James Finnerty, a 15-year-old rugby player from Parma Heights, Ohio, woke up with a piercing pain in his head one morning last April and, barely able to walk, stumbled to the bathroom vomiting.
The emergency room doctors where James sought treatment assumed he had a severe migraine and delayed treatment for 25 hours before his mother insisted he be transferred to Cleveland Clinic where they discovered he had suffered a stroke.
The swelling in his brain was so intense that part of his skull was removed to relieve the pressure and, in a second stroke, he lost the use of speech and his limbs.
Almost a year later, after months of physical therapy, James, now 16, is on the road to recovery, but his experience is a shocking reminder that strokes can strike even the young.
"I am practically 100 percent," said James, who has now returned to school. "I am very, very lucky."
About 3,000 children a year will suffer a stroke -- one of the top 10 causes of death among children, according to Dr. Neil Friedman, a pediatric neurologist at the Cleveland Clinic's Center for Pediatric Neurology, where James was treated. The majority of these children will live, but will face lingering neurological or cognitive impairment.
"The big difference in pediatric stroke is that there is an almost 100 percent recovery because of the ability of children to adapt and accommodate far better than adults," said Friedman. "When they do survive, they can have six or seven decades of disability."
James still has some deficits in his comprehension and balance problems, and even though a recent MRI showed his artery has no blockage, he is still at risk for future strokes.
"People tend not to realize that two thirds of children have some residual deficits from stroke and the recurrence rate is 20 percent," said Friedman.
And those residual deficits mean high health care costs. One study Friedman cited showed that the first year of care for a child disabled by stroke is $42,000, not including loss of parents' work.
Stroke is more common in boys than in girls. African Americans are also more vulnerable, even excluding those who have sickle cell anemia, which is associated with stroke risk.
A stroke happens when the blood supply to part of the brain is cut off, resulting in tissue injury and loss of brain function. When tissue is starved of oxygen for more than three minutes, it begins to die.
The two types of strokes are ischemic, when brain arteries are blocked by a clot, and hemorrhagic, when brain arteries rupture from trauma or malformation.
In older children, about one third of all strokes are associated with heart disease. But that was not the case with James Finnerty, who had no such history. After taking a hit in a rugby game in 2012, an artery formed a clot in his brain.
"It's a common story," said Friedman. "There was initial damage to the artery, and he did weightlifting and extended the tear and stroked his cerebellum. It wasn't for another 25 hours that he had progressive worsening of the headache that we realized he had a stroke.… The brain was basically being pushed down through an opening in the skull."
Because his diagnosis was delayed to the point of herniation of the brain, the chance of James dying was "really high," according to Friedman.
Quick medical attention is critical when treating stroke, and yet the average delay in diagnosis of pediatric cases is 28 hours, wasting precious time when a child could get life-saving medication.
Although stroke can occur anytime during childhood, the risk is highest in the late stages of pregnancy and the early newborn period, occurring in about 1 in 3,000 live births. An estimated 40 to 50 percent of all strokes in children happen in the first year of life.
"The first week of life is the highest risk in a child's whole life," said Friedman.
Such was the case with Collin Shaw, whose birth was premature and difficult. Doctors had to administer CPR and, as a result, the newborn was put through a battery of tests. When he was five days old, an MRI revealed he'd had a "significant" stroke in the womb.
"It's all been an awakening for us," said his mother, Andrea Shaw, a 34-year-old pharmacist from Solon, Ohio. She and her husband Adam wondered if they had been carriers of a genetic disease that might be passed on to future children.
"My husband and I had every blood test under the sun to find out if we had a blood disorder, but we are fine."
And so was Collin. Cleveland Clinic doctors speculated that a a tiny piece of the placenta broke off or that an air bubble formed, causing his stroke.
Doctors reassured the family "there was nothing I could have done differently," said Shaw, who also has a 5-year-old daughter and is expecting twins.
Today, at 3, Collin will soon wear a cast on his right side to strengthen the weaker limbs on the left.
"He can walk and run, but he trips a bit more often -- his arm is what's mostly affected," said Shaw.
Fortunately, Collin has no cognitive deficits and his prognosis is bright, but he has physical therapy several times a week. He is monitored for potential seizures, but so far there have been none.
Friedman said many pediatricians often miss stroke in children until physical deficits show up in their later development.
As for James Finnerty, his symptoms -- headaches, nausea and sensitivity to light -- eluded doctors as well. His parents initially thought he had the flu, but when James couldn't comprehend the words on a note left on the kitchen counter, they called 911.
Local emergency room doctors assumed James was having a migraine with accompanying vertigo. But his mother, Stefania Finnerty, a nurse in the neurology unit at the Cleveland Clinic, insisted he be transferred.
"She kept yelling at the doctors," said James.
"I remember 95 percent of it," he said. "At the Cleveland Clinic they were trying to find out what was going on and decided to give me a CT scan. They made me get up from my stretcher and that's when the lights went out for me."
Once doctors saw the CT scan, they realized he'd had a stroke. James was put on a breathing machine for five days as surgeons removed the back of his skull to relieve the increasing pressure on the brain. They also put in a stent, which was the sight of a second stroke less than a month later.
"My left side was gone and I couldn't move at all," remembers James, who lost 40 pounds during the ordeal.
He could comprehend but not speak, using the phrase, "I have to go to the bathroom," whenever he wanted to express anything. He could only answer "yes" or "no" and called his 14-year-old brother Charlie "mailbox."
The timing could not have been worse for the family. His mother was just finishing chemotherapy for breast cancer and less than a month prior to James' stroke had undergone reconstruction surgery.