Residency · Residency · Medicine-Pediatrics

Stroke in Young Adults and Children

Introduction

Stroke in children and young adults is underrecognized, often leading to delayed diagnosis. Pediatric stroke affects approximately 2-13 per 100,000 children annually, while stroke in adults under 45 accounts for 10-15% of all strokes. The med-peds physician must maintain a high index of suspicion, as etiologies and management differ substantially from stroke in elderly populations.

Classification

Ischemic Stroke

Arterial ischemic stroke (AIS): Occlusion of a cerebral artery. Cerebral sinovenous thrombosis (CSVT): Venous system occlusion; more common in neonates and children.

Hemorrhagic Stroke

Intracerebral hemorrhage (ICH). Subarachnoid hemorrhage (SAH).

Perinatal Stroke

Occurs between 28 weeks gestation and 28 days postnatal life. Often presents with seizures or identified later as hemiparesis.

Etiologies by Age

Pediatric Stroke (0-18 years)

Cardiac disease: Congenital heart disease, post-cardiac surgery (most common cause) Arteriopathies: Moyamoya, focal cerebral arteriopathy, dissection. Sickle cell disease: Leading cause of stroke in African American children. Infection and inflammation (varicella vasculopathy, meningitis) Prothrombotic states (factor V Leiden, protein C/S deficiency)

Young Adult Stroke (18-45 years)

Cervical artery dissection: Most common cause in young adults; carotid or vertebral. Cardioembolic (PFO, endocarditis, atrial fibrillation); Vasculitis (CNS vasculitis, SLE, antiphospholipid syndrome); Substance use (cocaine, amphetamines); Oral contraceptive use, pregnancy/postpartum; CADASIL: Cerebral autosomal dominant arteriopathy.

Clinical Presentation

Recognition Challenges

Pediatric stroke is frequently misdiagnosed (median time to diagnosis >24 hours) Children may present with seizures, altered consciousness, or nonspecific symptoms. Young adults may have atypical presentations attributed to migraine or anxiety.

Symptoms by Age

Neonates: Seizures, apnea, lethargy, feeding difficulty. Children: Acute hemiparesis, speech difficulty, headache, ataxia. Young adults: Classic stroke syndromes (similar to older adults)

Posterior Circulation Stroke

More common in children relative to adults. Vertigo, ataxia, cranial nerve palsies, visual field deficits.

Diagnostic Evaluation

Acute Imaging

CT head without contrast: Rule out hemorrhage (first-line in emergency) MRI with DWI: More sensitive for ischemia, especially in posterior fossa. MRA/CTA: Evaluate for arteriopathy, dissection, moyamoya. MRV: If cerebral sinovenous thrombosis is suspected.

Laboratory Workup

CBC, coagulation studies, ESR/CRP; Thrombophilia panel: Protein C, protein S, antithrombin, factor V Leiden, prothrombin gene mutation. Lipid panel, HbA1c, homocysteine; Autoimmune markers (ANA, antiphospholipid antibodies, lupus anticoagulant); Sickle cell screening in at-risk populations; Toxicology screen in young adults.

Cardiac Evaluation

Echocardiography with bubble study (PFO evaluation) Telemetry/Holter monitoring. TEE if suspicion for endocarditis or intracardiac thrombus.

Acute Management

Pediatric AIS

No FDA-approved thrombolysis guidelines for children; tPA use is center-dependent. Thrombolysis in Pediatric Stroke (TIPS) trial data is limited. Anticoagulation with unfractionated heparin or LMWH for dissection or cardioembolic etiology. Aspirin for non-cardioembolic AIS. Exchange transfusion for sickle cell disease-related stroke.

Young Adult AIS

Standard adult stroke protocols apply: IV alteplase within 4.5 hours, mechanical thrombectomy for large vessel occlusion. Cervical artery dissection: Anticoagulation vs. antiplatelet therapy (similar outcomes per CADISS trial) Address modifiable risk factors.

Hemorrhagic Stroke

Blood pressure management. Reversal of anticoagulation if applicable. Neurosurgical consultation for AVM, aneurysm, or large ICH.

Secondary Prevention

Sickle cell disease: Chronic transfusion therapy to maintain HbS <30%. Moyamoya: Surgical revascularization (encephaloduroarteriosynangiosis) Cardioembolic: Anticoagulation; PFO closure in selected young adults. Lifestyle modification: Smoking cessation, exercise, healthy diet. Avoid estrogen-containing contraceptives in women with stroke history.

Clinical Pearls

Think stroke in any child with acute focal neurologic deficit; delay in diagnosis worsens outcomes. Sickle cell disease screening with transcranial Doppler can identify children at high risk and prevent stroke with chronic transfusions. Cervical artery dissection should be considered in any young adult with headache or neck pain followed by stroke symptoms. Patent foramen ovale closure is recommended for cryptogenic stroke in adults age 18-60 with specific anatomic features. Med-peds physicians should advocate for stroke awareness campaigns that include pediatric and young adult populations.

References

1. Ferriero DM, Fullerton HJ, Bernard TJ, et al. Management of stroke in neonates and children: A scientific statement from the American Heart Association/American Stroke Association. Stroke. 2019;50(3):e51-e96.
2. Markus HS, Hayter E, Levi C, et al. Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): A randomised trial. Lancet Neurol. 2015;14(4):361-367.
3. Adams RJ, McKie VC, Hsu L, et al. Prevention of a first stroke by transfusions in children with sickle cell anemia and abnormal results on transcranial Doppler ultrasonography (STOP). N Engl J Med. 1998;339(1):5-11.

For the intern

At 3am, focus on rapid imaging and ruling out time-sensitive interventions. Obtain urgent CT to exclude hemorrhage, then MRI with diffusion-weighted imaging (DWI) if possible—this is your most sensitive test for pediatric ischemic stroke. Contact neurology immediately for any young patient with acute focal deficit. For children with known sickle cell disease, initiate exchange transfusion urgently. Check basic labs including CBC, coagulation studies, and toxicology screen. Defer comprehensive thrombophilia panels, echocardiography, and extensive autoimmune workup until morning unless clinically unstable. The key is not missing the diagnosis—stroke in children is often delayed because it's not considered.

Common pitfalls

• Attributing symptoms to migraine or conversion disorder in young patients, leading to delayed imaging. Any acute focal neurologic deficit warrants immediate stroke evaluation regardless of age.
• Ordering CT alone and missing posterior circulation strokes, which are more common in children. MRI with DWI is far more sensitive, especially for brainstem and cerebellar lesions.
• Forgetting sickle cell screening in at-risk populations presenting with stroke. This diagnosis changes acute management completely (exchange transfusion) and requires chronic transfusion for secondary prevention.
• Not considering cervical artery dissection in young adults with neck pain or recent trauma followed by neurologic symptoms. This is the most common stroke etiology in the 18-45 age group.

Make it stick

You're covering the ED on a busy night and a 4-year-old presents with sudden right-sided weakness. The parents say she was fine at dinner, but then stumbled and now can't pick up her toy with her right hand. Initial thoughts might drift to Todd's paralysis post-seizure, or even a functional neurological disorder, especially given the young age. But remember the lecture: any acute focal neurological deficit in a child demands a high index of suspicion for stroke. Don't let her age or a busy ED distract you. Get that head CT STAT to rule out hemorrhage, and push for an urgent MRI with diffusion-weighted imaging (DWI) to quickly assess for ischemic changes. Early diagnosis drastically improves outcomes, and you, the med-peds intern, are key to initiating that critical pathway.

If you remember one thing

Any acute focal neurological deficit in a child or young adult warrants immediate stroke evaluation, including urgent neuroimaging (CT then MRI with DWI if possible) and neurology consultation. Don't let age or atypical symptoms delay diagnosis, as swift intervention significantly impacts long-term outcomes.

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