Different Strokes for Different Folks – Oncology Rina Meyer, MD Stony Brook Children’s Stony Brook University School of Medicine
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Different Strokes for Different Folks –
Oncology
Rina Meyer, MD
Stony Brook Children’s
Stony Brook University School of Medicine
Epidemiology
Causes of stroke in pediatric cancer patients
Case presentations
Prognosis
Treatment of stroke
OVERVIEW
Noje, et al (2013); Mueller, et al (2013)
EPIDEMIOLOGY
• 1-2% of all children with cancer within the first year after diagnosis
• ~4% risk of late stroke
• Risk of recurrence as high as 59% at 10 years
• Incidence is increasing…o Increased awareness
o Increased survival of pediatric cancer patients with late
stroke
• Still with delays in diagnosiso 19/45 children did not receive a correct diagnosis until
15 hours-3 months after presentation
o 28 hour delay in seeking medical attention
o 7.2 hour delay before imaging was performed
Tsze, et al (2011)
EPIDEMIOLOGY
http://blogs.shu.edu/cancer/2016/08/17/cancer-induces-a-hypercoagulable-state/
CAUSES OF STROKE IN PEDIATRIC CANCER
• High white blood cell count
• Low platelet count/platelet dysfunction
• Presence of a tumor
• Abnormal blood clotting proteinso Sometimes due to chemotherapy
• Cranial radiation
Noje, et al (2013)
CAUSES OF STROKE IN PEDIATRIC CANCER
• Andy is a 6 yo boyo 2 months of eye blinking
o 1 month of jaw twitching
o Slurred speech after jaw twitching
o 2-3 days of right arm weakness, now using left arm to right
o Ongoing right facial droop
• Diagnosed with tic disorder
CASE #1
CASE #1
• Anaplastic ependymomao Ultimately treated with surgery, radiation,
chemotherapy
• Tumor caused compression of vasculature deprived brain of blood supplyo Subtle residual deficits
• What were the red flags?
• What is his risk for future stroke?
CASE #1
• Emily is an 8 yo girlo Presented with fatigue, fever, signs of bleeding
o Found to have WBC 325,000
o Diagnosed with acute myeloid leukemia
o Increasingly confused, sleepy, and “out of it”
o Suddenly becomes unresponsive
CASE #2
CASE #2
• Hemorrhagic strokeo Caused increased intracranial pressure
• How did this happen?o Number and dysfunction of white blood cells
o Abnormal blood clotting
• What were the early signs/symptoms and
risk factors?
CASE #2
CASE #3
• Adele is a 12 yo girlo Diagnosed with T-cell acute
lymphoblastic leukemia
o Also diagnosed with
hemophagocytic
lymphohistiocytosis
o On intense chemotherapy;
last received PEG-
asparaginase ten days ago
o Brought to the ER by her
father for sudden confusion
and lethargy
CASE #3
• Cerebral sinus venous thrombosis
• What contributed to this problem?o Underlying leukemia diagnosis
o Dehydration (often common due to nausea/vomiting)
o Use of PEG-asparaginase
CASE #3
• Strokes can present in many ways!!o Weakness
o Change in mental status
o Seizures/abnormal movements
o Headaches or neck pain
o Change in speech
o Sleepiness
o Nausea/vomiting
o Visual changes
• The younger the patient, the more non-specific the signs and symptoms!
Tsze, et al (2011)
CASE REVIEW
• Clinicians, parents, and educators need to:o Maintain a high index of suspicion for strokes
o Identify risk factors early on in a child’s illness
o Intervene as soon as possible
CASE REVIEW
• Thankfully, stroke in pediatric cancer
patients is rare…why is this talk devoted to
it?o Significantly increased relative risk compared to
healthy counterparts
o Risk continues into adulthood for many patients!
o May significantly impact function and survival
PROGNOSIS
• Morbidityo Increased brain plasticity improved hope of
neurologic recovery
o Still up to 2/3 have neurologic sequelae (deficits, seizures, learning problems, developmental delays/disabilities)
o Often dependent on location, mechanism, etc.
o High chance of recurrence increased risk for further neurologic impairment
Tsze, et al (2011)
PROGNOSIS
• Mortality o 10-25% death
o Worse in patients with hemorrhagic stroke
o Often worse in patients with newly diagnosed leukemia
and other significant comorbidities
Tsze, et al (2011); Noje, et al (2013)
PROGNOSIS
TREATMENT AND FOLLOW-UP
Diagnose and stabilize
Treat underlying
cause(s)
Prevent complications and secondary
events
TREATMENT AND FOLLOW-UP
Community and
Educational System
Nursing, PT, OT, Speech,
Nutrition, SW, Child Life
Subspecialist and Primary Care Teams
Patient and Family
• Diagnose and stabilizeo Careful observation!!
o CT scan and MRI
o Careful neurologic examination
o Lab work
o +/- EEG
• Manage fever, blood glucose abnormalities,
anemia, and hypertension
TREATMENT AND FOLLOW-UP
• Treat underlying cause(s)o Identify risk factors
o Improve hydration
o Correct blood clotting abnormalities
o Consider leukapheresis, transfusions, etc.
o Consider thrombolysis (tPA)
o Need for surgery?
o Investigate other causes…
TREATMENT AND FOLLOW-UP
• Prevent complications and secondary
eventso Role for anticoagulation (heparin, enoxaparin, warfarin)
o Role for anti-platelet therapy (aspirin, clopidogrel)
o Early initiation of rehabilitation services
o Consideration of neuropsychological testing
o Involvement of educational system
TREATMENT AND FOLLOW-UP
PARTICULAR SCHOOL CHALLENGES
QUESTIONS?
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