Take a Class Resources Blog Pediatric Stroke: Signs, Symptoms and First Aid

  • Pediatric Stroke: Signs, Symptoms and First Aid

    Date Published: July 15, 2024

    What are the common signs and symptoms of stroke in children under 18 years of age, and what is the appropriate first aid response to children presenting with these symptoms?

    Pediatric stroke is a time-critical condition, and first aid providers should be aware that children can have strokes. The first step in the management of any child with acute onset of neurological symptoms should be to activate the emergency medical system and support airway, breathing, and circulation.

    Summary

    The World Health Organization defines stroke as “a clinical syndrome typified by rapidly developing signs of focal or global disturbance of cerebral functions, lasting more than 24 hours or leading to death, with no apparent causes other than of vascular origin.” Stroke in children is rare, but occurs with an incidence of about 1-13/100,000 children per year (~40,000 cases/year) and is a neurologic emergency. There is an overall mortality of 2.6-5% from pediatric stroke with 70% of surviving children having persistent neurological deficits. Early identification of stroke in children in the first aid setting is important because a shorter time to hospital presentation and, for some children, to definitive therapy such as tissue plasminogen activator (tPA) and mechanical thrombectomy, has been shown to decrease morbidity and mortality from stroke. Shortening time from presentation in the first aid setting to an emergency department, preferably with pediatric neurology and stroke expertise, is an important component of this timeline.

    In childhood, stroke incidence peaks at three time points: the perinatal period, before age 5, and in adolescence. Symptoms and causes in the perinatal period are beyond the scope of this SAC answer. There are two types of stroke: ischemic, in which the blood supply is cut off to part of the brain, and hemorrhagic, in which bleeding damages brain tissue. There are specific conditions that put children at risk for stroke including congenital heart disease, blood clotting disorders, head trauma, some infections, sickle cell disease, vascular malformations, brain tumors, and Moyamoya disease, among others.

    Stroke in children can present in nonspecific ways and mimic other childhood diseases. Symptoms can present suddenly or come on more gradually, making identification even more difficult. Symptoms can be non-specific such as headache, altered mental status, and vomiting or more localized such as focal numbness or weakness, ataxia, and speech and visual disturbances. While headache and vomiting can be symptoms of other common childhood diseases, their presence in association with other neurological symptoms should raise concern for stroke. Some strokes can also present as either generalized or focal seizures, which is especially common in children under 1 year of age.

    Stroke scales such as those used in adult patients such as FAST are not validated in children. While there are pediatric stroke scales available, they are not widely used and are not validated in first aid settings. The most well-known of these is the Pediatric National Institute of Health Stroke Scale (PedNIHS), but this is unlikely to be familiar to first aid providers or first responders. Table 1 lists the most common signs and symptoms of pediatric stroke.

    Common Signs and Symptoms of Pediatric Stroke

    • Focal Signs & Symptoms
      • Hemiparesis
      • Limb weakness
      • Facial droop
      • Altered sensation
      • Visual disturbance
      • Speech disturbance
    • General Signs & Symptoms
      • Altered mental status
      • Seizure
      • Headache
      • Ataxia
      • Vertigo/Dizziness
      • Nausea/Vomiting

    References

    1. Oborska Z, Urban P, Wychowaniec K, Jóźwiak S. Paediatric stroke - a review of current guidelines for diagnosis and treatment. Neurologia i neurochirurgia polska. 2020;54(2):116-124. doi:10.5603/PJNNS.a2020.0010
    2. Mastrangelo M, Giordo L, Ricciardi G, de Michele M, Toni D, Leuzzi V. Acute ischemic stroke in childhood: a comprehensive review. European Journal of Pediatrics. Published online July 2021. doi:10.1007/s00431-021-04212-x
    3. Souto Silva R, Rodrigues R, Reis Monteiro D, et al. Acute Ischemic Stroke in a Child Successfully Treated with Thrombolytic Therapy and Mechanical Thrombectomy. Case Reports in Neurology. Published online 2019:47-52. doi:10.1159/000496535
    4. Rivkin MJ, de Veber G, Ichord RN, et al. Thrombolysis in pediatric stroke study. Stroke. 2015;46(3):880-885. doi:10.1161/STROKEAHA.114.008210
    5. Cao Q, Yang F, Zhang J, Liang H, Liu X, Wang H. Features of Childhood Arterial Ischemic Stroke in China. Fetal and Pediatric Pathology. 2019;38(4):317-325. doi:10.1080/15513815.2019.1588438
    6. Harrar DB, Salussolia CL, Kapur K, et al. A Stroke Alert Protocol Decreases the Time to Diagnosis of Brain Attack Symptoms in a Pediatric Emergency Department. In: Journal of Pediatrics. Vol 216. Mosby Inc.; 2020:136-141.e6. doi:10.1016/j.jpeds.2019.09.027
    7. Olivieri M, Sorg AL, Weinberger R, et al. Recanalization strategies in childhood stroke in Germany. Scientific reports. 2021;11(1):13314. doi:10.1038/s41598-021-92533-0
    8. Hollist M, Au K, Morgan L, et al. Pediatric Stroke: Overview and Recent Updates. Aging and disease. 2021;12(4):1043. doi:10.14336/ad.2021.0219
    9. Carey S, Wrogemann J, Booth FA, Rafay MF. Epidemiology, Clinical Presentation, and Prognosis of Posterior Circulation Ischemic Stroke in Children. Pediatric Neurology. 2017;74:41-50. doi:10.1016/j.pediatrneurol.2017.05.007
    10. Gerstl L, Weinberger R, von Kries R, et al. Symptom patterns in childhood arterial ischemic stroke: Analysis of a population-based study in Germany. Klinische Padiatrie. 2018;230(6):319-325. doi:10.1055/a-0684-9794
    11. Mallick AA, Ganesan V, Kirkham FJ, et al. Diagnostic delays in paediatric stroke. Journal of Neurology, Neurosurgery and Psychiatry. 2015;86(8):917-921. doi:10.1136/jnnp-2014-309188

    Approved January 2022

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