STROKE in STROKE in CHILDHOODCHILDHOOD

PROF. DR. AYÇA VİTRİNELPROF. DR. AYÇA VİTRİNEL

Sudden occlusion or rupture of cerebralSudden occlusion or rupture of cerebral

arteries or veins resulting in focal cerebral arteries or veins resulting in focal cerebral

damage and clinical neurologic deficitsdamage and clinical neurologic deficits

The incidence is 8-10.7/100000 The incidence is 8-10.7/100000 children/yearchildren/year

Cerebrovascular disorders occur more often inCerebrovascular disorders occur more often in

children than suspected.children than suspected.

These disorders are less common than in adults.These disorders are less common than in adults.

- The infrequency of cerebrovascular disorders in - The infrequency of cerebrovascular disorders in children makes it difficult to organize multicenter study.children makes it difficult to organize multicenter study.

- Lack of awareness contributes to delayed diagnosis.- Lack of awareness contributes to delayed diagnosis.

Recognition of stroke in children has increased because of the Recognition of stroke in children has increased because of the widespread application of noninvasive diagnostic studieswidespread application of noninvasive diagnostic studies

- MRI- MRI

- MRA- MRA

- CT- CT

- USG- USG

Patients with sickle cell disease, leukemia and congenital heart Patients with sickle cell disease, leukemia and congenital heart disease now have a larger life expantancy.disease now have a larger life expantancy.

1/3 of strokes can be seen in neonatal period 1/3 of strokes can be seen in neonatal period →→

Immaturity of cerebrovascular and neurological systemImmaturity of cerebrovascular and neurological system

Hemorrhagic strokes Hemorrhagic strokes

Ischemic strokes – OcclusionIschemic strokes – Occlusion

Venous/ arterielVenous/ arteriel

Ischemic Arteriel StrokeIschemic Arteriel Stroke

Arterial thrombosis / embolism may involveArterial thrombosis / embolism may involve

Major cerebral arteries Major cerebral arteries - İntermal carotid- İntermal carotid

- Ant cenebral- Ant cenebral

- Mid cenebral - Mid cenebral - Post cenebralPost cenebral

Smaller cerebral arteriesSmaller cerebral arteries

- Duration of ischemia- Duration of ischemia

- Localızation of ischemia- Localızation of ischemia

- Extention of ischemia- Extention of ischemia

- Development of collaterales- Development of collaterales

- Metabolic necesisity of brain- Metabolic necesisity of brain

Venous occlusion was discovered more quickly than Venous occlusion was discovered more quickly than arterial occlusion.arterial occlusion.

- Septic - Septic → direct invasion of bacteria→ direct invasion of bacteria

AOM , bacterial meningitis,encephalitisAOM , bacterial meningitis,encephalitis

- Aseptic - Aseptic → → Severe dehydration in infancy Severe dehydration in infancy hyperco agulopathyhyperco agulopathy Cyanotic heart diseases Cyanotic heart diseases Iron deficiency anemiaIron deficiency anemia protein C,S, antithrombin III protein C,S, antithrombin III

vascular disordersvascular disorders

Hemorrhagic strokeHemorrhagic strokeRupture of vessel ( hemorrhagic disorder)Rupture of vessel ( hemorrhagic disorder)

Pupture of aneurysm Pupture of aneurysm Congenital weakness of the vessel ,deficiency of type III collagenCongenital weakness of the vessel ,deficiency of type III collagen

Intracerebral HemorrhageIntracerebral Hemorrhage

HemophiliaHemophiliaITPITPHematologic disorders Hematologic disorders

Subarachnaid HemorrhageSubarachnaid HemorrhageIntense headacheIntense headacheNuchal rigidityNuchal rigidity

HemiparesisHemiparesis

Etiology of stroke in ChildrenEtiology of stroke in Children

30% of cases is idiopathic30% of cases is idiopathic

ISCHEMIAISCHEMIA1. Hematologic problems1. Hematologic problemsSickle cell anemiaSickle cell anemiaITPITPTrombotik trombocytopenic purpuraTrombotik trombocytopenic purpuraTrombositossTrombositossPolicytemiaPolicytemiaLeukemiaLeukemia

2. Acquired protrombotic problems2. Acquired protrombotic problemsProtrombotic drugs (L-Asparaginaz and oral Protrombotic drugs (L-Asparaginaz and oral contraseptives)contraseptives)Lupus anticoagulanLupus anticoagulanAnticardioli pin antikorlanAnticardioli pin antikorlanLipoprotein anomalies Lipoprotein anomalies

3. Congenital protrombotic problems3. Congenital protrombotic problemsAntitrombin deficiencyAntitrombin deficiencyProtein S deficiencyProtein S deficiencyProtein C deficiencyProtein C deficiencyProtrombin gen 20210 G-A mutationProtrombin gen 20210 G-A mutationFactorV 1691 G-A avd Factor V 1299 A-G mutationFactorV 1691 G-A avd Factor V 1299 A-G mutationHyperhomosisteinemi a/ MTHFR 677 C-T mutationHyperhomosisteinemi a/ MTHFR 677 C-T mutation

4. Metabolic diseases4. Metabolic diseases

Hiperli pidemiaHiperli pidemiaMitochondrial diseases (MELAS)Mitochondrial diseases (MELAS)

5. Infection5. InfectionCNS infectionsCNS infectionsSepsis / septic emboliSepsis / septic emboli

6. Vasculitis6. VasculitisSystemic Lupus Eritematosis (SLE)Systemic Lupus Eritematosis (SLE)Poliarteritis nodosaPoliarteritis nodosaGranulomatous anjitisGranulomatous anjitisTakayasu arteritisTakayasu arteritisRomatoid arteritisRomatoid arteritisDermatomyositisDermatomyositisInflamatuar bowel diseaseInflamatuar bowel disease

7.Systemic vascular diseases7.Systemic vascular diseasesDMDMEhler-Danlos SyndromeEhler-Danlos SyndromePseudodoksantoma elasticumPseudodoksantoma elasticumFabry diseaseFabry diseaseArteriel fibromuscular dysplasisArteriel fibromuscular dysplasisMoyamoya SyndromeMoyamoya SyndromePostradiation vasculopathyPostradiation vasculopathyMygrenMygren

8. Trauma8. TraumaPost-traumatic arteriel dissectionPost-traumatic arteriel dissectionLipid or air emboliLipid or air emboliForeign body emboliForeign body emboliCardiac cateterization Cardiac cateterization

9. Kongenital heart disease9. Kongenital heart disease

VSD, ASDVSD, ASD- Aort or mitral stenosis- Aort or mitral stenosisCoarctationCoarctationPatent foramen ovalePatent foramen ovale

10. Acquired heart diseases10. Acquired heart diseases

HEMORRHAGICHEMORRHAGIC

1. VASCULAR1. VASCULAR

A.Kongenital vascular anomaliesA.Kongenital vascular anomalies- Arterivenous malformation- Arterivenous malformation- Venous angiom- Venous angiom- Cavernous hemangiom- Cavernous hemangiom- Hereditary hemor telengiectasis- Hereditary hemor telengiectasis- İntracranial aneurism and coarctation- İntracranial aneurism and coarctation

B. VaskulopathyB. Vaskulopathy- EhIers-Oanlos Syndrome Tip IV- EhIers-Oanlos Syndrome Tip IV- Moyamoya Syndrome- Moyamoya Syndrome- Pseudoksantoma elasticum- Pseudoksantoma elasticum- Sickle cell anemia- Sickle cell anemia- Intracranial trauma- Intracranial trauma

C. Systemic diseasesC. Systemic diseases- Systemic hypertension- Systemic hypertension

D. VaskulitisD. Vaskulitis

- Hemolitic-uremic Syndrome- Hemolitic-uremic Syndrome- Drug dependence (cocain, - Drug dependence (cocain, amfetamin)amfetamin)

E. TraumaE. Trauma- Child abuse- Child abuse- Angioplasty- Angioplasty- Intracranial trauma- Intracranial trauma

2. İNTRAVASCULAR2. İNTRAVASCULAR

A. Hematologic diseasesA. Hematologic diseases- ITP- ITP- Trombotic trombocytopenic purpura- Trombotic trombocytopenic purpura

B. Coagulation disordersB. Coagulation disorders- Factor deficiency- Factor deficiency- Vit.K deficiency and liver dises- Vit.K deficiency and liver dises

Congenital heart disease and sickle cell disease are common Congenital heart disease and sickle cell disease are common causes of stroke in children. causes of stroke in children.

Atherosclerosis is common in adults.Atherosclerosis is common in adults.

No cause can be detected in about 30% of patients with No cause can be detected in about 30% of patients with ischemic infarct in childhood.ischemic infarct in childhood.

Clinical FindingsClinical Findings

HemiplegiaHemiplegia

SeizuresSeizures

HeadacheHeadache

LetargyLetargy

Paralysis of 6th nerveParalysis of 6th nerve

Unconsciousness Unconsciousness

Laboratory FindingsLaboratory FindingsCbc, blood smearCbc, blood smear

ESRESR

EKG, ECHOEKG, ECHO

Electrolyte, BUN, creatinin, serum glucose, total protein, uric acid, Ca, PElectrolyte, BUN, creatinin, serum glucose, total protein, uric acid, Ca, P

Cholesterol, triglyseridCholesterol, triglyserid

Blood and urine homosistein (increasing the activity of FV,X,XII and Blood and urine homosistein (increasing the activity of FV,X,XII and supression of protein C)supression of protein C)

Hb electrophoresisHb electrophoresis

ANAANA

LPLP

PT,PTT,plasminogenPT,PTT,plasminogen

Pr C,Pr SPr C,Pr S

Prothrombin gene mutationProthrombin gene mutation

Coagulation, factorsCoagulation, factors

Infection markersInfection markers

Serum and CSF Varicella AbSerum and CSF Varicella Ab

CSF lactateCSF lactate

Plasma ammonium, lactate,piruvatePlasma ammonium, lactate,piruvate

Urine organic acidsUrine organic acids

Radiologic FindingsRadiologic Findings

USUS- Used under 1 yr of ageUsed under 1 yr of age

CTCT- Sensitivity is low in the first 6 hrsSensitivity is low in the first 6 hrs

MRIMRI- Sensitivity is 80% in acute evaluation of vascular pathologySensitivity is 80% in acute evaluation of vascular pathology

Functional MRI ,MRAFunctional MRI ,MRA

- Diffusion- Diffusion Sensitive method for acute ischemiaSensitive method for acute ischemia

- Perfusion- Perfusion Shows all ischemic tissuesShows all ischemic tissues

- MRS- MRS Biochemical changesBiochemical changes

TREATMENTTREATMENTSince there are not randomized controlled studies for Since there are not randomized controlled studies for

childhood stroke treatment the treatment is still childhood stroke treatment the treatment is still controversial and relies on adult literaturecontroversial and relies on adult literature

AimAim

- Restriction of infarct area- Restriction of infarct area

- Restriction of infarct extension- Restriction of infarct extension

- İmproving prognosis- İmproving prognosis

- Prevention of recurrences- Prevention of recurrences

Supportive treatmentSupportive treatment

- OxygenisationOxygenisation- VentilationVentilation- HydrationHydration- Decreasing intracranial pressure(furosemid,mannitole)Decreasing intracranial pressure(furosemid,mannitole)- Anticonvulsant drugsAnticonvulsant drugs- Correction of metabolic disturbances(serum glucose etc.)Correction of metabolic disturbances(serum glucose etc.)

Treatment of acute stageTreatment of acute stage

Thrombolytic treatmentThrombolytic treatment- In the first three hoursIn the first three hours

Anticoagulation Anticoagulation

- In the first 7-10 days- In the first 7-10 days

Prophylactic therapyProphylactic therapy

Thrombolytic therapyThrombolytic therapy

Usage of Tissue plasminogen activator (t-PA) is limited in Usage of Tissue plasminogen activator (t-PA) is limited in childhoodchildhood

Causes severe bleedingCauses severe bleeding

Contrindicated in newbornsContrindicated in newborns

Anticoagulan TherapyAnticoagulan Therapy

Heparinization-low molecular weight heparinHeparinization-low molecular weight heparin

Oral anticoagulant drugsOral anticoagulant drugs

Prophylactic therapyProphylactic therapy

3 – 6 months3 – 6 months

Oral anticoagulant drugs-WarfarinOral anticoagulant drugs-Warfarin

Acety salisilic acid (antiplatelet effect ) Acety salisilic acid (antiplatelet effect )

( Aspirin)( Aspirin)

Physical therapyPhysical therapy

Speech therapySpeech therapy

Occupational therapyOccupational therapy

Pyscologic servicesPyscologic services