stroke in children.pptx

7/24/2019 Stroke in Children.pptx

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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



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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



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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



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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

stroke in children.pptx

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