Acute onset hemiplegiaAcute onset hemiplegia

Dr Surya KumarDr Surya Kumar

Paralysis of one half of the body Paralysis of one half of the body

Complete Complete

IncompleteIncomplete

CrossedCrossed

Anatomy of brainAnatomy of brain

PhysiologyPhysiology

CMRoCMRo2 2 is 3.5ml/100mgis 3.5ml/100mg Glucose storage upto 90 minGlucose storage upto 90 min CBF 30-60ml/100mg <3yrCBF 30-60ml/100mg <3yr 105-100ml/100mg in 3 -10 yr105-100ml/100mg in 3 -10 yr

2.5-2.7/100,000 population2.5-2.7/100,000 population

IncidenceIncidence

EtiologyEtiology

Cardiac ---CCHD, IE, RHD, Myxoma Cardiac ---CCHD, IE, RHD, Myxoma Blood dyscrasia---Blood dyscrasia--- Primary vascular disease Acute Primary vascular disease Acute

infantile hemiplegia, MoyaMoya, Takayasu, infantile hemiplegia, MoyaMoya, Takayasu, hemiplegic Migraine, fibromuscular hemiplegic Migraine, fibromuscular Dysplasia,Dysplasia,

Collagen Vascular Disease PAN, SLECollagen Vascular Disease PAN, SLE Infectious DiseaseInfectious Disease

Metabolic Disease Metabolic Disease Homocystinuria,MELAsHomocystinuria,MELAs

Trauma Carotid Trauma Carotid Dissection, Air Embolism, Fat Embolism, Dissection, Air Embolism, Fat Embolism, Vertebral occlusionVertebral occlusion

Vascular Malformation Aneurysm, Vascular Malformation Aneurysm, arteriovenous Malformation, Vein of galen arteriovenous Malformation, Vein of galen malformation,malformation,

Neurocutaneous syndrome Sturge Neurocutaneous syndrome Sturge WeberWeber

IschemicIschemic

HemorragicHemorragic

Share equal proportion of incidenceShare equal proportion of incidence

Ischemic strokeIschemic stroke Cardiac disease 19%Cardiac disease 19% Coagulation Disorder 14%Coagulation Disorder 14% Dehydration 11%Dehydration 11% Infection 6%Infection 6% Vasculitis 7%Vasculitis 7% Dissection 5%Dissection 5% Cancer 4%Cancer 4% Metabolic disorder 3%Metabolic disorder 3% Moyamoya ,SCA, 2%Moyamoya ,SCA, 2% MISC 4%MISC 4% No risk factor 21%No risk factor 21%

AISAISVulnerable sitesVulnerable sites

DiencephalonDiencephalon Watershed aresWatershed ares

SymptomsSymptoms

Focal neurological deficitFocal neurological deficit SeizureSeizure MigraineMigraine FeverFever LethargyLethargy HeadacheHeadache DYstoniaDYstonia Age relate and associted conditionsAge relate and associted conditions

Cadiac disorderCadiac disorder

CHDCHD RHDRHD Prosthetic ValveProsthetic Valve Shunts, Shunts, Patent foramen ovalePatent foramen ovale

causescauses

PolycythemiaPolycythemia AnemiaAnemia ArrythmiaArrythmia EndocarditisEndocarditis

IncidenceIncidence

Exact Data is not availableExact Data is not available Upto 9% undergoing fontan surgeryUpto 9% undergoing fontan surgery 50% occurred within 72 hr of surgery50% occurred within 72 hr of surgery

Hematological and hypercoaguble Hematological and hypercoaguble statesstates

22ndnd most important cause most important cause 2 to 7% of young patient2 to 7% of young patient Factor v leiden mutation, Factor v leiden mutation,

homocystinemia, deficiency of homocystinemia, deficiency of protein c and protein sprotein c and protein s

Sickle cell anemiaSickle cell anemia

300per 100,000 sickle cell patient300per 100,000 sickle cell patient Above 5 yrAbove 5 yr

Silent infarcts are presentSilent infarcts are present Associated with seizures, cranial Associated with seizures, cranial

nerves ,cognitive declinenerves ,cognitive decline Prone for recuurences, chronic Prone for recuurences, chronic

seizure disorderseizure disorder

Keep good hydrationKeep good hydration Transfusion to keep HbS <30%Transfusion to keep HbS <30%

InfectionInfection

5 to 12 % of meningitis5 to 12 % of meningitis Systemic infection Systemic infection

post varicella angiopathy, post varicella angiopathy, pneumonia, borrelia, HIV, pneumonia, borrelia, HIV, helicobacter, helicobacter,

May occur after weeks to months of May occur after weeks to months of infectioninfection

Post varicellea and herpes is Post varicellea and herpes is common common

Moya moyaMoya moya

Chronic,prgrssive,stenotic disease of Chronic,prgrssive,stenotic disease of arteryartery

Mainly females are involved. 6 timesMainly females are involved. 6 times Multiple telengtesia seen in brain Multiple telengtesia seen in brain

mainly in basal ganglonmainly in basal ganglon seizure seen in 335 of patientsseizure seen in 335 of patients Recurrent ischemic attack, mental Recurrent ischemic attack, mental

retardation,,infarction on CTretardation,,infarction on CT Treatment is surgeryTreatment is surgery

vasculitisvasculitis

Takayasu, SLE, MCTD,PANTakayasu, SLE, MCTD,PAN Present with associated symptomsPresent with associated symptoms Steroid and immunotherapySteroid and immunotherapy

MetabolicMetabolic

Homocystenemia, MELA, Familial Homocystenemia, MELA, Familial HypercholesteremiaHypercholesteremia

Family history, and characterstics Family history, and characterstics featurefeature

MigraineMigraine

More common in femalesMore common in females FamilialFamilial Occasionaly permanent deficitOccasionaly permanent deficit

TraumaTrauma

Dissecting aneurysm in arteryDissecting aneurysm in artery Barbershop,fall on pencil in mouth, Barbershop,fall on pencil in mouth,

popstick,barbershoppopstick,barbershop Symtoms come after 1 to 2 daysSymtoms come after 1 to 2 days

Sinovenous thrombosisSinovenous thrombosis

Risk factorsRisk factors

Prothrombotic disorder 30%Prothrombotic disorder 30% Dehydration 30%Dehydration 30% Sysystemic infection 8-10%Sysystemic infection 8-10% Head and neck infection 9%Head and neck infection 9% Rest by cardiac, leukemia,perinatal Rest by cardiac, leukemia,perinatal

complication, Drugscomplication, Drugs

featuresfeatures

Seizures, lethargy,jitterySeizures, lethargy,jittery Dilated scalp veins, anterior fontanel, Dilated scalp veins, anterior fontanel,

eyelid swellingeyelid swelling Headche, Headche,

OutcomeOutcome

53% normal53% normal 25% neurological deficit and seizure25% neurological deficit and seizure 5% seizure alone5% seizure alone 9% died9% died Perspective study of 80 infantsPerspective study of 80 infants

hemorrhagehemorrhage

Congenital vascular anamolyCongenital vascular anamoly VasculopathiesVasculopathies Systemic diseaseSystemic disease TraumaTrauma Hematological disodersHematological disoders

Intracerebral hemorrhageIntracerebral hemorrhage

At the entry point of brainAt the entry point of brain Hematoma and cerebral edema Hematoma and cerebral edema

produces mass like lesionproduces mass like lesion

FeaturesFeatures

Severe headache,Severe headache, SeizuresSeizures Focal signsFocal signs Decrease in conciousnessDecrease in conciousness AtaxiaAtaxia Dysconjugate gaitDysconjugate gait comacoma

Risk factorRisk factor

Trauma most commonTrauma most common Vascular malformationVascular malformation Degenerative vasculopathyDegenerative vasculopathy Hemophilic disorderHemophilic disorder

Subarachnoid hemoorrhageSubarachnoid hemoorrhage

Ateries forming circle of willis and Ateries forming circle of willis and surrounding itsurrounding it

Circle of willis seen more in adulutCircle of willis seen more in adulut

Erythrocytes in subarachnoid space Erythrocytes in subarachnoid space can cause severe spasm leading to can cause severe spasm leading to secondary ishemic infarctionsecondary ishemic infarction

FeatureFeature

Severe headache, neck rigidity,Severe headache, neck rigidity, Low grade feverLow grade fever LeckocytosisLeckocytosis Raised ICTRaised ICT

Malformation of vein of galenMalformation of vein of galen

ApporachApporach

Through examinationThrough examination HeaHea FaceFace EyesEyes EarsEars Paranasal sinusesParanasal sinuses Oral cavityOral cavity neckneck

SkinSkin Bone and jointsBone and joints ExtremitiesExtremities AnthropometryAnthropometry vitalsvitals

Per abdomenPer abdomen CVSCVS Suppurative lung diseaseSuppurative lung disease

InvestigationInvestigation

CBC,Platelet,ESRCBC,Platelet,ESR LFTLFT CholesterolCholesterol Coagulation profileCoagulation profile

ECG, chest X xay,ECG, chest X xay, USG abdomenUSG abdomen VDRL/HIVVDRL/HIV UrinanalysisUrinanalysis Lactate/pyruvateLactate/pyruvate

Ana,RA, anti cardiolipinAna,RA, anti cardiolipin Lumbar puntureLumbar punture CTCT MRIMRI AngiographyAngiography

TherapyTherapy

Absence of RCTAbsence of RCT Adapted from adultsAdapted from adults Treat underlying risk factorTreat underlying risk factor Prevent recurrencePrevent recurrence

Consensus on……Consensus on……

Sickle cell diseaseSickle cell disease Acute therapyAcute therapy

• Exchange transfusionExchange transfusion Preventive therapyPreventive therapy

• Blood transfusion every 3-6 weeks to Blood transfusion every 3-6 weeks to maintain HbS<30%maintain HbS<30%

• ?HU, stem cell transplant?HU, stem cell transplant• Transcranial dopplersTranscranial dopplers

Current recommendations……Current recommendations……

Neonatal AIS – no therapyNeonatal AIS – no therapy Dissecting vasculopathy – Dissecting vasculopathy –

anticoagulation 3-6 monthsanticoagulation 3-6 months Cardiogenic embolism – Cardiogenic embolism –

anticoagulation but no consensus on anticoagulation but no consensus on length of timelength of time

Vasculopathy – ASA (no consensus on Vasculopathy – ASA (no consensus on dose 1-5mg/kg/day)dose 1-5mg/kg/day)

Recurrent stroke – consider Recurrent stroke – consider anticoagulationanticoagulation

HeparinHeparin

For rapid anticoagulationFor rapid anticoagulation Bolus heparin 75-100u/kgBolus heparin 75-100u/kg Maintainence at 28 unit/kg/hr for Maintainence at 28 unit/kg/hr for

infantinfant 20u/hr for >1 yr20u/hr for >1 yr Adjust APTT to 1.5 to 2Adjust APTT to 1.5 to 2 Check APTT 4 hr after bolusCheck APTT 4 hr after bolus Daily APTT and CBCDaily APTT and CBC

LMW heparinLMW heparin

Lovenex Lovenex 1mg/kg in >1yr every 12 hr1mg/kg in >1yr every 12 hr 1.5mg/kg in neonate1.5mg/kg in neonate Monitor by antifactorXa weeklyMonitor by antifactorXa weekly

AspirinAspirin

3-5 mg/kg3-5 mg/kg Dose in less then 10% of antipyretic Dose in less then 10% of antipyretic

dosedose

WarfarinWarfarin

Used if secondary prevention with Used if secondary prevention with ASA failsASA fails

Maintain INR of 2 to 3Maintain INR of 2 to 3 In case of mechanical valve 2.5 to In case of mechanical valve 2.5 to

3.53.5

Supportive treatmentSupportive treatment

Manage ICTManage ICT Blood presureBlood presure Blood sugarBlood sugar Body temperatureBody temperature AntiepilepticAntiepileptic ImmunosuppresantImmunosuppresant TransfusionTransfusion Neurosurgery Neurosurgery Interventional neuroradiological techniqueInterventional neuroradiological technique RehabilitationRehabilitation Acute stroke careAcute stroke care

OutcomeOutcome

Mortality 20 to 30%Mortality 20 to 30% Residual neurological deficit in >50%Residual neurological deficit in >50% Risk of stroke recurrence is as high Risk of stroke recurrence is as high

as 20%as 20%

Differential DiagnosisDifferential Diagnosis

MigraineMigraine Todds paralysisTodds paralysis