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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