1. Stroke in Children SICU meeting Ri 郭佑民

2. Recognition and Treatment of Stroke in Children [Clinical Guideline] Reviewed July 1, 2001 Child Neurology Society Ad Hoc Committee on Stroke in Children: E. S. Roach, M.D., Dallas, TX, et al

3. Stroke in Children Epidemiology Etiology(Risk Factors) B. Chung and V. Wong Pediatric Stroke Among Hong Kong Chinese Subjects Pediatrics, August 1, 2004; 114(2): e206 - e212. Treatment Direction For Research

4. Introduction of Stroke in Children less common diversity of risk factors improved diagnostic techniques MRI,CT, cranial ultrasound lack of awareness delayed diagnosis

5. Epidemiology 2.5 cases /100,000/year( Schoenberg, 1978) Ischemic: hemorrhagic = 1:3 2.7 cases/100,000/year( Broderick, 1993) Top 10 pediatric death in US (2000, CDC) <1 yr: congenital anomalies(1st) 1-4 : unintentional injury(1st) 5-9 : stroke(10th) 10-14: stroke(8th)

6. Epidemiology in Chinese Incidence: 2.1 cases/100,000/year Ischemic: hemorrhagic = 72%: 28% (N, 36: 14) male/female ratio: 1.27:1 11-year period registry B. Chung and V. Wong: Pediatrics, August 1, 2004; 114(2): e206 - e212.

7. Etiology (Risk Factors) CHD Acquired Heart Disease Systemic Vascular Disease Structural Anomalies of the Cerebrovascular System Trauma

8. Congenital Heart Disease VSD ASD PDA AS MS Complex congenital heart defects Acquired Heart Disease Rheumatic heart disease Prosthetic heart valve Bacterial endocarditis Arrhythmia

9. Systemic Vascular Disease Systemic hypertension Diabetes Vasculitis – Meningitis – SLE – Polyarteritis nodosa Vasculopathies – Moyamoya syndrome Hematologic Disorders and Coagulopathies – Hemoglobinopathies (sickle cell anemia) – Immune thrombocytopenic purpura(ITP) – DIC – Leukemia, other neoplasm

10. Trauma Child abuse Carotid ligation (eg, ECMO) Blunt cervical arterial trauma Arteriography Structural Anomalies of the Cerebrovascular system Arteriovenous malformation

11. Etiology in Chinese children

13. Characteristic in Chinese no sinovenous thrombosis. 11/ 36 vascular territories: MCA congenital heart diseases (N = 15, 30%) hematologic diseases (N = 14, 28%) vascular diseases (N = 13, 26%) idiopathic (N = 6, 12%)

14. Presenting features Seizures (52%) hemiplegia (34%) decreased consciousness (30%) headaches (22%) visual field defects (12%) dysphasia (10%) lethargy (8%)

15. Prognosis Death rate (N = 9, 18%) risk factor: decreased levels of consciousness (OR = 15.6) Recurrence rate:10% Long-term neurologic deficits: 41% the only significant risk factor: seizures at the initial

16. Treatment Aspirin Heparin and LMWH Warfarin Thrombolytic Agents

17. Aspirin antiplatelet agents in children with ischemic cerebral infarction no RCT trials routine of clinical use low aspirin dose, no increasing Reye's syndrome rate 2-3 mg/Kg/day (Adult dosage)

18. Heparin and Low Molecular Weight Heparins for high risk group: arterial dissection, dural sinus thrombosis coagulation disorders, or a high risk of embolism loading dose of heparin is 75 units/Kg (IV) followed by 20 units/Kg/hour target APTT to 60-85s LMWM: two divided doses of 1 mg/Kg/dose (SC)

19. Warfarin most effective means of prolonged anticoagulation in children. Safety: hemorrhage due to trauma(e.g., contact sports) unfounded use in congenital or acquired heart disease, hypercoagulable states arterial dissection and dural sinus thrombosis. INR of 2.0 to 3.0; with mechanical valves the INR should be 2.5 to 3.5

20. Thrombolytic Agents One fourth had bleeding which required transfusion. not recommend delayed diagnosis in adults: more bleeding if> 4-6 hours after onset of stroke

21. Direction For Research adapt the knowledge obtained from adult stroke patients identify areas which are age-specific. Post-extracorporeal membrane oxygenation (ECMO) study 1) ligation and reconstruction of R ’ t carotid a. 2) long term effects of altered cerebral circulation 3) carotid a. trauma on the development of atherosclerosis.

22. Thank you for attention SICU meeting Ri 郭佑民