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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 8-10.7/100000 children/year. Cerebrovascular disorders occur more often in
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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 8-10.7/100000 children/year
Cerebrovascular disorders occur more often in 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
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 hyperco agulopathy Cyanotic heart diseases Iron deficiency anemia protein C,S, antithrombin III vascular disorders
Hemorrhagic stroke • Rupture of vessel ( hemorrhagic disorder) • Pupture of aneurysm Congenital weakness of the vessel ,deficiency of type III collagen • Intracerebral Hemorrhage Hemophilia ITP Hematologic disorders • Subarachnaid Hemorrhage Intense headache Nuchal rigidity Hemiparesis
Etiology of stroke in Children 30% of cases is idiopathic
ISCHEMIA 1. Hematologic problems Sickle cell anemia ITP Trombotik trombocytopenic purpura Trombositoss Policytemia Leukemia 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 20210 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 • Hemiplegia • Seizures • Headache • Letargy • 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 • ANA • LP • PT,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 - Perfusion Shows all ischemic tissues - MRS 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 Contrindicated in newborns
Anticoagulan Therapy Heparinization-low molecular weight heparin Oral anticoagulant drugs
Prophylactic therapy 3 – 6 months Oral anticoagulant drugs-Warfarin Acety salisilic acid (antiplatelet effect ) ( Aspirin)
Physical therapy • Speech therapy • Occupational therapy • Pyscologic services