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
| Age Group | Most Common Etiologies |
|---|---|
| Neonates | Perinatal asphyxia, cardiac disease, prothrombotic states, maternal factors |
| Children (1-18) | Congenital heart disease/post-cardiac surgery, arteriopathies (moyamoya, FCA), sickle cell disease, infection/varicella vasculopathy |
| Young adults (18-45) | Cervical artery dissection (most common), cardioembolic (PFO), vasculitis/APS, substance use, OCP/pregnancy, CADASIL |
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
- 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.
- 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.
- 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.