Perinatal and infantile Stroke-FAQ

Here are our answers to all the frequently asked questions.
Because we believe that only the widespread and scientifically validated knowledge of Strokes affecting infants and children can help science evolve and families not to lose hope.

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What is stroke?

Stroke (often referred to as the Anglo-Saxon "stroke") occurs when blood flow to the brain is blocked by obstruction or by rupture of a blood vessel.

In the first case we talk about Ischemic stroke, in the second of Hemorrhagic stroke. In the case of a hemorrhagic stroke the situation is quicker as an onset, with often more severe outcomes and with a higher risk of fatal outcomes.

When it comes to perinatal stroke (fetal/prenatal and Neonatal) – Pediatric/infantile – juvenile?

Contrary to what most people believe, stroke can also affect babies and infants even before birth.

You define Perinatal Stroke Stroke occurring in the last 18 weeks of gestation until the first 30 days after birth. Other terms for this age group include "fetal", "prenatal" for the period before birth, ' neonatal ' for that occurring in the first month of life. Finally, it is called "presumably perinatal" the one identified later but that on the basis of the neuroradiological and clinical features probably occurred within the first month of life.

You define Pediatric Stroke (or infantile) that occurred between 1 month of life and 18 years, Juvenile stroke That occurred between 18 and 35 years ca. 

How common is stroke in the infant and child?

Most strokes in children under the age of 18 occur in the perinatal period.

To the surprise of many, the most "risky" days of ischemic stroke in a man's life correspond to the first week of life.

Previous estimates reported an incidence of about 1 for 3000 live births. However, the most recent studies suggest that the risk may even reach 1:1000 births. Its incidence in subjects aged 28 days and 18 years is estimated between 2 and 13 of 100,000 children per year (not so rare, just think that this incidence is comparable to that of childhood brain tumors).

What are the main causes and risk factors of stroke in children?

The causes of stroke in children are largely unknown and depend on the age of the child, more than 100 risk factors are estimated for this category of patients.

The main risk factors for stroke are:

  • Congenital heart disease but also acquired heart disease (especially when associated with heart valve damage)

  • Genetic pathologies (e.g. vascular wall anomalies)

  • Abnormalities in blood coagulation (especially for bleeding forms)

In the case ofPre-natal or perinatal stroke, the above mentioned risk factors add more specific ones such as:

  • Disorders in the functioning of the placenta

  • Premature birth or small infant for gestational age

  • Alterations of coagulation or autoimmune diseases in the mother

  • Severe hypoglycemia of the newborn or infections

  • Complications during childbirth (less than 10%)

In the case ofStroke in older children and young people Other risk factors are:

  • Head trauma

  • Autoimmune diseases

  • Sickle cell anemia

  • Infections (especially chickenpox, but also other viral and bacterial forms)

  • Leukemias and tumors (especially brain tumors)

How can you manifest stroke in the newborn?

In the newborn the stroke can manifest with tremors at one side of the body, in II-III day of life, sometimes associated with Apnee. In Many cases these symptoms are not recognized, sometimes even absent, and stroke by self-sign several months later when the child begins to initially present a preferential use of the limb "spared" until a frank hemiparesis of the Limb " Hit. " In These cases the diagnosis of stroke is delayed and the "presumably perinatal stroke" is spoken.

How can you manifest the stroke in the child?

In the infant and in the smaller child the Clinical symptomatology It may be nonspecific and accompanied by modest focal clinical manifestations such as convulsions, fever, irritability or headache, dystonias, and alteration of the sensorium. In the second childhood and later ages the prevailing clinical presentation consists, however, in a focal acute neurological deficit, such as an emiparesis, associated or not with convulsive phenomena.

In addition to the age of the child, clinical symptomatology is related to the vascular territory involved. The most commonly affected district is the middle cerebral artery.

How do you diagnose strokes in your child and newborn?

The diagnosis of stroke always requires a thorough evaluation of both the clinic and the Neuroradiological examinations by a specialist.

Once the symptoms are recognized, in fact, it is necessary to diagnose the acquisition of images of the brain (neuroimaging).

The best methodical to date is the magnetic resonance imaging (MRI). This method is without radiation (and therefore safe), and optimal for the differential diagnosis of stroke, however it takes rather long time and is not available in all hospitals.

Other types of images such as computed tomography (commonly referred to as TC) or transfontanellar ultrasonography (in infants), available in most hospitals, may suggest a stroke even if the MRI remains usually necessary. 

What are the recommended post-stroke therapies?

With regard to treatment, in the case of ischemic stroke the objective will be the reperfusion of the brain tissue by removing the obstacle, however the drugs now widely used in the adult (thrombolytics) are not recommended to date in the child and They require large-scale clinical studies (due to possible side effects related to their use and the strict suitability of use criteria).

There are some conditions requiring specific treatment such as sickle cell anemia or vasculitis.

In the case of hemorrhagic stroke the first objective will be to stop bleeding once the cause is identified (whether it is a vascular malformation or a problem of alteration in the coagulation...). Moreover, if there is blood flooding inside the ventricles – the main complication to be prevented or treated prematurely is hydrocephalus (excessive accumulation of fluid within the brain), in which case it is often necessary to intervene with The insertion of a small probe, which makes the excess liquids flow.

Alongside these treatments proper to the acute phase, the therapies recommended for children and young people, provide rehabilitation programs to adapt to age (physiotherapy, psychomotricity, speech therapy) and to integrate with a plan of activity to be carried out at home, In the family environment.

This type of treatment is fundamental to allow an adequate functional recovery of the brain areas involved (i.e. the recovery of the functions that the brain performed before the stroke occurred) and stimulate the brain plasticity (i.e. the Ability of surviving nerve cells to vicariate/replace the function of the Lost ones).

Is it possible to prevent stroke in infants and children?

Prevention depends on the type of stroke and the age of onset.

As far as perinatal forms are concerned, since it is not yet well identified the cause in most cases, it is not possible to identify which mothers or infants are at risk. As a result, there are no preventive measures that can be considered effective at the moment.

There is therefore, in most cases, no wrong behaviour of mothers during pregnancy, which may have caused or favored stroke in the child.

As regards infantile and paediatric forms, they are considered preventive:

  • Vaccinations (reducing the risk of post-infectious stroke)

  • The early identification of subjects at risk (children with sickle cell anemia or other genetic diseases predisposing ischemic stroke and on the other hand coagulopathies e.g. hemophilia, for hemorrhagic stroke) and implementation of specific preventive measures To the underlying pathology, where provided.

What kind of consequences or disabilities can cause stroke?

Stroke is a brain injury. Therefore, it is possible that in the long term it can go to compromise any area of brain function and therefore any of its functions. The consequences of brain damage due to stroke depend on the location and extent of the damage, as well as the age at which it occurred.

It is important to remember that the development of the brain of a child is an extremely rapid process especially in the first two to three years of life but remains constantly evolving and this evolution continues for many years.  This also means that some brain activity develops, in the individual that is growing, over the years (e.g. logical reasoning, computing skills, attention, ability to plan) and for this reason can emerge Some functional deficits (i.e. some gaps/deficiencies in specific brain areas). As a result, difficulties could only be recognized around the time when the different skills should develop.  For example, complex learning (such as calculus) is usually not learned until school, so difficulties in this area may not be recognized for many years.

Although recent studies have improved our ability to test and predict possible long-term disabilities, even at the time of diagnosis, also in the clearest cases, the doctor may actually provide only a number of possible outcomes. Each child will then write his story, thanks to the external stimuli and his genetic outfit.

Considering globally perinatal and child forms the main consequences that stroke can cause are:

  • Reduced motor and coordination skills

  • Impaired learning Skills

  • Epilepsy

  • Difficulties in language

  • Difficulty in feeding

  • Irritability, alterations of the psychic sphere as well as alteration of the sleep-wake Rhythm

  • Disturbances in the view

What are the main differences between stroke in children and stroke in adults?

Stroke in adults presents risk factors such as high blood pressure, smoking, diabetes, arteriosclerosis, obesity and high cholesterol that can be largely reduced through a healthy lifestyle and good habits. In the case of children the risk factors are more complex, less known and more difficult to preventable.

The symptoms in the child and even more in the newborn are more difficult to recognize; The infant and the infant can not communicate symptoms that are often not easily visible (drowsiness, marked inconsolability, poor sucking ability, etc.).

There are still today average times of diagnostic delay ranging from 24 hours in paediatric forms to a few months or years in perinatal forms.

Is there an increased risk for a child who has had a stroke to have others during his childhood?

The risk of "recurrence" (i.e. having new strokes) in a child who had a first occurrence depends on the underlying cause.

In most perinatal forms, the risk is extremely reduced (much less than 1%) and after the first year of life it becomes practically overlapping with that of the other children. Different is the case where they remain alterations of the vessels of the Brain (shrinkments) in which, in some cases it may be necessary a tighter monitoring and any preventive measures.

There are rare perinatal forms due to predisposing genetic diseases, in these cases the risk of recurrence depends on the pathology itself.

As regards paediatric forms, the risk of recurrence depends on the underlying cause.

Also in this case in the forms due to genetic diseases predisposing the risk of recurrence depends on the pathology itself.

In post-infectious forms, however, the risk of recurrence is usually limited to the first 6 months after the first stroke.

If I have a child with a perinatal stroke is there a risk that this situation will reoccur in other children?

The risk of recurrence of stroke in infants/subsequent pregnancies is extremely low.

Few studies have addressed this problem, but the current evidence suggests that the risk to the same parents who are otherwise healthy is probably much less than 1%.

How important is the plasticity of the brain?

It is certainly true that "young brains" respond differently to injuries such as those caused by stroke.

However, the mechanisms through which these responses take place are still being studied.

Recent studies indicate that the adaptation of the developing brain after a pediatric stroke and even more perinatal allows the recovery of some functions, but with regard to other functions this is not possible. A better understanding of these mechanisms will allow to develop new treatment strategies.

 

Milano, Last updated: April 2019

Thanks to the scientific validation of this information the team of physicians belonging to the Board of Www. FightTheStroke . org.

 

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