Peds

Cerebrovascular Accident in Children

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Cerebrovascular Accident in Children, Pediatric CVA, CVA in Children, Pediatric Stroke, Stroke in Children

  • See Also
  1. Ischemic CVA
  2. CVA Management
  3. Transient Ischemic Attack
  4. CVA Thrombolysis
  5. CVA Blood Pressure Control
  6. Prevention of Ischemic Stroke (includes Anticoagulation in Ischemic Stroke)
  • Epidemiology
  1. Incidence: 3-15 in 100,000 children per year
    1. Similar Incidence to Pediatric Brain Tumor
  • Types
  1. Acute ischemic Cerebrovascular Accident (55%)
  2. Hemorrhagic Cerebrovascular Accident
  3. Cerebral Venous Thrombosis
  • Risk Factors
  1. Cardiac Causes (15 to 30% Pediatric CVA cases)
    1. Congenital Heart Disease
    2. Endocarditis
    3. Rheumatic Heart Disease
    4. Patent Foramen Ovale
    5. Prosthetic Heart Valves
  2. Hypercoagulable or Thrombotic Disorders (20 to 50% of cases)
    1. Sickle Cell Anemia (6-9% of Pediatric CVA cases, RR 200)
    2. Cancer
    3. Polycythemia
    4. Vasculopathy or Vasculitis
    5. Coagulopathy
  3. Other Causes
    1. Head Trauma
    2. Metabolic Disorders
    3. Acute Infections
  1. Perinatal Ischemic Stroke
    1. Focal and unilateral Seizure
      1. See First Time Seizure in Children
    2. Cardiovascular Signs
    3. Altered Level of Consciousness
    4. Failure to Thrive
    5. Feeding intolerance
  2. Childhood Ischemic Stroke
    1. Hemiparesis
    2. Unilateral facial weakness
    3. Altered Speech
    4. Vision changes
    5. Altered Level of Consciousness
  • Differential Diagnosis
  1. See Cerebrovascular Accident
  2. Common alternative diagnoses
    1. Complicated Migraine
    2. Hypoglycemia
    3. Seizure (post-ictal paralysis or Todd's Paralysis)
      1. However acute strokes may also present with unilateral Focal Seizure
  3. Other alternative diagnoses
    1. Intracranial Hemorrhage
    2. Venous sinus thrombosis
    3. Bell Palsy
    4. Intracranial Mass in Children
    5. CNS Abscess or oither intracranial infection
    6. Alternating Hemiplegia of Childhood
    7. Posterior Reversible Encephalopathy Syndrome (PRES)
    8. Acute Disseminated Encephalomyelitis (ADEM)
    9. Idiopathic Intracranial Hypertension
    10. Acute Cerebellar Ataxia
    11. Moyamoya Disease
  4. References
    1. Kundurti and Bullard-Berent (2022) Crit Dec Emerg Med 36(5): 12-4
  • Imaging
  1. CT Head
    1. Evaluate for Hemorrhagic Cerebrovascular Accident
  2. MRI/MRA Brain
    1. Discuss indications with neurology stroke team
    2. Do not delay definitive management (i.e. CVA Thrombolysis) if clear CVA findings and no Hemorrhage on CT Head
    3. If used to confirm Ischemic CVA within 3 hour time frame, then obtain stat with TPA ready to infuse
  • Precautions
  1. Although rare in children, Cerebrovascular Accident is devastating
    1. Longterm morbidity in 75% of cases (Seizures, Hemiparesis, Learning Disorders)
  2. Keep Cerebrovascular Accident on differential diagnosis in children
    1. Do not always assume benign cause (e.g. complicated Migraine Headache or post-seizure Todd's Paralysis)
  3. As with adults presenting with possible CVA, do not delay evaluation and management
  • Management
  1. See CVA Management
  2. See CVA Thrombolysis
  3. See CVA in Sickle Cell Disease
  4. Consult neurology stroke team
  5. Consider TPA within 3 hours of Ischemic CVA
    1. Same dose as adults (0.9 mg/kg split dosing with 10% given as bolus and 90% given over 1 hour)
    2. Limited data regarding TPA in CVA under age 18 years old
    3. Amlie-Lefond (2009) Lancet Neurol 8(6): 530-6 [PubMed]
    4. Janjua (2007) Stroke 38(6): 1850-4 [PubMed]
  6. Antiplatelet Therapy following ischemic Cerebrovascular Accident
    1. Aspirin daily
  • References
  1. Chan and Mann (2023) Crit Dec Emerg Med 37(5): 14-5
  2. Spangler and Sanossian in Herbert (2014) EM:Rap 14(3): 2-4
  3. Tsze (2011) Emerg Med Int +PMID: 22254140 [PubMed]
    1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3255104/