Stroke

STROKE
Prepared by: Dr. Shreya Thapa

2nd year resident, PAHS
ARTERIAL SUPPLY
Right common carotid ar. Aorta
Brachiocephalic trunk left subclavian ar. vertebral ar.

left common carotid ar.
Right subclavian ar.
External carotid ar. Internal carotid ar.
Anterior cerebral ar. Middle cerebral ar.

Circle of willis
Areas of brain
Arteries Areas supplied Defect
ACA medial surface of hemisphere(leg/foot area of motor- contralateral leg weakness and
sensory cortices), anterior portion of putamen, caudate sensory loss
nucleus, anteroinferior portion of internal capsule
MCA most of the lateral surface of cerebral hemisphere. Broca’s contralateral face, arm, leg with /
and Wernicke’s speech areas, face, arms of motor-sensory without visual field and gaze palsy
cortices, frontal eye field
PCA occipital lobes, inferomedial portion of temporal lobes, visual field loss with macular sparing
midbrain, thalamus
Characteristics Anterior circulation (Internal carotid: Posterior circulation (vertebral, basilar,
middle and anterior cerebral artery) cerebellar and posterior cerebral arteries)
Motor Contralateral hemiparesis and facial palsy Ataxia, vertigo more common
Sensory loss Contralateral Hemianesthesia May occur
Vision Field defects and gaze palsy Cortical blindness
Language Aphasia Dysarthria (9th and 10th CN involved)

VENOUS DRAINAGE
3 superficial veins
• Superior cerebral vein superior sagittal sinus
• Superficial middle cerebral vein cavernous sinus, superior sagittal
sinus and transverse sinus
• Inferior cerebral vein transverse sinus
3 deep veins
• 2 internal cerebral veins (thalamostriate vein and choroidal vein)
unite to form great cerebral vein
• Great cerebral vein
• 2 Basal veins (anterior cerebral vein and deep middle cerebral
vein)drain into great cerebral vein
Introduction
• Acute onset of focal neurologic deficits in a child is stroke until proven

• Hemiparesis, visual, speech, sensory and balance deficits, new onset
focal motor seizures
Stroke
Hemorrhagic
Ischemic stroke
stroke
Spontaneous Isolated Nontraumatic

intracerebral intraventricular subarachnoid
hemorrhage hemorrhage hemorrhage
ISCHEMIC STROKE
Clinical manifestations
1. Focal manifestations: hemiparesis, hemifacial weakness,
speech/language disturbance, visual disturbance, ataxia
2. Non localizing manifestations: headache, altered mental status,
vomiting
3. Seizures especially focal motor seizures
Most common artery affected in middle cerebral artery

ARTERIOPATHY (>50%) CARDIAC (25%) Hematologic METABOLIC/GENETIC
RISK FACTORS
Transient cerebral Congenital heart diseases IDA Acute systemic infections
arteriopathy
Focal cerebral arteriopathy Cardiac catheterization SCD Chronic systemic illness
Post varicella angiopathy Ventricular assistive devices Inherited prothrombotic: Drugs, toxins
Factor V leiden mutation
Secondary systemic Cardiac surgery Acquired prothrombotic: Ehler's Danlos syndrome,
vasculitis (Takayasu arteritis) protein C, protein S marfan’s syndrome
deficiency, antithrombin III
deficiency, antiphospholipid
antibody
Moya moya disease Septal defects Menke’s syndrome
Meningitis, TB Arrhythmia Hypohomocysteinemia,

homocystinuria
Traumatic, vertebral artery Valvular heart disease NF-1
dissection
Migraine Cardiomyopathy, Familial
endocarditis hypercholesterolemia
Congenital/genetic Familial
arteriopathies hypoalphalipoproteinemia
Evaluation
• Urgent
• Etiology
Urgent evaluation
Goals of initial evaluation
• Confirming the diagnosis of acute arterial ischemic stroke and
excluding stroke mimics
Urgent
evaluation
Imaging Laboratory
CBC, RFT, RBS, PT/INR,

MRI with MRA CT scan
APTT
EVALUATION FOR ETIOLOGY
• Cardiac evaluation
• Arteriopathy evaluation
• Hypercoagulable evaluation
• Additional evaluation for selected patients
Stroke in children is a multifactorial disease, and the presence of multiple risk

factors for stroke increases recurrence risk, so the full diagnostic evaluation should
be completed even if one risk factor is identified
Cardiac evaluation
• Electrocardiogram (ECG)
• Transthoracic echocardiography (TTE)
• Cardiac enzymes and troponin (if there is clinical suspicion of
myocardial ischemia)
Arteriopathy evaluation
• Magnetic resonance angiography (MRA) of the neck and head (three-
dimensional time-of-flight)
• Computed tomography angiography (CTA)
Hypercoagulable evaluation
• Protein C functional
• Protein S free and total or protein S functional
• Antithrombin activity
• Lipoprotein (a)
• Prothrombin G20210A variant
• Factor V Leiden
• Antiphospholipid antibody panel
• Factor VIII activity
Additional evaluation
• Inflammatory: ESR, CRP, ANA
• Vasculitis (TB meningitis, SLE): LP
• Focal cerebral arteriopathy: LP for HSV and VZV PCR and IgG, IgM
antibodies
MANAGEMENT
Reperfusion with thrombolysis and
thrombectomy
• In children, safety and efficacy of reperfusion therapy not well studied
• Various recommendation
• Emergency thrombolysis and mechanical thrombectomy is not recommended
for young children
• Some pediatric stroke centers offer thrombolysis with or without
thrombectomy (especially in preteen or adolescent)
• Acute reperfusion therapies with intravenous thrombolysis and/or
mechanical thrombectomy (where available at experienced centers) may be
appropriate for selected children with arterial ischemic stroke
IV thrombolysis with alteplase (recombinant tissue-type plasminogen activator,
tPA) for adolescents (age ≥13 years) who otherwise fit eligibility criteria used for
adults
• Given to children within 4.5 hours of symptom onset
Mechanical thrombectomy, in selected patient should be started within 24 hour

time last known to be well. Done in case of
• Acute ischemic stroke on neuroimaging
• Persistent disabling neurologic deficits
• CTA/MRA shows large artery occlusion
Early antithrombotic therapy
• For most children with acute arterial ischemic stroke, we suggest
starting aspirin (3 to 5 mg/kg per day, maximum 300 mg daily) as soon as possible
within 24 hours of confirming the diagnosis, in the absence of contraindications
such as hemorrhagic transformation.
• However, the approach to acute antithrombotic treatment varies, and some
pediatric centers start with anticoagulation (heparin)
HEMORRHAGIC STROKE
• 50% of all the stroke
• 3 types: Intraparenchymal hemorrhage
1. Spontaneous ICH
2. Isolated IVH Intraparenchymal hemorrhage and IVH
3. Nontraumatic SAH
ETIOLOGY
VASCULAR BLOOD DISORDER TRAUMA
Arteriovenous malformation* ITP Epidural and subdural
hematoma
Cavernous malformation HUS SAH
Intracranial aneurysm# Hepatic disease Iatrogenic
Hereditary hemorrhagic Vit. K deficiency

telangiectasia
Inflammatory vasculitis DIC
Drugs: amphetamine, toxins: SCD

cocaine
Cerebral Sino venous Hemophilia

thrombosis
* = M/C/C ICH
# = M/C/C
nontraumatic SAH
Clinical manifestations
• Headache: most common
• N/V
• Seizures
• Focal neurologic deficits
• Neck pain
• Altered sensorium
Sudden onset headache and altered level of consciousness points

toward hemorrhagic stroke!!!
Diagnosis
• Imaging: investigation of choice MRI>CT scan
• Laboratory:
1. CBC
2. RFT, RBS
3. Coagulation profile
Management
• Immediate: Vit. K, PC and FFP
Decompression craniectomy for large or rapidly expanding hemorrhage
• Supportive: isotonic fluids with no glucose, normothermia, anti seizures drugs
• ICP management: hemorrhagic stroke has sudden increase in ICP compared to

ischemic stroke
ICP management
MEDICAL SURGICAL
Hypoxia, hypercarbia, hypotension Hematoma evacuation and craniectomy
Elevation of head end
Head and neck midline
Fever
Analgesics
Control of shivering
Hyperosmolar therapy
• IV mannitol (bolus 1 g/kg, given as an intravenous infusion through an in-line filter over 20 to 30 minutes,
followed by infusions of 0.25 to 0.5 g/kg as needed, generally every six to eight hours) or
• Hypertonic saline to promote osmotic diuresis
SUMMARY
Clinical suspicious of stroke
Initial stabilization (ABC, IV access, baseline laboratory)
Neuroprotective measurement (Head position, NPO, normoglycemia,

normothermia, normotension
Obtain brain imaging (prefer MRI)

Ischemic stroke Hemorrhagic stroke
Selected patient
Neurosurgical consultation and
Reperfusion therapy if required neuro surgery
(within 4.5 hours) And/or
mechanical thrombectomy
Management of raised ICP
Secondary prevention with
antithrombotic agent (aspirin)
Evaluation for risk factors and

treat underlying causes
REFERENCES
• Nelson text book of pediatrics, 21 edition
• Piyush Gupta clinical methods in pediatrics, 5th edition
THANK YOU

Stroke

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STROKE

Prepared by: Dr. Shreya Thapa

Brachiocephalic trunk left subclavian ar. vertebral ar.

External carotid ar. Internal carotid ar.

Anterior cerebral ar. Middle cerebral ar.

Sensory loss Contralateral Hemianesthesia May occur

Vision Field defects and gaze palsy Cortical blindness

Language Aphasia Dysarthria (9th and 10th CN involved)

• Acute onset of focal neurologic deficits in a child is stroke until proven

Spontaneous Isolated Nontraumatic

Most common artery affected in middle cerebral artery

Meningitis, TB Arrhythmia Hypohomocysteinemia,

CBC, RFT, RBS, PT/INR,

Stroke in children is a multifactorial disease, and the presence of multiple risk

Mechanical thrombectomy, in selected patient should be started within 24 hour

Cavernous malformation HUS SAH

Intracranial aneurysm# Hepatic disease Iatrogenic

Hereditary hemorrhagic Vit. K deficiency

Inflammatory vasculitis DIC

Drugs: amphetamine, toxins: SCD

Cerebral Sino venous Hemophilia

Sudden onset headache and altered level of consciousness points

• Supportive: isotonic fluids with no glucose, normothermia, anti seizures drugs

• ICP management: hemorrhagic stroke has sudden increase in ICP compared to

Initial stabilization (ABC, IV access, baseline laboratory)

Neuroprotective measurement (Head position, NPO, normoglycemia,

Obtain brain imaging (prefer MRI)

Evaluation for risk factors and

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