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Oshi MAM, Aljabri MF, Alotaibi S, Alzahrani Y, Alfaifi J, Abosabie SAS, Abosabie SA, Algethami SS, Younes AE, Almanjoomi RK, Babkour, B, Kamal NM. Vertebral artery dissection aneurysm in a pediatric patient: A rare case with unusual clinical manifestations, diagnostic, and management challenges. Medicine (Baltimore) 2023; 102:e35906. [PMID: 38013323 PMCID: PMC10681449 DOI: 10.1097/md.0000000000035906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/12/2023] [Indexed: 11/29/2023] Open
Abstract
Vertebral artery aneurysm is a rare condition with diverse clinical manifestations in pediatric patients. We present the case of a 12-year-old male who presented with diplopia, vomiting, ataxia, and severe headache. Diagnostic evaluation revealed an extracranial vertebral artery dissection with an associated aneurysm at the C3-C4 level. Despite the absence of recurrent ischemic strokes, the aneurysm posed challenges in differentiating the symptoms from other inflammatory demyelinating disorders, particularly internuclear ophthalmoplegia. Diagnosis relied on a thorough history, physical examination, and imaging studies. Magnetic resonance imaging with magnetic resonance angiography confirmed the diagnosis and played a crucial role in assessing the size, location, and extent of the aneurysm. Additionally, the imaging findings helped guide treatment decisions and determine the need for anticoagulation therapy. Regular follow-up imaging was initiated to monitor for late complications and evaluate the effectiveness of the management approach. This case highlights the atypical presentation of vertebral artery aneurysm in a pediatric patient, underscoring the importance of clinical suspicion and the role of advanced imaging techniques in facilitating accurate diagnosis and guiding appropriate management. Prompt diagnosis and optimal utilization of imaging modalities are essential in preventing severe morbidity and mortality. Further research is warranted to enhance our understanding of this condition and refine imaging and management protocols in pediatric population.
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Affiliation(s)
- Mohammed A. M. Oshi
- Neurology Division, Gaafar Ibnauf Children’s Emergency Hospital, Khartoum, Sudan
- Alhada Armed Forces Hospital, Department of Pediatrics, Neurology Division, Taif, Kingdom of Saudi Arabia
| | - Mohammed Fahad Aljabri
- Alhada Armed Forces Hospital, Department of Pediatrics, Neurology Division, Taif, Kingdom of Saudi Arabia
| | - Saad Alotaibi
- Department of Radiology, Neuroradiology Section, Alhada Armed Forces Hospital, Taif, Kingdom of Saudi Arabia
| | - Yahea Alzahrani
- Department of Radiology, Faculty of Medicine, Taif University, Taif, Kingdom of Saudi Arabia
| | - Jaber Alfaifi
- Department of Child Health, College of Medicine, University of Bisha, Bisha, Saudi Arabia
| | | | - Sara A. Abosabie
- Faculty of Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Alaa E. Younes
- Department of Surgery, College of Medicine, Taif University, Taif, Saudi Arabia
| | | | - Bashar Babkour,
- Department of Radiology, Neuroradiology Section, Alhada Armed Forces Hospital, Taif, Kingdom of Saudi Arabia
| | - Naglaa M. Kamal
- Pediatrics and Pediatric Hepatology, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
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2
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Hanalioglu D, Oncel I, Hanalioglu S, Cebeci D, Kurt F, Gunes A, Gurkas E. Interplay between carotid artery dissection and thrombophilia leading to ischaemic stroke after minor head trauma in an adolescent: a case report. Paediatr Int Child Health 2023; 43:13-18. [PMID: 37849317 DOI: 10.1080/20469047.2023.2269362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 10/06/2023] [Indexed: 10/19/2023]
Abstract
Stroke in children is more common than is often realised; there are numerous potential causes, including carotid artery injury resulting from minor head or neck trauma, as well as genetic conditions associated with thrombophilia. A 13-year-old boy suffered an arterial ischaemic stroke (AIS) secondary to dissection of the left internal carotid artery (ICA) after he headed the ball during a game of football. He presented with generalised tonic-clonic seizure, loss of consciousness, right-sided hemiplegia and aphasia. Neuroradiological imaging showed left caudate, putaminal and posterior insular ischaemic infarct secondary to complete occlusion of the left ICA and accompanying partial left middle cerebral artery occlusion. He was treated with anticoagulant and anti-aggregant agents. Rarely, minor head trauma can result in internal carotid artery dissection, thrombus formation and arterial occlusion, leading to arterial ischaemic stroke. Prompt diagnosis and management are crucial to achieve a good neurological outcome.Abbreviations: AIS: arterial ischaemic stroke; ANA: anti-nuclear antibody; APA: anti-phospholipid antibody; APTT: activated partial thromboplastin time; CAD: carotid artery dissection; CCAD: cranio-cervical artery dissection; CRP: C-reactive protein; CT: computed tomography; CTA: computed tomography angiography; dsDNA: double-stranded DNA; ESR: erythrocyte sedimentation rate; ICA: internal carotid artery; LA: lupus anticoagulant; MCA: middle cerebral artery; MRA: magnetic resonance angiography; MRI: magnetic resonance imaging; MTHFR: methylenetetrahydrofolate reductase; PT INR: prothrombin time international normalised ratio.
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Affiliation(s)
- Damla Hanalioglu
- Department of Paediatrics, Division of Paediatric Emergency Medicine, University of Health Sciences, Ankara, Turkey
- Department of Paediatrics, Division of Paediatric Emergency Medicine, Hacettepe University Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Ibrahim Oncel
- Department of Paediatrics, Division of Paediatric Neurology, University of Health Sciences, Ankara, Turkey
| | - Sahin Hanalioglu
- Department of Neurosurgery, University of Health Sciences, Ankara, Turkey
| | - Dilek Cebeci
- Department of Paediatrics, Division of Paediatric Neurology, University of Health Sciences, Ankara, Turkey
| | - Funda Kurt
- Department of Paediatrics, Division of Paediatric Emergency Medicine, University of Health Sciences, Ankara, Turkey
| | - Altan Gunes
- Department of Radiology, University of Health Sciences, Ankara, Turkey
| | - Esra Gurkas
- Department of Paediatrics, Division of Paediatric Neurology, University of Health Sciences, Ankara, Turkey
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3
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Rawanduzy CA, Earl E, Mayer G, Lucke-Wold B. Pediatric Stroke: A Review of Common Etiologies and Management Strategies. Biomedicines 2022; 11:biomedicines11010002. [PMID: 36672510 PMCID: PMC9856134 DOI: 10.3390/biomedicines11010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/12/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
Pediatric stroke is an important cause of mortality and morbidity in children. There is a paucity of clinical trials pertaining to pediatric stroke management, and solidified universal guidelines are not established for children the way they are for the adult population. Diagnosis of pediatric stroke can be challenging, and it is often delayed or mischaracterized, which can result in worse outcomes. Understanding risks and appropriate therapy is paramount to improving care.
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Affiliation(s)
| | - Emma Earl
- School of Medicine, University of Utah, Salt Lake City, UT 84112, USA
| | - Greg Mayer
- School of Medicine, University of Utah, Salt Lake City, UT 84112, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
- Correspondence:
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4
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Radhakrishnan R, Shea LAG, Pruthi S, Silvera VM, Bosemani T, Desai NK, Gilbert DL, Glenn OA, Guimaraes CV, Ho ML, Lam HFS, Maheshwari M, Mirsky DM, Nadel HR, Partap S, Schooler GR, Udayasankar UK, Whitehead MT, Wright JN, Rigsby CK. ACR Appropriateness Criteria® Ataxia-Child. J Am Coll Radiol 2022; 19:S240-S255. [PMID: 36436955 DOI: 10.1016/j.jacr.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
Childhood ataxia may be due to multifactorial causes of impairment in the coordination of movement and balance. Acutely presenting ataxia in children may be due to infectious, inflammatory, toxic, ischemic, or traumatic etiology. Intermittent or episodic ataxia in children may be manifestations of migraine, benign positional vertigo, or intermittent metabolic disorders. Nonprogressive childhood ataxia suggests a congenital brain malformation or early prenatal or perinatal brain injury, and progressive childhood ataxia indicates inherited causes or acquired posterior fossa lesions that result in gradual cerebellar dysfunction. CT and MRI of the central nervous system are the usual modalities used in imaging children presenting with ataxia, based on the clinical presentation. This document provides initial imaging guidelines for a child presenting with acute ataxia with or without a history of recent trauma, recurrent ataxia with interval normal neurological examination, chronic progressive ataxia, and chronic nonprogressive ataxia. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Rupa Radhakrishnan
- Associate Division Chief, Neuroradiology, Indiana University Health, Indianapolis, Indiana.
| | - Lindsey A G Shea
- Research Author, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sumit Pruthi
- Panel Chair, Vanderbilt Children's Hospital, Nashville, Tennessee
| | | | | | | | - Donald L Gilbert
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; American Academy of Neurology
| | - Orit A Glenn
- Director, Pediatric Neuroradiology, University of California, San Francisco, San Francisco, California
| | - Carolina V Guimaraes
- Division Chief, Pediatric Radiology, Lucile Packard Children's Hospital at Stanford, Stanford, California
| | - Mai-Lan Ho
- Nationwide Children's Hospital, Columbus, Ohio
| | - H F Samuel Lam
- Sutter Medical Center Sacramento, Sacramento, California; American College of Emergency Physicians
| | - Mohit Maheshwari
- Director of Pediatric Neuroradiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David M Mirsky
- Director of the Pediatric Neuroradiology Fellowship, Children's Hospital Colorado, Aurora, Colorado
| | - Helen R Nadel
- Lucile Packard Children's Hospital at Stanford, Stanford, California
| | - Sonia Partap
- Neuro-Oncology Fellowship Director, Stanford University, Stanford, California; American Academy of Pediatrics
| | - Gary R Schooler
- Associate Division Director, Pediatric Radiology, UT Southwestern Medical Center, Dallas, Texas
| | | | | | | | - Cynthia K Rigsby
- Specialty Chair; Chair, Medical Imaging Department, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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5
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Davila-Williams D, Barry M, Vargas C, Vossough A, Bernard TJ, Rafay MF. Cerebral Arteriopathies of Childhood - Current Approaches. Semin Pediatr Neurol 2022; 43:101004. [PMID: 36344018 DOI: 10.1016/j.spen.2022.101004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 09/07/2022] [Accepted: 09/26/2022] [Indexed: 10/14/2022]
Abstract
Up to more than half of previously healthy children presenting with their first arterial ischemic stroke have a cerebral arteriopathy. Cerebral arteriopathies during childhood can be congenital, reflecting abnormal vessel development, or acquired when caused by disruption of vascular homeostasis. Distinguishing different types of cerebral arteriopathies in children can be challenging but of great clinical value as they may dictate different disease and treatment courses, and clinical and radiologic outcomes. Furthermore, children with stroke due to a specific arteriopathy exhibit distinctive features when compared to those with stroke due to other causes or a different type of arteriopathy. These features become crucial in the management of pediatric stroke by choosing appropriate diagnostic and treatment strategies. The objective of this article is to provide the reader with a comprehensive up-to-date review of the classification, symptoms, diagnosis, treatment, and outcome of cerebral arteriopathies in children.
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Affiliation(s)
| | - Megan Barry
- Section of Neurology, Department of Pediatrics, Hemophilia & Thrombosis Center, University of Colorado, Aurora, Co, USA
| | - Carolina Vargas
- Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Arastoo Vossough
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy J Bernard
- Section of Neurology, Department of Pediatrics, Hemophilia & Thrombosis Center, University of Colorado, Aurora, Co, USA
| | - Mubeen F Rafay
- Children's Hospital Winnipeg, Department of Pediatrics and Child Health, Max Rady College of Medicine, University of Manitoba, Children's Hospital Research Institute of Manitoba, Manitoba, Canada.
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Identification of Cervical Artery Dissections: Imaging Strategies and Literature Review. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2022. [DOI: 10.1007/s40138-022-00247-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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McGuire D, Mielke N, Bahl A. Atypical Presentation of Traumatic Pediatric Carotid Artery Dissection: A Case Report. Clin Pract Cases Emerg Med 2022; 6:229-231. [PMID: 36049190 PMCID: PMC9436487 DOI: 10.5811/cpcem.2022.4.56488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/15/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction: Carotid artery dissection is a rare but serious condition manifesting with signs and symptoms that closely overlap with other more benign medical diagnoses. This vascular injury, however, can result in debilitating sequelae, including thromboembolic cerebrovascular accidents. Case Report: We describe the atypical presentation of a healthy eight-year-old male who presented to the emergency department (ED) with generalized abdominal pain and non-bloody, non-bilious emesis. These symptoms occurred nine days after he sustained blunt head trauma after a non-syncopal fall from standing while playing hockey. He was initially diagnosed with gastroesophageal reflux disease and constipation and was discharged home. The following day he developed an acute headache followed shortly by gait ataxia, prompting a return visit to the ED. Imaging of the head and neck revealed a left internal carotid artery dissection. The patient was started on intravenous unfractionated heparin and admitted to the hospital. He was later discharged symptom-free on therapeutic enoxaparin for eight weeks, followed by daily aspirin therapy. Conclusion: Pediatric trauma patients, especially those sustaining insult to the head and cervical spine, are at risk for craniocervical arterial injuries. This rare but dangerous pathology often manifests in a non-specific, delayed fashion making it a challenging diagnosis for physicians to make on the initial medical encounter.1,2 Maintaining a high clinical suspicion for carotid artery dissection is required to make this diagnosis and should guide a thorough history, physical examination, and appropriate imaging in order to improve patient morbidity and mortality. This case emphasizes key clinical features and risk factors of this disease that may help emergency clinicians promptly recognize and treat this entity.
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Affiliation(s)
- Duncan McGuire
- Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan
| | - Nicholas Mielke
- Oakland University William Beaumont School of Medicine, Department of Emergency Medicine, Royal Oak, Michigan
| | - Amit Bahl
- Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan
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8
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Ritchey Z, Bernard TJ, Fenton LZ, Maloney JA, Mirsky DM, Neuberger I, Sriram I, Seinfeld J, Stence NV. Stroke Recurrence in Children with Vertebral Artery Dissecting Aneurysm. AJNR Am J Neuroradiol 2022; 43:913-918. [PMID: 35550284 DOI: 10.3174/ajnr.a7518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/21/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PURPOSE Pediatric vertebral artery dissecting aneurysm is a subtype of vertebral artery dissection that can be challenging to diagnose and may be associated with stroke recurrence. This study examines the presenting features, clinical outcomes, and recurrence risk in a cohort of children with vertebral artery dissection, comparing those with aneurysms with those without. MATERIALS AND METHODS The medical records of children evaluated for vertebral artery dissection were retrospectively reviewed for neurologic presentation, treatment, stroke recurrence, and angiographic appearance of dissection. Cohort patients were categorized into 2 groups based on the presence or absence of a vertebral artery dissecting aneurysm and compared via the Fisher exact test, Student t test, and log-rank analyses. P < .05 was deemed statistically significant. RESULTS Thirty-two patients met the inclusion criteria, including 13 with vertebral artery dissecting aneurysms. Five cases of vertebral artery dissecting aneurysm were missed on the initial evaluation and diagnosed retrospectively. All patients received antiplatelet or anticoagulation therapy at the time of diagnosis. Children in the vertebral artery dissecting aneurysm group were more likely to present with stroke (P = .059), present at a younger age (P < .001), and have recurrent stroke (P < .001) compared with the group of children with vertebral artery dissection without an aneurysm. After surgery, no patients with vertebral artery dissecting aneurysm experienced recurrent stroke (P = .02). CONCLUSIONS Vertebral artery dissecting aneurysm is often missed on the initial diagnostic evaluation of children presenting with stroke. In children with vertebral artery dissection, the presence of an aneurysm is associated with stroke presentation at a younger age and stroke recurrence.
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Affiliation(s)
- Z Ritchey
- From the Department of Radiology (Z.R.), University of Colorado School of Medicine, Aurora, Colorado
| | - T J Bernard
- Section of Child Neurology (T.J.B), Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado.,Hemophilia and Thrombosis Center (T.J.B.), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - L Z Fenton
- Department of Radiology (L.Z.F., JA.M., D.M.M., I.N., N.V.S.), Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - J A Maloney
- Department of Radiology (L.Z.F., JA.M., D.M.M., I.N., N.V.S.), Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - D M Mirsky
- Department of Radiology (L.Z.F., JA.M., D.M.M., I.N., N.V.S.), Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - I Neuberger
- Department of Radiology (L.Z.F., JA.M., D.M.M., I.N., N.V.S.), Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - I Sriram
- Department of Pediatrics (I.E.), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - J Seinfeld
- Department of Neurosurgery (J.S.), University of Colorado School of Medicine, Aurora, Colorado
| | - N V Stence
- Department of Radiology (L.Z.F., JA.M., D.M.M., I.N., N.V.S.), Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
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9
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Dmytriw AA, Bickford S, Pezeshkpour P, Ha W, Amirabadi A, Dibas M, Kitamura LA, Vidarsson L, Pulcine E, Muthusami P. Rotational Vertebrobasilar Insufficiency: Is There a Physiological Spectrum? Phase-Contrast Magnetic Resonance Imaging Quantification in Healthy Volunteers. Pediatr Neurol 2022; 128:58-64. [PMID: 35101804 DOI: 10.1016/j.pediatrneurol.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/07/2021] [Accepted: 12/11/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Some cases of cerebral ischemia have been attributed to dynamic flow limitation in neck vessels. It however remains unknown whether this represents the extreme end of a physiological response. METHODS Eighteen healthy volunteers were recruited to this prospective study. Cervical blood flow (ml/min/m2) was assessed using phase-contrast MRI, and cerebral perfusion ratios were assessed using arterial spin labeling perfusion at neutral position, predefined head rotations, as well as flexion and extension. Inter-reader agreements were assessed using intraclass correlation coefficient. RESULTS The mean age was 38.6 ± 10.8 (range = 22-56) years, for five male participants and 13 females. The means for height and weight were 168 cm and 73.2 kg, respectively. There were no significant differences in individual arterial blood flow with change in head position (P > 0.05). Similarly, the repeated-measures analysis of variance test demonstrated no significant difference in perfusion ratios in relation to head position movement (P > 0.05). Inter-reader agreement was excellent (intraclass correlation coefficient = 0.97). CONCLUSIONS There is neither significant change in either individual cervical arterial blood flow nor cerebral perfusion within the normal physiological/anatomical range of motion in healthy individuals. It is therefore reasonable to conclude that any such hemodynamic change identified in a patient with ischemic stroke be considered causative.
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Affiliation(s)
- Adam A Dmytriw
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada.
| | - Suzanne Bickford
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Parneyan Pezeshkpour
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Winston Ha
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Afsaneh Amirabadi
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Mahmoud Dibas
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Lee Ann Kitamura
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Logi Vidarsson
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth Pulcine
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Prakash Muthusami
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada
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10
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Abstract
Complaints related to the neck are common following mild pediatric trauma. Although significant cervical spine injuries are most often seen and evaluated in the emergency room or inpatient setting, the primary care provider is faced with the evaluation of lower acuity complaints. We provide a review to assist with the efficient evaluation of these patients to facilitate decisions regarding return to play, the need for imaging, and need for referral to subspecialty providers.
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Affiliation(s)
- Andrew Jea
- Department of Neurosurgery, University of Oklahoma College of Medicine, 1000 North Lincoln Boulevard, Suite 4000, Oklahoma City, OK 73104, USA.
| | - Ahmed Belal
- Department of Neurological Surgery, Indiana University School of Medicine, 355 West 16th Street, Suite 5100, Indianapolis, IN 46202, USA
| | - Mohamed A Zaazoue
- Department of Neurological Surgery, Indiana University School of Medicine, 355 West 16th Street, Suite 5100, Indianapolis, IN 46202, USA
| | - Jonathan Martin
- Division of Neurosurgery, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT 06106, USA
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11
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Hypoxic-ischemic injury causes functional and structural neurovascular degeneration in the juvenile mouse retina. Sci Rep 2021; 11:12670. [PMID: 34135369 PMCID: PMC8209038 DOI: 10.1038/s41598-021-90447-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 05/04/2021] [Indexed: 12/11/2022] Open
Abstract
Ischemic stroke is a major cause of long-term disabilities, including vision loss. Neuronal and blood vessel maturation can affect the susceptibility of and outcome after ischemic stroke. Although we recently reported that exposure of neonatal mice to hypoxia–ischemia (HI) severely compromises the integrity of the retinal neurovasculature, it is not known whether juvenile mice are similarly impacted. Here we examined the effect of HI injury in juvenile mice on retinal structure and function, in particular the susceptibility of retinal neurons and blood vessels to HI damage. Our studies demonstrated that the retina suffered from functional and structural injuries, including reduced b-wave, thinning of the inner retinal layers, macroglial remodeling, and deterioration of the vasculature. The degeneration of the retinal vasculature associated with HI resulted in a significant decrease in the numbers of pericytes and endothelial cells as well as an increase in capillary loss. Taken together, these findings suggest a need for juveniles suffering from ischemic stroke to be monitored for changes in retinal functional and structural integrity. Thus, there is an emergent need for developing therapeutic approaches to prevent and reverse retinal neurovascular dysfunction with exposure to ischemic stroke.
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12
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Abstract
Neurovascular disorders are an important cause of brain injury in the paediatric population, leading to substantial mortality and morbidity. These include ischaemic, haemorrhagic strokes, and cerebral venous sinus thromboses. Despite remarkable improvements in our understanding and management of strokes in general, and in the quality of immediate care and rehabilitation, the outcomes in childhood strokes lag far behind adult strokes. This is a multifaceted problem. There remain several challenges including delays in recognition due to vague clinical presentations, a failure to consider strokes in many cases, delays in obtaining imaging and inadequate imaging when performed, as well as limited evidence and availability for hyper acute intervention in children. Stroke in children is also a vastly different entity to adult strokes, with a unique set of risk factors and often with an underlying cause to be found. This review is by no means exhaustive, but instead aims to provide an overview of the epidemiology, sub-classification and aetiology of paediatric neurovascular disorders, mainly ischaemic, haemorrhagic strokes and cerebral venous sinus thrombosis. We also focus on the risk factors for each of these, the clinical presentation, recommended diagnostic protocol, pertinent imaging findings, as well as the current treatment and follow-up practices.
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Affiliation(s)
- Richa Sinha
- Department of Neuroradiology, Royal Preston Hospital, Preston, UK
| | - Saipriya Ramji
- Department of Neuroradiology, Charing Cross Hospital, London, UK
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13
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A rare cause of ischemic stroke in childhood: spontaneous long segment intracranial dissection. Childs Nerv Syst 2020; 36:2871-2875. [PMID: 32034519 DOI: 10.1007/s00381-020-04530-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 01/31/2020] [Indexed: 10/25/2022]
Abstract
Craniocervical arterial dissection is an important cause of arterial ischemic stroke in children. Recognition of dissections is of particular importance both in determining the risk of recurrence and in bringing about different treatment alternatives. We report a 10-year-old girl who presented with acute ischemic stroke due to spontaneous long segment dissection involving the parasellar internal carotid artery up to the distal M1 portion of the middle cerebral artery. Three-dimensional digital subtraction angiography with flat panel detector revealed the presence of major vessels originating from both true and false lumens and had a critical role in the treatment decision of the case.
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14
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Meder G, Świtońska M, Płeszka P, Palacz-Duda V, Dzianott-Pabijan D, Sokal P. Endovascular Treatment of Stroke Caused by Carotid Artery Dissection. Brain Sci 2020; 10:brainsci10110800. [PMID: 33143117 PMCID: PMC7692463 DOI: 10.3390/brainsci10110800] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/21/2020] [Accepted: 10/27/2020] [Indexed: 12/17/2022] Open
Abstract
Ischemic stroke due to large vessel occlusion (LVO) is a devastating condition. Most LVOs are embolic in nature. Arterial dissection is responsible for only a small proportion of LVOs, is specific in nature and poses some challenges in treatment. We describe 3 cases where patients with stroke caused by carotid artery dissection were treated with mechanical thrombectomy and extensive stenting with good outcome. We believe that mechanical thrombectomy and stenting is a treatment of choice in these cases.
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Affiliation(s)
- Grzegorz Meder
- Department of Interventional Radiology, Jan Biziel University Hospital No. 2, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland
- Correspondence: ; Tel.: +48-52-3655-143; Fax: +48-52-3655-364
| | - Milena Świtońska
- Stroke Intervention Centre, Department of Neurosurgery and Neurology, Jan Biziel University Hospital No. 2, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (M.Ś.); (P.P.); (V.P.-D.)
- Department of Neurosurgery and Neurology, Faculty of Health Sciences, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland;
| | - Piotr Płeszka
- Stroke Intervention Centre, Department of Neurosurgery and Neurology, Jan Biziel University Hospital No. 2, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (M.Ś.); (P.P.); (V.P.-D.)
| | - Violetta Palacz-Duda
- Stroke Intervention Centre, Department of Neurosurgery and Neurology, Jan Biziel University Hospital No. 2, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (M.Ś.); (P.P.); (V.P.-D.)
| | - Dorota Dzianott-Pabijan
- Neurological Rehabilitation Ward Kuyavian-Pomeranian Pulmonology Centre, Meysnera 9 Street, 85-472 Bydgoszcz, Poland;
| | - Paweł Sokal
- Department of Neurosurgery and Neurology, Faculty of Health Sciences, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland;
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15
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Cerebrovascular Complications of Pediatric Blunt Trauma. Pediatr Neurol 2020; 108:5-12. [PMID: 32111560 PMCID: PMC7306436 DOI: 10.1016/j.pediatrneurol.2019.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 12/02/2019] [Accepted: 12/08/2019] [Indexed: 12/13/2022]
Abstract
Ischemic and hemorrhagic stroke can occur in the setting of pediatric trauma, particularly those with head or neck injuries. The risk of stroke appears highest within the first two weeks after trauma. Stroke diagnosis may be challenging due to lack of awareness or concurrent injuries limiting detailed neurological assessment. Other injuries may also complicate stroke management, with competing priorities for blood pressure, ventilator management, or antithrombotic timing. Here we review epidemiology, clinical presentation, and diagnostic approach to blunt arterial injuries including dissection, cerebral sinovenous thrombosis, mineralizing angiopathy, stroke from abusive head trauma, and traumatic hemorrhagic stroke. Owing to the complexities and heterogeneity of concomitant injuries in stroke related to trauma, a single pathway for stroke management is impractical. Therefore providers must understand the goals and possible costs or consequences of stroke management decisions to individualize patient care. We discuss the physiological principles of cerebral perfusion and oxygen delivery, considerations for ventilator strategy when stroke and lung injury are present, and current available evidence of the risks and benefits of anticoagulation to provide a framework for multidisciplinary discussions of cerebrovascular injury management in pediatric patients with trauma.
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16
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Ryan ME, Pruthi S, Desai NK, Falcone RA, Glenn OA, Joseph MM, Maheshwari M, Marin JR, Mazzola C, Milla SS, Mirsky DM, Myseros JS, Niogi SN, Partap S, Radhakrishnan R, Robertson RL, Soares BP, Udayasankar UK, Whitehead MT, Wright JN, Karmazyn B. ACR Appropriateness Criteria® Head Trauma-Child. J Am Coll Radiol 2020; 17:S125-S137. [PMID: 32370957 DOI: 10.1016/j.jacr.2020.01.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 01/22/2020] [Indexed: 12/15/2022]
Abstract
Head trauma is a frequent indication for cranial imaging in children. The majority of accidental pediatric head trauma is minor and sustained without intracranial injury. Well-validated pediatric-specific clinical decision guidelines should be used to identify very low-risk children who can safely forgo imaging. In those who require acute imaging, CT is considered the first-line imaging modality for suspected intracranial injury because of the short duration of the examination and its high sensitivity for acute hemorrhage. MRI can accurately detect traumatic complications, but often necessitates sedation in children, owing to the examination length and motion sensitivity, which limits rapid assessment. There is a paucity of literature regarding vascular injuries in pediatric blunt head trauma and imaging is typically guided by clinical suspicion. Advanced imaging techniques have the potential to identify changes that are not seen by standard imaging, but data are currently insufficient to support routine clinical use. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Maura E Ryan
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Sumit Pruthi
- Panel Chair, Vanderbilt Children's Hospital, Nashville, Tennessee
| | | | - Richard A Falcone
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; American Pediatric Surgical Association
| | - Orit A Glenn
- University of California San Francisco, San Francisco, California
| | - Madeline M Joseph
- University of Florida College of Medicine Jacksonville, Jacksonville, Florida; American College of Emergency Physicians
| | | | - Jennifer R Marin
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; Society for Academic Emergency Medicine
| | - Catherine Mazzola
- Rutgers, New Jersey Medical School, Newark, New Jersey; Neurosurgery expert
| | - Sarah S Milla
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - John S Myseros
- Children's National Health System, Washington, District of Columbia; Neurosurgery Expert
| | | | - Sonia Partap
- Stanford University, Stanford, California; American Academy of Pediatrics
| | | | | | - Bruno P Soares
- The University of Vermont Medical Center, Burlington, Vermont
| | | | | | | | - Boaz Karmazyn
- Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana
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17
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Robertson RL, Palasis S, Rivkin MJ, Pruthi S, Bartel TB, Desai NK, Kadom N, Kulkarni AV, Lam HFS, Maheshwari M, Milla SS, Mirsky DM, Myseros JS, Partap S, Radhakrishnan R, Soares BP, Trout AT, Udayasankar UK, Whitehead MT, Karmazyn B. ACR Appropriateness Criteria® Cerebrovascular Disease-Child. J Am Coll Radiol 2020; 17:S36-S54. [PMID: 32370977 DOI: 10.1016/j.jacr.2020.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 10/24/2022]
Abstract
Stroke is an uncommon but an important and under-recognized cause of morbidity and mortality in children. Strokes may be due to either brain ischemia or intracranial hemorrhage. Common symptoms of pediatric acute stroke include headache, vomiting, focal weakness, numbness, visual disturbance, seizures, and altered consciousness. Most children presenting with an acute neurologic deficit do not have an acute stroke, but have symptoms due to stroke mimics which include complicated migraine, seizures with postictal paralysis, and Bell palsy. Because of frequency of stroke mimics, in children and the common lack of specificity in symptoms, the diagnosis of a true stroke may be delayed. There are a relatively large number of potential causes of stroke mimic and true stroke. Consequently, imaging plays a critical role in the assessment of children with possible stroke and especially in children who present with acute onset of stroke symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Susan Palasis
- Panel Chair, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Michael J Rivkin
- Boston Children's Hospital, Boston, Massachusetts; American Academy of Neurology
| | - Sumit Pruthi
- Panel Vice Chair, Vanderbilt Children's Hospital, Nashville, Tennessee
| | | | | | - Nadja Kadom
- Emory University and Children's of Atlanta (Egleston), Atlanta, Georgia
| | - Abhaya V Kulkarni
- Hospital for Sick Children, Toronto, Ontario, Canada; Neurosurgery expert
| | - H F Samuel Lam
- Sutter Medical Center, Sacramento, California; American College of Emergency Physicians
| | | | - Sarah S Milla
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - John S Myseros
- Children's National Health System, Washington, District of Columbia; Neurosurgery expert
| | - Sonia Partap
- Stanford University, Stanford, California; American Academy of Pediatrics
| | | | - Bruno P Soares
- The University of Vermont Medical Center, Burlington, Vermont
| | - Andrew T Trout
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | - Boaz Karmazyn
- Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana
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18
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Hejrati N, Ebel F, Guzman R, Soleman J. Posttraumatic cerebrovascular injuries in children. A systematic review. Childs Nerv Syst 2020; 36:251-262. [PMID: 31901968 DOI: 10.1007/s00381-019-04482-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/17/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Posttraumatic craniocervical vascular injuries in pediatric traumatic brain injury (TBI) are rare, and children-specific, evidence-based standards on screening and therapy of posttraumatic carotid-cavernous fistula (CCF), craniocervical artery dissections (CCAD), traumatic aneurysms (TA), and posttraumatic sinus venous thrombosis (SVT) is lacking. The aim of this review is to summarize the data on epidemiology, clinical presentation, and treatment of these traumatic lesions in a systematic manner. METHODS We performed a systematic PubMed search for records of CCF, CCAD, TA, and SVT related to pediatric TBI published until June 2019. RESULTS After screening 2439 records, 42 were included in the quantitative analysis. Incidences for CCAD in blunt TBI were 0.21% (range 0.02-6.82%). 11.7% (range 1.69-15.58%) of pediatric aneurysms were found to be traumatic of origin, whereas 38.2% (range 36.84-40%) of all pediatric SVT were due to blunt TBI. For all of the posttraumatic cerebrovascular pathologies, we found a clear male predominance with 68.75% in CCF, 63.4% in CCAD, 60% in TA, and 58.33% in SVT. Clinical presentation did not differ from the adult population with exception of young child. While there is only recommendation for the therapy of CCAD and SVT in the pediatric population, no such recommendation exists for the treatment of CCF's and TA's, and data from randomized controlled trials is lacking. CONCLUSION While these results show that posttraumatic CCF, CCAD, TA, and SVT are rarely encountered in children, misdiagnosis may have potentially drastic consequences due to a longer lifetime burden in the pediatric population. Awareness, early recognition, and prompt initiation of the appropriate therapy are essential to avoid morbidity and mortality. Further studies should focus on the development of clinical and radiological screening criteria of posttraumatic vascular lesions in children.
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Affiliation(s)
- Nader Hejrati
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Florian Ebel
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.,Division of Pediatric Neurosurgery, University Children's Hospital of Basel, Spitalstrasse 33, Basel, 4056, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.,Division of Pediatric Neurosurgery, University Children's Hospital of Basel, Spitalstrasse 33, Basel, 4056, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
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19
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Baltensperger A, Mirsky D, Maloney J, Neuberger I, Fenton L, Bernard T, Borgstede J, Stence N. Cost and Utility of Routine Contrast-Enhanced Neck MRA in a Pediatric MRI Stroke Evaluation Protocol. AJNR Am J Neuroradiol 2019; 40:2143-2145. [PMID: 31727745 DOI: 10.3174/ajnr.a6315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 09/18/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Cervical arterial dissection is one of the frequent causes of pediatric arterial ischemic stroke. Out of concern for missing cervical arterial dissection in patients in whom pediatric stroke is suspected, our tertiary children's hospital added contrast-enhanced 3D neck MR angiography to every pediatric stoke work-up. This research investigated whether the routine use of contrast-enhanced neck MRA in our MR imaging stroke protocol ever detected a cervical arterial abnormality when the DWI, SWI/gradient recalled-echo, or circle of Willis MRA findings from the brain MR imaging were reported as normal. MATERIALS AND METHODS The institutional PACS data base was searched for stroke protocol MRIs that included DWI, gradient recalled-echo or SWI, circle of Willis MRA, and 3D contrast-enhanced neck MRA in patients younger than 18 years of age with examinations performed between September 2010 and June 2017. RESULTS In only a single case (0.15%) were the DWI, SWI/gradient recalled-echo, or circle of Willis MRA findings all separately reported as normal and the contrast-enhanced neck MRA findings reported as abnormal. To reach these findings, we screened 681 patients, which would have resulted in an estimated >$200,000 in Medicare charges and $80,000 in of out-of-pocket cost to patients. CONCLUSIONS In our large series, the addition of a routine contrast-enhanced neck MRA to our pediatric stroke MR imaging protocol was of extremely low yield. We believe the use of neck MRA should reasonably be limited to cases in which abnormalities are initially detected on standard brain sequences or to patients with atypical presentation or recurrent pathology.
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Affiliation(s)
| | - D Mirsky
- Section of Child Neurology, Department of Radiology (D.M., J.M., I.N., L.F., N.S.)
| | - J Maloney
- Section of Child Neurology, Department of Radiology (D.M., J.M., I.N., L.F., N.S.)
| | - I Neuberger
- Section of Child Neurology, Department of Radiology (D.M., J.M., I.N., L.F., N.S.)
| | - L Fenton
- Section of Child Neurology, Department of Radiology (D.M., J.M., I.N., L.F., N.S.)
| | - T Bernard
- From the Department of Pediatrics (A.B., T.B.)
| | - J Borgstede
- Section of Pediatric Radiology, and Department of Radiology (J.B.), University of Colorado School of Medicine, Aurora, Colorado
| | - N Stence
- Section of Child Neurology, Department of Radiology (D.M., J.M., I.N., L.F., N.S.)
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20
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Thompson EJ, Wildman-Tobriner B, Parente V. Case 1: Delayed Diagnosis in a 13-year-old with Persistent Neurologic Symptoms after a Carnival Ride. Pediatr Rev 2019; 40:359-361. [PMID: 31263044 DOI: 10.1542/pir.2017-0270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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21
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Affiliation(s)
- Philip Overby
- Department of Neurology and.,Department of Pediatrics, New York Medical College, Valhalla, NY
| | - Matthew Kapklein
- Department of Pediatrics, New York Medical College, Valhalla, NY
| | - Ronald I Jacobson
- Department of Neurology and.,Department of Pediatrics, New York Medical College, Valhalla, NY
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22
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Nash M, Rafay MF. Craniocervical Arterial Dissection in Children: Pathophysiology and Management. Pediatr Neurol 2019; 95:9-18. [PMID: 30955992 DOI: 10.1016/j.pediatrneurol.2019.01.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 01/24/2019] [Accepted: 01/26/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Craniocervical arterial dissection is a commonly reported arteriopathy associated with stroke in children. It is characterized by a high stroke recurrence rate and variable outcomes. Here we review the pathophysiology, clinical presentation, and diagnostic neuroimaging approaches that are helpful in accurate diagnosis and follow-up of children with arterial dissection. METHODS MEDLINE searches (2000 to 2018) for articles that contained patients aged less than 18 years with craniocervical arterial dissection was performed, with the goal of analyzing their presenting features, pathophysiological mechanisms, and imaging characteristics and interventions. RESULTS Sixteen articles met the study criteria and reported 182 cases of craniocervical arterial dissection, 68% male, average age 8.6 years. Dissection was associated with head and neck trauma in 56% of the cases and frequently involved the posterior (61%) and extracranial locations (64%); the vertebral artery was the most commonly involved artery (60%). The most common clinical presentation was hemiparesis (80/160, 50%), followed by headache (64/164, 39%). Magnetic resonance imaging was the preferred neuroimaging method, followed by cerebral catheter angiography as a gold standard definitive neurovascular imaging modality when the initial vascular imaging revealed nondiagnostic findings. CONCLUSIONS The diagnosis of arterial dissection requires a high index of suspicion and consideration for detailed neurovascular imaging, including both the cranial and cervical regions. Neurovascular imaging challenges, especially visualization of arterial abnormalities, highlight the importance of appropriate and timely use of specific neurovascular imaging techniques. Magnetic resonance imaging appears to be the preferred neurovascular imaging modality in children with arterial dissection and may obviate the need for invasive cerebral catheter angiography.
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Affiliation(s)
- Monica Nash
- Department of Nursing, Red River College, Winnipeg, Manitoba, Canada
| | - Mubeen F Rafay
- Section of Pediatric Neurology, Department of Pediatrics and Child Health, University of Manitoba, Manitoba, Canada; Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada.
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23
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Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke 2019; 50:e51-e96. [DOI: 10.1161/str.0000000000000183] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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24
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Kovalchuk PV, Katilov OV, Panenko SO. Modern approaches to diagnostics and treatment of migraine in children. PAIN MEDICINE 2019. [DOI: 10.31636/pmjua.v3i4.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This article reviews modern approaches to diagnostics and treatment of a very common and simultaneously underestimated and often maltreated disorder in children. It is fallacious management of migraine masked behind the diagnoses such as autonomic vessel dysfunction and vascular headache here in Ukraine. This is a tremendous problem and it should be solved with appropriate information spread across the medical community.
Up-to-date classification according to the International Headache Society, diagnostic criteria, differential diagnosis, investigation and treatment strategies are presented in the article. All supported data are com-pliant with guidelines of developed countries with evidence-based medicine (US, Canada, Great Britain, Japan, Australia, New Zealand) enhanced with new trials and approved methods. Migraine management is a rapidly evolving concept, where major changes were done during recent years (transcranial Deep Brain Stimulation, vagus stimulation, CGRP-receptor mono-clonal antibodies).
Considering disorder incidence and its impact on life quality and the existence of options for alleviating symptoms, this information is important for physicians who work with children, especially for general practitioners, pediatrics, pediatric and adult neurologists.
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25
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Abstract
Vascular injury is increasingly recognized as an important cause of mortality and morbidity in children (29 days to 18 years of age). Since vascular brain injury in children appears to be less common than in adults, the index of suspicion for vascular brain injury is usually lower. In this review article, we describe frequent and rare conditions underlying pediatric stroke including cardioembolic, viral, autoimmune, post-traumatic, and genetic etiologies. Furthermore, we provide a neuroimaging correlate for clinical mimics of pediatric stroke. This review highlights the role of multimodal noninvasive neuroimaging in the early diagnosis of pediatric stroke, providing a problem-solving approach to the differential diagnosis for the neuroradiologist, emergency room physician, and neurologist.
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26
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Carotid Dissection and Cerebral Infarction From Posterior Oropharyngeal Trauma: The Diagnostic and Therapeutic Challenges. Pediatr Emerg Care 2019; 35:e17-e21. [PMID: 30608333 DOI: 10.1097/pec.0000000000001708] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Posterior oropharyngeal trauma commonly occurs in children and frequently presents to the emergency department (ED). Rarely, serious infectious and neurologic sequelae result. Emergency providers are tasked with the challenge of diagnosing the minority with life-threatening complications while maintaining thoughtful stewardship regarding radiation exposure. A previously healthy 2-year-old girl sustained trauma to her posterior oropharynx with a toothbrush that resulted in a left carotid dissection. This dissection was diagnosed in the ED via computed tomography angiogram, Otolaryngology and neurosurgery were consulted in the ED, and anticoagulation therapy was initiated with aspirin. The child did initially well and was without neurologic deficit and no brain ischemia on magnetic resonance imaging. She was discharged home on aspirin therapy. Four days after initial injury, the child returned to the ED after a seizure. Computed tomography scan of the head demonstrated infarction at the junction of the left parietal and temporal areas. Although neurologic complications are rare, posterior oropharyngeal trauma in children is not. There are many diagnostic and therapeutic challenges in its management. This case is, to the authors' awareness, the first case report in the English literature of a known and treated carotid dissection in a child after posterior oropharyngeal trauma that resulted in stroke despite diagnosis and initiation of treatment. The diagnostic and therapeutic challenges of posterior oropharyngeal trauma in children are discussed in this article.
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Mehdi E, Aralasmak A, Toprak H, Yıldız S, Kurtcan S, Kolukisa M, Asıl T, Alkan A. Craniocervical Dissections: Radiologic Findings, Pitfalls, Mimicking Diseases: A Pictorial Review. Curr Med Imaging 2018; 14:207-222. [PMID: 29853818 PMCID: PMC5902863 DOI: 10.2174/1573405613666170403102235] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background: Craniocervical Dissections (CCD) are a crucial emergency state causing 20% of strokes in patients under the age of 45. Although DSA (digital substraction angiography) is regarded as the gold standard, noninvasive methods of CT, CTA and MRI, MRA are widely used for diagnosis. Aim: Our aim is to illustrate noninvasive imaging findings in CCD. Conclusion: Emphasizing on diagnostic pitfalls, limitations and mimicking diseases.
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Affiliation(s)
- Elnur Mehdi
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
| | - Ayse Aralasmak
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
| | - Huseyin Toprak
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
| | - Seyma Yıldız
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
| | - Serpil Kurtcan
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
| | - Mehmet Kolukisa
- Bezmialem Vakif University, Department of Neurology, Istanbul, Turkey
| | - Talip Asıl
- Bezmialem Vakif University, Department of Neurology, Istanbul, Turkey
| | - Alpay Alkan
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
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28
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Sarikaya H, Steinlin M. Cerebellar stroke in adults and children. HANDBOOK OF CLINICAL NEUROLOGY 2018; 155:301-312. [DOI: 10.1016/b978-0-444-64189-2.00020-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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29
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Özge A, Abu-Arafeh I, Gelfand AA, Goadsby PJ, Cuvellier JC, Valeriani M, Sergeev A, Barlow K, Uludüz D, Yalın OÖ, Faedda N, Lipton RB, Rapoport A, Guidetti V. Experts' opinion about the pediatric secondary headaches diagnostic criteria of the ICHD-3 beta. J Headache Pain 2017; 18:113. [PMID: 29285571 PMCID: PMC5745369 DOI: 10.1186/s10194-017-0819-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 11/09/2017] [Indexed: 12/12/2022] Open
Abstract
Background The 2013 International Classification of Headache Disorders-3 was published in a beta version to allow clinicians to confirm the validity of the criteria or suggest improvements based on field studies. The aim of this work was to review the Secondary Headache Disorders and Cranial Neuralgias and Other Headache Disorders sections of ICHD-3 beta data on children and adolescents (age 0–18 years) and to suggest changes, additions, and amendments. Methods Several experts in childhood headache across the world applied different aspects of ICHD-3 beta in their normal clinical practice. Based on their personal experience and the available literature on pediatric headache, they made observations and proposed suggestions for the mentioned headache disorders on children and adolescents. Results Some headache disorders in children have specific features, which are different from adults that should be acknowledged and considered. Some features in children were found to be age-dependent: clinical characteristics, risks factors and etiologies have a strong bio psychosocial basis in children and adolescents making primary headache disorders in children distinct from those in adults. Conclusions Several recommendations are presented in order to make ICHD-3 more appropriate for use in children.
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Affiliation(s)
- Aynur Özge
- Department of Neurology, Mersin University Medical Faculty, Mersin, Turkey
| | | | - Amy A Gelfand
- UCSF Headache Center and UCSF Benioff Children's Hospital Pediatric Brain Center 2330 Post St, 6th Floor, Campus Box 1675, San Francisco, CA, 94115, USA
| | - Peter James Goadsby
- NIHR-Wellcome Trust King's Clinical Research Facility, King's College London, London, UK
| | - Jean Christophe Cuvellier
- Division of Paediatric Neurology, Department of Paediatrics, Lille Faculty of Medicine and Children's Hospital, Lille, France
| | - Massimiliano Valeriani
- Division of Neurology, Ospedale Pediatrico Bambino Gesù, Piazza Sant'Onofrio 4, Rome, Italy.,Center for Sensory-Motor Interaction Aalborg University, Aalborg, Denmark
| | - Alexey Sergeev
- Department of Neurology and Clinical Neurophysiology, University Headache Clinic, Moscow State Medical University, Moscow, Russia
| | - Karen Barlow
- Faculty of Medicine, University of Calgary, Alberta Children's Hospital, C4-335, 2888 Shaganappi Trail NW, Calgary, AB, T3B 6A8, Canada
| | - Derya Uludüz
- Cerrahpaşa Medical Faculty, Deaprtment of Neurology, İstanbul University, Kocamustafapaşa, İstanbul, Turkey
| | - Osman Özgür Yalın
- İstanbul Research and Education Hospital, Kocamustafapaşa, İstanbul, Turkey
| | - Noemi Faedda
- Phd program in Behavioural Neuroscience, Department of Paediatrics and Child and Adolescent Neuropsychiatry, Sapienza University of Rome, Rome, Italy
| | - Richard B Lipton
- Department of Psychiatry and Behavioral Sciences, Department of Epidemiology & Population Health, Montefiore Headache Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Alan Rapoport
- The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Vincenzo Guidetti
- Department of Pediatrics and Child and Adolescent Neuropsychiatry, Sapienza University, Rome, Italy.
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Ghali MGZ, Srinivasan VM, Cherian J, Kim L, Siddiqui A, Aziz-Sultan MA, Froehler M, Wakhloo A, Sauvageau E, Rai A, Chen SR, Johnson J, Lam SK, Kan P. Pediatric Intracranial Aneurysms: Considerations and Recommendations for Follow-Up Imaging. World Neurosurg 2017; 109:418-431. [PMID: 28986225 DOI: 10.1016/j.wneu.2017.09.150] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 09/20/2017] [Accepted: 09/21/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Pediatric intracranial aneurysms (IAs) are rare. Compared with adult IAs, they are more commonly giant, fusiform, or dissecting. Treatment often proves more complex, and recurrence rate and de novo aneurysmogenesis incidence are higher. A consensus regarding the most appropriate algorithm for following pediatric IAs is lacking. METHODS We sought to generate recommendations based on the reported experience in the literature with pediatric IAs through a thorough review of the PubMed database, discussion with experienced neurointerventionalists, and our own experience. RESULTS Digital subtraction angiography (DSA) was utilized immediately post-operatively for microsurgically-clipped and endovascularly-treated IAs, at 6-12 months postoperatively for endovascularly-treated IAs, and in cases of aneurysmal recurrence or de novo aneurysmogenesis discovered by non-invasive imaging modalities. Computed tomographic angiography was the preferred imaging modality for long-term follow-up of microsurgically clipped IAs. Magnetic resonance angiography (MRA) was the preferred modality for following IAs that were untreated, endovascularly-treated, or microsurgically-treated in a manner other than clipping. CONCLUSIONS We propose incidental untreated IAs to be followed by magnetic resonance angiography without contrast enhancement. Follow-up modality and interval for treated pediatric IAs is determined by initial aneurysmal complexity, treatment modality, and degree of posttreatment obliteration. Recurrence or de novo aneurysmogenesis requiring treatment should be followed by digital subtraction angiography and appropriate retreatment. Computed tomography angiography is preferred for clipped IAs, whereas contrast-enhanced magnetic resonance angiography is preferred for lesions treated endovascularly with coil embolization and lesions treated microsurgically in a manner other than clipping.
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Affiliation(s)
- Michael George Zaki Ghali
- Department of Neurosurgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA; Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | | | - Jacob Cherian
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Louis Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Adnan Siddiqui
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | - M Ali Aziz-Sultan
- Vascular and Endovascular Neurosurgery, Department of Neurosurgery, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Froehler
- Department of Neurology, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | - Ajay Wakhloo
- Department of Radiology, University of Massachusetts, Worcester, Massachusetts, USA
| | - Eric Sauvageau
- Baptist Neurological Institute, Lyerly Neurosurgery, Jacksonville, Florida, USA
| | - Ansaar Rai
- Department of Interventional Neuroradiology, West Virginia University, Morgantown, West Virginia, USA
| | - Stephen R Chen
- Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
| | - Jeremiah Johnson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Sandi K Lam
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.
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Topcuoglu OM, Topcuoglu ED, Altay CM, Genc S. Imaging pearls of pediatric Behçet’s disease. Eur J Radiol 2017; 94:115-124. [DOI: 10.1016/j.ejrad.2017.06.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 06/18/2017] [Accepted: 06/21/2017] [Indexed: 12/30/2022]
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Rollins N, Braga B, Hogge A, Beavers S, Dowling M. Dynamic Arterial Compression in Pediatric Vertebral Arterial Dissection. Stroke 2017; 48:1070-1073. [DOI: 10.1161/strokeaha.116.016236] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 12/16/2016] [Accepted: 12/30/2016] [Indexed: 12/31/2022]
Abstract
Background and Purpose—
The pathogenesis of spontaneous pediatric vertebral artery dissections (VAD) is poorly understood but most often involves the V3 segment where C1 rotates on C2. We studied children with VAD with provocative digital catheter angiography and found an association between VAD and rotational compression.
Methods—
Seven boys (12 months to 9 years; median 4 years) presented over 38 consecutive months with V3 VAD and underwent digital catheter angiography with provocative passive bilateral neck rotation.
Results—
VAD were bilateral in 2 patients and unilateral in 5. Provocative digital catheter angiography showed dynamic V3 compression in 6 of 9 dissections, most pronounced or seen only with head rotation to the contralateral side. Two patients had VAD without dynamic compression; both returned 4 months later with a new dissection in a previously normal VA and worsening VAD in 1 patient each. Dynamic compression was also seen in 2 nondissected VA. Surgical management was C1/2 posterior fusion in 5 of 7 patients; 1 underwent unilateral C2 decompression with recurrent VAD and was subsequently fused.
Conclusions—
The association of dynamic VA compression and VAD at the same level suggests that the compression may contribute to the VAD. However, as dynamic compression was observed in nondissected VA and some VAD were not associated with dynamic compression, VAD may be multifactorial.
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Affiliation(s)
- Nancy Rollins
- From the Divisions of Pediatrics in the Departments of Radiology (N.R.), Neurosurgery (N.R., B.B.), and Neurology (M.D.), Children’s Health System of Texas, University of Texas Southwestern Medical Center, Dallas; and Anesthesia for Children (A.H.) and Center for Cerebrovascular Disease in Children (S.B.), Children’s Health System of Texas, Dallas
| | - Bruno Braga
- From the Divisions of Pediatrics in the Departments of Radiology (N.R.), Neurosurgery (N.R., B.B.), and Neurology (M.D.), Children’s Health System of Texas, University of Texas Southwestern Medical Center, Dallas; and Anesthesia for Children (A.H.) and Center for Cerebrovascular Disease in Children (S.B.), Children’s Health System of Texas, Dallas
| | - Amy Hogge
- From the Divisions of Pediatrics in the Departments of Radiology (N.R.), Neurosurgery (N.R., B.B.), and Neurology (M.D.), Children’s Health System of Texas, University of Texas Southwestern Medical Center, Dallas; and Anesthesia for Children (A.H.) and Center for Cerebrovascular Disease in Children (S.B.), Children’s Health System of Texas, Dallas
| | - Stefanie Beavers
- From the Divisions of Pediatrics in the Departments of Radiology (N.R.), Neurosurgery (N.R., B.B.), and Neurology (M.D.), Children’s Health System of Texas, University of Texas Southwestern Medical Center, Dallas; and Anesthesia for Children (A.H.) and Center for Cerebrovascular Disease in Children (S.B.), Children’s Health System of Texas, Dallas
| | - Michael Dowling
- From the Divisions of Pediatrics in the Departments of Radiology (N.R.), Neurosurgery (N.R., B.B.), and Neurology (M.D.), Children’s Health System of Texas, University of Texas Southwestern Medical Center, Dallas; and Anesthesia for Children (A.H.) and Center for Cerebrovascular Disease in Children (S.B.), Children’s Health System of Texas, Dallas
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Pediatric arterial ischemic stroke: Epidemiology, risk factors, and management. Blood Cells Mol Dis 2017; 67:23-33. [PMID: 28336156 DOI: 10.1016/j.bcmd.2017.03.003] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 03/06/2017] [Accepted: 03/06/2017] [Indexed: 12/17/2022]
Abstract
Pediatric arterial ischemic stroke (AIS) is an uncommon but important cause of neurologic morbidity in neonates and children, with consequences including hemiparesis, intellectual disabilities, and epilepsy. The causes of pediatric AIS are unique to those typically associated with stroke in adults. Familiarity with the risk factors for AIS in children will help with efficient diagnosis, which is unfortunately frequently delayed. Here we review the epidemiology and risk factors for AIS in neonates and children. We also outline consensus-based practices in the evaluation and management of pediatric AIS. Finally we discuss the outcomes observed in this population. While much has been learned in recent decades, many uncertainties sill persist in regard to pediatric AIS. The ongoing development of specialized centers and investigators dedicated to pediatric stroke will continue to answer such questions and improve our ability to effectively care for these patients.
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Whitcomb V, Kannikeswaran N, Bhaya N, Altinok D, Sivaswamy L. Speechless After a Roller Coaster Ride. Clin Pediatr (Phila) 2017; 56:190-193. [PMID: 28006955 DOI: 10.1177/0009922816684614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Valerie Whitcomb
- 1 Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
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Abstract
Despite being as common as brain tumors in children, lack of awareness of pediatric stroke presents unique challenges, both in terms of diagnosis and management. Due to diverse and overlapping risk factors, as well as variable clinical presentations, the diagnosis can be either missed or frequently delayed. Early recognition and treatment of pediatric stroke is however critical in optimizing long-term functional outcomes, reducing morbidity and mortality, and preventing recurrent stroke. Neuroimaging plays a vital role in achieving this goal. The advancements in imaging over the last two decades have allowed for multiple modality options for suspected stroke with more accurate diagnosis, as well as quicker turnaround time in imaging diagnosis, especially at primary stroke centers. However, with the multiple imaging possibilities, referring physicians can be overwhelmed with the best option for each clinical situation and what the literature recommends. Here the authors review the etiology of pediatric stroke in the settings of arterial ischemia, hemorrhage, and cerebral sinovenous thrombosis (CSVT), with emphasis on the best diagnostic tools available, including advanced imaging techniques.
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Affiliation(s)
- Aashim Bhatia
- Department of Diagnostic Radiology, Monroe Carell, Jr. Children's Hospital at Vanderbilt, Nashville, TN, 37232, USA
| | - Sumit Pruthi
- Department of Diagnostic Radiology, Monroe Carell, Jr. Children's Hospital at Vanderbilt, Nashville, TN, 37232, USA.
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Rosa M, De Lucia S, Rinaldi VE, Le Gal J, Desmarest M, Veropalumbo C, Romanello S, Titomanlio L. Paediatric arterial ischemic stroke: acute management, recent advances and remaining issues. Ital J Pediatr 2015; 41:95. [PMID: 26631262 PMCID: PMC4668709 DOI: 10.1186/s13052-015-0174-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 09/21/2015] [Indexed: 01/06/2023] Open
Abstract
Stroke is a rare disease in childhood with an estimated incidence of 1-6/100.000. It has an increasingly recognised impact on child mortality along with its outcomes and effects on quality of life of patients and their families. Clinical presentation and risk factors of paediatric stroke are different to those of adults therefore it can be considered as an independent nosological entity. The relative rarity, the age-related peculiarities and the variety of manifested symptoms makes the diagnosis of paediatric stroke extremely difficult and often delayed. History and clinical examination should investigate underlying diseases or predisposing factors and should take into account the potential territoriality of neurological deficits and the spectrum of differential diagnosis of acute neurological accidents in childhood. Neuroimaging (in particular diffusion weighted magnetic resonance) is the keystone for diagnosis of paediatric stroke and other investigations might be considered according to the clinical condition. Despite substantial advances in paediatric stroke research and clinical care, many unanswered questions remain concerning both its acute treatment and its secondary prevention and rehabilitation so that treatment recommendations are mainly extrapolated from studies on adult population. We have tried to summarize the pathophysiological and clinical characteristics of arterial ischemic stroke in children and the most recent international guidelines and practical directions on how to recognise and manage it in paediatric emergency.
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Affiliation(s)
- Margherita Rosa
- Department of Translational Medicine-Section of Pediatrics, Federico II University, Naples, Italy.
| | - Silvana De Lucia
- Department of Paediatrics, Aldo Moro University of Bari, Bari, Italy.
| | | | - Julie Le Gal
- Paediatric Migraine & Neurovascular diseases Unit, Department of Paediatrics, Robert Debré Hospital, Paris Diderot University, Sorbonne Paris Cité, Paris, France.
| | - Marie Desmarest
- Paediatric Migraine & Neurovascular diseases Unit, Department of Paediatrics, Robert Debré Hospital, Paris Diderot University, Sorbonne Paris Cité, Paris, France.
| | - Claudio Veropalumbo
- Department of Translational Medicine-Section of Pediatrics, Federico II University, Naples, Italy.
| | - Silvia Romanello
- Paediatric Emergency Department, Robert Debré Hospital, Paris Diderot University, Sorbonne Paris Cité, Paris, France.
| | - Luigi Titomanlio
- Paediatric Migraine & Neurovascular diseases Unit, Department of Paediatrics, Robert Debré Hospital, Paris Diderot University, Sorbonne Paris Cité, Paris, France.
- Paediatric Emergency Department, Robert Debré Hospital, Paris Diderot University, Sorbonne Paris Cité, Paris, France.
- Pediatric Emergency Department, INSERM U-1141 AP-HP Robert Debré University Hospital, 48, Bld Sérurier, 75019, Paris, France.
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Abstract
OPINION STATEMENT Children who present with acute neurological symptoms suggestive of a stroke need immediate clinical assessment and urgent neuroimaging to confirm diagnosis. Magnetic resonance imaging (MRI) is the investigation of first choice due to limited sensitivity of computed tomography (CT) for detection of ischaemia. Acute monitoring should include monitoring of blood pressure and body temperature, and neurological observations. Surveillance in a paediatric high dependency or intensive care unit and neurosurgical consultation are mandatory in children with large infarcts at risk of developing malignant oedema or haemorrhagic transformation. Thrombolysis and/or endovascular treatment, whilst not currently approved for use in children, may be considered when stroke diagnosis is confirmed within 4.5 to 6 h, provided there are no contraindications on standard adult criteria. Standard treatment consists of aspirin, but anticoagulation therapy is frequently prescribed in stroke due to cardiac disease and extracranial dissection. Steroids and immunosuppression have a definite place in children with proven vasculitis, but their role in focal arteriopathies is less clear. Decompressive craniotomy should be considered in children with deteriorating consciousness or signs of raised intracranial pressure.
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Affiliation(s)
- Maja Steinlin
- Paediatric Neurology, University Children's Hospital and Neurocentre, Inselspital Bern, Bern, 3010, Switzerland,
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ACR Appropriateness Criteria head trauma--child. J Am Coll Radiol 2014; 11:939-47. [PMID: 25164794 DOI: 10.1016/j.jacr.2014.07.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 07/08/2014] [Indexed: 12/11/2022]
Abstract
Head trauma is a frequent indication for cranial imaging in children. CT is considered the first line of study for suspected intracranial injury because of its wide availability and rapid detection of acute hemorrhage. However, the majority of childhood head injuries occur without neurologic complications, and particular consideration should be given to the greater risks of ionizing radiation in young patients in the decision to use CT for those with mild head trauma. MRI can detect traumatic complications without radiation, but often requires sedation in children, owing to the examination length and motion sensitivity, which limits rapid assessment and exposes the patient to potential anesthesia risks. MRI may be helpful in patients with suspected nonaccidental trauma, with which axonal shear injury and ischemia are more common and documentation is critical, as well as in those whose clinical status is discordant with CT findings. Advanced techniques, such as diffusion tensor imaging, may identify changes occult by standard imaging, but data are currently insufficient to support routine clinical use. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Rollins N, Pride GL, Plumb PA, Dowling MM. Brainstem strokes in children: an 11-year series from a tertiary pediatric center. Pediatr Neurol 2013; 49:458-64. [PMID: 24080274 DOI: 10.1016/j.pediatrneurol.2013.07.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Revised: 07/08/2013] [Accepted: 07/09/2013] [Indexed: 11/25/2022]
Abstract
METHODS Potential clinical barriers to making a timely diagnosis of pediatric brainstem stroke and pitfalls of noninvasive vascular imaging are presented. METHODS An institutional review board-approved institutional database query from 2001-2012 yielded 15 patients with brainstem strokes. Medical records were reviewed for symptoms, stroke severity using the Pediatric National Institutes of Health Stroke Scale, and outcomes using the Pediatric Stroke Outcome Measure. Magnetic resonance angiography was compared with digital subtraction angiography. RESULTS There were 10 boys and five girls; 9 months to 17 years of age (mean 7.83 years). Symptoms were headaches (eight); visual problems (eight), seizure-like activity (seven), motor deficits (six), and decreased level of consciousness in four. Time since last seen well was 12 hours to 5 days. Pediatric National Institutes of Health Stroke Scale was 1-34; <10 in eight; 3 in 1, 10-20 in two, and >20 in four. Strokes were pontine in 13/15 and involved >50% of the pons in six and <50% in seven; 2/15 had medullary strokes. Magnetic resonance angiography showed basilar artery occlusion in 8/13 patients and vertebral artery dissection in two. Digital subtraction angiography done within 9-36 hours of magnetic resonance angiography in 10/15 patients confirmed the basilar artery occlusion seen by magnetic resonance angiography and showed vertebral artery dissection in four patients. Patients were systemically anticoagulated without hemorrhagic complications. One patient died. Pediatric Stroke Outcome Measures at 2-36 months is 0-5.0/10 (mean 1.25). CONCLUSIONS Vague symptoms contributed to delays in diagnosis. Magnetic resonance angiography was equivalent to digital subtraction angiography for basilar artery occlusion but not for vertebral artery dissection. Even with basilar artery occlusion and high stroke scales, outcome was good when systemic anticoagulation was started promptly.
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Affiliation(s)
- Nancy Rollins
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas.
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Agostini M, Lupica MM, Mostert M, Deluca N, Cordero di Montezemolo L. Cervical arterial dissection and ischaemic stroke in children: two cases. Acta Paediatr 2013; 102:e142-3. [PMID: 23278682 DOI: 10.1111/apa.12123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Manuela Agostini
- Department of Pediatrics; Regina Margherita Children's Hospital; University of Turin; Turin Italy
| | - Maria Maddalena Lupica
- Department of Pediatrics; Regina Margherita Children's Hospital; University of Turin; Turin Italy
| | - Michael Mostert
- Department of Pediatrics; Regina Margherita Children's Hospital; University of Turin; Turin Italy
| | - Nicola Deluca
- Department of Neurology; Degli Infermi Hospital; Rivoli Italy
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Titomanlio L, Zanin A, Sachs P, Khaled J, Elmaleh M, Blanc R, Piotin M. Pediatric ischemic stroke: acute management and areas of research. J Pediatr 2013; 162:227-35.e1. [PMID: 23153863 DOI: 10.1016/j.jpeds.2012.09.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Revised: 08/08/2012] [Accepted: 09/10/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Luigi Titomanlio
- Pediatric Emergency Department, APHP, Robert Debré Hospital, Paris Diderot University, Paris, France.
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