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CHILDREN
Puji Pinta O. Sinurat
Dept. Neurologi FK USU/
RSUP H Adam Malik Medan
2015
INTRODUCTION
Stroke :
Tsze DS and Valente JH. Pediatric Stroke : a Review. Emerg Med Int vol 2011.
.
INTRODUCTION
Cont
STROKE in CHILDREN :
3 groups :
- Prenatal phase
- Newborn phase (the first 28 days of life)
- from infant to 18 years of age
One of the top 10 causes of death
about 1 in 4000 live birth
Risk of stroke from birth 18 y o is almost 11
in 100.000 children/year
INTRODUCTION
Cont
Boys
Definition
Stroke (WHO,1978) : a clinical syndrome of
rapidly developing focal or global
disturbance of brain function, lasting > 24 h
or leading to death, with no obvious non
vascular cause
Ischemic Stroke when the blood flow to
the brain is diminished, usually because of
clot (thrombus) in one of the blood vessel in
the brain
Causes:
A stroke is caused by the interruption of
normal flow of blood to the brain, either by a
blockage or a rupture in the blood vessels.
When a part of the brain doesnt receive
its regular flow of blood that carries vital
nutrients and oxygen, brain cells die
causing a loss of brain function.
Incidence
o Childhood : 5-8 per 100.000 children
annually 50% ischemic (AIS or CSVT)
o Neonatal : 1 in 3000-5000 live births
o Sinovenous thrombosis : 1 in 6000
newborns
o Arterial ischemic Stroke : 1 in 4000
newborns
Risk Factor
Cardiac disease
Sickle-cell disease
Immune disorders
Abnormal blood clotting
Head and neck trauma
Infection
Maternal history of infertility
Maternal infection in the fluid surrounding an
unborn baby
Clinical Presentationcont
Premature rupture of membrane during
pregnancy
Pregnancy related high blood pressure in
the mother
AVM
Drugs
Clinical Presentation
The Specific symptom in children depend on their age:
In Newborns and infants:
- Focal seizure
- Irritability
- Crying
- Feeding difficulty
- Vomiting
- Extreme sleepiness
- Sepsis-like symptoms
- Tendency to use only one side of their body
Differential Diagnosis
-
Complicated Migraines
Todds Paresis
Intracranial Neoplasm
Intracranial infection
Hypoglicemia
Uncommon metabolic disorders (MELAS:
mtochondrial myopathy, encepahalopathy,
lactic acidosis and stroke)
ARTERIAL ISCHEMIC
STROKE (AIS) in Children
- An important cause of long-term morbidity
- 2-3 children per 100.000 per year
- About 50% children with AIS will have a
preexisting medical condition relevant to AIS:
Congenital Heart Disease, Sickle Cell
Disease, iron deficiency, Prothrombotic
states and infection.
TREATMENT of AIS in
CHILDREN
I.
Acute treatment
to limit or reverse the effect of stroke on
brain injury
to look for etiology and risk factors that
also may need treatment
supportive neuroprotective
treatment of seizure
management of raised ICP (lifesaving)
Sickle cell Disease
Antithrombotic therapy No clear Data
Nj J, et al, Moharir M, et al, Roach ES,et al, Monagle P, et al. cit Nierenarten MB. 2015 .
Long-term Deficits in
neonates and children after
AIS
Moharir M, et al, Golomb MR, Westmacott R, et al, Fox CK, et al.cit Nierengarten MB. 2015
Causes
1. Aneurysm : blood vessels have a
weakened area where the blood causes
the wall to ballon
2. Arteriovenous malformation (AVM) : a
tangle group of abnormally formed blood
vessels can burst and bleed into the
brain
3. Damaged or Fragile blood vessels
4. Clotting abnormality : hemophilia
Jordan LC, HillisnAE. Hemorrhagic Stroke in Children. Ped Neurol. 2007
Symptoms
In Children :
Severe headache especially with vomiting
and sleepiness
Seizures : Focal and are followed by
paralysis on the side of the seizure activity
Loss of consciousness after one or more
of the above symptoms Followed by:
Weakness or numbness of the face, arm or
leg, usually on one side of the body
Hemiplegia
Jordan LC, HillisnAE. Hemorrhagic Stroke in Children. Ped Neurol. 2007
Seizures
Extreme irritability
Vomiting
Bulging fontanelle (soft spot on top of the baby's
head)
Loss of consciousness
Jordan LC, HillisnAE. Hemorrhagic Stroke in Children. Ped Neurol. 2007
Diagnostic
Computed tomography (CT)
Magnetic Resonance Imaging
Magnetic Resonance Angiography
Cerebal Aniography
Medical Management
No medical management guideline are
available guided by extrapolation from
adult literature
Fluid management to maintain euvolemia
Maintenance body temperature to normal
levels
Monitoring and treatment of hydrocephalus
Jordan LC, HillisnAE. Hemorrhagic Stroke in Children. Ped Neurol. 2007
Medical Management
Cont
Osmotherapy is recommended for elevated
intracranial pressure
Corticosteroid are not recommended
Treatment of brain AVM depend on the size,
Location
Embolization reducing the size / obliterate
of AVM
Medical Management
Cont
Large AVM & deep venous drainage in
eloquent area not be ameable to therapy
Stereotactic and endoscopic surgical
evacuation of the ICH or Hemostatic agent
being investigated
Prognosis
Recurrent risk in childhood HS depends on
underlying etiology
Predict Poor neurologic outcome :
- Location : infratentorial
- GCS 7 at admission
- Aneurysm
- age < 3 years at the time of HS
- Underlying hematological disorders
Mortality rate : 25% (7-54%)
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