Pediatric stroke guidelines stress differences from adult treatment

Key Points

The management of stroke in children is significantly different from the approach recommended for adults, according to the first published pediatric stroke guidelines. The new recommendations of the American Heart Association (AHA) Stroke Council were unveiled in the Online First issue of Stroke and will be in the September issue of Circulation.

"We must be cautious when applying our knowledge of stroke in adults to children with stroke, important differences remain between pediatrics and adults – not the least of which is the dose and schedule of the drugs themselves," guidelines lead author E. Steve Roach, MD, professor of pediatrics and neurology at Ohio State University College of Medicine and chief of child neurology at Nationwide Children's Hospital, wrote.

In recognizing the major roadblocks in the management of pediatric stroke, the document highlights recommendations to prevent ischemic stroke related to sickle cell disease (SCD), moyamoya disease, cervicocephalic arterial dissection (CCAD), and cardiogenic embolism. Suggestions for management of hemorrhagic stroke are also provided.

According to the guidelines, acute management of ischemic stroke resulting from SCD should include optimal hydration and correction of hypoxemia and systemic hypotension. Periodic transfusions to reduce the percentage of sickle hemoglobin are effective in lowering stroke risk in children 2 to 16 years of age with abnormal transcranial Doppler (TCD). Hydroxyurea may be considered in patients with SCD and stroke who cannot continue on long-term transfusion.

Accounting for about 6 percent of childhood strokes in Western countries, moyamoya syndrome is often characterized by chronic progressive stenosis of the distal intracranial internal carotid artery (ICA). Surgical revascularization procedures are useful to effectively reduce the risk of stroke resulting from moyamoya disease. According to the guidelines, antiplatelet agents such as aspirin may be considered in patients with moyamoya after revascularization surgery or in asymptomatic individuals for whom surgery is not anticipated. Anticoagulants such as warfarin are rarely initiated because of the difficulty in maintaining therapeutic levels in pediatrics and the risk of hemorrhage after inadvertent trauma; however, low molecular weight heparin (LMWH) has been used.

For medical treatment for extracranial CCAD, the guidelines advocate initiating either unfractionated heparin (UFH) or LMWH as a bridge to oral anticoagulation. It is reasonable to treat a majority of these patients with either subcutaneous LMWH or warfarin for three to six months. Alternatively, an antiplatelet agent may be substituted for LMWH or warfarin. The guidelines do not recommend anticoagulation in children with an intracranial dissection or SAH resulting from CCAD.

In children with stroke and heart disease, therapy for congestive heart failure is recommended in the guidelines. For patients with cardiac embolism with a high risk of recurrent embolism, either UFH or LMWH is indicated while warfarin therapy is initiated and adjusted. In these patients, therapy with either LMWH or warfarin may continue for at least one year.

Costello noted that the guidelines outline protocols for dosing schemes and monitoring recommendations for UFH, LMWH, and warfarin in pediatrics. The guidelines state that this information is primarily derived from an often-fragmented literature on pediatric stroke as well as the authors' experience with those medications over the years.