Stroke In Children

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Stroke In Children

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

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