Pediatricstroke Sst Spring 2013

7/30/2019 Pediatricstroke Sst Spring 2013

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1Simon Lalehzarian and Marci RosenbergMay 8, 2013

Pediatric Stroke


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Do children really have strokes?

Yes, though rare estimated incidence = 13/100,000

(Ciccone et al. 2011)

Both ischemic and hemorrhagic

20% of adult strokes are hemorrhagic 45% of pediatric strokes are hemorrhagic

One of top ten causes of death in children


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What does the presentation of stroke look like

in children?

Presentation fairly similar to adults (Tsze and Valente 2011)


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Pediatric stroke mimics

Complicated migraines

Focal seizures

Meningitis

Herpes simplex encephalitis


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Treatment & therapies

tPA what is the inclusion factor age?

> 18; also, usually out of time window

Ok, so no tPA. Whats left?

Not much Supportive care, including maintaining stable respiratory and

cardiovascular functions, treating infections, seizures, and fevers,

and oxygen supplementation

Anticoagulants (Heparin)* and antiplatelet (aspirin)


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Risk Factors

60% of pediatric stroke cases are seen in boys

Trauma (e.g. artery dissection)

BUT, this male-to-female discrepancy remains even when trauma

is accounted for

Blood clotting disorders (e.g. sickle cell disease or

hemophilia)

Cardiac disorders

Infections


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Case Study

13-year-old right-handed girl

History:

Ischemic stroke secondary to internal carotid artery dissection

Presented with:

Subacute onset of headache and sensory deficit in her left hand


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Scans and Results

Noncontrast head CT: showed possible

clot in the right middle cerebral artery

(MCA) and an area of poor

differentiation in right parietal region

Angiography: right internal carotid

dissection

Believed to be initiated from the patient

bumping her head on the pool bottom

Treated with warfarin (anticoagulant;

prevention of thrombosis)

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Round 2

Eight months later she walked toward her parents, and

said: here I go again, and collapsed

On arrival to the Pediatric Emergency Department,neurological examination showed:

Dense left hemiplegia (total weakness of the left side of the body;

no movements at all)

Right gaze preference

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Scans (round 2)

Head CT showed probably thromboembolus from the

healing right internal carotid artery

Initially planned to proceed with angiography, but since ithad been less than 3 hours since onset of her deficit,

decision was made to treat with IV rt-PA

What is IV rt-PA? Recombinant tissue plasminogen activator

Simply means the tPA was manufactured using recombinant

biotechnology techniques

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Post IV rt-PA Scans

Angiography showed branch

occlusion in superiordivision of the middle

cerebral artery (M3

segment) with slow

anterograde flow

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Round 2 Scans (cont.)

Head CT scan showed a new area of decreased

attenuation in the anterior right parietal lobe (anterior left

parietal lobe is pictured below)

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Recovery

Next 12 hours, she progressed to 4/5 muscle strength in

her left arm and leg

5 months later she had only minimal slowing of fine fingermovements in her left hand

Decision was made to recommend life-long warfarin

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Discussion

1 to 13/100,000 children/year are affected by stroke

In contrast to the adult population, in which the principal

causes are atherosclerosis and hypertension, theprincipal causes in children include a higher prevalence

of cardioembolic sources, as well as rare metabolic and

genetic causes

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Whats the point?

In this patient, multiple factors contributed to the recurrent

thrombotic stroke:

Prior carotid dissection and increased propensity for thrombosis

Mild hypercholesterolemia (high levels of cholesterol in the blood) Slight elevations of homocysteine (increased risk of thrombosis

and cardiovascular disease)

Neurological deficit improved rapidly with rt-PA

administration, and therefore should be considered in

children with acute thromboembolic stroke

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citations

Carlson MD, Leber S, Deveikis J, Silverstein FS.

Successful use of rt-PA in pediatric stroke Neurology

vol. 57 (July 2001): 157, 158. Neurology. Web. 07 May

2013.

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Documents

Pediatricstroke Sst Spring 2013