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More Children Becoming Stroke Victims

Symptoms are different but risks are similar

July 18, 2008

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Older adults are not the only people in danger of suffering a stroke. Increasingly, children are also stricken, according to the American Heart Association/American Stroke Association.

In fact, it happens often enough that the association has released a scientific statement addressing treatment, symptoms and risk for stroke in infants and children.

The "Management of Stroke in Children" statement published in Stroke: Journal of the American Heart Association provides healthcare professionals with evidence-based guidelines for prevention, evaluation and treatment.

"Children and adolescents with stroke have remarkable differences in presentation (symptoms) compared with adults," said E. Steve Roach, M.D., chair of the statement writing group and professor of pediatric neurology at the Ohio State University College of Medicine.

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

Roach emphasized, however, that while stroke symptoms may differ between children and adults, speedy diagnosis and treatment are still very important to minimize the risk for brain damage, disability and death. In addition to prompt treatment, age-appropriate rehabilitation and therapy is indicated for children after a stroke.

"Stroke in children is uncommon but not as rare as we used to think," said Roach, who is also chief of neurology at Nationwide Children's Hospital in Columbus, Ohio. "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 risk of stroke from birth through 18 years is 10.7 per 100,000 children per year.

He added that improvements in diagnostic techniques such as magnetic resonance imaging (MRI) and vascular ultrasound have made it possible to confirm that a stroke has occurred when it was only suspected before. Research has also helped to better define treatment protocols. Because of these advances, experts now believe that a significant number of cerebral palsy cases may be due to strokes before or right after birth.

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 include:

• head and neck infections;
• systemic conditions such as inflammatory bowel disease and autoimmune disorders;
• head trauma; and
• dehydration.

According to the statement, more than half of children who have a stroke have a known risk factor, and one 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 two months. It decreases after that. Data from the statement shows that stroke in the first month of life (neonatal stroke) occurs in about one 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 (over 55), 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 behaviors or medication to prevent a first stroke. Prevention in children is focused on reducing the likelihood of second or additional strokes.

"Primary prevention — stopping the first stroke from occurring — 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," Roach said. "That's why it's critical to promptly recognize 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 ischemic stroke who also have migraines may be evaluated for other stroke risks. Common migraine isn't likely linked to stroke, but migraine with aura seems to increase risk.
• It is reasonable to counsel children with stroke and their families about the benefits of a healthy diet, exercise and avoiding tobacco products.
• It is reasonable to suggest an alternative to oral contraceptives after a stroke or cerebral venous sinus thrombosis (CVST).
• Children with brain hemorrhage not caused by trauma should undergo a thorough risk factor evaluation, including standard cerebral angiography when noninvasive tests have failed to establish a cause to identify treatable risk factors before another hemorrhage occurs.

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