
“In terms of consequences, the development of the perinatal stroke is generally more severe than that of the older child”, says Auriti.
Types of paediatric stroke
Paediatric strokes can be divided into several main categories:
- Arterial ischaemic stroke (AIS): the most common type in children, caused by occlusion of a cerebral artery. In young children, symptoms may include lethargy, irritability and convulsions, while in older children the signs are more like those of adults, with hemiparesis and speech problems.
- Haemorrhagic stroke (HS): less common but more severe, is caused by the rupture of a blood vessel, resulting in intracerebral haemorrhage. Symptoms include acute headache, nausea and vomiting.
- Cerebral sinus venous thrombosis (CSVT): a rare form of stroke characterised by occlusion of the cerebral sinuses, which can cause headache, seizures and papilledema.
Diagnosis and treatment
Magnetic resonance imaging (MRI) is the preferred diagnostic tool for confirming a stroke. The use of neuroradiological diagnostics is fundamental. “An MRI of the brain is considered far more advanced than a CT scan. In case of clinical suspicion, an MRI should be performed within 24 hours, even if the CT scan is negative”, explains Auriti.
After the initial diagnostic assessment, investigations should continue, bearing in mind that the different causes of perinatal stroke require specific therapeutic approaches. This is important for planning possible surgery or other targeted therapies, reducing the risk of further complications or recurrence, and improving long-term management.
Initial treatment aims to stabilise the patient and prevent further brain damage. For ischaemic stroke, thrombolysis or mechanical thrombectomy may be used, but their effectiveness in paediatric patients has not been fully validated. Neurosurgery may be needed for haemorrhagic stroke.
What are the consequences of paediatric stroke?
“The consequences of a child having a stroke are very serious. Reported childhood mortality rates are 3.1, 0.4 and 0.2 per 100,000 for children under 1, 1-4 and 5-14 years of age, respectively, with a decrease in mortality and morbidity over the last 30 years. The category with the highest risk of death is children under one year of age, and in particular the highest mortality rate is observed in infants within the first six days of life”, says Auriti.
And if they survive? Permanent effects are observed in 50 % of cases. “In terms of severity and chances of recovery, as with stroke in adults, it is essential to minimise the time elapsing between the onset of symptoms, diagnosis and the initiation of appropriate treatment”, concludes Auriti, highlighting the importance of identifying symptoms immediately, without neglecting any form of suspicion. In some cases, it is better to commit the sin of alarmism than superficiality, especially in the case of very young children who are unable to describe their discomfort.