Mimi Lu, MD Clinical Assistant Professor Department of Emergency Medicine University of Maryland School of Medicine
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1 Mimi Lu, MD Clinical Assistant Professor Department of Emergency Medicine University of Maryland School of Medicine
2 Disclosures I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity I do not intend to discuss unapproved or investigative uses of a commercial product in my presentation
3 Objectives Determine stroke risk factors in young patients Demonstrate best practice in diagnosis and management including use of tpa Review differential diagnosis for stroke in younger patients
4 Case 23 month male decreased LOC and vomiting DC for RSV 2 days prior POV from UC, P 60, SBP 130 Courtesy of Ashley Strobel, MD
5
6
7 Incidence
8 By the Numbers Adults Risk factor 80-85% ischemic Kids 2-3/100K/year 2000/year 1/3 dx in kids <1 yr 55% ischemic 30% posterior circulation
9 Why it matters 5-7% mortality 50-80% permanent neurologic sequellae Clinically silent
10 Cerebral arteriopathy Risk Factors Sickle cell disease Cardioembolic Neonates Prothrombotic state Congenital Heart Disease Critical illness Trauma Infection
11 Stoke Mimics Complex migraines Focal seizures (Todd s Paralysis) Intracranial malignancy/ infection Metabolic abnormality (hypoglycemia)
12 Stroke vs Mimic No antecedent illness Inability to walk Focal weakness Mackay, Stroke, 2016
13 Exam
14 Neurologist Tool Kit
15 EM Neuro Tool Kit
16 EM Neuro Tool Kit
17 Check the Reflexes DTRs abnormal if: Asymmetric Exaggerated Absent
18 Look at their eyes CN III, IV, VI palsy Relative afferent pupillary defect (RAPD)
19 Watch them walk
20 Neuro Tips Visual acuity Reaching of objects of varying size > 6 mo: scraps < 5 mm on dark background Optokinetic drum
21 Neuro Tips Visual fields Quick check of posterior lesions Count fingers (1, 2, or 4) vs toys
22 Neuro Tips CN 6 palsy Persistent nystagmus at extreme side gaze Esotropia worse in the distance
23 Hypotonia in infants Neuro Tips Resting posture: decreased flexion UE then LE Passive tone: Scarf sign Active tone: Head lag Landau reflex (horizontal suspension)
24 Check the Reflexes DTRs abnormal if: Asymmetric Exaggerated Absent
25 Primitive reflexes
26 Babinski Upper Motor Neuron lesion Upgoing / extensor through 12 months
27 The Work Up Pediatric NIHSS 1
28 Labs Bedside glucose CBC CMP PT/PTT Infection? Inflammation/ vasculitis?
29 Imaging
30 EKG
31 Echocardiogram
32 CXR
33 Treatment options
34 Target: Sickle Cell Adams R, NEJM, 1998 Adams RJ, NEJM, 2005 Lee MT, Blood, 2006
35 Unproven therapies Thrombolytics (tissue plasminogen activator) Endovascular retrieval Oxygenation without hypoxemia Thrombocyte aggregation inhibitors (GP-IIb/IIIareceptor antagonist) Antiepileptic drugs High dose insulin therapy Corticosteroids Hypothermia
36 Tissue Plasminogen Activator Rivkin MJ, Stroke, 2015
37 Thrombolytics in kids Limited to multidisciplinary pediatric stroke center Consider in: >2 years with imaging confirmation Within 4.5 hours of stroke onset No contraindication to tpa Rivkin MJ, Pediatric Neurology, 2016
![Thrombectomy may be reasonable for some patients < 18 years of age with AIS [with] large vessel occlusion Powers](/docs-images/95/124837086/images/38-1.jpg "WJ, Stroke, 2015 Tabone L, Stroke, 2017 Satti S, J Neurointerv Surg, 2017 Pacheco JT, Eur J Paediatr Neurol,")
38 Thrombectomy may be reasonable for some patients < 18 years of age with AIS [with] large vessel occlusion Powers WJ, Stroke, 2015 Tabone L, Stroke, 2017 Satti S, J Neurointerv Surg, 2017 Pacheco JT, Eur J Paediatr Neurol, 2018
39 Homeostasis and reduce metabolic demand: Normothermia Normal oxygenation Normotension Euvolemia Normoglycemia Target Normal-range hemoglobin
40 Case 23 month male decreased LOC and vomiting DC for RSV 2 days prior POV from UC, P 60, SBP 130 Courtesy of Ashley Strobel, MD
41 Courtesy of Ashley Strobel, MD
42 Radiology: negative for mass or bleed Normal variant? Neuroradiologist: venous sinus thrombosis Heparin started MRI/MRV: multiple thromboses (sagittal, vein of Galen) Courtesy of Ashley Strobel, MD
43 Take Home Points Maintain index of suspicion Focal deficits (detailed neuro exam!) Be prepared (including transfer protocols)
44 Stay tuned. Emerging clinical decision tools Emerging diagnostic strategies Novel therapeutic agents and modalities
45 Questions
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