2. Stroke-important cause of acquired brain injury in newborns
and children.
Relatively rare-children- Arterial orVenous stroke.
Incidence of Arterial ischemic stroke (AIS) and CSVT -
5/100,000/yr and affects 1 in 2000 newborns.
3. A review of 13 years of data in New Jersey found equal rates of ischemic and
hemorrhagic stroke
Neonates - higher risk than older children.
Symptomatic ICH affects 1 in 100 full-term neonates.
Asymptomatic subdural hemorrhage affects almost half of term neonates and can
occur in infants delivered by both vaginal and cesarean delivery
arterial ischemic stroke around 1 in 4000 neonates
4. Strokes also occur in utero, Unilateral spasticity accounts for
19% to 35% of the total CP
rate of 0.67 cases of cerebral venous thrombosis (CVT) per
100,000 children per year, with neonates making up 43% of
cases
10. Sudden onset of pediatric stroke-no specific cause
delineated.
Thrombotic occlusions of carotid artery or branches of
middle cerebral artery- frequently documented causes of
strokes in children.
MRA- demonstrate significant vascular abnormalities in
75% of children with strokes.
Infants- seizures, motor signs few, abnormal hand
preference.
Older children- sudden onset of hemiparesis, seizures.
11. Primary vascular disease- stenosis- occlusion of intracranial portion of
Internal carotid artery & proximal ACA and MCA.
Chronic inflammatory, occlusive intracranial vasculopathy affecting ACA,
MCA associated with extensive network of collaterals.
Changes in pulmonary, renal, pancreatic arteries.
Multiple telangiectasias in basal ganglia- hazy, smoke like appearance-
Japanese word moyamoya applied.
Pattern represents opening of collateral channels.
12. Symptoms in childhood- females frequent.
MultipleTIA with or without residua ,Sudden
hemiparesis,, Seizures- 33 % - children <6yrs.
Disease is progressive
Poor prognostic factors- early age of onset, typical
clinical pattern, involvement of dominant hemisphere
or both hemisphere, complete occlusion of cerebral
blood vessels.
13. Cerebral angiography- definitive diagnosis.
Revascularization procedures like - STA-MCA procedure(of
choice), Encephalo duroarterio synangiosis (EDAS) or
multiple burr holes procedure in treatment of moya moya
disease.
14.
15. Pulseless disease
Chronic large vessel vasculitis of unknown etiology
Predom. Involves aorta & branches.
Females common-15-20 yrs.
Arteritis involving aorta & its branches - Inflammation of vessel wall-
granulomatous inflammation in media- blood vessel dilatation & aneurysm
formation.
Hypertension, absent pulses, vascular bruits.
16. Non atherosclerotic, non inflammatory vascular disease that causes
abnormal growth within wall of artery.
Common arteries- carotid & renal arteries.
Cause for childhood stroke & secondary hypertension.
Fibromuscular dysplasia of intra cranial vessels in children rare.
Angiographic finding of string of beads appearance of artery.
17. Hemiplegic migraine- transient hemiparesis with severe headache.
Familial forms & sporadic forms.
Transient loss of vision in one eye- amaurosis fugax
The risk is more apparent for individuals who have migraine with aura,
smokers, and women who use oral contraceptives
18. Children with complex congenital heart disease are
at risk for cardioembolic stroke, thrombotic stroke,
watershed infarcts from drops in perfusion pressure
and CVT
27% of children with stroke associated with cardiac
disease had recurrent stroke.
Mechanical heart valves, prothrombotic conditions,
and infection - vegetation
19. CVA- complication-TOF, TGA- common.
“Any child < 2 yrs with CHD , who has acute onset of neurological
signs- CVA should be considered as primary diagnosis ‘’
Chronic hypoxemia in severe cases of congenital heart disease may
lead to polycythemia,
20. Sickle cell anemia (SCA)
most common Hemoglobinopathy assoc. with CVA.
Incidence- 700 per 1 lakh children with SCA.
Stroke in SCA- large vessel disease, venous occlusion or intracerebral
hemorrhage(very rare)
21. Strokes in children with SCA- highest incidence in 5-10 yrs.
Hemiparesis- most common symptom, Aphasia- 20 %, Seizures- 15 %,
TIA- 10 %
Children with HBSS - highest incidence of stroke- monitor with trans
cranial USG.
22. Blood transfusion & exchange transfusion- standard mode
of treatment of acute stroke in SCA.
Periodic blood transfusions- decrease productions of sickle
cells- reduce recurrence of strokes by 90 %.
incidence of first stroke in children with sickle cell anemia
dropped from 0.88 per 100 person-years to 0.17 per 100
person-years
exchange transfusion -The Stroke Prevention in Sickle Cell
Trial (STOP) - keep the HbS < 30% reduced the risk of
recurrent stroke by 90%
23. Bleeding occurs in 25 %.
Bleeding more common in factor IX deficiency.
Intra cranial Hemorrhage common in children <18 yrs, esp. <3yrs.
Serious permanent deficit- 50 %, mortality- 35 %.
Complications of labour or delivery produce intracranial hemorrhage in
newborns with hemophilia.
Treatment- replace deficient clotting factors- performed prophylactically.
24. Homozygous deficiency of Protein C in newborns- venous thrombosis-
thrombosis of cerebral veins.
Strokes –significantly reduced levels of protein C.
ITP- major intracranial hemorrhage can occur.
Subdural, intra parenchymal, intra ventricular hemorrhage- infants b/w
2 weeks - 12- Vitamin K deficiency.
Hemolytic uremic syndrome- seizures, depressed consciousness,
subarachnoid hemorrhage, hemiparesis,.
25. Stroke affects approximately 1% of children with cancer
at risk for both intracranial hemorrhage and ischemic infarction.
Intracranial hemorrhage- 20% , secondary to thrombocytopenia
infarction or CVT due to leukostasis
CVA also occur after bone marrow transplantation.
26. Acute bacterial meningitis- vasculitis, vasospasm,
intracranial aneurysm formation.
Stroke common sequel of Severe meningitis- Group B
streptococcal & Listeria (<2 months), H. Influenza,
Pneumococcal (>2 months),Tuberculous meningitis.
Occlusion of veins or dural sinuses- follow otitis media,
mastoiditis, sinusitis & infection of scalp & face.
Post varicella angiopathy, mycoplasma pneumonia, borrelia-
burgdorferi, chlamydia pneumonia, HIV, helicobactor pylori,
hemolysing streptococci- predisposition for stroke.
27. HIV : marantic endocarditis,
arteriopathy of medium and small vessels or
aneurysms,
secondary infection,
ART - dyslipidemia – accelerated atherosclerosis
Brucellosis
Lymes disease
28. SLE- 40% of patients have neurologic abnormalities- psychiatric,
behavioral abnormalities & focal neurologic signs.
HSP- headaches, mental status changes, seizures, focal neurologic
deficits, involvement of peripheral nerves.
Kawasaki disease- aseptic meningitis, hemiparesis.
29. Infants with fever & dehydration- primary venous or sinus thrombosis.
Hypernatremic dehydration- seizures, depressed state of
consciousness.
Juvenile onset Insulin dependent Diabetes mellitus- acute
hemiparesis.
30. MELAS SYNDROME- epilepsia partialis continua or status epilepticus,
repeated strokes.
MELAS - L-Arginine improves endothelial dysfunction- in treating the
stroke-like episodes
Homocystinuria may lead to infarction, presumably through elevated
homocysteine levels and subsequent vascular injury.
Homocysteine – FA, B6, B12
31. Fabry disease is an X-linked LSD - deficiency of α-galactosidase -
accumulation of glycolipids in the endothelial wall.
Both male and female heterozygotes are susceptible to cerebral
thrombosis - increase in vasoreactivity in damaged vessels or
endothelial and leukocyte activation.
Males may be more severely affected but rarely show cerebrovascular
involvement before age 23.
32. Trauma to carotid artery- delayed onset of neurological signs-
thrombosis in vessel & extension into cerebral vessels.
Severe cerebral edema- death.
Permanent neurological residua- seizures & neuropsychological
deficits.
33. External trauma to carotid artery- hematoma on lateral portion of
neck, Horners syndrome,TIA followed by lucid interval –then sudden
onset of hemiplegia or hemiparesis.
trauma to cervical spine- sudden twisting or jerking of head- injure
carotid or vertebral arteries.
Basilar skull fracture can cause laceration of carotid artery at foramen
magnum- severe bleeding from mouth & ipsilateral ear.
34. Arteriovenous malformations
4 types of vascular malformations- Arteriovenous malformations, venous
angioma, capillary telangiectasias, cavernous angioma.
Admixture of normal & abnormal blood vessels.
Surrounding brain contains areas of fibrosis, inflammation, glotic
changes, calcification.
Seizures- common clinical abnormality than hemorrhage.
Subarachnoid, intraparenchymal, or combined can occur.
35. Vascular malformations may be located in cerebellum & brainstem.
50 % of children with intracranial arteriovenous malformations have
bruits heard over head.
“A cranial bruit heard in an infant younger than 4 months of age ,
even in the presence of loud cardiac murmur , is always assoc. with
intracranial arteriovenous malformation”
36. CT with contrast, MRI, Arteriography.
RX- surgical accessibility of lesion.
Total surgical excision is curative,
Embolization of lesion may be effective.
Stereotactic radiosurgery with linear accelerator – effective modality
for some patients.
37. Arteriovenous malformation ofVein of Galen- direct connection
between branches of carotid or vertebral circulation &Vein of Galen.
Vein undergoes aneurysmal dilatation because of high pressure &
arteries divide forming a network of vessels adjacent to the vein.
Development of malformation in infancy forms a hemodynamically
significant arteriovenous shunt.
38. Neonatal period- signs & symptoms of high output congestive heart failure.
Children- systolic heart murmur, cranial bruit, cardiomegaly, hepatomegaly,
tachycardia, respiratory distress, & pulmonary edema.
Death – cardiac failure.
Presentation in later infancy- Hydrocephalus, Subarachnoid hemorrhage.
Dilated veins over scalp, intracranial bruits.
Poor prognosis- death from hemorrhage, increased intracranial pressure or
cardiac failure.
39. Presentation in later life- Headache, signs of intracranial hemorrhage- convulsions & focal
neurological signs.
Signs of brain stem dysfunction & raised intracranial pressure.
Calcification within malformation on CT scan.
Arteriography- diagnostic.
RX- difficult- location, surrounding network of blood vessels, poor cardiovascular status of
pt.
Microsurgical techniques & staged surgical procedures.
Embolization not effective.
40. Uncommon in children less than 10 yrs.
Located in either anterior or posterior circulation.
Sudden onset of massive subarachnoid hemorrhage & depressed state
of consciousness.
Commonly occur on anterior cerebral artery or internal carotid artery.
Usually >1cm – intracranial hemorrhage, seizures.
Surgery, microsurgical techniques- definitive RX for aneurysms.
Aneurysm not removed- 50 % will bleed- serious neurological deficits.
41. Sturge weber syndrome
Port wine stain on face & scalp , capillary venous angioma of meninges,
vascular abnormality within cortex & white matter of ipsilateral
hemisphere.
Intractable Seizures, hemiparesis, mental retardation.
Eye- glaucoma, angioma of retina & choroid.
Early excision of abnormal areas of cortex.
Affected area is large- hemispherectomy
42. Common in children under 3 yrs, often during first year of life.
Septic venous sinus thrombosis- most common in neonates.
Occlusion of sagittal sinus in older children- syndrome of pseudo tumor
cerebri , headache, CN 6 palsy- false localizing sign, papilledema, visual
loss.
Good prognosis.
CT, MRV
anticoagulation
43. Clinical- seizures, increased intracranial tension, decreased level of
consciousness.
Predisposing factors- otitis media, mastoiditis.
Otitic hydrocephalus- when otitis media & mastoiditis led to lateral
sinus thrombosis & increased intracranial pressure.
Vigorus RX for otitis media & mastoiditis
44. Cavernous sinus- CN 3, 4, 6, ophthalmic division of CN5, internal
carotid artery.
Rupture of artery- massive arteriovenous shunt with proptosis, bruit,
involve. of CNs.
Internal carotid artery becomes thrombosed in segment- cavernous
sinus- massive hemispherical infarction.
Predisposing factors- infection of orbit, paranasal sinus, skin of
periorbital & malar areas.
45. Clinical- conjunctival suffusion- peripheral conjunctival capillaries,
conjunctival edema, retinal edema.
Ptosis- CN 3.
External opthalmoplegia- CN3, 4, 6.
Septic cavernous sinus thrombosis- medical emergency- vigorous
antibiotic therapy.
No role for anticoagulant therapy.
47. CECR1 – ADA 2
AB collagen type IV alpha
glutathione peroxidase gene (GPX3)
ADAMTS13 -VWF
48. Older children : Hemiplegia, Hemi sensory loss, Aphasia &
other neurological deficits.
Younger children(< 1 yr) : subtle, variable findings,
seizure(mc),
early hand preference, limp during walking.
49. Todds paralysis-Transient post ictal hemiparesis(< 24hrs,
rarely few days)
Hemiplegic migraine (temporary motor deficit)
Syndrome of alternating hemiplegia
ICSOL ( Intracranial space occupying lesion )
ADEM, MS, vasculitis
50. H/o delivery , perinatal period and basic developmental milestones.
Development of a hand preference before 1 year of age may be a sign of a mild
hemiparesis
H/O ear, throat, mastoid infection.
H/O intra oral or neck trauma.
H/O cardiac d/s.
H/O Hematological disorders.
H/O multifocal seizures, raised intracranial pressure, vomiting- ? Superior sagittal sinus
thrombosis.
H/O Hemiparesis & seizures in first two years of life- ?
Arterial occlusions.
51. face - signs of dysmorphic features
head circumference - macrocephaly due to hydrocephalus ,
microcephaly due to tissue loss
Skin – pallor, cyanosis, petechiae, neurocutaneous markers
Auscultate – bruit/ murmur
54. TCD - screen children with sickle cell anemia - high flow velocities -
higher stroke risk.
Magnetic resonance angiography (MRA).
Conventional angiography - the most accurate method - vascular
malformations , moyamoya, vasculitis, and dissection
Digital subtraction angiography (DSA).
56. Arterial Ischemic Stroke
No randomized control trial on children with AIS.
Treatment primary directed towards stabilizing systemic factors &
management of underlying causes.
Supportive care
Manage raised intracranial pressure, blood pressure & fluid balance.
Blood glucose carefully monitored-Hyperglycemia exacerbate infarct
size.
Maintain normal body temperature.
Aggressive antiepileptic treatment.
57. Antithrombotic therapies
Use of anticoagulant therapy increasing in pediatric AIS.
No clear guidelines are available on the use of heparin in pediatric
arterial stroke
protein C or S deficiency, or with antiphospholipid antibody syndrome -
long-term anticoagulation
Neonatal AIS - Antithrombotic therapy is rarely indicated in most
cases because of negligible recurrence risk
58. Oral anticoagulation
Congenital or acquired heart disease
Severe hypercoagulable states
Arterial dissection
Recurrent AIS orTIA while on aspirin.
59. Thrombolytic agents
No evidence-based guidelines are currently available on using
intravenous or intra-arterial thrombolytics in children..
Non thrombotic therapies
Transfusion therapy
Neuroprotective agents – no role
Immunosuppressants
60. Surgical evacuation of hematomas, insertion of ventricular or
lumboperitoneal shunts & rarely revascularization procedures.
Rehabilitation therapy
Speech therapy
Occupational therapy
Physical & psychological therapy
61. Stroke in children relatively rare.
Recurrence is low in neonates
There are fundamental, etiologic & developmental differences
in children compared with adults .
Multiple causes for stroke in children & many risk factors.
Hemorrhagic stroke higher mortality than ischemic stroke.
62. Bradley’s textbook of neurology 7th ed
Nelson textbook of Pediatrics.19th edition;2080-2086.
Arterial Ischemic Stroke in Children andYoung Adults,Warren
D et al. Continuum ReviewArticle, 2017
PediatricArterial Ischemic Stroke, Moharir M. Continuum
ReviewArticle, 2014
