52 in 52 – #18: Comparison of Pediatric Arterial Ischemic and Hemorrhagic Stroke

Welcome back to the “52 in 52” series. This collection of posts features recently published must-know articles. Our eighteenth post looks at pediatric ischemic and hemorrhagic stroke.

Author: Christiaan van Nispen, MD (Emergency Medicine Physician Resident, San Antonio, TX) and Brannon Inman (Chief Resident, Emergency Medicine Physician, San Antonio, TX) // Reviewed by: Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)

Comparison of Arterial Ischemic and Hemorrhagic Pediatric Stroke in Etiology, Risk Factors, Clinical Manifestations, and Prognosis



What are the etiologies, risk factors, clinical manifestations, and prognostic outcomes between ischemic and hemorrhagic pediatric stroke?

Design: Retrospective review of cases




  • Retrospective review of all hospital medical records and pediatric neurology database for all children aged 1 month to 18 years diagnosed with ischemic (AIS) or hemorrhagic stroke (HS)
  • Single hospital in Thailand
  • 83 children were identified (51 AIS, 32 HS)
  • All selected individuals were Asian
  • Disproportionately female population (50 of 83)
  • Excluded:
    • Neonates
    • Cerebral venous sinus thrombosis
    • Traumatic brain injuries


  • Reviewed the medical records from the initial clinic of hospital visit until the most recent follow-up visit
  • Assessed age, sex, duration of symptoms from onset to time of diagnosis, time to assess neuroimaging, etiology, clinical symptoms, laboratory other diagnostic test results, medical and surgical history, clinical and developmental outcomes at discharge and recent follow-up


Comparator: AIS and HS compared to each other



  • Clinical manifestations in AIS are most likely to be hemiparesis, followed by seizures and headaches; in HS most common symptom was an altered mental state, then also seizures and headaches.
  • CT was highly sensitive for HS (identified 100% of cases); for AIS still very sensitive on noncontrasted study (92.2%, likely owing to the fact that most AIS cases presented 24 hours after symptoms), and those with negative non-contrast studies were identified with either CTA or MRI with MRA.
  • The most common risk factor for AIS were Moyamoya disease and iron deficiency anemia; for HS it was arteriovenous malformation (AVM).
  • The most common age group affected was 1 month to 6 years in both stroke types.
  • AIS is more likely to have a delayed diagnosis from the onset of symptoms (an average of 24 hours).
  • 10 of the12 observed fatalities had HS, as with adults HS carries high morbidity and mortality.
  • Both groups are unlikely to sustain full recovery, but the AIS group had twice the incidence of persistent “neurological symptoms” while almost half of HS patients suffered from epilepsy.

Take Aways:

  • This is a review of the presentation, risk factors, and outcomes of pediatric strokes in a select, convenient sample of patients.
  • Consider acute stroke in pediatric patients suffering hemiparesis or altered mental status, especially given the delay such patients seem to have experienced in this study in diagnosis.
  • Important risk factors unsurprisingly included diseases involving anatomical variations of the vasculature, such as Moyamoya and AVMs. Risk factors in your patient population may vary, as this was in a select patient population in Asia.
  • Limited discussion on medical management in the emergency department; study mentions imaging, and post-stroke antithrombotic prophylaxis. Moyamoya patients required encephalo-duro-arterio-synangiosis (EDAS). Otherwise, this study did not discuss emergency department based treatments such as blood pressure management or administration of parenteral thrombolytics. Likely care is regionally, and specialist dependent.
  • The study could have done a better job elucidating outcomes; stating that a certain percentage of patients had persistent “neurological symptoms” is not as useful as stating specifically the prevalence of specific symptoms and how debilitating they were (such as by modified Rankin Scores).
  • Study was limited by occurring at a single institution, thus limiting the generalizability of statistical findings.


My Take:

  • Do not hesitate to order a stroke workup in pediatric patients, especially with concerning symptoms such as hemiparesis or altered mental state or if the patient has known abnormal vasculature.


Please see the awesome Pediatric Small Talk on Pediatric Stroke.



  1. Pangprasertkul S, Borisoot W, Buawangpong N, et al. Comparison of Arterial Ischemic and Hemorrhagic Pediatric Stroke in Etiology, Risk Factors, Clinical Manifestations, and Prognosis. Pediatr Emerg Care. 2022;38(9):e1569-e1573. doi: 10.1097/PEC.0000000000002614

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