Stroke Subtypes

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• Arterial Ischemic Infarction (AIS)

• Cerebral Sinovenous Thrombosis (CSVT)

• Hemorrhagic stroke (e.g. intracranial hemorrhage)

 

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Perinatal and Perinatal Stroke (AIS)

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• Definition - AIS in a child from birth (28 weeks gestation) – 28 days of age

• Etiology   - Unknown, likely multifactorial

  • 85% born at term

• Prevalence -Rate 1/2000-5000 births

• Presentation:

  • Seizure (neonate)

  • Hemiparesis or early handedness ( at ~ 5 months for presumed perinatal)

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Presenting symptoms for pediatric stroke (AIS)

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• Hemiparesis (~50%)

• Seizure (~50%)

• Speech disturbance (~20%)

 

High Risk Populations

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• Congenital heart disease

• Sickle cell disease

• Down’s syndrome

• Complex medical disorders

• ECMO/VAD

• Acute critical illness

• Neonates

• Head and neck infections

• Trauma

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Stroke Mimics

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• Hemiplegic migraine

• Todd’s paralysis

• Spinal cord disease (e.g. AFM)

• PRES

• MTX toxicity

• Musculoskeletal disorder

• Conversion disorder

• ADEM

• CNS infection

• CNS neoplasm

 

Differential diagnosis for hemiparesis:

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 Stroke (AIS)

• Acute onset (sudden, abrupt)

• Symptoms localize to a vascular territory  (e.g. ipsilateral face, arm, leg)

• Painless gait disturbance

• Typically without MS change

• Low tone, normal of decreased reflexes

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Musculoskeletal

• Monoparesis

• Guarding of the extremity

• Refusal to walk, pain, agitation

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ADEM

• Gradual onset (hours to days)

• Associated encephalopathy

• Neurological deficits in varying locations suggesting more than one location of brain involvement

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Conversion

• Sensory complains prominent

• Tone and reflexes normal

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Hemiplegic migraine

• Headache or history of migraine

• History of similar event that resolved

• Typically strong sensory component

• Jacksonian onset, (i.e. starts in fingers and travels up arm in a matter of a few minutes)

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MTX toxicity

• Onset may be sudden or gradual

• History of recent MTX (most often IT)

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Differential diagnosis for new onset seizure

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Stroke

• Neonate

• Persistent weakness of an affected limb after seizure

• Normal or mildly elevated BP

• Recent “viral” illness 

• h/o complex medical disease

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CSVT

• Associated encephalopathy

• Progressive headache or visual disturbance

• h/o aspariginase, OCP, head/neck infection

        Encephalitis

• Encephalopathy

• Subtle onset or gradual development of focal neurological deficits

• Fever

  Neoplasm

• +/- gradual onset of deficits

• History of progressive headaches

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PRES

• Associated medical conditions (e.g. Lupus or BMT) or HTN urgency

• Preceding visual symptoms

• Encephalopathy present

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Neurological Examination

PedNIH Stroke Scale (PedNIH SS)

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Pediatric Stroke Outcome Measure (PSOM)

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Outcomes

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• Immediate mortality quoted as high as 10-40%

• Mortality from stroke itself is very low (add references)

• High neurologic morbidity

• Only 37% of ischemic stroke survivors have full recovery

• ~ 40% of children with AIS have moderate-to-severe persistent deficits (add reference)

• >25% risk of epilepsy as a late complication (add reference)

• Recurrence: 6-14%

  • Risk is greatest in the first 6 months

  • Increased in the presence of  sickle cell disease, vasculopathy and coagulation abnormalities

  • Increased in the presence of multiple risk factors  (~40%  > 1 risk factor)

  • Mortality rates are 40% for recurrent strokes vs 3% for first AIS