Stroke

     b. Vision loss or double vision
c. Speech or language difficulty: dysarthria/aphasia
d. Dizziness, trouble walking or ataxia
2. Did the symptoms start suddenly OR get worse suddenly?
3. Was the child last seen well within 5 hours?

• Obtain Venous Access
  Labs: CBC, BMP, coagulation studies, and EKG
• NPO and head of bed flat 
• Normotension: target SBP between 50th percentile and 15% above 95th percentile for age, treat hypotension with NS +/- pressors, treat significant HTN , to lower by 25% over 24 hours
• Normovolemia: isotonic fluids at maintenance
• Normoglycemia: no glucose in fluids unless hypoglycemic
• Normal O2, CO2, pH
• Normothermia: treat patient with T> 37 Celsius with acetaminophen
• Seizure control: AED ASAP
• Obtain Acute Stroke imaging (MRI brain: DWI, T2 Flair, ASL, SWAN and MRA head); if MRI not possible, combination CT/CT angiogram can be considered                           
  • (+) hemorrhagic stroke: consult Neurosurgery
  • (-) hemorrhage stroke
    • evidence of early infarct, free of hemorrhage, and w/ evidence of vascular occlusion
      • Time from onset + estimated time to arrival ≥ 4.5 hours, or age ≤ 2 years or resolving deficits or tPA contraindication**  → Admit to PICU
      • Time from onset + estimated time to arrival ≤ 4.5 hours and age ≥ 2 years, and persistent deficit and no tPA contraindications** → consider tPA
• For tPA, should have BOTH proven infarct AND arterial occlusion on MR    
  • IF tPA candidate

    • Total Dose: Alteplase (tissue plasminogen activator 1mg/ml), 0.9 mg/kg IV
    • Bolus: 10% dose IV over 1-2 minutes
    • Infusion: remaining 90% over 1 hour
    • Maximum total dose: 90 mg                                                          

• PICU Management
  • Continuous cardiac monitoring
  • Transthoracic ECHO with bubbles
  • Consider 4 Extremity Doppler
  • EEG if seizure activity suspected
  • Neuro Checks Q1 hour
  • DVT prophylaxis with compression devices
  • Labs: Coags, ESR, CRP, Lactate, Tox screen, Urine pregnancy. Blood culture
  • Consider LP for infectious/inflammatory etiologies
  • Hx Sickle cell: reticulocyte count, Hemoglobin S%, type/cross, call HEME
  • Send relevant supplemental labs with aid of neurology and hematology

Therapy:

• Initial Therapy per neurology (if no hemorrhage)
  • Aspirin3-5mg/kgdaily(MAX 162 mg)
  • If cardiac source or cervicocerebral dissection suspected initiate unfractionated heparin IV (goal anti-factor Xa level 0.35-0.7)

HISTORY

• > 4.5 hrs from last seen well
• Patients in whom time of symptom onset is unknown
• Stroke, major head trauma or intracranial surgery in the last 3 months
• History of prior intracranial hemorrhage, known AVM or aneurysm
• Major surgery or parenchymal biopsy within 10 days
• GI or GU bleeding within 21 days
• Patient with neoplasm/malignancy or within one month of completion of treatment for cancer
• Patients with underlying significant bleeding disorder. Patients with mild platelet dysfunction , mild von Willebrand disease or other mild bleeding disorders are not excluded
• Previously dx d primary angiitis of the central nervous system or secondary arteritis.

PATIENT FACTORS

• Patient who would decline a blood transfusion if indicated.
• Clinical presentation c/w acute myocardial infarction or post MI pericarditis that requires evaluation by cardiology before treatment
• Arterial puncture at non-compressible site or lumbar puncture w/in last 7 days. Patients who have had cardiac cath via a compressible artery are NOT excluded.

ETIOLOGY

• Stroke due to SBE, sickle cell disease, meningitis, embolism (bone marrow, air or fat), or moyamoya disease.

EXAM

• Persistent systolic blood pressure >15% above the 95th percentile for age while sitting or supine
• Mild deficit (PedNIHSS <6) at start of tPA infusion
• Severe deficit suggesting very large territory stroke pre -tPA 
• PedNIHSS >25, regardless of infarct volume seen on neuroimaging

IMAGING

• Symptoms suggestive of SAH even if CT or MRI of head are normal 
• CT with hypodensity/sulcal effacement >33% of MCA territory / ASPECTS ≤7
• Intracranial cervicocephalic arterial dissection.

LAB DATA

• Glucose <50 mg/dL (2.78 mmol/L) or >400 mg/dL (22 mmol/L)
• Bleeding diathesis including Platelets <100,000, PT >15 sec (INR >1.4) or elevated PTT > upper limits of the normal range.