Cerebral artery ischemic stroke in children: Clinical and diagnostic

Article written by Master, Doctor Vu Duy Dung - Doctor of Neurology - Department of General Internal Medicine - Vinmec Times City International Hospital

Cerebral artery ischemic stroke in children is currently an extremely dangerous disease and seriously affects health if it is not detected and intervened in time. Therefore, recognizing the signs and giving treatment in this case is extremely necessary.

The majority of children with acute ischemic stroke will have focal neurological deficits, although recognition of these deficits can be difficult in very young or frail children. The diagnosis of ischemic stroke is often delayed because stroke is less common in children compared with adults and is more common with stroke-like conditions such as: seizures, migraine, encephalitis, demyelinating, and functional neurological disorders.
Early diagnosis of cerebral ischemic stroke in children can be based on using the same diagnostic procedures as in adults, although a full neurologic evaluation will be necessary to confirm stroke and rule out stroke-like conditions. The most common stroke-like conditions in children are epilepsy, migraine, encephalopathy, mass lesion, infection, methotrexate toxicity, reversible posterior encephalopathy syndrome (PRES) and metabolic stroke.
The most common cause of sudden onset focal neurological deficits in adults is acute stroke, and treatment of ischemic stroke in adults can be developed based on imaging Cranial CT has ruled out intracranial bleeding and evaluated for early signs of stroke. In contrast, because of the high prevalence of stroke-like conditions in children, neuroimaging is necessary, not only to rule out hemorrhagic stroke (which accounts for half of all strokes in children). ) but also to determine whether there is an ischemic stroke and to rule out acute stroke-like conditions before deciding on treatment.
Cerebrovascular disease is a common risk factor for ischemic stroke in children. Strokes associated with cerebrovascular disease often have preceded transient ischemic attacks, and transient neurologic deficits are an indication for acute cerebral angiography because treatment can prevent future attacks. subsequent transient ischemic attack or permanent ischemic injury.

Because of the high incidence of pseudo-stroke conditions in children, the diagnosis should be confirmed by neuroimaging. Emergency imaging is indicated, as urgent intervention may be required, including malignant infarction and consideration of reperfusion strategies in the emergency and with comorbid conditions that pose a high risk of recurrent stroke. develop or progress without treatment. These include dissection of the arteries of the head and neck and thrombosis from the heart.

When possible, MRI is the optimal investigation for the diagnosis of acute ischemic stroke in children. Diffuse pulses (DWI), which are highly sensitive to ischemia, can be pre-imposed to guide subsequent pulse capture. A rapid MRI scan can be performed in about 20 minutes and is useful in children requiring sedation if the scan is lengthy or if resources are limited. Ideally, this procedure should include transverse T2 or FLAIR pulses, SWI or GRE pulses to detect bleeding, DWI/ADC pulses to detect ischemia, and pulsed magnetic resonance angiography (MRA) pulses. Head and neck TOF to evaluate cerebrovascular disease. In addition, vascular imaging is being used to evaluate arterial wall pathology, such as inflammation. Even when DWI does not show ischemia, MRA is still indicated in children with transient deficits suspicious of a transient ischemic attack, because there may be an underlying cause of cerebrovascular disease.
CT of the brain can rule out intracranial bleeding, but is not sensitive to early acute ischemic stroke. Although head and neck CT angiography can detect arterial abnormalities, including stenosis and occlusion, it requires extensive irradiation and contrast medium which usually does not provide additional information compared with MRA. Cranial CT may be indicated in children unable to undergo MRI (eg, children with pacemakers).
Catheter angiography is the most sensitive method for vascular angiography in cerebrovascular disease, including stenosis and occlusion. It is invasive and requires a lot of radiation and sedation; however, complications are rare in experienced radiologists.

Tests for the cause of stroke in children will be guided by medical history, clinical presentation, and neuroimaging, including neurovascular imaging.
3.1 Cardiac Evaluation Transthoracic echocardiography is indicated when intracardiac thrombus or valvular disease is suspected, or to evaluate right-left shunting, in children at risk of venous thrombosis when the cause of sudden cardiac arrest is present. stroke is not clear. Rarely, abnormalities seen on transesophageal echocardiography that cannot be detected on transthoracic echocardiography, especially valvular warts and left atrial thrombus. ECG is indicated when arrhythmia or heart failure is suspected. If an arrhythmia is suspected but not seen on the ECG, an electrocardiogram Holter may be indicated.
3.2 Tests in stroke Tests for acute ischemic stroke in children will depend on the suspected etiology, clinical presentation, and potential treatment options. Because the risk factors for ischemic stroke in children are often multifactorial, screening tests for hyperactivity are often indicated. Not all tests are indicated in all patients, and the blood volume required for these tests should be considered, especially in infants.
Evaluation for cerebrovascular disease is performed as described above on diagnosis. Cerebrospinal fluid (CSF) testing for markers of inflammation or infection should be considered in children with cerebrovascular disease of unknown or suspected meningitis or encephalitis. If varicella-zoster virus-associated cerebrovascular disease is suspected, CSF testing is indicated for diagnosis. Varicella vascular disease is defined as the presence of varicella-zoster viral DNA in the CSF or evidence of intramedullary anti-varicella-zoster virus antibody synthesis. CSF testing in primary CNS vasculitis may show leukocytosis or increased protein, although this is not usually seen, particularly in medium-large vascular disease.
Investigations and tests in cerebral ischemic stroke in children:

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References: Amlie-Lefond C. Evaluation and Acute Management of Ischemic Stroke in Infants and Children. Continuum (Minneap Minn) 2018;24(1, Child Neurology): 150-170.