Introduction to Pediatric Stroke Management by Miya Bernson-Leung for OPENPediatrics
Introduction to Pediatric Stroke Management by Miya Bernson-Leung for OPENPediatrics
In this video, Dr. Miya Bernson-Leung discusses pediatric stroke and its signs and symptoms, diagnosis, treatment, and occurrence rates.
Direct links to chapters:
0:30 Chapter 1: Incidence of Stroke
1:16 Chapter 2: Classification
2:58 Chapter 3: Risk Factors
6:24 Chapter 4: Clinical Presentation
9:55 Chapter 5: Prognosis
10:51 Chapter 6: Differential Diagnosis
16:03 Chapter 7: Treatment
Initial publication: August 1, 2018.
Please visit: www.openpediatrics.org
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Content
0 ->
13.99 -> Introduction to Pediatric
Stroke Management
17.47 -> by Miya Bernson-Leung.
20.75 -> Hello.
21.32 -> My name is Miya Bernson-Leung
from the Boston Children's
24.11 -> Hospital Stroke and
Cerebrovascular Center.
26.78 -> Today, I will be speaking
about pediatric stroke.
29.96 -> Incidence of Stroke.
31.025 ->
33.54 -> Stroke is unfortunately
common among serious pediatric
36.78 -> neurologic problems.
38.7 -> About 1 in 1,600 to
1 in 4,000 neonates
41.94 -> will have a stroke
around the time
43.41 -> of birth, defined as between
the 20th week of gestation
46.89 -> and the 28th postnatal day.
49.2 -> In older children one
month of age to 18 years,
52.44 -> the annual incidence of
stroke is between 2.3 and 4.6
56.7 -> per 100,000 children per year.
59.59 -> This means that at least 1,000
neonates and 1,600 children
63.42 -> will have a stroke in the
United States this year.
66.27 -> Of note, we will not talk
about neonatal stroke
68.61 -> for the remainder of this
video, as the risk factors
71.49 -> and treatments for
neonatal stroke
73.05 -> and stroke in older children
are completely different.
76.26 -> Classification.
77.163 ->
79.83 -> Stroke can be divided into
ischemic and hemorrhagic.
83.24 -> And in children, about half
of strokes are ischemic,
85.44 -> and half are hemorrhagic.
87.005 -> An ischemic stroke
occurs when brain tissue
89.7 -> is damaged due to the
blockage of an artery or vein.
93.38 -> An arterial ischemic
stroke, or AIS,
96.45 -> is caused by the loss of
downstream blood supply
99.15 -> when an artery is occluded.
101.19 -> This can be resulting from
areas of vessel lumen narrowing
104.19 -> or endothelial injury, an
increase in clot formation,
107.67 -> what we call hypercoagulability,
or thromboembolism,
111.12 -> when a clot formed elsewhere in
the body, such as in the heart,
114.24 -> moves and becomes lodged
in a cerebral artery.
117.09 -> Ischemic stroke resulting
from the blockage of a vein
119.7 -> is called "venous infarction."
121.53 -> The loss of venous
drainage leads
123.06 -> to pressure buildup and
therefore tissue damage.
126.06 -> This is one possible result of a
cerebral sinovenous thrombosis,
129.9 -> or CSVT, when a clot
forms within the draining
133.23 -> sinuses of the brain.
135.27 -> Symptoms of each type of
stroke will be discussed
137.52 -> at a later point in the video.
139.41 -> Transient ischemic
attack, or TIA,
142.32 -> is defined as the symptoms of
an ischemic stroke that resolve.
146.55 -> In adults, this has been defined
as symptom resolution within 24
150.03 -> hours without ischemic injury
being apparent on imaging.
153.69 -> And we now know that TIA
can also occur in children.
157.5 -> TIA is important because it
often heralds a future stroke.
160.8 -> And therefore, a complete
workup is warranted.
163.86 -> Hemorrhagic strokes
occur when there
165.45 -> is tissue damage due to
bleeding within the brain,
168.12 -> an intraparenchymal hemorrhage,
or adjacent to the surface
171 -> of the brain, a
subarachnoid hemorrhage.
173.48 -> This produces mass
effect and ischemia
175.41 -> of the adjacent tissues.
178.06 -> Risk factors.
180.374 -> A number of risk
factors have been
181.79 -> identified for arterial
ischemic stroke in children.
184.572 -> And often, these are
quite different from those
186.53 -> for adults.
187.85 -> Many of these are also
risk factors for CSVT.
191.48 -> It's important to identify
these risk factors
193.91 -> because many of them may
be of value for prognosis
197.66 -> or may necessitate
a targeted therapy.
200.2 -> The major category, at 53%
of arterial ischemic strokes
203.66 -> in children, is
arteriopathy, a congenital
206.42 -> or acquired abnormality of
the cerebral blood vessels.
209.99 -> Examples include dissection,
vasculitis, the arteriopathy
214.43 -> associated with sickle
cell disease, moyamoya,
217.91 -> and focal cerebral arteriopathy,
a unique phenomenon
221.15 -> in children that may have
an infectious trigger.
224.61 -> The second major
category of risk factors
226.71 -> for arterial ischemic stroke
in children is cardiac disease.
230.07 -> This includes congenital heart
disease, particularly cyanotic
233.22 -> lesions, and acquired
heart disease,
235.62 -> such as endocarditis
or cardiomyopathy.
238.86 -> Children with
cardiac disease are
240.33 -> at particular risk of stroke
around the time of procedures
243.15 -> such as surgeries or
cardiac catheterizations
246.33 -> or when requiring mechanical
circulatory support,
249.09 -> such as with an
ECMO or VAD device.
251.82 -> The next category, at 23% of
arterial ischemic strokes,
255.12 -> is acute head and
neck conditions,
256.74 -> including head trauma,
intracranial surgery,
260.13 -> meningitis, and pharyngitis.
262.56 -> Following that, at 22% of
arterial ischemic strokes,
265.47 -> is acute systemic conditions,
including sepsis and shock.
269.04 -> A number of chronic
systemic conditions
271.02 -> are seen in about
19% of children
273.36 -> with arterial ischemic stroke.
275.23 -> And these include
sickle cell disease,
277.47 -> other genetic disorders, such
as connective tissue disorders,
280.8 -> systemic malignancies,
indwelling catheters,
283.89 -> and the use of oral
contraceptives.
286.08 -> Similarly, a prothrombotic
state is found in about 13%
289.62 -> of children with
ischemic stroke,
291.51 -> including genetic or
acquired thrombophilias
294.09 -> or hypercoagulable states.
296.31 -> Importantly,
atherosclerosis, which
298.23 -> is a major contributor to
stroke burden in adults,
301.14 -> is seen in only 2% of
children with stroke.
304.11 -> All told, about 24% of
children with stroke
307.44 -> will have some sort of
infection around the time
309.54 -> of presentation.
310.77 -> And oftentimes, this can serve
as the acute trigger for stroke
314.01 -> in a child who has an
underlying predisposition.
317.91 -> In fact, about 50% of children
with arterial ischemic stroke
321.69 -> will be found to have
two or more risk factors.
324.16 -> And therefore, it's
important to keep looking,
326.19 -> even after a single risk
factor has been identified.
329.58 -> All told, 90% of children will
have one or more risk factors,
332.97 -> leaving only 10% unexplained.
335.73 -> Factors associated with
hemorrhagic stroke in children
338.28 -> include vascular anomalies, such
as arteriovenous malformation,
342.33 -> aneurysm, and cavernous
malformation, vasculopathies,
345.97 -> such as those associated with
sickle cell disease or moyamoya
349.05 -> syndrome due to the fragility
of those blood vessels,
352.05 -> coagulation disorders such
as hemophilia, vitamin K
355.2 -> deficiency, or
anticoagulant therapy--
358.09 -> and this is one reason that
children with cardiac disease
360.48 -> may be at risk for both
ischemic and hemorrhagic stroke
363.21 -> if they are using
anticoagulants--
365.49 -> and, finally, brain tumors.
367.2 -> Hemorrhage can also
occur secondary to CSVT
370.2 -> due to the buildup
of venous pressure.
372.7 -> And finally, an ischemic
stroke can undergo
374.82 -> hemorrhagic transformation.
376.74 -> Similar to ischemic stroke
in children, about 90%
380.082 -> of children with
hemorrhagic stroke
381.54 -> will have at least one
identifiable risk factor.
384.27 -> Clinical Presentation.
387.17 -> The presentation of acute
ischemic stroke in children
389.99 -> can be similar to
that of adults.
392.12 -> The hallmark is the acute onset
of a focal neurologic deficit.
396.53 -> About 85% of children with
arterial ischemic stroke
399.59 -> will have focal signs, including
hemiparesis in 60 to 80%,
404.66 -> a speech difficulty
in 10 to 35%,
407.81 -> or visual field
defects in 5 to 20%.
411.26 -> Focal symptoms of
ischemic stroke
413.17 -> may be localizable to
specific areas of brain tissue
416.99 -> that correspond to
the vascular territory
419.12 -> of the occluded vessel.
420.8 -> I'll highlight a number of
these vascular syndromes.
423.41 -> But it's important to
recognize that children may not
425.96 -> manifest all of the symptoms
of a given vascular syndrome
429.95 -> and that other
combinations of symptoms
431.63 -> may be possible depending
on the territory affected.
435.27 -> Strokes affecting the
anterior cerebral artery
438 -> often involve weakness
of the contralateral leg
440.61 -> and may also have
behavior changes.
443.22 -> Strokes of the middle
cerebral artery
445.38 -> can manifest as weakness
of the contralateral face
447.96 -> and arm, a speech disturbance,
such as aphasia or dysarthria,
452.43 -> a visual field
deficit, or hemianopia,
455.55 -> inattention to stimuli
on one half of the body
458.19 -> or in one half of space,
called hemineglect,
460.95 -> and sensory deficits.
463.39 -> Stroke in the posterior
cerebral artery territory
466.27 -> can also produce visual field
deficits and sensory deficits.
470.26 -> Strokes in the
vertebrobasilar system
472.21 -> can be harder to identify
because they often
474.94 -> don't manifest with
lateralized signs.
477.67 -> For instance, symptoms
of vertebrobasilar stroke
480.22 -> can include dizziness,
ataxia, impaired balance,
484.21 -> abnormalities of eye
movements or pupils,
487.12 -> changes in speech or
swallowing, and weakness
489.73 -> and sensory changes
in various patterns,
493.36 -> as well as a decrease in
the level of consciousness.
496.8 -> Finally, occlusions of the
cerebral veins and sinuses,
499.59 -> such as CSVT, can
produce decreased level
502.44 -> of consciousness, headache,
vomiting, and papilledema,
506.07 -> particularly as a late sign.
508.56 -> Children with ischemic
strokes can also
510.33 -> present with diffuse
signs, making recognition
512.94 -> that a stroke has
occurred challenging.
515.61 -> About 61 to 64% of children
with arterial ischemic strokes
519.57 -> will have diffuse signs,
such as altered mental status
522.57 -> in 42 to 52% or
headache in 24 to 40%.
527.88 -> And in fact, about 10%
of children with stroke
530.34 -> may have only diffuse signs.
532.83 -> Similarly, about 33%
to 49% of children
536.01 -> with an arterial stroke
will have both focal signs
539.01 -> and diffuse signs that
are not referable to
541.02 -> a specific vascular territory.
543.36 -> There's an important
relationship between stroke
545.7 -> and seizures for children.
547.29 -> About 25 to 31% of children
with an arterial ischemic stroke
551.25 -> will have a seizure around
the time of presentation.
553.92 -> And as many as 42% of younger
children will have a seizure.
557.73 -> This is in comparison to only
5% of adults having a seizure
561.24 -> at the time of their stroke.
563.58 -> Oftentimes, the acute
onset of focal deficits
566.76 -> is attributed to a postictal,
or Todd's, paralysis.
570.06 -> But it's important to
recognize that the incidence
572.4 -> of a new onset focal
epilepsy presenting
574.83 -> with a Todd's paralysis is
about comparable to that
577.86 -> of a new stroke.
579.6 -> And so it's important
to consider stroke
581.49 -> for all first-time
focal seizures,
583.35 -> regardless of the
presence of paralysis.
586.51 -> About 37% of hemorrhagic strokes
will have acute seizures.
590.62 -> And 20 to 48% of CSVT
will have acute seizures.
595.15 -> Prognosis.
597.93 -> The prognosis of
stroke in children
599.67 -> is unfortunately mixed.
601.74 -> The immediate mortality
is between 10 and 40%,
605.1 -> making cerebrovascular
disorders among the top 10
607.65 -> causes of child mortality.
610.09 -> Only 37% of children who
have an ischemic stroke
613.27 -> will make a full recovery.
615.22 -> And 41% of children with
arterial ischemic stroke
618.4 -> or CSVT will have moderate
to severe deficits.
622.36 -> The recurrence risk of arterial
stroke within five years
625.21 -> ranges between 7% and 41%
depending on the etiology
629.08 -> and the population studied.
631 -> For example, perinatal
strokes have only a 1 to 2%
634.81 -> recurrence rate, whereas strokes
associated with arteriopathy
638.44 -> have a 66% recurrence
rate within five years.
642.58 -> And finally, regardless
of the presence
644.35 -> of seizure at the time of
acute stroke, more than 25%
647.89 -> of children with stroke
will go on to have epilepsy.
651.19 -> Differential Diagnosis.
653.87 -> There's a broad list of
differential diagnoses
656.56 -> for the acute onset
of neurologic deficits
658.81 -> in children.
659.83 -> But many of them, like
stroke, are serious
662.65 -> and warrant rapid recognition.
664.84 -> The list of
differential diagnoses
666.52 -> for stroke in children includes
complicated migraine, seizure
670.24 -> or postictal symptoms not
due to stroke, hemorrhage,
673.99 -> such as traumatic hemorrhage
or a hemorrhagic stroke
676.55 -> being on the differential
for an ischemic stroke,
679.21 -> intracranial infection, such as
meningitis or abscess, trauma,
683.83 -> tumor, demyelinating diseases,
such as multiple sclerosis
687.97 -> or acute disseminated
encephalomyelitis,
689.995 -> or ADEM, posterior reversible
encephalopathy syndrome,
693.88 -> or PRES, toxic exposures,
metabolic derangements,
698.68 -> idiopathic intracranial
hypertension, formerly known
701.44 -> as pseudotumor cerebri,
post-infectious processes,
705.1 -> such as cerebellitis
or acute cerebellar
706.87 -> ataxia, musculoskeletal causes
of weakness, and finally,
711.46 -> somatoform disorders.
713.68 -> The literature has consistently
demonstrated significant delays
717.1 -> in the diagnosis of
pediatric stroke.
719.83 -> The delay from symptom
onset to diagnosis
722.11 -> in children with
arterial ischemic stroke
724.63 -> has consistently been shown
to be greater than 24 hours.
728.68 -> While some of this may
be attributable to a lack
730.93 -> of recognition by the
lay public that stroke
733.15 -> can happen to
children, diagnoses
735.49 -> are delayed even in strokes
that occur in hospital.
739.21 -> This highlights the
need to establish
740.8 -> pathways of rapid triage
and definitive diagnosis
743.77 -> for pediatric stroke.
745.78 -> These pathways
are often referred
747.37 -> to as stroke STAT, code stroke,
or hyperacute stroke protocols
752.58 -> and are based on models
from the adult stroke world.
755.44 -> In general, the goal is for
the time of presentation
758.44 -> to the hospital, to
diagnosis, to institution
762.73 -> of targeted therapies, the
so-called door-to-needle time,
766.18 -> as being under 60 minutes.
768.46 -> The rationale for
having hyperacute stroke
770.8 -> protocol for children
is that time is brain.
773.62 -> For every minute
of brain ischemia,
775.84 -> 1.9 million neurons are lost.
778.38 -> 14 billion synapses are lost.
780.46 -> And 7.5 miles of
myelinated fibers are lost.
784.75 -> Some children, those who present
within a narrow time window
788.41 -> and don't have other
contraindications,
790.55 -> may be candidates for acute
reperfusion therapy with tissue
794.23 -> plasminogen activator, TPA,
or mechanical thrombectomy,
798.5 -> an endovascular approach
with stent retrievers
801.28 -> or other devices.
803.09 -> However, even
patients who are not
804.82 -> candidates for these acute
reperfusion therapies
807.52 -> will benefit from the rapid
institution of therapies
810.52 -> that aim to maximize the
supply and minimize demand
814.09 -> to the area of
ischemic brain, as well
816.58 -> as rapid attention to preventing
or managing complications
819.97 -> should they arise, such
as seizures or aspiration.
824.05 -> Imaging pathways
have been developed
826.21 -> for the rapid diagnosis of
hyperacute stroke in children.
829.54 -> And the preferred modality is
magnetic resonance imaging,
832.45 -> or MRI.
833.77 -> The reason for
this is that an MRI
835.9 -> can demonstrate an
area of ischemic injury
838.54 -> within minutes
after it has begun
840.88 -> and thereby allow
a patient to be
842.68 -> a candidate for an acute
reperfusion therapy.
846.64 -> The sequences that
should be considered
848.65 -> include a diffusion
weighted image,
850.6 -> which will show the
development of ischemia,
853.06 -> and a susceptibility
weighted image,
854.972 -> which will rule out
hemorrhage without the need
856.93 -> for an additional CT scan.
858.95 -> Other sequences
that are important
860.77 -> are the FLAIR, or T2,
sequence to look for edema
864.34 -> and, if possible,
perfusion weighted imaging
866.56 -> to assess regional blood flow.
868.67 -> It's very important
to do an angiogram
871.18 -> of the head and
the neck to assess
873.25 -> for areas of vessel occlusion
and vascular abnormalities.
877.48 -> With magnetic
resonance imaging, this
879.22 -> can be performed as a
time of flight MRA, which
882.61 -> is a non-contrast study.
884.68 -> And it's very important to
include the neck as well
887.14 -> as the head in order to
assess the entire course
890.02 -> of the cervicocephalic vessels.
892.51 -> The alternative imaging
pathway is based
894.64 -> on computed tomography, CT.
896.89 -> But it's important to recognize
that CT done early after
900.43 -> the onset of stroke will not
demonstrate any abnormalities
904.21 -> and so cannot be used to prove
that there is ischemic injury
907.33 -> that has occurred.
908.77 -> A non-contrast head CT will rule
out the presence of hemorrhage
912.55 -> but, again, will not show
any signs of ischemia early
915.67 -> in the course.
917.49 -> CT angiography can also be used
to assess for vessel occlusions
921.54 -> or vascular abnormalities.
923.28 -> And again, this should
involve the head and the neck.
926.07 -> A CTA or a CT Angiogram,
is a contrast study.
929.79 -> Here, we demonstrate
some of the imaging
931.5 -> findings of an acute
arterial ischemic stroke.
935.22 -> The first image is diffusion
weighted imaging, specifically
938.22 -> the trace sequence.
939.6 -> And you can see a large area
of bright signal corresponding
943.23 -> to an acute stroke in the
left-middle cerebral artery
946.65 -> territory.
947.88 -> The magnetic resonance
angiogram shows
950.67 -> the area where the left middle
cerebral artery should be
953.79 -> is not opacifying,
and therefore is
955.71 -> likely to be occluded,
corresponding
958.14 -> to the area of left-middle
cerebral artery
960.3 -> stroke that we saw on the
diffusion weighted imaging.
963.63 -> Treatment.
966.6 -> In terms of acute
stroke treatments,
968.58 -> for arterial ischemic strokes
with a demonstrated vascular
971.73 -> occlusion, intravenous TPA,
and intra-arterial therapy,
976.02 -> such as endovascular
stent retrieval,
978.33 -> has been performed
in research settings
980.22 -> and on a case-by-case basis.
982.53 -> For all children with
arterial ischemic stroke,
985.14 -> secondary stroke
prevention should
986.85 -> be initiated with either
aspirin, three to five
989.91 -> milligrams per
kilogram once per day
992.28 -> for a maximum of 81
milligrams, or with therapeutic
995.52 -> anti-coagulation
with a heparin drip
998.13 -> or injection of low
molecular weight heparin,
1001.04 -> depending on the etiology or
while the evaluation of stroke
1004.16 -> etiology is ongoing.
1006.41 -> For children with stroke
due to sickle cell disease,
1008.79 -> an emergent exchange
transfusion is
1010.7 -> indicated to reduce the
fraction of sickle hemoglobin.
1014.26 -> For CSVT, anti-coagulation
is generally warranted,
1018.23 -> even in some cases if
hemorrhage is already present,
1021.29 -> in order to prevent further
propagation of the thrombus.
1024.859 -> All children with
stroke will benefit
1026.72 -> from neuroprotective and
supportive care measures
1029.69 -> to maximize perfusion to the
area of ischemic brain tissue.
1033.68 -> This always starts
with the ABCs,
1035.839 -> maximizing oxygenation
and perfusion.
1039.114 -> The head of the
bed should be laid
1040.53 -> flat to increase forward flow
to the area of ischemic brain.
1044.7 -> Perfusion can be supported
with isotonic fluids running
1048 -> at maintenance
with consideration
1049.71 -> of an additional bolus.
1051.76 -> Our blood pressure targets
are usually greater
1054.12 -> than the 50th percentile for
the patient's age and height.
1057.75 -> Fever and seizures,
should they arise,
1059.88 -> should be treated aggressively
to minimize metabolic demand
1063.42 -> on the already ischemic brain.
1065.76 -> Sodium and glucose
should be normalized.
1068.64 -> And in cases in which
severe edema develops,
1071.31 -> such as the malignant
MCA syndrome,
1074.01 -> hyperosmolar therapy and
decompressive hemicraniectomy
1077.72 -> may be indicated.
1081.22 -> In summary, stroke in
children is not rare
1084.28 -> and has significant
mortality and morbidity.
1087.34 -> The rapid recognition and
diagnosis of pediatric stroke
1090.58 -> can enable the delivery of
time-sensitive therapies
1093.37 -> and can minimize complications.
1095.71 -> And finally, ischemic
and hemorrhagic stroke
1098.56 -> and cerebral
sinovenous thrombosis
1100.78 -> have many causes in children,
and a detailed evaluation
1103.78 -> is warranted.
1105.53 -> Thank you for watching.
1107.48 -> Please help us improve the
content by providing us
1109.99 -> with some feedback.
1111.81 ->
Source: https://www.youtube.com/watch?v=IvZVP2kGGls