Transcript Pediatric Stroke

Pediatric Stroke
Last Updated by Lindsay Pagano
Summer 2013
Epidemiology of Childhood Stroke
Childhood
Stroke
2-3/100,000*
Hemorrhagic
Stroke
1.1/100,000
ICH
0.8/100,000
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Ischemic Stroke
1.2/100,000
SAH
0.3/100,000
• *Incidence rate is per 100,000 child-years
Overall, childhood stroke is as common as brain tumor in childhood !!
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Numbers from: Fullerton et al. Neurology 2003.
Signs, Symptoms and Differential
Symptoms/Signs
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Hemiparesis/focal motor 60%
Aphasia 10-15%
Seizure
25% (vs. 5% in adults)
Headache 32%
Altered mental status 21%
Differential
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Complex Migraine: eg focal aura, hemiplegic migraine
Focal seizure with postictal focal weakness (Todd’s paralysis/plegia)
Stroke – Ischemic/Hemorrhagic
Other focal brain pathology
Stroke Mimics can include:
– Encephalopathy related to hypertension, intracranial infection, tumor, drug toxicity,
pseudotumor cerebri, inflammatory disease, epilepsy
Etiology of Ischemic Stroke in Older Kids:
Think Embolic or Arteriopathy
• Arteriopathy – present in 60-80% of Children
– Arterial Dissection in 25% , also Focal cerebral arteriopathy,
Moyamoya, post-infectious, HIV, Varicella, etc.
• Cardioembolism 25-35%
• Sickle Cell Anemia
– 10% will have a clinical stroke by age 20
– 20% more will have a silent infarct
• Hypercoaguable state
• More unusual causes: vasculitis, pregnancy, metabolic disorders, cerebral
sinus venous thrombosis
• Idiopathic 5-30%
Acute Management of Child with Possible
Stroke: The First 15 Minutes!
Goals:
1. cerebral perfusion
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2. oxygenation
3. minimize demands for cerebral blood flow
Head of Bed Flat –if alert, or 30 degrees if not alert/aspiration risk.
IV Fluids: isotonic, at maintenance+, no dextrose – as want to avoid
hyperglycemia. Check sugars
Oxygen only if needed to keep sats > 95%
Acetaminophen if temp > 37.0
Get a neuro exam you can follow serially
– Peds NIHSS- Peds Stroke Cards
Diagnostic Evaluation
Ischemic Stroke: Head, Neck, Heart, Blood
Acutely
• MRIbrain, MRA head,neck
– At VCH: Order emergent peds stroke protocol brain MRI in all kids with symptoms <
48 hours or if stroke will change management dramatically
• Protocol takes 10 minutes and includes:
– DWI bright and ADC dark = acute stroke (within the last 10 days)
– FFE/GRE: sequence for blood
– No MRA if MRI shows stroke
– +/- MR Venogram (especially consider with sickle cell disease)
• Note: Head CT will miss 60% of acute stroke within 12 hours of symptom onset.
Need MRI.
• Note: Neck vessel imaging - MR or CT Angiography, NOT ultrasound
After initial head imaging
• Echo – Transthoracic Echo with bubble study to eval for PFO, thrombus source
• Coagulation evaluation
Treatment
Aspirin
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For all older children with ischemic stroke except kids with sickle cell disease
Typical dose is 3-5 mg/kg/day
Risk of Reye’s syndrome is very low. Still we strongly recommend annual flu vaccine
and some will hold aspirin with high fever or flu-like symptoms (I don’t).
Anticoagulation
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Consider if suspicion high for cardioembolic stroke, arterial dissection, posterior
circulation stroke, stuttering deficits suggestive of thrombosis.
Risk of hemorrhagic transformation of ischemic stroke is less after 48 hours.
May prevent further strokes, but won’t help this one improve.
**Sickle Cell Disease/HbSS
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Treatment is Transfusion (usually, pRBC in ED, exchange transfusion in PICU)
Regular transfusions through heme/onc as indicated in the future
PREP Question
A 6 year old right handed girl with no significant past medical history presents
to the emergency department for concerns of new onset right sided weakness that was
first noted when she tried to get out of bed that morning. Her speech was also slurred.
Her symptoms seemed to improve throughout the morning but did not completely
resolve. There were no witnessed convulsions or associated loss of consciousness. Her
birth history was uncomplicated, and her development has been appropriate.
PE is significant for slurred speech with short sentences, difficulty following
commands, and flattening of the right nasolabial fold. She also has a slight decrease in
right sided tone and 4/5 strength on the right. There is a right plantar extensor response.
Of the following, the MOST accurate statement is:
A. The most likely vascular territory involved is the right middle cerebral artery.
B. The most likely lesion producing these symptoms is one involving the left internal
capsule.
C. Angiogram could show abnormal collateral arterial networks.
D. The most likely diagnosis is complicated migraine, and the family can be reassured
and the patient discharged.
E. The best characterization of her speech deficit is dysarthria.
C. Angiogram could show abnormal collateral arterial
networks
Moyamoya Vasculopathy
• Idiopathic versus associated with other disease states
– NF1, fibromuscular dysplasia, Marfan syndrome, Down syndrome, radiation vasculitis,
vasculitis, infectious/postinfectious vasculopathy, congenital heart disease, sickle cell
disease, Fanconi anemia, atherosclerosis, head trauma
• Noninflammatory, progressive cerebrovascular occlusive disease slowly causing stenosis
and occlusion of cerebral arteries, especially those surrounding or feeding the Circle of
Willis
• “puff of smoke”
• Regarding the other choices:
A. The most likely vascular territory involved is the right MCA: left MCA is most likely
since she is right handed, and her cortical language and left motor areas are involved
B. The most likely lesion producing these symptoms is one involving the right internal
capsule: as above
D. The most likely diagnosis is complicated migraine, and the family can be reassured
and the patient discharged: this may be the diagnosis, but need to rule out acute stroke
E. The best characterization of her speech deficit is dysarthria: dysarthria AND aphasia
(both receptive and expressive)