Paediatrics: Stroke in childhood

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