Pediatric emergency medicine trisk 2630 2630
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mimic stroke, including complicated migraine, structural brain lesion, central
nervous system (CNS) infection, Todd paresis, and psychogenic causes (see
Chapters 17 Coma and 82 Weakness ).
Diagnostic Testing
Investigations in a child for whom there is a concern for stroke should be directed
at confirming the diagnosis of stroke and attempting to identify an underlying
cause. Cross-sectional neuroimaging is recommended for all children with
suspected stroke. MRI with diffusion-weighted imaging is considered the most
sensitive imaging modality and can identify ischemic changes within hours of
onset. Limited, or Quick brain MRI with DWI series has demonstrated good
sensitivity for the identification of acute ischemic stroke, however, it is not as
sensitive in the identification of hemorrhage, which may limit its role for those
patients for whom thrombolysis is a consideration. Cranial CT without contrast is
the study of choice for identifying acute hemorrhage; however, CT scan may be
normal in the first 12 to 24 hours after an ischemic stroke. Vascular imaging of
the cervical vessels as well as proximal intracranial vessels should be included.
This can be done with magnetic resonance angiography in most patients. MRV
imaging should be strongly considered as a significant proportion of hemorrhages
are secondary to cerebral venous sinus thrombosis. Several factors should be
considered in the choice of initial imaging modality; radiation exposure,
sensitivity, and specificity in identifying acute ischemia and hemorrhage, ability
to complete in a timely manner, the need for anesthesia, and consideration of
thrombolytic therapy. In a child without a known predisposing condition,
ancillary tests may be helpful in revealing the cause of the stroke. Studies worth
considering in such patients, depending on the clinical picture, are listed in Table
97.6 . In one series of 129 children with ischemic stroke, no cause was found in
35%.
Management
Initial treatment after an acute stroke should focus on stabilization and prevention
of secondary neuronal injury. This includes maintenance of normotension,
normothermia, euglycemia, and treatment of hypoxemia and seizures.
Hypertension must be treated cautiously, and the blood pressure lowered
gradually in order to maintain adequate cerebral perfusion. Both hypoglycemia
and hyperglycemia can exacerbate ischemic stroke. Careful monitoring of serum
glucose levels and judicious use of insulin are important. Fever, which can occur
