1. MOHAMMAD EZADEEN
House paediatrecian
Umdurman pediatrics Hospital-SUDAN
MOHEZDNSR@HOTMAIL.COM

2. WHO DEFINITION OF STROCK 2004
• “A clinical syndrome in which there
is rapidly developing signs of focal
or global disturbance of cerebral
functions, lasting more than 24
hours or leading to death, with no
apparent causes other than of
vascular origin”

3. INCIDENCE
• One of the top 10 causes of death in childhood
• Hemiplegia secondary to vascular disorders
occurs in children with an incidence of 1–
3/100,000 per year
Neonatal stroke: 28/100,000 live births
Several studies have found that pediatric ischemic
stroke is more common in boys than in girls

4. Questions should be answered
• WHAT IS THE LESION?
• WHERE IS THE LESION?
• WHAT IS THE CAUSE?

5. WHAT IS THE LESION
• FOCAL
• SYSTEMIC
• DISSEMINATED

6. Where is the lesion
• CORTEX
• CORONA RADIATA
• INTERNAL CAPSULE
• BRAIN STEM
• SPINAL CORD

11. Case
YEARS RT.HANDED BOY PRESENTED WITH SUDDEN
ATTACH OF ATTAXIA VERTIGO .OE LEFT HORNER
, HORIZONTAL NYSTAGMUS,ABSENT GAG REFLEX,LOSS OF
PINPRINK SENSATION OF LEFT .FACE AND LOSS OF TEMP
AND PAIN SENSATION OF THE RT.BODY WITH NO APPARENT
MOTOR DYSFUNCTION
WHAT COULD BE THE LESION

13. WHAT IS THE CAUSE
• 1-CONGENITAL
• 2- TRAUMA
• 3-VASCULAR
• 4-INFLAMMATORY
• 5-NEOPLASM
• 6-METABOLIC DEGENERATIVE

14. CASE
• YEAR OLD GIRL PRESENT WITH TENITUS
VERTIGO AND DEAFNESS. O/E THERE IS LEFT
SIDE LOWER MOTOR FACIAL NERVE PALSY
AND LOSS OF CORNEAL REFLES
• WHERE IS THE LESION
• WHAT IS THE CAUSE

15. COMMONCAUSES OF ACUTE STROKE
SYNDROM IN CHILDREN
• The most common causes are congenital
heart disease (cyanotic), sickle cell anemia
(SS), meningitis, and hypercoagulable states.
• The cause of stroke in children is established
in approximately 75% of cases

16. CASE
• yeas old well being boy presented with fever, headache,
confusion the mother has found him lieing in the front of the
door with no trauma .He developed partial seizures with
secondary generalisation and a right parieto-temporal
syndrome consisting of left hemiparesis with hypoesthesia,
left homonymous hemianopia, topographical isorientation
and sensorineural deafness of acute onset. PH and FH
unremarkable.anti vrus has given but with no
improvment Cerebrospinal fluid was normal. Brain Magnetic
Resonance showed cortical and subcortical hyperintensities
located unilaterally in the right parietal and temporo-occipital
lobes and diffuse atrophy of the cerebellar cortex
• BLOOD CHOLESTROL FOUND TO BE ELEVATED mg/dl

17. MELAS
• Mitochondrial Encephalopathy and Lactic Acid
Strok like syndrome
• Pathophysiology
• Eeg
• Csf
• A3243G levels
• Treatment

18. GENERAL CAUSES OF ACUTE STROKE
SYNDROM IN CHILDREN
• GENERAL CAUSES
• Arterial thrombosis
• Arterial embolism
• Venous thrombosis
• AVM
• Vasculitis

19. Arterial thromboembolism
• Sickle cell diseas
• Cyanotic heart disease / mainly of MCA
oxygen saturation is significantly decreased
together with a viral illness or dehydration
-cardiac procesures
• Trauma Thrombosis of the internal carotid
artery

20. • Hypercoagulablity syndrom
• Moyamoya
• deficiencies in protein C, protein S, and
antithrombin III, as well as antiphospholipid
syndrome
• Cardiac causes: AF, DCM,Myxoma, IE,prosthetic
valave and RHD
• dissection
• TTP
• DIC
• IBD

21. Venous thrombus
• Septic
encephalitis and bacterial meningitis
-Aseptic
severe dehydration in infancy, may cause
thrombosis of the superior sagittal sinus
hypercoagulopathy, cyanotic congenital heart
diseases, and leukemic infiltrates of cerebral
veins

22. vasculitis
• Arteritis
• Kawasaki arteritis
• Homocystinurea
• SLE
• Wegner granulomatosis
• juvenile RA
• PAN
• Behchets Dsease
• Sjogren syndrom

23. Other causes
• Migrain vasospasm
• Focal cerebral arteriopathy of childhood (FCA) is the
term used by the International Pediatric Stroke Study
(IPSS) group to describe an unexplained focal arterial
stenosis in a child with CVA
• Arterial tortuosity syndrome
• Fibromuscular dysplasia
• Vasospasm resulting from subarachnoid hemorrhage

24. MET AND DEG
• CADASIL (cerebral autosomal-dominant
arteriopathy with subcortical infarcts and
leukoencephalopathy) is caused by a mutation
in the Notch3 gene
• progressive degeneration of smooth muscle
cells in the vessel wall
• may present with migraine, TIA, or ischemic
stroke in late childhood or early adulthood

25. • Fabry disease, an X-linked lysosomal storage
disorder due to deficiency of a-galactosidase
A, may result in vessel narrowing and
infarction in affected young adult males and
carrier females
• Menkes' disease, a rare X-linked condition
resulting in impaired copper transport, is
associated with cerebral vessel tortuosity and
stroke
-MELAS

26. DIFERENTIAL DIAGNOSIS
• TODDS PALSY
• Alternating hemiplegia of childhood is
occasionally associated with migraine
• encephalitis (particularly herpes)
• demyelinating conditions such as acute
disseminated encephalomyelitis,

27. • A retropharyngeal abscess
• idiopathic intracranial hypertension
• drug toxicity
• postinfectious cerebellitis
• PSYCHOLOGICAL

28. INVESTIGATIONS FOR STROKE
• In children, head CT is generally considered
inadequate to diagnose stroke
• Brain MRI is more sensitive for acute ischemia
than CT.it should be obtained ASAP
• brain MRI provides better visualization of the
posterior fossa.
Current UK guidelines from the Royal College
of Physicians (RCP) recommendation

29. • Magnetic resonance angiography (MRA) of the
head to evaluate the intracranial large arteries.
Computed tomography angiography (CTA) can be
substituted
• MRA of the neck to evaluate the extracranial
large arteries. CTA can be substituted
• Axial T1 MRI of the neck to evaluate for
dissection
• Transcranial Doppler when MRA or CTA are
nondiagnostic and there is a high index of clinical
suspicion for intracranial large artery disease

30. LABORATORY
• Electrocardiogram
• Complete blood count including platelets
• Electrolytes, urea nitrogen, creatinine
• Serum glucose
• Prothrombin time (PT) and international normalized ratio (INR)
• Partial thromboplastin time (PTT)
• HB Electrophoresis

31. • Cardiac enzymes and troponin if there is
clinical suspicion of myocardial ischemia
• Ooxygen saturatio
• Electroencephalogram if seizures are
suspected
• Echo
• Transesophageal echocardiography (TEE) if
TTE is nondiagnostic
• Holter monitor if there is suspicion for cardiac
arrhythmia, particularly atrial fibrillation

32. • Liver function tests
• Toxicology screening
• Blood alcohol level
• Lumbar puncture, if there is clinical suspicion
for subarachnoid hemorrhage and head CT
scan is negative for blood, or if there is
suspicion for an infectious etiology of stroke

33. • Hypercoagulable evaluation
• Protein C and protein S , antithrombin
III,lipoprotein , homocystin,anticardiolipin
antibody,lupus anticoagulant tests
• Vasculitis evaluation
• ESR,CRP,ANA,HIV VDRL

34. MANAGMENT
• SUPPORTIVE
• Airway an respiration managment
• Circulation and bp managment
• Care of the skin
• Care of nutrition
• Care of the bladder
• Care of the bowel
• Physiotherapy

35. TREATMENT
• No randomized controlled trials of treatment in
acute childhood stroke have been performed
• In general, treatment of pediatric stroke is largely
adapted from treatment of adult stroke.
• Thrombolysis — Alteplase (rt-PA) is not approved
for use in children less than 18 years of age with
ischemic stroke

36. Initial antithrombotic
• there are no randomized controlled trials
examining the effectiveness of antiplatelet or
anticoagulation therapy for the treatment of
acute arterial ischemic stroke in children
• The American Academy of Chest Physicians
(ACCP) recommends either unfractionated
heparin or low molecular weight heparin (LMWH)
or aspirin as initial therapy until dissection and
embolic causes have been excluded

37. • The American Heart Association Stroke Council
guideline states that it may be reasonable to
initiate anticoagulation with LMWH or
unfractionated heparin in children with arterial
ischemic stroke pending completion of the
diagnostic evaluation
• UPTODATE RECOMENDATION
• suggest aspirin 3 to 5 mg/kg per day rather
than anticoagulation as initial therapy for most
children with acute arterial ischemic stroke of
unknown etiology

38. NICE GUIDELINES
for adults

40. SICKLER MANAGMENT
• For children with arterial ischemic stroke and
sickle cell disease, UPTODATE suggest urgent
intravenous hydration with intravenous
normal saline rather than hypotonic saline
• also recommend urgent exchange transfusion.
• The goal of exchange transfusion is to achieve
a hemoglobin S fraction <30 percent of total

41. PROGNOSIS
• A study of national registry data from the
United States reported that in-hospital
mortality after ischemic stroke in children
ages one to 17 years was 3.4 percent
• In young adults, mortality is approximately 4
to 6 percent in the first year after ischemic
stroke

42. DISABILITY
• Despite the neural plasticity present in
children, the majority of children with stroke
have persistent disability
RECURRENCY
• Recurrent cerebral ischemia, including stroke
and TIA, is common ranging from 6.6 to 20
percent

43. PREVENTION
• the American College of Chest Physician (ACCP)
guideline for antithrombotic therapy in children
recommends daily aspirin (1 to 5 mg/kg daily)
for a minimum of two years
• NO GUIDELINE supprt use of adding with asprin
clopedogril
• limited data suggest that combined treatment
with aspirin and clopidogrel is associated with an
increased risk of intracranial bleedin

44. • For stroke secondary to a cardioembolic cause,
the ACCP guideline recommends anticoagulant
therapy with LMWH or warfarin for at least six
weeks, with ongoing treatment dependent upon
radiologic assessment but asprin not
recommended
• For children with ischemic stroke due to arterial
dissection, uptodate suggest anticoagulation with
warfarin or low molecular weight heparin for
three to six months after stroke onset, followed
by long-term therapy with aspirin

45. • For children with ischemic-type moyamoya
surgical revascularization at a center with
expertise in the surgical treatment of
moyamoya
• For children with sickle cell disease, uptodate
suggest chronic transfusion therapy to
maintain hemoglobin S less than 30 percent of
total hemoglobin
• For children with stroke related to vasculitis,
treatment of the underlying condition

46. Recurrent ischemia despite aspirin
• If in aspirin therapy
changing therapy to either clopidogrel or
anticoagulation (with low molecular weight
heparin or warfarin)

47. STROK IN NEONATES
Stroke is more common in the newborn period
than at any other time in childhood and
carries the risk of significant long-term
neurodevelopmental morbidity.
acutely in the neonatal period
later when the child develops a hemiparesis or
symptomatic epilepsy syndrome

48. CAUSES
• congenital heart disease
• placental pathology
• Thrombophilia
INVESTIGATION OF CHOICE
MRI
Wayne State University, School of Medicine, Detroit, MI, USA

49. RECENT RESEARCHES
• Stem cell therapy for stroke
• In the past 10 years there has been an explosion of
research interest in how a variety of stem cell populations
respond in animal models of stroke
• IDEA stem cells may improve aspects of cellular and
functional recovery following largely ischemic models of
stroke
• TRIAL STILL ONGOING
(Journal of Pediatric Neurology 2010

50. Role of Chlamydia pneumoniae in
pediatric acute ischemic stroke
• Several studies have shown that Chlamydia
pneumoniae accelerates atherothrombosis by
cytokine-mediated process with increased risk of
cerebral ischemia in adults
• ONE study has proved that in children
• Journal of Pediatric Neurology 2010

51. QUIZ
• A dilated and unreactive pupil indicates the
compression of what structure?

52. Quiz
• Pinpoint pupils and respiratory changes
indicate the compression of what structure?

53. Quiz
• How does the presentation of stroke differ
between infants and older children?
• Infants usually have a seizure, whereas older
children have acute hemiplegia.
Calder K, Kokorowski P, Tran T, Henderson S: Emergency department presentation of stroke.
Pediatr Emerg Care 19:320-328, 2003

54. Quiz
• A child who develops
weakness, incontinence, and ataxia 10 days
after a bout of influenza likely has what
diagnosis?

55. Acute disseminated
encephalomyelitis
• Any portion of the white matter
• small foci of perivenular inflammation
and demyelination
• mumps, measles, rubella, varicella-
zoster, influenza, parainfluenza, mononucleosis, a
nd immunization
• CSF examination shows mild increase of pressure
and up to 250 cells/mm3, with a lymphocyte
predominance
• steroids

56. CT scan V/S MRI
• CT scan without contrast
• head trauma for skull fractures
• acute strokes
• subarachnoid hemorrhages
• ventricular shifts caused by masses
• edema or increased ICP

57. CT scan with contrast
• better identification of disruptions in the
blood-brain barrier or of highly vascular
structures
• tumors, edema, focal inflammation,
hemangiomas, and arteriovenous
malformations.

58. MRI
• image in three dimensions
• subacute and chronic HG
• tumors or masses
• MRI with contrast is helpful for defining brain
metastases
• Magnetic resonance angiography
arterial stenosis hemangiomas, arteriovenous
malformations, and vascular aneurysms

68. THANK YOU
• References
• Uptodate
• Nelson
• NICE guidelines for strok managment
• Prof Farook Yaseen notes
• Said Elwan neurology
• E-medicine web site
• Pediatric journal of neurology
• International journal of neurology
• Netter atlas of neuroanatomy
• Pediatric secrets
• Dr.Mamdooh mahfoooz lectures