Presented byDr Harish Kumar Singhal

MD (Ay)Sch

Guided by Dr Abhimanyu Kumar

Dr Moti Rai

Department of Bal RogaNIA,Jaipur

Stroke is defined as the

sudden onset of focal neurorological deficit due to occlusion of blood supply or hemorrhage in the brain causing symptom & sign lasting greater than 24 hours.

Stroke is defined as the

sudden onset of focal neurorological deficit due to occlusion of blood supply or hemorrhage in the brain causing symptom & sign lasting greater than 24 hours.

Infants, children & Young adults accounts for less than 5% of all strokes.

Pediatric stroke affects 2-3 in 100,000 newborns and 12 in 100,000 children under 18 years of age.

(A study conducted in Children’s hospital of Philadelphia)

Epidemiological studies have revealed an annual incidence of 2.5-2.7 pediatric strokes per 100,000 children.This figure comprises ischemic and hemorrhagic events, and excludes strokes from trauma or birth-related complications.

(Schoenberg BS, Mellinger JF, Schoenberg DG. Cerebrovascular disease in infants and children: A study of incidence, clinical features, and survival. Neurology. 1978; 28:763-768)

Risk of ischemic stroke was 0.63/100,000 /year as compared to 1.89/100,000 /year for hemorrhagic strokes.

In INDIA the average annual incidence rates are reported to be 13-33/100,000 /year.

Stroke is the sixth leading cause of death in children while in adult it is thrid leading cause of death , ranking behind heart disease & cancer . (H.J.M.Barnett).

Hemorrhagic strokes – 11.4% Ischemic strokes – 88.6%

Prothrombotic states – 38.7% Cardiac disease – 19.3% Hyperlipidemia – 16% Homocystinurea – 14.6%

Newborns, especially full-term infantsOlder children with sickle cell anemia, congenital

heart defects, immune disorders or problems with blood clotting

Previously healthy children who are found to have hidden disorders such as narrow blood vessels or a tendency to form blood clots easily.

A) Congenital

Aortic Stenosis MS VSD PDA Cyanotic congenital HD involving R-L shunt

B) AquiredEndocarditisCardiomyopathyArrthymiaRheumatic fever Psoriatic heart disease

Disorder of RBC: Sickle cell disease Polycythemia

Disorder of WBC : Leukemia Lymphoma

Disorder of Platelets : Thrombocytosis Thrombocytopenia

Disorders of Coagulations : Protein C deficiency Protein S deficiency Factor V deficiency Antithrombin III deficiency Paroxysmal nocturnal hemoglobinuria IBD Lupus anticogulants

Moya –Moya disease Arteriovenous malformations(AVM’s) Aneurysm Sturge Weber syndrome Fibromuscular displasia

Infective disease Meningitis ( Viral,Bacterial,Tubercular) HIV encephalopathy Local head & neck infections

Autoimmune disease SLE Takayasu arterites Poly arteritis nodosa Sarcodiasis Mixed C T Disorders

Amphetamines Cocaine

Homicystinuria Pseudoxanthoma elasticum Fabry disease Mitochondrial encephalopathies :

MELAS Leigh’s syndrome

Trauma Child abuses Placentral embolism ECMO therapy Post varicella

Primary injury : cellular damage caused directly by the insults.

Secondary injury : various derangements set into motion by the primary injury.

20 % of strokes are due to intracranial hemorrhage from rupture of intracranial aneurysm.

Chacot – Bouchard aneurysm occur where hemorrhage is common –basal ganglia , thalamus, cerebellum, Pons &sub cortical areas.

Arterial ischemic stroke (AIS)Cerebral sinovenous thrombosis (CSVT) Intracranial hemorrhage

Lesion above the level of brain stem (Ipsilateral hemiplegia)

Lesion can be at the level of either :- Cortex Internal capsule Sub cortical region

Hemiparesis or Monoparesis Differential involvement { Upper limb > Lower

limbs or vice versa } Altered sensorium Convulsion Cortical sensory loss Astereognosis Aphasia ( If dominant cortex )

Altered behavior Upper limb > lower limb Motor aphasia Convulsions Bladder & bowel involvement Persistent neonatal reflexes on opposite side

Cortical sensory lossAstereognosis

Temporal lobe epilepsy Sensory aphasia Memory loss

Homonymous hemianopia

Dense hemiplegiaHemianaesthesiaHomonymous hemianopiaDysartria

Similar to cortical lesion except loss of cortical sensation & convulsions.

Lesion at / below the level of brain stem (Contra lateral hemiplegia )

Lesion can be either of :MidbrainPonsMedullaSpinal cord ( b /w C 1 – C4 )

Weber’s syndrome : 3 CN palsy +contra lateral hemiplegia

Benedict’s syndrome : 3 CN palsy +contra lateral hemiplegia +red nucleus affection( tremor, rigidity & ataxia on opposite side)

Millard Gubbler’s syndrome : 7 CN palsy +contra lateral hemiplegia

Foville’s syndrome: 6 & 7 CN palsy+ contra lateral hemiplegia

Jackson’s syndrome : 12 CN palsy + contra lateral hemiplegia

Brown Sequrd syndrome :Hemiplegia +CN palsy +differential sensory loss ( i.e. loss of vibration & joint sense on same side & pain ,touch & temperature on opposite.

Focal cerebral ischemia Intracranial hemorrhage Cerebral abscess Encephalitis (herpes simplex virus) Brain tumor Alternating hemiplegia of infancy Multiple sclerosis Malingering/conversion disorder Epilepsy: post-ictal Todd's paralysis or a focal inhibitory seizure Complicated migraine

FIRST LINE: Performed within first 48 hours of admission

SECOND LINE: Performed within first week THRID LINE : Performed as per need

CBC ESR Blood sugar BUN Serum electrolytes ( Na,K,Ca,Mg,Phos.) AST,ALT S / lipid profile Plain x ray chest

CT brain MRI brain & MR angiography Ultrasonography ANA ECG

Echocardiogram (transthoracic) with saline contrast Transcranial and/or carotid dopplers MR angiogram EEG Rheumatoid factor Serum amino acids Urine for organic acids Blood culture Hemoglobin electrophoresis Complement profile VDRL

Lactate/pyruvate Ammonia CSF: cell count, protein, glucose, lactate Lipid profile

Antithrombin III Protein C (activity and antigen) Factor V (leiden) mutation Antiphospholipid antibody Anticardiolipin Lupus-anticoagulant

HIV Lyme titers Mycoplasma titers Cat-scratch titers Cardiac MRI Echocardiogram (transesophageal) Muscle Biopsy DNA testing for MELAS Cerebral angiogram (transfemoral) Leptomeningeal biopsy Serum homocystine after methionine load

1st step is to differentiate ischemic & hemorrhagic stroke.

Anticoagulant therapy is contraindicated in hemorrhagic strokes.

Hyperglycemia & hypertension worsen the stroke.

Treatment primarily directed towards stabilizing systemic factors & management of the underlying causes.

Manage :- Intracranial tension:1. Fluid restriction2. Mannitol3. Steroids

4. Shunt surgery ( In special case)

Hypertension : by appropriate antihypertensive

Fluid balance Hyperglycemia Hyperthermia Seizures with antiepileptic drugs. Antibioitic therapy to prevent secondary infection.

The prognosis for childhood strokes is variable and most dependent upon underlying etiology.

80% of children survived 10 years after an ischemic stroke, although most had residual hemi paresis.

Schoenberg BS, Mellinger JF, Schoenberg DG. Cerebrovascular disease in infants and children: A study of incidence, clinical features, and survival. Neurology. 1978; 28:763-768.

Poor prognosis of strokes with seizures during infancy, and with an angiographic pattern of Moyamoya disease.

Solomon GE, Hilal SK, Gold AP, Carter S. Natural history of acute hemiplegia of childhood. Brain. 1970; 93:107-120.

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A study on 42 children with idiopathic ischemic stroke exclusively concluded poor outcome in 43% of patients at an average of 7.4 years following the stroke. Recurrent stroke occurred in 7 children. In the children who did well, an early recovery was observed.

Abram HS, Knepper LE, Warty VS, Painter MJ. Natural history, prognosis and lipid abnormalities of idiopathic ischemic childhood stroke. J Child Neurol. 1996; 11:276-282

Hemorrhagic stroke have higher mortality rates as compared to ischemic stroke.

Patients with hemorrhagic infarction & coma have higher risk of acute death.