Pediatric Stroke

Simon Lalehzarian and Marci Rosenberg May 8, 2013

Do children really have strokes?

Yes, though rare estimated incidence = 13/100,000 (Ciccone et al. 2011) Both ischemic and hemorrhagic
20% of adult strokes are hemorrhagic 45% of pediatric strokes are hemorrhagic

One of top ten causes of death in children

What does the presentation of stroke look like in children?

Presentation fairly similar to adults (Tsze and Valente 2011)

Pediatric stroke mimics

Complicated migraines Focal seizures Meningitis Herpes simplex encephalitis

Treatment & therapies

tPA what is the inclusion factor age?
> 18; also, usually out of time window

Ok, so no tPA. Whats left? Not much

Supportive care, including maintaining stable respiratory and cardiovascular functions, treating infections, seizures, and fevers, and oxygen supplementation Anticoagulants (Heparin)* and antiplatelet (aspirin)

Risk Factors
60% of pediatric stroke cases are seen in boys
Trauma (e.g. artery dissection) BUT, this male-to-female discrepancy remains even when trauma is accounted for

Blood clotting disorders (e.g. sickle cell disease or hemophilia) Cardiac disorders Infections

Case Study
13-year-old right-handed girl History:
Ischemic stroke secondary to internal carotid artery dissection

Presented with:
Subacute onset of headache and sensory deficit in her left hand

Scans and Results

Noncontrast head CT: showed possible clot in the right middle cerebral artery (MCA) and an area of poor differentiation in right parietal region Angiography: right internal carotid dissection
Believed to be initiated from the patient bumping her head on the pool bottom

Treated with warfarin (anticoagulant; prevention of thrombosis)

Round 2
Eight months later she walked toward her parents, and said: here I go again, and collapsed On arrival to the Pediatric Emergency Department, neurological examination showed:
Dense left hemiplegia (total weakness of the left side of the body; no movements at all) Right gaze preference

Scans (round 2)
Head CT showed probably thromboembolus from the healing right internal carotid artery Initially planned to proceed with angiography, but since it had been less than 3 hours since onset of her deficit, decision was made to treat with IV rt-PA What is IV rt-PA?
Recombinant tissue plasminogen activator
Simply means the tPA was manufactured using recombinant biotechnology techniques
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Post IV rt-PA Scans

Angiography showed branch occlusion in superior division of the middle cerebral artery (M3 segment) with slow anterograde flow

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Round 2 Scans (cont.)

Head CT scan showed a new area of decreased attenuation in the anterior right parietal lobe (anterior left parietal lobe is pictured below)

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Recovery
Next 12 hours, she progressed to 4/5 muscle strength in her left arm and leg 5 months later she had only minimal slowing of fine finger movements in her left hand Decision was made to recommend life-long warfarin

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Discussion
1 to 13/100,000 children/year are affected by stroke In contrast to the adult population, in which the principal causes are atherosclerosis and hypertension, the principal causes in children include a higher prevalence of cardioembolic sources, as well as rare metabolic and genetic causes

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Whats the point?

In this patient, multiple factors contributed to the recurrent thrombotic stroke:
Prior carotid dissection and increased propensity for thrombosis Mild hypercholesterolemia (high levels of cholesterol in the blood) Slight elevations of homocysteine (increased risk of thrombosis and cardiovascular disease)

Neurological deficit improved rapidly with rt-PA administration, and therefore should be considered in children with acute thromboembolic stroke

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citations
Carlson MD, Leber S, Deveikis J, Silverstein FS. Successful use of rt-PA in pediatric stroke Neurology vol. 57 (July 2001): 157, 158. Neurology. Web. 07 May 2013.

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