Hemorrhagic stroke in children: Etiology, outcome and predictors of treatment

Pediatric hemorrhagic stroke has an incidence of 1.1 per 100,000 person-years and encompasses subarachnoid hemorrhage and intracerebral (parenchymal) hemorrhage. Given the rarity of the condition and the under-recognition of cerebrovascular disease in children, it is not surprising that hemorrhagic stroke in children has not been well studied. This thesis will focus on information needed to move the field forward in terms of predicting hemorrhagic stroke etiology and outcome, as well as on improving treatment options. In the initial chapter, existing studies are reviewed with a focus on intracerebral hemorrhage.Next, a series of 30 children with intracerebral hemorrhage from a single medical center were carefully studied. This study showed that intracerebral hemorrhage volume, particularly when expressed as a percentage of total brain volume was a predictor of poor neurologic outcome at 30 days post-hemorrhage.In the third chapter, using a large, retrospective cohort of children in Northern California with 116 incident cases of hemorrhagic stroke, predictors of underlying cerebral aneurysms were found to be older adolescent age and subarachnoid hemorrhage pattern. Stroke etiology was also examined based on hemorrhage pattern: subarachnoid hemorrhage, intracerebral hemorrhage or both. The combined pattern of both subarachnoid and intracerebral hemorrhage seen on head CT was most commonly due to a brain arteriovenous malformation.In the fourth chapter, data from the International Pediatric Stroke Study (case series data) was used to look at treatment patterns in neonates with cerebral sinovenous thrombosis (CSVT). CSVT is an important cause of intracerebral hemorrhage in full term neonates. The only predictor of treatment in neonatal CSVT was the geographic location of the medical center. Newborns from the United States received antithrombotic treatment far less frequently than children seen elsewhere in the world.The final chapter outlines future directions for research in pediatric hemorrhagic stroke. While a multicenter clinical trial would be ideal, a prospective natural history study of pediatric ICH is needed first. This prospective study will further examine the relationship between hemorrhage size and neurologic outcome. Carefully collected neurologic outcome data as well as data on hemorrhage location that has been lacking in previously published studies will be obtained.