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Pediatric ischemic stroke management-1.pptx
- 1. Pediatric ischemic stroke Dr.Ahmed Kohail Assistant lecturer of neurology Faculty of medicine Al-Azhar university –FEBN Dr.Mohammed Abdo Egyption fellowship of neurology
- 2. Agenda Introduction Pediatric Stroke Risk Factors Imaging In Acute Ischemic Stroke. Hyperacute Treatment For Pediatric Stroke Early Management . Secondary Stroke Prevention, Outcomes, And Recovery. Perinatal Stroke
- 3. 13 years old girl, aphasia , right side weakness present to ER one hour from the onset , recentaly she had upper respiratory infection MRI and MRA done (apatchy left basal ganglia infarction irregular left middle cerebral artery without dissection. Your approach? Case 1
- 5. Case 2 12 years boy, right handed, exercise intolerance due to complex congenital heart disease, was admitted for a cardiac catheterization 12 hours post procedure he appeared confused and had not recovered from the procedure and anesthesia as expected.
- 7. Introduction stroke is uncommon in children but can be a major cause of childhood mortality and morbidity when it occurs result in long-term neurologic sequelae and disabilities over many years costly care The burden on mental and emotional health is often high for children and caregivers a stroke that occurs in children after the first 28 days of life is considered a childhood stroke. A stroke that occurs during the first 28 days of life is considered a perinatal stroke (1/3000 live full-term births)
- 8. presumed perinatal stroke: when imaging demonstrates a chronic infarct in an older child who begins to show focal deficits during development. Childhood and perinatal strokes are categorized as distinct entities they differ in (management, workup, risk factors, and secondary stroke prevention)
- 9. How pediatric ischmic stroke differ from adult ischmic stroke stuttering rather than an abrupt symptom onset Headache acute symptomatic seizure (1/3 of patients more at younger ages) initially attributed to a stroke mimic(seizure, migraine, functional neurologic deficit, infection, demyelinating disease, methotrexate toxicity, or posterior reversible encephalopathy syndrome -PRES) Challenges in young patient (determining time of stroke onset-assessing neurologic deficit-posterior circulation strokes-initial stroke in healthy child )
- 10. PEDIATRIC STROKE RISK FACTORS Multifactorial rather than related to a single etiology, Overlapping genetic predisposition and acquired risk factors.
- 11. Young SCD patients with a PFO are more susceptible to developing RLS and PE, further increasing their susceptibility to stroke
- 12. Complex Cardiac Disease Congenital heart disease or acquired heart disease are major risk factors for perinatal or childhood stroke, together accounting for almost one- third of arterial ischemic strokes in children. Atrial or ventricular dilation and dysfunction, right to left shunting, or alteration in blood flow patterns that increase risk for embolic disease Disruptions in the balance of hemostasis, alteration in blood composition, or loss of endothelial integrity may result in thrombosis, bleeding, or both.
- 13. “Many cardioembolic strokes in children occur in perioperative phase for correction of cardic defects (Barriers to early diagnosis are common, including sedating or paralytic medications in critically ill children, emergence from anesthesia after a procedure)”
- 14. Patent foramin ovale children with otherwise cryptogenic stroke may benefit from PFO closure for secondary stroke prevention. The Risk of Paradoxical Embolism (RoPE) score is used to select adult patients. In the presence of other pediatric stroke risk factors, a paradoxical embolism through a PFO is less likely to be the causative etiology When a PFO is identified during a childhood stroke assessment, venous ultrasound of the extremities and laboratory testing for thrombophilia risk factors should be performed
- 15. Clinical features that suggest stroke is due to a paradoxical embolus include 1)Echocardiogram demonstrating a large PFO 2) PFO with aneurysm 3)Significant right-to-left shunting, 4)Stroke onset after a Valsalva maneuver, 5)An identified deep venous thrombosis.
- 16. 1)AHA consensus statement does not provide a recommendation for PFO closure in preventing recurrent stroke in children due to insufficient evidence. For healthy children with an incidental discovery of isolated PFO, no further treatment or follow-up is advised as there is currently no evidence of future complications associated with isolated PFO in children 2)PFO is more prevalent in children with migraine with aura. However, there is still a lack of evidence from RCTs to support medical treatment or PFO closure in children with migraines 3)an observational study in children with migraine with aura did observe symptomatic improvement after PFO closure
- 17. Arteriopathy Cerebral arteriopathy is present in at least half of all children with ischemic stroke and is a risk factor for initial stroke and stroke recurrence. The most common cause of ischemic stroke in a previously healthy child is a cervicocephalic dissection or a presumed inflammatory intracranial focal cerebral arteriopathy.
- 20. Inflammatory arteriopathy The definitive etiology of inflammatory type focal cerebral arteriopathy(FCA) remains unknown( varicella zoster-SARS-CoV-2) Distal carotid terminus, proximal middle cerebral artery, proximal anterior cerebral artery, lenticulostriates, or a combination of these. The natural history is monophasic(progression of the stenosis in the first days to weeks) 25% risk of recurrence due to (progressive lenticulostriate involvement, artery-to-artery emboli, or flow-related ischemia)
- 21. “step-wise acute ischemic stroke events that crescendo over days to weeks”
- 22. PASTA (Pediatric Arteriopathy Steroid Aspirin Project) Estimated completion 2027
- 23. The FOCAS (Focal Cerebral Arteriopathy Steroid)50 comparative effectiveness study of early versus late corticosteroid started in USA 2023
- 24. Cervicocephalic arterial dissection accounts for approximately 10% of childhood arterial ischemic stroke and half of posterior circulation childhood arterial ischemic stroke spontaneously or following trauma. collagenopathies or elastinopathies such as Ehlers-Danlos syndrome, Marfan syndrome, Loeys-Dietz syndrome, and arterial tortuosity syndrome
- 25. Crescent sign
- 26. String sign
- 28. Moyamoya disease a progressive steno-occlusive arteriopathy, may be the most prevalent risk factor for childhood stroke in Asian countries Adults experience hemorrhage more commonly; cerebral ischemic events are more common in children Watershed infarcts are also very commonly identified
- 29. Cerebral angiography is the criterion standard for the diagnosis of moyamoya disease. The following findings support the diagnosis: 1. Stenosis or occlusion at the terminal portion of the internal carotid artery or the proximal portion of the anterior or middle cerebral arteries 2. Abnormal vascular networks in the vicinity of the occlusive or stenotic areas 3. Bilaterality of the described findings (although some patients may present with unilateral involvement and then progress)
- 31. "puff of smoke"
- 32. “Studies(not randomized) have suggested that revascularization surgery is superior to medical management alone to decrease risk of ischemic injury”
- 33. Sickle Cell Disease Without intervention, about 10% of people with sickle cell disease will sustain an ischemic stroke during childhood. About 20% of children with sickle cell disease who have had a stroke go on to have a recurrent stroke, even if chronic red blood cell transfusion is started. Sickle cell disease can lead to a moyamoya-like syndrome, with progressive steno-occlusive arteriopathy and collateral formation
- 35. STOP (Stroke Prevention Trial in Sickle Cell Anemia) The Stroke Prevention Trial in Sickle Cell Anemia (STOP) was a randomized trial to evaluate whether chronic transfusion could prevent initial stroke in children with sickle-cell anemia at high risk as determined by transcranial Doppler (TCD)
- 36. TWiTCH (TCD With Transfusions Changing to Hydroxyurea) trial found that children without severe arteriopathy whose TCDs had normalized after a period of transfusion therapy could safely transition to hydroxyurea
- 37. American Society of Hematology’s recommended algorithm for management of acute ischemic stroke in sca patient IV fluids
- 38. “A transfusion should be performed for all children with sickle cell disease who present with focal neurologic symptoms, even if symptoms are resolving or have resolved”
- 39. Exhange transfusion vs Simple transfusion “Exchange transfusion is preferred when it can be done quickly, but a simple transfusion is acceptable if exchange transfusion cannot be provided quickly.”
- 40. Infectious disorder activation of the coagulation cascade, thrombosis from a systemic inflammatory response, septic emboli, and direct invasion of the endothelium 37% of children with bacterial meningitis one study in South Africa 71% of patient with TB meningitis Focal cerebral arteriopathy SARS-CoV2 virus
- 41. Imaging in acute ischemic stroke Brain MRI with magnetic resonance angiography (MRA) is the optimal study for diagnosis of acute childhood arterial ischemic stroke because it readily differentiates an ischemic infarct from more common childhood stroke mimics. Head CT with CT angiography is a reasonable alternative because it is more readily available and may be easier to obtain quickly. Head CT and CT angiography may also be the preferred initial study in children with known heart disease to avoid imaging delays while assessing whether cardiac hardware is present and magnetic resonance–conditional
- 42. “Vascular imaging is crucial to identify a large vessel occlusion or an arteriopathy that influences management” “In cases with moyamoya, DSA is typically performed to delineate anatomy before surgery.” “When sedation is required for neuroimaging, blood pressure should be maintained to optimize brain perfusion, particularly in the setting of arteriopathy or dependency on collateral circulation”
- 44. Hyperacute Treatment For Pediatric Stroke Although guidelines support consideration of IV thrombolysis or thrombectomy in children in specific circumstances on a case- by-case basis, these treatments are not considered a requirement. using weight-based dosing similar to that in adults. Hyperacute treatment decisions should be made in conjunction with neurologists with expertise in the treatment of children with stroke. the estimated risk of symptomatic intracranial hemorrhage after thrombolysis is low
- 45. Cerebral arteries do not approximate adult size until around the age of 5 years, so the size and age of a child should be considered for device selection. In systems of care without availability of providers experienced in pediatric stroke treatment, the priority should instead be stabilization and transfer to the appropriate centers.
- 46. Children have an increased tendency to form early collaterals, so the selection criteria for children likely to benefit from mechanical thrombectomy during this extended time window are especially uncertain. If durable collateral circulation is already well established, recanalization may not improve outcomes.
- 47. The Pediatric National Institutes of Health Stroke Scale (PedNIHSS) Pediatric NIH Stroke Scale (NIHSS) (mdcalc.com) A modification of the adult scale Use in children aged 2 years and older
- 48. International muti center cohort study Stopped due to failure in enrollment 54% of patient was stroke mimics
- 49. provide considerations in which it may be reasonable or appropriate to consider hyperacute reperfusion treatment in children based on evidence extrapolated from adults
- 50. In the absence of pediatric clinical trial data to guide treatment decisions, hyperacute therapies for childhood AIS remain controversial ?. It would be reasonable to limit consideration of this intervention to children meeting these criteria: Persistent disabling neurological deficits (eg, Pediatric NIH Stroke Scale score 6 at the time of intervention or higher) ≥ Radiographically confirmed cerebral large artery occlusion Larger children.
- 51. Treatment decision made in conjunction with neurologists with expertise in the treatment of children with stroke Intervention performed by an endovascular surgeon with experience in both treating children and performing thrombectomy in adult stroke patients
- 52. The findings of this cohort study suggest that use of EVT and/or IVT is safe in children with AIS.
- 53. This cross-sectional evaluation of the clinical course and short-term outcomes of pediatric patients with ischemic stroke treated with EVT demonstrates that EVT is likely a safe modality which confers high rates of favorable functional outcomes.
- 54. Adjunctive IVT may not provide benefit to MT in patients with AIS caused by distal and medium vessel occlusion.
- 55. Early Management The goals of acute care 1. Limiting injury by rescuing penumbra 2. Preventing stroke extension or early recurrence 3. Treating complications
- 56. “Because of the prevalence of arteriopathies in childhood stroke with subsequent cerebrovascular narrowing or loss of normal hemodynamic compensatory mechanisms, collateral cerebral flow should be supported by initial fluid resuscitation if needed ,keeping the head of bed flat, instituting bed rest, and avoiding hypotension.”
- 57. “In Hypertensive crisis ,blood pressure should be lowered cautiously top prevent stroke extension” “Electroencephalography monitoring maybe needed to detect subclinical seizures.” “Mechanical deep vein thrombosis prevention or anticoagulation)may be indicated in older children”
- 58. “Early assessment of progressive intracranial hypertension and need for urgent decompressive hemicraniectomy maybe lifesaving in children with malignant middle cerebral artery infarction or large cerebellar infarcts.”
- 59. Workup for Acute Childhood Stroke Urgent labs: complete blood count with differential, screening coagulation laboratory tests, and a metabolic panel with renal function. The traditional cardiovascular risk factors of diabetes, hypertension, and hyperlipidemia are less frequently a concern in children than in adults, but screening laboratory tests could be considered in older teens or when strongly suggested by family history.
- 60. “An echocardiogram should be obtained urgently to evaluate for possible cardiac thrombus or vegetation and should include a bubble study or color flow Doppler study to evaluate for a right-to- left shunt” “When a right-to-left shunt is identified, venous Doppler of the extremities should then be performed to evaluate for venous thrombosis.”
- 61. “Although arrhythmias are less common in children than in adults, a screening electrocardiogram is recommended”
- 62. Secondary Stroke Prevention, Outcomes, And Recovery In children with ischemic stroke who do not have sickle cell disease or cardioembolic stroke - aspirin (1 mg/kg/dose to 5 mg/kg/dose orally once daily) The optimal duration of aspirin use following childhood stroke is not known, but guidelines recommend a minimum of 2 years. and it is sometimes used indefinitely. In children with presumed cardioembolic stroke and significant thrombophilic states - Anticoagulation cervical artery dissection –the choise of anticoagulation or antiplatelets is controversial.
- 63. prevention This prospective multicenter follow-up study has provided evidence that low- dose LMWH is not superior to aspirin and vice versa in preventing recurrent stroke in white pediatric stroke patients. However, further adequately sized randomized trials are required to obtain reliable information on safety and efficacy with respect to the antithrombotic medications used.
- 64. Perinatal Stroke Risk factors (chorioamnionitis or other systemic or central nervous system infections, inherited thrombophilia, and complex congenital heart disease Presentation: Usually late in infancy period with( focal motor fits, encephalopathy) In newborn period(early handedness or fail to meet developmental milestones) Acute treatment ( treatment of infection or dehydration, optimization of oxygenation, and cerebral perfusion with normalization of systemic blood pressure) Neonatal seizures due to a stroke may require multiple loads of antiseizure medicines to end status epilepticus.
- 65. Recanalization not recommended secondary stroke prevention not recommended (less recurrence risk), except in infants with complex congenital heart disease
- 66. Case 1 She was diagnosed with an inflammatory focal cerebral arteriopathy. She was treated with a course of corticosteroids and a daily aspirin .After her acute stay ,she completed 2months of inpatient rehabilitation. Duringth at time,her speech recovered ,and she regained power in her right arm and leg. Two years following the stroke, she was able to run and was back to playing sports despite mild residual weakness of her right arm
- 67. Case 2 Neurologist agreed to proceed with thrombectomy. The procedure wassuccessful, with recanalization and complete reperfusion of all distal branches. She recovered slowly during several monthsof inpatient pediatric rehabilitation.