Infantile hemiplegia

Dr. Surender Singh
2nd yr PG Pediatrics
Synonyms
 Definition
 Epidemiology
 Types
 Ischaemic stroke
 Haemorrhagic stroke
 Perinatal stroke
 Diagnosis
 Management
 Prognosis
 Conclusion

 Pediatric Stroke
 Cerebral apoplexy
 Acute hemiplegia of childhood
 Congenital hemiplegia
 Hemiplegic cerebral palsy
 CVA
 ‘A
clinical syndrome of rapidly developing
signs of focal or global disturbance of
cerebral functions, lasting more than 24
hours or leading to death, with no apparent
causes other than of vascular origin’
(World Health Organization 1978).
 WHO
definition is far from ideal for children.
 Children
with transient ischemic attack (TIA),
have brain infarction on brain imaging despite
the transient symptoms
 Children
with cerebral sinus venous
thrombosis (CSVT) commonly present with
headache or seizures and no focal deficit
 Incidence:
Children: 2.3-13/100 000
Neonate :25-30/100 000
 More common in boys than girls
 Black > Asian > White (including mortality)
 Ischaemic > haemorrhagic
 Ischemic
Stroke
◦ Thrombosis /Embolism
 Arterial – Arterial Ischemic Stroke(AIS)
 Venous – Cerebral Sinus Venous
Thrombosis(CSVT)
 Hemorrhagic
Stroke
◦ Intra-cerebral Hemorrhage
◦ Subarachnoid hemorrhage

Defined as
“an acute-onset neurologic deficit conforming
to an arterial distribution associated with
infarction in a vascular territory corresponding
to the clinical deficit “

Cardiac:
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Cyanotic cong heart disease
Infective endocarditis
Cardiomyopathy
Rheumatic heart disease
Cardiac arrhythmias
Haematological:
◦ Sickle cell disease, iron deficiency anemia
◦ Prothrombotic disorders - deficiencies of protein C
and S,or plasminogen , factor V Leiden, lupus
anticoagulant
◦ Anti Thrombin deficiency - Nephrotic
syndrome,protein-losing enteropathy

Cerebrovascular malformation

Vasculitis
Infections (viral, bacterial)
Autoimmune disease (SLE, PAN)

Metabolic/genetic:
◦ Homocystinuria,
◦ Fabry’s disease
◦ Mitochondrial disorders, e.g. MELAS

Infants
◦ Seizures, fever and lethargy

older children
◦ Acute neurologic deficit - hemiparesis with or without
seizures.
◦ Dystonia in basal ganglia infarction
Vascular territory
Clinical features
Internal carotid artery
Hemiparesis, aphasia, and hemianopsia
Anterior cerebral art
Hemiparesis, especially leg
Middle cerebral art
Arm hemiparesis, hemianopsia, and aphasia
Posterior cerebral art
Hemianopsia,ataxia,hemiparesis,dizziness
Basilar art
Sensory or balance disturbances, ataxia,
nystagmus, opisthotonus, tremor, vomiting
Cerebellar art
Sensory disturbances, headache, fever,
vomit, and cerebellar signs

Dehydration

Infection- URTI or septic thrombophebitis

Hypercoagulable states – eg., Nephrotic syndrome

Congenital heart disease

Hyper viscosity– Polycythemia, Sickle cell anemia,
Leukemia , Lymphoma , CNS tumors

Cerebrovascular malformations

Arteriovenous malformation

Cavernous angioma

Vein of Galen malformations

Moya moya disease

Rarely due to Arterial aneursym

Hematological
◦ Coagulopathies- Factor VIII and Vit K deficiency, liver failure,
DIC , drug induced .
◦ Thrombocytopenia
Clinical features
 Headache – ‘thunderclap headache’
 vomiting
 Seizures
 Impaired consciousness
 Focal neurologic deficits

Perinatal stroke - ischemic event that occurs between
28 weeks gestation and 7 days age and includes in-utero
strokes

Neonatal stroke- events between birth and end of 1st
month
Etiology
• Ischemic (80%) and
• CVST or haemorrhage (20%)
*Avery Neonatology.2012
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Risk factors: CHD, coagulopthy, infection, birth trauma,
perinatal asphyxia and CNS malformations
Clinical features:
Seizures, typically focal motor seizures
Some present later with early handedness or developmental
delay
CBC, PCV, Platelet count,
 PT, APTT, factor V Leiden, antithrombin III,
 Blood C&S
 Lipid profile
 Toxic screen
 Homocystine levels
 chest xray,echo , ECG,
 Tests for connective tissue disease, Nephrotic
syndrome, etc.

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Computed Tomography (CT)

Magnetic Resonance imaging(MRI) Magnetic
resonance angiography (MRA)

Magnetic resonance venography (MRV)

CT angiography (CTA) and CT venography (CTV)

Conventional, digital subtraction angiography
(DSA)
1. Neuroprotective strategies
Maintain normoglycemia
 Maintenance of normothermia

◦ acetaminophen administration
◦ use of cooling blankets
Control of seizures
 Maintenance of cerebral perfusion pressure
 Maintain systolic blood pressure in high normal
range
 Provision of sufficient IV fluids to maintain euvolemia

2. To reduce elevated Intra Cranial Pressure(ICP)
◦ keep the head end elevation
◦ Hyperventilation to a pCO2 of 25-30 mmHg to constrict
cerebral blood vessels
◦ Mannitol or hypertonic saline—to promote osmotic diuresis.

Monitor ICP: Intraventricular catheter, Subdural Bolt,
or 3rd ventriculostomy

Surgical decompression – if raised ICP persists
3. Correction of hematological abnormalities:
◦ Sickle cell anemia –hydration, correction of hypoxemia, systemic
hypotension, blood transfusions
Hydroxyurea, bone marrow transplantation
◦ Iron deficiency anemia
Specific treatment of risk factors
 Thrombolysis –tissue Plasminogen Activator(tPA), not
generally recommended in children, still in trial stage

Anticoagulants: used in cardio embolic stroke(cong.heart disease),
cervical artery dissection, thrombophilias
◦ LMW heparin or warfarin for 3-6 months, in heart disease till
the heart defect is corrected.
◦ Antiplatelet therapy- aspirin - used for all other stroke subtypes or
in children with contraindications for chronic anticoagulation
therapy
◦ Aspirin - 1-5 mg/kg/day until cervicocephalic arterial dissection or
cardioembolic causes have been excluded, followed by long-term
aspirin therapy for a minimum 2 years.

Surgery to correct Vascular anomalies – Moyamoya disease,
Arterial dissection

Endovascular Procedures
◦ Removing the blood clot via catheter from blocked blood vessel
◦ tPA being administered directly into the blood clot (called intraarterial treatment) to help dissolve the blockage
General Measures:
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Rehydration
Treat infection with broad spectrum antibiotics
Treat seizures
Medical and surgical measures to decrease intracranial pressure
Specific treatment:
◦ Anticoagulants: LMW Heparin, Warfarin – 3-6 months
◦ Thrombolysis, Thrombectomy, surgical decompression may be
beneficial in some

General Stabilizing measures
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optimizing the respiratory effort
control systemic hypertension
control seizures
managing increased intracranial pressure
Fluid management to maintain euvolemia
maintain body temperature- acetaminophen and cooling
blankets
Treat other risk factors for hemorrhage

Children with severe coagulation factor deficiency appropriate factor replacement therapy
◦ Recombinant Factor VIIa - promotes hemostasis and is licensed for
use in adults and children with hemophilia who have systemic
bleeding and who are resistant to factor VIII therapy

Children with less severe factor deficiency should receive
factor replacement following trauma.

Congenital vascular anomalies
◦ should be identified and corrected if feasible
◦ Treatment of arteriovenous malformation consists of a
combination of embolization, sclerotherapy, and surgical
resection.

Surgical evacuation of a supratentorial intracerebral
hematoma◦ not recommended routinely
◦ done if developing brain herniation or extremely elevated
intracranial pressure

Correct dehydration and anemia
Control of seizures

In Hemorrhagic stroke:

◦ Correct low platelet count
◦ replacement of the deficient coagulation factors
◦ Vitamin K
◦ High ICP -evacuate an intraparenchymal hematoma
if Hydrocephalus - ventricular drainage and later shunting

*AHA Scientific Statement .Management of Stroke in Infants and Children. Stroke. 2008; 39: 2644-2691

Anticoagulation with LMWH may be considered in
select neonates with
◦ severe thrombophilic disorders
◦ multiple cerebral or systemic emboli
◦ or clinical or radiological evidence of propagating CVST
despite supportive therapy

Thrombolytic agents are not recommended in
neonates
*AHA Scientific Statement .Management of Stroke in Infants and Children. Stroke. 2008; 39: 26442691

Rehabilitation programs are required for most survivors
targeting
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Motor deficits
Language and intellectual impairments
Behavioural and social disabilities
Epilepsy
Long term attention to arterial health lifestyle factors -avoiding
obesity and smoking

Outcomes after childhood stroke include
Death in 6-10%,
Neurological deficits in 60-70%,
Seizure disorders in 15%.
Strokes occur not only in adults, but also in childhood
and perinatal period
 Causes of stroke in children are different from those in
adults
 High index of suspiscion is necessary to diagnose stroke
 An acute onset of focal deficit in children, or seizures in
newborn should be suspected
 Imaging is the mainstay to establish diagnosis so that
early treatment is initiated

General measures, Neuroprotective strategies are
important to restrict damage
 Thrombolytics in children are still under trials
 Anticoagulants and antiplatelet agents are used when
indicated
 Patient Education – to be ‘Stroke Savvy’ is essential to
prevent recurrence, early identification and minimize
damage


Nelson textbook of paediatrics-19th ed

Avery Neonatology.2012

American Heart Association Scientific Statement
.Management of Stroke in Infants and Children. Stroke.
2008; 39: 2644-2691
Thank u