Presented by Yasser Yamed MD Neurology

1
??? ???? ?????? ??????
2
Presented by Yasser HamedMD Neurology

• In Children Stroke

3

• Pediatrics is the branch of medicine that deals
  with the medical care of infants, children, and
  adolescents, and the age limit up to 18 (in some
  places until age 21 as in the United States)
• Pediatric stroke is an important cause of
  long-term disability, with children often living
  for many years with significant neurological
  deficits.
• In children, 55 of strokes are ischemic, in
  contrast to adults in whom 8085 of all strokes
  are ischemic.

4

• Strokes in children differ from those in adults
  in three important ways
• Predisposing factors (In children, congenital and
  acquired heart disorders, hematologic conditions
  are common causes. In contrast, hypertension,
  smoking and hypercholesterolemia are more common
  predispositions in adults..
• Clinical evolution (children often improve much
  more than an adult with a comparable lesion
  because of the abundant collateral circulation or
  because of the differences in response of the
  immature brain to the lesion).
• Anatomic site of pathology (children commonly
  show occlusion of the intracranial portion of the
  internal carotid artery, whereas adults more
  frequently show extracranial occlusions of the
  internal carotid).

5
Epidemiology

• The reported incidence of pediatric stroke ranges
  from 1.2 to 13 cases per 100,000 children under
  18 years of age.
• In Egypt (Al kharga District), the incidence of
  pediatric stroke was 4/100,000 and prevalence was
  26/100,000 children under 20 years of age..
• However, pediatric stroke is likely more common
  than that reported as it is thought to be
  frequently undiagnosed or misdiagnosed.
• In one report, 19 out of 45 children with a
  stroke did not receive a correct diagnosis until
  15 hours to 3 months after initial presentation.

6

• Stroke is more common in boys than girls.
• Stroke is appear to be more predominant in black
  children.
• This difference may be attributed to sickle cell
  anemia.

7
Risk Factors and Causes

• Cardiac (CCHD, VSD, ASD and RHD) are the most
  common cause of stroke in childhood, accounting
  for up to a third of all AIS.
• Hematologic
• Sickle cell disease (SCD) is a very common cause
  of stroke.
• AIS is more common in the younger age whereas
  hemorrhagic strokes occurs more frequently in
  older children and adults.
• Children with SCD develop all types of ICH

8

• Hypercoagulable disorder including antithrombin
  III, protein C S deficiencies, factor V Leiden
  mutation, elevated levels of lipoprotein (a) and
  antiphospholipid antibody syndrome.
• It is suspected in individuals with recurrent
  DVT, recurrent pulmonary emboli, or a family
  history of thrombotic events or if thrombotic
  events occur during childhood or adolescence.
• Hemophilia A (factor VIII deficiency) and B
  (factor IX deficiency) are the two most common
  hereditary bleeding disorders that cause
  intracranial hemorrhage.
• Vitamin K deficiency results in decreased factors
  II, VII, IX, and X.
• Thrombocytopenia results from either immune
  thrombocytopenic purpura (ITP) or the combined
  effects of leukemia or its treatment.
  Nontraumatic brain hemorrhage does not usually
  occur with platelets counts above 20,000 to
  30,000,

9

• Infection
• Varicella infection within the past year can
  result in basal ganglia infarction.
• HIV infection can cause stroke secondary to
  HIV-induced vasculitis, vasculopathy with
  subsequent aneurysms, or hemorrhage in the
  context of immune thrombocytopenia
• Vascular
• Arteriovenous malformations (AVM) are the most
  common cause of hemorrhagic stroke, but can also
  cause thrombotic stroke. AVM may be associated
  with neurocutaneous syndromes such as
  Sturge-Weber disease, tuberous sclerosis and
  neurofibromatosis.
• Moyamoya is another important vascular cause of
  childhood stroke and is associated with
  conditions such as Down syndrome,
  neurofibromatosis, and sickle cell disease.

10

• Syndromes and Metabolic Disorders
• Marfan syndrome are at risk of ischemic stroke.
• Homocysteinuria can cause AIS and should be
  suspected in the presence of mental retardation
  associated with lens dislocation and occasionally
  pectus excavatum.

11

• Vasculitis
• Cerebral vasculitis is a less common cause of
  stroke in children, and is more common in
  children older than 14 years of age. Although
  idiopathic vasculitis is most often diagnosed,
  signs and symptoms of systemic vasculitides with
  Kawasaki disease, Henoch-Schnlein Purpura (HSP),
  polyarteritis nodosa, Takayasus arteritis,
  juvenile rheumatoid arthritis, systemic lupus
  erythematosus, inflammatory bowel disease,
  sarcoidosis, Sjogren syndrome, or Behcet disease
  should be considered

12

• Oncologic
• Children with cancer are at increased risk for
  AIS as a result of their disease, subsequent
  treatment, and susceptibility to infection.
• Intracranial hemorrhage may complicate an
  intracranial tumor.
• Leukemia and lymphoma create a hypercoagulable
  state.
• L-asparaginase decreases antithrombin levels, and
  may trigger venous thrombosis.
• Radiation therapy for brain tumours can cause
  vasculopathies.

13

• Trauma
• Dissection of the carotid or vertebral arteries
  resulting from hyperextension or rotational
  injuries of the neck.
• Symptoms of traumatic arterial dissection can be
  delayed by 24 hours, and the risk is greatest
  within a few days of the vascular injury.
• Drugs
• Cerebral infarcts and hemorrhage have been
  reported in patients abusing drugs such as
  amphetamines, cocaine and glue sniffing.
• Stimulants and heroin can also cause
  vasculopathies.
• Adolescent girls using oral contraceptives are at
  higher risk of cerebral venous thrombosis.
• Overuse of ergot alkaloids are also associated
  with increased risk of ischemic events.

14
Clinical Presentation

• AIS most often presents as a focal neurologic
  deficit. Hemiplegia is the most common focal
  manifestation, occurring in up to 94 of cases.
• Hemorrhagic strokes most commonly present as
  headaches or altered level of consciousness.
• Seizures are common in both ischemic and
  hemorrhagic strokes.

15

• There can be significant differences in the
  clinical presentation based on the childs age.
• Neonatal strokes present with focal seizures or
  lethargy.
• Infants present with lethargy, apnea spells, or
  hypotonia.
• Toddlers present with deterioration of their
  general condition, increased crying and
  sleepiness, irritability, feeding difficulty,
  vomiting, and sepsis-like symptoms with cold
  extremities.
• Older children demonstrate more specific
  neurological defects similar to adults.

16
Differential Diagnosis

• Hemiplagic migraine.
• Focal seizures associated postictal hemiparesis
  (Todds Paresis).
• Intracranial neoplasms.
• Trauma as extradural, subdural, SA and
  intracerebral haematoma.
• Intracranial infections such as meningitis, brain
  abscess, and herpes simplex encephalitis.
• Metabolic abnormalities like hypoglycemia,
  CADASIL and MELAS syndrome.

17
Diagnostic Evaluation Ischemic Stroke

• A- Imaging
• Noncontrast head CT to exclude a hemorrhagic
  stroke.
• Diffusion-weighted MRI of the brain is the most
  sensitive method to diagnose acute AIS.
• MRA head, neck.
• MR Venogram (especially consider with sickle cell
  disease).
• CT angiography. MRA may be preferable to CTA
• Other investigations as ultrasound to evaluate
  the extracranial carotid circulation, ECG, chest
  radiograph, and transthoracic or transesophageal
  echocardiography.

18

• B- Laboratory
• Prothrombin time and concentration, INR.
• Antithrombin, factor V Leiden, protein CS.
• Lipid profile, CBC and C-reactive protein levels.
• Tests for vasculitis (ESR, antinuclear
  antibodies, antidouble strand antibodies, lupus
  anticoagulant and anticardiolipin antibodies).

19
A- Recommended universal supportive measures

• Fever control (hypothermia should not be used in
  children with stroke)
• Normalization of serum glucose
• Maintenance of normal oxygenation
• Ameliorate increased intracranial pressure
• Treat dehydration
• Correct anemia

20
B- Blood pressure management

• The AHA guidelines suggest control of systemic
  hypertension in children with AIS and
  hemorrhagic stroke.
• Specific guidelines for blood pressure values are
  absent.

21
C- Anticonvulsants and EEG monitoring

• Seizures are a common complication of pediatric
  stroke, affecting up to 25 with AIS and up to
  20 with ICH. When they occur, seizures should be
  treated aggressively.
• Prophylactic anticonvulsants are often used in
  the setting of intraparenchymal or subarachnoid
  hemorrhage in adults, although this approach is
  not evidence-based practice.
• The AHA pediatric stroke guidelines recommend
  against prophylactic anticonvulsant use in
  ischemic stroke but do not make recommendations
  in the setting of hemorrhagic stroke.

22
D- Management of intracranial pressure

• Nonsurgical methods
• Keeping the head of a patients bed at 30.
• Hyperventilation to a pCO2 of 2530 mmHg.
• Hyperosmolar therapywith either mannitol or
  hypertonic saline.
• In some cases, sedation may be required to help
  manage elevated ICP.
• Corticosteroids should be avoided.

23

• Surgical
• An intraventricular catheter (IVC) providing both
  a means to measure ICP and, via drainage of
  cerebrospinal fluid.
• Hemicraniectomy may be both life-saving and
  function-sparing in adults with a large AIS who
  progress to signs and symptoms of impending
  herniation.
• In children, study of 10 children with malignant
  middle cerebral artery infarction, seven
  underwent hemicraniectomy, all of whom survived
  and had moderately good recovery.

24
AIS-specific treatments

• A- Antiplatelet
• I- Aspirin
• For all older children with ischemic stroke
  except kids with sickle cell disease
• Typical dose is 3-5 mg/kg/day. This dose can be
  reduced to 1 to 3 mg/kg for long-term
  prophylaxis.
• Risk of Reyes syndrome is very low. It recommend
  to discontinue or reduce dose to half during
  febrile illness.
• It recommend to vaccinate for varicella and give
  an annual influenza vaccine.
• II- Clopidogrel
• For children unable to take aspirin.
• Typical dose is 1mg/kg/day.

25

• B- Anticoagulant
• I - UH with loading dose 75 units/kg IV followed
  by 20 units/kg/hour for children over 1 year of
  age or 28 units/kg/hour below 1 year of age. The
  target APTT is 60 to 85 seconds.
• II- LMWH doses of 1 mg/kg every 12 hours or in
  neonates, 1.5 mg/kg every 12 hours.
• III- Warfarin with target of INR 2.5 to 3.5.

26

• Consider if suspicion high for cardioembolic
  stroke, arterial dissection, posterior
  circulation stroke.
• According to the Australian AIS treatment
  guideline, for children with confirmed AIS, UH or
  LMWH is recommended in the first 5 to 7 days
  until the evaluation for underlying etiologies
  and risk factors is completed.
• Children are continued on either oral or
  subcutaneous anticoagulants for 3-6 months and
  then switched to an antiplatelet agent, usually
  aspirin.
• Platelet count should be monitored

27
C- Thrombolytic therapy

• Use of thrombolytic therapy for patients aged lt18
  years is much more controversial. The current
  AHA guidelines recommend that tPA use in young
  children is limited to a clinical trial.
• Evidence for the safety and efficacy of
  thrombolysis in children with stroke is extremely
  limited. The existing studies of this treatment
  suggest a high risk of hemorrhagic complications.

28
Recommendations for stroke and heart disease

• Therapy for congestive heart failure is
  indicated.
• When feasible, congenital heart lesions,
  especially complex heart lesions with a high
  stroke risk, should be repaired.
• Resection of an atrial myxoma is indicated.
• Surgical repair or transcatheter closure is
  reasonable in individuals with a major atrial
  septal defect.

29

• In children with a risk of cardiac embolism, it
  is reasonable to continue either LMWH or warfarin
  for at least 1 year or until the lesion
  responsible for the risk has been corrected.
• Anticoagulant therapy is not recommended for
  individuals with native valve endocarditis
• Surgical removal of a cardiac rhabdomyoma is not
  necessary in asymptomatic individuals.

30
Recommendations for children with SCD

• Risk factors for stroke include high blood flow
  velocity on TCD, low hemoglobin value, high white
  cell count, hypertension, silent brain
  infarction, and history of chest crisis.
• Acute management of ischemic stroke resulting
  from SCD should include optimal hydration,
  correction of hypoxemia, and correction of
  systemic hypotension.

31

• Periodic transfusions to reduce the percentage of
  sickle hemoglobin are effective for reducing the
  risk of stroke in children 2 to 16 years of age.
• For acute cerebral infarction, exchange
  transfusion designed to reduce sickle hemoglobin
  to lt30 total hemoglobin.
• Hydroxyurea may be considered in children and
  young adults with SCD and stroke who cannot
  continue on long-term transfusion.
• Bone marrow transplantation.
• Surgical revascularization procedures.

32
Recommendations for treatment of coagulation
disorders

• Antithrombin deficiency is resistant to heparin.
  
• After a thrombotic event, lifelong warfarin is
  indicated.
• Patients with protein C or S deficiency or factor
  V Leiden mutation and stroke are treated with
  anticoagulation.
• The prophylactic anticoagulation for asymptomatic
  patients is controversal.

33

• Sinus thrombosis
• The antithrombotic therapy is aimed at preventing
  the clot propagation and recurrence within the
  cerebral venous system.
• For children without evidence of significant
  intracranial haemorrhage, anticoagulation for 3-6
  months is recommended, with reassessment of
  re-canalization at 3-months.
• With significant intracranial haemorrhage,
  monitoring with serial neuroimaging is advised.
• In case of clot propagation, treatment with
  anticoagulation is advised.

34
Recommendations for treatment of hemorrhage in
Children

• Children with brain hemorrhage should undergo a
  thorough risk factor evaluation, including
  cerebral angiography when noninvasive tests have
  failed to establish an origin.
• Children with a severe coagulation factor
  deficiency should receive appropriate factor
  replacement therapy, and children with less
  severe factor deficiency should receive factor
  replacement after trauma.
• Given the risk of repeat hemorrhage from
  congenital vascular anomalies, these lesions
  should be identified and corrected whenever it is
  clinically feasible.
• Stabilizing all supportive measures.

35

• Individuals with SAH may benefit from measures to
  control cerebral vasospasm.
• Surgical evacuation of a supratentorial
  intracerebral hematoma is not recommended.
  However, surgery may help selected individuals
  with developing brain herniation or extremely
  elevated intracranial pressure.
• There are no data to indicate that periodic
  transfusions reduce the risk of ICH caused by
  SCD.

36
THANK YOU..
37
(No Transcript)
38
(No Transcript)