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Therapy in pediatric stroke
B Simma1, I Höliner, J Luetschg
1Department of Pediatrics, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch 6800, Austria. burkhard.simma@lkhf.at
Insights
Pediatric stroke management lacks consensus, with guidelines differing globally. Acute anticoagulation is recommended, but long-term treatment and thrombolysis use remain debated.
Area of Science:
- Pediatric Neurology
- Cerebrovascular Diseases
- Clinical Management
Background:
- Pediatric stroke is an underestimated condition with an incidence comparable to pediatric brain tumors.
- Etiologies are diverse, including vasculopathies, congenital heart diseases, and coagulopathies.
- Current therapeutic guidelines are largely extrapolated from adult studies and are controversial.
Purpose of the Study:
- To review and summarize existing literature on the therapy and management of cerebrovascular insults in children and adolescents.
- To highlight the current gaps in evidence and consensus regarding pediatric stroke treatment.
Main Methods:
- Systematic literature search of MEDLINE, PubMed, and Cochrane Library.
- Inclusion of relevant bibliographies and adult stroke guidelines for comparison.
- Analysis of studies focusing on pediatric stroke incidence, etiology, and therapeutic interventions.
Main Results:
- Pediatric stroke incidence is estimated at 3-15 per 100,000 children annually.
- Antithrombotic therapy is recommended in the acute phase, but consensus on specific agents like aspirin or heparin is lacking.
- Thrombolysis is generally not advised outside clinical trials, though practice varies.
Conclusions:
- Therapeutic guidelines for pediatric stroke are based on expert opinion and vary internationally.
- Acute anticoagulation is widely agreed upon, but long-term secondary prevention strategies, including aspirin duration, require further investigation.
- There is a critical need for evidence-based guidelines tailored to pediatric stroke management.
Abstract:
The aim of this review is to summarize the existing literature on therapy and management of cerebrovascular insults in children and adolescents. As data sources, studies were identified by MEDLINE, PubMed, Cochrane Library, and relevant bibliographies for the topic "pediatric stroke." We also reviewed guidelines for "stroke in adults." As a result, pediatric stroke is underestimated. The annual incidence for all stroke entities (cerebral venous thrombosis and hemorrhagic and arterial ischemic stroke) is as high as for pediatric brain tumors, 3-15/100.000 children per year. A distinct etiology can be determined only in a minority of them. Underlying risk factors are multiple, mainly vasculopathies, congential heart diseases, coagulopathies, lipometabolic disorders, and sickle cell anemia. Current recommendations for therapy are based on adult studies, are preliminary, and discussed controversially. Antithrombotic therapy is uniformly recommended for the acute stage of pediatric stroke; no consensus exists on antiplatelet therapy with acetylsalicylic acid (ASA, aspirin) (5 mg/d), with ultra-fractionated or low-molecular-weight heparin. Thrombolysis using recombinant tissue plasminogen activator is not advised, despite the fact that current practice takes a different approach. None of the guidelines specify the duration of ASA for secondary prevention. Additional supportive therapy measures are osmotherapy and decompressive craniectomy. Oxygen in the absence of hypoxemia, intensive insulin therapy, antiepileptic drugs in the absence of clinical or electrographic seizures, corticosteroids, and GP-IIb/IIIa-receptor antagonists should not be used outside clinical trials. In conclusions, current therapeutic guidelines for pediatric stoke are still based on consensus and expert and society opinions and differ between countries. Consensus prevails on the need for acute anticoagulation using either antiplatelets or heparin. Long-term treatment with acetylsalicylic acid in all or only high-risk patients and for how long remains the subject of debate. Lifelong secondary prevention has never been investigated in children or adults. All guidelines agree that there is no indication for thrombolysis in children outside clinical trials, although clinical practice in large centers differs.
