Pediatric stroke: Current diagnostic and management challenges

Stroke is not a diagnosis which springs to mind within the pediatric age group. Nonetheless, the combined incidence of ischemic and hemorrhagic stroke is estimated at 1.3 to 13.0 children per 100,000 (1) and the overall incidence is increasing (2) due to a combination of improved survival of those with risk factors and increased recognition. Pediatric stroke is a heterogeneous entity, both in terms of etiology and presentation. This makes accurate and timely diagnosis challenging, and leaves uncertainty regarding optimum acute management. The 2017 Royal College of Pediatrics and Child Health guidelines on pediatric stroke (3) aimed to ameliorate these issues and provide a model for standardized pediatric stroke management in the United Kingdom. This long-awaited document was the combined work of multiple organizations, reflecting the multidisciplinary approach required for pediatric stroke management. Adult stroke management is a standard against which pediatric stroke management can be compared and provides a template for potential improvement. Within the adult population, stroke diagnosis and management is streamlined and algorithm-based and has a robust evidence base (4). Rapid identification facilitates the provision of potentially life-saving treatments such as fibrinolysis and mechanical thrombectomy. However, unlike children, adult stroke care is underpinned by the relative uniformity of clinical presentation and underlying pathology. In children, the heterogeneous etiology, combined with a variable presentation creates diagnostic delays and management challenges (3). These challenges need addressing in order to avoid the significant morbidity and mortality and the potential for lifelong disability which is associated with childhood stroke. This article will summarize current challenges in pediatric stroke management and address the ways in which radiology can support timely diagnosis and assist patient selection for potentially life-saving treatments.