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Prakapenia A, Barlinn K, Pallesen LP, Köhler A, Siepmann T, Winzer S, Barlinn J, Daubner D, Linn J, Reichmann H, Puetz V. Low Diagnostic Yield of Routine Cerebrospinal Fluid Analysis in Juvenile Stroke. Front Neurol 2018; 9:694. [PMID: 30186227 PMCID: PMC6113395 DOI: 10.3389/fneur.2018.00694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 07/31/2018] [Indexed: 11/13/2022] Open
Abstract
Background: The diagnostic value of cerebrospinal fluid (CSF) analysis in juvenile stroke, i.e., stroke in young adult patients, is not well studied. We sought to determine the therapeutic impact of routine CSF-analysis in young adults with acute ischemic stroke or transient ischemic attack (TIA). Methods: We abstracted data from patients with acute cerebral ischemia aged 18–45 years who were consecutively admitted to our stroke center between 01/2008 and 12/2015. We routinely performed CSF-analysis in patients with hitherto unknown stroke etiology after complete diagnostic work up. We assessed the frequency and underlying causes of abnormal CSF-findings and their impact on secondary stroke prevention therapy. Results: Among 379 patients (median [IQR:IQR3-IQR1] age 39 [10:43-33] years, 48% female) with acute ischemic stroke (n = 306) or TIA (n = 73), CSF analysis was performed in 201 patients (53%). Of these, 25 patients (12.4 %) had CSF pleocytosis (leucocyte cell count ≥ 5 Mpt/L), that was rated as non-specific (e.g., traumatic lumbar puncture, reactive pleocytosis) in 22 patients. Only 3 patients (1.5% of all patients who underwent CSF-analysis) with CSF-pleocytosis had specific CSF-findings that were related to stroke etiology and affected secondary stroke prevention therapy. Imaging findings had already suggested cerebral vasculitis in two of these patients. Conclusions: The diagnostic yield of routine CSF-analysis in juvenile stroke was remarkably low in our study. Our data suggest that CSF-analysis should only be performed if further findings raise the suspicion of cerebral vasculitis.
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Affiliation(s)
- Alexandra Prakapenia
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Lars-Peder Pallesen
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Anne Köhler
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Timo Siepmann
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Simon Winzer
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Jessica Barlinn
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Dirk Daubner
- Institute of Neuroradiology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Jennifer Linn
- Institute of Neuroradiology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Heinz Reichmann
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Volker Puetz
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
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2
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Abstract
Diseases of the central nervous system that are caused by an underlying vascular pathology typically result in either hemorrhage or ischemia. Most prominent entities include spontaneous subarachnoid hemorrhage, spontaneous intracerebral hemorrhage, and ischemic stroke. For anatomic reasons, cerebrospinal fluid (CSF) qualifies as body fluid for the exploration of biomarkers in these disorders. Even though in subarachnoid hemorrhage a few CSF parameters have been established for routine diagnostic purposes, there is still an unmet need and broad interest in the identification of molecules that would allow further insight into disease mechanisms and supplement patients' medical care. This chapter provides an overview on what is presently known about CSF biomarkers in spontaneous subarachnoid hemorrhage, spontaneous intracerebral hemorrhage, and ischemic stroke. We recapitulate current evidence on established diagnostic tests, discuss the role of various CSF molecules in the pathophysiology of these diseases, and illuminate their potential use in future clinical practice. Furthermore, we address methodologic aspects as well as shortcomings of research in this field.
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Affiliation(s)
- Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.
| | - Michael Auer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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3
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Illes S. More than a drainage fluid: the role of CSF in signaling in the brain and other effects on brain tissue. HANDBOOK OF CLINICAL NEUROLOGY 2018; 146:33-46. [PMID: 29110778 DOI: 10.1016/b978-0-12-804279-3.00003-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Current progress in neuroscience demonstrates that the brain is not an isolated organ and is influenced by the systemic environment and extracerebral processes within the body. In view of this new concept, blood and cerebrospinal fluid (CSF) are important body fluids linking extracerebral and intracerebral processes. For decades, substantial evidence has been accumulated indicating that CSF modulates brain states and influences behavior as well as cognition. This chapter provides an overview of how CSF directly modulates the function of different types of brain cells, such as neurons, neural stem cells, and CSF-contacting cells. Alterations in CSF content occur in most pathologic central nervous system (CNS) conditions. In a classic view, the function of CSF is to drain waste products and detrimental factors derived from diseased brain parenchyma. This chapter presents examples for how intra- and extracerebral pathologic processes lead to alterations in the CSF content. Current knowledge about how pathologically altered CSF influences the functionality of brain cells will be presented. Thereby, it becomes evident that CSF has more than a drainage function and has a causal role for the etiology and pathogenesis of different CNS diseases.
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Affiliation(s)
- Sebastian Illes
- Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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4
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Abstract
Over the last decades, the importance of inflammatory processes in pediatric stroke have become increasingly evident. Ischemia launches a cascade of events: activation and inhibition of inflammation by a large network of cytokines, adhesion and small molecules, protease, and chemokines. There are major differences in the neonatal brain compared to adult brain, but developmental trajectories of the process during childhood are not yet well known. In neonatal stroke ischemia is the leading pathophysiology, but infectious and inflammatory processes have a significant input into the course and degree of tissue damage. In childhood, beside inflammation lanced by ischemia itself, the event of ischemia might be provoked by an underlying inflammatory pathophysiology: transient focal arteriopathy, dissection, sickle cell anemia, Moyamoya and more generalized in meningitides, generalized vasculitis or genetic arteriopathies (as in ADA2). Focal inflammatory reactions tend to be located in the distal part of the carotid artery or the proximal medial arteries, but generalized processes rather tend to affect the small arteries.
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Yeon JY, Shin HJ. Nonprogressive Unilateral Intracranial Arteriopathy in Children with Arterial Ischemic Stroke. J Korean Neurosurg Soc 2015; 57:401-7. [PMID: 26180606 PMCID: PMC4502235 DOI: 10.3340/jkns.2015.57.6.401] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 04/08/2015] [Accepted: 04/09/2015] [Indexed: 12/31/2022] Open
Abstract
The nonprogressive unilateral intracranial arteriopathy known as transient (focal) cerebral arteriopathy is not a well-recognized arteriopathy among practitioners of Korea and Japan, although it cannot be easily differentiated from early moyamoya disease. This review summarizes the nomenclature, pathophysiology, diagnostic evaluation, clinico-radiological features, and management of nonprogressive (reversible or stable) unilateral arteriopathy based on the relevant literature and our own experiences. Nonprogressive unilateral arteriopathy should be strongly suspected in children presenting with basal ganglia infarction and arterial beading. The early identification of patients likely to have nonprogressive or progressive arteriopathy would ensure proper management and guide further research for secondary stroke prevention.
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Affiliation(s)
- Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyung Jin Shin
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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6
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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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7
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Abstract
Stroke is as common as brain tumor in children. The etiology of childhood arterial ischemic stroke (AIS) appears to be multifactorial, resulting from the interaction between genetic predisposition and environmental triggers. The risk factors for AIS in children are markedly different from the atherosclerotic risk factors in adults. Trauma and infections have been identified as associations in previous studies and are exposures of particular interest because of their increased prevalence in the children. The aim of this review article is to provide an overview of the research studies that have addressed the role of infections and trauma in pediatric AIS.
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Affiliation(s)
- Elena Moraitis
- Rheumatology/Infectious Diseases and Immunity Unit UCL Institute of Child Health and Rheumatology Department, Great Ormond Street Hospital for Children, London, UK,
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8
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Cachia D, Singh C, Tetzlaff MT, Penas-Prado M. Middle cerebral artery territory infarct due toCryptococcusinfectionstitle. Diagn Cytopathol 2014; 43:632-4. [DOI: 10.1002/dc.23219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Accepted: 10/06/2014] [Indexed: 12/26/2022]
Affiliation(s)
- David Cachia
- Department of Neuro-Oncology; University of Texas MD Anderson Cancer Center; Houston Texas
| | - Charanjeet Singh
- Division of Cytopathology, Department of Pathology; University of Texas MD Anderson Cancer Center; Houston Texas
| | - Michael T. Tetzlaff
- Division of Dermatopathology, Department of Pathology; University of Texas MD Anderson Cancer Center; Houston Texas
| | - Marta Penas-Prado
- Department of Neuro-Oncology; University of Texas MD Anderson Cancer Center; Houston Texas
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9
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Jeon JH, Jung HW, Jang HM, Moon JH, Park KT, Lee HC, Lim HY, Sur JH, Kang BT, Ha J, Jung DI. Canine model of ischemic stroke with permanent middle cerebral artery occlusion: clinical features, magnetic resonance imaging, histopathology, and immunohistochemistry. J Vet Sci 2014; 16:75-85. [PMID: 25269716 PMCID: PMC4367152 DOI: 10.4142/jvs.2015.16.1.75] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 09/26/2014] [Indexed: 01/17/2023] Open
Abstract
The purpose of this study was to identify time-related changes in clinical, MRI, histopathologic, and immunohistochemical findings associated with ischemic stroke in dogs. Additionally, the association of cerebrospinal fluid (CSF) and tissue levels of interleukin (IL)-6 with clinical prognosis was assessed. Ischemic stroke was induced by permanent middle cerebral artery occlusion (MCAO) in nine healthy experimental dogs. The dogs were divided into three groups according to survival time and duration of the experimental period: group A (survived only 1 day), group B (1-week experimental period), and group C (2-week experimental period). Neurologic status was evaluated daily. Magnetic resonance imaging (MRI) was performed according to a predetermined schedule. Concentration of IL-6 in CSF was measured serially after ischemic stroke. Postmortem examination was performed for all experimental dogs. During histopathological examination, variable degrees of cavitation and necrosis due to neuronal cytopathic effects, such as pyknotic nuclei and cytoplasmic shrinkage, were observed on the affected side of the cerebral cortex in all dogs. Immunohistochemistry specific for IL-6 showed increased expression in the ischemic lesions. CSF IL-6 concentrations and ischemic lesion volumes 1 day after ischemic stroke were significantly higher in group A compared to groups B and C.
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Affiliation(s)
- Joon-Hyeok Jeon
- Institute of Animal Medicine, College of Veterinary Medicine, Gyeongsang National University, Jinju 660-701, Korea
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10
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Vergaro R, Cordelli DM, Miniaci A, Tassinari D, Spinardi L, Pession A, Franzoni E. Cerebral ischemic involvement in Vogt-Koyanagi-Harada disease. Pediatr Neurol 2014; 51:119-22. [PMID: 24830768 DOI: 10.1016/j.pediatrneurol.2014.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Revised: 03/04/2014] [Accepted: 03/10/2014] [Indexed: 01/09/2023]
Abstract
BACKGROUND Vogt-Koyanagi-Harada (VKH) disease is an autoimmune disorder characterized by ocular, auditory and neurological manifestations (headache, meningismus and/or aspeptic meningoencephalitis). PATIENT We describe a 12-year-old African boy with bilateral uveitis who presented with acute unilateral hearing loss and neurological symptoms such as left-sided dyskinesias, unsteady gait and throbbing headache. Brain magnetic resonance imaging showed ischemic lesions of the right basal ganglia in the territory of lenticulostriate and thalamic arteries. He improved after treatment with intravenous and oral steroids. CONCLUSION Cerebral ischemic episodes should be included in the possible neurological manifestations of VKH.
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Affiliation(s)
- Raffaella Vergaro
- Child Neuropsychiatry Unit, Department of Pediatrics, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
| | - Duccio Maria Cordelli
- Child Neuropsychiatry Unit, Department of Pediatrics, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Angela Miniaci
- Department of Pediatrics, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Davide Tassinari
- Department of Pediatrics, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Luca Spinardi
- Neuroradiology Unit, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Andrea Pession
- Department of Pediatrics, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Emilio Franzoni
- Child Neuropsychiatry Unit, Department of Pediatrics, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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11
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Monteventi O, Chabrier S, Fluss J. [Current management of post-varicella stroke in children: a literature review]. Arch Pediatr 2013; 20:883-9. [PMID: 23838069 DOI: 10.1016/j.arcped.2013.05.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Revised: 04/05/2013] [Accepted: 05/07/2013] [Indexed: 12/28/2022]
Abstract
Among infectious factors, varicella-zoster virus (VZV) is a leading cause of central nervous system vasculopathy and stroke in childhood. Not only have viral markers been detected in the cerebrospinal fluid of affected patients, but also direct evidence of viral particles in the wall of cerebral arteries has been demonstrated in rare pathological specimens. This certainly reflects a localized infectious process likely associated with variable indirect inflammatory responses. Yet the usefulness in this setting of a lumbar puncture as well as of subsequent targeted antiviral and/or anti-inflammatory therapies is uncertain. Indeed, in the majority of cases, the so-called post-varicella angiopathy has a monophasic evolution with spontaneous resolution or stabilization, explaining diverging diagnostic and treatment approaches. In this paper, we have addressed this problematic area by reviewing 26 published cases from the year 2000 and three unpublished cases. Post-varicella stroke is typically associated with angiopathy most often involving the initial portion of the middle cerebral artery, causing a basal ganglia stroke. It tends to occur in young immunocompetent children. Thrombophilia work-up is in general negative. Lumbar puncture was performed in 17 out of 29 cases. Viral markers were examined in 14 cases, but were positive in only eight cases. Antiviral therapy was administrated in 11 children. In this small retrospective study, the treated children's vasculopathy did not progress more favorably nor was there a better outcome compared with untreated subjects.
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Affiliation(s)
- O Monteventi
- Hôpitaux universitaires de Genève, hôpital des enfants, service des spécialités pédiatriques, neuropédiatrie, rue Willy-Donzé 6, 1211 Genève 14, Suisse
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12
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Steinlin M. Cerebrovascular disorders in childhood. HANDBOOK OF CLINICAL NEUROLOGY 2013; 112:1053-64. [PMID: 23622311 DOI: 10.1016/b978-0-444-52910-7.00023-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Cerebrovascular problems in childhood include diverse problems of vascular supply to the brain and occur with an overall frequency of from 5 to 8/100000 children/year. Signs and symptoms at manifestation are manifold. They depend not only on localization of the infarction but also on age at injury and specific risk factors. Acute arterial ischemic insult in neonates is oligosymptomatic (short-lasting seizures); hemiparesis is the most common symptom in children. Risk factors are multiple for both neonates and children, with more thromboembolic events in neonates and (infection-related) vasculopathies or cardiac problems in children. MRI (diffusion weighted) is the golden standard for diagnosis. In the absence of evidence for treatment in both groups, guidelines suggest use of platelet aggregation. There are some special indications for anticoagulation. Thrombolysis should be evaluated. Two-thirds of children and neonates face lifelong neurological and neuropsychological problems. Spinal artery ischemia presents with acute spinal symptoms, mostly paraplegia. Risk factors and prognosis are similar to cerebral insults. Sinus venous thromboses are significantly less common. Provoking factors in newborns are mainly neonatal problems, and in children infections, especially in the ENT region. For diagnosis the delta sign in CT is less sensitive than MR/MR venography. In the absence of any evidence, LMWH or heparinization for 3-6 months are recommended. Prognosis is better in children than in neonates. Deep vein thrombosis and/or young age worsen the outcome.
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Affiliation(s)
- Maja Steinlin
- Neuropaediatric Department, University Children's Hospital Inselspital, Bern, Switzerland.
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13
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Cisterna magna cannulated repeated CSF sampling rat model – effects of a gamma-secretase inhibitor on Aβ levels. J Neurosci Methods 2012; 205:36-44. [DOI: 10.1016/j.jneumeth.2011.12.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 12/19/2011] [Accepted: 12/20/2011] [Indexed: 11/17/2022]
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14
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Geraldes R, Fonseca AC, Canhão P, Melo TP, Ferro JM. Why did we perform a lumbar puncture in a young patient with ischemic stroke? J Neurol 2012; 259:1472-3. [PMID: 22218652 DOI: 10.1007/s00415-011-6385-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Revised: 12/14/2011] [Accepted: 12/15/2011] [Indexed: 10/14/2022]
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15
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Affiliation(s)
- Rinze F Neuteboom
- Department of Paediatric Neurology, Erasmus MC, Erasmus University Hospital Rotterdam, Netherlands.
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16
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Ng J, Ganesan V. Expert opinion on emerging drugs in childhood arterial ischemic stroke. Expert Opin Emerg Drugs 2011; 16:363-72. [DOI: 10.1517/14728214.2011.565050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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17
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Lebas A, Toulgoat F, Saliou G, Husson B, Tardieu M. Stroke Due to Lyme Neuroborreliosis: Changes in Vessel Wall Contrast Enhancement. J Neuroimaging 2010; 22:210-2. [DOI: 10.1111/j.1552-6569.2010.00550.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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19
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Sas AMG, Niks EH, Lequin MH, Catsman-Berrevoets CE, de Wit MCY. Herpes simplex virus type-1 encephalitis and occipital ischemic stroke. Pediatr Neurol 2009; 41:294-6. [PMID: 19748051 DOI: 10.1016/j.pediatrneurol.2009.04.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Revised: 03/30/2009] [Accepted: 04/06/2009] [Indexed: 10/20/2022]
Abstract
Childhood ischemic stroke is a rare complication of herpes simplex virus type-1 encephalitis. We describe a previously healthy 3-year-old girl who presented with bilateral occipital ischemic stroke, attributable to herpes simplex virus type-1 encephalitis, highlighting the importance of viral diagnostics in cerebrospinal fluid.
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Affiliation(s)
- Antonetta M G Sas
- Department of Pediatric Neurology, Erasmus MC Sophia Children's Hospital, 3000 CB Rotterdam, The Netherlands
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20
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Braun KPJ, Bulder MMM, Chabrier S, Kirkham FJ, Uiterwaal CSP, Tardieu M, Sébire G. The course and outcome of unilateral intracranial arteriopathy in 79 children with ischaemic stroke. Brain 2008; 132:544-57. [PMID: 19039009 PMCID: PMC2640213 DOI: 10.1093/brain/awn313] [Citation(s) in RCA: 166] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Arteriopathies are the commonest cause of arterial ischaemic stroke (AIS) in children. Repeated vascular imaging in children with AIS demonstrated the existence of a ‘transient cerebral arteriopathy’ (TCA), characterized by lenticulostriate infarction due to non-progressive unilateral arterial disease affecting the supraclinoid internal carotid artery and its proximal branches. To further characterize the course of childhood arteriopathies, and to differentiate TCA from progressive arterial disease, we studied the long-term evolution of unilateral anterior circulation arteriopathy, and explored predictors of stroke outcome and recurrence. From three consecutive cohorts in London, Paris and Utrecht, we reviewed radiological studies and clinical charts of 79 previously healthy children with anterior circulation AIS and unilateral intracranial arteriopathy of the internal carotid bifurcation, who underwent repeated vascular imaging. The long-term evolution of arteriopathy was classified as progressive or TCA. Clinical and imaging characteristics were compared between both groups. Logistic regression modelling was used to determine possible predictors of the course of arteriopathy, functional outcome and recurrence. After a median follow-up of 1.4 years, 5 of 79 children (6%) had progressive arteriopathy, with increasing unilateral disease or bilateral involvement. In the others (94%), the course of arteriopathy was classified as TCA. In 23% of TCA patients, follow-up vascular imaging showed complete normalization, the remaining 77% had residual arterial abnormalities, with improvement in 45% and stabilization in 32%. Stroke was preceded by chickenpox in 44% of TCA patients, and in none of the patients with progressive arteriopathies. Most infarcts were localized in the basal ganglia. In 14 (19%) of TCA patients, transient worsening of the arterial lesion was demonstrated before the arteriopathy stabilized or improved. Thirteen TCA patients (18%) had a recurrent stroke or TIA. Thirty TCA patients (41%) had a good neurological outcome, compared with none of the five patients with progressive arteriopathy. Arterial occlusion, moyamoya vessels and ACA involvement were more frequent in progressive arteriopathies. Cortical infarct localization was significantly associated with poor neurological outcome (OR 6.14, 95% CI 1.29–29.22, P = 0.02), while there was a trend for occlusive arterial disease to predict poor outcome (OR 3.00, 95% CI 0.98–9.23, P = 0.06). Progressive arteriopathy was associated with recurrence (OR 18.77, 95%CI 1.94–181.97, P = 0.01). The majority of childhood unilateral intracranial anterior circulation arteriopathies (94%) have a course that is consistent with TCA, in which transient worsening is common. Although the arterial inflammation probably causing TCA is ‘transient’, most children are left with permanent arterial abnormalities and residual neurological deficits.
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Affiliation(s)
- K P J Braun
- Department of Child Neurology, Rudolf Magnus Institute of Neuroscience, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.
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21
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Amlie-Lefond C, Sébire G, Fullerton HJ. Recent developments in childhood arterial ischaemic stroke. Lancet Neurol 2008; 7:425-35. [DOI: 10.1016/s1474-4422(08)70086-3] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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