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Paediatrics: Stroke in childhood

Cerebrovascular stroke—although commonly presenting with congenital hemiplegia—is rare in childhood, but it does cause significant morbidity.

Stroke in childhood

 

Cerebrovascular stroke—although commonly presenting with congenital hemiplegia—is rare in childhood, but it does cause significant morbidity. The cause can be arterial-ischaemic, haemorrhagic, or venous in origin. The majority of cases will have a likely cause identified on history and/or examination. The main causes are:

·  sickle cell disease;

 

·  congenital cardiac defects;

 

·  cerebral infection;

 

·  trauma (arterial dissection).

 

Management

 

Children with stroke will need initial attention to ABC and treatment of acute conditions such as mastioditis/meningitis before early transfer to a specialist unit.

 

Investigation

 

Once stable all children will require brain imaging—preferably magnet-ic resonance imaging and angiography of both cerebral and neck vessels, rather than CT scan (although CT will show the distribution of injury and exclude haemorrhage). Even with a known cause such as trauma, all child-ren require screening for underlying thrombophilia as these conditions may co-exist. If there is no obvious cause then the investigations in the box should be considered.

 

Treatment

 

After stabilization, acute treatment should be undertaken in a specialist centre. Subsequent management, although acute, would be undertaken with the same team and aims as that outlined for cerebral palsy.

Investigation for stroke

 

Blood: haematology

 

·FBC, ESR: polycythaemia

 

·Thrombophilia screen, fibrinogen: thrombophilia

 

Blood: biochemistry

 

·Electrolytes, magnesium

 

·Liver function tests

 

·CRP: inflammation

 

·Plasma lactate and CSF lactate: mitochondrial disorders

 

·Fasting glucose: diabetes

 

·Fasting lipid screen: hyperlipidaemias

 

·Thyroid function tests: Hashimoto thyroiditis/encephalopathy

 

·Ammonia: urea cycle disorders

 

·Homocysteine (free and total): methyltetrahydrofolate reductase (MTHFR) deficiency can also be picked up by common mutation analysis on the thrombophilia screen, and if symptomatic has a raised plasma homocysteine

·Serum iron, total iron binding capacity, ferritin, red cell folate, and vitamin B12: iron deficiency and other nutritional disorders

·Plasma amino acids: aminoacidurias

 

·Carnitine (acyl, free, and total): B-oxidation defects

 

Urine: biochemistry

 

Urine organic and amino acids: homocystinuria, MTHFR deficiency

 

Blood immunology and infection screen

 

·IgG, IgM, IgA: immunodeficiency

 

·Titres for infection screen of: Mycoplasma, Chlamydia, Helicobacter, Borrelia, Brucella; viruses (echo, Coxsackie, Epstein–Barr, Varicella, hepatitis B)

 

·ASOT, Anti DNAase B: streptococcal disease

 

·ANA, ANCA, anticardiolipin and antiphospholipid antibody: SLE and autoimmune disease

 

 

Imaging studies

 

·Magnetic resonance imaging and angiography of head/neck: vascular disease, particularly dissection and thromboembolism

 

Echocardiogram: endocarditis and other cardiac disease

 

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Paediatrics: Neurology : Paediatrics: Stroke in childhood |


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