different strokes for different folks oncology

Different Strokes for Different Folks –

Oncology

Rina Meyer, MD

Stony Brook Children’s

Stony Brook University School of Medicine

Epidemiology

Causes of stroke in pediatric cancer patients

Case presentations

Prognosis

Treatment of stroke

OVERVIEW

Noje, et al (2013); Mueller, et al (2013)

EPIDEMIOLOGY

• 1-2% of all children with cancer within the first year after diagnosis

• ~4% risk of late stroke

• Risk of recurrence as high as 59% at 10 years

• Incidence is increasing…o Increased awareness

o Increased survival of pediatric cancer patients with late

stroke

• Still with delays in diagnosiso 19/45 children did not receive a correct diagnosis until

15 hours-3 months after presentation

o 28 hour delay in seeking medical attention

o 7.2 hour delay before imaging was performed

Tsze, et al (2011)

EPIDEMIOLOGY

http://blogs.shu.edu/cancer/2016/08/17/cancer-induces-a-hypercoagulable-state/

CAUSES OF STROKE IN PEDIATRIC CANCER

• High white blood cell count

• Low platelet count/platelet dysfunction

• Presence of a tumor

• Abnormal blood clotting proteinso Sometimes due to chemotherapy

• Cranial radiation

Noje, et al (2013)

CAUSES OF STROKE IN PEDIATRIC CANCER

• Andy is a 6 yo boyo 2 months of eye blinking

o 1 month of jaw twitching

o Slurred speech after jaw twitching

o 2-3 days of right arm weakness, now using left arm to right

o Ongoing right facial droop

• Diagnosed with tic disorder

CASE #1

CASE #1

• Anaplastic ependymomao Ultimately treated with surgery, radiation,

chemotherapy

• Tumor caused compression of vasculature deprived brain of blood supplyo Subtle residual deficits

• What were the red flags?

• What is his risk for future stroke?

CASE #1

• Emily is an 8 yo girlo Presented with fatigue, fever, signs of bleeding

o Found to have WBC 325,000

o Diagnosed with acute myeloid leukemia

o Increasingly confused, sleepy, and “out of it”

o Suddenly becomes unresponsive

CASE #2

CASE #2

• Hemorrhagic strokeo Caused increased intracranial pressure

• How did this happen?o Number and dysfunction of white blood cells

o Abnormal blood clotting

• What were the early signs/symptoms and

risk factors?

CASE #2

CASE #3

• Adele is a 12 yo girlo Diagnosed with T-cell acute

lymphoblastic leukemia

o Also diagnosed with

hemophagocytic

lymphohistiocytosis

o On intense chemotherapy;

last received PEG-

asparaginase ten days ago

o Brought to the ER by her

father for sudden confusion

and lethargy

CASE #3

• Cerebral sinus venous thrombosis

• What contributed to this problem?o Underlying leukemia diagnosis

o Dehydration (often common due to nausea/vomiting)

o Use of PEG-asparaginase

CASE #3

• Strokes can present in many ways!!o Weakness

o Change in mental status

o Seizures/abnormal movements

o Headaches or neck pain

o Change in speech

o Sleepiness

o Nausea/vomiting

o Visual changes

• The younger the patient, the more non-specific the signs and symptoms!

Tsze, et al (2011)

CASE REVIEW

• Clinicians, parents, and educators need to:o Maintain a high index of suspicion for strokes

o Identify risk factors early on in a child’s illness

o Intervene as soon as possible

CASE REVIEW

• Thankfully, stroke in pediatric cancer

patients is rare…why is this talk devoted to

it?o Significantly increased relative risk compared to

healthy counterparts

o Risk continues into adulthood for many patients!

o May significantly impact function and survival

PROGNOSIS

• Morbidityo Increased brain plasticity improved hope of

neurologic recovery

o Still up to 2/3 have neurologic sequelae (deficits, seizures, learning problems, developmental delays/disabilities)

o Often dependent on location, mechanism, etc.

o High chance of recurrence increased risk for further neurologic impairment

Tsze, et al (2011)

PROGNOSIS

• Mortality o 10-25% death

o Worse in patients with hemorrhagic stroke

o Often worse in patients with newly diagnosed leukemia

and other significant comorbidities

Tsze, et al (2011); Noje, et al (2013)

PROGNOSIS

TREATMENT AND FOLLOW-UP

Diagnose and stabilize

Treat underlying

cause(s)

Prevent complications and secondary

events

TREATMENT AND FOLLOW-UP

Community and

Educational System

Nursing, PT, OT, Speech,

Nutrition, SW, Child Life

Subspecialist and Primary Care Teams

Patient and Family

• Diagnose and stabilizeo Careful observation!!

o CT scan and MRI

o Careful neurologic examination

o Lab work

o +/- EEG

• Manage fever, blood glucose abnormalities,

anemia, and hypertension

TREATMENT AND FOLLOW-UP

• Treat underlying cause(s)o Identify risk factors

o Improve hydration

o Correct blood clotting abnormalities

o Consider leukapheresis, transfusions, etc.

o Consider thrombolysis (tPA)

o Need for surgery?

o Investigate other causes…

TREATMENT AND FOLLOW-UP

• Prevent complications and secondary

eventso Role for anticoagulation (heparin, enoxaparin, warfarin)

o Role for anti-platelet therapy (aspirin, clopidogrel)

o Early initiation of rehabilitation services

o Consideration of neuropsychological testing

o Involvement of educational system

TREATMENT AND FOLLOW-UP

PARTICULAR SCHOOL CHALLENGES

QUESTIONS?