STROKE in CHILDHOOD PROF. DR. AYÇA VİTRİNEL

Sudden occlusion or rupture of cerebral arteries or veins resulting in focal cerebral damage and clinical neurologic deficits The incidence is / children/year The incidence is / children/year

Cerebrovascular disorders occur more often in children than suspected. children than suspected. These disorders are less common than in adults. - The infrequency of cerebrovascular disorders in children makes it difficult to organize multicenter study. - Lack of awareness contributes to delayed diagnosis.

Recognition of stroke in children has increased because of the widespread application of noninvasive diagnostic studies - MRI - MRA - CT - USG Patients with sickle cell disease, leukemia and congenital heart disease now have a larger life expantancy. 1/3 of strokes can be seen in neonatal period → Immaturity of cerebrovascular and neurological system

Hemorrhagic strokes Ischemic strokes – Occlusion Venous/ arteriel Venous/ arteriel

Ischemic Arteriel Stroke Arterial thrombosis / embolism may involve Major cerebral arteries - İntermal carotid - Ant cenebral - Mid cenebral -Post cenebral Smaller cerebral arteries - Duration of ischemia - Localızation of ischemia - Extention of ischemia - Development of collaterales - Metabolic necesisity of brain

Venous occlusion was discovered more quickly than arterial occlusion. - Septic → direct invasion of bacteria AOM, bacterial meningitis,encephalitis - Aseptic → Severe dehydration in infancy - Aseptic → Severe dehydration in infancy hyperco agulopathy hyperco agulopathy Cyanotic heart diseases Cyanotic heart diseases Iron deficiency anemia Iron deficiency anemia protein C,S, antithrombin III protein C,S, antithrombin III vascular disorders vascular disorders

Hemorrhagic stroke Rupture of vessel ( hemorrhagic disorder) Pupture of aneurysm Congenital weakness of the vessel,deficiency of type III collagen Intracerebral Hemorrhage HemophiliaITP Hematologic disorders Subarachnaid Hemorrhage Intense headache Nuchal rigidity Hemiparesis Hemiparesis

Etiology of stroke in Children 30% of cases is idiopathic 30% of cases is idiopathic

ISCHEMIA 1. Hematologic problems Sickle cell anemia ITP Trombotik trombocytopenic purpura TrombositossPolicytemiaLeukemia 2. Acquired protrombotic problems Protrombotic drugs (L-Asparaginaz and oral contraseptives) Lupus anticoagulan Anticardioli pin antikorlan Lipoprotein anomalies 3. Congenital protrombotic problems Antitrombin deficiency Protein S deficiency Protein C deficiency Protrombin gen G-A mutation FactorV 1691 G-A avd Factor V 1299 A-G mutation Hyperhomosisteinemi a/ MTHFR 677 C-T mutation 4. Metabolic diseases Hiperli pidemia Mitochondrial diseases (MELAS) 5. Infection CNS infections Sepsis / septic emboli 6. Vasculitis Systemic Lupus Eritematosis (SLE) Poliarteritis nodosa Granulomatous anjitis Takayasu arteritis Romatoid arteritis Dermatomyositis Inflamatuar bowel disease 7.Systemic vascular diseases DM Ehler-Danlos Syndrome Pseudodoksantoma elasticum Fabry disease Arteriel fibromuscular dysplasis Moyamoya Syndrome Postradiation vasculopathy Mygren 8. Trauma Post-traumatic arteriel dissection Lipid or air emboli Foreign body emboli Cardiac cateterization 9. Kongenital heart disease VSD, ASD - Aort or mitral stenosis Coarctation Patent foramen ovale 10. Acquired heart diseases

HEMORRHAGIC 1. VASCULAR A.Kongenital vascular anomalies - Arterivenous malformation - Venous angiom - Cavernous hemangiom - Hereditary hemor telengiectasis - İntracranial aneurism and coarctation B. Vaskulopathy - EhIers-Oanlos Syndrome Tip IV - Moyamoya Syndrome - Pseudoksantoma elasticum - Sickle cell anemia - Intracranial trauma C. Systemic diseases - Systemic hypertension D. Vaskulitis - Hemolitic-uremic Syndrome - Drug dependence (cocain, amfetamin) E. Trauma - Child abuse - Angioplasty - Intracranial trauma 2. İNTRAVASCULAR A. Hematologic diseases - ITP - Trombotic trombocytopenic purpura B. Coagulation disorders - Factor deficiency - Vit.K deficiency and liver dises

Congenital heart disease and sickle cell disease are common causes of stroke in children. Atherosclerosis is common in adults. No cause can be detected in about 30% of patients with ischemic infarct in childhood.

Clinical Findings HemiplegiaSeizuresHeadacheLetargy Paralysis of 6th nerve Unconsciousness

Laboratory Findings Cbc, blood smear ESR EKG, ECHO Electrolyte, BUN, creatinin, serum glucose, total protein, uric acid, Ca, P Cholesterol, triglyserid Blood and urine homosistein (increasing the activity of FV,X,XII and supression of protein C) Hb electrophoresis ANALPPT,PTT,plasminogen Pr C,Pr S Prothrombin gene mutation Coagulation, factors

Infection markers Serum and CSF Varicella Ab CSF lactate Plasma ammonium, lactate,piruvate Urine organic acids

Radiologic Findings US - Used under 1 yr of age CT - Sensitivity is low in the first 6 hrs MRI - Sensitivity is 80% in acute evaluation of vascular pathology Functional MRI,MRA - Diffusion Sensitive method for acute ischemia Sensitive method for acute ischemia - Perfusion Shows all ischemic tissues Shows all ischemic tissues - MRS Biochemical changes Biochemical changes

TREATMENT Since there are not randomized controlled studies for childhood stroke treatment the treatment is still controversial and relies on adult literature Aim - Restriction of infarct area - Restriction of infarct extension - İmproving prognosis - Prevention of recurrences

Supportive treatment -Oxygenisation -Ventilation -Hydration -Decreasing intracranial pressure(furosemid,mannitole) -Anticonvulsant drugs -Correction of metabolic disturbances(serum glucose etc.)

Treatment of acute stage Thrombolytic treatment - In the first three hours Anticoagulation - In the first 7-10 days Prophylactic therapy

Thrombolytic therapy Usage of Tissue plasminogen activator (t-PA) is limited in childhood Causes severe bleeding Causes severe bleeding Contrindicated in newborns Contrindicated in newborns

Anticoagulan Therapy Heparinization-low molecular weight heparin Heparinization-low molecular weight heparin Oral anticoagulant drugs Oral anticoagulant drugs

Prophylactic therapy 3 – 6 months Oral anticoagulant drugs-Warfarin Oral anticoagulant drugs-Warfarin Acety salisilic acid (antiplatelet effect ) Acety salisilic acid (antiplatelet effect ) ( Aspirin) ( Aspirin)

Physical therapy Speech therapy Occupational therapy Pyscologic services