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The Evolving Management of Pediatric Stroke

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The Evolving Management of Pediatric Stroke

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  1. <?xml version="1.0"?><AllQuestions /> <?xml version="1.0"?><Settings><answerBulletFormat>Numeric</answerBulletFormat><answerNowAutoInsert>No</answerNowAutoInsert><answerNowStyle>Explosion</answerNowStyle><answerNowText>Answer Now</answerNowText><chartColors>Use PowerPoint Color Scheme</chartColors><chartType>Horizontal</chartType><correctAnswerIndicator>Checkmark</correctAnswerIndicator><countdownAutoInsert>No</countdownAutoInsert><countdownSeconds>10</countdownSeconds><countdownSound>TicToc.wav</countdownSound><countdownStyle>Box</countdownStyle><gridAutoInsert>No</gridAutoInsert><gridFillStyle>Answered</gridFillStyle><gridFillColor>0,0,0</gridFillColor><gridOpacity>50%</gridOpacity><gridTextStyle>Keypad #</gridTextStyle><inputSource>Response Devices</inputSource><multipleResponseDivisor># of Responses</multipleResponseDivisor><participantsLeaderBoard>5</participantsLeaderBoard><percentageDecimalPlaces>0</percentageDecimalPlaces><responseCounterAutoInsert>No</responseCounterAutoInsert><responseCounterStyle>Oval</responseCounterStyle><responseCounterDisplayValue># of Votes Received</responseCounterDisplayValue><insertObjectUsingColor>Blue</insertObjectUsingColor><showResults>Yes</showResults><teamColors>User Defined</teamColors><teamIdentificationType>None</teamIdentificationType><teamScoringType>Voting pads only</teamScoringType><teamScoringDecimalPlaces>1</teamScoringDecimalPlaces><teamIdentificationItem></teamIdentificationItem><teamsLeaderBoard>5</teamsLeaderBoard><teamName1></teamName1><teamName2></teamName2><teamName3></teamName3><teamName4></teamName4><teamName5></teamName5><teamName6></teamName6><teamName7></teamName7><teamName8></teamName8><teamName9></teamName9><teamName10></teamName10><showControlBar>Slides with Get Feedback Objects</showControlBar><defaultCorrectPointValue>100</defaultCorrectPointValue><defaultIncorrectPointValue>0</defaultIncorrectPointValue><chartColor1>187,224,227</chartColor1><chartColor2>51,51,153</chartColor2><chartColor3>0,153,153</chartColor3><chartColor4>153,204,0</chartColor4><chartColor5>128,128,128</chartColor5><chartColor6>0,0,0</chartColor6><chartColor7>0,102,204</chartColor7><chartColor8>204,204,255</chartColor8><chartColor9>255,0,0</chartColor9><chartColor10>255,255,0</chartColor10><teamColor1>187,224,227</teamColor1><teamColor2>51,51,153</teamColor2><teamColor3>0,153,153</teamColor3><teamColor4>153,204,0</teamColor4><teamColor5>128,128,128</teamColor5><teamColor6>0,0,0</teamColor6><teamColor7>0,102,204</teamColor7><teamColor8>204,204,255</teamColor8><teamColor9>255,0,0</teamColor9><teamColor10>255,255,0</teamColor10><displayAnswerImagesDuringVote>Yes</displayAnswerImagesDuringVote><displayAnswerImagesWithResponses>Yes</displayAnswerImagesWithResponses><displayAnswerTextDuringVote>Yes</displayAnswerTextDuringVote><displayAnswerTextWithResponses>Yes</displayAnswerTextWithResponses><questionSlideID></questionSlideID><controlBarState>Expanded</controlBarState><isGridColorKnownColor>True</isGridColorKnownColor><gridColorName>Yellow</gridColorName><AutoRec></AutoRec><AutoRecTimeIntrvl></AutoRecTimeIntrvl><chartVotesView>Percentage</chartVotesView></Settings> <?xml version="1.0"?><AllAnswers /> The Evolving Managementof Pediatric Stroke Christopher A. Miller, MD July 21, 2012

  2. Epidemiology • Neonatal Stroke 1/4000 live births annually • Childhood Stroke: • Schoenberg 2.52/100,000/year • Fullerton 0.63/100,000/year

  3. Epidemiology Rochester, MN Study (1978) • Hemorrhagic Stroke 1.89 cases/100,000/yr • Ischemic Stroke 0.63 cases/100,000/yr

  4. Outcome Data • Persistent deficit 60 – 80% • Mortality 2 - 10 % • Recurrence Risk 5 – 18 % Data from Western Europe, North America

  5. Risk Factors for Ischemic Stroke • Heart Disease – Congenital • Heart Disease – Acquired • Cerebrovascular Disorders • Hematologic Disorders

  6. Risk Factors for Ischemic Stroke • Non-structural Vascular Disorders • Infection • Vasculitis • Trauma

  7. Evaluation of Suspected Stroke

  8. Clinical Presentation Onset of Deficit Evolution Localizing Signs

  9. Diagnostic Tools • Neuroimaging (CT, MRI) • Non-invasive Vascular Studies (CTA, MRA, MRV) • Angiography

  10. Treatment Options • Symptomatic Management • Thrombolysis • Clot Extraction

  11. Use of IV rt-PA Eligibility: (a) Clinical diagnosis of acute ischemic stroke. (b) Onset (at most) 3 – 4.5 hours prior to anticipated treatment.

  12. <

  13. Use of IV rt-PA Contraindications: SBP > 185 or DBP > 110 mm Hg CT shows ICH, SAH or established stroke Other suspicion of SAH Seizure at onset Recent Intracranial/Spinal surgery or head trauma Major recent (3 months) surgery or trauma

  14. Use of IV rt-PA Contraindications: - History of prior intracranial hemorrhage History of known vascular malformation or tumor Recent active systemic bleeding Thrombocytopenia or recent heparin use Known bleeding diathesis

  15. Use of IV rt-PA Warnings: Age < 15 years Difficulty determining eligibility Glucose < 50 or > 400 mg/dl Left heart thrombus Life expectancy < 1 year Pregnancy Rapid Improvement Recent other anticoagulant use CT evidence of very large stroke Comorbid conditions with a high risk of bleeding

  16. NINDS Recommended Time Frames forIV rt-PA Use From Arrival in ER 10 minutes Initial ER physician evaluation 15 minutes Notify Stroke Team 25 minutes Initiate Head CT scan 45 minutes Interpretation of CT scan 60 minutes administer IV rt-PA

  17. Use of IV rt-PA Treatment: Infuse 0.9 mg/kg (max = 90 mg) over 60 minutes with 10% of dose given as initial bolus over one minute.

  18. Mechanical Intervention/ Clot Extraction

  19. FDA approved for retrieval of acute intracranial thrombus or emboli within 8 hours of onset of symptoms Merci Retrieval Catheter

  20. Left MCA occlusion distal to Anterior Temporal Artery origin MERCI Case

  21. MCA occlusion crossed with Merci retrieval catheter MERCI Case

  22. MCA occlusion relieved Fully recovered, NIHSS 0 MERCI Case

  23. FDA approved for retrieval of acute intracranial thrombus within 8 hours of onset of symptoms Penumbra Aspiration Catheter

  24. Penumbra Aspiration Catheter

  25. Penumbra Case Pre and Post Treatment Angiograms

  26. Ad Hoc Committee – Pediatric Stroke Joseph Childs, MD (PICU) Sid Roberts, MD (Radiology) Frankie Crain, MD (PICU) Keith Woodward, MD (Radiology) Lise Christensen, MD (ER) Chris Miller, MD (Neurology) ShahidMalik, MD (Hematology) Anna Kosentka, MD (Neurology) Lewis Harris, MD (Neurosurgery) KarstenGammeltoft, MD (Neurology) JeanannPardue, MD (Hospitalist)

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