Stroke
Stroke: Excerpt from The 5-Minute Pediatric Consult
Peter M. Bingham, MD
Stroke - BASICS
Stroke - description
A neurologic deficit progressing over minutes to hours, due to insufficient perfusion of the brain or spinal cord. Also, otherwise ’asymptomatic,’ remote strokes may present as epilepsy.
Stroke - epidemiology
Stroke - incidence
Overall incidence is ~2.5 per 100,000, but certain groups are at higher risk (those with heart disease, sickle cell disease, hereditary thrombophilias).
Stroke - risk factors
Stroke - genetics
- Various hereditary and metabolic disorders:
- Neurocutaneous diseases, Down syndrome, collagen disorders, congenital heart disease syndromes, coagulation disorders, hereditary cavernoma or telangiectasia, hyperhomocysteinemia, and others
Stroke - pathophysiology
Abnormalities of the blood, vasculature, or the heart (dysrhythmia or anatomic) lead to embolism or intravascular thrombosis: Edema, neuronal swelling, cellular infiltrate, and cavitation evolving from the 1st minutes through several months after an ischemic brain injury
Stroke - etiology
- Underlying causes of stroke include hematologic, circulatory, and cardiac disorders.
- Hematologic:
- Factor V mutation
- Prothrombin gene mutation
- Anticardiolipin/Antiphospholipid syndrome
- Sickle cell
- Hemolytic-uremic syndrome
- Hyperhomocysteinemia
- Dyslipidemia
- Protein S or C
- Antithrombin III deficiency
- Asparaginase treatment
- Hyperviscosity syndromes (including leukemia)
- Thrombocythemia ± iron deficiency
- Extreme dehydration
- Vascular:
- Carotid or vertebral dissection
- Arteriovenous malformation (AVM)
- Carotid trauma
- Moyamoya
- Cavernous angioma (“occult cerebrovascular malformations”)
- Vasculitis (especially due to bacterial meningitis)
- Brain tumor surgery
- Rarely, aneurysm, Takayasu arteritis, chronic meningitides (tuberculosis, Lyme, or sarcoidosis)
- Cardiac:
- Rheumatic heart disease, cyanotic congenital heart disease, heart failure, cardiomyopathy
- Possible association with mitral prolapse, atrial septal defects
- Atrial myxoma, aortic dilatation (Marfan syndrome), pulmonary AVM
Stroke - DIAGNOSIS
Stroke - signs & symptoms
Stroke - history
- Occurrence of stroke in specific settings may point to the diagnosis; previous migraines may point to complicated migraine (rare).
- Inquire about substance use, prior trauma, infection, excessive bleeding or spontaneous clotting, or history of heart disease.
- Family history of premature thrombosis, hemoglobinopathy, or vascular malformations (e.g., cavernous hemangioma or hereditary hemorrhagic telangiectasia)
- Perinatal stroke frequently presents with neonatal seizures: May be associated with multiple gestation
- Complications of labor or fetal exposure to vasoactive compounds may be associated.
Stroke - physical exam
- Note level of alertness and capacity for sustained attention; fluency, appropriateness, and construction of speech; comprehension; emotional state; and subjective or objective pain.
- Vital signs, color, and respiratory pattern may disclose existing or impending respiratory failure due to loss of protective airway reflexes.
- General examination should include peripheral pulses and perfusion; palpation and auscultation of the precordium and cervical area may reveal evidence of dysrhythmia or anatomic lesions.
- Note confrontation visual fields, funduscopy (especially for papilledema), eye movements, facial symmetry, pattern of movement of affected limbs, and extensor response of great toe to plantar stimulation (Babinski sign).
- In the absence of sensory complaints, detailed sensory exam is often fruitless. Conversely, isolated sensory complaints are rarely an indication of stroke.
Stroke - tests
Stroke - lab
- Blood chemistry, particularly glucose; mild hyperglycemia may reflect stress response; marked elevation (e.g., in diabetics) should be treated, because hyperglycemia may aggravate ischemic brain injury.
- Toxin screen
- CBC, PT, and PTT may prompt important therapeutic decisions.
- Consider lumbar puncture (if neuroradiologic findings show no risk of incipient herniation) to look for evidence of inflammatory/infectious basis.
- More extensive testing in undiagnosed cases may include the following:
- Tests for specific coagulopathies (see “Differential Diagnosis”)
- Varicella serology (may be a common cause of stroke in children)
- Toxin screen (association with cocaine)
- Amino acid screening (for homocysteine)
- Hemoglobin electrophoresis (sickle hemoglobin)
- Lipid profile (hypercholesterolemia)
Stroke - imaging
- Individuals with stable vital signs and suspected stroke should undergo a brain imaging study promptly.
- Non–contrast-enhanced images are important to look for possible hemorrhage and may be followed by contrast-enhanced images to evaluate for possible focal encephalitis or underlying vascular lesions.
- Many diagnostic questions can be resolved equally well by CT or MRI, although CT may be preferable in suspected subarachnoid hemorrhage; MRI is much more sensitive in the 1st 24 hours after symptom onset and may identify venous or sinus thrombosis or smaller bilateral lesions pointing to systemic embolization.
- More extensive testing in undiagnosed cases may include the following:
- ECG (atrial–septal defect, luminal lesion)
- Carotid Doppler (stenosis/dissection)
- Specialized neuroradiologic studies (MRA, standard angiography)
- AVMs may not be seen on angiography immediately after a primary intracerebral hemorrhage. Consider repeat angiography weeks or months later.
- CT scan may be normal in the 1st 24 hours after nonhemorrhagic stroke. A follow-up study may be necessary.
- Suspected transient ischemic attack (TIA) should prompt a vigorous diagnostic evaluation.
Stroke - differencial diagnosis
Several disorders may mimic the presentation of stroke:
- Migraine
- Demyelinating disease
- Focal encephalitis
- Postepileptic paralysis (Todd paresis)
- Conversion disorder
- Brachial plexus palsy, spinal cord lesion, intracranial neoplasm, abscess, subdural empyema, or mitochondrial disease may present as stroke.
Stroke - TREATMENT
Stroke - initial stabilization
- Address airway compromise due to impaired protective reflexes.
- Stroke may present as new-onset seizures: Follow protocol for emergency treatment of seizures.
- Urgent neurosurgical evaluation indicated in cases of large cerebral hemispheric stroke, intracranial hemorrhage, or posterior fossa ischemic stroke
- Empiric antibiotics indicated in the setting of stroke and fever (abscess, septic emboli, empyema)
Stroke - general measures
- Hospitalization:
- Patients with radiologically documented or clinically suspected stroke who have stable airway, breathing, and circulation are most often hospitalized for observation and supportive therapy.
- Those with a diminished or fluctuating level of alertness or with radiographically extensive area(s) of infarction are often monitored in an intensive care unit for changes in respiratory status or signs of increased intracranial pressure.
- Strokes involving the posterior fossa or cerebellum, or affecting a large area of the cerebrum, are of particular concern because of the risk of tentorial or subfalcine herniation: A neurosurgical consult should be obtained for these cases and for those with intracranial hemorrhage above or below the tentorium.
- Consultation with neurology, cardiology, hematology, other pediatric subspecialists
Stroke - special therapy
Stroke - phys therapy
Rehabilitation and physical therapy may improve outcome: Institute as soon as the patient’s condition permits.
Stroke - medication
- Investigational therapies include hypervolemic hemodilution, thrombolytic agents, calcium channel antagonists, and neuroprotective agents such as glutamate receptor antagonists.
- In most cases, there is no contraindication to pharmacotherapy appropriate to any identified underlying condition; the decision to use antiplatelet or thrombolytic therapy or anticoagulation is complex and depends on risk of hemorrhage, experience of the clinician, and potential side effects.
Stroke - FOLLOW UP
The usual course in stroke of any cause is for gradual improvement after the acute onset of symptoms: Significant recovery of neurologic function may continue for months after the ictus, especially in infants and toddlers.
Stroke - disposition
Stroke - issues for referral
Involvement of child developmentalists and/or ophthalmologists in follow-up depends on the etiology and residual deficits of the stroke.
Stroke - complications
- Remote sequelae that may not be evident for months or years after stroke include epilepsy, hydrocephalus, learning difficulties, depression, short attention span, posture disturbances (especially cerebral palsy), sphincter disturbances, pressure sores, and susceptibility to infection if airway protective reflexes are impaired.
- Other complications include the following:
- Seizures
- Respiratory insufficiency
- Intracranial hypertension
- Motor, visual, and cognitive deficits
- Autonomic disturbances
- Infection susceptibility
Stroke - bibliography
- Ganesan V, Chong WK, Cox TC, et al. Posterior circulation stroke in childhood: Risk factors and recurrence. Neurology. 2002;59:1552–1556.
- Gunther G, Junker R, Strater R, et al. Symptomatic ischemic stroke in full-term neonates: Role of acquired and genetic prothrombotic risk factors. Stroke. 2000;31:2437–2441.
- Hogeveen M, Blom HJ, Van Amerongen M, et al. Hyperhomocysteinemia as risk factor for ischemic and hemorrhagic stroke in newborn infants. J Pediatr. 2002;141:429–431.
- Jayawant S, Parr J. Outcome following subdural haemorrhages in infancy. Arch Dis Child. 2007;92:343–347.
- Mercuri E, Barnett A, Rutherford M, et al. Neonatal cerebral infarction and neuromotor outcome at school age. Pediatrics. 2004;113:95–100.
- Molofsky WJ. Managing stroke in children. Pediatr Ann. 2006;35:379–384.
- Yamamoto LG, Yim GK, Bart RD Jr. Emergency department presentations of cerebrovascular disease in children. Am J Emerg Med. 1999;17:163–171.
Stroke - CODES
Stroke - icd9
436 Stroke
Stroke - PATIENT TEACHING-MED
- Internet information for families: National Stroke Association (www.stroke.org)
- Children’s Hemiplegia and Stroke Association (www.chasa.org)
- Pediatric Stroke Network (www.pediatricstrokenetwork.com)
Stroke - FAQ
- Q: Will my child have another stroke?
- A: The chance of recurrence depends on remediation of the underlying cause. Available evidence suggests that children with no identifiable underlying basis for stroke have a very low recurrence risk.
- Q: Are there any medicines for acute stroke?
- A: Tissue plasminogen activator (TPA) appears to be useful in some cases of adult nonhemorrhagic stroke, but its usefulness in childhood stroke has not been studied. Depending on the presence or degree of secondary cerebral hemorrhage, many specialists favor the use of heparin or low-molecular-weight heparin in the setting of stroke due to venous sinus thrombosis.
Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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