A stroke occurs when blood flow to the brain stops because of a clot (ischemic stroke) or because a blood vessel ruptures (hemorrhagic stroke). Blood carries oxygen and other nutrients to the body’s cells and organs. When it cannot reach the brain for more than three minutes, brain cells begin to die. The brain cells continue to die for as long as they are deprived of oxygen.

At this time, no treatment exists to fix brain cells that have died. Prompt diagnosis, treatment and rehabilitation therapy can save a child’s life and minimize long-term disability.

Childhood stroke is most common during the first year of life, but can occur any time throughout childhood or adolescence. Each year, about 11 in 100,000 children from birth through age 18 experience a stroke. Boys and African-American children are at a higher risk for stroke than other groups of children.

The main types of stroke (in children and adults) are:

• Ischemic stroke
• Transient ischemic attack (TIA)
• Hemorrhagic stroke

Ischemic stroke is the most common type of childhood stroke. This occurs when a blood clot forms and becomes stuck in an artery to the brain. In some cases, a clot may become stuck in an artery that is injured or narrowed. Sometimes clots form somewhere else in the body, such as the heart, and travel to the brain. Clotting disorders can increase the likelihood of an ischemic stroke.

Transient Ischemic Attack, or TIA, occurs when blood flow to the brain is blocked only briefly — usually no more than five minutes. Sometimes called a “mini-stroke,” a TIA is:

• A medical emergency, just like a major stroke
• Usually caused by blood clots (not a hemorrhage)
• A warning sign of a future stroke. More than a third of people who have a TIA have a major stroke within one year if they don’t receive treatment

When symptoms first appear, it is not possible to know whether they are caused by a TIA or major stroke. If it is a TIA, your child’s doctor can work to identify the cause and take steps to help prevent a major stroke from happening.

Hemorrhagic stroke is far less common in children. It occurs when a blood vessel in the brain ruptures. Blood leaks into the brain and flows into areas where it isn’t supposed to go. Pressure builds, which interferes with blood flow to the affected area of the brain. Sometimes, as the blood accumulates in brain tissues, a clot forms.

In adults, the main risk factors for strokes are hardening of the arteries, high cholesterol and diabetes. In children, they are very different.

Ischemic strokes and TIAs usually are related to:

• Lack of oxygen during birth
• A heart defect present at birth
• Blood disorders such as sickle cell disease
• Injury to a blood vessel in the brain
• Clotting disorders
• Dehydration
• Genetic disorders
• An infection, such as meningitis or chicken pox
• Problems that occurred during the mother’s pregnancy, such as gestational diabetes or maternal high blood pressure (these can cause an ischemic stroke before or after birth)

Hemorrhagic strokes may be associated with:

• A broken blood vessel related to a head injury
• An arteriovenous malformation, which is a tangle of abnormal blood vessels connecting arteries and veins in the brain
• An aneurysm, which is a bulge or weakness in an artery wall
• In infants, premature birth or low birth weight

Medical tests can confirm that a stroke has occurred, but cannot always reveal the cause of a stroke. In about one-third of all childhood strokes, doctors are not able to identify a cause.

Some symptoms of childhood stroke mimic those associated with adult stroke. These include weakness on one side of the body and difficulty communicating. Other symptoms, such as seizure, nausea and vomiting, are more common in children.

The following symptoms are common in newborns and infants who are having a stroke:

• Seizures. The child may stare into space, or one arm or leg may shake violently
• Extreme sleepiness
• A tendency to use only one side of their body

The most common symptoms of stroke in children and teens include:

• Weakness, numbness or paralysis on one side of the body
• Difficulty speaking or understanding others
• Blurred or double vision
• Dizziness or loss of balance or coordination

Less common symptoms of stroke in children and teens include:

• Severe headaches, possibly with vomiting
• Extreme sleepiness
• Tightness or restricted movement in the arms and legs
• Seizures
• Trouble swallowing
• Memory loss and difficulty concentrating
• Sudden mood or behavioral changes

It is not always easy to tell when a child of any age is having a stroke. This is especially true in infants, since their symptoms may not be obvious, and they cannot communicate what their symptoms are. In some cases, parents aren’t aware that their baby has had a stroke until months later, when they notice developmental delays or other concerns.

It is important to know the signs and symptoms of a stroke and to seek help as quickly as possible.

Most strokes in children involve a sudden onset of symptoms. If your child experiences symptoms of a stroke, take the following actions:

• Dial 911.
• Lay your child flat.
• Do not give your child food or drink.
• Request a stroke evaluation from your pediatric health care provider or contact Cincinnati Children’s.

A number of tests can help doctors determine whether your child has experienced a stroke, understand the extent of the damage to the brain and establish a treatment plan. These tests may include:

• Computed tomography (CT) helps confirm that a hemorrhagic stroke has occurred and, in some cases, that an ischemic stroke has occurred
• Computed tomography angiography (CTA) uses contrast material (dye) to detect blockages or find an underlying cause for the stroke
• Echocardiography (ECHO) and electrocardiography (ECG or EKG) can help detect heart-related causes of stroke
• Magnetic resonance imaging (MRI)
• Magnetic resonance angiography (MRA) and magnetic resonance venography (MRV)
• Cranial ultrasound uses high-frequency sound waves to provide information about the condition of the arteries.
• Blood tests can help identify clotting disorders, infection, anemia and other abnormalities

If testing confirms that a stroke has taken place, the medical team may order additional tests to determine the cause of the stroke or detect other medical conditions that may be present.

• Blood tests can sometimes detect underlying medical problems, such as infection, high blood glucose levels and clotting disorders
• Electrocardiography (ECG or EKG) is used when a heart problem is present or suspected
• Electroencephalogram (EEG) can help assess seizure activity and seizure complications in the brain
• Neurologic tests can reveal how the stroke may have affected the child’s ability to move, speak, swallow, etc.

Treatment for a childhood stroke takes place in two different phases: initial care and long-term therapy.

Initial care
Immediate treatment for a stroke can save a child’s life. When a child has an ischemic stroke, the goal is to restore blood flow to the brain. Typically, this involves using medication to thin the blood and prevent new clots from forming.

When a child has a hemorrhagic stroke, the focus is on controlling bleeding in the brain. A child with either ischemic or hemorrhagic stroke may need emergency surgery to relieve pressure on the brain caused by the stroke.

After the child’s condition is stable, the hospital medical team will encourage healing by keeping the child comfortable, hydrated and in a quiet environment. Other early therapies may be used to treat underlying medical conditions. They include:

• Antibiotic therapy to treat infection
• Anti-seizure medication
• Blood transfusions for children with sickle cell disease
• Treatment for any heart-related conditions

Long-term therapy
As the child stabilizes, rehabilitation therapy can begin. The goal of treatment is to help recover as much lost function as possible, address any underlying causes of the stroke and prevent a future stroke. Physical therapy, occupational therapy and speech therapy can begin during the hospital stay and may continue for weeks, months or even years after a stroke.

A child’s long-term outlook after stroke depends on many factors, including the type, size and location of the stroke. In general, however, children usually recover better from strokes than adults do. This is because their brains are better able to reorganize and recover after a stroke. For example, surviving brain cells can learn to perform some of the jobs of cells that have died.

The brain damage that occurs during a stroke can cause a number of other problems that could affect a child throughout life, including:

• Weakness or paralysis on one side of the body
• Mental retardation
• Difficulty with communication, trouble swallowing
• Vision and hearing problems
• Loss of emotional control and changes in mood
• Cognitive changes or problems with memory, judgment, focus and problem-solving
• Learning disabilities, including poor attention skills

Sixty percent of the children who survive a stroke will have permanent neurological problems, ranging from mild to significant. Children often receive occupational and physical therapies for decades to help them learn functional skills of daily living and increase movement if they’re experiencing motor difficulties. Special educational programs may address learning and behavioral differences.

Some children who have had a stroke have complex medical problems that require lifelong care. These can include:

• Cerebral palsy
• Epilepsy
• Cardiac conditions

Children may need to see multiple specialists, who can work together to provide coordinated care. A coordinated approach to care can help the child reach his or her full potential.

Sometimes, a stroke is the first sign of a medical problem. This type of stroke is not preventable. But taking steps to prevent stroke is possible when:

• A child has a medical condition known to increase their risk for stroke (such as sickle cell disease or artery disease)
• A child has already experienced a stroke (about one in five children who have had a stroke will experience another one)

Your child’s medical team will talk to you about important steps to minimize your child’s risk for stroke. These steps may include:

• Treating underlying medical conditions
• Taking antithrombotic medications to help prevent clots from forming or growing
• Being screened for diabetes, hypertension and dyslipidemia (abnormal levels of fats in the blood)
• Maintaining healthy habits such as following a balanced diet, exercising regularly, staying hydrated and not smoking