Cerebrovascular disease stroke

I67.9

DESCRIPTION

Cerebrovascular disease can be ischaemic (thrombotic or embolic) or haemorrhagic, arterial or venous.
Arterial ischaemic stroke must always be considered in any child with sudden onset of hemiparesis or other focal neurological disturbance.
The clinical features of cerebral venous thrombosis (CVT) include headache, papilloedema, focal neurological signs, seizures (often focal), and alteration of consciousness.


Risk factors:

  • cardiac disorders;
  • infections, e.g. meningitis, varicella, HIV, etc.;
  • prothrombotic disorders, e.g. nephrotic syndrome, protein S/C deficiencies, etc.;
  • haematologic disorders, e.g. sickle cell anaemia;
  • vasculopathies, e.g. vasculitis, HIV, Moya Moya syndrome.

The initial evaluation in children includes the following:
CT/MRI brain to ascertain whether it is ischaemic or haemorrhagic infarct

  • Electrocardiography, echocardiography.
  • Full blood count, INR, PTT.
  • CSF analysis as indicated.
  • Infectious screening, including varicella, HIV, mycoplasma, TB.
  • Connective tissue and vasculitic screening.
  • Thrombophilia screening. See Chapter 3: Blood and Blood Forming Organs, Venous thrombo-embolic disease .

GENERAL AND SUPPORTIVE MEASURES

Acute supportive and neuroprotective care directed at preserving damaged but salvageable brain tissue includes the following:

  • Maintain body temperature in the low to normal range.
  • Maintain euglycaemia.
  • Maintain O₂ saturation above 95%.
  • Maintain adequate cerebral perfusion and manage raised intracranial pressure.
  • Treat anaemia.
  • Treat acute seizures promptly.

Haemorrhagic stroke requires referral to a centre with neurosurgical expertise and facilities.
Early disability assessment and management, includes physiotherapy, speech therapy, occupational therapy, etc.

MEDICINE TREATMENT

Arterial ischaemic stroke without haemorrhage

All patients with confirmed arterial ischaemic stroke:

  • Aspirin soluble, oral 1–5 mg/kg as a daily dose.
    • Contraindicated in haemorrhagic stroke or bleeding tendency.

REFERRAL

  • All patients to specialist paediatrician for investigation.
  • Anticoagulation with enoxaparin and warfarin is best done in a specialised setting under cardiologist, haematologist and neurologist supervision.