Effects of Stroke on Children Aged 2 to 8 Years - Essay Example

?Effects of stroke on children aged 2 to 8 years According to WHO stroke is defined as a clinical syndrome of rapidly developing focal or global lasting more than 24 hours or leading to death with no obvious non vascular cause. This definition although suitable for stroke in adults does not ideally apply to children. Stroke can be broadly categorised into two types, Hemorrhagic stroke and ischemic stroke. Ischemic stroke is the more common of the two, with 85% of all strokes in adults being ischemic. In children however 55% strokes are ischemic while the rest are hemorrhagic. Stroke in children is considered a very different entity than stroke in adults. An important contributor to this difference is the vast array of predisposing risk factors in paediatric population that leads to stroke compared to atherosclerosis being the single most important risk factor in adults. The rarity of this event in paediatric population and the multiple risk factors which are involved makes it very difficult to conduct research on stroke in children. Hence it is a very difficult diagnosis to establish (E. S. Roach). When symptoms lack for less than 24 hours it is called a transient ischemic attack. There are three types of recognised stroke syndromes in children 1. Arterial ischemic stroke: caused by ischemia due to blockage of an artery because of a clot or stenosis. 2. Cerebral Sinovenous thrombosis: Brain injury because of clotting of blood in the venous system. This may lead to an ischemic stroke or haemorrhage or get better on its own because of the anti thrombotic mechanisms of the body. 3. Intracranial haemorrhage. Injury to a brain vessel leading to haemorrhage in the brain tissue. Initial symptoms can include weakness in hands or face towards one side of the body, sudden headache, vomiting, slurred speech and problems with vision on one or both eyes. Initial management: The initial management of stroke in children is remarkably different from that in adults. In children because of the various risk factors, varied presentation and not enough research it is necessary to evaluate the child thoroughly. The most important step in management is neuroimaging. It is necessary to establish that the patient has had a cerebrovascular event. Neuroimaging gives us a direct approach and is the best way to ascertain the diagnosis. Once it is established that the patient has had a cerebrovascular event and the extent of damage is known it is important to identify the risk factors for stroke. Stroke in children is varied in its aetiology and a general set of criteria for management is not agreed upon. This leads to the practice of treating every patient individually, but treatment is guided by the type of stroke that the patient has had to some extent. Generally every patient must have a complete blood work to rule out clotting disease, should be checked for congenital heart disease because of increased likelihood of stroke recurrence and should be evaluated for sickle cell disease as strokes are very common in patients with sickle cell disease. Since all the different types have different treatment and symptoms each one is given in detail below. 1. Arterial ischemic stroke. Arterial ischemic stroke can occur because of several reasons including but not limited to thrombosis, embolism, and stenosis, clotting disease and damaged arteries because of trauma or inflammation. Symptoms occur suddenly most of the time and include weakness of the face and arms towards one side, slurred speech, lack of understanding, loss of balance and severe headache with nausea and vomiting. New incidence of seizures followed by paralysis to one side of the body can be an important symptom. It is hard to find out the exact cause for AIS in children still one has to look for risk factors. The most common ones being congenital heart defects, sickle cell anemia, neck radiation, moyamoya disease, serious infections like meningitis, drug abuse and chronic metabolic disorders. Diagnosis is achieved through obtaining a detailed history trying to include or exclude any risk factors for stroke. This is followed by a thorough physical examination including a full neurological evaluation. This helps in finding out the extent of brain tissue damage caused by the stroke. A full blood panel is ordered which is focussed on checking the clotting status of the patient. Finally radiological imaging is done. Imaging can include CT, MRI and MRA( Magnetic resonance angiography). The physician can also order an echocardiogram to check for cardiac defects. Depending on the Childs status and possibility of infection a lumbar puncture can also be ordered. Treatment of the patient focuses mainly on controlling the extent of the damage done by the stroke. This is done by maintain adequate pressures and keeping the child from developing further ischemia in the areas affected. Reperfusion is a goal that needs to be achieved quickly. The patient is started on IV fluids for adequate hydration and pressure maintenance. Some kind of pain killers is also given but narcotics are usually avoided as they may further dull the mental status of the patient. Reperfusion is maintained through thrombolytic therapy. Anticoagulants are administered which can include aspirin, heparin or warfarin. Further therapy is directed according to the cause of the stroke. Recovering from AiS can be a long and tiring process for the patient. Rehabilitation should begin within 48 hours of stroke provided that the patient is medically stable. Neurological deficits although cannot be fully reversed but some improvement in function can be brought about through various exercise regimes. These exercises are individually tailored to every patient. Physiotherapists are involved in the whole process of rehabilitation in consultation with the primary physician of the patient. Speech therapists, occupational therapists and neuropsychologists may also be involved in this process. Prognosis usually depends on the site of injury and the extent of damage as well as the time between the occurrence of event and getting medical help. (Rebecca N. Ichord, 2006) 2. Cerebral Sinovenous thrombosis: Cerebral sinovenous thrombosis occurs when a thrombus is formed in the venous system of the brain. This leads to increased pressure in the venous system and a backflow in blood flow to the brain. This makes it harder for the blood to supply oxygen and nutrients to the brain tissue. If the thrombus doesn’t dissolve in time it can lead to permanent damage to the tissue. Symptoms of CST usually develop overtime and are not as sudden in their onset as those of AIS. Symptoms can include a gradual dullness in mental function which slowly deteriorates loss of balance, severe headache, loss of vision in one or both eyes and double vision. Causes of CST could include dehydration, cancer and cancer treatment, ear or sinus infection, severe infection e.g. sepsis, heart defects, Immune disease including inflammatory bowel disease, head and neck surgery and clotting disorders. Initial management of the patient would include a detailed history and a full physical examination. A detailed neurologic assessment is mandatory and can influence the subsequent management in a major way. Depending on the condition of the patient initial lab tests can be ordered. If the patient is unstable, getting the patient hemodynamically stable becomes the first priority. In case of hypotension/hypovolemia insert two large bore IV catheters preferably in the antecubital veins and start the patient on IV fluids till his pressures are normalised. Lab tests involve a full blood work looking for causes of stroke. Ruling out infection is an important consideration while ordering lab tests. The patient should undergo neuroimaging to ascertain the cause of stroke and extent of damage. A CT scan or an MRI or an MRA can be used here. Lumbar puncture could be useful in determining whether there is any CNS infection or not. Treatment is usually dictated by the cause of stroke. Treating the underlying condition is very important since it will also help in preventing further strokes in the patient. General management will include anticoagulants to stop the clot from developing further. This is achieved through Aspirin, heparin or warfarin. Thrombolytic therapy can help in certain cases. Infection if present needs to be controlled with antibiotics. Steroids might have a role to play in the treatment, depending on the cause of the stroke. Rehabilitation is done through physiotherapy. As with rehabilitation after every type of stroke this is also a very long and tiring process. The patient has to cooperate with the rehabilitation team and it needs a lot of emotional support from the family and the rehabilitation team. Psychotherapists and occupational therapists can be very useful in this process. A neuropsychologist could help motivate the child. Rehabilitation is the mainstay of treatment in achieving long term goals. (A Review: Cerebral Sinovenous Thrombosis (CSVT)) 3. Intracranial haemorrhage. Intracranial haemorrhage can be very difficult to assess and manage in children. It occurs when there is disruption in the vessel wall which leads to bleeding in the brain tissue. This causes the intracranial pressure to rise and subsequently the areas downstream to the area of haemorrhage do not receive any sort of blood supply. There could be many causes of intracranial haemorrhage in children. 1. Aneurysms. 2. Atrivenous malformations 3. Damaged or fragile vessels 4. Clotting abnormalities All these could result in intracranial haemorrhage. Aneurysm walls are areas of weakness and can burst anytime leading to haemorrhage. Atriovenous malformations have a tendency to bleed. Similarly damaged vessels and clotting disorders can also lead to bleeding in the brain. Intracranial haemorrhage usually has very subtle signs of severe headache and dizziness; Seizures can accompany these symptoms and are followed by weakness and paralysis usually on one side of the body. Loss of consciousness could be the first symptom at times. All this could lead to focal neurological abnormalities including weakness or numbness in one specific part of the body. Risk factors in intracranial haemorrhage could include congenital malformations, moyamoya disease, clotting disorders, trauma and infections. All these could contribute to the development of intracranial haemorrhage. Management of the patient includes a detailed history and a thorough physical examination. A neurological exam is very important and could go a long way in determining the course of action taken during treatment. Patients with intracranial haemorrhage need immediate treatment as the bleeding could worsen and cause increased intracranial pressure. Lab tests should include complete blood work. Clotting studies are very important. Neurological imaging, to determine the extent of damage and check for raised ICP is very important. After the initial investigation and preliminary management immediate treatment for intracranial haemorrhage should be initiated. Treatment mainly depends on the cause of the haemorrhage. A combined medical and surgical approach to treatment is taken. Neurosurgical opinion is taken regarding the treatment. Once the best course for treatment is decided on the patient can be treated either through an open surgical approach where the surgean can clip the aneurysm or the malformations. Another approach to treatment is the endovascular approach. In this approach an interventional radiologist guides a wire through the vasculature to the area of haemorrhage and with the help of radiological studies tries to clip the aneurysm. ( A Review: Hemorrhagic Stroke) Rehabilitation as in case of other forms of stroke is a very long process which usually involves a multidisciplinary team. The family is involved in the process so that they can support their child in the rehab process. This concludes the discussion on the three main types of stroke syndromes in pediatric population. These are very general lines of management and each case is taken individually. As mentioned earlier stroke in children is a very rare occurrence. It has gradually increased in incidence because of increased life expectancy of children with risk factors. It is important that more research should be done on management and risk factors of these patients so that a better understanding of stroke in children can be obtained and its subsequent treatment can be streamlined as well. BIBLIOGRAPHY E. S. Roach, G. d. (n.d.). Recognition and Treatment of Stroke in Children Child Neurology Society Ad Hoc Committee on Stroke in Children. Rebecca N. Ichord, M. (2006). A Review: Cerebral Sinovenous Thrombosis (CSVT). Rebecca N. Ichord, M. (2006). A Review: Hemorrhagic Stroke. Rebecca N. Ichord, M. (2006). Review: Arterial Ischemic Stroke (AIS). Read More