For no apparent reason, Zander Maclane suddenly started experiencing several episodes of dizziness and fatigue. The Stevensville, Md. six-year-old was often hungry and thirsty, as well, says his mother, Amanda Maclane. She consulted a nurse in the family, who suggested his symptoms might be the result of low-blood sugar and not to worry unless symptoms worsened. They did when this past March Zander suffered a severe headache and vomited. Upon examination, Zander’s pediatrician said he appeared to be constipated and dehydrated, perfectly manageable conditions. But a few days after the visit Zander woke up unable to speak or swallow.

“He started to talk but he couldn’t use the right side of his mouth—he was drooling,” says his mom. “We couldn’t comprehend what he was saying.”

Following the pediatrician’s orders, Zander’s family drove him to the hospital ED closest to their home on the Eastern Shore. There a CT revealed a mass in his brain, perhaps a tumor. An ED physician called Johns Hopkins Children’s Center, where pediatric neurologist Ryan Felling recommended immediate air transport to Hopkins. Felling, who specializes in diagnosing and treating stroke in children, identified the symptoms right away.

“For me, it was a pretty classic presentation of a stroke,” says Felling. “When they present with those acute weakness symptoms we’re going to get them here as quickly as possible to treat and protect the brain as much as we can in that acute phase.”

But for parents and even many pediatricians, Felling adds, the signs of stroke in children can be easily missed. The word “stroke” usually prompts a picture of an ailing senior citizen. Indeed, studies show the risk of stroke doubles with each decade after age 55. However, according to the National Stroke Association, 6 in every 100,000 children in the United States are afflicted by stroke—and stroke rates are on the rise in children.

Felling says the numbers may have more to do with better recognition of stroke in children rather than an actual increase in incidence. The causes of stroke in children, he adds, are often very different than the causes of stroke in an adult. While high blood pressure, irregular heartbeat and atherosclerosis are some of the common risk factors for stroke in adults, around half of all strokes in children are due to an underlying condition like sickle cell disease or congenital heart disease. Even normal, healthy children can have strokes related to trauma or infections that affect blood vessels.

“We usually go on a pretty widespread search to find the reason and many times there’s more than one reason,” says Felling. “They may have some underlying risk factor, but another event or illness can occur and trigger a stroke at a specific time.”

For Zander, further blood work and imaging showed his stroke trigger was not a tumor but Moyamoya disease, a rare genetic condition that causes narrowing of blood vessels in the brain. Felling referred Zander to Johns Hopkins pediatric neurosurgeon Edward Ahn, who—once the brain has had some time to heal—will surgically reroute those vessels to restore normal blood flow. Also, Felling treated the child with blood thinners and recommended that his parents keep him well hydrated to keep his blood pressure up to prevent future strokes.

Had Zander’s stroke not been detected and treated promptly, Felling says, it could have been worse or he could have suffered another stroke. Unfortunately, around 20 to 40 percent of children die after a stroke, and up to 80 percent of the survivors suffer lifelong neurologic deficits, including permanent weakness, cognitive problems or epilepsy. Another stroke is still a risk for Zander, Felling adds, but one that’s been significantly reduced by early detection and treatment.

“The key message is strokes can occur in children, so if you see symptoms suggestive of stroke, like weakness or numbness on one side of the body, sudden vision loss or speech difficulty, treat urgently,” Felling says.

How is Zander doing today?

“He’s great, almost back to his normal self,” says Amanda Maclane. “Dr. Felling says he’s pretty much 100 percent except for some weakness in his right hand.”

At Johns Hopkins Children’s Center, stroke in pediatric patients is diagnosed and treated through a multidisciplinary approach involving cardiologists, hematologists, intensivists, neurosurgeons and neurologists like Felling.
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