Strokes (Ischemic) in Children by Dr. Azher Shah Associate Professor Department of Paediatric Medicine Azra Naheed Medical College, Lahore.

Strokes (Ischemic) in Childrenby

Dr. Azher ShahAssociate Professor

Department of Paediatric MedicineAzra Naheed Medical College, Lahore

Introduction

Stroke is the acute neurologic injury that occurs as a result of either Brain Ischemia or Brain Haemorrhage

Approximately 80 percent of strokes are due to Ischemic Cerebral Infarction and 20 percent due to Brain Haemorrhage

Introduction

More common in older adults, stroke also occurs in neonates, infants, children, and young adults, resulting in significant morbidity and mortality

Annual incidence rates of arterial ischemic stroke (AIS) in infants and children range from 0.6 to 7.9/100,000 children per year

Paediatric ischemic stroke is more common in boys than in girls

Etiology

Etiologies and risk factors for arterial ischemic stroke (AIS) in children differ from those in older adults • Congenital and acquired heart problems• Hematologic conditions• Vasculopathies• Metabolic disorders• Drug ingestion

Children

Etiology (Cont…)

Older Adults

• Hypertension• Smoking• Diabetes• Hypercholesterolemia

Risk Factors in ChildrenCardiac abnormalities

Vascular lesions

Hematologic abnormalities

Infection

Head and neck trauma

Genetic conditions

Clinical Features

Infants

• Focal weakness• Seizures• Altered mental status

Clinical Features (Cont…)

Older Children

• Hemiparesis• Focal neurologic signs such as aphasia, visual

disturbance• Cerebellar signs• Seizures, headache and lethargy• Neck pain (with cervical artery dissection)• Horner's syndrome (carotid dissection)

Differential Diagnoses

Vascular Abnormalities

• Intracranial haemorrhage• Aneurysm• Arteriovenous malformation• Cerebral venous sinus thrombosis

Differential Diagnoses (Cont…)

Nonvascular Conditions

• Intracranial infection (brain abscess or meningoencephalitis)• Demyelinating conditions (such as acute disseminated

encephalomyelitis)• Tumours and other structural brain lesions• Prolonged postictal paresis (Todd's paralysis)• Complicated migraine• Familial alternating hemiplegia• Reversible posterior leukoencephalopathy syndrome• Metabolic stroke• Drug toxicity• Postinfectious cerebellitis• Psychogenic conditions

Evaluation

Urgent Neuro-imaging

• Cardiac• Vascular• Hematologic risk factors

Thorough investigation for

Evaluation (Cont…)

Neuroimaging • Brain CT is generally considered inadequate to diagnose stroke• MRI may be required to reliably exclude stroke mimics• Brain MRI is more sensitive for acute ischemia than CT• Brain MRI provides better visualization of the posterior fossa

MRI Brain or CT Brain

Magnetic resonance angiography (MRA) of the head

MRA of the neck to evaluate the extracranial large arteries

Evaluation (Cont…)

Laboratory studies

• Complete blood count including platelets • Prothrombin time (PT) and international normalized ratio (INR) • Partial thromboplastin time (PTT) • Electrolytes, urea nitrogen, creatinine • Liver function tests• Serum glucose • Hemoglobin electrophoresis in patients with possible sickle cell disease

Evaluation (Cont…)

Laboratory studies

• Electrocardiogram (ECG)• Oxygen saturation • Transthoracic echocardiography • Holter monitoring - if there is suspicion for cardiac arrhythmia, particularly atrial fibrillation • Electroencephalogram (EEG) - if seizures are suspected• Lumbar puncture – if infection is suspected• Toxicology screen – if drug ingestion is suspected

Evaluation (Cont…)

Laboratory studies

• Hypercoagulable evaluation • Protein C functional • Protein S free and total or protein S functional • Antithrombin III activity • Lipoprotein (a) • Homocysteine • Prothrombin gene mutations • Factor V Leiden gene mutation • Anticardiolipin antibodies (IgG and IgM) • Beta2-glycoprotein I antibodies (IgG and IgM) • Lupus anticoagulant tests, including dilute Russell viper venom time and dilute activated PTT • Factor VIII activity • D-dimer

Evaluation (Cont…)

Laboratory studies

• Evaluation for the Vasculitis • Erythrocyte sedimentation rate• C-reactive protein level • Antinuclear antibody assay • Varicella titers • Cerebral digital subtraction angiography

Initial Management

Supportive Measures

• Maintain airway, breathing, and circulation (ABCs) • Maintain normoglycemia and normothermia; start

normal saline intravenously at maintenance rate • Allow modest hypertension • Perform frequent neurologic checks • Begin respiratory and oxygen saturation monitoring-

keep oxygen saturation >95 percent • Utilize cardiac monitoring for the first 24 hours• Patient should be positioned as flat as possible in bed

for at least the first 24 hours from stroke onset, ideally with head-of-bed elevation kept between 0 and 15 degrees

Initial Management (Cont…)

Thrombolysis

• Start venous thromboembolism prophylaxis for patients restricted to bed• Alteplase (rt-PA)

GuidelinesDifferences among consensus guidelines regarding the initial treatment of children with acute arterial ischemic stroke

American Academy of Chest Physicians (ACCP) recommends either unfractionated heparin or low molecular weight heparin (LMWH) or aspirin as initial therapy until dissection and embolic causes have been excludedAmerican Heart Association Stroke Council guideline states that it may be reasonable to initiate anticoagulation with LMWH or unfractionated heparin in children with arterial ischemic stroke pending completion of the diagnostic evaluation

The Royal College of Physicians recommends initial therapy with aspirin

Acute Treatment for Specific Causes of Arterial Ischemic Stroke

Unknown Etiology

• Aspirin 3 to 5 mg/kg per day rather than anticoagulation as initial therapy

Arterial Dissection or Cardioembolism

• Short-term anticoagulation with low molecular weight heparin

Hypercoagulable state

• Anticoagulation treatment (rather than aspirin ) with intravenous unfractionated heparin (goal PTT 60 to 85) or subcutaneous low molecular weight heparin (eg, enoxaparin [1 mg/kg dose every 12 hours] to achieve a goal anti-factor Xa level of 0.5 to 1.0 U/mL) for five to seven days, followed by treatment with low molecular weight heparin or warfarin

Acute Treatment for Specific Causes of Arterial Ischemic Stroke

Sickle cell disease

• Intravenous hydration• Urgent exchange transfusion

Vasculopathy (excluding dissection)

• Aspirin (3 to 5 mg/kg per day) rather than anticoagulation• Immunosuppression may be indicated for confirmed inflammatory vasculitis

Large "malignant" middle cerebral artery territory stroke

• Decompressive hemicraniectomy

Prognosis

Mortality

• In hospital mortality after ischemic stroke in children ages 1 to 17 years is 3.4 percent

Disability

• Despite the neural plasticity present in children, the majority of children with stroke have persistent disability

• Disability that interfere with daily life is present in 60 percent

Prognosis

Predictors of Poor Outcome

• Young age • Altered consciousness at presentation • Fever at presentation • Middle cerebral artery territory stroke- volume greater than 10 percent of the intracranial volume • Right middle cerebral artery territory infarction• Bilateral ischemia• Arteriopathy

SummaryStroke in Childhood is acute neurological injury, mainly due to Brain Ischemia

Neuoimaging is the most important aspect of evaluation

Supportive measures are necessary during initial management

Thrombolytic therapy is still controversial in children

There is very high rate of disability after stroke