1. The Evolving Management of Pediatric Stroke Christopher A. Miller, MD July 21, 2012

2. Epidemiology Neonatal Stroke 1/4000 live births annually Childhood Stroke: – Schoenberg2.52/100,000/year – Fullerton0.63/100,000/year

3. Epidemiology Rochester, MN Study (1978) Hemorrhagic Stroke1.89 cases/100,000/yr Ischemic Stroke0.63 cases/100,000/yr

4. Outcome Data Persistent deficit60 – 80% Mortality 2 - 10 % Recurrence Risk5 – 18 % Data from Western Europe, North America

5. Risk Factors for Ischemic Stroke Heart Disease – Congenital Heart Disease – Acquired Cerebrovascular Disorders Hematologic Disorders

6. Risk Factors for Ischemic Stroke Non-structural Vascular Disorders Infection Vasculitis Trauma

7. Evaluation of Suspected Stroke

8. Clinical Presentation Onset of Deficit Evolution Localizing Signs

9. Diagnostic Tools Neuroimaging (CT, MRI) Non-invasive Vascular Studies (CTA, MRA, MRV) Angiography

23. Treatment Options Symptomatic Management Thrombolysis Clot Extraction

24. Use of IV rt-PA Eligibility: (a) Clinical diagnosis of acute ischemic stroke. (b) Onset (at most) 3 – 4.5 hours prior to anticipated treatment.

26. <

27. Use of IV rt-PA Contraindications: - SBP > 185 or DBP > 110 mm Hg - CT shows ICH, SAH or established stroke - Other suspicion of SAH - Seizure at onset - Recent Intracranial/Spinal surgery or head trauma - Major recent (3 months) surgery or trauma

28. Use of IV rt-PA Contraindications: - History of prior intracranial hemorrhage - History of known vascular malformation or tumor - Recent active systemic bleeding - Thrombocytopenia or recent heparin use - Known bleeding diathesis

29. Use of IV rt-PA Warnings: Age < 15 yearsDifficulty determining eligibility Glucose 400 mg/dl Left heart thrombus Life expectancy < 1 yearPregnancy Rapid ImprovementRecent other anticoagulant use CT evidence of very large stroke Comorbid conditions with a high risk of bleeding

30. NINDS Recommended Time Frames for IV rt-PA Use From Arrival in ER 10 minutesInitial ER physician evaluation 15 minutesNotify Stroke Team 25 minutesInitiate Head CT scan 45 minutesInterpretation of CT scan 60 minutesadminister IV rt-PA

31. Use of IV rt-PA Treatment: Infuse 0.9 mg/kg (max = 90 mg) over 60 minutes with 10% of dose given as initial bolus over one minute.

32. Mechanical Intervention/ Clot Extraction

33. Merci Retrieval Catheter FDA approved for retrieval of acute intracranial thrombus or emboli within 8 hours of onset of symptoms

34. MERCI Case Left MCA occlusion distal to Anterior Temporal Artery origin

35. MERCI Case MCA occlusion crossed with Merci retrieval catheter

36. MERCI Case MCA occlusion relieved Fully recovered, NIHSS 0

37. Penumbra Aspiration Catheter FDA approved for retrieval of acute intracranial thrombus within 8 hours of onset of symptoms

38. Penumbra Aspiration Catheter

39. Penumbra Case Pre and Post Treatment Angiograms

40. Ad Hoc Committee – Pediatric Stroke Joseph Childs, MD (PICU)Sid Roberts, MD (Radiology) Frankie Crain, MD (PICU)Keith Woodward, MD (Radiology) Lise Christensen, MD (ER)Chris Miller, MD (Neurology) Shahid Malik, MD (Hematology)Anna Kosentka, MD (Neurology) Lewis Harris, MD (Neurosurgery)Karsten Gammeltoft, MD (Neurology) Jeanann Pardue, MD (Hospitalist)