2. Strokes (Ischemic) in Children by Dr. Azher Shah Associate Professor Department of Paediatric Medicine Azra Naheed Medical College, Lahore

3. Introduction Stroke is the acute neurologic injury that occurs as a result of either Brain Ischemia or Brain Haemorrhage Approximately 80 percent of strokes are due to Ischemic Cerebral Infarction and 20 percent due to Brain Haemorrhage

4. Introduction More common in older adults, stroke also occurs in neonates, infants, children, and young adults, resulting in significant morbidity and mortality Annual incidence rates of arterial ischemic stroke (AIS) in infants and children range from 0.6 to 7.9/100,000 children per year Paediatric ischemic stroke is more common in boys than in girls

5. Etiology Etiologies and risk factors for arterial ischemic stroke (AIS) in children differ from those in older adults Children Congenital and acquired heart problems Hematologic conditions Vasculopathies Metabolic disorders Drug ingestion

6. Etiology (Cont…) Older Adults Hypertension Smoking Diabetes Hypercholesterolemia

7. Risk Factors in Children Cardiac abnormalitiesVascular lesionsHematologic abnormalitiesInfectionHead and neck traumaGenetic conditions

8. Clinical Features Infants Focal weakness Seizures Altered mental status

9. Clinical Features (Cont…) Older Children Hemiparesis Focal neurologic signs such as aphasia, visual disturbance Cerebellar signs Seizures, headache and lethargy Neck pain (with cervical artery dissection) Horner's syndrome (carotid dissection)

10. Differential Diagnoses Vascular Abnormalities Intracranial haemorrhage Aneurysm Arteriovenous malformation Cerebral venous sinus thrombosis

11. Differential Diagnoses (Cont…) Nonvascular Conditions Intracranial infection (brain abscess or meningoencephalitis) Demyelinating conditions (such as acute disseminated encephalomyelitis) Tumours and other structural brain lesions Prolonged postictal paresis (Todd's paralysis) Complicated migraine Familial alternating hemiplegia Reversible posterior leukoencephalopathy syndrome Metabolic stroke Drug toxicity Postinfectious cerebellitis Psychogenic conditions

12. Evaluation Urgent Neuro-imagingThorough investigation for Cardiac Vascular Hematologic risk factors

13. Evaluation (Cont…) Neuroimaging MRI Brain or CT Brain Brain CT is generally considered inadequate to diagnose stroke MRI may be required to reliably exclude stroke mimics Brain MRI is more sensitive for acute ischemia than CT Brain MRI provides better visualization of the posterior fossa Magnetic resonance angiography (MRA) of the headMRA of the neck to evaluate the extracranial large arteries

14. Evaluation (Cont…) Laboratory studies Complete blood count including platelets Prothrombin time (PT) and international normalized ratio (INR) Partial thromboplastin time (PTT) Electrolytes, urea nitrogen, creatinine Liver function tests Serum glucose Hemoglobin electrophoresis in patients with possible sickle cell disease

15. Evaluation (Cont…) Laboratory studies Electrocardiogram (ECG) Oxygen saturation Transthoracic echocardiography Holter monitoring - if there is suspicion for cardiac arrhythmia, particularly atrial fibrillation Electroencephalogram (EEG) - if seizures are suspected Lumbar puncture – if infection is suspected Toxicology screen – if drug ingestion is suspected

16. Evaluation (Cont…) Laboratory studies Hypercoagulable evaluation Protein C functional Protein S free and total or protein S functional Antithrombin III activity Lipoprotein (a) Homocysteine Prothrombin gene mutations Factor V Leiden gene mutation Anticardiolipin antibodies (IgG and IgM) Beta2-glycoprotein I antibodies (IgG and IgM) Lupus anticoagulant tests, including dilute Russell viper venom time and dilute activated PTT Factor VIII activity D-dimer

17. Evaluation (Cont…) Laboratory studies Evaluation for the Vasculitis Erythrocyte sedimentation rate C-reactive protein level Antinuclear antibody assay Varicella titers Cerebral digital subtraction angiography

18. Initial Management

19. Supportive Measures Maintain airway, breathing, and circulation (ABCs) Maintain normoglycemia and normothermia; start normal saline intravenously at maintenance rate Allow modest hypertension Perform frequent neurologic checks Begin respiratory and oxygen saturation monitoring- keep oxygen saturation >95 percent Utilize cardiac monitoring for the first 24 hours Patient should be positioned as flat as possible in bed for at least the first 24 hours from stroke onset, ideally with head-of-bed elevation kept between 0 and 15 degrees

20. Initial Management (Cont…) Thrombolysis Start venous thromboembolism prophylaxis for patients restricted to bed Alteplase (rt-PA)

21. Guidelines Differences among consensus guidelines regarding the initial treatment of children with acute arterial ischemic stroke American Academy of Chest Physicians (ACCP) recommends either unfractionated heparin or low molecular weight heparin (LMWH) or aspirin as initial therapy until dissection and embolic causes have been excluded American Heart Association Stroke Council guideline states that it may be reasonable to initiate anticoagulation with LMWH or unfractionated heparin in children with arterial ischemic stroke pending completion of the diagnostic evaluation The Royal College of Physicians recommends initial therapy with aspirin

22. Acute Treatment for Specific Causes of Arterial Ischemic Stroke Unknown Etiology Aspirin 3 to 5 mg/kg per day rather than anticoagulation as initial therapy Arterial Dissection or Cardioembolism Short-term anticoagulation with low molecular weight heparin Hypercoagulable state Anticoagulation treatment (rather than aspirin ) with intravenous unfractionated heparin (goal PTT 60 to 85) or subcutaneous low molecular weight heparin (eg, enoxaparin [1 mg/kg dose every 12 hours] to achieve a goal anti-factor Xa level of 0.5 to 1.0 U/mL) for five to seven days, followed by treatment with low molecular weight heparin or warfarin

23. Acute Treatment for Specific Causes of Arterial Ischemic Stroke Sickle cell disease Intravenous hydration Urgent exchange transfusion Vasculopathy (excluding dissection) Aspirin (3 to 5 mg/kg per day) rather than anticoagulation Immunosuppression may be indicated for confirmed inflammatory vasculitis Large "malignant" middle cerebral artery territory stroke Decompressive hemicraniectomy

24. Prognosis Mortality In hospital mortality after ischemic stroke in children ages 1 to 17 years is 3.4 percent Disability Despite the neural plasticity present in children, the majority of children with stroke have persistent disability Disability that interfere with daily life is present in 60 percent

25. Prognosis Predictors of Poor Outcome Young age Altered consciousness at presentation Fever at presentation Middle cerebral artery territory stroke- volume greater than 10 percent of the intracranial volume Right middle cerebral artery territory infarction Bilateral ischemia Arteriopathy

26. Summary Stroke in Childhood is acute neurological injury, mainly due to Brain Ischemia Neuoimaging is the most important aspect of evaluation Supportive measures are necessary during initial management Thrombolytic therapy is still controversial in children There is very high rate of disability after stroke