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Childhood Stroke

Childhood Stroke

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Childhood Stroke

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  1. Childhood Stroke Gita V. Massey, MD Coagulation Update 2006 September 30, 2006

  2. The challenge…………….. • How to cover this enormous topic in 30 minutes and give some insightful advice to the practicing hematologist……………

  3. What the experts say……. • Jordon, LC; Stroke in Childhood. The Neurologist; 12, 94-102; 2006 • deVeber, G; In pursuit of evidence-based treatments for paediatric stroke. The Lancet Neurology; 4, 432-436; 2005 • Lynch, JK and Han CJ; Pediatric Stroke: What do we know and what do we need to know? Sem in Neurology; 25,410-423; 2005 • deVeber, G; Arterial ischemic strokes in infants and children: and overview of current approaches; Sem in Thromb and Hemost; 29, 567-573; 2003.

  4. Epidemiology • Incidence 8/100,000/year (1.3-13) • Incidence in neonates 1/4,000/year • Incidence increasing • More sensitive imaging • Effective Rx for predisposing condition (CHD, prematurity, tumors) • Death in 6% (top 10 causes of death in children) • Neurologic deficits in 2/3 • 20-30% recurrence risk

  5. Children are not little adults…… • Incidence is rare • Subtle neurologic presentation • Underdiagnosis and delay in diagnosis • Multiple types of stroke • Multiple risk factors

  6. Type of Stroke

  7. Acute Ischemic Stroke • Incidence is 3/100,000, year • Neonates account for 25% of AIS – median age 5 yrs • Male predominance (60%) • Predominance in African-American population

  8. Clinical Features of AIS • Canadian Registry • 51% hemiparesis • 48% seizures • 17% speech disorder • 50% headache, lethargy, confusion • Neonates • <25% hemiparesis • Lethargy and seizures predominate • No symptoms (early hand dominance)

  9. Risk Factors for AIS

  10. Vascular Risk Factors

  11. Embolic Risk Factors

  12. Intravascular Risk Factors(The Hematologist’s Domain)

  13. The Acquired Prothrombotic States

  14. The Congenital Prothrombotic States

  15. The Confusing Realm of Prothrombotic States • How much do they contribute? • Rare disorders • Age related differences • Acute differences • Dietary variations

  16. Inter-relations

  17. The Diagnostic Work-Up • History • Trauma, infection, palpitations, mental status chages, underlying disease • Previous DVT’s, family history • Physical Exam • Marfanoid body habitus • Cutaneous lesions • Café au lait spots • xanthoma

  18. The Diagnostic Work-Up • Laboratory Studies • CBC, comprehensive metabolic panel, ESR • Toxicology and infectious studies • The hypercoagulation studies • Imaging Studies • CT • MRI/MRA/MRV • Echo

  19. The hypercoagulation profile • Implicated in 38%-75% of childhood stroke patients • Expensive • Rare disorders • Transient disorders • What can you do about it? • B12, folate, B6 in hyperhomocystenemia • Niacin in lipoprotein a

  20. Therapy • Absence of RCT • Adapted from adults • Treat underlying risk factor • Prevent recurrence

  21. Consensus on…… • Sickle cell disease • Acute therapy • Exchange transfusion • Preventive therapy • Blood transfusion every 3-6 weeks to maintain HbS<30% • ?HU, stem cell transplant • Transcranial dopplers

  22. Current recommendations…… • Neonatal AIS – no therapy • Dissecting vasculopathy – anticoagulation 3-6 months • Cardiogenic embolism – anticoagulation but no consensus on length of time • Vasculopathy – ASA (no consensus on dose 1-5mg/kg/day) • Recurrent stroke – consider anticoagulation

  23. Current practice….. • Most (>50%) will use LMWH/UH 5-7 days in non neonatal period followed by ASA • Thrombolytic agents are rarely used in pediatrics and their use is recommended only in conjuction with clinical trials.

  24. Outcomes of Childhood AIS • 1991 – 85% long-term sequelae • 2001 – 60% long-term sequelae • Hemiparesis, speech, learning and behavior • WORSE IF….. • Multiple risk factors • CHD/progressive vasculopathy • Larger infarct • Stroke after neonatal period • Seizures with stroke

  25. What do we need for the future? • Prospective cohort studies • Standard evaluation of risk and outcome • Develop therapy and prevention strategies • Incidence studies • Case control studies of risk factors • Outcome studies