A stroke is caused by the interruption of normal flow of blood to the brain, either by a blockage or a rupture in the blood vessels. When a part of the brain doesn’t receive its regular flow of blood that carries vital nutrients and oxygen the brain uses as fuel, brain cells die, causing a loss of brain function. This can happen in people of all ages, including infants and children.
The age of the child at the time of stroke makes a difference in how doctors identify and treat the problem.
Stroke can occur in these three different age groups:
The prenatal phase, or in the womb.
Stroke in babies during pregnancy to within 28 days of birth (known as pre and perinatal ischemic stroke) are usually caused by clots breaking off from the placenta and lodging in the child’s brain or because of a blood clotting disorder that the mother or baby may have.
The first 28 days of life, or newborn phase.
Strokes in children most often happen within the first month after birth. These are sometimes called perinatal (or neonatal) strokes. Most perinatal (pair-ih-NAY-tul) strokes happen during delivery or right after delivery when the baby doesn't get enough oxygen while traveling through the birth canal.
From the infant years up to 18 years of age.
Stroke in children can be linked to existing conditions, most commonly congenital heart disease and sickle cell disease (SCD). Other risk factors are infectious diseases, trauma to the head or neck, vascular problems and blood disorders. In many cases of childhood stroke, there is more than one risk factor. Stroke can also affect previously healthy children and in some cases, there can be no apparent cause.
What are the Most Common Types of Strokes in Children?
Hemorrhagic stroke occurs when a blood vessel ruptures in the brain. If an artery wall is weak, blood can collect in the wall causing it to balloon (aneurysm). If the pressure builds, the aneurysm can rupture and damage the brain either by flooding at the leakage site or by shortage of blood supply beyond the leakage.
The causes of hemorrhagic stroke in children include:
An artery malformation or disorder.
A brain tumour.
In rare cases, drug or alcohol abuse by the mother.
Ischemic stroke is usually caused by a blood clot in the brain. This is the most common type in children.
The leading risk factors for ischemic stroke in children include:
Heart disease
When children are born with a heart defect (congenital heart disease), their risk of having a stroke is increased.
Heart disease, such as rheumatic heart disease, can also be acquired later in childhood.
Stroke is not usually the first sign of heart disease. Often heart disease has been diagnosed before the child has a stroke.
Blood-clotting disorders
Known as prothrombotic disorders, cause the blood to thicken and clot faster.
These disorders can be present at birth or acquired later on. A child can be born with a genetic mutation that makes the blood clot faster.
Stroke is often the first sign of a blood-clotting disorder.
Some illnesses, such as meningitis, sepsis, diarrhea, dehydration or an iron deficiency, can also lead to blood clotting abnormalities.
Irregular arteries
A child can have a stroke because the arteries in the brain are irregular or narrowed. This is called arteriopathy.
When children are born with this problem, it often goes undetected until a stroke occurs.
Children with irregular arteries need to be monitored closely by their stroke clinic team because they are at a higher risk of experiencing another stroke.
Other risk factors. Children are also at higher risk of having a stroke if they have any of the following risk factors:
Heart or brain surgery
Sickle cell disease
Autoimmune disease that attacks arteries in the brain
Trauma to the brain or neck
Leukemia
Some pediatric stroke cases have no known cause.
Pediatric stroke can also be related to:
lack of oxygen during birth
a heart defect the baby is born with
injury to an artery (a blood vessel that brings oxygen) in the brain
dehydration
an infection, such as meningitis or chickenpox
Some problems that affect a mother during pregnancy can cause a baby to have an ischemic stroke before or after birth. These include:
Preeclampsia (high blood pressure during pregnancy that can cause swelling in the hands, feet, and legs)
Premature rupture of the membranes (when a woman's water breaks more than 24 hours before labor starts)
Diabetes
Infections
Drug abuse
Placenta problems that decrease the baby's oxygen supply, such as placental abruption
What Are the Signs & Symptoms of a Stroke?
Babies who have a perinatal stroke often don't show any signs of it until months or years later. In some cases, they develop normally, but at a much slower pace than other kids. They also might tend to use one hand more than the other.
Children whose perinatal strokes cause more brain injury might have seizures. The severity of seizures can vary, ranging from the child simply staring into space to violent shaking of an arm or leg.
Signs of a stroke in infants:
Seizures in one area of the body, such as an arm or a leg
Problems eating
Trouble breathing or pauses in breathing (apnea)
Early preference for use of one hand over the other
Developmental delays, such as rolling over and crawling later than usual
Common signs of stroke in kids and teens:
Seizures
Headaches, possibly with vomiting
Sudden paralysis or weakness on one side of the body
Language or speech delays or changes, such as slurring
Trouble swallowing
Vision problems, such as blurred or double vision
Tendency to not use one of the arms or hands
Muscle weakness
Tightness or restricted movement in the arms and legs
Trouble with schoolwork
Memory loss
Sudden mood or behavioral changes
If your child has any of these symptoms, see a doctor right away or call 911.
Kids who are actively having a stroke can be given medicine that might reduce the severity of the stroke and the brain damage it can cause.
How is a Stroke in Children Diagnosed?
A quick diagnosis is important to minimize risk for brain damage. Doctors rely on imaging machines and other tests to see what has happened in a child’s brain.
Possible diagnosis tools include:
Computed tomography (CT) scan uses X-rays to take a detailed picture of the affected area of the brain. A CT scan will confirm whether or not the child has had a stroke, what kind of stroke it is and where in the brain it occurred.
Magnetic resonance imaging (MRI) uses magnetic radio waves to create an image of the brain. It provides greater visual details than a CT scan.
Cerebral arteriogram uses a special dye injected into the arteries of the brain and an X-ray is then taken.
Echocardiogram uses sound waves to take pictures of the heart to see whether there are problems with the heart valves or other heart functions that may be creating blood clots.
Electrocardiogram (ECG or EKG) measures the heart's electrical activity and any problems with heart rate or rhythm.
Blood tests may also be ordered to find out whether your child has a blood-clotting disorder.
Lumbar puncture (also known as a spinal tap) is performed to find out if there are signs of infection or inflammation in the nervous system.
What Treatments are Available for Children who have had a Stroke?
Treatment for a stroke is based on:
The child's age
What signs and symptoms the child has
Which area of the brain is affected
How much brain tissue was damaged
Whether an ongoing condition caused the stroke
Treatment for Hemorrhagic Stroke:
Treatment focuses on stabilizing the child (controlling blood pressure and body temperature and helping them breathe), and treating the hemorrhage itself.
Kids who have had a hemorrhagic stroke will be looked after by the vascular neurosurgery team.
Surgical options may include microsurgery to clip the aneurysm or remove the abnormal vessels.
Treatment for Ischemic Stroke:
The goal of treatment in ischemic stroke is to reduce damage to the brain and prevent another stroke.
If your child has been diagnosed with an ischemic stroke, doctors will most likely prescribe a blood thinner. These include:
Warfarin, given by mouth
Heparin, given by injection into a vein
Low molecular weight heparin, given by injection under the skin
ASA (acetylsalicylic acid, Aspirin), given by mouth
Clopidogrel, given by mouth.
Once a child has been treated for their initial stroke symptoms, they will be assessed to see how the stroke may affect them in the longer term. The healthcare team will monitor reflexes, eye movements, speech skills, swallowing and other body functions. The team may also administer tests to find out how well your child is doing in processing and reacting to light, pictures, sound and touch.
For most kids, treatment also involves:
Physical medicine and rehabilitation, or physiatry (fiz-ee-A-tree).
Physiatrists (fiz-ee-A-trists) are doctors who use many different types of therapy to help children recover from a stroke.
They work to enhance and restore functional ability and quality of life in people who have medical conditions that affect the brain, spinal cord, nerves, bones, joints, ligaments, muscles, and tendons.
What are the Possible Effects of a Stroke?
The area of the brain where the stroke takes place will determine the extent of the damage and the after-effects.
Stroke may cause after-effects in children. They include:
Weakness on one side of the body (hemiparesis)
Paralysis on one side of the body (hemiplegia)
One-sided neglect, where the child ignores the weaker side (unilateral neglect)
Difficulty with speech and language (aphasia)
Trouble swallowing (dysphagia)
Vision problems (decreased field of vision or perception)
Loss of emotional control and mood changes
Problems with memory, judgment or problem-solving (cognitive changes)
Behavioural or personality changes
Physical effects usually occur on the opposite side of the body from where the stroke occurred. For instance, children who have had a stroke affecting the left side of their brain may have weakness or paralysis on the right side. The left side of the brain controls reading, talking, thinking and mathematics, so these skills could be affected. On the other hand, children who have had a stroke affecting the right side of their brain, may have paralysis or weakness on their left side. The right side of the brain controls skills such as buttoning a shirt or tying shoes, as well as memory.
In children who have experienced a stroke, changes in physical abilities may be immediately apparent, but changes in cognition and behaviour tend to be discovered over time. Often children recover faster than adults because their brains are still growing. This is called plasticity. If children are quite young when they have a stroke, the extent of their deficits may not become apparent until they are older. For example, a reading problem may not be discovered until your child is in grade one.
A stroke may leave you and your child feeling overwhelmed, angry, depressed or frightened, which are all normal reactions. Speak to your hospital’s healthcare team about counselling options for yourself and your child.
What Rehabilitation Programs are Available?
Rehabilitation will allow your child to recover physical functions such as walking or reading. Getting help as soon as possible after the stroke will help. Children are likely to regain the most function in the first six months. They may continue to improve for two years or more. Speak to your hospital’s healthcare team about rehabilitation options!
Read A Family Guide to Pediatric Stroke to learn more about stroke and stroke care for children. This guide is based on the Canadian Stroke Best Practice Recommendations for Stroke Care (2010), current research and expert opinion. Get our free stroke pediatric guide.
· Visit Canadian Pediatric Stroke Support Association (CPSSA) to find support, education and resources for children with stroke.
· Visit SickKids to learn more about Stroke in Newborns, Childhood Stroke: Arterial Ischemic Stroke (AIS) and Childhood Stroke: Cerebral Sinovenous Thrombosis (CSVT).