Interview with Dr. Heather Fullerton: Treating Stroke in Newborns and Children

Audio Interview

Stroke — Hear Dr. Heather Fullerton talk about how stroke is diagnosed and treated in children.

Interview Transcript

Introduction

Andrew Schorr:

Hello and welcome to our Patient Power program sponsored by UCSF Medical Center. I'm Andrew Schorr. In this program we're discussing stroke in children; diagnosing and treating rare but potentially lethal pediatric stroke, and with us is a true expert in that, that's Dr. Heather Fullerton. Dr. Fullerton is director of the UCSF Pediatric Stroke and Cerebrovascular Disease Center.

Dr. Fullerton, when we think about stroke in children, I don't know that I've ever heard about it myself, it must be very rare. How often does it occur?

Dr. Heather Fullerton:

It's actually more common than you would think. We see it in about 1 per 4,000 live births, meaning 1 per 4,000 babies that are born will actually be born with a stroke, and then we see it less commonly in older children, but it happens in about 4 per 100,000 children every year, and so it ends up being about 4,000 children in the U.S. who will end up having a stroke every year.

Andrew Schorr:

Whoa, well that's scary certainly. So, what is happening? I know there are a variety of causes. Help us understand typically what must be going on, and does it happen right at birth right when the child may still be in the hospital, or how does this roll out, if you will?

Dr. Heather Fullerton:

So, we generally divide pediatric stroke into two very different categories — the neonatal strokes and the childhood strokes. The neonatal strokes are common but relatively poorly understood. We think that they do happen right around the time of birth and probably related to multiple different factors that are coming together at the time of birth to cause a blood clot to go to the brain and result in a stroke.

Part of that is actually physiologic in that a mother forms blood clots more easily around the time of birth. This is something she has to do so that when she delivers the placenta, she basically can clot off and not bleed after delivering the placenta, but other things are probably happening as well around the time of birth that lead to a stroke. It may be things related to inflammation of the placenta, like an infection in the placenta, or a blood clotting disorder in either the mother or the baby, but this actually is not very well understood. Fortunately though, those babies tend to do relatively well and are very unlikely to have any recurrent strokes.

Childhood stroke is a very different story. We do understand it somewhat better, and we know that the etiologies are very different from strokes that we see in adults. There are multiple etiologies in children, and we also know that children are at higher risk of suffering recurrent stroke, which is why it is important for us to evaluate children thoroughly so that we can figure out the best way of preventing recurrent strokes in them, but in children we find that congenital heart disease is a cause of stroke.

Also, children with sickle cell disease are at quite high risk of stroke, and then many other children who were just previously healthy and present with a first-time stroke actually have some sort of abnormalities of the blood vessels that lead to the brain, and the abnormalities, we're still trying to better understand.

We know that some children will actually develop tears in the blood vessels that go to the brain. Other children will develop blood vessel narrowing that seems to be related to infections such as chicken pox infection, and other children will just spontaneously develop narrowing of the blood vessels to the brain that we actually don't understand; we don't know why it happens, but it is something that can cause stroke and actually also can put those children at high risk of having a recurrent stroke.

Difficulties Diagnosing Childhood Stroke

Andrew Schorr:

Dr. Fullerton, you as a pediatric neurologist I know helped lead a team of specialists there at UCSF, and often, I mean, these kids could have this problem anywhere of course in the country or the world, and people come from far and wide to see you. Why is it so difficult to understand what's going on? What is it about diagnosing these problems that is so elusive?

Dr. Heather Fullerton:

I think one problem is that childhood stroke has generally fallen into a gap in clinical care. It is a rare disorder in general, and so most child neurologists will not be very comfortable in caring for children with stroke. Stroke is considered more a disease of adults, but then adult stroke neurologists aren't familiar of the etiologies of stroke in children or how to manage stroke in children, and so they're often uncomfortable with caring for a stroke in a child, and so that's why it's become increasingly important over time, especially as we have different treatment options we can offer to children, it's important that these children do get input from people who are comfortable taking care of childhood stroke patients in particular.

It can be difficult to diagnose the etiology of their strokes. It often takes sophisticated imaging studies and studies that are done by very experienced practitioners, and so experienced neuroradiologists, experienced neurointerventional radiologists. It really often does take a team approach to figure out why a child has had a stroke and figure out what is the best way to prevent more strokes in that child.

Treatment Options

Andrew Schorr:

From what I understand, what you've assembled there at UCSF is really that type of comprehensive team, and someone would be hard pressed to find that anywhere else. So for someone listening where this is suspected or their child is affected by it, what hope do you have now that there are treatment options that can really make a difference?

Dr. Heather Fullerton:

There are many treatment options, and it actually does depend very much on the cause of the stroke. When we deal with children who have blood vessel abnormalities, for instance, we can offer medical treatment with an antithrombotic agent, something as simple as aspirin, or at other times forms of heparin that we use in children. Other children are actually going to be benefited by surgical interventions and there are different bypass procedures that we can do to improve blood flow to the brain.

Another thing that is a similar issue kind of parallel are those children who have hemorrhagic stroke, and so in general when we talk about stroke, people often think about ischemic stroke where not enough blood gets to the brain, but we also see children with hemorrhagic stroke where you have bleeding into the brain, and those children have a whole different set of etiologies to their strokes. But many of them will have underlying vascular malformations of the brain or aneurysms in the brain, and those often require treatment by a combination of therapies both endovascular therapy that's done within the blood vessels by neurointerventional radiologists, surgical therapy that is done by neurosurgeons, and also at times radiation therapy such as gamma knife that also is done in combination between our neurosurgeons and radiation oncologists.

Andrew Schorr:

And you have all that at UCSF?

Dr. Heather Fullerton:

We have all that at UCSF. That's right, and we've basically developed a team approach where we see each child individually and then discuss the case as a group and review all the imaging as a group and then decide as a group what we think are the best treatment options for a child.

Andrew Schorr:

Now, parents have to wonder if it turns out that their child is afflicted with one of these conditions, they say, 'What did I do?' The mom may say, 'What did I do during pregnancy to cause this?' Should they take any of the blame? Should they feel guilty about this? What do we know from a scientific point of view now?

Dr. Heather Fullerton:

There's definitely no reason that a mother should feel guilty if her child has had a stroke. There is nothing that a mother could do to predict this. There's nothing that a mother could do to prevent this. I think the one exception would be illicit use of certain drugs during pregnancy. We know that drugs like cocaine and amphetamines used during pregnancy can increase the risk of stroke in a baby, but outside of that setting, there's absolutely nothing that a mother could do during a pregnancy to either increase or decrease that baby's risk of having a stroke.

Signs and Symptoms

Andrew Schorr:

Now what about recognizing the signs of this? So you have children and sometimes even teenagers where this shows up. Would there be any earlier indications that someone could be looking for that where otherwise it might be missed?

Dr. Heather Fullerton:

In the older children, the symptoms of a stroke are fairly similar to what we see in adults. The most common symptom is weakness on one side of the body, and so parents might notice that the child's face suddenly appears to be droopy on one side and that their smile is asymmetric, and then they'll also notice that the child has difficulty using the hand on one side and that they may be dragging the foot on that same side, and so if a child ever has sudden onset weakness on one side of the body, that certainly is a warning sign for a possible stroke, and that should be evaluated emergently. That child should be taken by ambulance to an emergency room to be evaluated.

Babies, when babies have strokes, they can present very, very differently. They often won't actually develop weakness on one side of the body at the time of the stroke. The only symptoms that they may have will be excessive sleepiness, and then they also may develop a seizure in the first few days of life. Some babies with stroke though won't develop any of those signs and symptoms at the time of birth, and then the only sign that they have of stroke is when later in infancy when they're maybe six or eight months of age, the parents or the pediatrician will notice that the child has a hand preference, that they prefer to use one hand to reach for things and that they won't use the other hand to reach, and that actually can be the first sign that a baby actually had a stroke around the time of birth.

Andrew Schorr:

Now, with the treatments that you can bring to bear, and I know it varies greatly by the individual situation, what is the prospect of a child going on and having a normal life?

Dr. Heather Fullerton:

So again it depends on the cause of the stroke, also the location of the stroke, and the age at which the child has the stroke.

When babies have strokes, they have remarkably good outcomes. About a third of those babies though will go on to have some sort of significant motor deficit meaning that they will have difficulty using one hand, and then we're also recognizing that many of these children will go on to have some difficulties in school, and that can often actually be under recognized, but for the most part these children can go on to lead very healthy and productive lives.

They use their good hand and learn how to do things with their good hand, and if they are recognized by their schools to have a problem, often they can get special education from the school, special sort of interventions by the school to allow them to really thrive and learn in school, so it's very important that the strokes are recognized, that the teachers are aware of the stroke, and that the school makes an attempt to basically create a specialized plan for that child's education.

In the older children, the same things applies. They can basically have difficulties with their motor strength, and they can be left with a disability. They can also have problems in school. And then the other thing that we worry more about in those children is also their risk of having a recurrent stroke, and certainly if you have a recurrent stroke, then you have additional brain injury, and the more injury that a child has to the brain over time certainly the worse they're going to do in the long run, and that's why it's just so important that children who have stroke be well evaluated to determine their risk of having a recurrence, and if there is a high risk of recurrence that they explore all treatment options that can potentially lower that risk.

Andrew Schorr:

I would imagine with the specialization of your center people come from far and wide, and you're very used to that at UCSF.

Dr. Heather Fullerton:

That's right. We do see children who come from far away, and unfortunately there are also children who would like to come here from far away and don't have the resources, but we do see children from all over.

Screening High Risk Children

Andrew Schorr:

So the last thing that I wanted to ask you about, Dr. Fullerton, is newborn babies are screened for so many things. Is this just so rare that it's not worth doing, or is there something you think as a pediatric neurologist could be done to try to evaluate newborns or even as a pediatrician see kids as they're growing up to look out for these sorts of potential problems?

Dr. Heather Fullerton:

I think that there's no good way of screening these children outside of the setting of sickle cell disease, and so sickle cell disease is something that's part of the newborn screen. Those children who have sickle cell disease actually should be carefully followed by a pediatric hematologist, and there's a way of actually preventing the strokes in those children. They can be screened with a very simple ultrasound device that basically evaluates the blood vessels to the brain, and then there actually is a way of preventing stroke in the high risk children.

Outside of that setting, stroke is rare enough that there really are no good screening techniques and no screening techniques that would be meaningful. In the case of the neonatal strokes, in particular, because their risk of recurrence is so low, there's not a big downside to a delayed diagnosis in those children. So if those children don't have their stroke diagnosed until they're six or eight months of age, there's not a big downside to that.

Andrew Schorr:

Well, while these conditions are rare, I am very glad that you have your center at UCSF with a multidisciplinary team, and I'm happy that we can do this program to let people know more about you and that there's help and very positive treatment options. Dr. Heather Fullerton, pediatric neurologist, Director of the UCSF Pediatric Stroke and Cerebrovascular Disease Center, thank you for being with us today on Patient Power.

Dr. Heather Fullerton:

Thank you very much.

Andrew Schorr:

As always, knowledge can be the best medicine of all. Thank you for joining us. I'm Andrew Schorr. You've been listening to Patient Power sponsored by UCSF Medical Center.

Recorded May 2008

 

Reviewed by health care specialists at UCSF Benioff Children's Hospital.

This information is for educational purposes only and is not intended to replace the advice of your doctor or health care provider. We encourage you to discuss with your doctor any questions or concerns you may have.

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1825 Fourth St., Fifth Floor
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Phone: (415) 353-7596
Fax: (415) 353-2400

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