Acute ischaemic stroke due to carotid dissection in a boy with Down syndrome

PPIENSENLo: A Novel Mnemonics in Spanish for Alarm Criteria in Secondary Headaches in Children

We present the first mnemonic in Spanish, "PPIENSENLo," for alarm criteria in secondary headaches in children in order to facilitate their identification, diagnosis, and treatment. A search was performed across different electronic databases for a mnemonics that applied to clinical alarm criteria in secondary headaches in children. None were found in English or Spanish. This tool is perhaps useful both for clinical and teaching purposes.

Cervicocerebral artery dissection

PURPOSE OF REVIEW

The purpose of this article is to review the epidemiology, pathophysiology, risk factors, clinical manifestations, diagnostic methods and current treatment options for cervicocerebral artery dissection (CCD).

RECENT FINDINGS

CCD incidence has increased over time largely because of improvements in and increasing availability of noninvasive imaging. CCD can be detected on computed tomography angiography, MRI, magnetic resonance angiography, carotid duplex ultrasonography and conventional catheter-based digital subtraction angiography. Additionally, ischemic stroke treatment with intravenous tissue plasminogen-activator for patients with suspected CCD appears to be well tolerated and effective. Moreover, a randomized clinical trial has shown antiplatelet agents to be as effective as anticoagulants at preventing recurrent ischemia. Surgical and endovascular techniques can be considered particularly for patients presenting with intracranial arterial dissection causing subarachnoid hemorrhage, developing recurrent ischemia due to hemodynamic impairment and whose dissecting aneurysms cause brainstem compression.

SUMMARY

CCD is an important and one of the most common causes of ischemic stroke in young patients without traditional vascular risk factors. Cases can occur shortly after trauma. However, spontaneous CCD is common and is associated with many genetic, acquired and anatomical risk factors. CCD should be detected early to avoid complications and prevent long-term disability.

Arteriopathy diagnosis in childhood arterial ischemic stroke: results of the vascular effects of infection in pediatric stroke study

BACKGROUND AND PURPOSE

Although arteriopathies are the most common cause of childhood arterial ischemic stroke, and the strongest predictor of recurrent stroke, they are difficult to diagnose. We studied the role of clinical data and follow-up imaging in diagnosing cerebral and cervical arteriopathy in children with arterial ischemic stroke.

METHODS

Vascular effects of infection in pediatric stroke, an international prospective study, enrolled 355 cases of arterial ischemic stroke (age, 29 days to 18 years) at 39 centers. A neuroradiologist and stroke neurologist independently reviewed vascular imaging of the brain (mandatory for inclusion) and neck to establish a diagnosis of arteriopathy (definite, possible, or absent) in 3 steps: (1) baseline imaging alone; (2) plus clinical data; (3) plus follow-up imaging. A 4-person committee, including a second neuroradiologist and stroke neurologist, adjudicated disagreements. Using the final diagnosis as the gold standard, we calculated the sensitivity and specificity of each step.

RESULTS

Cases were aged median 7.6 years (interquartile range, 2.8-14 years); 56% boys. The majority (52%) was previously healthy; 41% had follow-up vascular imaging. Only 56 (16%) required adjudication. The gold standard diagnosis was definite arteriopathy in 127 (36%), possible in 34 (9.6%), and absent in 194 (55%). Sensitivity was 79% at step 1, 90% at step 2, and 94% at step 3; specificity was high throughout (99%, 100%, and 100%), as was agreement between reviewers (κ=0.77, 0.81, and 0.78).

CONCLUSIONS

Clinical data and follow-up imaging help, yet uncertainty in the diagnosis of childhood arteriopathy remains. This presents a challenge to better understanding the mechanisms underlying these arteriopathies and designing strategies for prevention of childhood arterial ischemic stroke.

Headache with focal neurologic signs in children at the emergency department

OBJECTIVE

To identify predictors of secondary headache in children consulting at the pediatric emergency department (ED) for headache with a focal neurologic deficit.

STUDY DESIGN

In this prospective cohort study, we enrolled children aged 6-18 years presenting to the ED of a tertiary care hospital with moderate to severe headache and focal neurologic deficit. Enrollment took place between March 2009 and February 2012. Children with a history of trauma, fever, or neurosurgical intervention were excluded from the study. The final diagnosis was made after 1 year of follow-up. Our primary aim was to identify any differences in the frequency of clinical signs between children with a final diagnosis of primary headache and those with a final diagnosis of secondary headache.

RESULTS

Of the 101 patients included in the study, 66% received a final diagnosis of primary headache (94% migraine with aura), and 34% received a final diagnosis of secondary headache (76.5% focal epilepsy). On multivariate analysis, children with bilateral localization of pain had a higher likelihood (aOR, 8.6; 95% CI, 3.2-23.2; P<.001) of having secondary headache.

CONCLUSION

Among children presenting to the ED with focal neurologic deficits, a bilateral headache location was associated with higher odds of having a secondary cause of headache. Additional longitudinal studies are needed to investigate whether our data can aid management in the ED setting.