On the morning of Dec. 30, 5-year-old Isabella Morales was talking with her family about what they would have for breakfast at her Kendall home when she grabbed her forehead and screamed before eventually losing consciousness.
“It was like nothing my husband and I had ever seen,” said her mother, Elizabeth Morales, who along with her husband, Jorge, both 36, have two other children, Kevin, 11 and Brian, 9. “She was like a rag doll.”
Isabella suffered from an arteriovenous malformation (AVM) or abnormal blood vessels in her brain. The blood vessels ruptured and began bleeding, resulting in a hemorrhagic stroke.
Pediatric strokes are a leading cause of death in children nationwide, according to the National Stroke Association. Strokes affect six in 100,000 children.
Although pediatric strokes are not common, children diagnosed with sickle cell disease have the highest risk of strokes among children, said Dr. Ofelia Alvarez, professor of clinical pediatrics and the director of the sickle cell program at the University of Miami/Jackson Memorial Hospital.
In sickle cell patients, blood vessels narrow and decrease blood flow due to red blood cells becoming sticky, Alvarez said. Sickle cell patients who are at risk of a stroke are then given a blood transfusion every three to four weeks indefinitely.
Sickle cell disease can often appear like Moyamoya disease, said Dr. Mohamed Samy Elhammady, a neurosurgeon at the University of Miami Miller School of Medicine/Jackson Memorial Hospital. Moyamoya disease is a rare condition that can cause circulation to the brain to be disrupted by a narrowing of the brain’s blood vessels.
Doctors will perform a bypass procedure, cerebral revascularization, to divert arteries in the scalp into the brain, said Dr. Sanjiv Bhatia, pediatric neurosurgeon at Miami Children’s Hospital and associate professor in neurosurgery at the University of Miami Miller School of Medicine.
“Once the brain gets fresh arteries supplying blood to the brain these kids stop having strokes,” Bhatia said. “The procedure is used frequently with kids of Moyamoya disease that have had narrowing of arteries going to the brain.”
Patients can have other conditions that increase their risk of stroke such as congenital heart disease or hypercoagulability, where their blood vessels abnormally clot, said Dr. Jason Adler, medical director of the pediatric intensive unit at Joe DiMaggio Children’s Hospital and a physician of Pediatric Critical Care South Florida.
Signs of stroke
Some signs that a pediatric stroke has occurred are a very severe headache, changes in vision and swallowing, drooling, weakness on one side of the body, and changes in speech such as pronunciation or slurred words, said Dr. Laura Wilner, director of pediatric rehabilitation at Joe DiMaggio Children’s Hospital.
A pediatric stroke can also occur when a fetus is in the womb, said Dr. Sayed Naqvi, chief of inpatient pediatric neurology and director of the stroke program at Miami Children’s Hospital.
A sign of this is when a child prefers to use one hand only and not the other before age 2, when children generally become left- or right-handed, Naqvi said. This usually indicates hemiplegia, which is a total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain.
“It is not commonly known that children can have pediatric strokes,” said Naqvi. “People are [also] not aware that stroke can occur before birth.”
A patient’s recovery after a pediatric stroke varies depending on their condition, Adler said. Some, who have speech or learning issues from the stroke, may need therapy indefinitely. Others may have motor skill deficits such as a weakness on one side of the body.
In Isabella’s case, she made a full recovery after undergoing surgery at Miami Children’s Hospital to remove the abnormal blood vessels in her brain.
“She required very little therapy afterwards,” said Morales, noting that Isabella began kindergarten on Aug. 18. “She is back to writing, reading and playing sports.”
Isabella undergoes periodic testing including a cerebral angiogram scheduled in December. A catheter is used to inject dye into the blood vessels leading into the brain to locate abnormal configurations, Bhatia said.
“Her life went right back to normal, and for that we will forever be grateful,” Morales said.