2. rapidly developing clinical signs of focal (or global) disturbance of cerebral
function, with symptoms lasting 24 hrs or longer, or leading to death, with no
apparent cause other than of vascular origin.
Patients whose signs resolve within 24 hrs have transient ischemic attacks (TIAs) by
definition, but many have recent cerebral infarction or hemorrhage on imaging
Mortality is 6 - 20%, and at least 50% of children have residual disability.
3. DDs for acute FND
Primary hemorrhagic stroke +/- mass effect
Acute Ischemic arterial stroke +/- hemorrhage +/- mass effect
Acute venous stroke +/- hemorrhage +/- venous infarction +/- mass effect
Postictal (As Todd paresis is of short duration, if persistent, neuroimaging is
essential; children with prolonged seizures may develop permanent hemiparesis.)
Hemiplegic migraine (but diagnosis of exclusion, as migrainous symptoms are
commonly seen in cerebrovascular disease, e.g., dissection)
Acute disseminated encephalomyelitis
4. Brain tumor
Nonaccidental injury (subdural hematoma, strangulation with compression of
internal carotid artery)
Encephalitis, e.g., secondary to herpes simplex (usually have seizures)
Posterior leukoencephalopathy (hypertension/hypotension or immunosuppression)
Unilateral hemispheric/focal cerebral edema e.g., secondary to metabolic
Alternating hemiplegia
5. Types
Hemorrhagic stroke : ICH, arteriovenous malformation and SAH - secondary to
aneurysm.
Mortality is 8%- 40% in ICH and SAH
While hemorrhage is predictive of death, the incidence of neurologic disability ,
seizures, and recurrence is lower
Ischemic Stroke
6. Etiology
Arteriopathy
- Focal or transient cerebral arteriopathy (FCA/TCA).
- Vasculitis.
- Infection
- moyamoya disease ( progressive blockage of both distal internal carotid
arteries)
7. Cardiac
Complex congenital heart disease – (catheterization, surgery, infective endocarditis
Arrythmia
Treatments for severe cardiac failure - ECMO and ventricular assist devices
8. Hematologic
Blood clotting disorders –thrombophilias or prothrombotic disorders – Factor V
Leiden , antiphospholipid antibodies or protein C deficiency.
Sickle cell disease
Anemia
hemophilia
disorders of the coagulation system (e.g. liver failure)
low platelets - ITP
Aspirin
9. Hypertension
Nitric Oxide – imbalance between hypoxia-driven vasoconstriction and NO driven
vasodilatation in hypoxic conditions,
- factors that affect nitric oxide biosynthesis
Extracranial/Intracranial Dissection - trauma, infection migraine,
hyperhomocysteinemia, Marfans.
Sturge-Weber syndrome - venous angioma of the leptomeninges, facial capillary
hemangioma
10. Vein of Galen Malformation - neonatal period - heart failure , older children -
hydrocephalus, seizures, proptosis, or prominent scalp veins.
Aneurysms – mycotic : Staphylococcus, Streptococcus, Gram-negative organisms,
and HIV,
Other causes : polycystic kidney disease, SCD, tuberous sclerosis, Marfan
syndrome, Ehlers-Danlos syndrome.
ADEM
Metabolic Stroke - IEM
16. Intravenous Maintenance Fluids
Glycemic Control
Management of Intractable Intracranial Hypertension
Decompressive Craniectomy
Hypothermia
17. Specific Measures
Hemorrhagic Stroke
Exclude/ treat intracranial hemorrhages, reverse any coagulopathy, and treat any
associated vasospasm with volume expansion and CCB
HDN - vitamin K, DIC – FFP , thrombocytopenia - Fresh platelet , hemophilia-
recombinant factor VIII.
18. Ischemic Stroke
anticoagulation for venous sinus thrombosis
Stroke Due to Sickle Cell Disease
Hb and sickle Hb percentages should be measured at presentation with any
neurologic complication,
packed red blood cells (20 mL/kg) transfusion within 2-4 hrs of presentation
19. Anticoagulation
LMWH>Aspirin
anticoagulation for 3 - 6 months - in children with confirmed extracranial arterial
dissection associated with AIS or cerebral sinus venous thrombosis
