• Cerebrovascular events (CVO) are roughly examined under two headings as ischemic and hemorrhagic.
ICHEMIC Stroke
• Stroke is an important cause of acquired brain damage in newborns and children.
• Ischemic stroke in children is more common than intracranial malignancies.
• Ischemic strokes may occur due to arterial and venous embolisms.
Cerebral Artery Embolism
• It occurs most frequently in the middle cerebral artery and its branches. The most common finding is hemiparesis.
• The most important cause of hemiparetic cerebral palsy is perinatal arterial ischemic stroke.
• Its etiology is mainly examined in 3 categories as arteriopathy, cardiac or hematological causes. The most common cause is cerebral arteropathy. It is the most common transient cerebral arteriopathy syndrome caused by unilateral irregular stenosis of the proximal middle cerebral artery in school-age children. It is found in bacterial meningitis and tuberculosis that cause arterial infection among arteriopathies.
• Cardiac causes: Complex congenital heart diseases (more common in cyanotic patients), arrhythmias, endocarditis and valvular diseases are among the cardiac causes of stroke.
• Hematological causes: sickle cell anemia, iron deficiency anemia, hereditary or acquired prothrombotic causes
• Metabolic/genetic causes: Fabry disease, mitochondrial encephalopathies, OTC deficiency, Sulfite oxidase deficiency, Organic acidemias (Methylmalonic, propionic, isovaleric acidemia, glutaric aciduria type 2), Ehlers-Danlos syndrome (type 4), Marfan syndrome, Homocystinuria, Menkes syndrome
• Diagnosis is usually delayed in children, and stroke should be considered in children with acute onset focal neurological deficits. The most common form of application is hemiparesis. However, it can also present with acute vision, speech, sensation problems and instability.
• CT is often useless, diffusion-weighted MR imaging is required. It results in 6-10% death.
• Arterial stroke is also seen in Moyamoya disease and PHACES (posterior fossa anomalies, hemangiomas, arterial cardiac-eye-sternal anomalies) syndrome.
Moyamoya disease
• Moyamoya means cigarette smoke in Japanese. On cranial angiography, there are vascular anomalies resembling cigarette smoke.
• Progressive occlusion of the internal carotid artery is seen. Acute hemiplegia, mental-motor retardation, hyperkinesia, seizure can be seen.
• NF-1 may occur in association with Down syndrome, Alagille syndrome, sickle cell anemia, chromosomal microdeletion/duplications and postradiation.
Cerebral Synovenous Thrombosis
• Cerebral sinovenous thrombosis (SSVT) is thought to be more common in children than adults. The risk is especially high in the neonatal period.
• Symptoms in children resemble idiopathic intracranial hypertension. Progressive headache, papilledema, diplopia due to 6th cranial nerve palsy, and acute focal deficit are common, as well as seizures, lethargy, and confusion.
• Optic neuropathy may occur due to increased intracranial pressure secondary to SSVT.
It is an important complication that can be easily missed.
• CT venography or MR venography imaging should be performed for diagnosis.
• Conditions that reduce blood fluidity/predispose to coagulation and disrupt the structure of blood vessels increase the risk.
Reducing blood fluidity/predisposing to coagulation: Hereditary or acquired prothrombotic conditions, dehydration, iron deficiency anemia, drugs (L-ASPA), nephrotic syndrome, metabolic diseases (such as homocystinuria)
Disrupting the structure of blood vessels: Infections/thrombophlebitis (otitis media, bacterial meningitis, sinusitis, Lemierre syndrome, sepsis), trauma, venous malformations, compression during birth in newborns
HEMORAGIC STROKE
• It can vary considerably depending on the location of clinical bleeding. Epidural hemorrhages are almost always secondary to trauma, while subdural hemorrhages may be spontaneous with bleeding from the bridging veins due to brain atrophy.
• Severe-unbearable headache is an important finding in acute hemorrhages. In addition, seizures, focal neurological deficits, changes in consciousness, neck stiffness may also be seen.
• Risk factors can be examined under 3 headings: vascular disorders, coagulation disorders and trauma.
Vascular causes: AV or cavernous malformations, aneurysms, Moyamoya disease/syndrome, inflammatory vasculitides, sinovenous thrombosis
Coagulation disorders: ITP, HUS, DIC, liver failure, vitamin K deficiency
Trauma: Epidural, subdural hemorrhages
• The first examination for diagnosis is brain CT.
• Arteriovenous (AV) malformations are the most common cause of hemorrhagic strokes in children.
It is mostly supratenteroial, with a murmur in the head with a pulse. Diagnosis is made by angiography.
• In newborns, aneurysm of the vein of Galen, hyperdynamic heart failure, progressive macrocephaly, hydrocephalus may rarely be seen together with hemorrhage. Hearing a high-frequency murmur in the baby's head is specific, besides, it is important to detect heart failure and especially to show a ringing phenomenon, although there is no cardiac cause on echocardiography. Survival was increased by performing embolizations with neurointerventional methods.
• Symptomatic cerebral aneurysms are rare in children.
• Compared with ischemic strokes, childhood hemorrhagic strokes have higher mortality but lower long-term deficits.
• Bleeding from the germinal matrix is common in premature babies, and most of the bleeding in term babies is idiopathic.
