the evolving management of pediatric stroke christopher a. miller, md july 21, 2012
TRANSCRIPT
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The Evolving Managementof Pediatric Stroke
Christopher A. Miller, MDJuly 21, 2012
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Epidemiology
• Neonatal Stroke 1/4000 live births annually
• Childhood Stroke:
–Schoenberg 2.52/100,000/year–Fullerton 0.63/100,000/year
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Epidemiology
Rochester, MN Study (1978)
• Hemorrhagic Stroke 1.89 cases/100,000/yr• Ischemic Stroke 0.63 cases/100,000/yr
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Outcome Data
• Persistent deficit 60 – 80%
• Mortality 2 - 10 %
• Recurrence Risk 5 – 18 %
Data from Western Europe, North America
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Risk Factors for Ischemic Stroke
• Heart Disease – Congenital
• Heart Disease – Acquired
• Cerebrovascular Disorders
• Hematologic Disorders
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Risk Factors for Ischemic Stroke
• Non-structural Vascular Disorders
• Infection
• Vasculitis
• Trauma
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Evaluation of Suspected Stroke
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Clinical Presentation
Onset of Deficit
Evolution
Localizing Signs
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Diagnostic Tools
• Neuroimaging (CT, MRI)
• Non-invasive Vascular Studies (CTA, MRA, MRV)
• Angiography
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Treatment Options
• Symptomatic Management
• Thrombolysis
• Clot Extraction
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Use of IV rt-PA
Eligibility:
(a) Clinical diagnosis of acute ischemicstroke.
(b) Onset (at most) 3 – 4.5 hours priorto anticipated treatment.
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Use of IV rt-PAContraindications:- SBP > 185 or DBP > 110 mm Hg
- CT shows ICH, SAH or established stroke
- Other suspicion of SAH
- Seizure at onset
- Recent Intracranial/Spinal surgery or head trauma
- Major recent (3 months) surgery or trauma
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Use of IV rt-PA
Contraindications:
- History of prior intracranial hemorrhage
- History of known vascular malformation or tumor
- Recent active systemic bleeding
- Thrombocytopenia or recent heparin use
- Known bleeding diathesis
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Use of IV rt-PAWarnings:
Age < 15 years Difficulty determining eligibility
Glucose < 50 or > 400 mg/dl Left heart thrombus
Life expectancy < 1 year Pregnancy
Rapid Improvement Recent other anticoagulant use
CT evidence of very large stroke
Comorbid conditions with a high risk of bleeding
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NINDS Recommended Time Frames forIV rt-PA Use
From Arrival in ER• 10 minutes Initial ER physician evaluation• 15 minutes Notify Stroke Team• 25 minutes Initiate Head CT scan• 45 minutes Interpretation of CT scan• 60 minutes administer IV rt-PA
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Use of IV rt-PA
Treatment:
Infuse 0.9 mg/kg (max = 90 mg) over 60minutes with 10% of dose givenas initial bolus over one minute.
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Mechanical Intervention/Clot Extraction
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Merci Retrieval Catheter
FDA approved for retrieval of acute intracranial thrombus or emboli
within 8 hours of onset of symptoms
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MERCI Case
Left MCA occlusion distal toAnterior Temporal Artery origin
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MERCI Case
MCA occlusion crossed withMerci retrieval catheter
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MERCI Case
MCA occlusion relievedFully recovered, NIHSS 0
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Penumbra Aspiration Catheter
FDA approved for retrieval of acute intracranial thrombus within 8
hours of onset of symptoms
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Penumbra Aspiration Catheter
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Penumbra Case
Pre and Post Treatment Angiograms
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Ad Hoc Committee – Pediatric Stroke
Joseph Childs, MD (PICU) Sid Roberts, MD (Radiology)
Frankie Crain, MD (PICU) Keith Woodward, MD (Radiology)
Lise Christensen, MD (ER) Chris Miller, MD (Neurology)
Shahid Malik, MD (Hematology) Anna Kosentka, MD (Neurology)
Lewis Harris, MD (Neurosurgery) Karsten Gammeltoft, MD (Neurology)
Jeanann Pardue, MD (Hospitalist)