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The recognition and diagnosis of pediatric strokes (PS) or cerebrovascular accidents (CVA) is a well known challenge.1 In postoperative environments, additional factors such as sedation, regional anesthesia, and postoperative limitations exacerbate the difficulty.2 This overview of PS etiology and clinical characteristics includes postoperative guidelines and identifies current literature gaps.


As in adults, PS can be ischemic: Arterial Ischemic Stroke (AIS) and Cerebral Sinovenous Thrombosis (CSVT); or hemorrhagic (HS): intracerebral and subarachnoid hemorrhage. The presentation of these varies substantially both from each other and their adult counterparts. Younger children and infants may have unexpected presentations such as seizure, lethargy, crying, irritability, and sepsis-like symptoms, with focal deficits occurring in the following weeks to months.3,4 Older children show more classical CVA symptoms including hemiparesis, speech and vision changes, and headache.3 Due to these nonspecific symptoms and its infrequent nature, CVA is often low on a clinician’s differential. Established stroke scales such as the modified NIH Stroke Scale (mNIHSS) are not designed for postoperative use, causing difficulty in CVA evaluation as they poorly distinguish stroke from lingering anesthesia effects. For example, up to 30% of adult patients show acute postoperative mNIHSS increases, well above the incidence of both ischemic and hemorrhagic stroke.2 An equivalent postoperative study has not been performed for the Pediatric NIH Stroke Scale, likely due to communication difficulty and more diverse signs and symptoms in pediatric populations. Due to the difficulty of a symptoms based approach, it is important to consider risk factors in postoperative CVA evaluation as only 11-36% of PS cases have unknown etiology; known cardiac disease for example accounts for almost 20% of pediatric acute ischemic strokes.5


Recognition of postoperative CVA in children requires a multifaceted approach. While focal neurological deficits can indicate stroke at all ages, children may show nonspecific symptoms. The sedative effects of analgesics and anesthetics in addition to the inherent communication difficulties with pediatric diagnosis should not reduce suspicion for CVA when evaluating children with CVA risk factors exhibiting nonspecific systemic symptoms in postop recovery.


  1. 10.1542/peds.2005-2676
  2. 10.1097/ANA.000000000000068
  3. 10.1155/2011/734506
  4. 10.1212/WNL.0000000000000343
  5. 10.1212/WNL.54.2.371



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