What are the presentation and management of brainstem stroke in pediatric patients?

Presentation of Brainstem Stroke in Children

Brainstem stroke in children presents with a constellation of vague, nonspecific symptoms that frequently lead to diagnostic delays, including headache, visual disturbances, seizure-like activity, motor deficits, and decreased level of consciousness—often with symptom onset occurring 12 hours to 5 days before diagnosis. 1

Clinical Presentation

Common Presenting Symptoms

The presentation of brainstem stroke in pediatric patients is notably nonspecific and differs substantially from adult presentations:

• Headache occurs in approximately 50-56% of cases and is one of the most frequent initial symptoms 2, 1
• Visual disturbances (diplopia, blurred vision, visual field defects) present in approximately 50% of patients, suggesting occipital or optic pathway involvement 3, 1
• Seizure-like activity occurs in approximately 21-47% of cases, which can mislead clinicians toward alternative diagnoses 2, 1
• Motor deficits including hemiparesis or focal weakness present in 35-40% of patients, indicating contralateral hemispheric or brainstem involvement 2, 3, 1
• Altered level of consciousness occurs in 21-27% of cases 2, 1
• Vomiting presents in approximately 36% of pediatric stroke cases 2
• Speech disturbances (dysarthria or aphasia) indicate dominant hemisphere or brainstem involvement 3
• Facial droop suggests facial nerve pathway involvement 3

Critical Diagnostic Pitfall

The time from last seen well to diagnosis ranges from 12 hours to 5 days, representing a dangerous diagnostic delay. 1 This delay occurs because:

• Symptoms are vague and nonspecific in children compared to adults 2, 1
• Stroke mimics are extremely common in pediatric populations (38% migraine, 15% seizures with postictal paralysis, 10% Bell's palsy) 2
• Adult stroke screening tools are not validated in children and miss the broad presentation spectrum 3
• Most children presenting with acute neurologic deficits do not have stroke 2

Anatomic Localization in Brainstem Stroke

Pontine Involvement (Most Common)

• Pontine strokes occur in 87% (13/15) of pediatric brainstem strokes 1
• Lesions may involve >50% of the pons in approximately 40% of cases or <50% in approximately 47% of cases 1
• Basilar artery occlusion is identified in approximately 62% (8/13) of patients with pontine stroke 1

Medullary Involvement

• Medullary strokes occur in approximately 13% (2/15) of pediatric brainstem strokes 1

Associated Vascular Pathology

• Vertebral artery dissection is a critical underlying etiology that can be missed on initial imaging 1
• Basilar artery occlusion is the most common large vessel pathology 1

Stroke Severity Assessment

Using the Pediatric National Institutes of Health Stroke Scale (PedNIHSS):

• Mild stroke (PedNIHSS <10): occurs in approximately 53% of brainstem stroke cases 1
• Moderate stroke (PedNIHSS 10-20): occurs in approximately 13% of cases 1
• Severe stroke (PedNIHSS >20): occurs in approximately 27% of cases 1

Management Approach

Immediate Actions

The American Heart Association recommends immediate activation of EMS for transport to an emergency department with pediatric neurology expertise when a child presents with suspected stroke. 3

Neuroimaging Protocol

MRI with diffusion-weighted imaging (DWI) is the imaging procedure of choice for acute pediatric stroke detection, with 77% sensitivity in the first 3 hours versus only 16% for CT. 3

• Rapid MRI stroke protocols should be used to overcome challenges with traditional protocols in pediatric patients 3
• Noncontrast CT is acceptable if MRI is not readily available or the child is unstable 3

Critical Vascular Imaging Considerations

MRA is equivalent to digital subtraction angiography (DSA) for detecting basilar artery occlusion but NOT for vertebral artery dissection—DSA should be performed within 9-36 hours if vertebral dissection is suspected. 1

• MRA showed basilar artery occlusion in 8/13 patients, which was confirmed by DSA 1
• MRA missed vertebral artery dissection in multiple cases that were subsequently identified on DSA 1
• Fat-saturated T1 imaging of the neck improves yield for extracranial arterial dissections 2

Acute Treatment

Systemic anticoagulation should be initiated promptly in pediatric brainstem stroke, even with basilar artery occlusion and high stroke severity scores, as this approach has been used without hemorrhagic complications and results in favorable outcomes. 1

• The therapeutic window for potential intervention extends up to 24 hours from last seen normal, though this is not FDA-approved 3
• Mechanical thrombectomy may be considered up to 6 hours or longer on a case-by-case basis, though systematic pediatric data are lacking 3
• IV tPA and mechanical thrombectomy have been successfully used in pediatric stroke despite limited data and lack of large randomized clinical trials 4

Respiratory Monitoring

Respiratory monitoring is essential in brainstem stroke, with a low threshold for intubation in patients with bulbar weakness or declining respiratory parameters. 5

Prognosis

Even with basilar artery occlusion and high stroke severity scales (PedNIHSS >20), outcomes can be good when systemic anticoagulation is started promptly. 1

• Pediatric Stroke Outcome Measures at 2-36 months range from 0-5.0/10 (mean 1.25) 1
• Mortality occurred in only 1/15 patients (7%) in a contemporary series with prompt anticoagulation 1
• Pediatric stroke mortality ranges from 5% to 20% depending on the cause 2
• Stroke is among the top 10 causes of childhood death and is probably increasing in prevalence 6

Key Clinical Pearls

• Do not wait for "classic" stroke symptoms—vague headache, visual problems, and seizure-like activity in combination should trigger immediate stroke evaluation 1
• The absence of obvious motor deficits does not exclude brainstem stroke—only 40% present with motor deficits 1
• Time delays are the enemy—the median time from symptom onset to diagnosis is measured in days, not hours 1
• Always obtain vascular imaging—structural vascular lesions (particularly vertebral dissection) require DSA if MRA is negative but clinical suspicion remains high 1