arterial ischaemic stroke in children - university of exeter...• acute hemiparesis commonest...
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Arterial Ischaemic Stroke in
Children
Vijeya GanesanSenior Lecturer in Paediatric Neurology
Developmental Neurosciences,
UCL Great Ormond Street Institute of Child Health
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Learning objectives
• Review causes and outcomes of arterial
ischaemic stroke in children
• Contrast these with stroke in adults
• Review current clinical guidelines for management
of childhood stroke
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FAST advert campaigns
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Vascular stroke syndromes
• Important paediatric problem– incidence approx. 5/100 000/year
– up to 1 000 children/year in UK
– as common as brain tumour
– one of the top 10 causes of childhood death
– 2/3rds of survivors have residual morbidity
– significant proportion of those with symptoms <24h will have cerebral infarction
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Vascular stroke syndromes
• Arterial ischaemic stroke (AIS)
• Venous thrombosis
– Sinovenous
– Cortical venous
• Intracranial haemorrhage
– Intraparenchymal
– Intraventricular
– Subarachnoid
– Subdural
– Extradural
Child
Adolescent
Newborn
Fetus
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Vascular stroke syndromes
• Arterial ischaemic stroke (AIS)
• Venous thrombosis
– Sinovenous
– Cortical venous
• Intracranial haemorrhage
– Intraparenchymal
– Intraventricular
– Subarachnoid
– Subdural
– Extradural
Child
Adolescent
Newborn
Fetus
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Childhood AIS: take home messages
• Acute hemiparesis commonest presentation
• May present with “soft signs” in children with SCD
(commonest RF world wide)
• Posterior circulation only accounts for 15%
– >90% male
– >50% secondary to vertebral dissection
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Childhood AIS: take home messages
• 50% have pre-morbid diagnosis e.g. congenital
heart disease
• Antecedent intercurrent infection (incl. varicella),
anaemia, minor head trauma common
• Thrombophilia/silent heart disease rare
• 80% have cerebral/cervical non-atherosclerotic
arteriopathy
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Arterial ischaemic stroke: varicella
• Increased incidence of chickenpox within
preceding 12m
• Rare (approx 1:16000 cases of chickenpox)
• Young children, otherwise healthy
• Characteristic radiological pattern
• Diagnosis of exclusion
• ?CSF VZV antibodies as biomarker
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Risk factor category Frequency N (%)
Arteriopathy (n=525) 277 (53%)
Cardiac disorders (n=667) 204 (31%)
Chronic systemic disorders (n=674) 199 (30%)
Prothrombotic states (n=674) 87 (13%)
Acute systemic disorders (n=658) 148 (23%)
Chronic head & neck disorders (n=667) 68 (10%)
Acute head & neck disorders (n=648) 148 (23%)
Infection (n=676) 165 (24%)
Risk factors for atherosclerosis (n=676) 12 (2%)
Other AIS risk factor recorded 150 (22%)
Mackay et al 2011
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Childhood AIS: key investigations that
change management
• Clinical examination
– Neurocutaneous
– Heart/pulses/bruit
– Blood pressure
– Horner’s syndrome
• MRA: neck & intracranial
• Echocardiogram
• ?LP
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Classification of childhood cerebral
arteriopathies
Current Opinion in Pediatrics 2004; 16: 617
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• Non-inflammatory vasculopathies
– Dissection
– Moyamoya (primary/secondary)
– Transient cerebral arteriopathy
– SCD
– Congenital hypoplasia/dysplasia
– FMD
– Drugs
• Primary vasculitides w CNS involvement
– incl primary CNS angiitis
• Secondary vasculitides w CNS involvement
– Collagen vascular diseases
– Infection
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Arteriopathy in
childhood AIS
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TCA/FCA
• Most commonly identified arteriopathy associated
with childhood AIS
• Occlusive disease of TICA/proximal MCA – i.e.
intracranial
• +/- associated with antecedent varicella infection
• Initial imaging may be normal
• Focal and monophasic (though FCA diagnosis
can be made on single scan)
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Childhood PACNS
• Inflammatory cerebrovascular disorder
confined to cerebral circulation
• Absence of systemic inflammation
• Controversy as to distinction between cPACNS &
TCA/FCA (e.g. Aviv et al 2006)
• Early results suggest that markers of endothelial
injury & repair might distinguish between these
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Arterial dissection
• Up to 15% AIS in young people
• Traumatic vs. non-traumatic
• Rarely associated with systemic connective tissue
disorder (e.g. vascular EDS) but 50% have
cutaneous connective tissue abnormalities
• Association with recent infection
• CADISS suggests no benefit to anticoag over
aspirin
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Moyamoya
• Terminal ICA occlusion with basal collaterals
• Radiological rather than clinical entity
• Primary vs. secondary
• Ethnicity
• Associated with genetic conditions: NF1, trisomy 21 etc.
• High rate of recurrence
• Surgical revascularisation
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• IPSS, n = 277/525 had abnormal vascular imaging
Subtypes of arteriopathy
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IPSS, AIS, n = 661
• 3% mortality
• 74% neurological morbidity at time of discharge
• Arteriopathy, bilateral injury, reduced LOC
predictive of adverse outcome
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Childhood AIS: outcome
• Most children with AIS will
– Walk out of hospital
– Go to mainstream school
– Live independently as adults
• Outcome not predictable on the basis of lesion
characteristics/aetiology/age
• Risk-benefit of high risk interventions undefined
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Childhood AIS: economic impact
• Acute treatment costs approx $70 000 USD/child
• At 5y healthcare costs = $135 000 USD
• Societal impact not quantified
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http://www.rcpch.ac.uk
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Management of childhood AIS
• Treatment = limit or reverse brain injury
– Maintain homeostasis/neuroprotect
– Exchange transfusion in SCD
– Recanalisation therapy
– Treat secondary complications e.g. decompression
• Secondary prevention
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Homeostatic management
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Supportive care
• Monitor vital signs & GCS
• SaO2 >96%
• Support BP; do not routinely treat hypertension
• Don’t feed
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TIPS
• 17/25 planned sites activated at study closure
• Active for mean of 9 months
• Closed Dec 2013
• 93 screened, 1 enrolled
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Decompressive hemicraniectomy
• MCA infarct
• <48h
• Drop in LOC to score 1 or more on 1(a) of NIHSS
• NIHSS >15
• Infarct of >50% of MCA territory
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Arterial ischaemic stroke: recurrence
• Clinical recurrence in 5% - 37%; >60% in children
with SCD
• Re-infarction in 33%, clinically silent in 11%
• Risk factors :
– vascular pathology (esp. moyamoya)
– protein C deficiency/increased lipoprotein (a)
– immunodeficiency
– thrombophilia in previously healthy
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AIS: secondary prevention
• Aspirin
• SCD: blood transfusion, BMT, adenotonsillectomy
• Refer moyamoya patients for surgical evaluation
• Consider anticoagulation in cardioembolic
• If recurrence occurs reconsider the diagnosis
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Primary AIS prevention: sickle cell disease
• Commonest risk factor world-wide
• 10% <20y; 2/3rds recur
• Risk factors: chest crisis, high WCC, hypoxaemia,
anaemia, SS phenotype
• “Silent” infarcts in 25%
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AIS prevention: sickle cell disease
• Primary prevention: STOP trial (Adams )1998– Children with SCD and no history of stroke studied with
transcranial Doppler (TCD)
– Patients with velocities>200cm/s randomised to transfusion or standard care
– 10/67 had stroke in standard care group vs. 1/63 in transfused group
– Screening w TCD now standard of care, annually from age 2 – 16y
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AIS prevention: sickle cell disease
• Primary prevention: STOP2 (Adams 2005):
– SCD children screened >> high risk >> transfused for at
least 30m; TCD had normalised
– Randomised to continue or stop transfusion
– Of those in stop transfusion group, 12/41 TCD reverted
to abnormal & 2/41 stroke vs. 0/38 in transfusion group
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Right MCA
220 cm/sec
Left MCA
130 cm/sec
TIAs, Seizures
HeadachesM Prengler, F Kirkham,
ICH, UCL
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Conclusions
• Causes and consequences of AIS are distinct in children
• Clinical guidelines are available to guide management of childhood AIS
• As well as medical therapies, surgical and endovascular treatments may have a role in some patients; a multidisciplinary approach is helpful
• AIS is preventable by blood transfusion in people with SCD