Pediatric Exams: Evaluating Stroke in Children

Rebecca Ichord, MD, director of the Pediatric Stroke Program at The Children’s Hospital of Philadelphia, reviews signs and symptoms of pediatric stroke and demonstrates a clinical exam with a child who has experienced a stroke.

Signs can include weakness or numbness; trouble walking, speaking or understanding simple directions; severe headaches; loss of vision or double vision; and severe dizziness. Just as when an adult experiences stroke symptoms, children should get medical help immediately.


Pediatric Exams: Evaluating Stroke in Children

Rebecca Ichord, MD: Hello my name is Dr. Rebecca Ichord. I’m a neurologist at The Children’s Hospital of Philadelphia and director of the Pediatrics Stroke Program. Stroke in childhood is an important problem. Although it’s rare, when it happens, it’s a serious emergency and it’s important for the general public as well as health practitioners to understand the signs and symptoms.

In the case of a child having an acute stroke, their symptoms may be among the following: They may suddenly have difficulty understanding where they are, who’s around them. They may have sudden loss of their ability to speak or understand speech. They may suddenly lose the ability to see things on one side of their body. They may have sudden loss of strength or sensation involving the face, the arm and the hand or the leg. Or they may have sudden difficulty in balance and gait.

And if these symptoms should occur, the child should be considered to possibly be having a stroke. And the thing to do in that situation would be to have the child lie flat, do not give him anything to eat or drink, and call 911. And when the emergency responders arrive they should be told that the child’s having signs and symptoms of what could be a stroke. We call this a brain attack and it should be treated as an emergency.

Today we’re going to do a check-up of a young man who had a stroke sometime in the past. And he has kindly allowed us to check him out today so we can show some of the signs and symptoms that we might see on an examination. Are you ready? All right, tell me your name.

Rebecca Ichord, MD: And so I’m checking to see if he’s aware of himself and his surroundings. And who’s that lady over there?

Patient: My grandma

Rebecca Ichord, MD: OK, and so you know where you are?

Patient: CHOP

Rebecca Ichord, MD: That’s right. And what year is it?

Patient: 2015

Rebecca Ichord, MD: OK, so we figured out that you know who you are, who’s around you, where you are and the date. And this is what we call orientation. A child who is having an acute stroke may have some confusion and be unable to describe where he is or who is around him.

Now I’m going to ask you to do some little tests that have to do with your speech. And testing speech is a very critical part of evaluating for signs and symptoms of a stroke. Some children may only have a loss of their speech as the sign of their stroke. And so I’m going to ask you to do a few things.

Let’s do, let’s see if you can repeat what I say. Little children like to play outdoors.

Patient: Little children like to play outdoors.

Rebecca Ichord, MD: Excellent, so I’m listening to hear how well he can formulate the words, how well he can make the sounds clear. Now I’m going to ask you to remember some words that I’m going to ask you to say. We call this recall. And I’ll ask you now, and then I’ll ask you again a little bit later. And that’s called delayed recall. Children who have an acute stroke may have trouble with recalling, or remembering words that they had just heard. You ready? Red, pencil, bridge. Go ahead and tell me.

Patient: Red, pencil, bridge

Rebecca Ichord, MD: 100%, I’ll ask you again in a few minutes. Now I’m going to ask you to name some things. So naming is another aspect of speech. And some children have difficulty with naming objects. So here we go. See these pictures, these are very simple, easy pictures. I want you to say the name of each thing. You ready? And what do you call that?

Patient: Clock, T-shirt, pencil, baseball, skateboard and bike

Rebecca Ichord, MD: Excellent, so he got them all correct. And in addition I could understand the words very clearly. In a child who’s having a stroke that affects speech, they have trouble getting the word out, or they may say the wrong word, or they may not be able to say the word at all. So your naming is great.

All right, let’s move on to some other things. Now I’m going to look at your vision. I want you to look at my nose right here. And first of all I notice that when you look at me, your eyes are looking straight ahead. And if I move your eyes follow me. So that tells me that you’re able to see things well enough to have your eyes look where they need to look. And children who have a sudden loss of vision on one side, their eyes may prefer to stay looking in one direction. So it’s very good, it’s very normal that your eyes are looking straight at me.

And now I’m going to test each eye by itself. And this is a way that we can tell if the vision problem is involving both eyes or just one, or it’s in the brain. Looking right here at my nose I’m going to cover your eye. And keep looking straight at my nose. Now what this is is called testing visual fields. And it’s simply showing a number and you tell me how many fingers you see. Ready, how many?

Patient: One, two

Rebecca Ichord, MD: How many?

Patient: Two, one

Rebecca Ichord, MD: Good, so I’m showing a finger in each field and to see if he can check them. And he got them all right. Ready, here we go with the other eye.

Patient: Two, four, one, two

Rebecca Ichord, MD: OK, so in the case of a child having a stroke, if I cover one eye and if I show him numbers over here and he gets these correctly, then I know this visual field is normal. If I show them over here, for example, and he can’t see them clearly on this side, that would mean that he has what we call visual field loss. And that’s a typical kind of abnormality in an acute stroke that helps us neurologists to figure out where the problem might be.

Very good, OK, now let’s see how your eyes are moving. Can you look at my thumb? And watch where it goes. Very good, and so his eyes are able to follow in all directions. And in some children who have certain areas of the brain that control eye movements, where there is a stroke in that location, they may not be able to move their eyes in all directions. But you did 100%.

OK, let’s look at your face. Can you give me that big smile again, excellent. And so we notice that his face is very strong, that his smile is very strong on both sides. And in the case of a child who has an acute stroke, the one side of the smile might be not present and be very weak. All right, let’s have you close your eyes really, really tight. And you can see that he’s able to squeeze his eyes tight on both sides. In a child who’s having an acute stroke with weakness of the face, they may not be able to close the weak side of the face, that eye very tightly. That’s good you can open your eyes. Your eyes, your face is very strong.

And now just again look straight at me, I’m going to check the sensations. So I want you to tell me if the two sides feel the same or different.

Patient: Same

Rebecca Ichord, MD: Same?

Patient: Same, same

Rebecca Ichord, MD: And let’s go on down to your arms. Same or different?

Patient: Same

Rebecca Ichord, MD: Same or different?

Patient: Same

Rebecca Ichord, MD: Same or different?

Patient: Same

Rebecca Ichord, MD: And again, in the case of a child who might have a stroke that affects sensations on one side, they may tell me that on one side of their body or one side or their face, it doesn’t feel the same as the other side. I’m going to check your ability to hear. Ready? OK, I want you to point to where you hear the sound.

Good, very good. So again, in a child how might have loss in their hearing you would expect to see possibly some loss in being able to detect hearing that little soft brush of the fingers on one side.

OK, let’s move on down, we’re doing great here. Can you show how you shrug your shoulders? All right, and what we notice is that his shoulder is a little weak on that side, he can’t raise it quite as much. Although he is trying really hard. OK, that’s good. So there’s weakness on that side. And then let’s look at your arms, can you hold your arms up like this for me? How about keeping them straight in front? And I’m going to let go. Keep your arms in front of you like that, and then try to turn your arm over like this. And so you can see this side moves very well, but this side he can’t move quit so well. And that’s because there’s weakness on this side of the body.

And again, in the case of a stroke, a child may be unable to lift that arm, or open their hands. Let’s see both of these hands, can you make that hand spread open? Beautiful, and make it a little “O” like that. And make your hands tap like that. And that’s good, that’s what we like to see. And the weak side, he can’t really make the hands open. Let’s see what you can do. I know you’re willing it, and it just won’t open. And how about if you try to make that “O”. Can’t quite do it. And can you tap it at all, no?

So he’s lost the fine dexterity and the strength that it takes to control that hand in a normal way. And so that’s what we might see in a child who has a stroke that affects strength on one side of their body. And it tends to especially involve the face and the arm and the hand. And then we see that combination, then that’s a situation where we especially would worry about a stroke being, going on in that child.

So let’s see onto your legs now, right. So let’s see, can you lift this knee up in the air like this? Good, keep it there really strong. And I’m pushing, pushing, and I can’t push it at all. So that’s very strong. How about this one? And you’re having to work just a little harder to make that strong. Let’s make your legs straight now. Keep it there nice and strong. And I’m gonna try and bend it. And I’m not able to bend it because it’s too strong. OK, how about this one?

So right away we can notice that this leg, he can’t quite get it all the way straight. And if I try to push it down, I’m able to push it down a little bit. And so that’s again, sign of weakness. And so what we see is weakness of the shoulder, the arm, the hand and the leg. And that’s the typical distribution, the typical location of loss of strength involving someone who has a stroke.

That’s right, OK, now let’s check your walking, you ready? There we go, can you stand over here? That’s it. And what you may notice is that because the left leg is a little bit weak, he can’t really keep it straight. And also the left arm is a little weak so it tends to kind of hang here a little bit more than the right side.

Now let’s see how you can walk. And so he can’t really push off quiet as strong with that left side. And come on back this way. And that left side just can’t make it, can’t make it as strong and straight as the right side. All right, very good, you can sit up here. Very good. And you can see, he’s figured out how to get around even though he’s weak on that left side. But even though he’s figured it out, he still has a little trouble and has to compensate for the weakness in that left side.

Alright, do you remember those three words? What were they?

Patient: Red, pencil and bridge

Rebecca Ichord, MD: Excellent, so his recall is very good. All right, I think we're done.

Topics Covered: Pediatric Stroke

Related Centers and Programs: Pediatric Stroke Program