Pediatric emergency medicine trisk 2626 2626
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more transient deficits. Stroke is relatively rare in healthy children but may
complicate a number of other pediatric medical conditions. For example, among
children with sickle cell disease, the incidence of stroke has been reported to be
6% to 9%. Others at risk are those with various forms of cardiac disease, which is
one of the most common causes of stroke in children. Table 97.5 lists some of the
common causes of stroke, as well as some more uncommon conditions in which
stroke is a prominent clinical feature. Generally, stroke is classified as either
primarily ischemic (including embolic phenomena) or hemorrhagic. In ischemic
stroke, there is focal reduction in cerebral blood flow, with hypoxic damage to
brain parenchyma, leading to neuronal injury and death. Further damage ensues
from reperfusion injury of ischemic areas.
Unlike in adults, there is currently no consensus on primary treatment for acute
stroke in childhood. This is due in large part to the rarity of stroke in children and
therefore the lack of pediatric randomized controlled trials. The efficacy of
systemic thrombolytic therapy is yet to be determined and safety remains a
primary concern. The only multicenter prospective pediatric trial to date, the
Thrombolysis in Pediatric Stroke Trial (TIPS), was terminated early due to slow
enrollment. Despite early termination, there were several significant findings
from the TIPS trial. Nearly 50% of eligible patients were ultimately found to have
a stroke mimic. This trial identified barriers to system and clinical readiness that
lead to delayed recognition and diagnosis and brought to light the need for and
value of multidisciplinary pediatric stroke teams. While there are no national
guidelines consensus, centers that successfully enrolled in the TIPS trial continue
to successfully treat pediatric patients with tPA and up to 2% of pediatric stroke
patients receive tPA. Observational studies in children also suggest the feasibility
and safety of primary endovascular therapies, including mechanical
thrombectomy. In the absence of consensus guidelines, these therapies should
only be considered on a case-by-case basis at sites with dedicated
multidisciplinary pediatric stroke teams, and the timing of administration must
follow adult stroke guidelines.
In the face of limited data for primary treatment, attention to secondary
prevention and factors that play an important part in determining the extent of
damage after acute ischemia is critical. Prevention of secondary injury is essential
as up to 20% of children have clinical and/or radiologic recurrence.
