The Evolving Managementof Pediatric Stroke

Christopher A. Miller, MDJuly 21, 2012

Epidemiology

• Neonatal Stroke 1/4000 live births annually

• Childhood Stroke:

–Schoenberg 2.52/100,000/year–Fullerton 0.63/100,000/year

Epidemiology

Rochester, MN Study (1978)

• Hemorrhagic Stroke 1.89 cases/100,000/yr• Ischemic Stroke 0.63 cases/100,000/yr

Outcome Data

• Persistent deficit 60 – 80%

• Mortality 2 - 10 %

• Recurrence Risk 5 – 18 %

Data from Western Europe, North America

Risk Factors for Ischemic Stroke

• Heart Disease – Congenital

• Heart Disease – Acquired

• Cerebrovascular Disorders

• Hematologic Disorders

Risk Factors for Ischemic Stroke

• Non-structural Vascular Disorders

• Infection

• Vasculitis

• Trauma

Evaluation of Suspected Stroke

Clinical Presentation

Onset of Deficit

Evolution

Localizing Signs

Diagnostic Tools

• Neuroimaging (CT, MRI)

• Non-invasive Vascular Studies (CTA, MRA, MRV)

• Angiography

Treatment Options

• Symptomatic Management

• Thrombolysis

• Clot Extraction

Use of IV rt-PA

Eligibility:

(a) Clinical diagnosis of acute ischemicstroke.

(b) Onset (at most) 3 – 4.5 hours priorto anticipated treatment.

<

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

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

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

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

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.

Mechanical Intervention/Clot Extraction

Merci Retrieval Catheter

FDA approved for retrieval of acute intracranial thrombus or emboli

within 8 hours of onset of symptoms

MERCI Case

Left MCA occlusion distal toAnterior Temporal Artery origin

MERCI Case

MCA occlusion crossed withMerci retrieval catheter

MERCI Case

MCA occlusion relievedFully recovered, NIHSS 0

Penumbra Aspiration Catheter

FDA approved for retrieval of acute intracranial thrombus within 8

hours of onset of symptoms

Penumbra Aspiration Catheter

Penumbra Case

Pre and Post Treatment Angiograms

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)