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Review
. 2022 Jan;181(1):45-58.
doi: 10.1007/s00431-021-04212-x. Epub 2021 Jul 29.

Acute ischemic stroke in childhood: a comprehensive review

Mario Mastrangelo  1 , Laura Giordo  1 , Giacomina Ricciardi  1 , Manuela De Michele  2 , Danilo Toni  2 , Vincenzo Leuzzi  3
Affiliations
Review

Acute ischemic stroke in childhood: a comprehensive review

Mario Mastrangelo et al. Eur J Pediatr. 2022 Jan.

Abstract

This review provides an updated analysis of the main aspects involving the diagnosis and the management of children with acute ischemic stroke. Acute ischemic stroke is an emergency of rare occurrence in children (rate of incidence of 1/3500 live birth in newborns and 1-2/100,000 per year during childhood with peaks of incidence during the perinatal period, under the age of 5 and in adolescence). The management of ischemic stroke in the paediatric age is often challenging because of pleomorphic age-dependent risk factors and aetiologies, high frequency of subtle or atypical clinical presentation, and lacking evidence-based data about acute recanalization therapies. Each pediatric tertiary centre should activate adequate institutional protocols for the optimization of diagnostic work-up and treatments.Conclusion: The implementation of institutional standard operating procedures, summarizing the steps for the selection of candidate for neuroimaging among the ones presenting with acute neurological symptoms, may contribute to shorten the times for thrombolysis and/or endovascular treatments and to improve the long-term outcome. What is Known: •Acute ischemic stroke has a higher incidence in newborns than in older children (1/3500 live birth versus 1-2/100,000 per year). •Randomized clinical trial assessing safety and efficacy of thrombolysis and/or endovascular treatment were never performed in children What is New: •Recent studies evidenced a low risk (2.1% of the cases) of intracranial haemorrhages in children treated with thrombolysis. •A faster access to neuroimaging and hyper-acute therapies was associated with the implementation of institutional protocols for the emergency management of pediatric stroke.

Keywords: Children; Diagnostic protocol; Neuroimaging; Recanalization therapies; Stroke; Thrombolysis.

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Conflict of interest statement

The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
A suggested protocol for the diagnostic work-up and the treatment of acute ischemic stroke in children. Legend: ED Emergency Department, rTPA recombinant tissue plasminogen activator, PICU pediatric intensive care unit, ANICU adults neurological intensive care unit, NICU neonatal intensive care unit, pedNIHSS Pediatric National Institute of Health Stroke Scale, ECG electrocardiogram, PCR protein C reactive, Inr interventional neuroradiologist, MRI magnetic resonance imaging, DWI diffusion weighted imaging, ADC apparent diffusion coefficient, FLAIR fluid attenuated inversion recovery, TOF time of flight angiography, MRA magnetic resonance angiography, COW circle of Willis, CT computed tomography, ASA acetylsalicylic acid, PT prothrombin time, INR international normalized ratio, aPTT activated partial thromboplastine time, LP lumbar puncture, CNS central nervous system, MCA middle cerebral artery, LMWH low molecular-weight heparin
Fig. 1
Fig. 1
A suggested protocol for the diagnostic work-up and the treatment of acute ischemic stroke in children. Legend: ED Emergency Department, rTPA recombinant tissue plasminogen activator, PICU pediatric intensive care unit, ANICU adults neurological intensive care unit, NICU neonatal intensive care unit, pedNIHSS Pediatric National Institute of Health Stroke Scale, ECG electrocardiogram, PCR protein C reactive, Inr interventional neuroradiologist, MRI magnetic resonance imaging, DWI diffusion weighted imaging, ADC apparent diffusion coefficient, FLAIR fluid attenuated inversion recovery, TOF time of flight angiography, MRA magnetic resonance angiography, COW circle of Willis, CT computed tomography, ASA acetylsalicylic acid, PT prothrombin time, INR international normalized ratio, aPTT activated partial thromboplastine time, LP lumbar puncture, CNS central nervous system, MCA middle cerebral artery, LMWH low molecular-weight heparin
Fig. 1
Fig. 1
A suggested protocol for the diagnostic work-up and the treatment of acute ischemic stroke in children. Legend: ED Emergency Department, rTPA recombinant tissue plasminogen activator, PICU pediatric intensive care unit, ANICU adults neurological intensive care unit, NICU neonatal intensive care unit, pedNIHSS Pediatric National Institute of Health Stroke Scale, ECG electrocardiogram, PCR protein C reactive, Inr interventional neuroradiologist, MRI magnetic resonance imaging, DWI diffusion weighted imaging, ADC apparent diffusion coefficient, FLAIR fluid attenuated inversion recovery, TOF time of flight angiography, MRA magnetic resonance angiography, COW circle of Willis, CT computed tomography, ASA acetylsalicylic acid, PT prothrombin time, INR international normalized ratio, aPTT activated partial thromboplastine time, LP lumbar puncture, CNS central nervous system, MCA middle cerebral artery, LMWH low molecular-weight heparin
Fig. 1
Fig. 1
A suggested protocol for the diagnostic work-up and the treatment of acute ischemic stroke in children. Legend: ED Emergency Department, rTPA recombinant tissue plasminogen activator, PICU pediatric intensive care unit, ANICU adults neurological intensive care unit, NICU neonatal intensive care unit, pedNIHSS Pediatric National Institute of Health Stroke Scale, ECG electrocardiogram, PCR protein C reactive, Inr interventional neuroradiologist, MRI magnetic resonance imaging, DWI diffusion weighted imaging, ADC apparent diffusion coefficient, FLAIR fluid attenuated inversion recovery, TOF time of flight angiography, MRA magnetic resonance angiography, COW circle of Willis, CT computed tomography, ASA acetylsalicylic acid, PT prothrombin time, INR international normalized ratio, aPTT activated partial thromboplastine time, LP lumbar puncture, CNS central nervous system, MCA middle cerebral artery, LMWH low molecular-weight heparin
Fig. 1
Fig. 1
A suggested protocol for the diagnostic work-up and the treatment of acute ischemic stroke in children. Legend: ED Emergency Department, rTPA recombinant tissue plasminogen activator, PICU pediatric intensive care unit, ANICU adults neurological intensive care unit, NICU neonatal intensive care unit, pedNIHSS Pediatric National Institute of Health Stroke Scale, ECG electrocardiogram, PCR protein C reactive, Inr interventional neuroradiologist, MRI magnetic resonance imaging, DWI diffusion weighted imaging, ADC apparent diffusion coefficient, FLAIR fluid attenuated inversion recovery, TOF time of flight angiography, MRA magnetic resonance angiography, COW circle of Willis, CT computed tomography, ASA acetylsalicylic acid, PT prothrombin time, INR international normalized ratio, aPTT activated partial thromboplastine time, LP lumbar puncture, CNS central nervous system, MCA middle cerebral artery, LMWH low molecular-weight heparin
Fig. 2
Fig. 2
A Right parietal FLAIR-hyperintense lesion in a 14-year-old girl who presented with a complete anaesthesia of the left forearm and hand, visual impairment and headache. B Left temporo-occipital T2-lesion in a 6-year-old boy who presented with aphasia. C and D Angio-MRI and PWI sequences in a 2-year-old boy with the occlusion of M1 tract of the left-middle cerebral artery and of the A1 tract of the ipsilateral anterior cerebral artery
See this image and copyright information in PMC

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