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TROKE IN
CHILDREN
Puji Pinta O. SinuratDept. Neurologi FK USU/
RSUP H Adam Malik Medan
2!"
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INTRODUCTION
troke :
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 !s Children " 55 are ischemic and
the rest are Hemorrhagic
#s$e %& and !alente 'H( )ediatric &tro*e : a +evie( merg .ed Int vol /0(
(
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INTRODUCTION
Cont
S#ROK$ in %H&'DR$N (
1 groups :
- )renatal phase
- 2eborn phase 3the first /8 days of life4
- from infant to 8 years of age
ne of the top 0 causes of death about in 6000 live birth
+is* of stro*e from birth 7 8 y o is almost
in 00(000 childrenyear
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INTRODUCTION
Cont
9oys are at higher ris* for stro*e than girls
&ymptoms : depend on the age of child and
the cause of stro*e
" /0 of children stro*e ill have stro*e
prevention of a second stro*e is important
/0-60 of children die after a stro*e
f children surviving stro*e, 50 - 80 ill
have permanent neurological deficits
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Definition
Stroke )*HO+!,- ( a clinical syndrome ofrapidly developing focal or global
disturbance of brain function, lasting /6 h
or leading to death, ith no obvious non
vascular cause
&01emi1 Strokehen the blood flo to
the brain is diminished, usually because ofclot 3thrombus4 in one of the blood vessel in
the brain
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Hemorragi1 Strokehen a blood
vessel in or near the brain rupture, causing
bleeding in the brain
&01emi1 Stroke ( Arterial &01emi1 Stroke ( te 1lot
i0 in arter3 in te 4rain
Sino5enou0 trom4o0i0 ( te 1lotin one o6 te 5ein in te 4rain
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Causes:
; stro*e is caused by the interruption of
normal flo of blood to the brain, either by a
bloc*age or a rupture in the blood vessels(
ygen, brain cells die
causing a loss of brain function(
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Incidence
oChildhood : 5-8 per 00(000 children
annually" 50 ischemic 3;I& or C&!#4
o 2eonatal : in 1000-5000 live births
o &inovenous thrombosis : in ?000
neborns
o ;rterial ischemic &tro*e : in 6000
neborns
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Risk Factor
@ Cardiac disease
@ &ic*le-cell disease
@ Immune disorders
@;bnormal blood clotting
@ Head and nec* trauma
@ Infection
@ .aternal history of infertility
@ .aternal infection in the fluid surrounding anunborn baby
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Clinical resentationcont
@ )remature rupture of membrane during
pregnancy
@ )regnancy related high blood pressure in
the mother@;!.
@ %rugs
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Clinical resentation
#he &pecific symptom in children depend on their age:In 2eborns and infants:
- Aocal sei$ure
- Irritability
- Crying
- Aeeding difficulty
- !omiting
- >treme sleepiness
- &epsis-li*e symptoms
- #endency to use only one side of their body
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In Children and teens:
- &ei$ure
- &evere headache
- !omiting
- &leepiness
- %i$$ines
- Boss of balance or coordination
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Differential Dia!nosis
- Complicated .igraines
- #odds )aresis
- Intracranial 2eoplasm
- Intracranial infection
- Hypoglicemia
- Dncommon metabolic disorders 3.B;&:
mtochondrial myopathy, encepahalopathy,lactic acidosis and stro*e4
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"RTERI"L I CHE#IC
TROKE $"I % in C&ildren
-;n important cause of long-term morbidity
- /-1 children per 00(000 per year
-;bout 50 children ith ;I& ill have a
pree>isting medical condition relevant to ;I&:
Congenital Heart %isease, &ic*le Cell%isease, iron deficiency, )rothrombotic
states and infection(
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resentation and Etiolo!' of "I
in c&ildren (s "dults
@ .ore rare ith a clinical presentation and ider
differential diagnosis
@ .ost children present ith focal neurologicdeficits : hemiplegia, sei$urebut symptoms
often are attributed to something other than
stro*e
@ 2eurologic systems differ in term of
Coagulation, vascular and adaptive
components
2j ', et al, .oharir ., et al, 2umis ;B, et al, 9raun E), et al( cit 2aerengarten .9( /05
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@ +is* factors are freFuently multiple and age
specific across childhood reFuiring a
comple> investigation of etiology
@;theromatous cerebrovascular disease and
ris* factors 3obesity, smo*ing, hypertension4
are rarely the cause of ;I& in children(
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Etiolo!ies of "IS in C&ildren
;rteriopathies
&ic*le cell disease 3&C%4
Congenital heart disease 3CH%4
)rothrombotic 3hypercoagulable4
disorders
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"I in C&ildren )it&
"rterio*at&ies
-;ccount for " ?0 of all ;I& in children
- .ay present as acute, transient or
progressive
- Common #ypes :#ransient cerebral arteriopathy : caused
by inflammation
Cervical arterial dissection: mechanicalinjury, major trauma to the head G nec*
.oya-moya disease
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- #ips for %iagnosis :o.+; or C#;for nec* vessel imaging
oCatheter cerebral angiographyfor
cervical arterial dissectiono.+;.oya-moya : absent flo voids
in the IC;, .C;, and ;C;
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"I in C&ildren )it& ickle
cell Disease $ CD%
@ 0 of children ith &C% causes ;I& by /0
yo and ?0 chance of ;I& recurrence
@ &ymptomps : - dysphasia
- gait disturbance- hemiparesis
- altered consciousness
@ #ips for %iagnosis:o.+I
o;ngiography
o#ranscranial %oppler
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"I in C&ildren )it& Con!enital
Heart Disease $CHD%
@ Can be caused by a number of mechanism:+elated to management of cardiac
problems 3cardiac catheteri$ation, surgical
procedure etc4
%isease mechanism : thromboembolism
from valvular or septal defects
@ #ips for %iagnosis:
oC
ochocardiography
o9lood Cultures 3if suspected
endocarditis4
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"I in C&ildren )it& rot&ro+,otic
$&'*ercoa!ula,le% disorders
@ /0-50 of children ith ;I& ill have prothrombotic abnormalities
@ Inherited abnormalities : deficiencies of
coagulation inhibitors
@;cFuired thrombophilia : &B, 2ephrotic
&yndrome
@ Common #ypes : )rotein C %eficiency
@ #ips for %iagnosis :oBab : #hrombophilia panel 3)rot C, )rot &,
;ntithrombin, Bupus anticoagulant,
anticardiolipin antibody, etc4
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TRE"T#ENT of "I in
CHILDREN
I( ;cute treatmentto limit or reverse the effect of stro*e on
brain injury
to loo* for etiology and ris* factors that
also may need treatment
supportive neuroprotective
treatment of sei$ure
management of raised IC) 3lifesaving4
&ic*le cell %isease
;ntithrombotic therapy2o clear %ata
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Su**orti-e care for "cute treat+ent:
2j ', et al, AreunlichCB, et al( cit 2aerengarten .9( /05(
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TRE"T#ENT of "I in CHILDREN
Cont
II( &econdary preventionIdentifying
underlying ris* factors to prevent tratment
and estimate prognosis(
Note: little evidence-based recommendationavailable to help guide physician 3e>cept for
&C%Chronic #ransfusion G for .oyamoya
diseasesurgical revasculari$ation4
.recommendation are e>trapolated from the
adult stro*e literature
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"ntit&ro+,otic t&era*' for "cute treat+ent of "I
2 ', et al, .oharir ., et al, +oach &,et al, .ona le ), et al( cit 2ierenarten .9( /05(
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Lon!.ter+ Deficits in
neonates and c&ildren after
"I
.oharir ., et al, olomb .+, CE, et al(cit 2ierengarten .9( /05
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"H" /uidelines on "ntit&ro+,otic T&era*' for
econdar' re-ention of "I C&ild&ood "I
+oach &, et al cit( 2ierengarten .9( /05
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HE#ORRH"/IC TROKE $H % in
CHILDREN
@ incidence: ,00(000 per year
Intra Cerebral Hemorrhage: 0,800(000
per year
&ubarachnoid Hemorrhage: 0,100(000
per year
@ .ortality of H& : /5
@ &ignificant disability : 6/
'ordan BC, Hillisn;( Hemorrhagic &tro*e in Children( )ed 2eurol( /00J
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Causes
( ;neurysm : blood vessels have a
ea*ened area here the blood causes
the all to ballon
/( ;rteriovenous malformation 3;!.4 : atangle group of abnormally formed blood
vesselscan burst and bleed into the
brain
1( %amaged or Aragile blood vessels
6( Clotting abnormality : hemophilia
'ordan BC, Hillisn;( Hemorrhagic &tro*e in Children( )ed 2eurol( /00J
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S'+*to+s
&n %ildren (
&evere headache especially ith vomiting
and sleepiness
&ei$ures : Aocal and are folloed byparalysis on the side of the sei$ure activity
Boss of consciousness after one or more
of the above symptoms Aolloed by:
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)roblems spea*ing or understanding language,
including slurred speech,
#rouble seeing clearly in one or both eyes
%i$$iness or unsteadiness
&n ne74orn0 and in6ant0
&ei$ures
>treme irritability
!omiting
9ulging fontanelle 3soft spot on top of the babyKs
head4
Boss of consciousness
'ordan BC, Hillisn;( Hemorrhagic &tro*e in Children( )ed 2eurol( /00J
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Dia!nostic
@ Computed tomography 3C#4
@ .agnetic +esonance Imaging
@ .agnetic +esonance ;ngiography
@ Cerebal ;niography
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#edical #ana!e+ent
2o medical management guideline are
availableguided by e>trapolation from
adult literature
Aluid management to maintain euvolemia
.aintenance body temperature to normallevels
.onitoring and treatment of hydrocephalus
'ordan BC, Hillisn;( Hemorrhagic &tro*e in Children( )ed 2eurol( /00J
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#edical #ana!e+ent
Cont
smotherapy is recommended for elevated
intracranial pressure
Corticosteroid are not recommended
#reatment of brain ;!. depend on the si$e,
Bocation
mboli$ationreducing the si$e obliterate
of ;!.
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#edical #ana!e+ent
Cont
Barge ;!. G deep venous drainage in
eloFuent areanot be ameable to therapy
&tereotactic and endoscopic surgicalevacuation of the ICH or Hemostatic agent
being investigated
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ro!nosis
+ecurrent ris* in childhood H& depends on
underlying etiology
)redict )oor neurologic outcome :
- Bocation : infratentorial- C& J at admission
- ;neurysm
- age L 1 years at the time of H&- Dnderlying hematological disorders
.ortality rate : /5 3J-564
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#HANK 8OU