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.
Cyanotic congenital HD involving R-L shunt
Psoriatic heart disease
Disorder of RBC:
Sickle cell disease
Disorder of WBC :
Disorder of Platelets :
Disorders of Coagulations :
Protein C deficiency
Protein S deficiency
Factor V deficiency
Antithrombin III deficiency
Paroxysmal nocturnal hemoglobinuria
Moya –Moya disease
Sturge Weber syndrome
Meningitis ( Viral,Bacterial,Tubercular)
Local head & neck infections
Poly arteritis nodosa
Mixed C T Disorders
Mitochondrial encephalopathies :
Primary injury : cellular damage caused directly by the insults.
Secondary injury : various derangements set into motion by the primary injury.
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.
Arterial ischemic stroke (AIS)
Cerebral sinovenous thrombosis (CSVT)
Lesion above the level of brain stem (Ipsilateral 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
Encephalitis (herpes simplex virus)
Alternating hemiplegia of infancy
Epilepsy: post-ictal Todd's paralysis or a focal
FIRST LINE: Performed within first 48 hours of admission
SECOND LINE: Performed within first week
THRID LINE : Performed as per need
Serum electrolytes ( Na,K,Ca,Mg,Phos.)
S / lipid profile
Plain x ray chest
MRI brain & MR angiography
Echocardiogram (transthoracic) with saline contrast
Transcranial and/or carotid dopplers
Serum amino acids
Urine for organic acids
Complement profile VDRL Lactate/pyruvate
CSF: cell count, protein, glucose, lactate
Protein C (activity and antigen)
Factor V (leiden) mutation
DNA testing for MELAS
Cerebral angiogram (transfemoral)
Serum homocystine after methionine load
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.
Shunt surgery ( In special case )
Hypertension : by appropriate antihypertensive
Seizures with antiepileptic drugs.
Antibioitic therapy to prevent secondary infection.
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.