Paediatric stroke and cerebral sinovenous thrombosis: Viva

Branch 1: Classification and the bedside approach

The candidate should classify paediatric stroke into arterial ischaemic stroke, cerebral sinovenous thrombosis, and haemorrhagic stroke, and state that the division matters because each form carries a distinct cause, imaging target, and treatment. A strong candidate states that this girl, with headache, papilloedema, seizures, and a recent ear infection, has the classic presentation of cerebral sinovenous thrombosis, and that the ear infection likely spread to the adjacent dural sinuses to produce a transverse or sigmoid sinus thrombosis. [2]

If the examiner presses on the bedside approach, the candidate should state that the first move is to assess and support the airway, breathing, and circulation, to check the bedside glucose, and to establish the time of onset. The candidate should state that the stroke alert is activated, that the paediatric neurology and radiology teams are notified, and that the urgent imaging request is for an MRI brain with diffusion-weighted imaging, MRA, and MRV, because the MRV is the sequence that will reveal the venous sinus thrombosis that a plain MRI or CT would miss. [9]

Branch 2: The management of cerebral sinovenous thrombosis

If asked to manage this girl, the candidate should state that the definitive treatment is anticoagulation with unfractionated heparin or low-molecular-weight heparin. The candidate should give the enoxaparin dose at 1 mg per kg subcutaneously every twelve hours in a child over two months, and state that unfractionated heparin is an alternative when rapid reversal may be needed, given as a loading bolus of 75 units per kg followed by a maintenance infusion titrated to the anti-Xa level. The candidate should state that anticoagulation is continued for three to six months, and that the underlying ear infection is treated with antibiotics and, if needed, surgical drainage of the mastoid. [9][2]

If the examiner presses on the apparent paradox of anticoagulating a child who may have a haemorrhagic venous infarct, the candidate should explain the mechanism. The venous outflow obstruction raises the pressure in the upstream cortical veins, the thin-walled veins rupture, and the haemorrhagic infarct is a consequence of the obstruction. The anticoagulation removes the obstruction and addresses the root cause, which is why the American Heart Association recommends initiating anticoagulation even when haemorrhagic infarction is present. The candidate should cite deVeber and colleagues, who established the modern understanding of paediatric cerebral sinovenous thrombosis, and state that withholding anticoagulation out of fear of the bleed is the classic pitfall. [1][2]

Branch 3: The arterial ischaemic stroke scenario and the thrombolysis question

If the examiner shifts the scenario to an arterial ischaemic stroke, the candidate should state that the management is supportive care with antithrombotic therapy. Aspirin 1 to 5 mg per kg per day is the standard secondary prevention for most non-cardioembolic strokes, and anticoagulation is used for cardioembolic stroke, dissection, and documented prothrombotic conditions. The candidate should state that every childhood arterial ischaemic stroke needs a full vascular workup with MRA at the outset and serial imaging over months, because arteriopathy is the strongest predictor of recurrence. [2]

If the examiner asks about thrombolysis, the candidate should state that intravenous alteplase is not routinely recommended for paediatric arterial ischaemic stroke outside a clinical trial. The candidate should describe the Thrombolysis in Pediatric Stroke trial, which was the first prospective study of intravenous alteplase in children and which showed that children achieved lower systemic alteplase levels than adults at the standard 0.9 mg per kg dose, and which was closed early due to slow enrollment and could not establish efficacy. The candidate should conclude that this distinguishes paediatric stroke management sharply from adult practice, where thrombolysis is standard for eligible patients, and that the current paediatric standard is supportive care with antithrombotic therapy and a structured secondary prevention plan. [5][2]