Reducing the toll through greater awareness

When 14-year-old Zosia Wasylewski woke up with a sharp pain in her leg, she assumed it was nothing serious. But later that morning, playing with friends at school, she fell and couldn’t get up. That´s when she knew that something was terribly wrong. “Some people helped me into my chair and I was trying to keep my left hand up onto the table just to set it somewhere, because it was just drooping and I couldn’t move it,” she remembers in a dramatic documentary about suffering a stroke.

“In part because they are rare, just under half of pediatric strokes actually go undiagnosed or the diagnosis is delayed,” explains Justin Singer, MD, director of Vascular Neurosurgery and the endovascular program at Spectrum Health Medical Group in Grand Rapids, Michigan, where Zosia was treated. In fact, when Zosia was first rushed from school to a local hospital, doctors there didn’t immediately suspect a stroke. Fortunately, one emergency room physician assistant recognized the symptoms, and she was quickly transferred to the Comprehensive Stroke Center at Spectrum. 

That decision may well have spared her a lifetime of disability. The longer the delay in diagnosis and treatment of a stroke, the higher the danger of irreversible brain injury.

In newborns and infants, the symptoms of stroke may include seizures, extreme sleepiness, or a tendency to use only the right or left side of the body. In children under 18, the early warning signs include: 

• Weakness, numbness, or drooping usually on one side of the body
• Trouble walking or moving one side of the body 
• Slurred speech or inability to speak or understand
• Severe headache
• Severe dizziness or loss of coordination
• Unusual drowsiness
• Repeated vomiting
• Seizures

To encourage greater public awareness, experts devised the simple acronym F.A.S.T., which stands for facial drooping, arm weakness, speech difficulties, and time (because time is of the essence when a stroke occurs).

Because other conditions, including brain tumors and brain infections, can cause similar symptoms, definitively diagnosing stroke in children remains a challenge[1,6,7]. Fortunately, advanced imaging technologies can provide rapid and detailed images of the brain, supporting clinical decision-making when every minute counts.

Magnetic resonance imaging (MRI) or computed tomography (CT) are used to look for evidence of a blood clot or bleeding in the brain. These tests can also help to rule out other conditions. Physicians may turn to additional tests to pinpoint the cause of a stroke. These include an angiogram (in which a contrast agent is injected into blood vessels and X-rays are taken to reveal abnormalities), a heart ultrasound, and blood tests for clotting disorders[1,4].

The principle “time is brain” applies to both diagnosis and treatment. The faster the underlying cause of a stroke is treated, the less likely brain tissue will be harmed. The immediate goal of treatment is to restore normal blood flow to the brain. This may be accomplished in several ways.

Blood thinning medications and special vitamins may be given to improve blood flow. Children with SCD may receive blood transfusions.

Specialists called neuro interventionalists may perform a minimally invasive procedure in which a narrow tube, called a catheter, is inserted into the femoral artery in the groin and then threaded up into the brain. During this mechanical thrombectomy either an aspiration catheter or a specialized device called a stent retriever is introduced into the vessel, the neuro interventionalists can remove blood clots and restore blood flow to the brain. In some cases, ruptured blood vessels can also be repaired. These procedures are especially challenging in infants and children, because their blood vessels are much smaller than those of adults.

Some strokes may require surgery such as burring a hole to drain blood from the brain, do an aneurysm clipping, or open the skull cap for pressure relieve.

The risk of another stroke is highest in the first 30 days following a first stroke. For that reason, doctors monitor young patients closely during that period. In some children, blood thinning medicines such as aspirin may be continued for several years to prevent a recurrence[1,4].

A child’s long-term outlook depends on many factors, including the size of the core infarct and the penumbra, the brain tissue which is damaged but still viable and might be rescued with fast and appropriate therapies. The faster a treatment is carried out, the better the patient outcome with no or less disabilities.

Fortunately, children are much more likely to recover from a stroke than older people, because their brains are better able to adapt. Zosia’s story offers a compelling example. Even though she experienced serious symptoms of a stroke at school, “and the entire right side of her brain was at risk of being deprived of blood flow,” according to Dr. Singer, she quickly recovered because her circulation and brain were very resilient and could compensate for the blocked artery. “It’s remarkable that our bodies are able to compensate in that way,” Dr. Singer says. 

However, some children don’t recover completely. They may experience lingering or even long-term difficulties with walking, vision, speech, or reading. If children are very young when they have a stroke, some of the effects on the brain may not appear until they are older. Reading problems, for instance, may not show up until they enter school, for example. 

Rehabilitation programs can help children who have had a stroke recover as quickly and fully as possible. Occupational and physical therapy focuses on overcoming motor difficulties. Special education programs address learning or behavioral problems.