Stroke In Children
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Stroke In Children

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Stroke In Children Stroke In Children Presentation Transcript

  • Presented by Dr Harish Kumar Singhal MD (Ay)Sch Guided by Dr Abhimanyu Kumar Dr Moti Rai Department of Bal Roga NIA,Jaipur
    • Stroke is defined as the sudden onset of focal neurorological deficit due to occlusion of blood supply or hemorrhage in the brain causing symptom & sign lasting greater than 24 hours.
    • Infants, children & Young adults accounts for less than 5% of all strokes.
    • Pediatric stroke affects 2-3 in 100,000 newborns and 12 in 100,000 children under 18 years of age .
    • (A study conducted in Children’s hospital of Philadelphia)
    • Epidemiological studies have revealed an annual incidence of 2.5-2.7 pediatric strokes per 100,000 children.This figure comprises ischemic and hemorrhagic events, and excludes strokes from trauma or birth-related complications .
    • ( Schoenberg BS, Mellinger JF, Schoenberg DG. Cerebrovascular disease in infants and children: A study of incidence, clinical features, and survival. Neurology. 1978; 28:763-768)
      • Risk of ischemic stroke was 0.63/100,000 /year as compared to 1.89/100,000 /year for hemorrhagic strokes.
      • In INDIA the average annual incidence rates are reported to be 13-33/100,000 /year.
      • Stroke is the sixth leading cause of death in children while in adult it is thrid leading cause of death , ranking behind heart disease & cancer . (H.J.M.Barnett).
    • Hemorrhagic strokes – 11.4%
    • Ischemic strokes – 88.6%
          • Prothrombotic states – 38.7%
          • Cardiac disease – 19.3%
          • Hyperlipidemia – 16%
          • Homocystinurea – 14.6%
      • Newborns, especially full-term infants
      • Older children with sickle cell anemia, congenital heart defects, immune disorders or problems with blood clotting
      • Previously healthy children who are found to have hidden disorders such as narrow blood vessels or a tendency to form blood clots easily.
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    • A) Congenital
      • Aortic Stenosis
      • MS
      • VSD
      • PDA
      • Cyanotic congenital HD involving R-L shunt
    • B) Aquired
      • Endocarditis
      • Cardiomyopathy
      • Arrthymia
      • Rheumatic fever
      • Psoriatic heart disease
    • Disorder of RBC:
        • Sickle cell disease
        • Polycythemia
    • Disorder of WBC :
        • Leukemia
        • Lymphoma
    • Disorder of Platelets :
        • Thrombocytosis
        • Thrombocytopenia
    • Disorders of Coagulations :
      • Protein C deficiency
      • Protein S deficiency
      • Factor V deficiency
      • Antithrombin III deficiency
      • Paroxysmal nocturnal hemoglobinuria
      • IBD
      • Lupus anticogulants
      • Moya –Moya disease
      • Arteriovenous malformations(AVM’s)
      • Aneurysm
      • Sturge Weber syndrome
      • Fibromuscular displasia
    • Infective disease
      • Meningitis ( Viral,Bacterial,Tubercular)
      • HIV encephalopathy
      • Local head & neck infections
    • Autoimmune disease
      • SLE
      • Takayasu arterites
      • Poly arteritis nodosa
      • Sarcodiasis
      • Mixed C T Disorders
    • Amphetamines
    • Cocaine
    • Homicystinuria
    • Pseudoxanthoma elasticum
    • Fabry disease
    • Mitochondrial encephalopathies :
        • MELAS
        • Leigh’s syndrome
    • Trauma
    • Child abuses
    • Placentral embolism
    • ECMO therapy
    • Post varicella
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    • Primary injury : cellular damage caused directly by the insults.
    • Secondary injury : various derangements set into motion by the primary injury.
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    • 20 % of strokes are due to intracranial hemorrhage from rupture of intracranial aneurysm.
    • Chacot – Bouchard aneurysm occur where hemorrhage is common –basal ganglia , thalamus, cerebellum, Pons &sub cortical areas.
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          • Arterial ischemic stroke (AIS)
          • Cerebral sinovenous thrombosis (CSVT)
          • Intracranial hemorrhage
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    • Lesion above the level of brain stem (Ipsilateral hemiplegia)
    • Lesion can be at the level of either :-
        • Cortex
        • Internal capsule
        • Sub cortical region
    • Hemiparesis or Monoparesis
    • Differential involvement { Upper limb > Lower limbs or vice versa }
    • Altered sensorium
    • Convulsion
    • Cortical sensory loss
    • Astereognosis
    • Aphasia ( If dominant cortex )
    • Altered behavior
    • Upper limb > lower limb
    • Motor aphasia
    • Convulsions
    • Bladder & bowel involvement
    • Persistent neonatal reflexes on opposite side
          • Cortical sensory loss
          • Astereognosis
        • Temporal lobe epilepsy
        • Sensory aphasia
        • Memory loss
    • Homonymous hemianopia
    • Dense hemiplegia
    • Hemianaesthesia
    • Homonymous hemianopia
    • Dysartria
    • Similar to cortical lesion except loss of cortical sensation & convulsions.
    • Lesion at / below the level of brain stem (Contra lateral hemiplegia )
    • Lesion can be either of :
      • Midbrain
      • Pons
      • Medulla
      • Spinal cord ( b /w C 1 – C4 )
    • Weber’s syndrome : 3 CN palsy +contra lateral hemiplegia
    • Benedict’s syndrome : 3 CN palsy +contra lateral hemiplegia +red nucleus affection( tremor, rigidity & ataxia on opposite side)
    • Millard Gubbler’s syndrome : 7 CN palsy +contra lateral hemiplegia
    • Foville’s syndrome : 6 & 7 CN palsy+ contra lateral hemiplegia
    • Jackson’s syndrome : 12 CN palsy + contra lateral hemiplegia
    • Brown Sequrd syndrome :Hemiplegia +CN palsy +differential sensory loss ( i.e. loss of vibration & joint sense on same side & pain ,touch & temperature on opposite.
    • Focal cerebral ischemia
    • Intracranial hemorrhage
    • Cerebral abscess
    • Encephalitis (herpes simplex virus)
    • Brain tumor
    • Alternating hemiplegia of infancy
    • Multiple sclerosis
    • Malingering/conversion disorder
    • Epilepsy: post-ictal Todd's paralysis or a focal
    • inhibitory seizure
    • Complicated migraine
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    • FIRST LINE: Performed within first 48 hours of admission
    • SECOND LINE: Performed within first week
    • THRID LINE : Performed as per need
    • CBC
    • ESR
    • Blood sugar
    • BUN
    • Serum electrolytes ( Na,K,Ca,Mg,Phos.)
    • AST,ALT
    • S / lipid profile
    • Plain x ray chest
    • CT brain
    • MRI brain & MR angiography
    • Ultrasonography
    • ANA
    • ECG
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    • Echocardiogram (transthoracic) with saline contrast
    • Transcranial and/or carotid dopplers
    • MR angiogram
    • EEG
    • Rheumatoid factor
    • Serum amino acids
    • Urine for organic acids
    • Blood culture
    • Hemoglobin electrophoresis
    • Complement profile VDRL Lactate/pyruvate
    • Ammonia
    • CSF: cell count, protein, glucose, lactate
    • Lipid profile
    • Antithrombin III
    • Protein C (activity and antigen)
    • Factor V (leiden) mutation
    • Antiphospholipid antibody
    • Anticardiolipin
    • Lupus-anticoagulant
      • HIV
      • Lyme titers
      • Mycoplasma titers
      • Cat-scratch titers
      • Cardiac MRI
      • Echocardiogram (transesophageal)
      • Muscle Biopsy
      • DNA testing for MELAS
      • Cerebral angiogram (transfemoral)
      • Leptomeningeal biopsy
      • Serum homocystine after methionine load
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    • 1 st step is to differentiate ischemic & hemorrhagic stroke.
    • Anticoagulant therapy is contraindicated in hemorrhagic strokes.
    • Hyperglycemia & hypertension worsen the stroke.
    • Treatment primarily directed towards stabilizing systemic factors & management of the underlying causes.
    • Manage :-
    • Intracranial tension:
    • Fluid restriction
    • Mannitol
    • Steroids
    • Shunt surgery ( In special case )
    • Hypertension : by appropriate antihypertensive
    • Fluid balance
    • Hyperglycemia
    • Hyperthermia
    • Seizures with antiepileptic drugs.
    • Antibioitic therapy to prevent secondary infection.
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    • The prognosis for childhood strokes is variable and most dependent upon underlying etiology.
    • 80% of children survived 10 years after an ischemic stroke, although most had residual hemi paresis.
    • Schoenberg BS, Mellinger JF, Schoenberg DG. Cerebrovascular disease in infants and children: A study of incidence, clinical features, and survival. Neurology. 1978; 28:763-768.
    • Poor prognosis of strokes with seizures during infancy, and with an angiographic pattern of Moyamoya disease.
    • Solomon GE, Hilal SK, Gold AP, Carter S. Natural history of acute hemiplegia of childhood. Brain. 1970; 93:107-120.
    • .
    • A study on 42 children with idiopathic ischemic stroke exclusively concluded poor outcome in 43% of patients at an average of 7.4 years following the stroke. Recurrent stroke occurred in 7 children. In the children who did well, an early recovery was observed.
    • Abram HS, Knepper LE, Warty VS, Painter MJ. Natural history, prognosis and lipid abnormalities of idiopathic ischemic childhood stroke. J Child Neurol. 1996; 11:276-282
    • Hemorrhagic stroke have higher mortality rates as compared to ischemic stroke.
    • Patients with hemorrhagic infarction & coma have higher risk of acute death.
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