Childhood stroke

Joanne de Jesus M.D.

Pediatric resident
VRPMC
February 27, 2008
 Determine:
 How long the patient had hemiparesis?
 Hemiparesis intermittent?
 Onset? Sudden or gradual?
 History of trauma?
 Recent viral infection?
 Recent immunization?
 Risk factors for stroke/Subarachnoid
hemorrhage
 Past medical history
 Family history
 Stroke – focal neurologic deficit lasting for
more than 24 hours; vascular in origin
 Transient ischemic attack (TIA) – shorter
period of time
 Reversible ischemic neurologic deficit – lasts
more than 24 hours but the patient eventually
recovers fully
 A.R. 9/M
 Infarction left basal
ganglia, cannot rule
out non-
communicating
hydrocephalus
 Citicholine
 Mannitol
 Cefotaxime
 Amikacin
Congenital cyanotic heart disease
 Most common cause
 4% in pediatric cardiac patients
 75% - 1st 2 years of life

Heart disease was found in 40 of 228 (19%) of the

children with arterial thrombosis – Canadian
Pediatric ischemic stroke registry

Recognition and Treatment of Stroke in Children

by the Child Neurology Society Ad Hoc Committee on Stroke in Children:
 Infection
 1/3 of thrombotic carotid artery
 Pharynx and cervical infection
 Local inflammation of the arterial wall

 Cat-scratch fever
 Varicella associated with CVD
 Mycoplasma

 Viral encephalitis
 Hematologic causes???
 Hyperviscosity syndromes
 Polycythemia, hyper-leukocytosis, thrombocytosis
 Hemoglobinopathies (sickle cell disease)
 Antithrombin III deficiency
 Protein C and Protein S deficiency??????????
 Autoimmune disorders
 Vasculitis
 Hypercoagulable state (lupus anticoagulant
and anti-cardiolipin antibody)

 SLE – 50% neurologic involvement

 ANA????
 LE prep?????
 Other causes of stroke
 Trauma or neck injury
 Error in lipid metabolism
 Drug use
 Clinical Presentation
 size and location of the occluded vessel
 patient’s age
 Infants – pathologic hand preference
 anterior > posterior strokes
 Left hemisphere > right hemisphere
 2/3 patients – acute hemiplegia
 Sudden loss of neurological function
 Presentation, clinical course, and outcome of
childhood stroke. Lanska et al. Pediatric Neurology.
1991 Sep-Oct
 Seizures ( < 1 year old)
 Hemiparesis
 pathologic early hand preference without a
history of an ictus ( later in first year of life)
 sudden hemiparesis, often associated with
seizures
 most severe at the onset, followed by some
improvement in strength in all patients
 Evaluation
 1st - Recognize stroke has occurred and
distinguish this from similar process
 2nd – once stroke is confirmed, identify the
UNDERLYING CAUSE
 Diagnostic Evaluation in a Child
with Cerebrovascular Disease
 Performed electively as indicated
HIV
Lyme titers
Mycoplasma titers
Cat-scratch titers
Cardiac MRI
Echocardiogram (transesophageal)
Muscle Biopsy
DNA testing for MELAS
Cerebral angiogram (transfemoral)
Leptomeningeal biopsy
Serum homocystine after methionine load
 Diagnostic Evaluation in a Child
with Cerebrovascular Disease
 Perform within the 1st 48 hours of admission
CT scan of brain
MRI of brain
Complete blood count
PT/PTT
Electrolytes, Ca, Mg, Phos, glucose
Liver function test
Chest x-ray
ESR
ANA
Urinalysis
BUN, creatinine
Urine drug screen
12-lead EKG
 Diagnostic Evaluation in a Child with
Cerebrovascular Disease – ( within the 1st week)

Antiphospholipid antibody
Echocardiogram (transthoracic) with
Anticardiolipin
saline contrast
Lupus-anticoagulant
Holter monitor
Rheumatoid factor
Transcranial and/or carotid dopplers Serum amino acids
MR angiogram Urine for organic acids
EEG Blood culture
Hypercoaguable evaluation Hemoglobin electrophoresis
Complement profile
(Hematology consultation)
VDRL
Antithrombin III Lactate/pyruvate
Protein C (activity and antigen) Ammonia
Factor V (leiden) mutation CSF: cell count, protein, glucose, lactate
Lipid profile
 Management
 Oxygenation
 Fluids and electrolytes
 Seizure control
 Infections

 Treatment should be directed to the underlying

cause if it is identifiable.
 Cerebral edema –maximal 1st 72 hours
 Mannitol

 Therapeutic agents used for management of

stroke in children:
 Aspirin
 Heparin and LMWH

 Thrombolytic agents

 Tissue plasminogen activator

 Prognosis
 recurrence: 20-40%
 27% neurologically normal
 61% neurologically abnormal
 21.6% recurred
 12% dead

 CIPSR
 Research
 Risk factors, outcome and recurrence
 Acute therapies, primary and secondary prevention
 Safety and proper dosing
 Carotid occlusion surgery study (COSS)
 Warfarin vs Asprin in reduced cardiac ejection
fraction (WARCEF)
 Secondary prevention of small subcortical strokes
 Field administration of stroke therapy magnesium
trial (FAST-MAG)
Thank you
and
good day