Stroke advancements in children remain a challenge
Focusing on pediatric differences versus adults is critical.
Advances in managing adult ischemic stroke have been countless. But it’s a different story in pediatric stroke, where numerous uncertainties remain.
Although youth is perceived as an advantage in stroke recovery, young patients have high rates of mortality and disability, said Rachel Pearson, MD, assistant clinical professor of pediatrics at the University of California, Irvine and pediatric neurologist at Children’s Hospital of Orange County.
Pearson is among the presenters at a session Wednesday on pediatric ischemic stroke. In her presentation “Challenges and Advances in Prehospital Care for Pediatric Stroke,” she will break down uncertainties and strategies to move forward.
“There is a misconception that children with stroke ‘do better’ than adults in terms of recovery,” she said. “Although this can be true in some cases, many children have persistent neurological and/or neurodevelopmental impairments that they will carry with them for a lifetime. Such stroke-related disability not only affects these children and their families but also comes with significant long-term health care costs and resource utilization.”
Pearson said pediatric stroke diagnosis is often delayed because of factors including lack of awareness, frequency of stroke mimics in children, variability in clinical presentation and the need for MRI as the preferred diagnostic modality for pediatric ischemic stroke. Timely and accurate diagnosis is essential for modern stroke interventions such as thrombolysis and endovascular thrombectomy to succeed.
Achieving rapid diagnosis of stroke in children starts at the first point of contact, which is often in the emergency department or a prehospital setting, Pearson said.
“We first must increase awareness and knowledge of those in the community, first responders and emergency department providers,” she said. “To do this, it is critical to collaborate with local and regional partners like public health care agencies, emergency medical services and community emergency departments. In creating such partnerships, we can spread education and develop processes of care to improve pediatric stroke recognition, diagnosis and treatment.”
Pearson notes a few milestones in advancing pediatric ischemic stroke knowledge and care. For example, the International Pediatric Stroke Study — a multicenter, international, longitudinal, observational study and registry of pediatric stroke patients launched in 2003 — has broadened understanding of pediatric stroke epidemiology, risk factors and outcomes. And in 2019, the American Heart Association published its scientific statement on the management of stroke in neonates and children, a comprehensive guide for clinical practice that also highlights gaps in the literature and areas of focus for future studies.
Also among Wednesday’s speakers discussing pediatric stroke is Peter Sporns, MD, MHBA, FESO, associate professor in diagnostic and interventional neuroradiology at University Hospital Basel in Switzerland. His presentation, “Endovascular Management of LVO in Pediatric Patients,” will detail the recent results of the Save ChildS Pro study. This prospective, multicenter registry study follows children with arterial ischemic stroke caused by large vessel occlusion who underwent endovascular thrombectomy.
“These children had significantly better outcomes than children who received best medical therapy only,” Sporns said. “This study shows that it is important to perform this interventional procedure in eligible children and that there are no major safety concerns.”
The session will also delve into data from meta-analyses on endovascular interventions and discuss age limits for these procedures in neonates and infants. According to Sporns, there is no reliable meta-analysis on the age question; the best available data come from the Save ChildS Pro registry.
Many neurointerventionalists would agree that in children 6 years and older, endovascular management is feasible and safe in the hands of providers who are experienced in treating children, Sporns said. “Below this age, endovascular management of children with stroke may potentially improve outcomes in selected children, but this is not as well-investigated, especially for neonates. It’s very controversial due to different underlying etiologies.”
Overall, Pearson noted that to improve pediatric stroke outcomes, focusing on child-specific challenges is key.
“Most of these challenges boil down to the fact that children are not ‘little adults.’ Common etiologies and types of strokes differ in pediatrics compared to the adult population. Stroke recovery can look different in a developing brain, and stroke mimics are more common than true stroke in children,” she said.
“We must recognize these nuances and be thoughtful in how and when we extrapolate adult stroke therapies to the pediatric population to ensure we are doing the best thing for our patients.”
