小兒科topic four: stroke at young age

Stroke at young age

1. Stroke at young age: <45 y/o

2. Stroke is divided into two categories:

--hemorrhagic 

--ischemic (80%)

Key point: Need more strict fluid control in hemorrhagic pts

                Rule out ICH before lysis

                Rule out complex migraine with hemiparesis (rare but possible!)

3. Initial assessment:

FAST : face, arm, speech, time

First 10 minutes

-- ABCDE O2, monitor, IV (just like what we usually do in the ER)

    As for monitors, we may find AF via ECG, and may find aortic dissection with stoke-         like symptoms via CXR.

    As for IV, we may draw blood to check CBC, coagulation(before lysis), Cr(before contrast medium used), electrolytes/cardiac enzyme/glucose for DDx of cause.

-- history

-- PE (neurologic examinations)

First 25 minutes

-- CT scan to differentiate between hemorrhagic and ischemic stroke

-- Check the NIHSS 

First 45 minutes

-- CT report read

 3 hours after onset

-- Thrombolysis IV (0.9mg/kg, max:90mg, 10% bolus over 1 min, rest over 1 h)

However, children under 18 are usually NOT commended to receive thrombolytic therapy.

@ward

--  check consciousness, bilateral pupils, hemorrhagic signs( even if originally ischemic)

-- recurrent stroke within 2~4 wks

-- pneumonia , UTI, DVT

-- check underlying cause of the stoke

-- MRI

-- may transfer to other wards after 3 days with stable conditions

4. Those who cannot receive tPA:

-- aspirin 325 mg STAT

5. Special factors contributing to stroke at young age

-- MELAS( mitochondria, encephalopathy, lactate acidosis, stroke)

-- protein S, protein C, antithrombin, homocysteine, moyamoya

-- virus induced vasculitis

-- AIR: lupus coagulants, ANA

-- sickle cell disease
-- patent foramen ovale
-- Fabry disease

6. Treatment after 24 hrs 

-- aspirin 100 mg QD

-- dipyrimadole 25 mg TID

-- clopidogrel if old-aged, 75 mg QD

7. BP control

-- 185/110 before lysis, 220/120 after treatment (use labetalo= TRANDATE if HTN)

8. Random talk: ICH common spots

-- putamen

-- cerebellum

-- thalamus

-- subcortical region

-- pons