Stroke in Childhood 

What Is Stroke In Childhood?

[dropcap]S[/dropcap]troke in childhood is a medical emergency during which blood flow to an area of the brain is stopped, causing infarction or death of the area of cells in the brain fed by the blocked artery. Stroke is characterized by loss of muscle and brain function according to the location of the lost cells.

The brain is a highly active metabolic and complex organ of our body that performs important functions, therefore, any disruption in its normal functioning can have devastating effects on whole body.

After stroke, an immune response is initiated that leads to production of proinflammatory cytokines (chemicals) and gathering of various inflammatory cells like neutrophils, T-cells, macrophage, and monocytes to the affected area that exacerbate or worsen the ischemic (oxygen starved) injury.¹

Arterial ischemic stroke is an important cause of acquired brain injury in children.² This stroke results from loss of adequate blood flow through an artery that supplies the affected area of the brain with oxygen and nutrients.

A recent study found the majority of  children (85%) had focal features (most commonly one sided weakness or paralysis) at presentation to their medical practitioner. Seizures were more common in younger children a year old or younger and headache was more common in children 5 years or older.³

Who is at Risk in the General Population?

• A British study in 2014 found the crude incidence of childhood arterial ischemic stroke was 1.60 per 100,000 per year.
• The incidence of arterial ischemic stroke was highest in children aged under 1 year (4.14 per 100,000 per year).
• There was no difference in the risk of arterial ischemic stroke between sexes.
• Asian and black children were at higher risk than were white children.³

What Is Stroke in Childhood In Celiac Disease and/or Gluten Sensitivity?

• Relationship between stroke in childhood and celiac disease. Stroke in childhood is a neurologic disorder associated with celiac disease and may be an rare presenting feature of untreated celiac disease.

• Relationship between stroke in childhood and diagnosis. Because celiac disease is a potentially treatable cause of brain blood vessels, bloodwork – specifically anti-tissue transglutaminase antibodies (tTG) – should be included in the evaluation of  stroke of unknown origin in childhood, even in the absence of gut symptoms.⁴,⁵

How Prevalent Is Stroke In Childhood In Celiac Disease and/or Gluten Sensitivity?

The risk of childhood stroke in celiac disease is small.⁶ However, the risk is also small in the general population.

What Are The Symptoms of Stroke In Childhood?

• Sudden numbness or weakness of the face, arm or leg (especially on one side of the body).
• Sudden confusion, trouble speaking or understanding speech.
• Sudden trouble seeing in one or both eyes.
• Sudden trouble walking, dizziness, loss of balance or coordination.
• Sudden severe headache with no known cause.

If you have any of these symptoms, you must get to a hospital quickly to begin treatment. Acute stroke therapies try to stop a stroke while it is happening by quickly dissolving the blood clot or by stopping the bleeding. Post-stroke rehabilitation helps individuals overcome disabilities that result from stroke damage. Drug therapy with blood thinners is the most common treatment for stroke. ((https://www.nlm.nih.gov/medlineplus/stroke.html))

How Does Stroke In Childhood Develop In Celiac Disease and/or Gluten Sensitivity?

• Stroke in childhood results from direct effect of gluten on blood vessels in the brain. Tissue transglutaminase is an enzyme thought to maintain vascular endothelial integrity (health of arterial blood vessels) but it is, unfortunately, the major autoantigen in celiac disease that triggers production of anti-tissue transglutaminase antibodies.
• It has been found that anti-endomysial immunoglobulin A antibodies (EMA), demonstrated to be the same autoantibody as anti-tissue transglutaminase (tTG), react with cerebral vasculature (blood vessels), suggesting an autoimmune mechanism for celiac disease associated damage to blood vessels.⁷

Does Stroke In Childhood Respond To Gluten-Free Diet?

Yes. Also, gluten free diet would be preventive of childhood stroke in celiac disease.

Increase foods containing the amino acid tryptophan in the diet both before and after stroke. Here is why: the body uses tryptophan to make melatonin, a crucial brain chemical made by cells in the pineal gland, that reduces inflammation and swelling in the brain after stroke. Reducing inflammation is key to preventing further damage and improving brain health.¹ Melatonin has many natural hormone activities in the body such as regulating wake and sleep cycles.

Foods rich in tryptophan include turkey, chicken, shrimp, fish, seafood, milk, and cheese. Good amounts are in peas and beans, seeds and nuts.

On the other hand, caffeine decreases melatonin levels in the body. Look for caffeine in the ingredient list of items like soda or some candies so the child does not consume them.

6 Steps To Improve Stroke In Childhood In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both risk of stroke and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.⁸
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk, disrupts intestinal permeability causing leaky gut.⁹
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.⁹
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.⁹.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.⁹
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.⁹
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.⁹
• Cocoa and Black Tea increase blood sugar.
• Rosemary. Increases blood sugar levels and should not be used by persons with insulin resistance or diabetes. [/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes green leafy vegetables such as lettuce and kale, also onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

• [dropcap]4[/dropcap] Manage Your Medications Safely:

[box type=”shadow” ]

Certain medications may cause cerebral vasculitis which would aggravate gluten-related cerebral vasculitis as a cause of stroke. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.

Phenylpropanolamine (PPA) is the major ingredient in more than 70 over-the-counter preparations including diet pills, nasal decongestants, and the legal “look-alike” stimulants.¹⁰

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• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

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• Multivitamin/mineral combination that provides 100% once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
• Melatonin supplements are considered possibly not safe in children and for this reason should be monitored if prescribed for this condition. Melatonin come in pills and capsules to be taken by mouth or by skin patch.¹¹

Caution: Sedative medications (CNS depressants) interact with melatonin, causing too much sleepiness. Some sedative medications include clonazepam (Klonopin), lorazepam (Ativan), phenobarbital (Donnatal), zolpidem (Ambien), and others.

Medications that slow blood clotting interact with melatonin. Because melatonin might slow blood clotting, taking melatonin along with medications that also slow clotting might increase the chances of bruising and bleeding. Some medications that slow blood clotting include aspirin, clopidogrel (Plavix), diclofenac (Voltaren, Cataflam, others), ibuprofen (Advil, Motrin, others), naproxen (Anaprox, Naprosyn, others), dalteparin (Fragmin), enoxaparin (Lovenox), heparin, warfarin (Coumadin), and others.¹¹

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Amount of liquids depends on the age of the child.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• Encourage water. Add fresh, squeezed lemon to water with a sweetener to offset the tartness. Lemon is anti-inflammatory, alkalizing and provides vitamin C, which is a powerful antioxidant to protect the brain from free radical molecules produced during injury.
• What is wrong with soda? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion. However, because it increases blood sugar levels, it should not be used by persons with insulin resistance or diabete.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Stroke In Childhood In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Risk of stroke in 28,000 patients with celiac disease: a nationwide cohort study in Sweden.” This nationwide Swedish study collected biopsy data from all 28 pathology departments in Sweden and identified 28,676 individuals with celiac disease  diagnosed between 1969 and 2007 (Marsh 3: villous atrophy). Results show that patients with celiac disease are at only a small increased risk of stroke, which persists only for a brief period after diagnosis.

The absolute risk of stroke in patients with celiac disease was 267 per 100,000 person-years. The highest risk estimates occurred in the first year, with virtually no increased risk after more than 5 years of follow-up after celiac disease diagnosis. The hazard ratio (HR) for stroke in childhood celiac disease was 1.10.¹²

CASE REPORT SUMMARIES

“Stroke and dilated cardiomyopathy associated with celiac disease.” This case report describes diagnosis of celiac disease in an 8-year-old girl who presented with rarely seen dilated cardiomyopathy and stroke. The girl was admitted with left side weakness. Her medical history indicated abdominal distention, chronic diarrhea, failure to thrive, and geophagia (from vitamin B deficiency). On physical examination, short stature, pale skin and a grade 2 of 6 systolic murmur were detected. Muscle strength was 0/5 on the left side, and 5/5 on the right side.

Coagulation examinations were normal. Brain magnetic resonance imaging (MRI) and cerebral angiography showed an infarction area at the basal ganglia level. Examinations of serologic markers and intestinal biopsy revealed celiac disease. Anti-tissue transglutaminase IgA and IgG, and anti-endomysium IgA were found at a highly positive rate. Duodenal biopsy showed villous atrophy with hyperplasia of the crypts and an increased intraepithelial lymphocyte count (above 40%).

A gluten-free diet and nadroparin calcium treatment were initiated and physiotherapy was performed. At the 18th day of hospitalization, the patient, whose symptoms had regressed, was discharged with a gluten-free diet, nadroparin calcium, co-enzyme Q and salicylate treatment. Symptoms resolved by the following 7th wk. Muscle strength at the left upper and lower extremities was 5/5, and other neurologic examinations were normal.

Because celiac disease is a potentially treatable cause of cerebral vasculopathy, serology (specifically for anti-tissue transglutaminase antibodies) should be included in the evaluation of cryptogenic stroke in childhood, even in the absence of typical gut symptoms.

In conclusion, the cause of ischemic stroke in this case is thought to be multifactorial. “We suggest that celiac disease was a primary factor in its etiology, secondary to a contribution from dilated cardiomyopathy. In conclusion, we emphasize that in the differential diagnosis of ischemic stroke, celiac disease should be kept in mind.”⁵

“Celiac disease and childhood stroke.” This case report of a child presenting with a recurrent transient hemiplegia describes investigation for celiac disease. Magnetic resonance imaging of the brain confirmed infarction. Transcranial Doppler studies and magnetic resonance angiography were abnormal. Although there were virtually no gastrointestinal symptoms and the child was thriving, celiac disease serology was strongly positive and a duodenal biopsy confirmed the disease.

Tissue transglutaminase is the major autoantigen (target) in celiac disease and is thought to maintain vascular endothelial integrity (inside lining of blood vessels). Anti-endomysial immunoglobulin A antibodies, demonstrated to be the same autoantibody as anti-transglutaminase, react with cerebral blood vessels, suggesting an autoimmune mechanism for celiac disease associated vasculopathy. Because celiac disease is a potentially treatable cause of cerebral vasculopathy, serology – specifically antitissue transglutaminase antibodies – should be included in the evaluation of cryptogenic stroke in childhood, even in the absence of gut symptoms.¹³

Sources:

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2. Mallick AA, Ganesan V, Kirkham FJ, et al. Childhood arterial ischaemic stroke incidence, presenting features, and risk factors: a prospective population-based study. Lancet Neurol. 2014 Jan;13(1):35-43. doi: 10.1016/S1474-4422(13)70290-4. Epub 2013 Dec 2. [↩]
3. Mallick AA, Ganesan V, Kirkham FJ, et al. Childhood arterial ischaemic stroke incidence, presenting features, and risk factors: a prospective population-based study. Lancet Neurol. 2014 Jan;13(1):35-43. doi: 10.1016/S1474-4422(13)70290-4. Epub 2013 Dec 2. [↩] [↩]
4. Goodwin FC, Beattie RM, Millar J, Kirkham FJ. Celiac disease and childhood stroke. Pediatric Neurology. Aug 2004;31(2):139-42. [↩]
5. Doğan M, Peker E, Cagan E, Akbayram S, Acikgoz M, Caksen H, Uner A, Cesur Y. Stroke and dilated cardiomyopathy associated with celiac disease. World J Gastroenterol. 2010 May 14;16(18):2302-4. [↩] [↩]
6. Ludvigsson JF1, West J, Card T, Appelros P. Risk of stroke in 28,000 patients with celiac disease: a nationwide cohort study in Sweden. J Stroke Cerebrovasc Dis. 2012 Nov;21(8):860-7. doi: 10.1016/j.jstrokecerebrovasdis.2011.05.008. Epub 2011 Jul 5. [↩]
7. Goodwin FC, Beattie RM, Millar J, Kirkham FJ. Celiac disease and childhood stroke. Pediatric Neurology. Aug 2004;31(2):139-42. [↩]
8. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
9. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
10. Glick R, Hoying J, Cerullo L, Perlman S. Phenylpropanolamine: an over-the-counter drug causing central nervous system vasculitis and intracerebral hemorrhage. Case report and review. Neurosurgery. 1987 Jun;20(6):969-74. [↩]
11. Some side effects include headache, short-term feelings of depression, daytime sleepiness, dizziness, stomach cramps, and irritability.http://www.webmd.com/vitamins-supplements/ingredientmono-940-melatonin.aspx?activeingredientid=940 [↩] [↩]
12. Ludvigsson JF1, West J, Card T, Appelros P. Risk of stroke in 28,000 patients with celiac disease: a nationwide cohort study in Sweden. J Stroke Cerebrovasc Dis. 2012 Nov;21(8):860-7. doi: 10.1016/j.jstrokecerebrovasdis.2011.05.008. [↩]
13. Goodwin FC, Beattie RM, Millar J, Kirkham FJ. Celiac disease and childhood stroke. Pediatric Neurology. Aug 2004;31(2):139-42. [↩]