Quality of life in children with stroke

SUMMARY

Introduction. Pediatric stroke is a signifi cant emergency and an important health problem, being a major cause of acquired disability in childhood. Although survival is an outcome key indicator, quality of life is an important outcome in survivors. It provides information about how treatment and stroke complications aff ect the child and his/her ability to function within home, school, and community environment. Th is paper’s aim is to analyze the quality of life of children with stroke based on a synthesis of literature. A practical study is also expected for the future. Material and method. An analysis of the latest scientifi c sources was conducted using the search engines PubMed, “HINARI” and Google Academic using such keywords as: stroke, children, quality of life, motor disorders, cognitive disorders. Th e reference lists of articles have been consulted in search of additional references. Results and discussion. Cerebrovascular disease is among the top ten leading causes of death for children of all ages. Stroke incidence in children is estimated in a range from 1.3 to 13 per 100.000 children (aged 29 days to 18 years) per year and from 20 to 30 per 100.000 newborns per year. Th e quality of life is defi ned as physical, mental and social wellness, as well as the patients’ ability to perform ordinary tasks in everyday life. Th e quality of life can be appreciated through diff erent assessment scales, which include three dimensions: physical, psychological and social. Th e most commonly used questionnaires in children are PedsQL (Pediatric Quality of Life), which includes 23 items designed to measure the underlying health dimensions. Th e questionnaire was translated into several languages. In a study of quality of life in children with stroke, general wellness, physical wellness, self-esteem, family relationships were signifi cantly lower compared to the control group – healthy children. In the long term, stroke has signifi cant impact on the child quality of life because of its consequences: motor disorders, most commonly hemiparesis /hemiplegia, cognitive disorders, epilepsy, and social integration disorders. Conclusion. Pediatric stroke is a high mortality disorder with a specifi c morbidity (neurological, cognitive, emotional or behavioral disorders) which signifi cantly infl uences the quality of life of these children.   Assessing the quality of life in children who have suff ered a stroke is an easy to apply tools that provides detailed information for assessing physical, mental, social and physical eff ects as well as adjusting the rehabilitation treatment plan for these children.

Keywords: stroke, children, quality of life, motor disorders, cognitive disorders.

BACKGROUND

Stroke is defined by the World Health Organization as ‘a clinical syndrome consisting of rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than a vascular origin [1].

Pediatric stroke is a major emergency and an important health problem, it is associated with significant morbidity and mortality, being a major cause of acquired disability in childhood.

Recent studies reveal that the annual incidence rates of childhood stroke is 1,3-2,7 per 100.000 children, with the exception of two studies from France and the United States with significantly higher incidence rates of 4,3-13,0 per 100,000 children. Thus, current incidence of stroke incidence in children varies from 1,3 to 13 per 100.000 children (29 days to 18 years of age) and in newborns the incidence varies between 20 and 30 per 100.000 newborns, live  births/year (this is equivalent to an incidence of approximately 1 to 2500 to 1 in 5000 live births) [2,3].

Cerebrovascular disease is among the top ten leading causes of death for children of all ages. The mortality rate is estimated to be from 3% to 20% for ischemic stroke, 12% for sinus and cerebral vein thrombosis and up to 40% for hemorrhagic stroke [4].

Although survival is an outcome key indicator, quality of life is an important outcome in survivors. It provides information about how treatment and stroke complications affect the child and his/her ability to function within home, school, and community environment [5].

MATERIAL AND METHOD

An analysis of the latest scientific sources was conducted using the search engines PubMed, ”HINARI” and Google Academic using such keywords as: stroke, children, quality of life, motor disorders, and cognitive disorders.

RESULTS

The quality of life is defined by physical, mental and social well-being, as well as the ability of patients to carry out their ordinary tasks in their everyday life  [1].

Recent studies have reported that more than half of children who have suffered stroke have residual motor disorders, especially hemiplegia, which affect activities in everyday life.

In the long term in children, stroke has significant consequences: motor disorders, most often represented by hemiplegia, cognitive disorders, epilepsy, and social integration disorders. Thus, the impact of stroke on the child and his / her family is substantial (Fig. 1).

Since pediatric stroke may occur in various stages of brain maturation, the onset of this pathology may influence the degree of brain damage and clinical outcomes, and therefore the quality of life of these children. Some authors are of the opinion that the immature brain is predisposed to greater vulnerability, while others support the hypothesis of brain plasticity (meaning that the immature brain has a greater chance of recovery after an early lesion). Recent studies, however, suggest that children with early brain injury (before the age of 1-2 years) demonstrate negative neurocognitive and long-term motor outcomes [6].

In the specialty studies on quality of life in children who have suffered a stroke, some parameters such as: general welfare, physical well-being, self-esteem, family relationships, school results were significantly lower in children after stroke compared to the control – healthy children.

The conclusions of a study of the children who have suffered stroke, in which these children were followed from the onset of stroke and up to 1-15 years (on average 7 years) was that only 2 children (10%) of the 20 studied fully recovered, 5 of them showed long-term mild disturbances, 6 children – moderate disorders, 3 children – severe handicaps and 2 children died. Similarly, the results of this study showed that 55% of children had neurological and neuropsychological disorders  [7].

The long-term consequences of stroke are reflected in all “dimensions” of the quality of life, influenced by the age of the child, and the affected brain area (Figure 2).

1. Physical well-being

• Motor disorders

Motor disorders are the most characteristic symptoms of stroke, especially in older children, and remain one of the most common disabilities, with a significant impact on children’s independence for basic activities in everyday life as well as on social integration [8]. In a study in which the authors watched 37 children who had suffered strokes, 15 children had as a consequence hemiparesis of varying severity, and one child developed paraplegia [9].

Furthermore, according to recent studies, stroke is the main cause of unilateral cerebral palsy in termterm children [9], so Chambriet et al. were found to be the cause of unilateral cerebral palsy in 30% of children with neonatal ischemic stroke [10]. z

• Neurological disorders

Epilepsy. Compared to adults, children affected by a stroke are at greater risk for epilepsy. The rate of convulsions in the early stroke after stroke is reported in different studies as 25-58% and epilepsy secondary to stroke in 20-25%. Early convulsions were a predictor of long-term epilepsy [11].

Cognitive impairment. The results of several studies show that 20% to 50% of the children with ischemic stroke and  50% to 100% of those with hemorrhagic stroke have cognitive difficulties [12].

Sleep disorders. There is a correlation between problems associated with sleep and stroke. Thus, sleep disorders, especially sleep disturbances and insomnia, increase the risk of a stroke. And after a suffered stroke, sleep disturbances prolong recovery period, as sleep supports the neuroplasticity processes required for rehabilitation.

1. Psychological welfare

While motor deficits are easy to observe, cognitive deficits become evident when the child is cognitively required, during integration into kindergarten or school.

The most affected functions are language, attention, memory and mood [13]. Some recent research report that most children after a stroke develop cognitive impairments, emotional and behavioral disorders that significantly influence the quality of life of these children. Thus, a study performed by Germany researchers reported that 59% of children with stroke developed psychiatric disorders, compared with only 14% of children in the control group with chronic diseases. Other studies also reported learning and attention difficulties, anxiety, impulsivity in 50% and emotional disturbances in 25% of children after  stroke [14,15]. Pavlovic et al. performing a study on children who suffered stroke revealed neuropsychological disturbances in 75% of them  [7].

1. Social welfare

• Social skills disabilities

Social competences comprise more of the child’s ability to interact with the social world. Psychosocial problems are some of the most persistent and desolate problems reported by the children’s families with brain injuries  [16]. Poor social skills, which may result from stroke, can lead to social isolation, reduced self-esteem, and even mental illness, antisocial and criminal behavior [11].

There are studies demonstrating that after stroke, children experience changes in friendship with colleagues, low social support from colleagues, and lower integration and social participation skills  [5,11,17].

Some studies have not found associations between the onset of stroke and social disorders, while others have reported higher rates of psychosocial disturbance in children who have suffered a perinatal stroke [15].

Prognostic Factors

• Lesion site

According to the studies, an important predictor of quality of life is the degree of neurological deficit [5]. Thus, there was found a tendency of decreased quality of life indicators after bilateral injuries as well as after subcortical lesions. Also, combined cortical and subcortical lesions have proven to be the most unfavorable in terms of cognitive impairment, while the cortical stroke  has a less cognitive outcome than the subcortical stroke. De Schryver L.M. et al. reported results that more severe cognitive impairment occurred in children with larger injuries involving important functional regions of the cortex [13].

Other studies on the long-term complications of stroke in children have established that there is a relationship between ventral putamen lesions, medial prefrontal cortex and the presence of Hyperactivity and Attention Deficit Syndrome [14].

Also, studies that measured the volume of stroke and evaluated predictive factors for stroke consequences reported that higher volume predicted worse social skills [11].

• Age

Pavlovic et al. considered that the lower age at the onset of stroke is one of the predictors of a less favorable prognosis, and those who had a stroke during the average childhood had the best prognosis. The same results were reported by Allman & Scott, 2013, Everts et al., 2008, Jacobs, Harvey and Anderson, 2007 [18].

According to several studies achieved in several countries and by different authors (Anderson et al., 2010; Block et al., 1999; Lansing et al., 2004; Max, Bruce, Keatley and Delis, 2010) lower age at the onset of stroke is a risk factor for cognitive impairment  [18,19]. The effects of age on cognitive outcomes are potentially linked to periods of vulnerability or plasticity in the growing brain. A recent study reported better cognitive outcomes in children with stroke onset at the age of 5 to 10 years, and worse results in children with stroke onset before or after this age [1].

• Type of stroke (ischemic/hemorrhagic)

There is no clear evidence that the type of stroke (ischemic or haemorrhagic) could influence quality of life, although there are studies that show that neurological deficits are higher in ischemic than in hemorrhagic stroke [18].

CONCLUSIONS

Recent studies report that most children after suffering a stroke present neurological disorders and/ or cognitive impairment, emotional and/or behavior disturbances that significantly influence the quality of life of these children. Life quality dimensions are important characteristics for survivors and provide detailed information on the long-term consequences of stroke in children. Studies on the quality of life of the patient with stroke are particularly useful for medical practice, providing indispensable data for assessing the physical, mental and social effects of stroke and the individual rehabilitation treatment of the child who has suffered a stroke.

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