Arterial dissection and stroke in children

Arterial thromboembolic disease: a single-centre case series study

AIM

Paediatric venous thromboembolic disease has been reported with increased frequency during the last decade. In contrast, the pathophysiology of arterial thromboembolic disease in infants and children has not been adequately explored. The aim of this study was to determine the prevalence, aetiology, diagnostic criteria, management and outcome of arterial thromboembolism (TE) in a tertiary paediatric centre.

METHODS

A prospective, single-centre registry was established at an Australian tertiary paediatric centre in order to address the aim of this study.

RESULTS

One-hundred-and-two arterial thrombotic events occurred in 98 patients during 48 months. Infants were most likely to have a lower limb arterial TE (n = 22) whilst children were most likely to have a central nervous system arterial TE (n = 26). Surgery was a frequent predisposing factor in both infants and children. Doppler ultrasonography, computerized tomography and magnetic resonance imaging were the most commonly used diagnostic modalities. Unfractionated heparin was the most frequently used treatment in both age groups. At discharge, 25 infants and twelve children had complete resolution of their arterial TE. Direct thrombosis-related mortality was 4% in infants and 9% in children. Duration of follow-up ranged from 1 to 900 days, with thirteen infants and 32 children never achieving complete resolution. Forty-nine percent of post-discharge survivors had significant long term sequelae directly attributable to their arterial TE.

CONCLUSION

Arterial TE occurred as frequently as venous TE in our tertiary paediatric population. The clinical outcome and long term sequelae of such events are significant.

Cerebellar infarction in the territory of the superior cerebellar artery in children

Posterior circulation infarction is uncommon in children. Vertebral artery dissection is an unusual cause of posterior circulation infarction in children. We report on a 12-year-old boy with spontaneous left-extracranial vertebral artery dissection associated with isolated ipsilateral superior cerebellar artery territory infarction, diagnosed clinically and by brain computed tomography, magnetic resonance imaging, and magnetic resonance angiography. Cerebral angiography demonstrated a flame-like occlusion of the left vertebral artery at level C(2)-C(3), and indicated that artery-to-artery embolus may be a mechanism of superior cerebellar artery territory infarction. We emphasize that vertebral artery dissection should be considered in a child with acute signs of posterior circulation ischemia.

Arterial ischemic stroke in children

Stroke in children is relatively rare. Advances in the clinical recognition and radiographic diagnosis of ischemic stroke have increased the frequency of the diagnosis in infants and children and have raised the need for immediate therapy. A vast amount of data has recently become available through basic research and neuroimaging techniques shedding new light on the chain of events that occur in ischemic stroke in animal models and in the adult population. Whether this new information can also be applied to the pediatric population remains to be seen, but it is likely that the active management of children with acute ischemic stroke in the near future will include brain protection, brain reperfusion, and prevention measures.

Carotid dissection and stroke after tonsillectomy and adenoidectomy

Carotid dissection and cerebral infarction are extremely rare complications of tonsillectomy and adenoidectomy. We describe a 12-year-old boy who presented with a right internal carotid dissection and right middle cerebral artery infarction, associated with tonsillectomy and adenoidectomy. We discuss the risk factors that may predispose patients to these complications.

Association of cervical internal carotid artery aneurysm with ipsilateral vertebrobasilar aneurysm in two children: a segmental entity?

INTRODUCTION

A combination of cervical and intradural aneurysm in children in the absence of systemic disorders has previously not been reported.

CASE REPORT

We report two boys with an identical combination of fusiform cervical internal carotid aneurysm and ipsilaterally located vertebrobasilar aneurysm. They had no history of trauma, they did not display any personal or familial signs of systemic disease, and the testing for collagen disease was negative. The location and appearance of the aneurysms and the identical anatomical disposition in the patients indicated a non-randomly distributed segmental vulnerability.

CONCLUSION

The cases demonstrate primary morphological signs of a developmental error being expressed in two seemingly separate segments but linked by the hypoglossal artery. It suggests a segmental error related to this embryonic vessel. They also show that few phenotypes are specific for a genotypic disorder and highlight the importance of analysing different etiologies for aneurysm formation and anatomical disposition when taking treatment strategy decisions.

Intracranial vertebral artery dissection with subarachnoid hemorrhage following child abuse

Child abuse is often suspected based on particular patterns of injury. We report a case of intracranial vertebral artery dissection with subarachnoid hemorrhage (SAH) in a 3-month-old boy following child abuse. The mechanisms of injury and the clinical and imaging findings are discussed. This particular pattern of injury has rarely been reported in association with child abuse. We hope to raise physician awareness of child abuse when faced with these imaging findings.

Prognosis and Safety of Anticoagulation in Intracranial Artery Dissections in Adults

Background and Purpose— To characterize different forms of intracranial artery dissections (IADs), and to test the assumption that IADs are frequently associated with subarachnoid hemorrhage (SAH) and poor outcome, and that anticoagulant therapy is contraindicated in these patients.

Methods— We studied 81 consecutive non-SAH IAD patients and 22 IAD patients with SAH, diagnosed between 1994 and 2004 and 1998 and 2004, respectively, and treated the former patients immediately with heparin, followed with at least 3 months of warfarin. Outcomes were recorded at 3 months.

Results— Approximately one-third of all cervicocephalic artery dissections were identifiably either completely located intracranially or extended into the intracranial space. At 3 months, 64 of the 81 non-SAH patients (79%) had a favorable outcome (modified Rankin Scale, 0 to 2); 1 patient died of brain infarction in the acute stage. Only 1 aneurysm developed during follow-up in the non-SAH group, and no intracranial bleeding was observed during anticoagulant treatment. Those presenting with SAH formed ≈25% of all IADs, and 21 cases out of 22 (95%) were associated with ruptured fusiform dissecting aneurysm. This latter group displayed significantly worse outcomes: 7 died, and only 7 had modified Rankin Scale 0 to 2 at 3 months.

Conclusions— Our results provide important information for clinical practice. IADs appear to polarize into 2 groups: (1) nonaneurysmatic IADs presenting without SAH that are associated with favorable outcomes and safe anticoagulant therapy; and (2) aneurysmatic IADs, characterized by SAH and poorer prognosis. Literature on IADs may have been biased toward group 2.

Acute Stroke in the Burn Patient

A 3-year-old boy was brought to our hospital with 62% TBSA burn injury by boiled water. He received modern burn therapy, including early débridment and skin grafts. The patient discharged 70 days after being burned. Unfortunately, he sustained an acute right-sided hemiparesis 7 days after discharge. Magnetic resonance imaging revealed left middle cerebral artery territory infarction, and a magnetic resonance angiogram showed nonvisualization of left distal intra-cranial carotid artery and proximal middle cerebral artery. Thickened walls of these arteries indicated acute dissection. The patient received a follow-up magnetic resonance angiogram study 10 years later to check cerebral vascular lesions that may not have been apparent on the original image studies. It showed only persistently thickened left distal intra-cranial carotid artery and middle cerebral artery walls, indicative of old dissection. Therefore, carotid artery dissection must be considered as one cause of acute stroke in pediatric burn patient, even in the recovery phase of burn injury.

Imaging of the central nervous system in suspected or alleged nonaccidental injury, including the mimics

Because of the widely acknowledged controversy in nonaccidental injury, the radiologist involved in such cases must be thoroughly familiar with the imaging, clinical, surgical, pathological, biomechanical, and forensic literature from all perspectives and with the principles of evidence-based medicine. Children with suspected nonaccidental injury versus accidental injury must not only receive protective evaluation but also require a timely and complete clinical and imaging workup to evaluate pattern of injury and timing issues and to consider the mimics of abuse. All imaging findings must be correlated with clinical findings (including current and past medical record) and with laboratory and pathological findings (eg, surgical, autopsy). The medical and imaging evidence, particularly when there is only central nervous system injury, cannot reliably diagnose intentional injury. Only the child protection investigation may provide the basis for inflicted injury in the context of supportive medical, imaging, biomechanical, or pathological findings.

Paediatric dissecting posterior cerebral aneurysms: report of two cases and review of the literature

INTRODUCTION

Intracranial aneurysms in the paediatric population are uncommon, accounting for 2% to 6% of all aneurysms, and spontaneous arterial dissection is rarely reported as the cause of aneurysms in children, especially in the posterior cerebral artery.

METHODS

Two cases of paediatric spontaneous posterior cerebral artery dissecting aneurysms are reported, one in a 33-month-old male child presenting with aneurysmal rupture and subarachnoid haemorrhage and the other in a 9-year-old boy with an unruptured aneurysm.

RESULTS

The first child was successfully treated by endovascular parent vessel occlusion without neurological deficit and in the second a spontaneous thrombosis of the aneurysm and its parent artery occurred associated with hydrocephalus and a favourable outcome.

CONCLUSION

Dissecting aneurysms are dynamic lesions with variable and unpredictable evolution and close follow-up and/or early treatment is warranted. Spontaneous arterial dissection is a rare, probably still under-recognized, cause of intracranial aneurysms that may be responsible for a significant number of aneurysms and spontaneous aneurysmal thromboses in children.

Bilateral traumatic carotid artery dissection in a child

Traumatic dissection of the carotid artery is an infrequent but serious complication of blunt craniocervical injury. There is controversy regarding the need for diagnostic screening and management. This report presents a child with delayed neurologic symptoms and multiple cerebral infarcts secondary to bilateral extracranial traumatic carotid artery dissection. The pathophysiology, clinical presentation, and treatment options of blunt carotid artery trauma are discussed.

Temporal trends in the incidence and case fatality of stroke in children and adolescents

A recent study reported that mortality from stroke in children and adolescents decreased by 58% from 1979 to 1998, although it wasn't clear if the case fatality or the incidence of stroke in this age group is decreasing. We report trends of stroke incidence and case fatality in children and adolescents within a large biracial population. The study involved collection of all strokes in the study population between January 1, 1988 and December 31, 1989, July 1, 1993 and June 30, 1994, and January 1, 1999 and December 31, 1999, at all of the regional hospitals serving the Greater Cincinnati/Northern Kentucky population (only the children's hospital in 1988). Study nurses reviewed the medical records of all inpatients with stroke-related discharge diagnoses and abstracted relevant data. A study physician reviewed each abstract to determine whether a stroke or transient ischemic attack had occurred. A total of 54 strokes occurred in children or adolescents younger than 20 years during the three study periods (30% African American, 70% Caucasian, and 56% female). The overall incidence rate of all strokes in children younger than 15 years was 6.4/100,000 in 1999, a nonsignificant increase when compared to 1988. The 30-day case-fatality rates were 18% in 1988-1989, 9% in 1993-1994, and 9% in 1999. We found that the incidence of strokes in children has been stable over the past 10 years. The previously reported nationwide decrease in overall stroke mortality in children might be due to decreasing case fatality after stroke and not decreasing stroke incidence. Based on our data, we conservatively estimated that approximately 3000 children less than 20 years old would have a stroke in the United States in 2004.

Spontaneous intracranial arterial dissection in the young: diagnosis by CT angiography

Background

Spontaneous carotid artery dissections have been rarely reported in children. Diagnosis has traditionally been confirmed by catheter arteriography. More recently diagnosis has been made by magnetic resonance imaging and magnetic resonance angiography; however the sensitivity of these techniques has yet to be determined. The authors are unaware of reports of carotid dissection confirmed by dynamic computed tomography (computerized tomographic arteriography) in the young.

Case presentation

We recently evaluated a fourteen year-old male following the development of transient neurologic symptoms. There was no antecedent illness or trauma. Dynamic computed tomography revealed an intracranial dissection involving the supraclinoid segment of the left internal carotid artery (confirmed by catheter arteriography). Studies for vasculitis, pro-thrombotic states, and defects of collagen were negative.

Conclusion

Spontaneous carotid artery dissection is a potential cause of transient neurological symptoms and ischemic stroke in the pediatric population. Dynamic computed tomography appears to be a reliable diagnostic tool which can lead to early diagnosis.

Therapeutic approaches and advances in pediatric stroke

Evidence-based therapeutic interventions for pediatric ischemic cerebrovascular disease are beginning to emerge. The primary therapeutic target is usually the pathological prothrombotic disturbance that underlies the majority of pediatric stroke. A battle between anticoagulation and anti-platelet therapies continues to provide controversy and is the inspiration for upcoming randomized trials. Supportive care and neuroprotective strategies are an important consideration in children with stroke. Attempts to determine the safety of acute thrombolytic interventions are also underway. Finally, unique medical and surgical treatments for specific diseases leading to stroke in children continue to evolve. After briefly summarizing the epidemiology, pathophysiology, diagnosis, and outcomes of ischemic strokes in children, treatment approaches and alternatives will be reviewed in detail with emphasis placed on current areas of controversy and future directions for clinical research.

Pediatric stroke: the child is not merely a small adult

Arterial ischemic stroke and sinovenous thrombosis are a significant yet under-recognized causes of mortality and morbidity in the pediatric population. With increasingly complex etiologies yet urgency for rapid diagnosis and treatment, pediatric stroke teams likely will become the standard of care. A common terminology must be developed to avoid confusing types of acute cerebral insults--such as focal arterial ischemic stroke and global hypoxia and ischemia--that have different causes and pathophysiologic mechanisms of injury. Increased awareness of unique pediatric stroke subtypes, their clinical presentation, and their imaging findings will facilitate early identification and development of optimal treatment strategies.

Stroke in Childhood

BACKGROUND

Childhood stroke is increasingly recognized as an important cause of morbidity and mortality. Risk factors for stroke in childhood are different than those traditionally seen in adults.

REVIEW SUMMARY

This review summarizes, in brief, the epidemiology, risk factors, evaluation, treatment, outcome, and recurrence risk of children with arterial ischemic stroke (AIS). Areas of controversy and those that require further study are highlighted. Tables summarizing important points of the history, physical examination, and diagnostic evaluation of AIS are provided.

CONCLUSIONS

Children with stroke should be carefully evaluated for risk factors and possible etiology of stroke. At the present time, treatment is based upon extrapolation from the adult literature and expert opinion, as no evidence-based guidelines exist, except in sickle cell anemia. International, multicenter trials are beginning and should provide some answers over the next few years.

Treatment and prevention of cerebrovascular disorders in children

Cerebrovascular disorders are an important cause of mortality and chronic morbidity in children. Ischemic stroke is more common than cerebral venous thrombosis and hemorrhagic stroke in children. Several medical disorders have been associated with stroke in children, and a thorough evaluation of underlying causes is needed to determine the best treatment and prevention strategy. The treatment and prevention of stroke in children is not well studied, and current recommendations are based on adult studies, nonrandomized trials, or expert opinion. Children with stroke require immediate, special attention and if possible should be stabilized and transferred to an institution that can offer pediatric neurovascular expertise and care. All children with stroke should be referred to or have their care managed by a pediatric neurologist. The treatment of stroke in adults is well studied, and when applicable this evidence should be considered in the treatment of children with stroke. Data from animal and adult stroke studies have demonstrated a benefit for the aggressive treatment of infection, fever, blood pressure, hypo/hyperglycemia, intracranial pressure, and seizures, and should be applied to children with stroke. The use of thrombolytic, antithrombotic, and antiplatelet therapies is based on adult studies, cohort studies, and/or expert opinion. Two consensus guidelines regarding the treatment of arterial ischemic stroke and cerebral venous thrombosis were recently published and recommend the use of anticoagulants or antiplatelet agents in the acute setting, depending on the underlying cause of stroke. The evidence for the primary prevention of stroke in children is restricted to sickle cell disease (SCD) and derived from the Stroke Prevention in Sickle Cell Study Project studies. Long-term chronic transfusion therapy to maintain hemoglobin S levels below 30% is indicated in children with SCD and intracranial stenosis. It has also been recently determined that chronic transfusion therapy should not be stopped in children with SCD and an increased risk for stroke. The recurrence rate of arterial ischemic stroke (AIS) in children ranges from 6% to 30% and is highest among children with recurrent transient ischemic attack, cardiac disease, arteriopathies, and metabolic and coagulation abnormalities. Recommendations for secondary prevention are based on adult studies and the underlying pathophysiology of the stroke. Antiplatelet therapy (aspirin 1-5 mg/kg/day) is recommended in most children with a history of AIS. Although there is minimal evidence to support its use in children, anticoagulation may be indicated in AIS associated with extracranial arterial dissection, prothrombotic disorders, cardiac disease, severe intracranial stenosis, and recurrent AIS while on antiplatelet therapy.

Craniocervical arterial dissection in children: clinical and radiographic presentation and outcome

Craniocervical arterial dissection is a recognized cause of arterial ischemic stroke in children. Whether children with craniocervical arterial dissection have dissection characteristics different from those of adults is unclear. A retrospective review of children, 1 month to 18 years of age, with dissection from two Canadian pediatric ischemic stroke registry centers was conducted. From 213 patients with arterial ischemic stroke, 16 (7.5%) were identified with dissection, 37.5% had warning symptoms, and 50% had a history of head or neck trauma. The clinical presentation included headache (44%), altered consciousness (25%), seizures (12.5%), and focal deficits (87.5%). Dissection involved extracranial vessels in 75% and anterior circulation in 56%. Follow-up included complete recovery in 43%, mild to moderate deficits in 44%, and severe deficits in 13%. Fourteen (87.5%) children received antithrombotic treatment. Follow-up angiography showed resolution of abnormalities in 60% of vessels. Total occlusion had the worst outcome for recanalization. In conclusion, the etiology of arterial dissection in the majority of children appears to be either trauma or idiopathic. Long-term angiography shows variable outcomes, depending on the initial findings. The relationship of angiographic outcomes with recurrent strokes requires further study in pediatric dissection. (J Child Neurol 2006;21:8-16).

Cervical Artery Dissection: A 5-Year Prospective Study in the Belluno District

BACKGROUND

Artery dissection is an unusual cause of ischemic stroke, particularly frequent among young patients. The aim of this study was to collect epidemiological data on artery dissection in a hospital-based community, set up a diagnostic protocol and discover outcome predictors.

METHODS

Among patients suffering from cerebral infarction resident in our country, those with clinical and radiological features suggestive of artery dissection were selected. Risk factors, investigative techniques and treatment were evaluated. Patients were subjected to clinical examinations and were regularly tested neuradiologically.

RESULTS

Out of 895 ischemic stroke patients, 10 patients with cervical artery dissection (1.1%) were found. Seven patients were treated with anticoagulants and 3 received antiplatelet agents. One posttraumatic artery dissection patient died within a few days of the stroke. None of the patients suffered from a recurrence, while serious disability occurred in 4 of them.

CONCLUSIONS

Artery dissection should be suspected in any cerebral infarction patient, especially in young patients without risk factors for cerebrovascular diseases. The treatment of choice consists of anticoagulants. An early clinical diagnosis, strongly supported by radiological tests, is mandatory to start the proper treatment and achieve the best possible outcome.

Toward the definition of cerebral arteriopathies of childhood

PURPOSE OF REVIEW

To facilitate and standardize the diagnosis of cerebrovascular conditions in childhood, particularly in the field of arterial ischemic diseases.

RECENT FINDINGS

Progress in diagnostic techniques in the past decade have led to newly established etiologies for childhood stroke, most of which represent some form of vascular pathology. These advances must be integrated into a modern nomenclature system with revised definitions of stroke and arterial wall diseases-arteriopathies-in childhood.

SUMMARY

This nomenclature system is intended to facilitate and enhance clinical research in childhood stroke, particularly multicenter collaborative studies.

Cerebrovascular disorders in children

Cerebrovascular disorders are an important cause of mortality and chronic morbidity in children. International incidence rates for childhood stroke (ie, from 30 days to 18 years of age) have ranged from 1.3 to 13 per 100,000 children. Ischemic stroke is probably more common than hemorrhagic stroke in children. The clinical presentation of stroke in children varies according to age and location of the stroke. Over 100 risk factors for stroke in children have been reported, but in up to one third of cases no cause is identified. The management and prevention of stroke in children is not well studied and current recommendations are based on adult studies, nonrandomized trials, or expert opinion. Over half of children with stroke will develop lifelong cognitive or motor disability and up to one third will have a recurrent stroke. This review briefly describes the epidemiology, risk factors, evaluation, treatment, and outcome of stroke in children.

Radiological approach to disorders of arterial brain vessels associated with childhood arterial stroke-a comparison between MRA and contrast angiography

Recent studies of arterial ischaemic stroke in children have emphasised the higher frequency of cerebral arterial abnormalities than believed previously, explaining some of the strokes thought to have been idiopathic. Moreover, recurrent strokes are significantly more frequent in children with multiple risk factors, including those with demonstrable vascular abnormalities. Thus, cerebral arterial imaging is essential for the understanding and therapeutic approach to this pathology. Contrast angiography (CA) is the reference examination for the diagnosis of cerebral arterial abnormalities, but MR angiography (MRA) is a sensitive and non-invasive method to evaluate the vasculopathy of childhood stroke. In this article we highlight recent data concerning localisation and characterisation of arterial lesions and discuss the yield of MRA compared with CA.

Arterial infarction caused by carotid artery dissection in the neonate

Arterial stroke in a neonate caused by carotid artery dissection is rare. We report two cases, one with dissection at the level of the skull base, one just distal to the carotid bulb. Non-invasive techniques like MR angiography and sonography demonstrated the dissection accurately. MR imaging, especially the diffusion-weighted images, showed the extension and site of the cerebral infarction. In one case dissection could be suspected following vacuum and forceps extraction. In the other no obvious birth trauma was reported. In conclusion, in a neonate with clinical signs suggestive of cerebral infarction, dissection of the carotid artery should be considered.

Neuroimaging of intraparenchymal lesions predicts outcome in shaken baby syndrome

OBJECTIVE

Studies of long-term outcome on nonaccidental head injury (NAHI) in young children have shown severe neurodevelopmental sequelae in most cases. For improving the knowledge of outcome and for identifying prognostic factors, additional clinical and cerebral imaging data are needed. The aim of this study was to describe clinical and imaging features over time and to consider their value for predicting neurodevelopmental outcome.

METHODS

A retrospective medical record review was conducted of 23 children with confirmed NAHI, for whom an extended follow-up of 2.5 to 13 years (mean: 6 years) was contemplated. Glasgow Coma Scale scores, severity of retinal hemorrhages, presence of skull fractures, cranial growth deceleration, and sequential neuroimaging data (computed tomography and/or magnetic resonance imaging) were compared with patterns of clinical evolution assessed by the Glasgow Outcome Scale.

RESULTS

Clinical outcome showed that 14 (61%) children had severe disabilities, 8 (35%) had moderate disabilities, and 1 (4%) was normal. A low initial Glasgow Coma Scale score, severe retinal hemorrhages, presence of skull fracture, and cranial growth deceleration were significantly associated with poor developmental outcome. Eighteen of the 23 patients had abnormal magnetic resonance imaging scans. This examination disclosed atrophy when performed beyond 15 days of injury. Atrophy seemingly resulted from various brain lesions, namely, contusions, infarcts, and other lesions within the white matter. Presence of intraparenchymal brain lesions within the first 3 months was significantly associated with neurodevelopmental impairment. Severity of motor and cognitive dysfunctions was related to the extent of intraparenchymal lesions.

CONCLUSIONS

Early clinical and radiologic findings in NAHI are of prognostic value for neurodevelopmental outcome.

[Cerebral infarct secondary to carotid artery dissection]

Dissection of the internal carotid artery is an important cause of ischemic stroke in children and young patients. Trauma and/or an underlying structural defect of the arterial wall have been suggested to be predisposing factors. The typical patient presents with ipsilateral headache or neck pain, ipsilateral Horner's syndrome and delayed ischemic symptoms. Diagnosis is given by ultrasound, transcranial Doppler, magnetic resonance imaging, magnetic resonance angiography and conventional angiography. Treatment of this type of injury includes anticoagulation therapy, antiplatelet therapy and surgery. We report a 14-year-old boy with internal carotid artery dissection who presented with ischemic stroke.

Antithrombotic drug treatment of pediatric patients with ischemic stroke

Causes of stroke in children include congenital heart malformations, sickle cell disease, infections, and metabolic disorders. Up to 80% of children with ischemic stroke have cerebrovascular disease, and case control studies demonstrate an association of ischemic stroke in children with hereditary prothrombotic risk factors. There have been no randomized, clinical trials for primary prevention, short-term treatment, or secondary prevention of pediatric ischemic stroke. Treatment recommendations are based on small case series or case reports, and have mainly been adapted from adult stroke studies. Antiplatelet agents (e.g. aspirin [acetylsalicylic acid]) and heparins (e.g. low molecular weight heparin), have been used on an individual patient basis. Warfarin is administered in children with cardioembolic stroke, arterial dissection, or persistent hypercoagulable states. Alteplase has been used in a few patients within 3 hours of the onset of symptoms. In each patient treated the benefit of anticoagulation has to be weighed up against the individual bleeding risk.

Ischaemic stroke from dissection of the craniocervical arteries in childhood: report of 12 patients

Dissection of craniocervical arteries is the most common non-atherosclerotic cause of stroke in young adults. During childhood, it is described primarily as isolated reports. Among 59 patients with arterial ischaemic stroke seen consecutively in the same institution, 12 had a dissection of a cervical or cerebral artery. The diagnosis was established through imaging features. The dissection involved the cervical arteries in five patients and intracranial arteries in seven. A cervical or facial trauma preceded the onset of cerebral ischaemic symptoms in four patients with extracranial dissection by a few minutes to 10 days. For another six patients, the stroke occurred during physical exertion. The neurological deficit was preceded or associated with an intense headache or neck pain in nine patients. Initial treatment consisted of anticoagulation therapy in two patients with extracranial dissection, and aspirin in nine. There was only one recurrence of stroke after a mean follow-up of 3 years and 6 months. Four patients had persistent disabling neurological deficit. Dissection of cervical or cerebral arteries appears to be a common cause of stroke in childhood.

Arterial strokes in children

Pediatric stroke has received special attention in the recent literature. It is now recognized as an important cause of mortality and morbidity in pediatric population. Varied and poorly specific symptomatology as well as overlapping risk factors makes the diagnosis of stroke in childhood challenging. Therapy remains controversial. The use of anticoagulation and thrombolysis in the management of acute stroke in children has not been systematically studied. In this article, we discuss the natural history, investigation, and treatment of pediatric arterial hemorrhagic and ischemic strokes.

Stroke and the child's brain: an overview of epidemiology, syndromes and risk factors

Childhood stroke is emerging as a serious and frequent disorder. In contrast to adult stroke, the study of childhood stroke is in a very early stage of research development with no randomized controlled trials conducted to date outside of sickle cell stroke. The results of research in adults have limited applicability to children with stroke due to fundamental age-related differences in the neurological, cerebrovascular and coagulation systems. In recent years clinical and basic research studies have improved our understanding of childhood stroke. Population-based studies have resulted in an increased awareness of the frequencies and features of stroke syndromes in children. Cohort and case-control studies have led to an enhanced understanding of the multiple risk factors underlying childhood stroke. Advances in neuroimaging and in genetic and other laboratory testing approaches have resulted in an increased definition of stroke subtypes and risk factors.

Diagnosis and treatment of ischemic pediatric stroke

Tremendous progress has been made in the diagnosis, prevention, and treatment of pediatric stroke. With a complete investigation, stroke etiology can be determined in most children, and multiple factors are commonly identified. Stroke can be prevented in some children and treated in others. Children at risk for recurrent strokes can be treated effectively. The prognosis after pediatric stroke is usually good, but today we can identify and initiate treatment in selected patients at risk for long-term problems. This article reviews recent advances in the identification, prevention, treatment, and outcome in pediatric ischemic stroke.