Pediatric stroke: time lost is brain lost

Administrator: Tipu Sultan, Pakistan

Prof Tipu Sultan
The Children Hospital, University of Child Health Sciences, Lahore
tipusultanmalik@hotmail.com
Stroke management challenges in developing countries
Globally, Stroke affects 33 million individuals every year with two-thirds of all strokes occurring in the developing countries with significant population. Over the last few decades, the burden of stroke has been increasing worldwide, especially in developing countries. In a developing country like Pakistan, where Pediatric population is about 47% prevalence and incidence of stroke is quite high. Review of the reported case series from the medical literature pertaining to stroke incidence in Pakistan, it is apparent that Pakistan likely has the world’s highest rate of stroke.
There are three types of strokes that require immediate recognition. Ischemic stroke: A blood clot forms and blocks the artery in the brain. Hemorrhagic Stroke: It occurs when a brain blood vessel ruptures. Transient Ischemic Attack [TIA]: It is a warning that ischemic stroke is impending because of narrowing of blood vessel causing flow disruption.
Acute Ischemic Stroke (AIS) treatment has been revolutionized in the last two decades with the increasing use of Intravenous Thrombolysis (IVT) and with the advent of Endovascular therapy (EVT) & heparin. AIS treatment and outcome are time dependent and in the developed countries time saving measures are being implemented at every step of the treatment chain. These changes have resulted in lower treatment time’s in-hospital and excellent outcomes if stroke patients are treated within the Golden Hour i.e. treated within 60 minutes of symptom onset.

Dr Mubeen Fatima Rafay
Children's Hospital, Winnipeg, University of Manitoba, Canada
mubeen.rafay@utoronto.ca
Stroke Management Guidelines in Children
Hyperacute treatment with intravenous thrombolysis and/or endovascular thrombectomy, stroke prevention and post stroke rehabilitation have clearly shown to improve clinical outcome in adults with stroke and are hence adopted as standard management approaches in adults with arterial ischemic stroke (AIS). Similar acute stroke management approaches have also been adopted and experimented by pediatric physicians across the world for children with AIS. Recognizing the importance of hyperacute stroke treatment interventions, despite lack of direct clinical trial data in children with AIS, pediatric management guidelines have been strongly advocating for rapid and accurate stroke diagnosis. In addition, despite the acknowledgement of long existed unresolved areas of controversy and knowledge gap for the use of these adult specific acute stroke interventions, all guidelines have positively endorsed their use in select pediatric cases. However, these management guidelines stress that every effort should be made to undertake the acute stroke management interventions in institutions already equipped with hyperacute stroke management pathways/alerts and by experts in pediatric stroke and cerebral endovascular interventional procedures. This talk will focus on the most recent published pediatric stroke management guidelines and the good quality data that supported these recommendations for management of pediatric ischemic stroke.

Dr Naveed ur Rahman Siddiqui
Aga khan University, Karachi
naveed.rehman@aku.edu
Critical Care in Stroke Management
Pediatric neurocritical care is an emerging multi-disciplinary field and a new frontier in pediatric critical care and pediatric neurology. The central goal is improving outcomes in critically ill children with neurological illness or injury and limiting secondary brain injury through optimal critical care delivery and support of brain function. Pediatric stroke is an important cause of childhood disability, occurring at least as frequently as pediatric brain tumors. Children have excellent recovery has been well contradicted: 5 to 10% of children will die from acute stroke complications; recurs in as many as one third of these children and ≥70% will have seizures or other long-term neurological deficits. A lack of recognition of stroke symptoms in children may contribute to a >24- h delay from symptom onset to time of seeking medical treatment. Management of pediatric stoke includes multi-disciplinary care – Peads intensivists, Peads neurologists, Peads neuroradiologist, Peads interventional radiologist, Peads hematologist and Peads neurosurgeons at a minimum – with follow-up necessary to determine the effects of the changes in clinical practice. There is a potential significant role for continuous electroencephalographic (cEEG) and ICP monitoring in the management of pediatric stroke. Factors associated with childhood stroke include congenital heart disease, head and neck trauma, sickle cell anemia, genetic and metabolic diseases, prothrombotic abnormalities, and infection.

Dr Afzal Sawal
University of Birmingham, Royal Wolverhampton Hospital
sawal@doctors.org.uk
Post Stroke Rehabilitation in Children
Pediatrics Post Stroke Rehabilitation:
Post-stroke rehabilitation is a patient- centered, goal-driven process that attempts to maximize the functional independence of patients who suffer from a variety of stroke-related disabilities.
Post-stroke rehabilitation is delivered most effectively and efficiently by an interdisciplinary team comprised of healthcare professionals working together to achieve common, shared goals for a patient’s rehabilitation.Reducing risk factors and preventing complications:
1. Spasticity
2. Pain (central and nociceptive)
3. Pressure ulcers
4. Deep vein thrombosis and pulmonary embolism.
5. Urinary and faecal incontinence
6. Aspiration pneumonia
Spasticity:
o Passive stretching, positioning
o Splinting
o Posture and movement therapy
o Enhanced neuronal plasticity in developing brain, based mainly on neurogenesis, programmed cell death, and activity-dependent synaptic plasticity
o Hydrotherapy and hipotherapy are helpful
Pain:
o Strapping, massage or passive movements
Pressure ulcers:
o Prevention by regular turning when in bed, adequate nutrition and pressure care education of the families/caregivers
o Early assessment and treatment once developed.
Deep vein thrombosis and pulmonary embolism:
o positioning
o Compression stockings
o Vigilant monitoring for any signs and symptoms
Urinary and fecal incontinence:
o Strengthening of pelvic floor muscles
Aspiration pneumonia:
o Feed by nasogastric tube if indicated
o Chest Physiotherapy
o Interven