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)