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Handbook of Cerebrovascular Disease and Neurointerventional Technique pp 827–918Cite as

Ischemic Stroke

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Part of the book series: Contemporary Medical Imaging ((CMI))

Abstract

This chapter focuses on acute ischemic stroke: mechanisms, risk factors, clinical presentation, diagnostic evaluation, and treatment other than intravenous thrombolysis and mechanical thrombectomy, which are discussed in Chap. 8. The topics are arranged alphabetically. Ischemic stroke in pediatric patients is discussed separately in the Appendix.

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Change history

  • 29 June 2023

    A correction has been published.

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Authors and Affiliations

  1. Professor and Chair, Department of Neurology, Medical Director, Stroke Programs MetroHealth/Case Western Reserve University SOM, Cleveland, OH, USA

    Agnieszka A. Ardelt

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Appendices

Appendix 16.1: Kids Korner! Pediatric Ischemic Stroke

Ischemic stroke trials have typically excluded children, and much of what is currently written about approaches to pediatric stroke patients is based on the standard of care in adults. Mechanistically, what was described for adults more or less holds up in children (29 days to 18 years old), i.e., conditions leading to cerebral embolism and thrombosis may involve the heart, cervical and cerebral arteries, and/or the hematologic system itself, and although the types of specific conditions may be similar, their frequency is different in children. Thus, cerebral vasculopathy from chronic hypertension and atrial fibrillation are uncommon, while congenital heart disease and sickle cell disease are common etiologies of ischemic stroke in children. Ischemic stroke in neonates (<29 days old) are, on the other hand, is more dissimilar: maternal, including placental, diseases and perinatal conditions, including asphyxia and infections, figure prominently.

The approach to pediatric patients with ischemic stroke risk is similar to what has been discussed in this chapter for adults and consists of: primary prevention; acute assessment and management; supportive care during acute presentation; determination of ischemic stroke etiology; institution of appropriate secondary prevention; determination of rehabilitation strategy; and commencement of physical therapy. While the general approach is similar to that in adults, the details are quite different. In acute management, thrombolysis in pediatric acute ischemic stroke has not been recommended in guidelines primarily because much less is known about its risks and benefits in children, although low level of use of both intravenous and intraarterial thrombolysis has been reported in pediatric patients [267,268,269]. In the diagnostic evaluation, the determination of appropriate imaging modality in children, perhaps more so than in adults, takes into consideration exposure to ionizing radiation and the need for general anesthesia. And, of course, selection of antithrombotic or anticoagulant medications adheres to pediatric dosing regimens which are typically weight-based, and attention is paid to potential pediatric-specific adverse effects of medications such as Reye’s syndrome [269].

  1. 1.

    Epidemiology

    1. (a)

      Neonates (<29 days old): 17.8 per 100,000 [4]

    2. (b)

      Children (29 days to 18 years old): range from 1.2 to 2.4 per 100,000 [269, 270]

  2. 2.

    Presentation

    1. (a)

      Neonates: 72% present with seizures, 63% with nonfocal neurological signs [271].

      1. (i)

        Median time to diagnosis: 87.9 h from onset [272].

    2. (b)

      Children: 22% present with seizures [273]. Associated with seizures: focal deficits, younger age, may have nonconvulsive seizures [273].

      1. (i)

        Median time to diagnosis: 24.8 h from onset [272].

  3. 3.

    Risk factors [4, 269, 274]

    1. (a)

      Refer to specific risk factor subsections in Sect. 5 above, as well as other relevant chapters including Chaps. 13, 18, and 19.

    2. (b)

      Neonates

      1. (i)

        Congenital heart disease

      2. (ii)

        Coagulopathy

      3. (iii)

        Maternal risk factors including history of infertility, prolonged rupture of membranes, preeclampsia, chorioamnionitis

      4. (iv)

        Perinatal infection and asphyxia

    3. (c)

      Children: in up to 30% of cases no risk factor can be identified [269]. Pediatric stroke patients often have more than one risk factor; in one study 52% had multiple risk factors; [274] or a condition may lead to cerebral ischemia through more than one mechanism, e.g., sickle cell disease with hyperviscosity, arteriopathy, and moyamoya disease

      1. (i)

        Cardiac disease, 25% of cases: e.g., congenital or acquired heart disease, intracradiac tumors, cardiomyopathy.

      2. (ii)

        Systemic disease: e.g., sickle cell disease, acute infections, metabolic or mitochondrial disorders, head and neck trauma.

      3. (iii)

        Cerebral and cervical vasculopathy, 50–80% of cases: e.g., arterial dissection, fibromuscular dysplasia, vasculitis, moyamoya, post-varicella cerebral arteriopathy, focal cerebral arteriopathy of childhood (transient cerebral arteriopathy of childhood). [275, 276]

      4. (iv)

        Hypercoagulable states, 20–50% of cases: e.g., genetic thrombophilias, hemolytic-uremic syndrome, homocystinuria, as well as pregnancy and oral contraceptive use in adolescents.

  4. 4.

    Diagnostic evaluation [269, 277]

    1. (a)

      Brain tissue imaging

      1. (i)

        MRI and CT, including perfusion sequences, are available for children as for adults.

      2. (ii)

        In neonates and young children in whom fontanelles have not closed, ultrasound can be used to assess the brain parenchyma; however, ultrasound is relatively insensitive for detection of ischemic lesions and evaluation of the posterior fossa.

    2. (b)

      Vascular imaging (refer also Sect. 7.4 above)

      1. (i)

        MRA may be adequate in most pediatric patients, although it has low sensitivity for distal vasculature.

      2. (ii)

        Fat-saturated T1 MRI imaging is useful in the evaluation of extracranial vasculature for arteriopathy such as dissection.

      3. (iii)

        Conventional angiography is reasonable in cases where imaging of smaller cerebral vessel is required or an interventional procedure is anticipated.

      4. (iv)

        TCD is particularly useful in the monitoring of children with sickle cell disease and screening is recommended starting at 2 years of age [54].

    3. (c)

      Cardiac imaging: echocardiogram

    4. (d)

      Laboratory tests

      1. (i)

        Thrombophilia screening [277]

      2. (ii)

        Sickle cell screen

      3. (iii)

        Additional tests such as prothrombin gene mutation 20210A, activated protein C resistance, Factor V Leiden G1691A mutation, antiphospholipid antibody testing, protein C and S activity, antithrombin III activity, homocysteine level and lipoprotein (a) may be useful.

  5. 5.

    Management [269, 278]

    1. (a)

      Reduce ischemic stroke recurrence.

      1. (i)

        Institute appropriate antiplatelet drug or anticoagulate based on results of etiologic workup; [279] employ disease-specific treatments such as transfusion in sickle cell disease and repair of congenital cardiac anomalies.

      2. (ii)

        Unlike for adults, empiric anticoagulation while evaluating for ischemic stroke etiology (if not contraindicated) has been suggested for children because the probability that the ischemic stroke was due to a condition that will require anticoagulation is higher.

      3. (iii)

        Antithrombotic medications used in children include aspirin, clopidogrel, warfarin, as well as low molecular weight heparins [280]

    2. (b)

      Treat seizures: institution of prophylactic antiepileptic medications is generally not recommended.

    3. (c)

      Maintain supportive care: normothermia, euvolemia, and normoglycemia.

    4. (d)

      Manage blood pressure: although guidelines suggest control of systemic hypertension, specific goals are not proposed.

  6. 6.

    Outcome [4]

    1. (a)

      Moderate—severe disability: 42%

    2. (b)

      Recurrence: 10% within 5 years

    3. (c)

      Mortality: decreased by 19% between 1979 and 1998, but may be still be 3–11% [268]

Internet Ischemic Stroke Resources

American Academy of Neurology: http://www.aan.com

American Heart Organization: http://www.americanheart.org

American Stroke Association: http://www.strokeassociation.org

Internet Stroke Center at Washington University: http://www.strokecenter.org

National Stroke Association: http://www.stroke.or

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Ardelt, A.A. (2018). Ischemic Stroke. In: Handbook of Cerebrovascular Disease and Neurointerventional Technique. Contemporary Medical Imaging. Humana, Cham. https://doi.org/10.1007/978-3-319-66779-9_16

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  • DOI: https://doi.org/10.1007/978-3-319-66779-9_16

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