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Pediatric arterial ischemic stroke AIS - Coggle Diagram
Pediatric arterial ischemic stroke AIS
clinical presentation
focal
hemiparesis, hemifacial waekness 67-90%
speech disturbance 20-50%
visual disturbance 10-15%
ataxia 8-10%
nonlocalizing manifestations
headache 20-50%
altered mental status 17-38%
vomiting 10%
seizures 15-20%, mainly <6 y
relation to etiology
cardiac
6 mo -3 y
compex cardiac defect
seizures 40%
bilateral stroke, anterior and posterios, hemorrhagic transformation
posterior circulation
63-77% in boys
hemiparesis, ataxia, dysarthria, visual field deficts, oculomotor involvement, frequent non localizing sympoms
vertebral artery dissection, head trauma, cardioembolic stroke
urgent evaluation
imaging
MRI +DWI+MRA ASAP:more sensitive + differential diagnosis
CT: inadequate, MRI is more sensitive for hyperacute ischemia
if MRI+MRA is not available, or cardiac device: CT+CTA!
UK guidelines: CT+CTA in 1 hour OR MR+MRA if possible, if not, than in 24 h
AIS on MRI
DWI: restricted diffusion for 7-14 nap, then transforms to increased diffusion
increased T2 sign in subacute stroke + gadolinium enhancement
chronic stroke: increased diffusion, increased T2, vulume loss, ex vacue dilation of lateral ventricules, porencephaly
gradient echo: blood products
gadolinoum: helpful in differential, not necessary for diagnosis of AIS
AIS on CT
early: cortical effacement with loss of gray-white differenctiaion, loss of insular ribbon, hyperdense artery sign - within 24 h, maxbehypodensity in an arterial territory
neurovasular imaging
MRA for neck and head 3D time of flight TOF without and with contrast enhancement, aoric arch to the vertex!
triage for hyperacute reperfusion
laboratory studies
CBC, electrolits, urea, creatinine, se glucose, protrhombin time, INR, partial thromboplastin time, SatO2
LP if infectious etiology suspected
EEG if seizures
hemoglobin electrophoresis if possibel sickle cell disease
toxicology in unknown etiology
pregnancy test for girls of childbearing potential
thrombin time/ecarin clotting time if direkt thrombin inhibitor or direct factor Xa inhibitor is taken
differential diagnosis
intracranial hemorrhage
neuroimaging MRI+spin ceho+DWI/noncontrast CT -equally sensitive
LP if clinical suspicion for subarachnoid hemorrhage and MRI/CT negatíive for blood
cerebral venous sinus thrombosis
seizure with postictal paresis
migraine
Bell's palsy
alternating hemiplegia of childhood
brain tumors
CNS infections
posterior reversible encephalopathy syndrome
ADEM
Idiopathic intracranial hypertension
acute cerebellar ataxia
other: drug toxicity, musculoskeletal, psychogenic
evaluation for etiology
all patients
history of prior VZV infecion, immunization, dysmorphic features, neurocutan stigmata, autoimmunde disease, evidence of vascular disease in other organs
cardiac evaluation
ECG, transthoracic echo with agitated saline study
cardiac enzymes, troponin of myocardial ischemia suspected - congenital heart disease, heart transplant, substance abuse, prior Kawasaki
arteriopathy evaluation: MRA of the neck and head;
arterial wall imaging
with MRI 3T high resolution FLAIR after gadolinium, focal cerebral arteriopathy, moyamoya, Takayasu arteritis, cervial artery dissection - neck pain, carotid dissection Horner sy
hypercoagulable evaluation: protein C functional, protein S free+total+functional, antithrombin activity, lipoprotein a, prothrombin G20210A, factor V Leidel, antiphospholipid antibody panel, factor VIII activity
selected patients
inflammation evaluation - otherwise unexplaindes stroke, erythrocyte sedimentation rate, CRP, ANA; repeat 1 mo; SLE, ADA2, polyarteritis nodosa
focal cerebral arteriopathy
arterial wall imaging, follow up in 5-6 d for progression of stenosis
HSV, VZV PCR and antibody in blood and CSF
diffuse/multifocal cerebral vasculitis
CNS infetion: meningitis, tbc, sepsis
autoimmune diseases, Sle, rarely primary angiitis of the CNS, reversible cerebral vasoconstriction syndrome
ESR, CRP, ANA, cerebral digital substraction angiography - moyamoya, LP, CSF HSV PCR, VZV IgM, IgG, HIV, neurosyphilis
multiple posterior circulation infarctions
vertebral artery dissection
rotational vertebral arteriopathy: dynamic study - digital szbstraction angiography or CTA of the neck with head turning - risk of recurrent posterior ischemia!, cervical spine flexion and extension xray - instability, congenital arcuate foramen
rare causes
ADA2 deficienc - CECR1 mutations and plasma ADA2 activity
multisystem smooth muscle dysfunction syndrome ACTA2
Fabry disease
connective tissue disorders: Ehlers.Danlos tyoe IV - COL3A1, Loeys-Dietz sy - TGFBR1, TGFBR2, SMAD3
PHACE: syndrome of posterior fossa brain malformations, hemangiomas, arterial anomalies, coarctation of aorta and cardiac defects, exe abnormalities
mitochondrial
MELAS: mitochondrial encephalopathy with lactic acidosis and stroke-like episodes: lactate in serum and CSF
POLG-related disorders - POLG1