Childhood Stroke

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Childhood Stroke

• Gita V. Massey, MD
• Coagulation Update 2006
• September 30, 2006

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The challenge..

• How to cover this enormous topic in 30 minutes
  and give some insightful advice to the practicing
  hematologist

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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.

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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

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Children are not little adults

• Incidence is rare
• Subtle neurologic presentation
• Underdiagnosis and delay in diagnosis
• Multiple types of stroke
• Multiple risk factors

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Type of Stroke
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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

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Clinical Features of AIS

• Canadian Registry
• 51 hemiparesis
• 48 seizures
• 17 speech disorder
• 50 headache, lethargy, confusion
• Neonates
• lt25 hemiparesis
• Lethargy and seizures predominate
• No symptoms (early hand dominance)

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Risk Factors for AIS
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Vascular Risk Factors
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Embolic Risk Factors
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Intravascular Risk Factors(The Hematologists
Domain)
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The Acquired Prothrombotic States
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The Congenital Prothrombotic States
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The Confusing Realm of Prothrombotic States

• How much do they contribute?
• Rare disorders
• Age related differences
• Acute differences
• Dietary variations

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Inter-relations
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The Diagnostic Work-Up

• History
• Trauma, infection, palpitations, mental status
  chages, underlying disease
• Previous DVTs, family history
• Physical Exam
• Marfanoid body habitus
• Cutaneous lesions
• Café au lait spots
• xanthoma

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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

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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

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Therapy

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

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Consensus on

• Sickle cell disease
• Acute therapy
• Exchange transfusion
• Preventive therapy
• Blood transfusion every 3-6 weeks to maintain
  HbSlt30
• ?HU, stem cell transplant
• Transcranial dopplers

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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

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Current practice..

• Most (gt50) 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.

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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

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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

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