Challenges in the diagnosis and treatment of pediatric stroke

Abstract

Stroke in children is rarely due to traditional stroke risk factors such as hypertension and diabetes. Rather, stroke in this patient group typically results from the simultaneous occurrence of multiple stroke risk factors, the presence of which necessitates a thorough evaluation to determine the cause of this disorder. Several challenges exist in the care of children with stroke. Of note, recognition of pediatric stroke onset by parents and caregivers is often delayed, highlighting the need for increased awareness of and education regarding this condition. Moreover, various neurological conditions resemble stroke in pediatric patients and a definite diagnosis of this disorder requires MRI; adding to the diagnostic challenge, young children may need to be sedated to undergo acute MRI. Perhaps the most significant challenge is the need for clinical research studies focusing on pediatric stroke treatment, so as to allow evidence-based treatment decision-making. A final challenge is the standardization of outcome assessment after stroke for a wide range of ages and developmental levels. In this Review, we examine recent findings and diagnostic issues pertaining to both arterial ischemic stroke and hemorrhagic stroke in children.

Figure 1

Arteriopathy in pediatric stroke. a| Diffusion-weighted MRI shows an acute thalamic stroke (bright area; arrow) in a previously healthy 8 year-old girl. b | The apparent diffusion coefficient map is dark and confirms the acute stroke (arrow). c | Time-of-flight, noncontrast magnetic resonance angiography shows narrowing (near occlusion) of the posterior cerebral artery and superior cerebellar arteries on the same side (arrows). Extensive evaluation showed no cause for this arteriopathy.

Figure 2

Acute hemorrhagic stroke and susceptibility-weighted imaging. a | The head CT shows a single, small right frontal acute parenchymal hemorrhage. b | The MRI susceptibility-weighted image shows the right frontal hemorrhage as well as multiple additional hemorrhages not visualized on head CT. This child has multiple cerebral cavernous malformations.

Figure 3

Idiopathic moyamoya disease. a | Time-of-flight, noncontrast, magnetic resonance angiography shows moyamoya vasculopathy with bilateral occlusion of the internal carotid arteries (arrowheads). Robust lenticulostriate collaterals can also be observed (arrows). b | The lenticulostriate collaterals in moyamoya disease are also seen on the MRI scan, with multiple flow voids piercing the basal ganglia (arrow). c| These moyamoya collateral vessels are also seen as multiple small-flow voids around the brainstem (arrows).

Figure 4

Acute arterial ischemic stroke with diffusion–perfusion mismatch. a| The MRI reveals a small acute stroke that shows restriction on diffusion-weighted imaging in the periventricular region (arrow). b| The corresponding apparent diffusion coefficient map confirms the occurrence of acute ischemia (arrow). c| The perfusion-weighted image shows a large area of hypoperfusion—basically the entire left middle cerebral artery territory (arrow)—representing diffusion–perfusion mismatch. d| This stroke was caused by embolization of a cardiac thrombus that led to partial occlusion of the internal carotid artery—little flow is seen on magnetic resonance angiography (arrow)—and complete occlusion of the middle cerebral artery (arrowhead).