Analysis: Kids' strokes undertreated

SAN FRANCISCO, Feb. 8 (UPI) -- Doctors said Wednesday that treatment of children who suffer strokes tends to range all over the lot -- generally due to lack of guidelines on therapy for the uncommon but potentially devastating brain accidents.

Researchers at the annual International Stroke Conference in San Francisco scrutinized treatment of children and infants who suffer strokes, finding that as many as one-fifth to one-third of patients who are at risk of having a second stroke receive no treatment at all.

"There are many possible reasons for the lack of treatment -- particularly the failure to give anti-coagulant drugs to children," said Heather Fullerton, assistant professor of neurology at the University of California in San Francisco.

"There is an issue of delayed diagnosis," she told United Press International. Some infants are not diagnosed until months after the event, she said. She said that doctors at that point may believe that the stroke is over and the threat doesn't exist any longer.

Fullerton said that doctors may not treat children with a history of stroke because of the uncertainty of treatment since there are no studies to indicate how children will fare with those therapies; there is an issue of long-term safety with the use of anti-coagulants or even aspirin in children, and there is an issue of legal liability.

Yet Fullerton noted that 20 percent of the children who have had a stroke are likely to have another "brain attack" that can leave them with serious cognitive and physical deficits.

"We do not have evidence-based recommendation in the prevention of stroke in children," said Michael Sloan, director of the Stroke Center at Carolinas Medical Center in Charlotte, N.C.

"However, we believe that adults who are prone to stroke should have some type of treatment, so it is reasonable to extrapolate that to children," he told UPI. He said the studies show that practitioners are more likely to be sued for failing to treat patients than for treating patients even if it is unapproved use.

Another study at the conference, sponsored by the American Stroke Association, a division of the Dallas-based American Heart Association, highlighted differences in stroke treatment of children inside and outside the United States.

The International Paediatric Stroke Study revealed that about 23 percent of U.S. children with a stroke believed to be caused by clots were treated with blood thinners -- anti-coagulant agents -- compared with 44 percent of children with the same condition outside the United States.

"Despite recurrence rates of 20 percent in childhood arterial ischemic strokes, more than one-third of children receive no anti-thrombotic treatment," Fullerton told UPI. "Pediatric secondary stroke prevention trials are needed to guide care."

In some cases, doctors are willing to try anything available in serious stroke situations, said Catherine Amlie-Lefond, assistant professor of neurology at the Medical College of Wisconsin in Milwaukee. She reported on results of the use of tissue plasminogen activator (tPA) in children with strokes.

When used in adults promptly after stroke symptoms are observed -- within three hours of signs of the brain attack -- as many as 40 percent of patients walk out of the hospital without any deficits, Sloan said. "But there are no studies of tPA in children," he said.

Amlie-Lefond said the international survey reported 16 cases in which the drug was used within 20 minutes to 120 hours after the stroke. In three of the cases the children emerged with a normal neurological outcome; in 12 cases the children had neurological or cognitive damage, and in one case the child died. "The child that died had a stroke that was, in itself, life-threatening," she said.

"There are cases in which doctors will use desperate measure to treat children in desperate condition," said Donna Ferriero, chief of child neurology at the University of California in San Francisco.

Ferriero moderated a news briefing at which researchers presented several studies dealing with stroke in children.

Among the other findings:

-- The risk of stroke in African-American children is double that of white children, children of Asian descent and children of Hispanic descent, said Fullerton, reporting results of a Kaiser Permanente study.

"Even when we considered strokes caused by sickle cell anemia and access to care," the differences persisted. She said studies are ongoing to find why these children are prone to strokes.

-- The deficits caused by stroke appear in early childhood and then later when children start going to school, said Robyn Westmacott, assistant professor of neurology at the University of Toronto.

She and colleagues are following children who suffered strokes in the first 28 days of life. "These neonatal are more common than most people realize," she said. They occur in about one of every 2,500 to about one in every 4,000 live births, she said.

In an earlier study, the children appeared to have some neurological or cognitive deficits at age 1 and 2, but in the new study she said those deficits disappeared in the preschool period.

Once the children began using more complex thinking that occurs in school subjects, the deficits began appearing again, Westmacott said. The children had significantly lower IQ, verbal comprehension, perceptual reasoning, working memory and processing speed.

She said the studies with the children are continuing to see if these deficits are permanent or if the children catch up in their teen and adolescent years.