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Management of Stroke in Neonates and Children: a Scientific Statement from the American Heart Association/American Stroke Association

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Management of Stroke in Neonates and Children: a Scientific Statement from the American Heart Association/American Stroke Association UCSF UC San Francisco Previously Published Works Title Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association. Permalink https://escholarship.org/uc/item/0sw5j7c1 Journal Stroke, 50(3) ISSN 0039-2499 Authors Ferriero, Donna M Fullerton, Heather J Bernard, Timothy J et al. Publication Date 2019-03-01 DOI 10.1161/str.0000000000000183 Peer reviewed eScholarship.org Powered by the California Digital Library University of California AHA/ASA Scientific Statement Management of Stroke in Neonates and Children A Scientific Statement From the American Heart Association/American Stroke Association The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Donna M. Ferriero, MD, MS, FAHA, Co-Chair; Heather J. Fullerton, MD, MAS, Co-Chair; Timothy J. Bernard, MD, MSCS; Lori Billinghurst, MD, MSc, FRCPC; Stephen R. Daniels, MD, PhD; Michael R. DeBaun, MD, MPH; Gabrielle deVeber, MD; Rebecca N. Ichord, MD; Lori C. Jordan, MD, PhD, FAHA; Patricia Massicotte, MSc, MD, MHSc; Jennifer Meldau, MSN; E. Steve Roach, MD, FAHA; Edward R. Smith, MD; on behalf of the American Heart Association Stroke Council and Council on Cardiovascular and Stroke Nursing Purpose—Much has transpired since the last scientific statement on pediatric stroke was published 10 years ago. Although stroke has long been recognized as an adult health problem causing substantial morbidity and mortality, it is also an important cause of acquired brain injury in young patients, occurring most commonly in the neonate and throughout childhood. This scientific statement represents a synthesis of data and a consensus of the leading experts in childhood cardiovascular disease and stroke. Methods—Members of the writing group were appointed by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee and were chosen to reflect the expertise of the subject matter. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge. This scientific statement is based on expert consensus considerations for clinical practice. Downloaded from http://ahajournals.org by on January 28, 2019 Results—Annualized pediatric stroke incidence rates, including both neonatal and later childhood stroke and both ischemic and hemorrhagic stroke, range from 3 to 25 per 100 000 children in developed countries. Newborns have the highest risk ratio: 1 in 4000 live births. Stroke is a clinical syndrome. Delays in diagnosis are common in both perinatal and childhood stroke but for different reasons. To develop new strategies for prevention and treatment, disease processes and risk factors that lead to pediatric stroke are discussed here to aid the clinician in rapid diagnosis and treatment. The many important differences that affect the pathophysiology and treatment of childhood stroke are discussed in each section. Conclusions—Here we provide updates on perinatal and childhood stroke with a focus on the subtypes, including arterial ischemic, venous thrombotic, and hemorrhagic stroke, and updates in regard to areas of childhood stroke that have not received close attention such as sickle cell disease. Each section is highlighted with considerations for clinical practice, attendant controversies, and knowledge gaps. This statement provides the practicing provider with much-needed updated information in this field. (Stroke. 2019;50:e00–e00. DOI: 10.1161/STR.0000000000000183.) Key Words: AHA Scientific Statements◼ cerebrovascular accident ◼ genetics ◼ infarction ◼ perinatal care ◼ thrombosis The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on October 15, 2018, and the American Heart Association Executive Committee on November 27, 2018. A copy of the document is available at https://professional.heart.org/statements by using either “Search for Guidelines & Statements” or the “Browse by Topic” area. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@ wolterskluwer.com. The American Heart Association requests that this document be cited as follows: Ferriero DM, Fullerton HJ, Bernard TJ, Billinghurst L, Daniels SR, DeBaun MR, deVeber G, Ichord RN, Jordan LC, Massicotte P, Meldau J, Roach ES, Smith ER; on behalf of the American Heart Association Stroke Council and Council on Cardiovascular and Stroke Nursing. Management of stroke in neonates and children: a scientific statement from the American Heart Association/American Stroke Association. Stroke. 2019;50:e•••–e•••. doi: 10.1161/STR.0000000000000183. The expert peer review of AHA-commissioned documents (eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit https://professional.heart.org/statements. Select the “Guidelines & Statements” drop-down menu, then click “Publication Development.” Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at https://www.heart.org/permissions. A link to the “Copyright Permissions Request Form” appears in the second paragraph (https://www.heart.org/en/about-us/statements-and-policies/copyright-request-form). © 2019 American Heart Association, Inc. Stroke is available at https://www.ahajournals.org/journal/str DOI: 10.1161/STR.0000000000000183 e1 e2 Stroke TBD 2019 uch has transpired since the last scientific statement on be at particularly increased risk for recurrent strokes in later Mpediatric stroke was published 10 years ago. Although life related to these processes. This emphasizes the impor- stroke has long been recognized as an adult health problem tance of promoting ideal vascular health through good diet, causing substantial morbidity and mortality, it is also an im- physical activity, and avoidance of tobacco products to protect portant cause of acquired brain injury in young patients, occur- them from recurrent strokes in adulthood. ring most commonly in the neonate and throughout childhood. This scientific statement represents a synthesis of data and a Epidemiology consensus of the leading experts in childhood cardiovascular Perinatal Stroke disease and stroke. Arterial ischemic infarction accounts for ≈80% of perinatal strokes. The remainder are caused by CSVT or hemorrhage Overview of Childhood and Perinatal Stroke (excluding subarachnoid hemorrhage [SAH] and intraventric- Introduction and Definition ular hemorrhage [IVH] in premature babies). Ischemic stroke The standard adult definition of stroke—an acute onset neu- occurs in up to 1 in 3500 newborns, although some estimates rological sign or symptom attributable to focal brain infarction are as low as 1 in 10 000 newborns.7–9 The ratio of ischemic or hemorrhage—applies to children as reflected by the National stroke is dramatically higher in newborns, almost 6 times Institutes of Health (NIH) Common Data Elements definition.1,2 greater than in older children.8 However, in the neonatal period, the acute presentation can be Agarwal and colleagues9 identified 60 individuals with missed. Thus, it is important for pediatric health professionals to perinatal stroke among a cohort of 208 876 live births. This be able to recognize stroke at different ages and to treat stroke represents a frequency of 29 in 100 000 live births, or 1 per to preserve brain function and to promote repair and recovery. 3500 live births. Their overall stroke rate for both ischemic and hemorrhagic stroke was 37 per 100 000 live births, or 1 9 Classification per 2700 live births. 10 There are different ways of characterizing pediatric stroke. Armstrong-Wells et al identified 19 infants with hem- One is by age: Stroke occurring from 28 weeks’ gestation to 28 orrhagic stroke and 1 with SAH among 323 532 live births postnatal days of life is broadly classified as perinatal stroke, in the Northern California Kaiser-Permanente Medical Care and stroke occurring after 28 days to 18 years of age is clas- program, representing a population prevalence for perinatal 11 sified as childhood stroke. Within perinatal stroke, mode of hemorrhagic stroke of 6.2 per 100 000 live births. Cole et al calculated the incidence of perinatal hemorrhagic stroke as Downloaded from http://ahajournals.org by on January 28, 2019 presentation distinguishes 2 varieties. Acute perinatal stroke occurs in newborn infants at or near birth and typically pres- 1 per 6300 live births for both hemorrhage and hemorrhagic ents shortly after onset with focal seizures or encephalopathy. infarction. Presumed perinatal stroke refers
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