"Children and adolescents with stroke have remarkable differences in presentation compared with adults," said E. Steve Roach, MD, Department of Pediatric Neurology, Ohio State University College of Medicine, Columbus, Ohio, and Chair of the statement writing group.

"In newborns, the first symptoms of stroke are often seizures that involve only 1 arm or 1 leg. That symptom is so common that stroke is thought to account for about 10% of seizures in full-term newborns. Seizure is a much less common stroke symptom in adults."

Roach emphasised, however, that while stroke symptoms may differ between children and adults, speedy diagnosis and treatment are still very important to minimise the risk for brain damage, disability, and death.

A major treatment difference between adult and child stroke is the use of plasminogen activator (t-PA). The new statement does not generally recommend this treatment for young children, especially newborns, outside of a clinical trial until additional safety and efficacy data are published.

"Stroke in children is uncommon but not as rare as we used to think," said Dr. Roach. "Even as recently as 20 years ago, stroke was an unlikely diagnosis in a child because it was so strongly associated with adults with atherosclerosis."

The most common underlying risk factors for childhood stroke are sickle cell disease and congenital or acquired heart disease. However, the list of associated conditions includes head and neck infections, systemic conditions, head trauma, and dehydration.

Suspected maternal risk factors for infant stroke include a history of infertility, chorioamnionitis, premature rupture of membranes, and preeclampsia.

According to the statement, more than half of children who have a stroke have a known risk factor, and 1 or more risk factors are often discovered in others after a thorough evaluation.

The risk of stroke in children is greatest in the first year of life, particularly in the first 2 months, after which risk decreases. Neonatal stroke occurs in about 1 of every 4,000 live births. Stroke also can occur before birth.

In adults, stroke risk factors are much different and include high blood pressure, cigarette smoking, age (>55 years), artery disease, diabetes, and atrial fibrillation. Sickle cell disease is a risk factor common to both children and adults.

Prevention efforts are different for children as well. For adults, prevention often means adopting behaviours or medication to prevent a first stroke. Prevention in children is focused on reducing the likelihood of second or additional strokes.

"Primary prevention is sometimes possible in children when we know of an underlying risk factor such as a heart problem or sickle cell disease. Aside from those conditions, an initial stroke is difficult to prevent, because the stroke is often the first sign of a problem," Dr. Roach said. "That is why it is critical to promptly recognise and diagnose a stroke, because treating the cause reduces the likelihood of additional strokes."

Recommendations for preventing a second or subsequent stroke in children include:

· Children with ischaemic stroke who also have migraines may be evaluated for other stroke risks. Migraine with aura seems to increase risk.
· Counsel children with stroke and their families about the benefits of a healthy diet, exercise, and avoidance of tobacco products.
· Suggest an alternative to oral contraceptives after a stroke or cerebral venous sinus thrombosis.
· Children with brain haemorrhage not caused by trauma should undergo a thorough risk-factor evaluation, including standard cerebral angiography.

The incidence of ischaemic and haemorrhagic stroke is different in adults and children. According to the statement, 80% to 85% of adult strokes in Western countries are ischaemic. However, in children, about 55% of strokes are ischaemic and the other 45% are haemorrhagic.

The writing committee said the new guidelines will need to be updated as new information and technology become available. It urged continued research to better understand the unique diagnosis and treatment of stroke in children.


SOURCE: American Heart Association

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