What are the clinical presentation and treatment options for brainstem stroke in pediatric patients?

Clinical Presentation of Brainstem Stroke in Children

Brainstem stroke in children presents with a constellation of symptoms that are often vague and nonspecific, leading to diagnostic delays—headache and visual disturbances each occur in approximately 50% of cases, while seizure-like activity (21-47%), motor deficits (35-40%), and vomiting (36%) are also common presentations. 1, 2

Key Clinical Features by Frequency

Most Common Presentations (>50%)

• Headache occurs in 50-56% of pediatric brainstem stroke cases and represents one of the most frequent initial symptoms 1, 2
• Visual disturbances (diplopia, blurred vision, visual field defects) present in approximately 50% of patients, suggesting occipital or optic pathway involvement 1

Frequent Presentations (20-50%)

• Seizure-like activity occurs in 21-47% of cases, which frequently misleads clinicians toward alternative diagnoses such as epilepsy 1, 3
• Motor deficits including hemiparesis or focal weakness present in 35-40% of patients, indicating contralateral hemispheric or brainstem involvement 1, 3
• Vomiting presents in approximately 36% of cases 1, 2
• Altered mental status or decreased level of consciousness occurs in approximately 21% of cases 2, 3

Additional Brainstem-Specific Signs

• Ataxia and vertigo/dizziness suggest cerebellar or vestibular pathway involvement 2
• Facial droop indicates facial nerve pathway involvement at the pontine level 2, 4
• Speech disturbance (dysarthria or aphasia) indicates dominant hemisphere or brainstem involvement 2, 4
• Altered sensation localizes to sensory pathways within the brainstem 2, 4

Critical Diagnostic Pitfalls

The vague and nonspecific nature of symptoms contributes significantly to delays in diagnosis, with time from last seen well ranging from 12 hours to 5 days in documented series. 3 This delay is particularly dangerous given that early identification reduces mortality and permanent disability. 2, 4

Common Stroke Mimics

• Migraine accounts for 38% of stroke mimics in children 2
• Seizures with postictal paralysis account for 15% of stroke mimics 2
• Bell's palsy accounts for 10% of stroke mimics 2

Adult stroke screening tools should NOT be used as the sole method to identify pediatric stroke, as these are not validated in children and miss the broad presentation spectrum. 2, 4

Immediate Management Algorithm

Step 1: Recognition and Activation

When brainstem stroke is suspected based on any combination of the above symptoms, immediately activate EMS for transport to an emergency department with pediatric neurology expertise. 2, 4, 1 Do not delay for complete symptom characterization.

Step 2: Neuroimaging

MRI with diffusion-weighted imaging (DWI) is the imaging procedure of choice, with 77% sensitivity in the first 3 hours versus only 16% for CT. 4, 1 However, noncontrast CT is acceptable if MRI is not readily available or the child is unstable. 4

For brainstem stroke specifically, combining coronal sections with standard axial MRI-DWI facilitates early diagnosis, as axial imaging alone can fail to identify early brainstem lesions. 5

Fat-saturated T1 imaging of the neck should be obtained to evaluate for vertebral artery dissection, as magnetic resonance angiography may miss this critical finding. 1, 3 In one series, MRA was equivalent to digital subtraction angiography for basilar artery occlusion but missed vertebral artery dissection in multiple patients. 3

Treatment Considerations

Anticoagulation

Systemic anticoagulation should be initiated promptly in pediatric brainstem stroke, even with basilar artery occlusion and high stroke severity scores. 1, 3 In a series of 15 patients with brainstem strokes (including 8 with basilar artery occlusion), systemic anticoagulation was used without hemorrhagic complications and resulted in favorable outcomes (mean Pediatric Stroke Outcome Measure 1.25/10 at 2-36 months). 3

Thrombolysis and Thrombectomy

The therapeutic window for potential intervention extends up to 24 hours from last seen normal in pediatric stroke, though this is not FDA-approved. 4, 1 Less than 2% of children with acute ischemic stroke receive tissue-type plasminogen activator due to lack of safety and efficacy data. 2

Mechanical thrombectomy may be considered up to 6 hours or longer on a case-by-case basis, though systematic pediatric data are lacking. 4, 1 The decision to treat should be based on potential benefits and risks, made by a physician with pediatric stroke expertise in consultation with the neuro-interventionalist and family. 2

Respiratory Monitoring

Respiratory monitoring is essential in brainstem stroke, with a low threshold for intubation in patients with bulbar weakness or declining respiratory parameters. 1 This is critical given the proximity of respiratory centers in the medulla.

Prognosis

Pediatric stroke mortality ranges from 5% to 20% depending on the cause. 1, 2 However, even with severe presentations including basilar artery occlusion and high stroke severity scores, outcomes can be favorable when systemic anticoagulation is started promptly. 3

Children may "grow into their disability" as the full impact of stroke may not be known for years as the child reaches various developmental stages, necessitating long-term monitoring throughout maturation. 2