A Viable Strategy in the Era of Suggested Thrombolysis for "Brain Assaults" and Acute Stroke in Children

Melissa Shroff^*
*Correspondence: Melissa Shroff, Department of Paediatrics, University of Western Ontario, London, Canada, Email:

Keywords

Brain assaults • Acute stroke • Thrombolysis

Introduction

According to the Stroke Association, stroke affects over 400 children annually in the UK, making it at least as prevalent as brain tumors. Acute focal neurological disorders with imaging evidence of cerebral infarction in a corresponding arterial distribution are known as arterial ischaemic stroke (AIS) and hemorrhagic stroke (HS), respectively. While AIS-related deaths are uncommon, more than half will suffer long-term motor and cognitive impairments1. The 2017 RCPCH Stroke in Childhood guideline makes evidence-based recommendations for treating AIS and HS.

Description

Acute focal neurological dysfunction (such as lateralized weakness, difficulty speaking, or altered consciousness) is referred to as a "brain attack." Non-stroke disorders, or "stroke mimics," account for up to 50% of childhood brain attacks1. Meningitis/meningoencephalitis, acute disseminated encephalomyelitis, intracranial hypertension, and tumors are all examples of these conditions. Exclusion diagnoses include migraine, Todd's paresis (post-ictal paralysis), and functional neurological symptoms. A stroke-related brain attack is rare but urgent, necessitating immediate homeostasis and differentiation from mimics in order to consider brain-saving hyperacute therapies or other life-saving interventions. History and examination can help determine the cause, but they can't always tell the difference between stroke and mimic. For instance, the most common AIS and HS presentation is hemiparesis; however, 20-30% of children who are acutely hemiparetic will be diagnosed with a condition other than stroke1, indicating that imaging is necessary for an accurate diagnosis [1,2].

In childhood, HS is at least as prevalent as AIS, and the majority of cases reveal underlying vascular abnormalities (such as arteriovenous malformation, arterial aneurysm, or cavernous malformation). Sickle cell disease (SCD) and moyamoya are two additional vascular risk factors. HS is a symptom of factor X and XIII deficiency, a "rare coagulation disorder," and severe congenital hemophilia. Glanzmann's thrombosis, alpha 2-anti plasmin deficiency, and factor XIII deficiency are rare autosomal recessive conditions that cannot be detected by full blood count or coagulation screening and ought to be taken into consideration when there is parental consanguinity1. In immune thrombocytopenia, HS is a significant cause of morbidity and mortality. A paediatric haematologist should be consulted for suspected rare heritable bleeding disorders and abnormal haematology results. Administration of a blood product or factor, extended diagnostic investigations, and possibly referral to a paediatric haemophilia service are all options for management. All HS necessitate immediate neurosurgical discussion about transfer and treatment (such as hemorrhage evacuation). When weighing the risks and benefits of recurrence versus endovascular, surgical, or conservative treatment, a specialized neurovascular multidisciplinary team should evaluate each malformation individually [3,4].

A cerebral ischaemic stroke is defined as "acute focal neurological dysfunction caused by focal infarction at single or multiple sites of the brain" by the 11th International Classification of Diseases (ICD 11). Symptom duration that lasts longer than 24 hours or neuroimaging or another technique in the brain's clinically relevant region may provide evidence of acute infarction. Similar in definition, the term "transient ischaemic attack" (TIA) refers to a condition in which symptoms subside within 24 hours and there is no evidence of acute focal infarction. When these are applied to childhood AIS, there are a few caveats. While the majority of cases present as focal neurological manifestations, younger children may exhibit diffuse characteristics, such as encephalopathy. Because children's brain infarction is known to be linked to transient focal neurological dysfunction, the term "classical" TIA is not as useful (unless used in conjunction with an established vascular diagnosis). A stroke in a child is essentially a diagnosis made by radiology and supported by clinical suspicion. It is essential to provide meaningful definitions of childhood AIS to emphasize that stroke is not "just an adult disease" [5].

The rare primary inflammatory condition known as childhood primary angiitis of the central nervous system (cPACNS) affects cerebral arteries without causing systemic inflammation. The presentation includes both diffuse and focal neurologic deficits, such as headache, cognitive dysfunction, and behavioral change. In most cases, blood inflammatory markers don't stand out; Pleocytosis and/or elevated protein levels may be seen in the CSF. A brain MRI reveals white and/or grey matter lesions that are either widespread or focal; Stenoses of large vessels can be detected by MRA. Cerebral CA, like MRA, cannot detect disease in small vessels, but it can suggest vasculopathic features in large and medium vessels. In order to confirm vessel wall inflammatory infiltration, brain biopsy is frequently required, particularly in cases where angiography was negative. Secondary prevention and radiological surveillance strategies are determined by the aetiology, which influences the risk of repeat injuries. Arteriopathy is notable as a strong predictor of recurrence, especially if it is progressive or moyamoya. Aspirin is the first line of prevention, with the exception of SCD, for a time frame that regional teams recommend. A recurrence-free diagnosis may be avoided if early virologic confirmation of varicella vasculitis informs adjunct aciclovir and/or corticosteroid therapy [6,7].

Revascularization surgery lowers the risk of AIS for the long term in moyamoya patients who have recurrent clinical events or radiological progression. In cerebral vasculitis, immunomodulation may be used to reduce inflammation. Aspirin was found to be superior in the Cervical Artery Dissection in Stroke Study (CADISS, 2019) to heparin or warfarin. But in VA dissection, early recurrence on antiplatelet agents is common, and antithrombotic therapy frequently needs to be increased. After a joint cardiology-neurology discussion regarding the risk of intracranial hemorrhage versus further AIS, anticoagulation may be used in cardioembolic AIS. In SCD, rates of second stroke have been reported as high as 90% without secondary prevention1. Regular isovolemic exchange or top-up blood transfusion promotes cerebral oxygenation and reduces the risk of hyperviscosity and pronounced fluid shifts by maintaining sickle haemoglobin levels below 30% and above 9 g/dL. In cases of recurrent stroke or worsening vasculopathy that do not respond to conventional hemorrhagic treatment, haematopoietic stem cell transplantation (HSCT) may be an option. With additional neurocognitive testing and TCD in SCD, radiological surveillance for silent infarction/vessel progression typically consists of MRI/A at intervals determined by aetiology. CA is typically used to clarify a diagnosis or inform surgery. As some carry an increased risk of stroke into adulthood, modifiable risk factors like iron deficiency and lifestyle risk factors like obesity, smoking, and inactivity should be addressed. The majority of children with AIS leave the hospital, enroll in regular school, and eventually live on their own. It is erroneous to believe that children recover from strokes "better" than adults; rather, children "grow into" their deficits, limiting their capacity to learn new skills. Depressed levels are associated with increased mortality and neurological morbidity, making conscious level the best predictor of serious stroke outcome. Implementation of guidelines presents a chance to improve prospects for many. emphasized in "Brain attack": a childhood emergency, Ganesan3 looks at how upscaling stroke to an emergency by using the suggested routes for prompt triage, diagnosis, and transfer would probably also help many people who have brain attacks that aren't strokes [8,9].

Pediatric stroke patients can learn a lot from the adult experience. The government's "Act FAST" media campaign made people more aware of strokes, and including children in such health campaigns may be beneficial. Additionally, a mental shift is required. Recanalization therapies were used to change adult stroke from an untreatable emergency to one that could be treated. Existing time-critical concepts, such as the "golden hour" in pediatric sepsis and neonatal resuscitation, could be applied, despite the lack of evidence based on paediatric trials. Participating centers were able to increase their "stroke readiness" despite the collapse of TIPS by establishing a dedicated team, protocols, and access to sedated MRIs round-the-clock. The stroke guideline of 2017 provides a crucial framework for the implementation of similar pathways. It is anticipated that shorter diagnostic delays will be helped by faster MRI scanning times. It is necessary for healthcare professionals to continue their education and training.

Conclusion

This could include scenario inclusion in paediatric life support courses, certified PedNIHSS training, and an acute pathway simulation. With the way children's healthcare in the UK is currently structured, it is unrealistic to expect the development of pediatric HASUs. Using the resources and networks at their disposal, pediatricians, adult stroke specialists, and tertiary neuroscience services will increasingly be required to collaborate. The guideline is still the best evidence, but its application requires constant attention. Collins, Sawaragi, and Others Over the course of six months, 2020) retrospectively audited guideline implementation in a tertiary pediatric hospital with an A&E. PedNIHSS was calculated in six (9%) of the 65 children with a possible stroke, and urgent neuroimaging was performed in three (5%). Concerns about radiation exposure and a lack of familiarity with the PedNIHSS were hypothesized as contributing factors4. The small number of patients poses a challenge to research; As a result, patient registries and high-quality audits are probably the most likely means of expanding the evidence base right now [10].

Acknowledgement

None.

Conflict of Interest

None.

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