Review articleHemorrhagic Stroke in Children
Introduction
With an incidence of 2-3/100,000 children, stroke is among the top 10 causes of death in childhood [1], [2], and is as common as brain tumor in children [3]. A study of a California-wide hospital discharge database found an incidence rate of 1.1 per 100,000 person-years for hemorrhagic stroke and 1.2 per 100,000 person-years for ischemic stroke [4]. Thus, nearly half of pediatric strokes are hemorrhagic. Typically, the term hemorrhagic stroke includes spontaneous intraparenchymal hemorrhage and nontraumatic subarachnoid hemorrhage (Fig 1). Patients with traumatic intraparenchymal hemorrhage, primary subdural or epidural hematomas, or hemorrhagic transformation of ischemic stroke are usually not considered to have a hemorrhagic stroke [5], [6]. For the purposes of this article, we will focus on intraparenchymal hemorrhage, the most common type of hemorrhagic stroke. Nontraumatic subarachnoid hemorrhage is most often due to intracranial aneurysm and is evaluated and treated differently, though like intraparenchymal hemorrhage, recommendations for childhood subarachnoid hemorrhage are based on the adult literature. Two recent pediatric intracranial aneurysm case series and reviews of the literature are available [7], [8].
Pooled data from retrospective cohort studies and case series suggest that overall mortality from hemorrhagic stroke is approximately 25% in children; significant disability is present in 42% of those who survive [6]. Despite the public health impact of childhood hemorrhagic stroke, there are no management or treatment guidelines [4], [6], [9]. In contrast, two consensus papers provide guidelines for the evaluation and treatment of arterial ischemic stroke in childhood, although clinical trials are still lacking [10], [11]. Only one prospective cohort study of children with stroke included hemorrhagic stroke [12]. Additional literature consists primarily of case series and retrospective cohorts (Table 1); hence, there are limited data on risk factors, time to presentation, clinical-radiologic correlation, outcome, and recurrence. There are no proven or widely accepted strategies for acute management or diagnostic evaluation of intraparenchymal hemorrhage in childhood, and limited data exist on the risks vs benefits of existing treatment approaches. Current practices are based on experience and extrapolation from the few adult intraparenchymal hemorrhage clinical trials. However, because intraparenchymal hemorrhage in adults is most commonly caused by hypertension or amyloid angiopathy [13], the application of adult data in children is highly questionable. Unfortunately, clinicians treating children with intraparenchymal hemorrhage must extrapolate from the adult literature for diagnostic and treatment strategies [14].
Section snippets
Methods
A search of Medline and Embase (from 1966 to June 2006) was conducted with the following MESH search terms: “Cerebral hemorrhage AND child AND cerebrovascular accident.” Additional non-MESH searches were conducted using search terms “hemorrhagic stroke, intracerebral hemorrhage, intraparenchymal hemorrhage, children, spontaneous.” Searches were limited to humans. Additional articles were identified by reference review. Titles that suggested a paper about hemorrhagic stroke or intraparenchymal
Results
The prospective stroke registry in Dijon, France is the only prospective cohort study that met the criteria [12]. No treatment trials were found. All remaining studies were retrospective cohorts, case control studies, and case series.
Discussion
This review attempts to synthesize existing literature on hemorrhagic stroke in childhood. Studies published in English that included patients with hemorrhagic stroke are listed in Table 1 with information about study design, number of participants, mortality, and neurologic outcome. Table 2 summarizes the etiologies reported in these studies; this is clearly a heterogeneous group of studies with different methodologies, study populations, and inclusion criteria. The tables serve best as
Conclusion
While research in arterial ischemic stroke and cerebral venous sinus thrombosis is expanding, hemorrhagic stroke in children remains largely unstudied. Perhaps this should not be surprising; as recently as 1999, the American Heart Association Stroke Council formed a task force to recommend areas of “desperately needed” research in adult intraparenchymal hemorrhage [14]. Intraparenchymal hemorrhage remains the only stroke subtype in adults without a clearly defined treatment, though many
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