Stroke in Childhood Guideline

Prepared by the Paediatric Stroke Working Group
November 2004
Stroke in childhood
Clinical guidelines for diagnosis,
management and rehabilitation
Clinical Effectiveness
& Evaluation Unit
ROYAL COLLEGE OF PHYSICIANS
The Clinical Effectiveness and Evaluation Unit
The Clinical Effectiveness and Evaluation Unit (CEEU) of the Royal College of Physicians has expertise in the
develoment of evidence-based guidelines and the organising and reporting of multicentre comparative
performance data. The work programme is collaborative and multiprofessional, involving the relevant
specialist societies and patient groups, the National Institute for Clinical Excellence (NICE) and the
Healthcare Commission. The CEEU is self-financing with funding from national health service bodies, the
Royal College of Physicians, charities and other organisations.
Acknowledgement
The development of these guidelines was supported by funding from a variety of sources including: The
Stroke Association, Different Strokes, Boehringer Ingelheim, Merck Sharp & Dohme, and Sanofi-Synthelabo
& Bristol-Myers Squibb.
The Royal College of Physicians is also pleased to acknowledge a grant from The Haymills Charitable Trust
towards the cost of designing and printing the guidelines.
Front cover
Design by Merriton Sharp, London.
The cover photograph, of a young boy who suffered a stroke at 15 months but who has made an almost
complete recovery, is used by kind permission of Derek and Jane Walker and Different Strokes.
Different Strokes, 9 Canon Harnett Court, Wolverton Mill, Milton Keynes MK12 5NF. Tel: 0845 130 71 72;
E-mail: info@differentstrokes.co.uk; Website: www.differentstrokes.co.uk.
Website addresses
Every effort has been made to ensure that the website addresses in this document are valid at the time of
going to press. However, readers should be aware that they may be subject to change over time.
Royal College of Physicians of London
11 St Andrews Place, London NW1 4LE
Registered Charity No 210508
Copyright 2004 Royal College of Physicians of London
ISBN 1 86016 236 3
Text design by the Publications Unit of the Royal College of Physicians
Typeset by Dan-Set Graphics, Telford, Shropshire
Printed in Great Britain by The Lavenham Press Ltd, Suffolk
iii
The Paediatric Stroke Working Group
Vijeya Ganesan (Chair)
Senior Lecturer in Paediatric Neurology, Institute
of Child Health, University College London
Kling Chong
Consultant Neuroradiologist, Great Ormond
Street Hospital for Children NHS Trust
Jane Evans
Consultant Paediatric Haematologist, University
College London Hospital
Anne Gordon
Research Occupational Therapist, Institute of
Child Health, University College London
Dianne Gumley
Consultant Clinical Psychologist, Great Ormond
Street Hospital for Children NHS Trust
Penny Irwin
Stroke Programme Co-ordinator, Royal College of
Physicians, London
Fenella Kirkham
Reader in Paediatric Neurology, Institute of Child
Health, University College London
Janet Lees
Consultant Speech and Language Therapist and
Honorary Lecturer, Department of Human
Communication Sciences, University of Sheffield,
and Honorary Research Fellow, Neurosciences
Unit, Institute of Child Health, University College
London
Donal OKelly
Different Strokes
Terry Pountney
Senior Physiotherapist, Chailey Heritage School,
East Sussex
Eoin Redahan
The Stroke Association
Susan Rideout
Clinical Specialist Paediatric Neurology,
Physiotherapy Department, Birmingham
Childrens Hospital
Dominic Thompson
Consultant Neurosurgeon, Great Ormond Street
Hospital for Children NHS Trust
Beth Ward
Clinical Nurse Specialist, Great Ormond Street
Hospital for Children
Sue Wayne
Andrew Williams
Consultant Community Paediatrician,
Northampton General Hospital
Keith Wood
Different Strokes
Sickle cell subgroup
Kofi Anie
Consultant Clinical Psychologist, Brent Sickle Cell
& Thalassaemia Centre
Lola Oni
Nurse Director/Lecturer, Brent Sickle Cell &
Thalassaemia Centre
The Paediatric Stroke Working Group iii
Foreword vii
The child and family perspective ix
INTRODUCTION
1 Introduction 3
1.1 Background 3
1.2 Scope of the guidelines 4
1.3 Purpose of the guidelines 4
1.4 Methodology 4
1.5 Context and use 6
2 Terminology and theoretical framework 7
2.1 The International Classification of Functioning, Disability and Health 7
3 Service organisation 13
4 Children and their families 17
4.1 Consent 17
4.2 Families and carers 17
5 Acute diagnosis of arterial ischaemic stroke in children 21
5.1 Definition 21
5.2 Presentation and diagnosis 21
5.3 Investigations 23
6 Acute care 25
6.1 General care measures 25
6.2 Specific medical treatments 26
6.3 Secondary prevention of arterial ischaemic stroke in childhood 27
6.4 Early disability assessment and management 29
v
Chapter 8
Contents
Stroke in childhood: clinical guidelines for diagnosis, management and rehabilitation
7 Approaches to rehabilitation 31
7.1 Sensorimotor rehabilitation 32
7.1.1 Underlying approach to sensorimotor therapy 32
7.1.2 Delivery of sensorimotor therapy 33
7.1.3 Use of assessment measures 33
7.2 Motor impairment 34
7.2.1 Muscle strengthening 34
7.2.2 Management of spasticity 34
7.2.3 Ankle foot orthoses 35
7.3 Sensory impairment 36
7.3.1 Somatosensory impairment 36
7.3.2 Hearing and vision impairment 36
7.3.3 Pain 36
7.4 Language and communication 37
7.5 Cognitive affects 38
7.6 Mood and behaviour 40
7.7 Activities of daily living 41
8 Longer-term and community care 43
8.1 Return to school 43
8.2 Transition between paediatric and adult services 45
9 Primary prevention 47
APPENDICES
Appendix 1: Peer reviewers 51
Appendix 2: Proposed audit criteria 53
Appendix 3: An example of the ICF 55
Appendix 4: Useful addresses 57
EVIDENCE TABLES 61
REFERENCES 77
vi
Stroke, in both adults and children, used to be something that happened but which medicine
could do, or chose to do, little about. Over the last decade there has been a revolution in
stroke care for adults, with the advent of specialist stroke units and evolving treatments.
Publication of the first edition of the National clinical guidelines for stroke in 2000 and the
National Sentinel Audit of Stroke stimulated local units to consider the quality of the care
they were delivering and put improvements in place. Rehabilitative care after stroke for
adults is now considered the norm, and the collaboration between physicians, nurses,
therapists and patients in these projects has led to true multidisciplinary working much
to the benefit of patients.
Similar improvements, however, have not be seen in the treatment of childhood stroke
which, although less common than adult stroke, is still a serious problem and one which
anecdotal evidence suggests is prone to an even more variable quality of care. Thus, when
the national guidelines were being revised by the Intercollegiate Stroke Working Party, a
subgroup was formed to consider the paediatric aspects of stroke care. During development
it became clear that little evidence existed for many areas. The gaps were filled using the
expertise of the group and the views of patients, parents and carers, but it is clear that there
is a need for more formal research.
This guideline is aimed at healthcare staff in all parts of the NHS and related services, but
much of it may also be of value to patients, parents and families. It is hoped that it will help
childhood stroke services to emulate the improvement that has occurred, and is continuing
to occur, in the care of adults, bringing a consistency and a knowledge of best practice to
an area marked until now by dislocated care and uncertain standards.
To the casual reader wondering if this is important I would urge you to begin by glancing
at the italicised quotes from participants in the child and carer workshop which are scattered
through the document. They plainly show how much more should and can be done to
ensure good acute management, rehabilitation and secondary prevention, and to help these
young people and their parents and families adjust to and cope with the effects of their
stroke. Children have a lifetime ahead of them any benefits from improved care will also
last a lifetime.
November 2004 Professor Mike Pearson
Director, Clinical Effectiveness and Evaluation Unit,
Royal College of Physicians
vii
Chapter 8
Foreword
As part of the guideline development process a workshop was held for children affected by
stroke and their families. It gave a sense of the issues children and families felt to be
important. We particularly focused on these issues in developing the guidelines, and they
are outlined here.
The child is part of a family and, therefore, any childhood illness will have effects on both
the immediate and extended family. The diagnosis of stroke is an unexpected one in a child,
which compounds the shock experienced by families at the time of diagnosis.
The lack of information for families of children affected by stroke was a strong theme in
the workshop. Information on what has happened and what to expect could empower
families to ensure that the immediate and long-term needs of their child can be met.
Information for parents, carers and children should be designed to meet their specific needs.
The same information pack is unlikely to be appropriate in all cases but the information
leaflet provided with this document may form a useful starting point. It is important that
the questions asked by parents, carers, and children are answered. The communication of
information to children is often particularly neglected.
Parents and carers of children affected by stroke welcome support from those who have
had similar experiences they appreciate someone to talk to about what has happened and
to help them look at the future. Children also welcome meetings with those in their own
age group affected by stroke. Both parents and children explained that the diagnosis of
stroke is traumatic and that they need help in adjusting. It is important for families to see
that life goes on. At the end of this document there is a list of useful organisations, including
support groups, which may be able to provide information and support.
Families commented on significant gaps in communication between the various
professional teams involved in the care of a child affected by stroke, and, as discussed above,
between professionals and the family. This is an area which is extensively addressed in the
guidelines.
There are significant problems in accessing therapy following childhood stroke in some
areas. It is important that there is a coherent plan for rehabilitation which takes into account
all of the childs needs and which can be met within local resources. Gaps in service provision
should be highlighted and brought to the attention of service planners.
ix
Chapter 8
The child and family perspective
Introduction
4 Early disability assessment and man agement
Chapter 8
1 Introduction
1.1 Background
Childhood stroke is a neglected area, with both professionals and the general public lacking
awareness of the problem and its potential consequences. Stroke affects several hundred
children in the UK each year and is one of the top ten causes of childhood death (Fullerton
et al 2002). Many children who have a stroke have another medical condition (such as a
cardiac disorder or sickle cell disease) and, therefore, are already vulnerable to adverse
neurodevelopmental effects (Lanthier et al 2000, Ganesan et al 2003). The prevalence of
sickle cell disease varies widely within the United Kingdom. However, it is noteworthy that
at least 10% of these children and young people will have a stroke during childhood. The
burden of childhood stroke on the health services is, numerically, smaller than stroke in
the elderly. However, the long-lasting physical, emotional and social effects of stroke on an
individual near the beginning of their life affect not only the individual themselves, but
also their family and society as a whole.
Many professional agencies can be involved in helping the affected child fulfil their potential
and in providing support and advice to the family. These agencies may change in the course
of the childs life and it is important that they are all aware of the consequences of childhood
stroke, and that their efforts are co-ordinated. The childs cognitive, social and emotional
needs are in constant evolution and the functional impact of childhood stroke may, as a
consequence, vary over time.
We have taken a child-centred approach to formulating these guidelines, working in
partnership with children, families and support groups, specifically seeking the views of
children and families, and centring the guidelines on issues raised by them. Throughout
this document use of the term parents is intended to encompass the childs parents and
any other carers.
The large number of consensus statements and good practice points in these guidelines
emphasise that research in the field of childhood stroke is urgently needed to provide
definitive answers to many of the issues raised. There is an acknowledged need for
multicentre collaboration in such research to enable the design of studies with sufficient
power to produce definitive results. The networks necessary for this are beginning to be
established and may lead to work which could provide a firmer evidence base for the care
of children affected by stroke.
Participant in paediatric stroke workshop: I am not a stroke, I have had one.
3
1.2 Scope of the guidelines
These guidelines will primarily address the diagnosis, investigation and management of
acute arterial ischaemic stroke in children beyond the neonatal period (aged one month to
18 years at time of presentation), including acute presentation and management,
rehabilitation and longer-term care. Many of the issues covered here, in particular those
relating to rehabilitation, will also be relevant to children with other causes of stroke (for
example cerebral venous infarction, neonatal stroke or intracranial haemorrhage).
1.3 Purpose of the guidelines
These guidelines are aimed at professionals working in primary care, secondary level acute
and community paediatrics, tertiary level paediatric neurology and neurodisability,
education, and social services. The aim of the guidelines is to provide evidence-based
recommendations for clinicians.
1.4 Methodology
These guidelines were formulated in accordance with the principles specified by the
Appraisal of Guidelines Research and Evaluation (AGREE) collaboration (www.
agreecollaboration.org)
Following the publication of the National Clinical Guidelines for Stroke in 2000
(Intercollegiate Working Party for Stroke 2000) referred to hereafter, along with the second
edition (Intercollegiate Stroke Working Party 2004), as the adult guidelines several parties
approached the Royal College of Physicians inquiring about guidelines for childhood stroke.
The British Paediatric Neurology Association instigated a working party to formulate
guidelines. This work was done in collaboration with the Clinical Effectiveness and
Evaluation Unit of the Royal College of Physicians. Potential members were identified
through their recognised record of clinical and research activity in the field of paediatric
stroke and also through their professional organisations. Representation was sought across
a broad range of disciplines and two patient organisations (the Stroke Association and
Different Strokes). The members of the working party are listed at the front of this book.
Conflicts of interest were declared and monitored (and full statements held on file).
The working party began by constructing a list of headings using the existing adult stroke
guidelines (Intercollegiate Working Party for Stroke 2000) as a reference. We also considered
specific additional issues relevant to children (for example, return to school). For each area,
the group decided on a list of specific questions that would be considered. Searches were
done using key words relevant to these questions of available computerised databases from
1966 onwards: Medline, AMED, CINAHL and Embase. In addition, the Cochrane
Collaboration database was searched and other national guidelines and publications were
reviewed. Members of the working party brought their own expertise and knowledge of
the literature, as well as information from their organisations and professional bodies.
4
1 Introduction
Topics were divided and allocated to individual members for evaluation according to their
expertise. These individuals had responsibility for appraising the evidence and drafting the
recommendations. The Scottish Intercollegiate Guidelines Network (SIGN 50) guidelines
appraisal checklists were used to assess the quality of published articles (www.sign.ac.uk/
guidelines). Guidelines were written on the basis of the available evidence with grading of
the strength of the recommendation and explanatory statements where necessary. All
recommendations were then presented to the working party as a whole for discussion and
agreement.
Selection of articles for inclusion was based on the following principles. Where evidence
specifically relating to childhood stroke was available, this alone was used. However, such
literature is extremely limited and, therefore, research from other paediatric neurological
conditions was evaluated where these conditions were felt to be relevant to the issues being
considered. If a recommendation was based on extrapolation from research in a different
population to that covered by the guideline, the grade of recommendation was reduced by
one level.
Where evidence from meta-analyses or randomised controlled trials (RCTs) was available,
this was used. Where there was limited or no evidence from RCTs, then evidence from
observational group studies or small-group studies was used. In general, evidence from
single-case studies was not used, primarily because it is difficult to draw general conclusions
from them. Where there was no evidence base to support guidelines in areas which were
highly relevant to clinical practice, consensus statements from this working party, other
working parties and professional bodies were used. Many recommendations are in line
with those in the developing National Service Framework for Children (www.dh.gov.uk/
PolicyAndGuidance/HealthAndSocialCareTopics/ChildrenServices/fs/en).
The strength of evidence and recommendations were graded using the scheme proposed
by SIGN 50 and summarised in tables 1.1 and 1.2, overleaf. The Evidence sections following
guidelines give an indication of the nature and extent of the supporting evidence, together
with key references. Lastly, for each topic, there is an evidence table or group of evidence
tables giving further details of the main studies.
Children affected by stroke and their parents were invited to attend a structured workshop
in order to identify areas they thought should be addressed within the guidelines. The
findings were used to identify key themes, which were subsequently incorporated into the
issues addressed by the guidelines.
All the guidelines have been peer reviewed by external reviewers, a group which included
a range of stakeholders (see Appendix 1).
5
1.5 Context and use
These guidelines are intended to inform clinical decisions rather than to be rigidly applied.
6
Table 1.1 Guideline strength: levels of evidence
Level of
evidence Type of evidence
1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk
of bias
1+ Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk
of bias
I Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++ High quality systematic reviews of case control or cohort studies; high quality case
control or cohort studies with a very low risk of confounding, bias or chance and a high
probability that the relationship is causal
2+ Well-conducted case control or cohort studies with a low risk of confounding, bias or
chance and a moderate probability that the relationship is causal
2 Case control or cohort studies with a high risk of confounding, bias or chance and a
significant risk that the relationship is not causal
3 Non-analytic studies, eg case reports, case series
4 Expert opinion
Table 1.2 Guideline strength: grades of recommendation
Grade of
recommendation Evidence
A At least one meta-analysis, systematic review or RCT rated as 1++, and directly
applicable to the target population; or, a systematic review of RCTs or a body of
evidence consisting principally of studies rated as 1+, directly applicable to the target
population and demonstrating overall consistency of results
B A body of evidence including studies rated as 2++, directly applicable to the target
population, and demonstrating overall consistency of results; or, extrapolated evidence
from studies rated as 1++ or 1+
C A body of evidence including studies rated as 2+, directly applicable to the target
population and demonstrating overall consistency of results; or extrapolated evidence
from studies rated as 2++
D Evidence level 3 or 4; or, extrapolated evidence from studies rated as 2+
A tick after a guideline represents a good practice point the recommended best
practice based on the clinical experience of the guideline development group

Chapter 8
2 Terminology and theoretical framework
A factor interfering with delivery of good stroke care for children is the lack of a widely
accepted framework of care and universal vocabulary and terminology. Health professionals
have widely varying experiences of childhood stroke, but the problem is exacerbated by the
variation in expertise and preferences for intervention in the absence of an accepted
framework. The revised World Health Organization (WHO) classification (International
Classification of Functioning, Disability and Health (ICF)) is intended to include all aspects
of the health of an individual throughout life. This is designed to replace the former ICIDH
(International Classification of Impairments, Disabilities and Handicap), which was widely
accepted and used in describing health.
2.1 The International Classification of Functioning, Disability and Health
ICF classifies health and health-related states. The unit of classification is categories within
health and health-related domains. It is important to note, therefore, that in the ICF persons
are not the units of classification; that is, ICF does not classify people, but describes the
situation of each person within an array of health or health-related domains. Moreover,
the description is always within the context of environmental and personal factors. This
interaction can be viewed as a process or a result depending on the user. For an example of
how the ICF might be used in practice, see Appendix 3.
Overview of ICF components
In the context of health:
i body functions are the physiological functions of body systems (including psychological
functions)
i body structures are anatomical parts of the body such as organs, limbs and their
components
i impairments are problems in body function or structure such as a significant deviation or
loss
i activity is the execution of a task or action by an individual
i participation is involvement in a life situation
i activity limitations are difficulties an individual may have in executing activities
i participation restrictions are problems an individual may experience in involvement in life
situations
7
i environmental factors make up the physical, social and attitudinal environment in which
people live and conduct their lives.
An overview of these concepts is given [in the table below]. As the table indicates:
i ICF has two parts, each with two components:
Part 1. Functioning and Disability
(a) Body Functions and Structures
(b) Activities and Participation
Part 2. Contextual Factors
(a) Environmental Factors
(b) Personal Factors
i Each component can be expressed in both positive and negative terms...
An overview of ICF
Part 1: Functioning and Disability Part 2: Contextual Factors
Components Body Functions Activities and Environmental Personal
and Structures Participation Factors Factors
Domains Body functions Life Areas External influences Internal influences
Body sructures (tasks, actions) on functioning and on functioning
disability and disability
Constructs Change in body Capacity
functions Executing tasks
(physiological) in a standard
Facilitating or
environment
hindering impact
Impact of
of features of the
attributes of the
Performance
physical, social
person
Change in body Executing tasks in
and attitudinal
structures the current
world
(anatomical) environment
Positive Functional and Activities
Aspect structural integrity Participation Facilitators not applicable
Functioning
Negative Impairment Activity limitation
Aspect Participation
restriction Barriers /
hindrances not applicable
Disability
Source: World Health Organization (2001) ICF: International Classification of Functioning Disability and Health. WHO:
Geneva. Available at: www3.who.int/icf/icftemplate.cfm
8
2 Terminology and theoretical framework
Guidelines
1 Each team should use a consistent framework and terminology in providing care to the
child affected by stroke
2 It is recommended that the World Health Organizations International Classification of
Functioning (ICF) terminology is used
Evidence
1 & 2 Working party consensus
9
The guidelines
Chapter 8
3 Service organisation
Children affected by stroke make use of all levels of health, education and social services
in the United Kingdom. From a medical perspective the patient journey can be considered
in terms of acute medical care, and both acute and longer-term rehabilitation. Rehabilitation
should be integrated with the childs educational, social and emotional needs.
In contrast to adult stroke, where the model is to develop specialist stroke services, the relative
rarity of childhood stroke means that existing primary, secondary and tertiary systems of child
health will appropriately be involved. These services and their potential roles are outlined
in Table 3.1, overleaf. Services for the rehabilitation and longer-term needs of children with
any acquired brain injury, including stroke, are relatively underdeveloped in the United
Kingdom; in fact, their care challenges services and processes in both health and education,
which are typically built around the needs of children with much more stable, slowly changing
requirements (eg those with cerebral palsy). Although the development of more accurately
targeted services is being proposed, the following section will describe the potential roles, and
involvement in the management of children affected by stroke, of services as they are currently
structured. The wide variation in the nature and potential severity of the long-term effects of
stroke means that it is difficult to propose a single approach which would be suitable for all
children, and the applicability of each recommendation to the specific child and family should
be considered.
It is our view that all children affected by acute stroke should be referred to a consultant
paediatric neurologist. However, it may not always be appropriate for the child to be
transferred to an acute paediatric neurology unit. If this is the case, the childs management
should be discussed with the tertiary level paediatric neurology service. At present many,
but not all, tertiary paediatric neurology units have multidisciplinary teams with expertise
in the evaluation of children with acquired neurological problems. However in other tertiary
centres, and many secondary centres, formal acute-based teams do not exist and are
convened on an ad hoc basis. Where specialist expertise is not available locally professionals
are encouraged to liaise with, and obtain advice from, colleagues in specialist centres. The
needs of the child must remain central to the consideration of which professionals to involve.
The lack of structured paediatric rehabilitation services could be attributed to i) a lack of
research regarding long-term outcomes of acquired brain injury in childhood, ii) a misplaced
optimism regarding the plasticity of the childs brain and the potential for recovery, iii) a lack
of appreciation of the developmental context, and the fact that effects not apparent
immediately may emerge with time, iv) a lack of recognition of the invisible consequences
of brain injury (for example, cognitive or emotional effects). These factors all need to be
taken into account when considering the services available to children affected by stroke. The
13
14
Table 3.1 Composition of current paediatric services in the United Kingdom and potential
roles in the care of children affected by stroke
Service Professionals Roles
Tertiary care services
Specialist childrens Paediatric neurologist Establish diagnosis
hospital Nursing staff Acute medical (or surgical) treatment
Allied health professionals Early disability assessment and treatment
(occupational therapist, during inpatient period
physiotherapist, speech and Liaison with secondary acute and community
language therapist) services (including provision of advice and
Clinical psychologist support to secondary services after discharge)
Social worker
Other tertiary level paediatric
specialists
Specialist childrens Paediatrician with Assessment of impairment and disability
rehabilitation unit neurodisability or rehabilitation Rehabilitation
training Plan for transition to community services
Nursing staff Liaison with secondary acute and community
Allied health professionals services (including provision of advice and
Educational psychologist support to secondary services after
Teacher discharge)
Child and adolescent mental
health professionals
Secondary care services
Acute paediatrics Consultant paediatrician Establish diagnosis
Nursing staff Acute medical treatment
Allied health professionals Early disability assessment and treatment
Social worker during inpatient period
Teacher May take on longer-term rehabilitation
depending on availability of local services
Liaison with tertiary hospital and community
services
Community child health Child development service Assessment of impairments and disabilities
usually includes (Standards for Set up and deliver long-term package of care
child development services Liaison with educational and social services,
(RCPCH 1999)): secondary and tertiary hospital paediatric
Consultant paediatrician services
Community nurse
Allied health professionals
Clinical psychologist
Social worker
Portage worker
Teacher
Child psychiatrist
Educational psychologist
Primary care services
General practice General practitioner Ongoing developmental surveillance
Health visitor Management of general medical issues
Community nurse Liaison with secondary and tertiary care
services as required
3 Service organisation
proposed national working group to develop a paediatric rehabilitation policy would be
highly relevant to children affected by stroke. At present there are only 50 specialist paediatric
rehabilitation beds in the UK. This means that the rehabilitation of the majority of children
affected by stroke will take place either in the community or on general paediatric wards.
Multidisciplinary assessment and co-ordination, and the provision of long-term care, are
usually undertaken by community child health services, most often by the child
development service. It is also at this level that ongoing liaison between health, social and
education services should occur. In many areas there will be a specific team, usually based
in a child development centre, responsible for children aged five and under with disabilities
(Standards for child development services (RCPCH 1999)). The community child health
service, alongside professionals in the education services, will also be involved in the
management of school age children. It is important that services are not duplicated and
that all those involved are clear on who is taking the lead.
Primary care services are usually involved in general health issues, and the childs general
practitioner should be routinely and regularly informed by tertiary and secondary services
of a childs health and the services they are using. The health visitor may play an important
co-ordinating role within the multidisciplinary team.
Effective multi- and inter-agency working is essential to ensure comprehensive care in the
rehabilitation of children with acquired brain injury. This is also emphasised in several
documents, for example Together from the start (DfES 2002), and the Standards for child
development services (RCPCH 1999). Developments in information sharing resources, such
as the forthcoming Integrated Childrens System (DfES) should facilitate multi- and
interagency working.
The aim of team-working is to provide a smooth, coordinated and integrated service for
children and their families. A team is defined as a group of people working towards a single
goal or set of goals, but it is important that this is an interactive effort. The aim of the
multidisciplinary team is to provide a holistic perspective of the child and family in planning
or providing interventions, and to stop any duplication of questions, assessments or services.
The model of having a key worker for the child and family is controversial and has not been
researched in this group of children. However, documents relating to the management of
children with disability (for example Together from the start (DfES 2002) and Standards for
child development services (RCPCH 1999)) as well as the recent green paper, Every child matters
(DH 2003b), advocate such a model. Given the complex and evolving nature of the potential
consequences of childhood stroke and the multitude of agencies which could be involved,
we feel that a key worker is likely to increase the likelihood of delivering a co-ordinated care
package. A key worker is defined as a person who works in partnership with the family, with
the function of co-ordinating service provision and serving as a point of reference for the
family (Together from the start, DfES 2002). A further critical aspect of this role is that the
key worker takes responsibility for ensuring delivery of the package of care. Any professional
could take on the role of key worker, but it is likely to be most appropriate that this is a
member of the secondary level team. Additional factors which should influence the choice
of the key worker are the preference of the child and family and the key workers competencies.
The family should be given clear information about the identity and role of their key worker.
15
Guidelines
1 All children with acute stroke should be referred to, or have their management discussed
with, a consultant paediatric neurologist
2 Where specialist expertise is not available locally, professionals from all disciplines are
encouraged to liaise with, and obtain advice from, colleagues in specialist centres
regarding the acute assessment and management of the child affected by stroke
3 Care should be provided in an environment that is appropriate for the childs age and
developmental level (D)
4 The medical, social, emotional and educational needs of the child affected by stroke
should be considered early and systematically assessed in a co-ordinated manner when
planning their subsequent care (D)
5 All members of the healthcare team should work together with the child and family,
using an agreed therapeutic approach (D)
6 The longer-term management of the child affected by stroke should be co-ordinated by
a consultant paediatrician
7 A multidisciplinary team with expertise in the care of children with neurological
conditions should be involved in the management of the child affected by stroke. Whilst
this may initially be at tertiary level, it is essential that the relevant secondary level child
development service is involved from an early stage
8 A key worker should be appointed to co-ordinate the package of care, ensure its delivery
and to act as a central point of contact for the family (D). The key worker and their role
should be explained to the family
Evidence
1 Consensus of working party
3 Recommendation 18 of Learning from Bristol: the report of the public inquiry into
childrens heart surgery at the Bristol Royal infirmary 19841995 (www.bristol-
inquiry.org.uk); Childrens National Service Framework (www.dh. gov.uk) (4)
4 Together from the start (DfES 2002) (4); Standards for child development services (RCPCH
1999) (4)
5 Standards for child development services (RCPCH 1999) (4)
8 Together from the start (DfES 2002) (4); Standards for child development services (RCPCH
1999) (4)
16
Chapter 8
4 Children and their families
4.1 Consent
Children, whatever their age, have a right to be consulted and informed about any proposed
treatment. The UN Convention on Childrens Rights recognises the right of children to
make informed decisions. Information (either verbal or written) needs to be accessible to
children. Their dignity, self-respect, and rights to self-determination and non-interference
should be preserved (www.unicef.org/crc/crc.htm).
The Children Act 1989 and European Association for Children in Hospital charter
(www.each-for-sick-children.org/charter.htm) require that children and parents
participate in decision-making. Childrens feelings and wishes should be sought and taken
into account, and any reasons for not following them should be explained. Religious
persuasion, racial origin, culture and language should also be considered. Children should
be protected from unnecessary treatment and interference. The Gillick Judgement (Gillick
v West Norfolk Health Authority 1985) requires that consent be given by a child if they have
sufficient understanding and intelligence to enable understanding fully what is proposed,
even if under the age of consent.
4.2 Families and carers
The child and family perspective
I wanted to know if I could use my hand normally, how long it would take to heal (participant
in paediatric stroke workshop).
Parents of affected children had experienced not being told what is going on and being kept
in the dark. Parents and carers also reported feelings of helplessness, distress and guilt from
witnessing their childrens pain and fear and being unable to help them: I felt helpless, I
couldnt do anything for her, I rushed to the hospital, all I could hear was my niece screaming
I cried, saying to myself shes only 15 years old, Seeing your child suffering and feeling guilty.
Parents found it hard when they felt that their knowledge of their child was ignored: The
staff at hospital who did not listen to mother, Not having your mothering/fathering instincts
listened to. Parents suggested that it would be helpful if doctors could talk to them using
more accessible language when explaining what is wrong with their child: Getting doctors
to explain the childs condition in layman terms, not doctor speak.
Parents also reported significant emotional problems following their childs stroke and
17
suggested that meeting other parents would be very beneficial: We have at times both
seriously contemplated suicide, Parents benefit from meeting other parents.
The majority of parents felt that they have to constantly fight public services so their child
can receive the care and treatment that they should be getting: Having to constantly fight
for the justice of your child, Having to fight/ask for help when you are so vulnerable.
All quotes are from participants in the paediatric stroke workshop.
Communication with the child and their family
The recognition that the child is part of a family is central to paediatric care. Any childhood
illness has an impact on the whole family, including parents, siblings and grandparents.
Childhood stroke has been shown to have an adverse impact on parents emotional and
physical health (Gordon et al 2002).
Stroke is a completely unexpected illness in a child and parents and children feel emotionally
devastated by the diagnosis. This is compounded by the lack of awareness of childhood
stroke amongst professionals, which means that it is often left to the child and family to
pursue treatment, rehabilitation and appropriate educational support. All professionals
should be aware of the stress associated with a diagnosis of stroke on the child and family
from the outset. The importance of emotional support and sensitive and comprehensive
communication at the time of diagnosis of a disorder with potential long-term
developmental consequences is emphasised in Together from the start (DfES 2002) and the
Standards for child development services (RCPCH 1999).
The Stroke Association and Different Strokes (see Appendix 4 for contact details) provide
information and support for children affected by stroke and their families. Children, family
members or carers need both factual and practical information at various stages, presented
in a format appropriate to their needs (Rushforth 1999; Helps et al 2003). It should be
recognised that parents have particular knowledge of their child and, therefore, their
concerns should be addressed in planning the childs care and educational placement.
Guidelines
1 Families/carers should be given factual information about their childs condition as soon
as possible after diagnosis (D). This should be simple and consistent, avoiding technical
terms and jargon
2 Written information should be provided to the child and family regarding the childs
health and the statutory and voluntary services available (D)
3 Children should be given information about their condition at an appropriate level (D)
4 The child and family should be involved in making decisions about the childs care,
including rehabilitation and education (D)
5 The multidisciplinary health team at secondary level should provide co-ordinated care
and liaise closely with education and social services through the key worker (D)
18
4 Children and their families
Evidence
1 Paediatric stroke workshop (4); Together from the start (DfES 2002) (4); Standards for
child development services (RCPCH 1999) (4)
2 Together from the start (DfES 2002) (4); Paediatric stroke workshop (4)
3 Rushforth 2002 (4)
4 Report of Bristol enquiry (www.bristol-inquiry.org.uk) (4); Together from the start (DfES
2002) (4); Standards for child development services (RCPCH 1999) (4); Childrens National
Service Framework (DH 2003a) (www.dh.gov.uk) (4)
5 Consensus of working party (4); Mukherjee et al 1999 (4)
19
Chapter 8
5 Acute diagnosis of arterial ischaemic
stroke in children
5.1 Definition
The World Health Organization defines stroke as a clinical syndrome typified by rapidly
developing signs of focal or global disturbance of cerebral functions, lasting more than
24 hours or leading to death, with no apparent causes other than of vascular origin (World
Health Organization 1978). This definition is a clinical one and such a presentation has
many potential underlying causes in childhood. Brain imaging is mandatory for accurate
diagnosis, subsequent referral and, in particular, to exclude conditions requiring urgent
neurosurgical intervention. Arterial ischaemic stroke, which is the main focus of these
guidelines, can be defined as a clinical stroke syndrome due to cerebral infarction in an
arterial distribution. Transient ischaemic attacks (TIAs) (where the neurological deficit
resolves within 24 hours) may also occur in children. Although clinical symptoms may be
transient, a significant proportion of children with this presentation have cerebral
infarction. Terms such as acute infantile hemiplegia are clinical descriptions, which do not
identify the underlying aetiology; they should, therefore, be avoided.
The following sections will deal, firstly, with guidelines for establishing a diagnosis in a
child presenting with an acute clinical stroke syndrome (section 5.2), and then discuss the
further investigation of children with a diagnosis of arterial ischaemic stroke in order to
establish underlying aetiology (section 5.3). It may be pragmatic to combine the initial
(diagnostic) and subsequent investigations, especially in the case of imaging, and both
sections should, therefore, be considered together.
5.2 Presentation and diagnosis
At the time of stroke children and families reported feelings such as frightened, annoyed, angry,
confused, devastated.
Parents reported feeling concerned and frightened at the amount of time they had to wait for diagnosis,
treatment and information about their childs condition: Sitting for hours in the emergency department,
with , before it was finally acknowledged she had had a stroke (parent participant in paediatric
stroke workshop).
21
Recognition of clinical stroke may be difficult, particularly in infants and young children,
and especially as neurological signs may be relatively subtle. If there is doubt, the child
should be examined by a senior paediatrician. The most common clinical presentation of
clinical stroke in childhood is with acute hemiparesis. Focal signs may be absent in neonates
or young infants, in whom seizures may be the only manifestation of clinical stroke. Clinical
symptoms and signs of arterial ischaemic stroke may be particularly subtle in children with
sickle cell disease, and may be difficult to distinguish from painful crisis or the effects of
treatment, for example treatment with opiates. Advice should be sought from a tertiary
centre if there is concern about the acquisition and interpretation of imaging studies in a
child with clinical stroke.
Guidelines
1 All children with a clinical presentation of stroke should be under the care of a consultant
paediatrician
2 Cross-sectional brain imaging is mandatory in children presenting with clinical stroke (C)
3 Brain magnetic resonance imaging (MRI) is recommended for the investigation of
children presenting with clinical stroke (C)
4 Brain MRI should be undertaken as soon as possible after presentation. If brain MRI
will not be available within 48 hours, computed tomography (CT) is an acceptable initial
alternative
5 Brain imaging should be undertaken urgently in children with clinical stroke who
have a depressed level of consciousness at presentation or whose clinical status is
deteriorating
6 Any new neurological symptoms or signs in children with sickle cell disease should be
evaluated as potentially being due to stroke
7 All children with clinical stroke should have regular assessment of conscious level and
vital signs
Evidence (Tables 1 and 2)
2 Ganesan et al 2003 (2+)
3 Bryan et al 1991 (2+); Kucinski et al 2002 (2+); Barber et al 1999 (2); Lansberg et al
2000 (2)
22
5 Acute diagnosis of arterial ischaemic stroke in children
5.3 Investigations
This section aims to provide some guidance about investigations in the evaluation of a child
with arterial ischaemic stroke; it is not, however, intended to be comprehensive. There are
many potential risk factors for arterial ischaemic stroke in children and the diagnostic
process should be directed towards identifying as many of these as possible. The proportion
of patients in whom no risk factors are identified has decreased as understanding of aetiology
and investigation methods have improved. There is little information on the diagnostic
sensitivity of individual investigations. Although the investigations discussed below should
be undertaken in all cases, other investigations may be indicated in individual patients, and
should be considered on a case-by-case basis. For a more complete discussion of this topic
see Kirkham 1999. A clerking checklist is provided to highlight important aspects of the
clinical history and examination.
Transfer to a tertiary centre may be necessary if facilities for definitive imaging or other
investigations (eg echocardiography) are not available locally. As mentioned in relation to
brain imaging, advice should be sought from a tertiary centre if there is concern about the
acquisition and interpretation of paediatric echocardiography.
Non-invasive cerebrovascular imaging with techniques such as MR angiography (Husson
et al 2003), CT angiography, ultrasound with Doppler techniques or a combination of such
modalities can be applied in the first instance, and may be adequate. The existing research
on paediatric arterial ischaemic stroke only includes studies limited to visualisation of the
arterial vasculature between the distal common carotid artery and the circle of Willis. The
value of imaging the aortic arch and its proximal main branches is unknown. It is
acknowledged that, in some cases, non-invasive angiographic techniques alone will not
provide sufficient information to enable the planning of subsequent management, and in
these cases catheter cerebral angiography may also be required. Due to the lack of specific
research evidence we have not made more detailed recommendations regarding imaging
sequences but a helpful discussion of these can be found in the review article by Hunter
(Hunter 2002).
If there are unusual features to the identified infarct, such as the anatomical location, the
presence of excessive brain swelling and then the possibility of venous infarction or
haemorrhage should be considered. More specific venous imaging investigations may then
be applied by the radiologist as necessary. In the first instance, non-invasive options such
as MR venography or CT venography are preferred over catheter angiography.
The yield of investigating children with arterial ischaemic stroke for thrombophilia is
variable and will depend on factors such as ethnicity. Protein C deficiency and elevated
lipoprotein(a) have been shown to be associated with an increased risk of recurrence
(Strater et al 2002). Although the appropriate preventative treatment in affected patients
is unknown, identification of a prothrombotic tendency may have other implications for
the childs more general health, for example risk of venous thrombosis. Additional specific
investigations to be included when screening for thrombophilia should be discussed with
the local haematology service, with consideration of the local prevalence of specific
thrombophilia.
23
The importance of more conventional childhood stroke risk factors in children with sickle
cell disease has not been evaluated. The clinical experience of the working party is that
these may play a role in some patients and therefore we would not exclude children with
sickle cell disease from the recommendations below.
Guidelines
1 Imaging of the cervical and proximal intracranial arterial vasculature should be
performed in all children with arterial ischaemic stroke (C)
2 Imaging of the cervical vasculature to exclude arterial dissection should be undertaken
within 48 hours of presentation with arterial ischaemic stroke
3 Transthoracic cardiac echocardiography should be undertaken within 48 hours after
presentation in all children with arterial ischaemic stroke
4 All children with arterial ischaemic stroke should be investigated for an underlying
prothrombotic tendency. This should include evaluation for protein C protein S
deficiency, activated protein C resistance, increased lipoprotein (a), increased plasma
homocysteine, factor V Leiden, prothrombin G20210A and MTHFR TT677 mutations
and antiphospholipid antibodies (C)
Evidence (Tables 3 and 4)
The papers cited here provide information about risk factors associated with childhood
arterial ischaemic stroke, but do not all provide direct information about sensitivity or
specificity of specific diagnostic tests in the context of childhood arterial ischaemic stroke.
1 Levy et al 1994 (2+); Ganesan et al 2002 (2+); Husson et al 2003 (2+); Ganesan et al
1999 (3)
4 Nowak Gottl et al 1999 (2+); deVeber et al 1998b (2+); Strater et al 2002 (2+); Subcommittee
for Perinatal and Pediatric Thrombosis of the Scientific and Standardization Committee
of the International Society of Thrombosis and Haemostasis (4)
24
Chapter 8
6 Acute care
This section relates to all aspects of acute care. Medical care, early evaluation of disability
and rehabilitation are equally important aspects. These guidelines assume that, as is usual
in the United Kingdom, the early care of a child who has had a stroke will be undertaken
in a specialist paediatric neurology or general paediatric ward.
The acute medical management of arterial ischaemic stroke can be divided into general
care measures and measures aimed at limiting the extent of ischaemic damage or preventing
early recurrence. The latter depend on the likely cause of stroke in each case. As with the
adult guidelines, treatment of secondary complications or of associated diseases is not
considered here.
Early multidisciplinary evaluation is vital to prevent complications and plan rehabilitation.
If the child is in an acute paediatric neurology ward, he or she is likely to have access to a
multidisciplinary team with expertise in paediatric neurology. However, on a general
paediatric ward it may be necessary for any member of the team to seek advice from
colleagues in a tertiary centre. There is no specific research relating to the evaluation and
management of children affected by stroke, but principles relating to the evaluation and
care of children with other acute neurological conditions and, where available, published
guidelines have been applied in formulating these recommendations.
6.1 General care measures
There are no studies which have specifically examined the effect of disruptions in
homeostasis on stroke outcome in children but we have highlighted the points below based
on principles which would be applied to the care of any acutely ill child, as well as from
the evidence base in adults affected by stroke.
Guidelines
1 Temperature should be maintained within normal limits (D)
2 Oxygen saturation should be maintained within normal limits (D)
25
Evidence
1 Extrapolation from National clinical guidelines for stroke: second edition (Intercollegiate
Stroke Working Party 2004) (4)
2 Consensus of working party; National clinical guidelines for stroke: second edition
(Intercollegiate Stroke Working Party 2004) (4)
6.2 Specific medical treatments
There are no studies specifically examining the efficacy of acute treatments for arterial
ischaemic stroke in children. The following recommendations are based on the consensus
opinion of the working party.
The use of anticoagulation in children with cardiac embolism is controversial as it involves
balancing the risk of precipitating haemorrhagic transformation of the infarct with the
potential to prevent further embolic events. The decision may be influenced by the cardiac
pathology, time elapsed after the stroke and by neurological and imaging findings. In the
absence of any evidence, we were unable to make a general recommendation, but felt that
individual patient management should involve senior clinicians in paediatric cardiology
and neurology.
The efficacy and optimal dose of aspirin in the treatment of children with acute arterial
ischaemic stroke is unknown. The lowest dose recommended for treatment of other
paediatric conditions, such as Kawasaki disease, in the paediatric formulary Medicines for
children (Royal College of Paediatrics and Child Health 2003) is 5 mg/kg/day. This would
approximate to the dose (300 mg) recommended for acute treatment of ischaemic stroke
in adults (National clinical guidelines for stroke: second edition, Intercollegiate Stroke Working
Party 2004) and therefore has been recommended below. The lowest effective dose for long-
term prophylaxis may be lower, as discussed in the following section. Although children
with sickle cell disease have been excluded from the first guideline, aspirin or anticoagulation
may need to be considered if other risk factors, for example arterial dissection, are identified
in individual patients.
There is currently no evidence to support use of thrombolytic agents such as tissue
plasminogen activator (tPA) in the acute treatment of arterial ischaemic stroke in children.
Guidelines
1 Aspirin (5 mg/kg/day) should be given once there is radiological confirmation of arterial
ischaemic stroke, except in patients with evidence of intracranial haemorrhage on
imaging and those with sickle cell disease
2 In children with sickle cell disease and arterial ischaemic stroke:
i urgent exchange transfusion should be undertaken to reduce HbS to <30% and raise
haemoglobin to 1012.5 g/dl

26
6 Acute care
ii if the patient has had a neurological event in the context of severe anaemia (eg splenic
sequestration or aplastic crisis), or if exchange transfusion is going to be delayed for
more than four hours, urgent top-up blood transfusion should be undertaken
3 Providing there is no haemorrhage on brain imaging, anticoagulation should be
considered in children with:
i confirmed extracranial arterial dissection associated with arterial ischaemic
stroke
ii cerebral venous sinus thrombosis (C)
4 The decision to use anticoagulation in children with arterial ischaemic stroke who have
a cardiac source of embolism should be discussed with a consultant paediatric
cardiologist and paediatric neurologist
5 Early neurosurgical referral should be considered in children with stroke who have
depressed or deteriorating conscious level or other signs of raised intracranial
pressure
Evidence (Table 5)
1 Working party consensus
3 i) Working party consensus; ii) Extrapolation from Stam et al 2003 (1) (level of
recommendation downgraded from B to C due to small number of studies in Cochrane
review (n = 2) and based on adult data)
6.3 Secondary prevention of arterial ischaemic stroke in childhood
Child in paediatric stroke workshop: What happens if you get two strokes?
Stroke recurrence is a major concern for children and their families. Arterial ischaemic
stroke recurs in between 6% and 20% of all children and in over 60% of children with
sickle cell disease. The risk of recurrence is increased in children with multiple risk factors
(Lanthier et al 2000) and in those with protein C deficiency, increased levels of lipoprotein
(a) and vascular disease (Strter et al 2002). At present, there is very little evidence regarding
the efficacy of secondary prevention strategies (Strter et al 2001) but this is likely to change
as the need for multicentre trials is gaining momentum. Thus we would emphasise that the
consensus statements below are not long-term recommendations and will need to be
updated as new evidence emerges.
27
Although widely used, the dose of aspirin to be used for secondary prevention of ischaemic
stroke is undefined in childhood. Doses between 50300 mg/day are recommended for
adults (National clinical guidelines for stroke: second edition Intercollegiate Stroke Working
Party 2004) and doses between 13 mg/kg/day have been recommended for secondary
prevention in children (Nowak-Gottl et al 2003). Given the lack of evidence we have not
been able to recommend a specific dosage; however, complications such as bruising may
limit the dose which can be tolerated by the child.
Guidelines
1 Patients with cerebral arteriopathy other than arterial dissection or moyamoya syndrome
or those with sickle cell disease should be treated with aspirin (13 mg/kg/day)
2 Anticoagulation should be considered:
i until there is evidence of vessel healing, or for a maximum of six months, in patients
with arterial dissection
ii if there is recurrence of arterial ischaemic stroke despite treatment with aspirin
iii in children with cardiac sources of embolism, following discussion with the
cardiologist managing the patient
iv until there is evidence of recanalisation or for a maximum of six months after cerebral
venous sinus thrombosis
3 In children with sickle cell disease:
i regular blood transfusion (every three to six weeks) should be undertaken to maintain
the HbS% <30% and the Hb between 1012.5 g/dl (C)
ii transfusion may be stopped after two years in patients who experienced stroke in
the context of a precipitating illness (eg aplastic crisis) and whose repeat vascular
imaging is normal at this time (C)
iii after three years a less intensive regime maintaining HbS <50% may be sufficient
for stroke prevention (C)
iv those who cannot receive regular blood transfusions because of allo-immunisation,
auto-antibody formation, lack of vascular access or non-compliance with transfusion
or chelation may be considered for treatment with hydroxyurea (C)
4 Children with moyamoya syndrome (including those with sickle cell disease) should be
referred for evaluation to a centre with expertise in evaluating patients for surgical
revascularisation (D)
5 Children with sickle cell disease who have had a stroke should be referred to a specialist
centre for consideration of bone marrow transplantation (B)
6 Advice should be offered regarding preventable risk factors for arterial disease in adult
life, particularly smoking, exercise and diet (D)
28
6 Acute care
7 Blood pressure should be measured annually to screen for hypertension
8 Patients who are found to have a prothrombotic tendency should be referred to a
haematologist
Evidence (Tables 6, 7, 8 and 9)
3 i) Powars et al 1978 (2); Portnoy & Herion 1972 (2); Balkaran et al 1992 (2); Wilimas
et al 1980 (2+); Russell et al 1984 (2+); Wang et al 1991 (2+); Cohen et al 1992 (2+);
De Montalambert et al 1999 (2); Rana et al 1997 (2); Pegelow et al 1995 (2); Scothorn
et al 2002 (2+); Dobson et al 2002 (2+); ii) Dobson et al 2002 and Scothorn et al 2002
(both 2+); iii) Cohen et al 1992 (2+); iv) Ware 1999 (2+); Sumoza 2002 (2+)
4 Golby et al 1999; Olds et al 1987; George et al 1993; Ishikawa et al 1997; Matsushima
et al 1992; Fryer et al 2003 (all 3)
5 Vermylen et al 1998; Bernaudin 1999; Walters et al 2000 (all 2++)
6 Consensus of working party; Extrapolation from National clinical guidelines for stroke:
second edition, Intercollegiate Stroke Working Party 2004 (4)
6.4 Early disability assessment and management
The philosophy of paediatric medicine is for care to be delivered, where possible, in the
childs home environment and to minimise the time a child spends in hospital. The inpatient
period may be limited to the time when the child is acutely unwell or when there are
outstanding diagnostic issues. It is, therefore, important that links to community child
health services should be made from the outset in order for a package of care to be set up,
and that the child is not discharged until this is in place. Ultimately this package may be
delivered in a variety of settings, as discussed in chapter 3. Parents (and children when
possible and appropriate) should be involved in planning long-term care.
Guidelines
1 As soon as possible after admission, following stroke all children should have an
evaluation of:
i swallowing safety (D)
ii feeding and nutrition

29
iii communication (D)
iv pain (D)
v moving and handling requirements (D)
vi positioning requirements
vii risk of pressure ulcers (D)
2 All children affected by stroke should have a multidisciplinary assessment within
72 hours of admission to hospital
3 The professionals involved in the acute assessment and management of the child should
initiate early liaison with their counterparts in the community to ensure a smooth
transition of care
Evidence (Table 10)
1 i) Swallowing guidelines of the Royal College of Speech and Language Therapists (RCSLT
2004) (4); Morgan et al 2003 (3); ii) Working party consensus; iii) RCSLT guidelines on
assessment of acquired childhood aphasia from the RCSLTs Communicating quality (2)
(RCSLT 2001) (4); iv) Royal College of Nursings Clinical Practice Guidelines: The
recognition and assessment of acute pain in children (RCN 2001) (IV); v) Royal College
of Nursings The guide to the handling of patients: fourth edition (RCN 1999) (4); vi)
Working party consensus; vii) NICE guideline on pressure ulcer risk management and
prevention (Guideline B) (4); Working together to prevent pressure ulcers a guide for
patients and their carers (www.nice.org.uk/pdf/clinicalguidelinepressuresoreguidance
nice.pdf) (4); Pressure relieving devices CG7 (www.nice.org.uk/pdf/clinicalguidelines
pressuresorespatleafletenglish.pdf) (4)
30
Chapter 8
7 Approaches to rehabilitation
Parent in paediatric stroke workshop: When we came home from hospital it was as if youre home now
Goodbye and get on with it. Thats the way I feel and still feel. Theres been no physio or occupational
therapy yet and shes been home about eight weeks now. All Ive had is phone numbers and names which
are no help to me as theres very little for younger people with strokes. They dont cater for younger children
only adults. So it feels as if youre forgotten.
Parent in paediatric stroke workshop: After we came out of hospital the real problems began. The local
hospital had little experience of strokes in children. We waited six weeks for physio locally, eight weeks for
the OT to assess her. The problem seemed to be resources or shall we say Government funding!
Early rehabilitation of children with acquired brain injury is usually undertaken from the
time of diagnosis in the setting of the acute ward; however, subsequent rehabilitation is
usually carried out in the community or, in some cases, may be undertaken in a specialist
childrens rehabilitation unit or on a general paediatric ward (see chapter 3). As previously
stated, early liaison and communication between the professionals involved in rehabilitation
from tertiary through to primary care services is critical to smooth transition. Rehabilitation
interventions may include both hands-on intervention and equipment provision, thus
involving a variety of health professionals, education and social services agencies.
The impairments experienced by children affected by stroke, and their functional
consequences, may evolve over time due to ongoing growth and development. Rehabilitation
of children with limitation in functional skills requires consideration of the impact of sensory,
perceptual, motor and cognitive impairments on the individual so that interventions are
appropriate. The child and family should be encouraged to express their main concerns about
re-integration to the home, community and school environments, and to have these concerns
addressed. The impact of stroke on the psychological well-being of the family may adversely
affect the childs rehabilitation process. The rehabilitation professional should consult with
specialist acute and community-based rehabilitation teams if this is indicated.
There is little evidence on the effectiveness of rehabilitation interventions specifically for
children affected by stroke. It may appear in the following sections that there is undue
emphasis on sensorimotor function; however, this is because there is a wider availability of
research in this domain due to work undertaken in children with cerebral palsy. The reasons
for including this literature have been discussed in the introduction. We accept that there
are limitations in extrapolating from this population to children with acquired brain injury.
Some important differences between the two groups include the level of pre-morbid
functioning, age at injury and the rate of change in status. We would also emphasise that,
as in children with traumatic brain injury, invisible impairments are under-recognised
and a source of significant morbidity in children affected by stroke.
31
Guidelines
1 Children affected by stroke should be offered advice on, and treatment aimed to achieve,
play, self-care, leisure and school-related skills that are developmentally relevant and
appropriate to their home, community and school environment (D)
2 Equipment which is appropriate in meeting rehabilitation aims should be assessed on
an individual basis, provided in a timely manner, and regularly monitored by appropriate
professionals (D)
Evidence
1 The National Association of Paediatric Occupational Therapists Guidelines for good
practice (NAPOT 2000) (4); Association of Paediatric Chartered Physiotherapists
Paediatric physiotherapy guidance for good practice (APCP, revised 2002) (4)
2 The Audit Commissions Fully equipped (Audit Commission 2000/2002) (4)
7.1 Sensorimotor rehabilitation
7.1.1 Underlying approach to sensorimotor therapy
The aim of sensorimotor intervention is to improve motor control and physical independence,
and to promote developmentally appropriate functional skills. These principles are practised
in most therapy approaches. However, they vary according to the type of stimuli used, the
emphasis on task-specific practice and/or the principles of learning which are followed. There
is little evidence to support the superiority of one treatment approach over another.
Guidelines
1 Sensorimotor therapies should be practiced within a neurological framework, and
complement other interventions to improve functional skills
2 Rehabilitation activities should be task orientated and relevant to the individuals life (C)
3 Therapy should be integrated into the childs daily home and school activities (D)
Evidence (Table 11)
2 Ketelaar et al 1997 (2++); Butler & Darrah 2001 (4); Volman et al 2002 (2+)
3 The Association of Paediatric Chartered Physiotherapists Paediatric physiotherapy
guidance for good practice (APCP, revised 2002) (4); Chartered Society of Physiotherapy
Standards of physiotherapy practice (Chartered Society of Physiotherapy 2000) (4)
32
7.1.2 Delivery of sensorimotor therapy
Issues regarding the frequency and intensity of contact with therapists are frequently raised
by parents and older children. Play and daily living activities enable practice of functional
skills and are, therefore, of therapeutic benefit. Collaborative working between parents,
teachers or any other member of the multidisciplinary team can ensure that children are
able to practise such activities in all their environments.
Goal-setting in therapy involves identifying measurable objectives of performance which
are beyond the childs current abilities, but which are considered achievable and relevant
to the childs life. Goal-setting may be a helpful adjunct to therapy, in addressing issues of
concern to the child, family and therapists, and in measuring the outcome of intervention,
and can be useful to record functional changes.
Guidelines
1 Children should be given as much opportunity as possible to practise skills (C)
Evidence (Table 11)
1 Ketelaar et al 2001 (2++); Chartered Society of Physiotherapy Standards of physiotherapy
practice (Chartered Society of Physiotherapy 2000) (4); Downgraded to C as Ketelaar
et al 2001 was in children with cerebral palsy
7.1.3 Use of assessment measures
Assessment should aim to document a particular aspect of function, impairment, activity
and participation as objectively as possible. This will enable the dissemination of
information between professionals and services and facilitate the setting of measurable
rehabilitation goals and measurement of progress. A wide range of assessment tools is
available for the evaluation of children with neurological disorders, of which many are
potentially useful in the evaluation of children affected by stroke. It is not possible to make
recommendations regarding specific assessment tools as the most appropriate one will
depend on many factors, such as the age and developmental level of the child and the
resources and training of the team.
Guideline
1 The assessment tools selected should be appropriate for the childs age and developmental
and functional level
2 Standardised and validated assessment tools should be used where possible
Evidence
1 & 2 Consensus of working party
33
7.2 Motor impairment
Both central and peripheral components of motor impairment require consideration during
rehabilitation. Hemiparesis is the most common pattern of motor impairment resulting
from ischaemic stroke. Spasticity is also common; however, as the basal ganglia are
commonly affected in childhood stroke, dystonia or a mixed pattern are seen frequently as
well. Hemi-dystonia may have a delayed onset and may follow a period of initial good
recovery after the stroke. The upper limb, particularly the hand, tends to be more severely
affected than the lower limb in children with ischaemic stroke.
There are a wide variety of treatment interventions available to children with motor
impairments but not all have a strong evidence base. These include therapies such as lycra
splinting, inhibitive casting, treadmill training, constraint-induced movement therapy and
functional electrical stimulation. However, this does not suggest that these treatments are
not beneficial if used appropriately. The following guidelines are based on the interventions
with an evidence base to support their use.
7.2.1 Muscle strengthening
Muscle weakness is now recognised as a component of disability and studies show that
strength training does not increase spasticity and may, in fact, reduce it. Programmes to
improve childrens muscle strength can lead to improved functional skills. Muscle
shortening may also be linked with muscle weakness and interventions which immobilise
muscles should be evaluated in terms of their impact on muscle strength.
Guidelines
1 Muscle strengthening should be used as part of the therapy programme to prevent or
reverse contractures (D)
2 Muscle strengthening activities should be used to improve functional activity (D)
Evidence (Table 12)
1 Shortland et al 2002 (2+); Downgraded as study of children with cerebral palsy
2 Ross & Engsberg 2002 (2+); Damiano & Abel 1998 (2+); Downgraded as study of
children with cerebral palsy
7.2.2 Management of spasticity
Botulinum toxin is a drug used in the treatment of spasticity. It is only effective on the dynamic
component of muscle shortening and will not improve fixed contractures. Botulinum toxin
is generally safe, has minimal side effects and can be targeted at individual muscles. However,
it is an expensive intervention and its effects may reverse after three months. The long-term
effects of repeated injections in children are not known. Its potential benefits are enhanced
and maintained by concurrent therapy interventions. Currently there are no reliable
conclusions on the use of botulinum toxin but a number of studies are underway.
34
Guidelines
1 If spasticity results in functional limitation or discomfort, botulinum toxin injection
may be used to reduce muscle tone and improve range of joint motion (B)
2 The most effective dose for gastrocnemius injection is 20 u/kg to reduce the dynamic
component of muscle shortening and increase active length (C)
3 Botulinum toxin should not be used in isolation from other therapy interventions
Evidence (Table 14)
1 Ade-Hall et al 2003 (1+) found no strong evidence for or against treatment with
botulinum toxin in children with cerebral palsy; Working party consensus
2 Baker et al 2002 (2++); Downgraded as not specific to this population
7.2.3 Ankle-foot orthoses
The use of ankle-foot orthoses (AFOs) may be considered in children with lower limb
involvement. AFOs provide intimate control of the foot and ankle. They are used to maintain
muscle length and improve gait patterns. Rigid and hinged AFOs extend to just below the
knee with the latter being hinged to allow a limited range of ankle movement. Dynamic
ankle-foot orthoses (DAFOs) have a contoured foot support and extend to just above the
ankle. Continuous use of rigid orthoses may be implicated in reduced strength of the lower
leg muscles.
Guideline
1 A rigid AFO could be considered to aid standing balance, swing through in gait and
prevention of foot and ankle contractures
2 A hinged or posterior leaf spring AFO should be used to facilitate normal gait
patterns (D)
Evidence (Table 13)
1 Consensus of working party (IV)
2 Romkes & Brunner 2002 (2+); Ounpuu et al 1996 (2); Brunner et al 1998 (2+);
Desloovere et al 1999 (2)
35
7.3 Sensory impairment
Clinical experience suggests children may experience disturbance of a variety of sensory
modalities following stroke. Some of these may be more easily detectable than others, but
all should be considered by health professionals assessing and working with the child as
they have the potential to impact outcome and response to rehabilitation.
7.3.1 Somatosensory impairment
Clinical experience suggests that there may be transient or long-term alterations in tactile,
proprioceptive and kinaesthetic awareness following childhood stroke. These difficulties
may influence movement performance and sensorimotor rehabilitation. They may also
influence body awareness and have implications for safety in functional daily activities.
Somatosensory assessment relies on careful clinical observation in the absence of accepted
valid assessment methods.
Guideline
1 Rehabilitation professionals should consider the presence of somatosensory impairment
and integrate this in planning and implementing rehabilitation
Evidence
7.3.2 Hearing and vision impairment
There is no data on the incidence of vision or hearing impairment in children affected by
stroke; however, as with any acquired brain injury, these are potential consequences.
Assessment should be comprehensive and include evaluation of both perception and
processing of visual and auditory stimuli.
Guideline
1 Vision and hearing should be assessed as part of the multidisciplinary assessment
Evidence
36
37
7.3.3 Pain
Some children reported extreme pain at the time of stroke, for example one child at the workshop reported
that when they had the stroke they felt pain which was Awful, immense, thousand daggers in my eye,
horrible, terrifying.
Potential sources of pain after childhood stroke include headache, shoulder pain,
dysaesthesia and abdominal pain due to gastro-oesophageal reflux. Shoulder pain in adults
has been particularly associated with a prolonged hospital stay and poor recovery of arm
function, and clinical experience with children would support this. Proprioceptive
dysfunction may involve the whole body. Staff should be aware that children may experience
pain and discomfort due to sensory disturbance, but can have difficulty expressing this.
Guidelines
1 Children affected by stroke should be assessed for the presence of pain using a validated
paediatric pain tool (D)
2 All pain should be treated actively, using appropriate measures including positioning,
handling, and medication
3 In cases of intractable pain, the child should be referred to health professionals with
specialist expertise in pain management
Evidence
1 The Royal College of Nursings Clinical practice guidelines: the recognition and assessment
of acute pain in children (RCN 2001) (4)
7.4 Language and communication
The effects of childhood stroke on language and communication may be specific or global
and short- or long-term. Stroke may impair function at any stage of language input
(receptive aphasias), language processing (word-finding problems, grammatical problems
and other aphasias), speech production (dysarthria) and written language (dyslexia). There
may also be problems of social interaction and the willingness to communicate (mutism).
Unlike in adults, speech, language and communication consequences may not be
determined by which hemisphere is affected and is seen in children with both cortical and
subcortical injuries. The childs ability to communicate may also be adversely influenced
by physical and/or behavioural problems, their general health, other aspects of their
environment (for example, volume of ambient noise) or cognitive skills. Developmental
speech and language problems may have been present prior to the stroke and these will
need to be taken into consideration when planning management.

Communicating quality (2) (RCSLT 2001) states that a child with communication difficulties
requires comprehensive assessment, and that where indicated a specialist speech and
language therapist should be responsible for this. Whilst dramatic patterns of recovery have
been documented in the early stages of rehabilitation, the prospect of long-term residual
deficits, sometimes of a subtle or high level nature, should not be overlooked (Lees & Neville
1990, Lees 1997). Because language learning goes on through the first two decades of life,
and the child needs to accommodate to the changing demands of different communication
situations, difficulties may surface some time after the initial stroke.
Where children have restricted verbal output or are non-verbal following stroke, the use of
alternative and augmentative communication (AAC) systems should be considered. This
may include signing, symbols and simple or complex speech output devices. A useful
reference is the Communication Matters website (www.communicationmatters.org.uk).
Guidelines
1 Professionals working with children affected by stroke should be aware that language
and communication skills may be affected (D)
2 If parents, professionals or the childs educational assessment raise concerns regarding
language or communication, the child should be referred to a specialist speech and
language therapist (D)
3 A detailed assessment of the childs communication abilities should be carried out in
collaboration with the child, parents/carers, teachers and other therapists to identify the
childs strengths and weaknesses and plan intervention that aims to increase functional
abilities (D)
4 A collaborative approach to the management of communication difficulties that includes
working with an educational psychologist, other therapists, teachers and social workers
should aim to equip the child with a language for life (D)
Evidence
1 Lees 1997 (4)
2, 3 & 4 Communicating quality (2) (RCSLT 2001) (4)
7.5 Cognitive effects
The cognitive consequences of stroke in childhood are often underestimated, yet they can
impact on all aspects of functioning. Cognitive impairment is particularly likely to be
underestimated in children without a physical disability and these children may be
incorrectly perceived as not being disabled. Childhood stroke is known to affect both global
and specific aspects of cognitive function. The severity of cognitive impairment associated
with stroke is variable and, additionally, its impact has to be viewed in a developmental
context. Unlike adults, cognitive consequences are not only determined by which
hemisphere is affected. They may result from both cortical and subcortical injuries, although
limited evidence suggests they are greatest in children with large lesions. Deficits have been
38
reported in intellectual functioning, language and verbal abilities, visual-motor and visual-
spatial processing, performance, sequential memory and academic achievement. Specific
patterns of impairment may be related to the underlying aetiology or site of injury and,
additionally, may emerge during development. For example, attention and executive
functioning difficulties have been found in children with sickle cell disease and stroke as
these children are vulnerable to frontal lobe damage. Although the childs functioning may
still be within the normal range after a stroke, there may be a significant reduction in
cognitive functioning and the childs ability to access the curriculum may be altered.
Computer-assisted learning may need to be considered to help the child access the
curriculum, alongside other specialist interventions.
Cognitive impairment will impact on all aspects of daily functioning. Schools and teachers
need to be aware of the potential for cognitive difficulties as these may not be apparent
unless the child has a comprehensive assessment. Such an assessment should be carried out
in collaboration with colleagues in educational and therapy services and should generate
explicit recommendations to support the child both at home and at school. Studies of
children with traumatic brain injury suggest that such injury affects the ability of the child
to acquire new knowledge; this is also likely to apply to children affected by stroke.
Developmental factors, as well as the changing expectations of the child, mean that the
functional and educational impact of cognitive impairment is likely to change as the child
gets older and therefore their cognitive functioning will need to be reviewed over time.
Children with sickle cell disease are at risk of progressive cognitive dysfunction due to the
high incidence of stroke recurrence and silent cerebral infarction. Services for these children
should consider repeating cognitive assessments; however, there is no evidence on which
to base recommendations about the frequency with which they should take place and the
problems of repeated assessment should be considered.
Guidelines
1 Professionals working with children affected by stroke should be aware that cognitive
function may be affected, both immediately and in the longer term (C)
2 A detailed psychological assessment of the childs cognitive and functional abilities
together with any wider family concerns should be carried out in collaboration with
the child, parents/carers and teachers to identify any special educational needs (D)
3 Cognitive assessment should take account of the presence of any visual or hearing
deficits
Evidence (Table 15)
1 De Schryver et al 2000 (2+); Delsing et al 2001 (2+); Kral et al 2001 (4); Access to education
for children and young people with medical needs (DfES 2001) (4)
2 Working party consensus; Paediatric stroke workshop (4); Access to education for children
and young people with medical needs (DfES 2001) (4)
39
7.6 Mood and behaviour
Parent in paediatric stroke workshop: Because the brain is affected the child is in need of help physically,
emotionally and mentally. They often are not the same people they were before the stroke. The parents
cannot be expected to cope without the help of experts and the child/teenager definitely benefits if their
parent is not always around as family tension/fears can be the cause of much distress at the time.
Parent in paediatric stroke workshop: My daughter also heard voices in her head after her stroke telling
her the most distressing things. Stuff that made her feel anxious, guilty and afraid. She felt that her whole
life had been turned upside down and that she was going mad. She suffered from severe anxiety attacks,
exhaustion and her unhappiness led to a nervous breakdown five years after her stroke.
There is emerging evidence that childhood stroke has effects on many aspects of behaviour,
even in children without apparent difficulties in other domains. There is no specific research
on the effects of childhood stroke on mood. However, studies of children with hemiplegia
(a group which includes some children affected by acute stroke) has shown that these children
experience an increased rate of emotional difficulties (Goodman & Yude 2000). Studies in
children affected by stroke have shown that a third of parents feel that their childs behaviour
has altered following the stroke (Ganesan et al 2000). This observation has been confirmed
by a high rate of emotional and behavioural difficulties detected using a behaviour screening
questionnaire (Wraige et al 2003). In children with sickle cell disease, brain injury is associated
with difficulties in decoding emotions and interpreting social situations which may not
become evident until adolescence. Unidentified cognitive impairment may exacerbate mood
or behaviour problems so both these areas should be evaluated together.
Guidelines
1 Families and professionals should be aware that stroke may have effects on mood and
behaviour (D)
2 The psychological assessment of the child should include evaluation of mood and
behaviour, including wider family concerns (D). This should be undertaken in
conjunction with cognitive assessment
3 Mood and behaviour should be assessed if there is a change in the childs functioning
in the home or school environment
4 If mood or behaviour problems are identified and are having an impact on the childs
functioning, the child should be referred to professionals with expertise in treating such
problems, such as the local child and adolescent mental health team
Evidence (Table 15)
1 De Schryver et al 2000 (2+); Ganesan et al 2000 (2+)
2 Boni et al 2001 (2+); Max et al 2002 (2+); Consensus of working party
40
7.7 Activities of daily living
Motor, sensory and cognitive impairments resulting from a stroke may affect the childs
ability to engage in age-appropriate self-care, work and leisure activities. These may include
activities such as dressing, bathing, toileting and feeding, and the abilities to move around
the home or school environment, play and access the school curriculum. Assessment of the
childs ability to perform these activities in the home and school environment is important
in facilitating the childs return to community living.
Guidelines
1 Therapists working with a child affected by stroke should assess the childs ability to
perform daily living activities
2 An occupational therapist should be involved in identifying therapeutic need in self-
care, work/school and leisure activities and provision of intervention in this area if
indicated
Evidence
41
Chapter 8
8 Longer-term and community care
8.1 Return to school
Parent in paediatric stroke workshop: has been left both physically and mentally damaged! She
is unable to keep up with her peers and my once quite bright little girl is now unable to concentrate, take
her studies and pass exams.
It is likely that a child affected by stroke will be out of school for a significant length
of time. Whilst the child is an inpatient they may attend the hospital school; once
discharged, the home teaching service may be involved in provision of education if
they are unable to attend school. Access to education for children and young people with
medical needs (DfES 2001) states that all pupils should have access to as much education
as their medical condition allows and that each childs situation should be assessed and
addressed in a co-ordinated manner by the childs school and the agencies mentioned
above.
The timing of the return to school will vary according to the impact of stroke on the
individual child. Return to school is a major milestone in the childs recovery; a positive
experience is likely to enhance reintegration. Before the child goes back to school, the local
educational authority and school staff should be informed about relevant medical, physical,
emotional and cognitive issues. The local education authority is responsible for ensuring
that an individually tailored reintegration plan, with multi-agency approval, is in place for
all pupils before return to school (Access to education for children and young people with
medical needs DfES 2001). Although it is important that professionals familiar with the
child are involved in liaison, parents should also be encouraged to raise their concerns.
Communication is central and this should involve a named teacher (usually the special
educational needs coordinator (SENCO)) and the childs key worker.
As the childs physical appearance may have altered as a result of the stroke (for example,
if the child has a hemiparesis), staff and pupils should be encouraged to address this in
a sensitive manner. The reaction of others to changes in physical appearance is something
which many children are apprehensive about and the child should be involved in decisions
about how they wish information regarding their illness to be presented to teachers and
peers. Children often find it very tiring to return to a full school day after illness, and a
graded return to school or the provision of rest periods should be considered. Classrooms
are often noisy, with many potential distractions; this may exacerbate problems with
attention or concentration. Simple measures, such as changing the childs position in the
43
classroom, may be helpful but should only be undertaken after consultation with the
child. Formal therapy programmes should be integrated with the childs school
programme.
Special educational needs are defined as learning difficulties or disabilities which require
special educational provision. The Special educational needs code of practice (DfES 2002)
and Special educational needs toolkit (DfES 2001) clearly outline the steps to identify, assess
and meet childrens special educational needs. If children require additional input in order
to access the national curriculum, the first stages of provision are termed School Action
and School Action Plus. The aim of School Action and School Action Plus is to develop
individual plans for teaching and learning (termed individual education plans), additional
to and different from those usually provided in the childs educational setting, that will
enable the child to access an appropriate curriculum. School Action Plus is introduced when
changes for School Action have not had sufficient impact on the childs progress. If School
Action Plus does not provide appropriate or sufficient support to enable the child to access
the curriculum, then a referral can be made to the local educational authority for a statutory
assessment of the childs special educational needs, which may lead to a statement of
educational needs. If the childs difficulties are very significant from the outset a referral
for such an assessment can be made to the local educational authority by the school, parent
or by any professional at any stage of the treatment.
Guidelines
1 Child health services, usually community child health services, should take responsibility
for informing the local education authority of children who may have special educational
needs as soon as possible after the stroke (D)
2 The childs key worker should liaise with the special educational needs coordinator at
the childs school prior to school return (D)
3 A collaborative meeting should be undertaken to plan educational provision with
appropriate assessment or support (D)
4 Health and school staff should agree procedures for communicating information
5 For children presenting with mobility difficulties, the school environment should be
assessed prior to return to school, ideally by an occupational therapist
6 It is recommended that all children affected by stroke are placed on a minimum of
School Action (see above) as many difficulties remain latent
Evidence
1 Special educational needs code of practice (DfES 2002). Department of Education and
Skills 558/2001 (4)
2 Special educational needs code of practice (DfES 2002). Department of Education and
Skills 558/2001; Special educational needs toolkit (DfES 2001) (4)
44
8 Longer-term and community care
3 As above (4); Access to education for children and young people with medical needs (DfES
2001) (4)
8.2 Transition between paediatric and adult services
Childhood stroke may result in lifelong physical and cognitive impairments. The process
of transition from paediatric to adult services will depend on the current and future needs
of the individual, and will usually occur between 16 and 19 years of age. However, the
exact timing will depend on the individuals needs and should be discussed with the young
person and family. Key aspects of transition are the transfer of responsibility for health
care and the provision of education, training or employment after leaving school. A
coordinated approach is critical and advance planning is essential to ensure smooth
handover of any and all aspects. The period of transition is often a difficult time for young
people and families. Vulnerable aspects of functioning, such as emotion or cognition,
may be adversely affected by the stress associated with this if there is inadequate planning
and support.
Children with active medical needs will require transfer of health care. These needs may
relate to surveillance and management of an active condition (such as cardiac disease or
sickle cell disease), as well as to the management of chronic disability. There are different
models of transition (for example transfer from paediatric to adult sub-specialist or co-
ordination of transfer by the general practitioner (Tuffrey & Pearce 2003)). The most
appropriate model should take the young persons needs, as well as the available services,
into consideration. The medical team involved in overseeing the young persons health care
needs should be involved in planning and managing the handover of overall medical care.
The Special educational needs code of practice (DfES 2001) provides information on the
processes and agencies which should be involved in planning transition after school for
young people with special educational needs. It is recommended that a multi-agency
transition plan is developed to facilitate successful transition to post-school education,
training or work.
If formal medical and therapy interventions have ceased and new problems attributable to
the stroke or its aftermath become apparent, the young persons general practitioner should
refer them to an appropriate adult service. The paediatric services previously involved in
the young persons care should provide or share information. Primary health care
professionals should be aware of the potentially wide-ranging effects of childhood stroke
and, as emphasised elsewhere in this document, that functional difficulties may emerge
after a silent interval.
45
Guidelines
1 Paediatric general and specialty clinics and child development services should have a
local policy on transition to adult services, which should be the responsibility of a named
person (D)
2 A named professional should take responsibility for arranging an introduction to adult
health services
3 A flexible approach to the timing of this transfer needs to be considered which takes
into account the young persons readiness, current health status and links to other social
transitions such as leaving school (D)
4 A multi-agency transition plan should be formulated for young people with special
educational needs, with input from health, education and social services, and the young
person, to plan transition into further education, training or employment (D)
5 A named professional should take responsibility for co-ordinating the transition plan
and ensuring delivery of services (D)
Evidence
1 Standards for child development services (RCPCH 1999) (4)
3 Childrens National Service Framework (www.dh.gov.uk) (4)
4 Standards for child development services (RCPCH 1999) (4); The special educational needs
code of practice (DfES 2001) (4)
5 Special educational needs code of practice (DfES 2001) (4)
46
Chapter 8
9 Primary prevention
As the mechanisms and risk factors for arterial ischaemic stroke in children are not well
understood at present, there is no research on effective primary prevention strategies other
than in children with sickle cell disease. Although primary prevention of stroke in children
in sickle cell disease is possible with regular prophylactic blood transfusion, this has many
risks and disadvantages which should be clearly discussed with the child and family.
Guidelines
1 Children with haemoglobin SS or S thalassaemia should be screened yearly from the
age of three years for internal carotid artery or middle cerebral artery velocity >200 cm/s
using appropriately trained personnel and transcranial Doppler ultrasound (B)
2 Children with sickle cell disease who have internal carotid artery/middle cerebral artery
velocity >200 cm/s should be offered long-term blood transfusion (B)
Evidence
1 Adams et al 1998 (2++)
2 Adams et al 1998 (2++)
47
Appendices
51
Chapter 8
Appendix 1
Peer reviewers
Child and adolescent psychiatrist
Professor Robert Goodman Kings College Hospital, London
Child neurologist
Dr Gabrielle de Veber The Hospital for Sick Children, Toronto, Canada
Clinical psychologists
Dr Peter Fuggle British Psychological Society, Leicester
Ms Annette Lawson Birmingham Childrens Hospital
Ms Dianne Melvin Great Ormond Street Hospital for Children, London
Dr Arleta Staza Smith Queens Medical Centre, Nottingham
Community paediatricians
Dr Moira Dick Mary Sheridan Centre for Child Health, London
Dr Tom Hutchison Bath and NE Somerset Primary Care Trust
Education consultant
Ms Beth Wicks Nottingham
Neuroradiologists
Professor Paul Griffiths University of Sheffield
Dr Neil Stoodley Frenchay Hospital, Bristol
Occupational therapists
Ms Jane Galvin Royal Childrens Hospital, Melbourne
Dr Elizabeth White College of Occupational Therapists, London
Paediatrician (neurology and neurodisability)
Dr Diane Smyth St Marys Hospital, London
Paediatric neurologists
Dr Richard Appleton Alder Hey Childrens Hospital, Liverpool
Dr Tony McShane John Radcliffe Infirmary, Oxford
Dr Keith Pohl Guys Hospital, London
Dr William Whitehouse Queens Medical Centre, Nottingham
52
Paediatric neurology nurse specialist
Ms Shona Mackie Southampton General Hospital
Patient organisations
Mrs Margaret Goose Stroke Association, London
Mr Keith Wood Different Strokes, Milton Keynes
Physiotherapists
Ms Shelley Cox Southampton General Hospital
Ms Lorna Stybelska Cumberland Infirmary, Carlisle
Speech and language therapists
Ms Lucy Cuthbertson Southampton General Hospital
Ms Nicola Jolleff Wolfson Centre, London
Ms Valerie Moffatt Chailey Heritage School, East Sussex
Professor Bruce Murdoch University of Queensland, Brisbane
53
Chapter 8
Appendix 2
Proposed audit criteria
These criteria have been proposed by the working party for clinical audit. They are divided
into two sections one dealing with acute care and another with longer-term issues. We
recognise the importance of patient (child and family) and public involvement in the audit
process (see www.chi.nhs.uk/eng/audit/index.shtml). Due to lack of resources it has not
proved possible to include this perspective in the proposed criteria but this will be addressed
in future editions.
Acute care
1 During acute management:
i was the child referred to a consultant paediatric neurologist?
i if not, was the management of the child discussed with a consultant paediatric
neurologist?
2 How many hours after the onset of acute symptoms did the child undergo brain imaging
(includes all children presenting with clinical stroke)?
3 In children with arterial ischaemic stroke what other imaging studies were carried out
and when were these done:
i MRI brain
i MRA circle of Willis
i imaging of cervical vessels (any modality)
i cardiac echocardiogram?
4 When was the first documented assessment (state hours after admission) by:
i a nurse
i a physiotherapist
i an occupational therapist
i a speech and language therapist
i a psychologist?
54
5 Was a member of the community child health team contacted prior to transfer to the
community (state number of days before transfer and which professional was
contacted)?
6 During the initial admission, was the family provided with written information
regarding:
i childhood stroke
i statutory and voluntary agencies?
Longer-term care
7 Is the child under the care of a consultant paediatrician? If so, have they been seen in
the last 12 months?
8 Is the child on treatment for secondary prevention of stroke?
9 When was the first documented contact (state weeks after transfer home) by:
i a key worker
i a nurse
i a physiotherapist
i an occupational therapist
i a speech and language therapist
i a psychologist?
10 Was a meeting held between professionals in health and education services and the
childs parents prior to the childs return to school?
55
Chapter 8
Appendix 3
An example of the ICF
The components of the International Classification of Functioning, Disability and Health
(ICF) might be used to describe the health of a nine-year-old boy affected by a right
hemisphere ischaemic stroke in the following way.
Body functions and structures
Impairments include i) clinical findings of left sided hyperreflexia, hypotonia and persistent
posturing of the left foot and ankle, ii) imaging findings of right middle cerebral artery
territory infarction.
Functional and structural integrity includes the ability to swallow, speak and stand
independently and the absence of neurological signs in the right side.
Activities and participation
Activity limitations include difficulties transferring from chair to standing and negotiating
obstacles when walking. Short-term memory difficulties found on formal testing leading
to difficulties in maintaining attention in school, thus affecting school grades.
Activities able to be performed independently may include self-feeding with the right hand,
writing, managing buttons one-handed, and conversing with friends.
Participation restriction may include inability to rejoin the school football team (a major
source of social contact with friends at weekends) due to running difficulties. Parents may
report difficulty being sent on errands independently due to poor memory.
Participation that remains unaffected may include playing computer games with siblings,
reading with parents, and going for walks with friends in the neighbourhood.
Contextual factors
Environmental: The child must climb two flights of stairs to reach his class every morning
at school. He has difficulty walking quickly, especially when carrying a school bag. This is
compounded by the distance between classes and the number of children crowding the
corridor. The football coach is hesitant to allow the child to rejoin the football team in case
it places him at risk of injury. The boys friends welcome him back to school, but he not
always able to keep up with playground activities and so is sometimes left to play alone.
Personal: The boy does not want to be singled out so does not agree to leaving class earlier
than his peers in order to get to the next class on time. His sense of humour enables him
to make friends easily, and thus he widens his social network to include other children for
more variety of social contact at school.
56
57
Chapter 8
Appendix 4
Useful addresses
Acquire
Helps children, young people and
adults who have an acquired brain
injury and face difficulties in
learning as a result.
Manor Farm House,
Wendlebury, Bicester,
Oxfordshire OX25 2PW.
Tel: 01869 324339.
Fax: 01869 234683.
Email: info@acquire.org.uk
Website: www.acquire.org.uk
Afasic
Represents children and young
adults with communication
impairments, works for their
inclusion in society and supports
their parents and carers.
2nd Floor, 5052 Great Sutton
Street, London EC1V 0DJ.
Helpline: 0845 355 5577.
Fax: 020 7251 2834.
Email: info@afasic.org.uk
Website: www.afasic.org.uk
Chest, Heart & Stroke
Scotland
Provides advice and support for
people in Scotland affected by chest,
heart and stroke conditions.
65 North Castle St, Edinburgh
EH2 3LT.
Advice line: 0845 077 6000.
Fax: 0131 220 6313.
Email: adviceline@chss.org.uk
Website: www.chss.org.uk
Childrens Brain Injury Trust
Aims to improve the quality of life
for all children who have an
acquired brain injury (ABI) and to
enable them to achieve their full
potential.
Child Brain Injury Trust, The
Radcliffe Infirmary, Woodstock
Road, Oxford OX2 6HE.
Helpline: 0845 601 4939.
Tel: 01865 552 467.
Email: helpline@cbituk.org
Website: www.cbituk.org
Childrens Hemiplegia and
Stroke Association
Offers support and information for
families of children who have
hemiplegia, hemiparesis and/or
stroke. Based in the USA.
CHASA Foundation,
Suite 305, PMB 149,
4101 West Green Oaks,
Arlington TX 76016, USA.
Email: info437@chasa.org
Website: www.chasa.org
Contact a Family
Provides information for families of
children with disabilities and/or rare
syndromes.
209211 City Road, London
EC1V 1JN.
Tel: 020 7608 8700.
Fax: 020 7608 8701.
Freephone: 0808 808 3555.
Email: info@cafamily.org.uk
Website: www.cafamily.org.uk
Department for Education
and Skills
Provides advice for parents and
teachers of children with special
educational needs.
Website: www.dfes.gov.uk/sen
Department for Work and
Pensions
Provides information on a range of
benefits and services for families.
Public Enquiry Office
Tel: 020 7712 2171.
Fax: 020 7712 2386.
Website: www.dwp.gov.uk/
lifeevent/famchild/index.asp
Different Strokes
For younger people who have had a
stroke, mainly young adults. Includes
information on access to leisure
activities, counselling services,
benefits and rights information, and
information packs.
Information Officer, Different
Strokes, 9 Canon Harnett Court,
Wolverton Mill,
Milton Keynes MK12 5NF.
Helpline: 0845 130 7172.
Fax: 01908 313501.
Email:
info@differentstrokes.co.uk
Website:
www.differentstrokes.co.uk
58
Disability Alliance
Provides information and advice to
disabled people and their families
about entitlement to social security
benefits and services. Publications
include the Disability rights
handbook.
Universal House,
8894 Wentworth St,
London E1 7SA.
Tel: 020 7247 8776.
Fax: 020 7247 8765.
Website:
www.disabilityalliance.org
HemiHelp
Provides information and support
for children with hemiplegia and
their families.
Unit 1, Wellington Works,
Wellington Road, London
SW19 8EQ.
Helpline: 0845 123 2372.
Fax: 0845 120 3723.
Email:
support@hemihelp.org.uk
Website: www.hemihelp.org.uk
Independent Panel for
Special Education Advice
(IPSEA)
Gives free independent advice on
education issues, including appealing
to special educational needs
tribunals.
6 Carlow Mews, Woodbridge,
Suffolk IP12 1EA.
Tel: 01394 380 518.
England & Wales:
0800 018 4016 (freephone).
Scotland: 0131 665 4396
(freephone).
Website: www.ipsea.org.uk
Provides information and support
for people who have had a stroke
and their families. Produces wide
range of publications, supports
research and health education.
Provides a national Stroke
Information Service and helpline.
240 City Rd, London EC1V 2PR.
Helpline: 0845 3033 100 (local
rate within UK).
Fax: 020 7490 2686.
Email: info@stroke.org.uk
Website: www.stroke.org.uk
Sickle Cell Society
Provides information, counselling
and caring for those with sickle cell
disorders and their families.
54 Station Road, Harlesden,
London NW10 4UA.
Tel: 020 8961 7795.
Fax: 020 8961 8346.
Email:
sickleinfo.line@btinternet.com.
Website:
www.sicklecellsociety.org
Tables of evidence
T
a
b
l
e

1
A
c
u
t
e

d
i
a
g
n
o
s
i
s

a
n
d

p
r
e
s
e
n
t
a
t
i
o
n
S
o
u
r
c
e
D
e
s
i
g
n

a
n
d

s
u
b
j
e
c
t
s
I
n
t
e
r
v
e
n
t
i
o
n
O
u
t
c
o
m
e

m
e
a
s
u
r
e
s
R
e
s
u
l
t
s
Q
u
a
l
i
t
y

a
n
d

c
o
m
m
e
n
t
G
a
n
e
s
a
n

e
t

a
l
,
O
b
s
e
r
v
a
t
i
o
n
a
l

s
t
u
d
y

o
f

3
5
6

D
e
s
c
r
i
p
t
i
o
n

o
f

r
i
s
k

f
a
c
t
o
r
s

N
e
a
r
l
y

2
0
%

o
f

c
h
i
l
d
r
e
n

w
i
t
h

U
n
c
o
n
t
r
o
l
l
e
d

s
t
u
d
y
;
p
o
s
s
i
b
l
e

2
0
0
3
c
h
i
l
d
r
e
n

w
i
t
h

s
t
r
o
k
e

a
n
d

e
n
c
o
u
n
t
e
r
e
d
;
i
n
c
i
d
e
n
t
a
l

d
a
t
a

s
t
r
o
k
e

h
a
d

a

d
i
a
g
n
o
s
i
s

o
t
h
e
r

r
e
f
e
r
r
a
l
/
s
e
l
e
c
t
i
o
n

b
i
a
s
;
d
e
s
c
r
i
p
t
i
o
n

o
f

r
i
s
k

f
a
c
t
o
r
s

o
n

d
i
a
g
n
o
s
e
s

i
n

p
a
t
i
e
n
t
s

w
i
t
h

t
h
a
n

A
I
S
.
A
n
o
t
h
e
r

1
0
%

h
a
d

o
p
p
o
r
t
u
n
i
s
t
i
c

s
a
m
p
l
e
e
n
c
o
u
n
t
e
r
e
d

i
n

2
1
2

w
i
t
h

c
l
i
n
i
c
a
l

s
t
r
o
k
e

s
u
b
s
e
q
u
e
n
t
l
y

n
o
r
m
a
l

i
m
a
g
i
n
g
r
a
d
i
o
l
o
g
i
c
a
l
l
y

c
o
n
f
i
r
m
e
d

A
I
S

f
o
u
n
d

n
o
t

t
o

h
a
v
e

A
I
S
p
r
e
s
e
n
t
i
n
g

t
o

t
e
r
t
i
a
r
y

r
e
f
e
r
r
a
l

c
e
n
t
r
e
A
I
S

=

A
r
t
e
r
i
a
l

i
s
c
h
a
e
m
i
c

s
t
r
o
k
e
T
a
b
l
e

2
C
T

v
s
M
R
I

i
n

t
h
e

n
e
u
r
o
i
m
a
g
i
n
g

d
i
a
g
n
o
s
i
s

o
f

a
c
u
t
e

i
s
c
h
a
e
m
i
c

s
t
r
o
k
e
S
o
u
r
c
e
D
e
s
i
g
n

a
n
d

s
u
b
j
e
c
t
s
I
n
t
e
r
v
e
n
t
i
o
n
O
u
t
c
o
m
e

m
e
a
s
u
r
e
s
R
e
s
u
l
t
s
Q
u
a
l
i
t
y

a
n
d

c
o
m
m
e
n
t
B
r
y
a
n

e
t

a
l
,
O
b
s
e
r
v
a
t
i
o
n
a
l

s
t
u
d
y
;
n

=

3
1
C
T

a
n
d

M
R
I

p
e
r
f
o
r
m
e
d

w
i
t
h
i
n

M
R

a
p
p
e
a
r
s

t
o

b
e

m
o
r
e

S
t
u
d
y

d
e
s
i
g
n

f
a
v
o
u
r
s

M
R
I

o
v
e
r

1
9
9
1
2
4

h
o
u
r
s

a
n
d

a
t

7
1
0

d
a
y
s
s
e
n
s
i
t
i
v
e

t
h
a
n

C
T

i
n

t
h
e

C
T
.
J
u
s
t
i
f
i
c
a
t
i
o
n

b
y

a
u
t
h
o
r
s

i
n

i
m
a
g
i
n
g

o
f

a
c
u
t
e

s
t
r
o
k
e
s
u
b
s
e
q
u
e
n
t

c
o
m
m
e
n
t
a
r
y
K
u
c
i
n
s
k
i

e
t

a
l
,
O
b
s
e
r
v
a
t
i
o
n
a
l

s
t
u
d
y
;
n

=

2
5
Q
u
a
n
t
i
f
i
c
a
t
i
o
n

o
f

d
i
f
f
u
s
i
o
n

D
i
f
f
u
s
i
o
n

(
M
R
I
)

c
h
a
n
g
e
s

b
y

P
r
o
v
i
d
e
s

t
e
c
h
n
i
c
a
l

e
v
i
d
e
n
c
e

t
o
O
b
j
e
c
t
i
v
e

s
u
p
p
o
r
t

f
o
r

p
r
e
v
i
o
u
s

2
0
0
2
c
h
a
n
g
e
s

o
n

M
R
I

a
g
a
i
n
s
t

d
e
n
s
i
t
y

2
1
%
.
D
e
n
s
i
t
y

(
C
T
)

c
h
a
n
g
e
s

e
x
p
l
a
i
n

t
h
e

l
o
w
e
r

s
e
n
s
i
t
i
v
i
t
y

o
f

s
u
b
j
e
c
t
i
v
e

o
b
s
e
r
v
a
t
i
o
n
a
l

s
t
u
d
i
e
s

c
h
a
n
g
e
s

o
n

C
T

i
n

a
c
u
t
e

s
t
r
o
k
e
b
y

4
%
C
T

c
o
m
p
a
r
e
d

w
i
t
h

M
R
I

f
o
r

t
h
a
t

s
h
o
w

M
R
I

b
e
i
n
g

d
e
t
e
c
t
i
o
n

o
f

e
a
r
l
y

i
s
c
h
a
e
m
i
c

a
d
v
a
n
t
a
g
e
o
u
s

o
v
e
r

C
T

(
s
e
e

c
h
a
n
g
e
s

i
n

i
m
a
g
i
n
g

s
t
u
d
i
e
s
b
e
l
o
w
)
B
a
r
b
e
r

P
A

e
t

a
l
,
O
b
s
e
r
v
a
t
i
o
n
a
l

s
t
u
d
y
;
n

=

1
7
I
d
e
n
t
i
f
i
c
a
t
i
o
n

o
f

m
a
j
o
r

D
W
I

i
s

m
o
r
e

s
e
n
s
i
t
i
v
e

t
h
a
n

S
u
b
j
e
c
t
i
v
e

o
b
s
e
r
v
a
t
i
o
n
a
l

s
t
u
d
y

1
9
9
9
i
s
c
h
a
e
m
i
a

a
n
d

a
s
s
o
c
i
a
t
i
o
n

C
T

i
n

t
h
e

i
d
e
n
t
i
f
i
c
a
t
i
o
n

o
f

s
h
o
w
i
n
g

M
R
I

b
e
i
n
g

a
d
v
a
n
t
a
g
e
o
u
s

w
i
t
h

o
u
t
c
o
m
e
a
c
u
t
e

i
s
c
h
a
e
m
i
a

a
n
d

c
a
n

o
v
e
r

C
T
v
i
s
u
a
l
i
s
e

m
a
j
o
r

i
s
c
h
a
e
m
i
a

m
o
r
e

e
a
s
i
l
y

t
h
a
n

C
T
L
a
n
s
b
e
r
g

M
G

O
b
s
e
r
v
a
t
i
o
n
a
l

s
t
u
d
y
;
A
c
c
u
r
a
c
y

o
f

e
a
r
l
y

M
R
I

v
s
C
T

M
R
I

w
a
s

m
o
r
e

a
c
c
u
r
a
t
e

f
o
r

S
u
b
j
e
c
t
i
v
e

o
b
s
e
r
v
a
t
i
o
n
a
l

s
t
u
d
y

e
t

a
l
,
2
0
0
0
n

=

1
9
a
n
d

c
o
r
r
e
l
a
t
i
o
n

w
i
t
h

f
i
n
a
l
i
d
e
n
t
i
f
y
i
n
g

a
c
u
t
e

i
n
f
a
r
c
t
i
o
n

a
n
d

s
h
o
w
i
n
g

M
R
I

b
e
i
n
g

a
d
v
a
n
t
a
g
e
o
u
s

i
n
f
a
r
c
t

v
o
l
u
m
e
m
o
r
e

s
e
n
s
i
t
i
v
e
.
L
e
s
i
o
n

v
o
l
u
m
e

o
v
e
r

C
T
o
n

a
c
u
t
e

M
R
I
,
b
u
t

n
o
t

o
n

a
c
u
t
e

C
T
,
c
o
r
r
e
l
a
t
e
d

s
t
r
o
n
g
l
y

w
i
t
h

f
i
n
a
l

i
n
f
a
r
c
t

v
o
l
u
m
e
C
T

=

C
o
m
p
u
t
e
r
i
s
e
d

t
o
m
o
g
r
a
p
h
y
;
D
W
I

=

D
i
f
f
u
s
i
o
n

w
e
i
g
h
t
e
d

i
m
a
g
i
n
g
;
M
R
A

=

M
a
g
n
e
t
i
c

r
e
s
o
n
a
n
c
e

a
n
g
i
o
g
r
a
p
h
y
;
M
R
I

=

M
a
g
n
e
t
i
c

r
e
s
o
n
a
n
c
e

i
m
a
g
i
n
g
;
O
b
s

=

O
b
s
e
r
v
a
t
i
o
n
a
l

s
t
u
d
y
Tables of evidence
61
62
T
a
b
l
e

3
I
n
v
e
s
t
i
g
a
t
i
o
n
S
o
u
r
c
e
D
e
s
i
g
n

a
n
d

s
u
b
j
e
c
t
s
I
n
t
e
r
v
e
n
t
i
o
n
O
u
t
c
o
m
e

m
e
a
s
u
r
e
s
R
e
s
u
l
t
s
Q
u
a
l
i
t
y

a
n
d

c
o
m
m
e
n
t
G
a
n
e
s
a
n

e
t

a
l
,
O
b
s
e
r
v
a
t
i
o
n
a
l

s
t
u
d
y

o
f

D
e
s
c
r
i
p
t
i
o
n

o
f

r
i
s
k

f
a
c
t
o
r
s

R
a
d
i
o
l
o
g
i
c
a
l
l
y

c
o
n
f
i
r
m
e
d

A
I
S
1
.
7
9
%

h
a
d

c
e
r
e
b
r
a
l

a
r
t
e
r
i
a
l

U
n
c
o
n
t
r
o
l
l
e
d

s
t
u
d
y
,
n
o
t

a
l
l

2
0
0
3
3
5
6

c
h
i
l
d
r
e
n

w
i
t
h

s
t
r
o
k
e

a
n
d

e
n
c
o
u
n
t
e
r
e
d
;
i
n
c
i
d
e
n
t
a
l

d
a
t
a

a
b
n
o
r
m
a
l
i
t
i
e
s

p
a
t
i
e
n
t
s

h
a
d

a
l
l

i
n
v
e
s
t
i
g
a
t
i
o
n
s
;
d
e
s
c
r
i
p
t
i
o
n

o
f

r
i
s
k

f
a
c
t
o
r
s

o
n

d
i
a
g
n
o
s
e
s

i
n

p
a
t
i
e
n
t
s

w
i
t
h

2
.
S
i
g
n
i
f
i
c
a
n
t

a
s
s
o
c
i
a
t
i
o
n

p
o
s
s
i
b
l
e

r
e
f
e
r
r
a
l
/
s
e
l
e
c
t
i
o
n

b
i
a
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n

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3
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(
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y

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b
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g
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7
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2
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n
c
r
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a
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d

p
r
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t

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l
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9
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f

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4
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h
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a
n
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V
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t
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f

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a
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p
(
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r
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r
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a
d

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p
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p
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t
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8
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;
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t

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1

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b
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y
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2
5
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a
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d

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a
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b
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n

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p
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n

a
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b
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d
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e
s
2
3

h
a
d

a
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t
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c
a
r
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n

a
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b
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d
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s
,
6

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a
d

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p
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s

a
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t
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c
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a
g
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a
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t
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1
0

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a
d

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T

d
e
f
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c
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1
0

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a
d

p
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t
e
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d
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f
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c
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c
y
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a
d

p
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m
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g
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n

d
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f
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c
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6

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a
d

p
r
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t
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d
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f
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c
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6

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a
d

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0

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a
d

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o

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i
g
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f
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c
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t

d
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d

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d
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r

c
h
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l
d
r
e
n
c
o
n
t
i
n
u
e
d
Tables of evidence
63
T
a
b
l
e

3
I
n
v
e
s
t
i
g
a
t
i
o
n

c
o
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a
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t
c
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e

m
e
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R
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Q
u
a
l
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t
y

a
n
d

c
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m
m
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t
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a
t
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r

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t

a
l
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M
u
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-
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t
r
e

s
t
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y
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e
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a
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;
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l
l

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p
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0

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a
d

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o
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t

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d

b
y

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i
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y

2
0
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2
3
2
4

w
h
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t
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c
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d
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n

a
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d

t
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m
b
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(
p
r
o
t
e
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n

C
,
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c
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s
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c
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p
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g
r
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p

7

m
o
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t
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t
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1
8

y
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a
r
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a
t

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a
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d
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V

a
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m
o
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a
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3
.
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b
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t
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p
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m
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r
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d
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w
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T
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r
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f
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r
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m
b
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1
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h
a
d

a
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d
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d
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2
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3
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9
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p
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4
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R
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2
1
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c
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c
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t

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9
4
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b
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1
9
C
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p
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M
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a
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p
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64
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b
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c
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d
Tables of evidence
65
T
a
b
l
e

6
R
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v
a
s
c
u
l
a
r
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s
a
t
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t

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l
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1
5
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c
t

1
4
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n
d
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t

1
C
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3
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t
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m
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c
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n
g
.
f
o
r

a
t

l
e
a
s
t

2

y
e
a
r
s

b
u
t

w
e
r
e

m
a
x

3
0

m
g
/
k
g
/
d
a
y

f
o
r

3
5
2

b
e
f
o
r
e

m
a
x

H
b
F

i
n
c
r
e
a
s
e
.
S
o
m
e

p
a
t
i
e
n
t
s

d
i
d

n
o
t

h
a
v
e

a
l
l
o
m
m
u
n
i
s
e
d

(
n

=

2
)
,
h
a
d

(
m
e
d
i
a
n

2
2

m
o
n
t
h
s
)
I

p
a
t
i
e
n
t

w
h
o

w
a
s

v
a
s
c
u
l
o
p
a
t
h
y

s
o

h
a
d

l
o
w

r
i
s
k

o
f

a
u
t
o
a
n
t
i
b
o
d
i
e
s

(
n

=

4
)
,
h
a
d

n
o
n
-
c
o
m
p
l
i
a
n
t

w
i
t
h

r
e
s
t
r
o
k
e
?
s
t
r
o
k
e

o
n

t
x

(
n

=

1
)
,
h
a
d

h
y
d
r
o
x
y
u
r
e
a

a
s

w
e
l
l

a
s

b
l
o
o
d

f
e
r
r
i
t
i
n
>

(
n

=

1
1
)

o
r

w
e
r
e

h
a
d

s
t
r
o
k
e

4

m
o
n
t
h
s

a
f
t
e
r

n
o
n
-
c
o
m
p
l
i
a
n
t

(
n

=

5
)

w
i
t
h

s
t
o
p
p
i
n
g
b
l
o
o
d

t
x

a
n
d
/
o
r

c
h
e
l
a
t
i
o
n
S
u
m
o
z
a

e
t

a
l
,
V
a
l
e
n
c
i
a
,
V
e
n
e
z
u
a
l
a

c
o
h
o
r
t

H
y
d
r
o
x
y
u
r
e
a

4
0

m
g
/
k
g
/
d
a
y

i
n

R
e
c
u
r
r
e
n
t

s
t
r
o
k
e

o
r

T
I
A
N
o
n
e

h
a
d

r
e
c
u
r
r
e
n
t

e
v
e
n
t

C
o
h
o
r
t
;
s
m
a
l
l

n
u
m
b
e
r
s
;
n
o

2
0
0
2
n

=

5
;
1

T
I
A
,
4

s
t
r
o
k
e
.
4
,
3
0

m
g
/
k
g
/
d
a
y

i
n

1
o
v
e
r

4
2
1
1
2

m
o
n
t
h
s
v
a
s
c
u
l
a
r

i
m
a
g
i
n
g
;
p
a
r
i
e
t
a
l

i
n
f
a
r
c
t
s

R
x

h
y
d
r
o
x
y
u
r
e
a
;
2

a
f
t
e
r

2
n
d

o
r

w
h
i
t
e

m
a
t
t
e
r

a
b
n
o
r
m
a
l
i
t
y
.
s
t
r
o
k
e
s
;
3

-

1
s
t

s
t
r
o
k
e

(
n
o

T
x
)
V
e
n
o
u
s

i
n
f
a
r
c
t
s
Tables of evidence
67
68
T
a
b
l
e

9
S
e
c
o
n
d
a
r
y

p
r
e
v
e
n
t
i
o
n

o
f

s
t
r
o
k
e

i
n

s
i
c
k
l
e

c
e
l
l

d
i
s
e
a
s
e

(
b
o
n
e

m
a
r
r
o
w

t
r
a
n
s
p
l
a
n
t
a
t
i
o
n
)
S
o
u
r
c
e
D
e
s
i
g
n

a
n
d

s
u
b
j
e
c
t
s
I
n
t
e
r
v
e
n
t
i
o
n
O
u
t
c
o
m
e

m
e
a
s
u
r
e
s
R
e
s
u
l
t
s
Q
u
a
l
i
t
y

a
n
d

c
o
m
m
e
n
t
V
e
r
m
y
l
e
n

1
9
9
8
B
e
l
g
i
a
n

B
M

T
x
H
L
A
-
i
d
e
n
t
i
c
a
l

s
t
e
m

c
e
l
l

T
x

S
u
r
v
i
v
a
l
,
d
i
s
e
a
s
e
-
f
r
e
e

s
u
r
v
i
v
a
l
9
3
%

s
u
r
v
i
v
a
l
,
8
2
%

d
i
s
e
a
s
e

f
r
e
e
(
b
o
n
e

m
a
r
r
o
w
,
4
8
;
c
o
r
d

b
l
o
o
d
,
2
)
B
e
r
n
a
u
d
i
n

1
9
9
9
F
r
e
n
c
h

B
M

T
x
B
o
n
e

m
a
r
r
o
w

t
r
a
n
s
p
l
a
n
t

f
r
o
m

S
u
r
v
i
v
a
l
,
a
b
s
e
n
c
e

o
f

S
C
D
,
9
1
%

s
u
r
v
i
v
a
l
,
8
5
%

d
i
s
e
a
s
e

f
r
e
e
,
H
L
A
-
i
d
e
n
t
i
c
a
l

s
i
b
l
i
n
g
s
r
e
c
u
r
r
e
n
t

s
t
r
o
k
e
1
/
1
6

(
6
%
)

r
e
c
u
r
r
e
n
t

s
t
r
o
k
e
W
a
l
t
e
r
s

e
t

a
l
,
U
S
A

B
M

T
x

c
o
h
o
r
t

n

=

5
0

S
t
e
m

c
e
l
l

t
r
a
n
s
p
l
a
n
t

c

P
x

C
l
i
n
i
c
a
l

s
t
r
o
k
e
,
p
r
o
g
r
e
s
s
i
o
n

o
f

9
4
%

s
u
r
v
i
v
a
l
;
8
4
%

d
i
s
e
a
s
e

f
r
e
e
;
S
h
o
r
t

F
U
;
1

d
i
e
d

c
e
r
e
b
r
a
l

h
a
e
m

2
0
0
0
(
4
8

S
S
)
;
f
o
l
l
o
w

u
p

5
7
.
9

m
o
n
t
h
s

p
h
e
n
y
t
o
i
n
,
c
o
n
t
r
o
l

o
f

s
i
l
e
n
t

i
n
f
a
r
c
t
i
o
n

o
n

M
R
I
n
o

n
e
w

c
l
i
n
i
c
a
l

s
t
r
o
k
e
s
;
M
R
I

a
n
d

2

G
V
H
D
;
9
/
4
3

(
2
0
%
)

h
a
d

(
3
8
9
5
)
h
y
p
e
r
t
e
n
s
i
o
n
,
M
g
2
+

s
u
p
p
s

i
f

s
t
a
b
l
e

o
r

i
m
p
r
o
v
e
d

i
n

a
l
l
s
e
i
z
u
r
e
s

s
o
o
n

a
f
t
e
r

B
M

T
x
l
o
w
,
H
b

9
-
1
1
,
p
l
t
>
5
0
,
0
0
0
B
M

T
x

=

B
o
n
e

m
a
r
r
o
w

t
r
a
n
s
p
l
a
n
t
a
t
i
o
n
;
G
V
H
D

=

G
r
a
f
t

v
s
h
o
s
t

d
i
s
e
a
s
e
;
P
x

=

P
r
o
p
h
y
l
a
c
t
i
c
;
Q
A
L
Y

=

Q
u
a
l
i
t
y

a
d
j
u
s
t
e
d

l
i
f
e

y
e
a
r
s
;
F
U

=

F
o
l
l
o
w
-
u
p
T
a
b
l
e

1
0
E
a
r
l
y

d
i
s
a
b
i
l
i
t
y

a
s
s
e
s
s
m
e
n
t
S
o
u
r
c
e
D
e
s
i
g
n

a
n
d

s
u
b
j
e
c
t
s
I
n
t
e
r
v
e
n
t
i
o
n
O
u
t
c
o
m
e

m
e
a
s
u
r
e
s
R
e
s
u
l
t
s
Q
u
a
l
i
t
y

a
n
d

c
o
m
m
e
n
t
M
o
r
g
a
n

e
t

a
l
,
C
h
i
l
d
r
e
n

w
i
t
h

T
B
I

p
r
e
s
e
n
t
i
n
g

I
n
c
i
d
e
n
c
e

c
h
a
r
a
c
t
e
r
i
s
t
i
c
s

a
n
d

D
y
s
p
h
a
g
i
a
6
1

p
a
t
i
e
n
t
s

(
5
.
3
%
)

h
a
d

G
o
o
d

s
t
u
d
y
,
p
o
p
u
l
a
t
i
o
n

b
a
s
e
d

2
0
0
3
t
o

2

m
a
j
o
r

h
o
s
p
i
t
a
l
s

i
n

B
r
i
s
b
a
n
e
;
p
r
e
d
i
c
t
i
v
e

f
a
c
t
o
r
s

f
o
r

d
y
s
p
h
a
g
i
a

d
y
s
p
h
a
g
i
a
,
6
8
%

s
e
v
e
r
e

T
B
I
,
b
u
t

r
e
t
r
o
s
p
e
c
t
i
v
e
n

=

1
1
4
5

c
h
i
l
d
r
e
n

a
g
e
d

a
f
t
e
r

p
a
e
d
i
a
t
r
i
c

t
r
a
u
m
a
t
i
c

b
r
a
i
n

1
5
%

m
o
d
e
r
a
t
e

T
B
I

a
n
d

1
%

m
i
l
d

0
1
6

y
e
a
r
s
i
n
j
u
r
y
T
B
I

i
e

m
o
r
e

s
e
v
e
r
e

i
n
j
u
r
y

a
s
s
o
c
i
a
t
e
d

w
i
t
h

h
i
g
e
r

i
n
c
i
d
e
n
c
e

o
f

d
y
s
p
h
a
g
i
a
.
N
e
e
d

f
o
r

a
n
d

d
u
r
a
t
i
o
n

o
f

S
A
L
T

t
r
e
a
t
m
e
n
t

g
r
e
a
t
e
r

i
n

d
y
s
p
h
a
g
i
c

g
r
o
u
p
.
P
a
t
i
e
n
t
s

w
i
t
h

d
y
s
p
h
a
g
i
a

l
i
k
e
l
y

t
o

h
a
v
e

l
o
w
e
r

G
C
S

a
n
d

l
o
n
g
e
r

n
e
e
d

f
o
r

v
e
n
t
i
l
a
t
i
o
n
G
C
S

=

G
l
a
s
g
o
w

c
o
m
a

s
c
o
r
e
;
S
A
L
T

=

S
p
e
e
c
h

a
n
d

l
a
n
g
u
a
g
e

t
h
e
r
a
p
y
;
T
B
I

=

T
r
a
u
m
a
t
i
c

b
r
a
i
n

i
n
j
u
r
y
Tables of evidence
69
T
a
b
l
e

1
1
T
h
e
r
a
p
y

i
n
t
e
r
v
e
n
t
i
o
n
s
S
o
u
r
c
e
D
e
s
i
g
n

a
n
d

s
u
b
j
e
c
t
s
I
n
t
e
r
v
e
n
t
i
o
n
O
u
t
c
o
m
e

m
e
a
s
u
r
e
s
R
e
s
u
l
t
s
Q
u
a
l
i
t
y

a
n
d

c
o
m
m
e
n
t
v
a
n

d
e
r

W
e
e
l
M
a
t
c
h
e
d

c
o
n
t
r
o
l
s
;
7
1
1

y
e
a
r
s
;
3

c
o
n
d
i
t
i
o
n
s

o
f

f
o
r
e
a
r
m

C
o
m
p
u
t
e
r
i
s
e
d

m
e
a
s
u
r
e
s

o
f

I
n

a
f
f
e
c
t
e
d

a
r
m

2
0
%

i
n
c
r
e
a
s
e

G
o
o
d
.
I
m
p
l
i
c
a
t
i
o
n
s

f
o
r

a
s
s
e
s
s
m
e
n
t

e
t

a
l
,
1
9
9
1
9

h
e
m
i
p
l
e
g
i
a
;
1
2

n
o
r
m
a
l
p
r
o
n
a
t
i
o
n
/
s
u
p
i
n
a
t
i
o
n

p
a
s
s
i
v
e
,
r
a
n
g
e

o
f

m
o
v
e
m
e
n
t
i
n

r
a
n
g
e

o
n

a
c
t
i
v
e

m
o
v
e
m
e
n
t

a
n
d

t
h
e
r
a
p
y
a
c
t
i
v
e

n
o

t
a
s
k

a
n
d

a
c
t
i
v
e

w
i
t
h

w
i
t
h

t
a
s
k
t
a
s
k
L
a
w

e
t

a
l
,
1
9
9
1
R
C
T
,
2
x
2

f
a
c
t
o
r
i
a
l

d
e
s
i
g
n
.
U
p
p
e
r

l
i
m
b

(
U
L
)

i
n
h
i
b
i
t
i
v
e

P
e
a
b
o
d
y

S
c
a
l
e
s

(
h
a
n
d

f
u
n
c
t
i
o
n
)
;
N
o

s
i
g
n
i
f
i
c
a
n
t

d
i
f
f
e
r
e
n
c
e

W
e
l
l

d
e
s
i
g
n
e
d
.
P
o
t
e
n
t
i
a
l

7
2

c
h
i
l
d
r
e
n

a
g
e
d

1
8

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.
G
M
C
S

1
1
1

&

b
e
l
o
w
s
e
t
t
i
n
g
b
e
t
w
e
e
n

g
r
o
u
p
s
B
u
t
l
e
r

&

R
e
v
i
e
w

p
a
p
e
r
N
D
T

v
s
o
t
h
e
r

t
y
p
e
s

o
f

V
a
r
i
e
d
N
o

s
i
g
n
i
f
i
c
a
n
t

d
i
f
f
e
r
e
n
c
e
s

f
o
u
n
d

G
o
o
d
D
a
r
r
a
h

2
0
0
1
i
n
t
e
r
v
e
n
t
i
o
n
b
e
t
w
e
e
n

t
y
p
e
s

o
f

t
r
e
a
t
m
e
n
t

V
o
l
m
a
n

e
t

a
l
,
1
2

c
h
i
l
d
r
e
n

w
i
t
h

h
e
m
i
p
l
e
g
i
a
C
o
m
p
a
r
i
s
o
n

o
f

r
e
a
c
h
i
n
g

K
i
n
e
m
a
t
i
c
s

o
f

m
o
v
e
m
e
n
t

a
n
d

T
h
e

f
u
n
c
t
i
o
n
a
l

c
o
n
d
i
t
i
o
n

G
o
o
d
2
0
0
2
8
1
4

y
e
a
r
s
m
o
v
e
m
e
n
t
s

w
i
t
h

a
f
f
e
c
t
e
d

a
n
d

m
o
v
e
m
e
n
t

t
i
m
e
d
e
m
o
n
s
t
r
a
t
e
d

i
n
c
r
e
a
s
e
d

n
o
n
-
a
f
f
e
c
t
e
d

a
r
m

i
n

3

c
o
n
d
i
t
i
o
n
s
v
e
l
o
c
i
t
y

a
n
d

i
m
p
r
o
v
e
m
e
n
t
s

i
n

s
m
o
o
t
h
n
e
s
s

a
n
d

c
o
n
t
r
o
l
W
i
l
l
i
s

e
t

a
l
,
2
0
0
2
2
5

s
u
b
j
e
c
t
s
,
f
i
n
a
l

n
u
m
b
e
r

1
7
;
C
r
o
s
s
-
o
v
e
r

t
r
i
a
l
;
c
o
n
s
t
r
a
i
n
t
-
P
D
M
S
S
i
g
n
i
f
i
c
a
n
t

i
m
p
r
o
v
e
m
e
n
t
s

G
o
o
d
,
a
l
t
h
o
u
g
h

v
a
l
i
d
i
t
y

o
f

P
D
M
S

1
8

y
e
a
r
s
i
n
d
u
c
e
d

t
h
e
r
a
p
y

w
i
t
h

p
l
a
s
t
e
r

b
e
t
w
e
e
n

c
o
n
t
r
o
l

a
n
d

n
o
t

c
l
e
a
r
l
y

e
s
t
a
b
l
i
s
h
e
d
c
a
s
t

f
o
r

1

m
o
n
t
h
t
r
e
a
t
m
e
n
t

c
o
n
d
i
t
i
o
n
s
P
i
e
r
c
e

e
t

a
l
,
S
i
n
g
l
e

c
a
s
e

s
t
u
d
y
;
1

c
h
i
l
d
C
o
n
s
t
r
a
i
n
t
-
i
n
d
u
c
e
d

t
h
e
r
a
p
y
;
J
e
b
s
o
n

T
a
y
l
o
r

t
e
s
t

o
f

h
a
n
d

I
m
p
r
o
v
e
d

p
e
r
f
o
r
m
a
n
c
e

t
i
m
e
s

S
m
a
l
l

s
a
m
p
l
e

w
i
t
h

a
p
p
r
o
p
r
i
a
t
e

2
0
0
2
c
o
t
t
o
n

s
l
i
n
g

6

h
o
u
r
s

p
e
r

d
a
y

f
u
n
c
t
i
o
n
,
F
i
n
g
e
r

t
i
p

f
o
r
c
e

a
n
d

o
n

J
T
T
H
F
;
n
o

c
o
n
s
i
s
t
e
n
t

m
e
a
s
u
r
e
m
e
n
t
s
f
o
r

1
4

d
a
y
s
v
e
r
t
i
c
a
l

g
r
i
p

(
c
u
s
t
o
m

m
a
d
e
)
c
h
a
n
g
e
s

i
n

p
r
e
c
i
s
i
o
n

o
f

m
o
v
e
m
e
n
t
C
O
P
M

=

C
a
n
a
d
i
a
n

O
c
c
u
p
a
t
i
o
n
a
l

P
e
r
f
o
r
m
a
n
c
e

M
e
a
s
u
r
e
;
F
E
S

=

F
u
n
c
t
i
o
n
a
l

e
l
e
c
t
r
i
c
a
l

s
t
i
m
u
l
a
t
i
o
n
;
G
M
C
S

=

G
r
o
s
s

M
o
t
o
r

F
u
n
c
t
i
o
n

C
l
a
s
s
i
f
i
c
a
t
i
o
n

S
y
s
t
e
m
;
G
M
F
M

=

G
r
o
s
s

M
o
t
o
r

F
u
n
c
t
i
o
n

M
e
a
s
u
r
e
;
G
M
P
M

=

G
r
o
s
s

M
o
t
o
r
P
e
r
f
o
r
m
a
n
c
e

M
e
a
s
u
r
e
;
J
T
T
H
F

=

J
e
b
s
o
n

T
a
y
l
o
r

T
e
s
t

o
f

H
a
n
d

F
u
n
c
t
i
o
n
;
N
D
T

=

N
e
u
r
o
-
d
e
v
e
l
o
p
m
e
n
t
a
l

t
h
e
r
a
p
y
;
P
D
M
S

=

P
e
a
b
o
d
y

D
e
v
e
l
o
p
m
e
n
t
a
l

M
o
t
o
r

S
c
a
l
e
s
;
P
E
D
I

=

P
a
e
d
i
a
t
r
i
c

E
v
a
l
u
a
t
i
o
n

o
f

D
i
s
a
b
i
l
i
t
y

I
n
v
e
n
t
o
r
y
;
R
C
T

=

R
a
n
d
o
m
i
s
e
d

c
o
n
t
r
o
l
l
e
d

t
r
i
a
l
Tables of evidence
71
T
a
b
l
e

1
2
S
t
r
e
n
g
t
h

t
r
a
i
n
i
n
g
S
o
u
r
c
e
D
e
s
i
g
n

a
n
d

s
u
b
j
e
c
t
s
I
n
t
e
r
v
e
n
t
i
o
n
O
u
t
c
o
m
e

m
e
a
s
u
r
e
s
R
e
s
u
l
t
s
Q
u
a
l
i
t
y

a
n
d

c
o
m
m
e
n
t
D
a
m
i
a
n
o

&

A
b
e
l
,
2
3

+

9

C
P

M
e
a
s
u
r
e
m
e
n
t

o
f

s
t
r
e
n
g
t
h

a
n
d

D
y
n
a
m
o
m
e
t
e
r
;
G
M
F
M
M
u
s
c
l
e

s
t
i
f
f
n
e
s
s

r
e
l
a
t
e
d

t
o

G
o
o
d
1
9
9
8
f
u
n
c
t
i
o
n
w
e
a
k
n
e
s
s
;
i
m
p
r
o
v
e
d

m
u
s
c
l
e

s
t
r
e
n
g
t
h

c
o
r
r
e
l
a
t
e
d

w
i
t
h

i
m
p
r
o
v
e
d

G
M
F
M

s
c
o
r
e
s
R
o
s
s

&

E
n
g
s
b
e
r
g

R
e
t
r
o
s
p
e
c
t
i
v
e

a
n
a
l
y
s
i
s

o
f

d
a
t
a

S
t
r
e
n
g
t
h

a
n
d

s
p
a
s
t
i
c
i
t
y

t
e
s
t

a
t

D
y
n
a
m
o
m
e
t
e
r
N
o

r
e
l
a
t
i
o
n
s
h
i
p

b
e
t
w
e
e
n

G
o
o
d
2
0
0
2
k
n
e
e

a
n
d

a
n
k
l
e
;
6
0

c
h
i
l
d
r
e
n

s
p
a
s
t
i
c
i
t
y

a
n
d

s
t
r
e
n
g
t
h
w
i
t
h

d
i
p
l
e
g
i
a
,
m
e
a
n

a
g
e

1
2

y
e
a
r
s
S
h
o
r
t
l
a
n
d

e
t

a
l
,
5

a
d
u
l
t
s

&

5

c
h
i
l
d
r
e
n

w
i
t
h

C
P
U
l
t
r
a
s
o
u
n
d

i
m
a
g
i
n
g

o
f

D
e
c
r
e
a
s
e
d

m
u
s
c
l
e

f
i
b
r
e

S
h
o
r
t
e
n
i
n
g

r
e
l
a
t
e
d

t
o

d
e
c
r
e
a
s
e
d

G
o
o
d

q
u
a
l
i
t
y
:
s
m
a
l
l

s
t
u
d
y

o
n

o
n
e

2
0
0
2
g
a
s
t
r
o
c
n
e
m
i
u
s

m
u
s
c
l
e
d
i
a
m
e
t
e
r

i
n

c
h
i
l
d
r
e
n

w
i
t
h

C
P
m
u
s
c
l
e

f
i
b
r
e

d
i
a
m
e
t
e
r

a
n
d

m
u
s
c
l
e
e
f
f
e
c
t

o
n

a
p
o
n
e
u
r
o
s
i
s

i
n
d
i
c
a
t
i
n
g

m
u
s
c
l
e

w
e
a
k
n
e
s
s
C
P

=

C
e
r
e
b
r
a
l

p
a
l
s
y
;
G
M
F
M

=

G
r
o
s
s

M
o
t
o
r

F
u
n
c
t
i
o
n

M
e
a
s
u
r
e

T
a
b
l
e

1
3
O
r
t
h
o
t
i
c
s
S
o
u
r
c
e
D
e
s
i
g
n

a
n
d

s
u
b
j
e
c
t
s
I
n
t
e
r
v
e
n
t
i
o
n
O
u
t
c
o
m
e

m
e
a
s
u
r
e
s
R
e
s
u
l
t
s
Q
u
a
l
i
t
y

a
n
d

c
o
m
m
e
n
t
R
o
m
k
e
s

&

C
C
T
;
1
2

s
u
b
j
e
c
t
s

&

1
0

c
o
n
t
r
o
l
s
;
H
i
n
g
e
d

A
F
O
;
D
A
F
O
G
a
i
t

a
n
a
l
y
s
i
s
H
i
n
g
e
d

A
F
O

p
r
o
d
u
c
e
d

a

g
a
i
t

G
o
o
d
,
s
m
a
l
l

s
a
m
p
l
e
B
r
u
n
n
e
r

2
0
0
2
h
e
m
i
p
l
e
g
i
a
c
y
c
l
e

c
l
o
s
e
r

t
o

n
o
r
m
a
l
.
I
m
p
r
o
v
e

h
e
e
l

t
o
e

g
a
i
t

a
n
d

i
n
c
r
e
a
s
e
d

s
t
r
i
d
e

l
e
n
g
t
h

c
o
m
p
a
r
e
d

t
o

D
A
F
O
O
u
n
p
u
u

e
t

a
l
,
3
1

c
h
i
l
d
r
e
n

(
1
9

w
i
t
h

h
e
m
i
p
l
e
g
i
a
)
;
U
s
e

o
f

p
o
s
t
e
r
i
o
r

l
e
a
f

s
p
r
i
n
g

G
a
i
t

a
n
a
l
y
s
i
s

m
e
a
s
u
r
i
n
g

a
n
k
l
e

I
n
c
r
e
a
s
e
d

d
o
r
s
i
f
l
e
x
i
o
n

i
n

G
o
o
d
1
9
9
6
c
r
o
s
s
o
v
e
r

d
e
s
i
g
n
,
2

c
o
n
d
i
t
i
o
n
s

A
F
O

c
o
m
p
a
r
e
d

t
o

b
a
r
e
f
o
o
t

a
n
d

f
o
o
t

m
o
v
e
m
e
n
t

&

p
o
s
i
t
i
o
n
t
e
r
m
i
n
a
l

a
n
d

s
w
i
n
g

p
h
a
s
e
s
.
N
o

c
o
m
p
a
r
e
d
w
a
l
k
i
n
g
i
n
c
r
e
a
s
e

i
n

w
a
l
k
i
n
g

v
e
l
o
c
i
t
y

B
r
u
n
n
e
r

e
t

a
l
,
1
4

c
h
i
l
d
r
e
n
;
c
r
o
s
s
o
v
e
r

d
e
s
i
g
n

S
p
r
i
n
g

t
y
p
e
;
A
F
O

v
s
r
i
g
i
d
;
G
a
i
t

a
n
a
l
y
s
i
s
S
p
r
i
n
g

t
y
p
e

a
c
h
i
e
v
e
d

a
l
m
o
s
t

G
o
o
d
1
9
9
8
3

c
o
n
d
i
t
i
o
n
s
A
F
O

v
s
b
a
r
e
f
o
o
t
n
o
r
m
a
l

r
o
c
k
i
n
g

o
f

f
o
o
t
,
d
e
c
r
e
a
s
e
d

e
q
u
i
n
u
s

a
n
d

h
i
p

a
d
d
u
c
t
i
o
n
.
R
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72
T
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1
4
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a
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f

m
o
t
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n
Tables of evidence
73
T
a
b
l
e

1
5
P
s
y
c
h
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l
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m
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1
3

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n
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2
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5

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c
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d
Tables of evidence
75
T
a
b
l
e

1
5
P
s
y
c
h
o
l
o
g
y

c
o
n
t
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n
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d
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o
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D
e
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n

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n
d

s
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b
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s
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v
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t
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n
O
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t
c
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m
e

m
e
a
s
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e
s
R
e
s
u
l
t
s
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u
a
l
i
t
y

a
n
d

c
o
m
m
e
n
t
B
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n
i

e
t

a
l
,
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0
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1
5
2

c
h
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l
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n

A
g
e

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7

y
e
a
r
s

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h
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v
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a
t
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n

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f

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b
b
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a
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e
d

W
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c

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h
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n

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c
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d

l
o
w
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r

E
V
A

s
i
c
k
l
e

c
e
l
l

d
i
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e
a
s
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b
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h
a
v
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r

p
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b
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s
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l

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n
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y
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s

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f

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n
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r
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l

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c
c
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y

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Q

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a
d

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r

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s

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n

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m
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Chapter 8
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Prepared by the Paediatric Stroke Working Group

4 Early disability assessment and man agement

Stroke in childhood: clinical guidelines for diagnosis, management and rehabilitation

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