بسم اللة الرحمن الرحيم. presented by yasser hamed md neurology in children stroke
TRANSCRIPT
بسم اللة الرحمن
الرحيم
Presented by Presented by
Yasser HamedYasser HamedMD NeurologyMD Neurology
In Children Stroke
Pediatrics is the branch of medicine
that deals with the medical care of
infants, children, and adolescents, and
the age limit up to 18 (in some places
until age 21 as in the United States)
Pediatric stroke is an important cause of
long-term disability, with children often
living for many years with significant
neurological deficits.
In children, 55% of strokes are ischemic,
in contrast to adults in whom 80–85% of
all strokes are ischemic.
Strokes in children differ from those in
adults in three important ways: Predisposing factors (In children, congenital and acquired
heart disorders, hematologic conditions are common causes.
In contrast, hypertension, smoking and hypercholesterolemia
are more common predispositions in adults..
Clinical evolution (children often improve much more than
an adult with a comparable lesion because of the abundant
collateral circulation or because of the differences in
response of the immature brain to the lesion).
Anatomic site of pathology (children commonly show
occlusion of the intracranial portion of the internal carotid
artery, whereas adults more frequently show extracranial
occlusions of the internal carotid).
EpidemiologyEpidemiology
The reported incidence of pediatric stroke ranges from 1.2 to 13
cases per 100,000 children under 18 years of age.
In Egypt (Al kharga District), the incidence of pediatric stroke
was 4/100,000 and prevalence was 26/100,000 children under
20 years of age..
However, pediatric stroke is likely more common than that
reported as it is thought to be frequently undiagnosed or
misdiagnosed.
In one report, 19 out of 45 children with a stroke did not receive
a correct diagnosis until 15 hours to 3 months after initial
presentation.
Stroke is more common in boys
than girls.
Stroke is appear to be more
predominant in black children.
This difference may be attributed
to sickle cell anemia.
Risk Factors and CausesRisk Factors and CausesCardiac (CCHD, VSD, ASD and RHD) are the
most common cause of stroke in childhood,
accounting for up to a third of all AIS.
Hematologic
◦ Sickle cell disease (SCD) is a very common
cause of stroke.
◦ AIS is more common in the younger age
whereas hemorrhagic strokes occurs more
frequently in older children and adults.
◦ Children with SCD develop all types of ICH
◦ Hypercoagulable disorder including antithrombin III, protein
C & S deficiencies, factor V Leiden mutation, elevated levels
of lipoprotein (a) and antiphospholipid antibody syndrome.
◦ It is suspected in individuals with recurrent DVT, recurrent
pulmonary emboli, or a family history of thrombotic events
or if thrombotic events occur during childhood or
adolescence.
◦ Hemophilia A (factor VIII deficiency) and B (factor IX
deficiency) are the two most common hereditary bleeding
disorders that cause intracranial hemorrhage.
◦ Vitamin K deficiency results in decreased factors II, VII, IX,
and X.
◦ Thrombocytopenia results from either immune
thrombocytopenic purpura (ITP) or the combined effects of
leukemia or its treatment. Nontraumatic brain hemorrhage
does not usually occur with platelets counts above 20,000
to 30,000,
Infection Varicella infection within the past year can result in basal
ganglia infarction.
HIV infection can cause stroke secondary to HIV-induced
vasculitis, vasculopathy with subsequent aneurysms, or
hemorrhage in the context of immune thrombocytopenia
Vascular Arteriovenous malformations (AVM) are the most common
cause of hemorrhagic stroke, but can also cause
thrombotic stroke. AVM may be associated with
neurocutaneous syndromes such as Sturge-Weber
disease, tuberous sclerosis and neurofibromatosis.
Moyamoya is another important vascular cause of
childhood stroke and is associated with conditions such as
Down syndrome, neurofibromatosis, and sickle cell
disease.
Syndromes and Metabolic
Disorders
Marfan syndrome are at risk of
ischemic stroke.
Homocysteinuria can cause AIS and
should be suspected in the presence of
mental retardation associated with lens
dislocation and occasionally pectus
excavatum.
Vasculitis
Cerebral vasculitis is a less common cause of
stroke in children, and is more common in
children older than 14 years of age. Although
idiopathic vasculitis is most often diagnosed,
signs and symptoms of systemic vasculitides
with Kawasaki disease, Henoch-Schnlein
Purpura (HSP), polyarteritis nodosa, Takayasu’s
arteritis, juvenile rheumatoid arthritis, systemic
lupus erythematosus, inflammatory bowel
disease, sarcoidosis, Sjogren syndrome, or
Behcet disease should be considered
Oncologic
Children with cancer are at increased risk for AIS as
a result of their disease, subsequent treatment,
and susceptibility to infection.
Intracranial hemorrhage may complicate an
intracranial tumor.
Leukemia and lymphoma create a hypercoagulable
state.
L-asparaginase decreases antithrombin levels, and
may trigger venous thrombosis.
Radiation therapy for brain tumours can cause
vasculopathies.
Trauma
Dissection of the carotid or vertebral arteries resulting from
hyperextension or rotational injuries of the neck.
Symptoms of traumatic arterial dissection can be delayed by 24
hours, and the risk is greatest within a few days of the vascular
injury.
Drugs
Cerebral infarcts and hemorrhage have been reported in patients
abusing drugs such as amphetamines, cocaine and glue sniffing.
Stimulants and heroin can also cause vasculopathies.
Adolescent girls using oral contraceptives are at higher risk of
cerebral venous thrombosis.
Overuse of ergot alkaloids are also associated with increased risk
of ischemic events.
Clinical PresentationClinical Presentation AIS most often presents as a focal
neurologic deficit. Hemiplegia is the most
common focal manifestation, occurring in
up to 94% of cases.
Hemorrhagic strokes most commonly
present as headaches or altered level of
consciousness.
Seizures are common in both ischemic
and hemorrhagic strokes.
There can be significant differences in the clinical
presentation based on the child’s age.
Neonatal strokes present with focal seizures or
lethargy.
Infants present with lethargy, apnea spells, or
hypotonia.
Toddlers present with deterioration of their general
condition, increased crying and sleepiness,
irritability, feeding difficulty, vomiting, and sepsis-
like symptoms with cold extremities.
Older children demonstrate more specific
neurological defects similar to adults.
Differential DiagnosisDifferential Diagnosis Hemiplagic migraine.
Focal seizures associated postictal
hemiparesis (Todd’s Paresis).
Intracranial neoplasms.
Trauma as extradural, subdural, SA and
intracerebral haematoma.
Intracranial infections such as meningitis,
brain abscess, and herpes simplex
encephalitis.
Metabolic abnormalities like hypoglycemia,
CADASIL and MELAS syndrome.
Diagnostic EvaluationDiagnostic Evaluation Ischemic Ischemic StrokeStroke::
A- Imaging Noncontrast head CT to exclude a hemorrhagic stroke.
Diffusion-weighted MRI of the brain is the most
sensitive method to diagnose acute AIS.
MRA head, neck.
MR Venogram (especially consider with sickle cell
disease).
CT angiography. MRA may be preferable to CTA
Other investigations as ultrasound to evaluate the
extracranial carotid circulation, ECG, chest radiograph,
and transthoracic or transesophageal
echocardiography.
B- Laboratory:
Prothrombin time and concentration, INR.
Antithrombin, factor V Leiden, protein
C&S.
Lipid profile, CBC and C-reactive protein
levels.
Tests for vasculitis (ESR, antinuclear
antibodies, antidouble strand antibodies,
lupus anticoagulant and anticardiolipin
antibodies).
A- Recommended universal supportive A- Recommended universal supportive measuresmeasures
Fever control (hypothermia should not
be used in children with stroke);
Normalization of serum glucose;
Maintenance of normal oxygenation;
Ameliorate increased intracranial
pressure;
Treat dehydration;
Correct anemia;
B- Blood pressure B- Blood pressure managementmanagement
The AHA guidelines suggest
“control of systemic hypertension”
in children with AIS and
hemorrhagic stroke.
Specific guidelines for blood
pressure values are absent.
C- Anticonvulsants and EEG C- Anticonvulsants and EEG monitoringmonitoring
Seizures are a common complication of pediatric stroke,
affecting up to 25% with AIS and up to 20% with ICH.
When they occur, seizures should be treated aggressively.
Prophylactic anticonvulsants are often used in the setting
of intraparenchymal or subarachnoid hemorrhage in
adults, although this approach is not evidence-based
practice.
The AHA pediatric stroke guidelines recommend against
prophylactic anticonvulsant use in ischemic stroke but do
not make recommendations in the setting of hemorrhagic
stroke.
D- Management of intracranial D- Management of intracranial pressurepressure
Nonsurgical methods
Keeping the head of a patient’s bed at 30°.
Hyperventilation to a pCO2 of 25–30 mmHg.
Hyperosmolar therapy—with either mannitol or
hypertonic saline.
In some cases, sedation may be required to
help manage elevated ICP.
Corticosteroids should be avoided.
Surgical An intraventricular catheter (IVC) providing
both a means to measure ICP and, via drainage
of cerebrospinal fluid.
Hemicraniectomy may be both life-saving and
function-sparing in adults with a large AIS who
progress to signs and symptoms of impending
herniation.
In children, study of 10 children with malignant
middle cerebral artery infarction, seven
underwent hemicraniectomy, all of whom
survived and had moderately good recovery.
AIS-specific treatmentsAIS-specific treatmentsA- Antiplatelet
I- Aspirin
For all older children with ischemic stroke except kids with sickle cell
disease
Typical dose is 3-5 mg/kg/day. This dose can be reduced to 1 to 3
mg/kg for long-term prophylaxis.
Risk of Reye’s syndrome is very low. It recommend to discontinue or
reduce dose to half during febrile illness.
It recommend to vaccinate for varicella and give an annual influenza
vaccine.
II- Clopidogrel
For children unable to take aspirin.
Typical dose is 1mg/kg/day.
B- Anticoagulant
I - UH with loading dose 75 units/kg IV
followed by 20 units/kg/hour for children
over 1 year of age or 28 units/kg/hour
below 1 year of age. The target APTT is
60 to 85 seconds.
II- LMWH doses of 1 mg/kg every 12 hours
or in neonates, 1.5 mg/kg every 12
hours.
III- Warfarin with target of INR 2.5 to 3.5.
Consider if suspicion high for cardioembolic stroke,
arterial dissection, posterior circulation stroke.
According to the Australian AIS treatment guideline,
for children with confirmed AIS, UH or LMWH is
recommended in the first 5 to 7 days until the
evaluation for underlying etiologies and risk factors
is completed.
Children are continued on either oral or
subcutaneous anticoagulants for 3-6 months and
then switched to an antiplatelet agent, usually
aspirin.
Platelet count should be monitored
C- Thrombolytic therapyC- Thrombolytic therapy Use of thrombolytic therapy for patients aged <18 years
is much more controversial. The current AHA guidelines
recommend that tPA use in young children is limited to a
clinical trial.
Evidence for the safety and efficacy of thrombolysis in
children with stroke is extremely limited. The existing
studies of this treatment suggest a high risk of
hemorrhagic complications.
Recommendations for stroke and heart Recommendations for stroke and heart diseasedisease
Therapy for congestive heart failure is
indicated.
When feasible, congenital heart lesions,
especially complex heart lesions with a
high stroke risk, should be repaired.
Resection of an atrial myxoma is indicated.
Surgical repair or transcatheter closure is
reasonable in individuals with a major
atrial septal defect.
In children with a risk of cardiac embolism,
it is reasonable to continue either LMWH or
warfarin for at least 1 year or until the
lesion responsible for the risk has been
corrected.
Anticoagulant therapy is not recommended
for individuals with native valve
endocarditis
Surgical removal of a cardiac rhabdomyoma
is not necessary in asymptomatic
individuals.
Recommendations for children with Recommendations for children with SCDSCD
Risk factors for stroke include high blood flow
velocity on TCD, low hemoglobin value, high
white cell count, hypertension, silent brain
infarction, and history of chest crisis.
Acute management of ischemic stroke
resulting from SCD should include optimal
hydration, correction of hypoxemia, and
correction of systemic hypotension.
Periodic transfusions to reduce the percentage
of sickle hemoglobin are effective for reducing
the risk of stroke in children 2 to 16 years of
age.
For acute cerebral infarction, exchange
transfusion designed to reduce sickle
hemoglobin to <30% total hemoglobin.
Hydroxyurea may be considered in children
and young adults with SCD and stroke who
cannot continue on long-term transfusion.
Bone marrow transplantation.
Surgical revascularization procedures.
Recommendations for treatment Recommendations for treatment of coagulation disordersof coagulation disorders
Antithrombin deficiency is resistant to
heparin.
After a thrombotic event, lifelong
warfarin is indicated.
Patients with protein C or S deficiency or
factor V Leiden mutation and stroke are
treated with anticoagulation.
The prophylactic anticoagulation for
asymptomatic patients is controversal.
Sinus thrombosis The antithrombotic therapy is aimed at preventing
the clot propagation and recurrence within the
cerebral venous system.
For children without evidence of significant
intracranial haemorrhage, anticoagulation for 3-6
months is recommended, with reassessment of re-
canalization at 3-months.
With significant intracranial haemorrhage, monitoring
with serial neuroimaging is advised.
In case of clot propagation, treatment with
anticoagulation is advised.
Recommendations for treatment of Recommendations for treatment of hemorrhage in Childrenhemorrhage in Children
Children with brain hemorrhage should undergo a
thorough risk factor evaluation, including cerebral
angiography when noninvasive tests have failed to
establish an origin.
Children with a severe coagulation factor deficiency
should receive appropriate factor replacement therapy,
and children with less severe factor deficiency should
receive factor replacement after trauma.
Given the risk of repeat hemorrhage from congenital
vascular anomalies, these lesions should be identified and
corrected whenever it is clinically feasible.
Stabilizing all supportive measures.
Individuals with SAH may benefit from measures
to control cerebral vasospasm.
Surgical evacuation of a supratentorial
intracerebral hematoma is not recommended.
However, surgery may help selected individuals
with developing brain herniation or extremely
elevated intracranial pressure.
There are no data to indicate that periodic
transfusions reduce the risk of ICH caused by SCD.
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