What is the management approach for pediatric watershed infarct?

Management of Pediatric Watershed Infarct

The management of pediatric watershed infarct requires immediate neuroimaging with MRI as the preferred modality, followed by targeted treatment based on the underlying etiology, with supportive care focusing on controlling fever, maintaining normal oxygenation, normalizing blood pressure and glucose levels. 1

Initial Assessment and Imaging

Immediate Evaluation

• Perform rapid assessment of airway, breathing, and circulation
• Conduct detailed neurological examination using standardized stroke scale (NIHSS or CNS)
• Monitor vital signs: heart rate, blood pressure, temperature, oxygen saturation

Neuroimaging

• MRI with diffusion-weighted imaging is the preferred modality for diagnosis of watershed infarcts due to its superior sensitivity compared to CT 1, 2
• MRI can show T2 prolongation in watershed vascular territories in patients with sickle cell disease (SCD) 1
• Include MR angiography (MRA) to evaluate for vessel stenosis, particularly in children with SCD 1
• CT is less sensitive but may be used in acute settings if MRI is unavailable or to document hemorrhage 1

Etiology-Specific Management

Sickle Cell Disease

• For children with SCD presenting with acute stroke symptoms, immediate transfusion therapy is the treatment of choice 1
• Implement regular transcranial Doppler US screening every 6 months for children with SCD between 2-16 years of age 1

Cardiac Embolism

• Early echocardiography to evaluate for cardiac sources of embolism 3
• For children with substantial risk of recurrent cardiac embolism, anticoagulation with LMWH is recommended 1
• Dosing for enoxaparin:
  • <2 months: 1.5 mg/kg every 12 hours

  • 2 months: 1.0 mg/kg every 12 hours 1

Large Artery Atherosclerosis/Vasculopathy

• Internal watershed infarcts are significantly associated with large artery disease 4
• Consider anticoagulation with LMWH or UFH for up to 1 week while completing diagnostic evaluation 1
• Monitor for perfusion-diffusion mismatch, as this may predict severe progression of watershed infarction 5

Supportive Care Measures

Class I Recommendations 1

• Control fever
• Maintain normal oxygenation
• Control systemic hypertension
• Normalize serum glucose levels

Additional Supportive Measures

• Perform swallowing assessment before oral intake to reduce aspiration risk 3
• Initiate seizure management if seizures occur at presentation
• Encourage early mobilization when medically stable
• Implement VTE prophylaxis with intermittent pneumatic compression devices and/or LMWH 3

Monitoring and Follow-up

• Monitor for progression of infarct volume, which typically occurs within the first 2-3 days 5
• Perform serial neurological examinations to detect clinical deterioration
• Consider follow-up MRI to assess for infarct evolution and extent of tissue damage

Important Considerations and Pitfalls

• Do not administer supplemental oxygen in the absence of hypoxemia 1
• Do not administer prophylactic antiepileptic medications in the absence of clinical or electrographic seizures 1
• Do not use hypothermia except in the context of a clinical trial 1
• Be aware that watershed infarcts often begin as small volume lesions but may progress significantly during the acute stage 5
• Recognize that perfusion imaging may help predict which patients are at risk for severe infarct progression 5

Special Considerations for Pediatric Patients

• Children with watershed infarcts often have different etiologies than adults, with cardiac disease, vasculopathy, and hematologic disorders being more common 4
• Internal watershed infarcts in children may present with stepwise onset of contralateral hemiplegia, while partial internal watershed infarcts may present with discrete episodes of brachiofacial sensorimotor deficit 6
• Consider uncommon causes such as vasculitis, hypercoagulability, and aneurysms in cryptogenic cases 4