Learning About Hemorrhagic Stroke in Children

A stroke is a brain injury. It occurs when blood flow is interrupted to part of the brain. Brain tissue needs a constant supply of oxygen, which is carried by the blood. When blood flow stops, brain cells start to die. This may lead to permanent brain injury.

A stroke caused by bleeding from a broken blood vessel is called a hemorrhagic (say "heh-muh-RA-jick") stroke. Blood from a broken blood vessel floods into nearby brain tissue. But it can’t travel to other brain tissue. The brain tissue that doesn’t get blood starts to die.

A hemorrhagic stroke is much more common in adults than in children. This type of stroke isn't expected in a child, so the diagnosis may be delayed. A child often recovers more abilities after a hemorrhagic stroke than an adult does. That's because a child's brain is still developing.

A child is more at risk of a hemorrhagic stroke if they have:

• An abnormal blood vessel in the brain called an arteriovenous malformation (AVM). It can tear and bleed.
• A bulging blood vessel in the brain (aneurysm).
• A bleeding disorder such as hemophilia or severe thrombocytopenia.
• A brain tumor that bleeds.
• Sickle cell disease.
• A brain infection such as meningitis.
• A head injury.
• Injury from sports or accidents.
• Blood vessel inflammation (vasculitis).
• Ehlers-Danlos syndrome that causes tears in blood vessels.
• Severe high blood pressure.

In some children, no cause can be found.

Symptoms of a hemorrhagic stroke in a child depend on the child's age and the cause of the stroke.

A baby or young child may have:

• Seizures.
• Extreme sleepiness.
• A change in awareness.

Older children tend to have symptoms like those in adults. These can include:

• A severe headache, possibly with vomiting.
• Sleepiness or passing out (loss of consciousness).
• Dizziness or sudden confusion.
• Loss of balance or coordination.
• Seizure.
• Trouble walking.
• Trouble seeing.
• Trouble speaking or understanding words or sentences.

The doctor will ask about your child's symptoms and health history. The doctor will ask about injuries, infection, problems with growth and development, and any family history of bleeding problems.

The doctor will give your child a physical exam. The doctor will look for any signs of weakness, numbness, and other signs of a hemorrhagic stroke.

Tests will be done to help make the diagnosis. These may include:

Brain imaging tests. Brain imaging is done right away to confirm the diagnosis and determine treatment options. Magnetic resonance imaging (MRI) is the main test to diagnose hemorrhagic stroke in children. A head CT scan may be done if MRI is not available. Magnetic resonance angiography may be done as part of the MRI. For this, a dye is injected to help show the blood vessels. Transcranial doppler or ultrasound may be done to look for problems in blood vessels in the brain.

Blood tests. Blood is tested for signs of infection, sickle cell disease, blood vessel inflammation, and blood clotting problems.

Heart and blood vessel studies. Heart rhythm is checked with an electrocardiogram (ECG). An ultrasound of the heart may be done to look for possible causes of air embolism or a blood clot. The child may need to wear a monitor for a few days or weeks to look for heart rhythm problems.

Lumbar puncture (spinal tap). Cerebrospinal fluid (CSF) from around the brain and spinal cord may be examined for blood or signs of infection.

Electroencephalogram (EEG). This test looks at the electrical activity of the brain. This is done to look for seizure activity.

Pulse oximetry. This helps make sure there is enough oxygen in the blood.

Treatment works best if it's started as soon as possible.

Treatment depends on the cause of the hemorrhagic stroke. It may include:

• An intravenous (I.V.) tube to give medicines and replace fluids.
• Oxygen.
• Managing blood pressure.
• Monitoring and managing the pressure inside the skull.
• A blood transfusion.
• Medicine to prevent seizures.
• A thin tube (catheter) put in a vessel of the brain (interventional neuroradiology).
• Surgery for some causes.

In children, there may be no way to prevent the first hemorrhagic stroke. A hemorrhagic stroke occurs in children for many reasons, including conditions present at birth (congenital conditions). There's no way to prevent these conditions.

If your child has an AVM or hemophilia, doctors will treat those conditions. Treatment can help prevent future hemorrhagic strokes. Your child may need tests over time to see if they're at high risk for more strokes.

A stroke caused by accident or injury may be prevented by protective gear such as helmets and seatbelts.

Call 911 right away if your child has signs of a hemorrhagic stroke.

B.E.F.A.S.T. is an easy way to remember the signs of a hemorrhagic stroke. When you see the signs, you will know that you need to call 911 fast.

• B is for balance: Sudden loss of balance or coordination.
• E is for eyes: Vision changes in one or both eyes.
• F is for face drooping: One side of the face is drooping or numb. When the child smiles, the smile is uneven.
• A is for arm weakness: One arm is weak or numb. When the child lifts both arms at the same time, one arm may drift downward.
• S is for speech difficulty: You may notice slurred speech or trouble speaking. The child can't repeat a simple sentence correctly when asked.
• T is for time to call 911: If a child shows any of these symptoms, even if they go away, call 911 right away. Make note of the time the symptoms first appeared.