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Evaluation or Diagnosis of Stroke in Children

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The most common clinical presentation of clinical stroke in childhood is acute hemiparesis. 

  • Focal neurologic deficits, usually hemiplegia and seizures in ischemic stroke
  • Headache and vomiting in hemorrhagic stroke
  • Headache and decreased level of consciousness in children with cerebral venous thrombosis

 Focal signs may be absent in neonates or young infants and seizures may be the only signs of stroke in this group.

The following is a summary of information provided at the CHASA medical conference, 2002 by John K. Lynch, DO, NINDS.  There are no published consensus guidelines on the evaluation of stroke in children, but several systematic approaches have been recommended. The evaluation should include:

  • Questions about any history of head trauma, neck trauma, recent infection, illness, unexplained fever or malaise, drug ingestion, developmental delay, family history of bleeding problems, and associated headache

  • Careful family history, with special attention to premature vascular disease, hematologic disease, mental retardation

  • Physical exam including head circumference in children, skin abnormalities, cardiac evaluation and carotid artery exam

  • MRI and MRA (CT if MR unavailable)

If the MRI and MRA reveal an infarct, with vascular distribution, then consider the following diagnostic tests:

  • Echocardiogram, EKG, holter monitor

  • Blood studies including CBC, ESR, Iron, folate, red cell folate, hemoglobin electrophoresis, Protein S, Protein C, Antithrombin III, Factor V Leiden, Heparin cofactor II, plasminogen, Factor VIII, Factor XII, anticardiolipin antibodies, lupus anticoagulant, prothrombin mutation, homocysteine, lipoprotein a, fasting cholesterol, infection screen, serum and CSF antibodies to varicella

  • Lumbar puncture

  • Transcranial Doppler with bubble study

  • X-ray cervical spine (posterior infarctions)

If the MRI and MRA reveal an infarct, with non-vascular distribution, then consider the following diagnostic tests:

  • CSF Lactate

  • Plasma ammonia and amino acids

  • Urine organic acids

If the MRI and MRA reveal a hemorrhage, then consider the following diagnostic tests:

  • Coagulation studies

  • Conventional Angiography

If the MRA is normal, then consider the following diagnostic tests:

  • Conventional Angiography

Journal Articles

Childhood Strokes: Evaluation And Management, Nov. 1998. Harry S. Abram, M.D., a pediatric Neurologist on faculty at Mayo Graduate School of Medicine

Diagnostic pitfalls in paediatric ischaemic stroke. Dec. 2006. The Netherlands.

Stroke in Childhood: Clinical guidelines for diagnosis, management and rehabilitation. Prepared by the Paediatric Stroke Working Group, Nov. 2004. Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians.

Emergency department presentation of pediatric stroke. Oct. 2003. Los Angeles, CA. Calder, Kokorowski, Tran, Henderson. It is important for the emergency physician to recognize acute neurologic events in pediatric patients to minimize complications.

Diagnosis of Stroke Information about the different tests used in diagnosing a stroke.

MRI Imaging Answers questions about the MRI test

General movements detect early signs of hemiplegia in term infants with neonatal cerebral infarction. April 2003. Italy. Guzzetta.

Neonatal cerebral infarction diagnosed by diffusion-weighted MRI: pseudonormalization occurs early April 2002

Magnetic resonance imaging in pediatric stroke Feb. 2002. Houston. Hunter. Magnetic resonance imaging provides a noninvasive method of investigating childhood stroke, aiding in both better diagnosis and management of this problem.

MRI and clinical characteristics of children with hemiplegic cerebral palsy Oct. 1999

What is a Stroke? Information on the different types of strokes, again from an adult perspective.

Etiology of stroke in children 2000

Specifics in pediatric arterial cerebral infarctions 2001

The Whole Brain Atlas Contains illustration of the brain and the different sections and their function. Please remember that they are referring to stroke in an adult whose brain is already organized and the results of a stroke are very different in a young child's pliable brain.

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