What causes an Ischemic Stroke in a child?

When we discuss causes of a stroke in childhood,  we're actually discussing risk factors for childhood stroke.  A risk factor is something that may increase the likelihood of a disease, condition, or injury.   Listed below are risk factors that may be associated with stroke in a child.  Even though a risk factor may be identified, this does not necessarily mean that the risk factor is what caused the stroke.

The cause of stroke in children is unknown in one-third of cases.  The most common reported risk factors for stroke in children include cardiac disorders, sickle cell disease, coagulation disorders, arterial dissection, moya moya, infection, and other rare genetic disorders.

Cardiac disorders or heart diseases are the most common cause of ischemic stroke in children and account for up to 50% of strokes in case series. The risk of stroke in children with congenital heart disease is related to the abnormality, diagnostic and surgical procedures, and associated genetic or acquired factors that predispose children to thrombosis. Cardiac disorders can lead to the development of intracardiac thrombi that may embolize to the brain or can lead to thrombosis in cyanotic patients with anemia.

Blood disorders are the second most common cause of stroke in children.  Several blood disorders associated with stroke in children include:

• Sickle cell disease is the most common cause of stroke in African American children. The recurrence risk for this group is very high.

• Coagulation disorders can lead to a tendency to clot or hemorrhage.  The risk of stroke seems to be greatest among children who have a combination of genetic factors. Multiple factors are associated with a heightened risk of thrombosis and recurrence.

Infectious Disorders

• Meningitis and encephalitis were among the most common risk factors in children hospitalized with stroke in California between 1991 and 2000.

• Varicella infection, also known as chicken pox, has been associated with stroke in children. The prevalence of stroke among children who have chicken pox is estimated to be between one in 6,500-15,000 children.

• Brain abscess, sepsis, HIV, infection with Mycoplasma pneumoniae, and parvovirus B19 infections

Vascular Disorders - 23% of children with arterial ischemic stroke in one study (1)

• Moya-Moya disease is a chronic non-inflammatory occlusive intracranial vasculopathy of unknown cause.  

• Arterial dissection, a common cause of stroke in children, is usually due to trauma.

Rare disorders. Over 100 different risk factors for stroke in children have been reported in the literature.

What causes a Hemorrhagic Stroke in a child?

When we discuss causes of a hemorrhagic stroke in childhood,  we're actually discussing risk factors for hemorrhagic childhood stroke.  A risk factor is something that may increase the likelihood of a disease, condition, or injury.   Listed below are risk factors that may be associated with hemorrhagic stroke in a child.  Even though a risk factor may be identified, this does not necessarily mean that the risk factor is what caused the stroke.

Vascular malformations, blood disorders and malignancy have been identified as risk factors in children who have a hemorrhagic stroke.

• Vascular malformations, including arteriovenous malformations (AVMs), aneurysms, and cavernous malformations are the most common risk factors for children with hemorrhagic stroke.

• Blood disorders, including thrombocytopenia, leukemia, SCD, and coagulopathies have been identified in some children with hemorrhagic stroke.  Acquired thrombocytopenia and coagulopathies were the most common blood risk factors in one report.

• Intracranial tumors, including medulloblastomas and primitive neuroectodermal tumors, have been identified in cases of children who have a hemorrhagic stroke.

Journal Articles

Clinical and radiological recurrence after childhood arterial ischemic stroke. Nov. 14, 2006. UK

Perinatal stroke in Saudi children. Clinical features and risk factors. March 2006, Saudi Arabia

Evolution of cerebral arteriopathies in childhood arterial ischemic stroke. January 2006, UK.

Ischemic stroke in childhood and adolescence. A study of 46 cases in the south of Brazil. Dec. 2005, Brazil.

Pediatric stroke: the child is not merely a small adult. August 2005. Boston.

A proposed classification for subtypes of arterial ischaemic stroke in children.  April 2005, UK.

Cerebrovascular disorders in children. March, 2004. Lynch, NINDS, Maryland.

Risk factors for pediatric cerebrovascular disease This article by Dr. E. S.  Roach, lists different types of congenital heart disease, acquired heart disease, hematologic disorders and coagulopathies, systemic vascular disease, vasculitis, structural anomalies of the cerebrovascular system, vasculopathies, vasospastic disorders, and trauma as possible risk factors for pediatric stroke.

Recognition and Treatment of Stroke in Children  Informative overview of causes and treatment of stroke in children

Emergency department presentations of cerebrovascular disease in children

Risk factors for arterial ischemic stroke in childhood. June 2004. UK.

Pediatric stroke among Hong Kong Chinese Subjects. The incidence of stroke among Chinese children was slightly lower than that in Europe or North America. The etiologic pattern was different in our cohort, and there was no sickle cell anemia, thrombophilia, or sinovenous thrombosis. Despite these differences, however, mortality and long-term neurologic deficit rates were similar.  August 2004. Hong Kong. Chung, Wong.

The recurrence risk of ischemic stroke in childhood (neonatal infarction not included in study). May-June 2004. Belgrade

Cerebral infarcts in a pediatric patient secondary to phenylpropanolamine, a recalled medication. April 2004. Delorio. Oregon.

Cerebrovascular disorders in children. March 2004. NINDS, Maryland.

Ischaemic stroke subtypes in children and adults, April 2003. UK

Causes Of Paediatric Ischaemic Stroke Different From Adult Stroke DGReview of Ischaemic stroke subtypes in children and adults, March, 2003

Stroke in children. Aug. 2003. India. Gulati. Overview of information on stroke in children.

Cerebrovascular stroke as a sign of atrial myxoma in childhood, March 2003

Investigation of risk factors in children with arterial ischemic stroke. Feb., 2003, United Kingdom

Report of the National Institute of Neurological Disorders and Stroke workshop on perinatal and childhood stroke 2002

Prospective assessment of risk factors for recurrent stroke during childhood--a 5-year follow-up study. Nov. 2002, Germany.

Neurologic manifestations of iron deficiency in childhood, Aug. 2002, Canada

Deaths from stroke in US children, 1979 to 1998. July 2002. California.

Minor head injury as cause and co-factor in the aetiology of stroke in childhood, July 2002. Germany.

Arterial ischemic stroke in childhood: the role of plasma-phase risk factors April 2002

Stroke and the child's brain: an overview of epidemiology, syndromes and risk factors April 2002

Reversible vascular changes in children with cerebral infarction Jan. 2002

Cerebrovascular disease in childhood and adolescence. Ischaemic cerebral accidents. Jan 2002. Argentina

Etiology of stroke in children. 2000. Dallas

Risk factors for arterial ischemic stroke in children. May 2000. UK

Stroke in children: genetic and metabolic issues May 2000. New York

Spontaneous carotid and vertebral artery dissection in children Sept. 2001

Ischemic cerebrovascular stroke of arterial origin in the child October 2001

Arterial dissection and stroke in children October 2001

Intracranial aneurysms in Ehlers-Danlos syndrome type IV in early childhood October 2001

Genetics and ischaemic stroke Sept. 2000,UK

Family Study of Young Stroke A Study of the Inheritance of Stroke

Genetic risk factors of thrombophilia in ischaemic childhood stroke of cardiac origin. A prospective ESPED survey Dec. 1999

Subtypes of ischemic stroke in children and young adults. Dec. 1997. Indiana

Ischemic strokes in children Ischemic stroke is an uncommon, but significant cause of disability in childhood. 1997

Iron deficiency: a cause of stroke in infants and children. Jan. 1997. Canada.

Hereditary and acquired risk factors for childhood stroke. Oct. 1994. Finland.

Mendelian etiologies of stroke. August 1987. Philadelphia.

(1) Ganesan, V, Prengler, M, McShane, MA, et al;  Investigation of risk factors in children with arterial ischemic stroke.  Ann Neurol 2003, 53:167-173.

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