Although, predominantly a disease of adults, its occurrence in children (0-16 years) is not so rare as once thought due to the advent of more accurate diagnostic techniques.

1. STROKE IN INFANCY AND CHILDHOOD
Dr.Mariam Mahmoud Hassan
Specialist Paediatrician
Cairo University , Cairo, Egypt

2. Definition
Stroke is defined as the sudden onset of focal
neurological deficit due to occlusion of blood supply or
hemorrhage in the brain causing symptom & sign
lasting greater than 24 hours.
Although, predominantly a disease of adults, its
occurrence in children (0-16 years) is not so rare as once
thought due to the advent of more accurate diagnostic
techniques.

3. It’s a myththat only older adults have strokes. Stroke can
happen to anyone at any time, including teenagers, children,
newborns, and unborn babies.

4. Incidence
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
It may even occur before birth
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.
Stroke remains among the top 10 causes of death in
children.

5. Types of Stroke Syndromes
•Arterial ischemic stroke (AIS)
•Cerebral sino-venous thrombosis (CSVT)
•Intracranial hemorrhage

11. CAUSES AND RISK
FACTORS

12. RISK GROUPS
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.

13. Cardiac causes
Congenital Heart diseases
Cyanotic heart diseases R-T shunt
Acyanotic HD (eg.VSD , PDA,PDA )
Acquired heart diseases
Rheumatic fever
Endocarditis
Arrhythmia
Patient with prosthetic cardiac
valves

14. Hematological Causes
Disorder of RBC:
• Sickle cell disease
• Polycythemia
Disorder of WBC :
• Leukemia
• Lymphoma
 Disorder of Platelets :
• Thrombocytosis
• Thrombocytopenia

15. CONT.
Disorders of Coagulations :
 Protein C deficiency
Protein S deficiency
Factor V deficiency
Thrombophilia
Antithrombin III deficiency
Paroxysmal nocturnal hemoglobinuria
Lupus anticoagulants

16. Vascular Causes
•Moya –Moya disease
•Arteriovenous malformations(AVM’s)
•Aneurysm
• Sturge Weber syndrome
•Fibromuscular dysplasia.

17. Inflammatory disorders
 Infection
•Meningitis ( Viral,Bacterial,Tubercular)
• HIV encephalopathy
• Local head & neck infections
Autoimmune disease
•SLE
• Takayasu arterites
• Poly arteritis nodosa

18. Metabolic Disorders
Homicystinuria
Fabry disease
Mitochondrial encephalopathies :
• MELAS
• Leigh’s syndrome

19. Miscellaneous Causes
•Trauma
•Child abuses
•Placental embolism
• ECMO therapy (Extracorporeal membrane
oxygenation)
• Post varicella
•Drug induced: Amphetamines and Cocaine

20. Neonatal stroke
• Neonatal stroke is a medical condition that occurs when an
infant’s blood supply is disturbed within the first 28
days of life. If an infant has a stroke within the first 7 days
of life, it’s known as a perinatal stroke.

21. Causes of Neonatal stroke

22. Overview of some
Diseases in Childhood
stroke

23. Sickle Cell Anemia

26. Moya-Moya Disease
•Moya -Moya disease is a progressive, occlusive
disease of the cerebral vasculature with particular
involvement of the circle of Willis and the arteries
that feed it.
•The term Moya -Moya (Japanese for "puff of
smoke") refers to the appearance on angiography
of abnormal vascular collateral networks that
develop adjacent to the stenotic vessels.
•The cause of moyamoya disease is not known. The
disease is believed to be genetic.

29. ECMO
Extracorporeal membrane oxygenation (ECMO) is a treatment
that uses a pump to circulate blood through an artificial lung
back into the bloodstream of a very ill baby. This system
provides heart-lung bypass support outside of the baby's body.

31. • Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke
(MELAS) syndrome is a progressive neurodegenerative disorder.
Patients may present sporadically or as members of maternal
pedigrees with a wide variety of clinical presentations

33. SIGNS AND SYMPTOMS

35. Newborn and Infants
Seizures
Extreme sleepiness
Tendency to use only one side of their body
Blank staring
Pedaling movements with the legs
Apnea
Jerking movements
In some instances, there are no outward symptoms of
neonatal stroke. Unfortunately, when there are no obvious
symptoms, an infant stroke may go undetected for several
months. As the child grows older, symptoms such as speech
difficulties, imbalance, and numbness on one side of the
body may appear

36. Children and Teenagers

37. CONT.

38. Localization of lesion in case of Hemiplegia

39. Cranial Nerve palsy on same side as that of
Hemiplegia
Lesion above the level of brain stem (Ipsilateral
hemiplegia)
 Lesion can be at the level of either :-
• Cortex
• Internal capsule
• Sub cortical region

41. Cranial Nerve palsy on opposite to that
of Hemiplegia
Lesion at / below the level of brain stem
(Contralateral hemiplegia )
Lesion can be either of :
•Midbrain
•Pons
•Medulla
•Spinal cord ( b /w C 1 – C4 )

43. COMPLICATION
• Hemiparesis (weakness on one side of the body), or
hemiplegia (paralysis on one side of the body).
• Aphasia (difficulty with speech and language), or dysphagia
(trouble swallowing).
• Decreased field of vision and trouble with visual perception.
• Loss of emotional control and changes in mood.
• Cognitive changes or problems with memory, judgment and
problem-solving.
• Behavior changes or personality changes, improper
language or actions.

44. Differential Diagnosis
•Cerebral abscess
• Encephalitis (herpes simplex virus)
•Brain tumor
• Multiple sclerosis
•Epilepsy
• Complicated migraine

46. Diagnostic Evaluation
•FIRST LINE: Performed within first 48 hours of
admission
•SECOND LINE: Performed within first week
•THRID LINE : Performed as per need

47. First Line
Laboratory
• CBC
• ESR
• Blood sugar
• BUN and Serum electrolytes ( Na,K,Ca,Mg,Phos.)
• AST,ALT
• lipid profile
• ANA
Imaging
• CT brain
• MRI brain & MR angiography
• Cranial Ultrasonography
• Plain x ray chest
• ECG

48. Second Line
• Echocardiogram (transthoracic) with saline contrast
• Transcranial and/or carotid dopplers
• MR angiogram
• EEG
• Serum amino acids
• Urine for organic acids
• Coagulation profile
• Thrombophilia screening
• Hemoglobin electrophoresis
• Complement profile VDRL
• Lactate/pyruvate
• Ammonia
• CSF: cell count, protein, glucose, lactate

49. Third Line
•Muscle Biopsy
•DNA testing for MELAS
•Serum homocystine after methionine load

50. MANAGEMENT

52. Supportive treatment
Intracranial tension:
• Fluid restriction
• Mannitol
• Steroids
Hypertension : by appropriate antihypertensive
Seizures with antiepileptic drugs.
Antibiotic therapy to prevent secondary infection

54. CONT.
•Antiplatelet :Aspirin 3-5 mg/kg /d
•Oral anticoagulant: Warfarin for
1.2ndry prevention of stroke
2.If aspirin fails
3.In Congenital or acquired Heart Diseases
4.Recurrent AIS or TIA while on Aspirin
•Thrombolytic agents :Streptokinase and Urokinase
to dissolve the existing thrombus

57. • NB: BT (blood transfusion), IS ( ischemic stroke) Hs ( Hemorrhagic stroke) SCD
( sickle cell disease) AVM ( Arterio-venous malformation)HCP ( health care