The incidence of stroke in children is relatively low, but the death rate is high. The incidence rate in Europe and the United States is about 1.3 to 13 per 100,000 population per year, and the incidence rate in Europe is slightly higher than that in North America. The incidence rate in Hong Kong is 2.1 per 100,000 population per year, which is consistent with foreign reports. The risk of stroke is high during the first 2 months of life, with approximately one in every 4000 live births.
1. Etiology
The risk factors for stroke in children are different from those in adults, mainly congenital or acquired heart disease, sickle cell disease (the most common cause in some regions of the world) and other types of anemia, head and neck infections, autoimmune diseases, head trauma, and dehydration.
2.Clinical manifestations and diagnosis
Stroke in children is divided into ischemic stroke (IS) and hemorrhagic stroke (HS). The diagnosis of IS in children must focus on cerebral venous sinus thrombosis (CVST), arterial ischemic stroke (AIS), and transient ischemic attack (TIA).
Children with CVST present with headache, convulsions, lethargy, focal or generalized neurological deficits, and imaging confirmed thrombosis.
Children with AIS often present with acute onset neurological deficits, but in neonates, convulsions may be the only manifestation, and imaging may reveal foci of parenchymal infarction in the cerebral artery region consistent with the clinical presentation.
Children with TIA present with an acute onset of episodic focal neurological deficits that recover completely within 24 hours, but imaging does not reveal a substantial cerebral infarct consistent with the clinical presentation.
(TCA), smoker’s disease, and arterial stripping. Other rare diagnoses include chronic inflammatory vasculitis, type I multiple neurofibromas, fibromuscular dysplasia, metabolic arteriopathy, and other arteriopathies of unknown origin.
3.Treatment
Infection, fever, abnormal blood pressure or blood sugar, elevated intracranial pressure and convulsions can affect the prognosis of the child, so comprehensive treatment is the key. The current treatment for IS in children includes thrombolysis, anticoagulation and antiplatelet therapy, as well as blood transfusion and surgical treatment.
(1) Thrombolytic therapy
In the 2008 AHA Scientific Statement, fibrinogen activator is not routinely recommended for the treatment of children, especially neonates, but there are few reports of prognosis in children with partial stenosis-occlusive disease, arterial dissection, or other coagulation abnormalities treated with thrombolysis. In 63 children treated with thrombolysis, the early perfusion of brain tissue was improved, and the safety was good.
(2) Anticoagulation therapy
The main purpose of this treatment is to limit the expansion of existing clots and to prevent further thrombus formation. The more commonly used anticoagulants include normal heparin (UFH) and low molecular weight heparin (LMWH). UFH has a shorter half-life and its adverse effects can be reversed with fisetin; LMWH has more stable pharmacokinetics and few drug interactions. The use of anticoagulant therapy needs to be accompanied by vigilance against the risk of bleeding, especially in the presence of infarcted lesions. Anticoagulation should be avoided in children with bleeding disorders, thrombocytopenia, uncontrollable hypertension, and progressive renal and/or hepatic disease.
(3) Anti-platelet therapy
The use of this therapy in the acute phase in children with AIS is inconclusive. Antiplatelet agents include aspirin, clopidogrel, ticlopidine, pentoxifylline, and aspirin combination. Aspirin is more experienced and clopidogrel is better tolerated in children, but the safety of combination therapy (aspirin and clopidogrel) and other antiplatelet agents in children is currently unknown.
(4) Blood transfusion therapy
This treatment is mainly for sickle cell disease and is rarely used in China.
(5) Surgical treatment
This treatment is mainly for smoldering disease, and may be effective in preventing recurrence of stroke.