🧠 Chapter 64: Stroke

Acute ischaemic stroke (AIS) · Haemorrhagic stroke · Risk factors (CHD, sickle cell, CVL, trauma) · MRI gold standard · Anticoagulation (UFH, LMWH) · Antiplatelets (aspirin) · Thrombolysis (limited in children) · Sickle cell — exchange transfusion · CVST · Heparin-induced thrombocytopenia (HIT)

🔍 Core Concepts: Stroke

📌 Types
Ischaemic (arterial or CVST) and haemorrhagic. Children present later than adults. MRI is gold standard. Risk factors: CHD, sickle cell, central lines, trauma, prothrombotic states.
🩸 Anticoagulation (UFH & LMWH)
Indicated for CVST, cardioembolic stroke, dissection. Unfractionated heparin (UFH): bolus 75 U/kg, infusion 20-28 U/kg/h, target aPTT 60-85s. LMWH (enoxaparin): 1 mg/kg/dose Q12H, target anti-Xa 0.5-1 U/mL.
💊 Antiplatelet Therapy
Aspirin 3-5 mg/kg/day for arterial ischaemic stroke (AIS) without dissection or cardioembolism. Start within 48h.
⚠️ HIT (Heparin-Induced Thrombocytopenia)
Suspected if platelet drop >50% 5-10 days after heparin. Discontinue all heparin. Use non-heparin anticoagulant (argatroban, lepirudin).
🩸 Sickle Cell Disease & Stroke
Acute: IV hydration, exchange transfusion (target HbS <30%). Long-term: chronic transfusions to keep HbS <30%.
📊 Thrombolysis (tPA)
No definite evidence in children. May be considered in select cases (complete occlusion of basilar artery, experienced centre). Avoid if anticoagulants given in prior 24h.

🩺 Stepwise Approach: Paediatric Stroke

1
Emergency stabilisation & rapid imaging
ABCs, O2, IV access. Non-contrast CT brain to rule out haemorrhage. MRI/MRA/MRV is gold standard for ischaemic stroke/CVST. Obtain baseline labs (CBC, PT/PTT, fibrinogen, thrombophilia screen).
2
Differentiate ischaemic vs haemorrhagic
Haemorrhagic: neurosurgical consult, reverse anticoagulation (vitamin K, FFP, platelets), control BP. Ischaemic: proceed to anticoagulation/antiplatelet.
3
Antithrombotic therapy for AIS
Start aspirin 3-5 mg/kg/day within 48h. If cardioembolic or dissection, start anticoagulation (UFH or LMWH) after excluding haemorrhage. Target aPTT 60-85 (UFH) or anti-Xa 0.5-1 (LMWH).
4
CVST (Cerebral Venous Sinus Thrombosis)
Anticoagulation for 3-6 months (LMWH or UFH then warfarin). Treat underlying prothrombotic condition. Monitor for increased ICP.
5
Sickle cell stroke
IV hydration, exchange transfusion (target HbS <30%). Long-term chronic transfusions to prevent recurrence. Hydroxyurea if transfusions not feasible.
6
Supportive care & monitoring
Neuroprotective measures: normothermia, normoxia, normocapnia, euvolemia, treat seizures. Monitor for HIT (platelet count). Rehab early.