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STROKE IN

CHILDREN
Puji Pinta O. Sinurat
Dept. Neurologi FK USU/
RSUP H Adam Malik Medan
2015

INTRODUCTION
Stroke :

is neurological injury caused by occlusion or rupture of


cerebral blood vessel

can happen to anyone at any time

Can be Ischemic, Hemorrhagic, or both


In adults: 80-85% Vs Children 55% are ischemic and
the rest are Hemorrhagic

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

are at higher risk for stroke than girls

Symptoms : depend on the age of child and


the cause of stroke
20% of children stroke will have > 1 stroke
prevention of a second stroke is important
20-40% of children die after a stroke
Of children surviving stroke, 50 - 80% will
have permanent neurological deficits

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

Hemorrhagic Stroke when a blood


vessel in or near the brain rupture, causing
bleeding in the brain
Ischemic Stroke :
Arterial Ischemic Stroke : the clot
is in artery in the brain
Sinovenous thrombosis : the clot
in one of the vein 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

In Children and teens:


- Seizure
- Severe headache
- Vomiting
- Sleepiness
- Dizzines
- Loss of balance or coordination

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.

Presentation and Etiology of AIS


in children Vs Adults
More rare with a clinical presentation and wider
differential diagnosis
Most children present with focal neurologic
deficits : hemiplegia, seizure but symptoms
often are attributed to something other than
stroke
Neurologic systems differ in term of
Coagulation, vascular and adaptive
components
Nj J, et al, Moharir M, et al, Numis AL, et al, Braun KP, et al. cit Naerengarten MB. 2015

Risk factors are frequently multiple and age


specific across childhood requiring a
complex investigation of etiology
Atheromatous cerebrovascular disease and
risk factors (obesity, smoking, hypertension)
are rarely the cause of AIS in children.

Etiologies of AIS in Children


Arteriopathies
Sickle cell disease (SCD)
Congenital heart disease (CHD)
Prothrombotic (hypercoagulable)
disorders

AIS in Children with


Arteriopathies
- Account for 60% of all AIS in children
- May present as acute, transient or
progressive
- Common Types :
Transient cerebral arteriopathy : caused
by inflammation
Cervical arterial dissection: mechanical
injury, major trauma to the head & neck
Moya-moya disease

- Tips for Diagnosis :


o MRA or CTA for neck vessel imaging
o Catheter cerebral angiography for
cervical arterial dissection
o MRA Moya-moya : absent flow voids
in the ICA, MCA, and ACA

AIS in Children with Sickle


cell Disease (SCD)
10% of children with SCD causes AIS by 20
yo and > 60% chance of AIS recurrence
Symptomps : - dysphasia
- gait disturbance
- hemiparesis
- altered consciousness
Tips for Diagnosis:
o MRI
o Angiography
o Transcranial Doppler

AIS in Children with Congenital


Heart Disease (CHD)
Can be caused by a number of mechanism:
Related to management of cardiac
problems (cardiac catheterization, surgical
procedure etc)
Disease mechanism : thromboembolism
from valvular or septal defects
Tips for Diagnosis:
o ECG
o Echocardiography
o Blood Cultures (if suspected
endocarditis)

AIS in Children with Prothrombotic


(hypercoagulable) disorders
20-50% of children with AIS will have 1
prothrombotic abnormalities
Inherited abnormalities : deficiencies of
coagulation inhibitors
Acquired thrombophilia : SLE, Nephrotic
Syndrome
Common Types : Protein C Deficiency
Tips for Diagnosis :
o Lab : Thrombophilia panel (Prot C, Prot S,
Antithrombin, Lupus anticoagulant,
anticardiolipin antibody, etc)

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

Supportive care for Acute treatment:

Nj J, et al, FreunlichCL, et al. cit Naerengarten MB. 2015.

TREATMENT of AIS in CHILDREN


Cont

II. Secondary prevention Identifying


underlying risk factors to prevent tratment
and estimate prognosis.
Note: little evidence-based recommendation
available to help guide physician (except for
SCD Chronic Transfusion & for Moyamoya
disease surgical revascularization)
.recommendation are extrapolated from the
adult stroke literature

Antithrombotic therapy for Acute treatment of AIS

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

AHA Guidelines on Antithrombotic Therapy for


Secondary Prevention of AIS Childhood AIS

Roach ES, et al cit. Nierengarten MB. 2015

HEMORRHAGIC STROKE (HS) in


CHILDREN
incidence: 1,1/100.000 per year
Intra Cerebral Hemorrhage: 0,8/100.000
per year
Subarachnoid Hemorrhage: 0,3/100.000
per year
Mortality of HS : 25%
Significant disability : 42%

Jordan LC, HillisnAE. Hemorrhagic Stroke in Children. Ped Neurol. 2007

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

Problems speaking or understanding language,


including slurred speech,
Trouble seeing clearly in one or both eyes
Dizziness or unsteadiness
In

newborns and infants

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%)

THANK YOU

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