Optimising functional recovery after paediatric stroke: Complications, non-pharmacological management and neurorehabilitative strategies: A comprehensive literature review

PS overview

An acute neurologic emergency, such as a stroke, necessitates prompt diagnosis, central nervous system imaging, and treatment ideally within the designated time limit. In paediatric patients, stroke is linked to considerable morbidity and mortality.^[8] It has a significant impact on a child’s development, influencing their social skills, learning, and quality of life.^[9] Research has revealed that the prevalence of infantile stroke varies greatly. According to estimates, there are between 2.5 and 13 strokes for every 100,000 children annually.^[10] PS is divided into two categories based on when it occurs: perinatal stroke, which happens between the 20^th week of pregnancy and 28 days after delivery, and childhood stroke, which happens between 29 days and 18 years of age.^[9]

Children experience strokes for a far wider range of reasons than adults do. In adults, the major risks usually come from long-term conditions like atherosclerosis, diabetes, or high blood pressure.^[11] In contrast, paediatric AIS can result from many different problems, such as vascular abnormalities, congenital heart disease, blood conditions including sickle cell disease or clotting issues, infections, trauma and even certain genetic or metabolic conditions.^[12]

The most common stroke symptom in infants is seizures. Older children were more likely to have focal deficits, primarily hemiparesis. Most importantly, seizures that were experienced by 37% of attendees indicate that they are extremely common in all age categories. In general, non-specific systemic symptoms such as fever, headache, nausea/ vomiting, and cardio-pulmonary failure were prevalent, both with and without focal deficits.^[10] In children who are thought to be having a stroke, the first test usually done is a non-contrast computed tomography (CT) scan. It is quick and can reliably show fresh bleeding, but it is not always good at detecting subarachnoid haemorrhage or the very early signs of ischaemia. MRI, along with magnetic resonance angiography (MRA) and magnetic resonance venography (MRV), tends to provide a much clearer view, especially when doctors need to check for venous thrombosis, look for areas of infarction, or assess the blood vessels in detail. CT angiography can also give fast information about the vessels, though it comes with higher radiation exposure. Catheter angiography is still considered the most accurate way to assess the cerebral circulation, but because it is invasive, it is used only when really needed. Other parts of the work-up may include a carotid scan, a heart examination, and laboratory tests to look for underlying metabolic or haematologic issues.^[11]

Treatment options such as IV thrombolysis, mechanical thrombectomy, and antiplatelet therapy are mostly borrowed from adult practice, which creates real challenges when managing children. If blood flow cannot be restored early, the injured brain tissue often cannot recover, and this delay usually leads to significant long-term disability.^[12] Effective implementation necessitates the involvement of clinicians, hospital administrators, government officials, research funding organisations, and stroke advocacy groups. Priorities include coordinated regional stroke systems with established hospital bypass procedures to accredited primary stroke centres capable of providing reperfusion therapies, multidisciplinary PS teams, and the development of institutional PS Code protocols, which include rapid imaging protocols, validated clinical decision support tools, and parallel work practices to increase efficiencies.^[1]

Although people are becoming more aware of the challenges young stroke survivors face, there’s still very little research on what their return to school looks like. The majority of reviews that are currently available concentrate on rehabilitation or general cognitive problems, but they rarely dive into how these children manage academically or how well they cope with day-to-day school demands.^[9] Creating dedicated stroke clinics that can offer thrombolysis, thrombectomy, and follow-up treatment is essential to improve outcomes for young stroke patients. However, we still need much more research to ascertain the most efficient and secure dosage and protocols for thrombolytic therapy in paediatric acute stroke. In addition, gaining real-world clinical experience and stronger evidence on the use of endovascular bridging therapy in children is key to advancing treatment options for this population.^[12]

PS statistical analytic incidence

Stroke is one of the principal causes of disability and mortality among children.^[13] Every year, about 1 in 25,000 children have a childhood stroke, and 75% of them have long-term neurologic morbidity.^[14] Stroke was the third-largest cause of mortality at the Global Burden of Disease level 3 in 2021, after only ischaemic heart disease and Covid-19, and ranked fourth in disability-adjusted life years (DALYs). Globally, there were 11.9 million strokes in 2021, which led to 7.3 million fatalities and 160.5 million DALYs.^[15]

In the current study, common risk factors for AIS were vasculitis, vasculopathy, hyper coagulopathy, and cardiac disease, while common risk factors for HS were bleeding diathesis, vascular abnormality, and intracranial tumour. There is a trend of difference in stroke risk factors between developed and developing nations, with infectious causes being more prevalent in developing nations. Vasculopathy (35.5%), heart disease (17.4%), metabolic disease (14.5%), infection (14.5%), and coagulopathy (1.6%) were among the risk factors identified in another study. Major cardiovascular risk factors include congenital heart disease, particularly cyanotic heart disease, acquired heart disease, and patent foramen ovale. Prior studies have linked congenital heart disease, mainly cyanotic congenital heart disease (CHD), to as much as 15% of ischaemic strokes.^[16]

The most frequent presenting symptoms in stroke patients are facial weakness (33.3%), impaired mental status (50%), and hemiparesis (66.7%). Non-stroke patients, on the other hand, were more likely to present with hemiparesis (57.1%), speech alterations such as dysarthria or aphasia (39.3%), sensory changes such as loss or numbness (32.1%), and facial weakness (35.7%).^[14] A 16-year prospective national study called the Canadian Paediatric Ischaemic Stroke Registry produced comprehensive data on the incidence, presentation, risk factors, and therapies of paediatric arterial ischaemic stroke. The incidence of stroke among the 1,129 children who participated in the study was 1.72/100,000/ year for children aged 29 days to 18 years and 10.2/100,000 live births for neonates aged 0–28 days. In addition, boys have a greater prevalence and incidence than girls, and black children have an increased risk compared to Caucasian and Asian children. Stroke mortality in children ranges between 10-25%.^[10] In 2013, the global prevalence of ischaemic stroke in the paediatric population was 40,000, a 35% increase from 1990, with death rates of 7–28% after childhood arterial ischaemic stroke.^[15] The analysis’s pooled yearly incidence rates of AIS for the entire age group (4.58/100,000 children aged 0–17/18 years) fell within the range in previous studies (0.6–7.9/100,000 children)^[17] [Figure 1].

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Figure 1:

Identified risk factors for PS. PS: Paediatric stroke.

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Arterial ischaemic stroke (AIS) is exceedingly rare in children, occurring in <2–3/100,000. Compared with adults, presentations are frequently inconsistent, which delays identification and treatment. If the delay is longer than 24 h, it can spike mortality and morbidity and can lead to long-term neurologic compromise in up to 85% of patients.^[18] The rates for paediatric arterial ischaemic stroke, neonatal stroke, and cerebral sinus venous thrombosis are 1.28, 18.51, and 0.56/100,000 person-years, respectively.^[19] In developing nations, the prevalence of HS is about twice as high as in developed countries. On the contrary, the prevalence of ischaemic stroke has historically been 4–5 times higher in developing nations than in developed countries. Based on one study, among the causes of HS, 13% of patients had an underlying cerebral aneurysm, 31% had brain arteriovenous malformations, 2.5% had brain tumours, 25% had an unexplained aetiology, and 28.5% had various medical and structural aetiology origins.^[20] The mortality rate of HS is substantially higher than that of arterial ischaemic stroke.^[10] Arterial ischaemic stroke (AIS) mortality ranges between 3.6-14%, while HS mortality ranges from 6-54%, with the stroke or underlying illness being the cause of death.^[1] Following the first occurrence, up to 25% of children will experience a recurrent stroke^[10] [Figure 2].

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Figure 2:

Aetiology of paediatric haemorrhagic stroke. AVM: Arteriovenous malformation.

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PS complications

Stroke is in the top 10 causes of death in children and survivors having disabilities, at a substantial cost to themselves and their families.^[1] PS causes significant morbidity in children, resulting in lifelong neurological disability.^[21] Commonly, it is more detrimental in the paediatric population due to its occurrence at a younger age and therefore could result in a longer duration of disability that can last an entire lifespan.^[10]

Although congenital heart disease and transient cerebral arteriopathy are two common causes of PS, post-minor injury basal ganglia stroke has recently been identified as a common aetiology in resource-limited settings.^[22] Despite having a better prognosis than adults, more than 20% children experience a moderate to severe degree of neurologic damage, and their incidence of depression is nearly double that of their matched cohorts.^[10] Concerningly, some of the patients reported having movement disorders like hemidystonia on the hemiparetic side, a few days after the onset of stroke. Acute illness is significantly more common in young (<5 years) children with stroke, and it strongly predicts abnormal outcomes. Nevertheless, acute illnesses concurrent with the stroke, with their associated fever, hypoxia, hypoglycaemia, azotaemia, and so on, may have increased stroke severity through altered metabolism both within the involved part of the brain and the surrounding penumbra.^[23] Children’s HSs can be classified as intracerebral haemorrhage (ICH), intraventricular haemorrhage, or subarachnoid haemorrhage. HS accounts for over half of all PSs, with an annual incidence of around 1–1.7/100,000.^[24]

After an arterial ischaemic stroke (AIS), the rate of fatal events spans from 1-32% among various paediatric patient groups.^[19] The emergence of an arteriopathy was the best predictor of stroke recurrence, giving rise to a 5-fold increase in risk. This risk was present despite increased use of antithrombotic agents.^[24]

PS is a complicated neurological concern that has significant cognitive and functional detriments. Therefore, an effective rehabilitation is critical for supporting the recovery and improving outcomes in affected children^[9] [Figure 3].

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Figure 3:

Description for PS outcomes, complications, and challenges. PS: Paediatric stroke; ICH: intracerebral haemorrhage; IVH: Intraventricular haemorrhage; SAH: Subarachnoid haemorrhage; AIS: Arterial ischaemic stroke.

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Neurorehabilitation for PS

The rarity of PS compared to adult stroke contributes to limited specialised rehabilitation protocols, yet the consequences are profound. Motor impairments post-PS often manifest as hemiparesis or hemiplegia, with very high persistence rates. Long-term motor outcomes after childhood stroke have reported persisting hemiplegia in 44–66% of cases.^[25] The term ‘robotic rehabilitation’ describes therapies that help retrain movement using robotic equipment (such as exoskeletons, robotic arms and legs, gait trainers, hand and arm robots). The term ‘robotic rehabilitation’ describes therapies that help retrain movement using robotic equipment (such as exoskeletons, robotic arms and legs, gait trainers, hand and arm robots). These tools enable controlled, repetitive, and frequently intense training that might be challenging to duplicate in conventional therapy.

A frequent outcome of this seen post-stroke is unilateral hand disability and hemiparesis.

A case study was conducted on a 7.5-year-old girl in the chronic phase of post-stroke rehabilitation. Robotic neurorehabilitation was started 18 months after the stroke, and it consisted of 30 min of personalised kinesitherapy and 30 min of VR-based rehabilitation using the robotic smart glove. Among the measurement variables examined were the arm’s functional motor state, gripping, spasticity, and participation in everyday activities. The study found that the combination of kinesitherapy and robotic rehabilitation greatly enhanced the arms’ functional motor performance.^[26]

On the gait side, powered wearable robotic exoskeletons, which are electromechanical devices with bilateral motorised support at the knee and hip joints, have been the focus of recent technological developments. They reduce the therapist’s work by offering adjustable high-intensity, high-dose therapy sessions with efficient over-ground ambulation. In comparison to the group that received only physical therapy (PT), the patients treated with the wearable powered robotic exoskeleton regained a more physiological stride, as seen by the proximal lower limb muscle activation patterns. One of the chief goals of a rehabilitation program for stroke patients is the restoration of symmetric and effective walking. When combined with physical treatment, the usage of overground exoskeletons may promote rhythmic muscle activation, which could result in a more effective gait. The same study systematically evaluated therapist workload- It showed that patients and parents embrace robotic neurorehabilitation therapy and that physiotherapists derive some professional fulfilment from it, despite the fact that initially it requires more work.^[27] There isn’t a single, widely recognised ‘technique’. Different facilities combine robotics with traditional therapy or VR.^[28] Economic and long-term burdens amplify the need for effective interventions.^[29] Although promising, case reports must be replicated in a larger youth stroke cohort that includes both ischaemic and haemorrhagic patients to evaluate differences in treatment costs, efficacy, and quality of life improvements before fuller deployment in clinical practice.^[27]

PS non-pharmacologic interventions

Research on cognitive rehabilitation in children after brain injury is still quite limited, and we do not have strong evidence to guide many of the approaches used today. So far, a range of non-pharmacological methods has been explored, which mainly include exercise programs, psychological support, neuromodulation, computer-based cognitive training, brain-computer interfaces, VR activities, music therapy, and even acupuncture. While these interventions show promise, the overall data supporting them remain restricted.^[30]

NMES avoids the brain and spinal cord to cause a reaction at the motor unit junction (the most common) or depolarises a neuron before it reaches the neuromuscular junction. According to research, NMES may cause the following changes in the brain: An increase in motor-evoked potentials, which measure how easily the brain produces movement, an increase in blood flow to brain regions linked to movement, an increase in the activity of genes that code for factors crucial to brain plasticity, and the formation of new neurons surrounding the lesion.^[31]

In normal prepubertal children who engage in moderate-to-vigorous physical activity and exercises, particularly vigorous physical activity, they will have better cognitive functions than children with cerebral palsy.^[32] Exercises were focused on strengthening muscles, reducing spasticity, enhancing transfer skills and postural adjustments, improving balance and posture control when standing and walking. To avoid contractures and maintain a complete active range of motion, a carbon fibre ankle-foot orthosis and a night-time brace for the right upper limb were used.^[33] Psychological intervention is also essential to treat the emotional and social effects of stroke. Children who have suffered a stroke may experience anxiety, depression, or odd behaviour.^[34] The most popular psychological intervention for kids with cognitive impairments following an ischaemic stroke is now strategy training.^[35] Despite being rated National Health and Medical Research Council (NHMRC) grade D due to low evidence quality, it is the only treatment with direct medical support.^[36] Support groups and psychological counselling can assist kids and their families in overcoming these obstacles and fostering emotional health.^[37]

Music therapy has proven that it restores vital signs in children with neurological abnormalities both during and after treatment, as evidenced by lower heart rate, respiratory rate, and higher oxygen saturation.^[38] According to brain imaging research, listening to music activates a broad bilateral network of frontal, temporal, parietal, and subcortical areas linked to attention, semantic and musical syntactic processing, memory, and motor function in addition to the auditory cortex.^[5] VR is frequently utilised in children’s cognitive rehabilitation therapy to improve anxiety, happiness, and relaxation.^[39] The combined effects of VR and computer game-based cognitive therapy create simulated environments where a person’s sense of agency, that is, the feeling of initiating and controlling their own actions, arises through coordinated sensorimotor interactions.^[40]

Paediatric palliative care is defined by the WHO as measures taken to alleviate the suffering and enhance the quality of life for children with severe, chronic, progressive, incapacitating, advanced, or life-threatening illnesses, irrespective of the disease’s stage.^[41] Compared to adult stroke rehabilitation services, PS rehabilitation services are less developed, and stroke incidence in children is low. Medical treatments, including physiotherapy and speech and language therapy, were also considered beneficial, according to Howdle et al.^[42] PT, occupational therapy (OT), speech and language pathology (SLP), and physiatry (Physical Medicine and Rehabilitation Physician) should begin treating these patients.^[43] Examples of motor interventions that could be useful for stroke rehabilitation in children include electromyography, triggered neuromuscular stimulation, functional electrical stimulation, bi-manual therapy, VR, and constraint-induced movement therapy (CIMT).^[25] Despite this belief that therapeutic touch is a crucial component of clinical practice, there has been controversy about its application in paediatric PT, especially when it comes to children with cerebral palsy. Green light (do it), yellow light (moderate evidence, evaluate the results), and red light (lack of evidence, don’t do it) are the three categories of evidence for treatments, according to a recent systematic review. Any child-initiated method to problem-solving that did not involve a therapist’s touch, such as task-specific training and CIMT, was considered a ‘green light’ intervention.^[44] Three main components make up CIMT: (1) Restricting the use of the less-impaired upper extremity (UE); (2) Practicing motor movements with the impaired UE on a daily basis under the guidance of a therapist for a prolonged period of time (2–3 weeks) and (3) Shaping more complex action patterns by rewarding successive approximations to the target action.^[45] Repetitive TMS (rTMS) has been shown in some studies to enhance the grip strength of upper limb impairments following a childhood stroke. When rTMS and CIMT are applied together, the results are better than when CIMT is applied alone. The new aspect is that while tDCS by itself has not been effective and was not advised, its combination with CIMT or OT has had favourable results.^[25] In contrast, OT seeks to enhance pertinent performing skills or create and instruct compensating procedures to regain lost performance skills to facilitate task performance.^[46]

Several studies show that language difficulties, oral motor problems, difficulties in speech motor skills, and dysphagia often present as early manifestations of acute stroke among children. In neonates and children who have suffered from an acute arterial ischaemic stroke, 39–41% experience dysphagia. This is often associated with difficulties in motor speech and language. These problems can impact health outcomes and cause increased stress levels among caregivers if not addressed immediately.^[47] Speech therapy is essential for children who have suffered from a stroke. Speech-language pathologists (SLPs) are the focal point of PS rehabilitation because they help assess oral motor strength. Provide therapy to address speech articulation, language, and swallowing. They also teach compensatory and rehabilitative strategies.^[48] For the case of speech problems, which include dysarthria and aphasia, the following therapies are used: Articulation and phonation exercises to build the strength of the speaking muscles of the body. Language therapies, which include expressive and receptive language therapies. Data on aphasia therapies for children are limited, but language therapies can lead to neuroplastic adaptation.^[49]

The major muscle groups used during speaking and swallowing are targeted by oral and pharyngeal motor exercises. These exercises are widely used as rehabilitative treatments. To improve lingual pressure, it is recommended that exercises to strengthen the tongue and improve pressure resistance be used. To improve laryngeal elevation, head lift, and shaker exercises may be used. To improve cough strength, exercise of the respiratory muscles may be used.^[50] Despite the fact that much of this information is derived from adult stroke neurology, neuroplasticity and task specificity are applied to paediatric populations whenever possible. Since most of the research available today is based on adult post-stroke rehabilitation, it’s necessary for more paediatric-focused studies. These problems can impact health outcomes and cause increased stress levels among caregivers if not addressed [Table 1].

Neonates (<29 days of age) and children (29 days to <19 years) suffer from dysphagia and oral motor dysfunction due to arterial ischaemic stroke.^[51] Dysphagia has a higher risk of malnutrition due to decreased dietary intake, increased nutritional requirements, and gastrointestinal issues. In turn, malnutrition can worsen functional impairment, developmental delay, and growth and increase morbidity.^[52] For individuals with dysphagia, dietary modifications and nutritional support are the two main methods of addressing their nutritional requirements.^[53] When combined with resistance training or structured exercise rehabilitation regimens, protein supplementation seemed to enhance functional outcomes. This suggests that consuming enough protein in addition to therapy may help patients perform better on daily tasks and build muscle. It has been shown that these advantages are more consistent than using non-protein supplements.^[54] Nutrients such as polyphenols and omega-3 fatty acids can contribute to neuroprotective mechanisms due to their anti-inflammatory and antioxidative properties.^[55] Beyond providing fundamental nutritional support, these fatty acids are essential because they influence the intricate processes of brain repair and functional recovery following a stroke. The trajectory of long-term recovery, particularly concerning cognitive and functional abilities, is significantly impacted by early post-stroke nutritional interventions.^[56] Furthermore, micronutrients, including vitamin D and B-complex vitamins, are gaining recognition for their roles in neurological repair and cognitive function.^[57,58] For managing gastrointestinal symptoms, soluble, viscous fibre (like psyllium) that has a high water-holding capacity and resistance to fermentation can help with diarrheal symptoms by promoting the formation of stools and slowing down transit time, and constipation symptoms by softening stools. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition recommends a 6-month assessment of children with neurological impairment utilising several approaches, such as height, weight, skinfold thickness, and mid upper arm circumference (MUAC). The nutritional treatment must strike a balance between preventing overnutrition and its negative long-term implications on cardiometabolic health and providing enough nutrition to sustain growth, development, and well-being.^[59]

According to a few studies, post-stroke paediatric acquired brain injuries have been linked to fatigue. Fatigue factor is further associated with older age of patients, single-parent households, mental dysfunction, sleep disorders, and motor and physical disabilities.^[60] Following a stroke, 20–78% of individuals experience disrupted sleep. Post-stroke sleep-associated disorders often get ignored due to a lack of awareness about them. The gold standard for identifying sleep disturbances is polysomnography (PSG), but because of its high cost and limited availability, PSG cannot be used on all stroke patients. Poor sleep profile is directly linked to a decline in neurological function and increased risk of further coronary heart disorders.^[61] Various studies show how acute ischaemic stroke (AIS) often coexists with sleep-disordered breathing (SDB) and alterations in sleep architecture. SDB is a common complication of AIS. Rapid eye movement (REM) sleep architecture is the primary area of variation in acute ischaemic stroke patients with SDB. Various other types of sleep architecture modifications also occur, corresponding to varying degrees of sleep-disordered breathing. Keeping a close, long-term track of sleep in AIS patients can help clinicians design more personalised treatment plans and give patients a better chance of recovery. Due to technical constraints, current research on the possible link between stroke and sleep, particularly the ongoing changes in sleep states following stroke, remains very limited.^[62]

Screening methods for stroke in the paediatric population

Stroke in children is uncommon compared with adults, but the impact is often much more complicated because the brain is still maturing at the time of injury. Consequently, the impact of a childhood stroke can extend beyond the child and influence the family’s daily routines, long-term decisions, and overall quality of life.^[63] The delay in symptoms makes early detection especially vital. A key obstacle in identifying stroke in children is the absence of a unified screening protocol. Symptoms can vary widely with age. Older children usually show clearer neurological signs, especially sudden weakness of the face or limbs, and acute hemiparesis remains one of the most classic findings in arterial ischaemic stroke (AIS) in this age group. Younger children, however, are far less straightforward. Infants and toddlers frequently present with seizures, and many show only vague symptoms such as vomiting, fussiness, fever, or general instability, which can easily be mistaken for common infections or metabolic problems. Since focal deficits are often subtle in the youngest children, stroke is not always considered early, and this increases the risk of missed or delayed diagnosis. Because of this, tools built specifically for children and increased awareness among clinicians are essential.^[20] When it comes to imaging, MRI is preferred in children whenever it is available quickly and does not require prolonged sedation. Unlike adults, where CT is often done first, children benefit from MRI because it avoids radiation, shows early ischaemic changes more clearly, and helps identify subtle vascular abnormalities that CT might miss. Since many stroke mimics in children also appear normal on CT, MRI provides more reliable early diagnostic information.^[64]