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Ghosh S, Lien IG, Martinez K, Lin T, Bleiweis MS, Philip J, Jordan LC, Pavlakis SG. Prevalence and Risk Factors for Cerebral Palsy in Children With Congenital Heart Disease Based on Risk of Surgical Mortality. Pediatr Neurol 2024; 155:133-140. [PMID: 38640862 DOI: 10.1016/j.pediatrneurol.2024.02.011] [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: 01/30/2023] [Revised: 12/20/2023] [Accepted: 02/26/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Children with congenital heart disease (CHD) have a higher prevalence of motor impairment secondary to brain injury, resulting in cerebral palsy (CP). The purpose of this study is to determine the prevalence of CP in CHD in a single-center cohort, stratify risk based on surgical mortality using Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) categories and identify risk factors. METHODS Retrospective cohort study of pediatric patients registered in the University of Florida (UF) Society of Thoracic Surgeons Congenital Heart Surgery database from 2006 to 2017 with a diagnosis of CHD who continued follow-up for more than two years at UF. RESULTS A total of 701 children with CHD met inclusion criteria. Children identified to have CP were 54 (7.7%). Most common presentation was spastic hemiplegic CP with a Gross Motor Function Classification System of level 2. Analysis of surgical and intensive care factors between the two groups showed that children with CHD and CP had longer time from admission to surgery (P = 0.003), higher STAT categories 4 and 5 (P = 0.038), and higher frequency of brain injury and seizures (P < 0.001). Developmental disabilities and rehabilitation needs were significantly greater for children with CHD and CP when compared with those with CHD alone (P < 0.001). CONCLUSIONS In our cohort, 7.7% children with CHD develop CP; this is significantly higher than the 2010 US population estimate of 0.3%. Our study suggests higher STAT categories, brain injury, and seizures are associated with developing CP in children with CHD.
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Affiliation(s)
- Suman Ghosh
- State University of New York at Downstate Health Sciences University, Brooklyn, New York; Department of Neurology, New York City Health and Hospitals Corporation Kings County Hospital, Brooklyn, New York.
| | - Ing Grace Lien
- Department of Neurology, University of Florida, Gainesville, Florida
| | - Kerstin Martinez
- Herbert Wertheim College of Engineering, University of Florida, Gainesville, Florida
| | - Tracy Lin
- College of Liberal Arts and Sciences, University of Florida, Gainesville, Florida
| | - Mark S Bleiweis
- University of Florida Health Congenital Heart Center, Gainesville, Florida
| | - Joseph Philip
- University of Florida Health Congenital Heart Center, Gainesville, Florida
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Steven G Pavlakis
- State University of New York at Downstate Health Sciences University, Brooklyn, New York; Department of Neurology, New York City Health and Hospitals Corporation Kings County Hospital, Brooklyn, New York
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Robertson CMT, Khademioureh S, Dinu IA, Sorenson JA, Joffe AR. Differences in gross motor and fine motor outcomes for toddlers after early complex cardiac surgery. Cardiol Young 2024:1-9. [PMID: 38606603 DOI: 10.1017/s1047951124000428] [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] [Indexed: 04/13/2024]
Abstract
OBJECTIVES To determine whether gross motor scores of toddlers after complex cardiac surgery were different from fine motor scores and were adequately represented by motor composite scores and, whether acute care predictors and chronic childhood health markers of gross motor scores differed from those of fine motor. METHODS This prospective inception-cohort outcomes study included 171 toddlers after complex cardiac surgery with cardiopulmonary bypass at age <6 months, born in Northern Alberta from 2009 to 2019, and without known chromosomal abnormalities. At a mean (standard deviation) age of 21.7 (3.7) months, the Bayley Scales of Infant and Toddler Development-III determined motor composite and scaled scores (normative values, 100 (15), 10 (3), respectively). The same variables from surgery and assessment were analysed using multivariate regression to predict gross and fine motor scores; results expressed as effect size (95% confidence interval) with % variance. RESULTS Composite, fine, and gross motor scores were 89.7 (14.2), 9.4 (2.5), and 7.2 (2.7), respectively. Predictive variables accounted for 21.2% of the variance for fine motor, and 36.9% for gross motor. Multivariate analysis for gross motor scores included toddlers need for cardiac medication, effect size (95% confidence interval) -0.801 (-1.62, -0.02), gastrostomy, -1.35 (-2.39, -0.319), and single ventricle, -0.93 (-1.71, -0.15). These same variables did not predict fine motor scores. CONCLUSION Gross motor skills commonly were lower than fine motor skills for toddlers after complex cardiac surgery. Predictors for gross motor scores differed from fine motor scores. Separate reporting of gross motor scores could lead to improved identification of predictors of delay and to optimised early intervention.
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Affiliation(s)
- Charlene M T Robertson
- Department of Pediatrics, Division of Developmental Pediatrics, University of Alberta, Edmonton, AB, Canada
- Developmental Pediatrics, Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
| | - Sara Khademioureh
- Biostatistics, School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Irina A Dinu
- Biostatistics, School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Julie A Sorenson
- Department of Physical Therapy, Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
| | - Ari R Joffe
- Pediatric Intensive Care, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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Paul DA, Poon E, Nambiar M, Anderson D. Bilateral thalamic high-grade astrocytomas in an early-adolescent child: A case report. J Med Imaging Radiat Oncol 2024. [PMID: 38185912 DOI: 10.1111/1754-9485.13620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/21/2023] [Indexed: 01/09/2024]
Abstract
An early-adolescent girl presented with incoordination, headache, vomiting and dysphonia. MRI brain demonstrated diffuse increased T2 and FLAIR signal in bilateral thalami, consistent with anaplastic astrocytomas. A stereotactic burr-hole biopsy provided frozen tissues sections demonstrating an IDH-1 wildtype astrocytoma (anaplastic grade III according to prior WHO classification 2016-21). Chemoradiotherapy was commenced. Bilateral thalamic high-grade astrocytomas are very rare in the paediatric population and require timely diagnosis and interdisciplinary management. CT and MR imaging help point towards this diagnosis in the correct clinical context.
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Affiliation(s)
- Dion A Paul
- Department of Imaging, Monash Health, Melbourne, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Emma Poon
- Department of Imaging, Monash Health, Melbourne, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Mithun Nambiar
- Department of Imaging, Monash Health, Melbourne, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Douglas Anderson
- Department of Imaging, Monash Health, Melbourne, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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4
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Vega Puyal L, Llurba E, Ferrer Q, Dolader Codina P, Sánchez García O, Montoliu Ruiz A, Sanchez-de-Toledo J. Neurodevelopmental outcomes in congenital heart disease: Usefulness of biomarkers of brain injury. An Pediatr (Barc) 2024; 100:13-24. [PMID: 38185573 DOI: 10.1016/j.anpede.2023.12.007] [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: 07/14/2023] [Accepted: 10/17/2023] [Indexed: 01/09/2024] Open
Abstract
INTRODUCTION At present, neurodevelopmental abnormalities are the most frequent type of complication in school-aged children with congenital heart disease (CHD). We analysed the incidence of acute neurologic events (ANEs) in patients with operated CHD and the usefulness of neuromarkers for the prediction of neurodevelopment outcomes. METHODS Prospective observational study in infants with a prenatal diagnosis of CHD who underwent cardiac surgery in the first year of life. We assessed the following variables: (1) serum biomarkers of brain injury (S100B, neuron-specific enolase) in cord blood and preoperative blood samples; (2) clinical and laboratory data from the immediate postnatal and perioperative periods; (3) treatments and complications; (4) neurodevelopment (Bayley-III scale) at age 2 years. RESULTS the study included 84 infants with a prenatal diagnosis of CHD who underwent cardiac surgery in the first year of life. Seventeen had univentricular heart, 20 left ventricular outflow obstruction and 10 genetic syndromes. The postoperative mortality was 5.9% (5/84) and 10.7% (9/84) patients experienced ANEs. The mean overall Bayley-III scores were within the normal range, but 31% of patients had abnormal scores in the cognitive, motor or language domains. Patients with genetic syndromes, ANEs and univentricular heart had poorer neurodevelopmental outcomes. Elevation of S100B in the immediate postoperative period was associated with poorer scores. CONCLUSIONS children with a history of cardiac surgery for CHD in the first year of life are at risk of adverse neurodevelopmental outcomes. Patients with genetic syndromes, ANEs or univentricular heart had poorer outcomes. Postoperative ANEs may contribute to poorer outcomes. Elevation of S100B levels in the postoperative period was associated with poorer neurodevelopmental outcomes at 2 years. Studies with larger samples and longer follow-ups are needed to define the role of these biomarkers of brain injury in the prediction of neurodevelopmental outcomes in patients who undergo surgery for management of CHD.
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Affiliation(s)
- Laia Vega Puyal
- Hospital Universitario Dexeus, Grupo Quironsalud, Barcelona, Spain.
| | - Elisa Llurba
- Women and Perinatal Health Research Group, Institut d'Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona. Spain; Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin Network (RICORS-SAMID) (RD21/0012), Instituto de Salud Carlos III, Madrid, Spain; Departmento de Obstetricia y Ginecología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Queralt Ferrer
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain; Hospital Universitario Vall d'Hebrón. Servicio de Cardiología Pediátrica, Barcelona. Spain
| | - Paola Dolader Codina
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain; Hospital Universitario Vall d'Hebrón. Servicio de Cardiología Pediátrica, Barcelona. Spain
| | - Olga Sánchez García
- Women and Perinatal Health Research Group, Institut d'Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona. Spain; Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin Network (RICORS-SAMID) (RD21/0012), Instituto de Salud Carlos III, Madrid, Spain
| | - Alba Montoliu Ruiz
- Hospital Universitario Vall d'Hebrón. Servicio de Cardiología Pediátrica, Barcelona. Spain
| | - Joan Sanchez-de-Toledo
- Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain; iCare4Kids Research Group, Institud de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain; Department of Critical Care Medicine, Universityy of Pittsburgh, Pittsburgh, PA, United States
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Yelton SEG, Flores S, Sun LR, Nelson-McMillan K, Loomba RS. Association Between Congenital Heart Disease and Stroke: Insights from a National Database. Pediatr Cardiol 2024; 45:1-7. [PMID: 37837542 DOI: 10.1007/s00246-023-03315-6] [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: 07/26/2023] [Accepted: 09/26/2023] [Indexed: 10/16/2023]
Abstract
To delineate prevalence of stroke in the pediatric intensive care unit and to determine risk factors for stroke and association of stroke with mortality in patients with congenital heart disease. Retrospective cohort study. Patients admitted to pediatric intensive care units in the USA participating in the Pediatric Health Information System database from 2016 to 2021. Patients were categorized as those who experienced ischemic or hemorrhagic stroke and those with congenital heart disease. We performed univariate and multivariate logistic regressions to determine risk factors associated with stroke and then developed a predictive model for stroke development in patients with congenital heart disease. Of 426,029 admissions analyzed, 4237 (0.9%) patients experienced stroke and 1197 (1.4%) of 80,927 patients with congenital heart disease developed stroke (odds ratio 1.15, 95% confidence interval 1.06-1.24). Patients with congenital heart disease, younger age, extracorporeal membrane oxygenation, mechanical ventilation, and cardiac arrest were most strongly associated with increased risk of stroke. Stroke increased odds of mortality for patients with congenital heart disease (odds ratio 2.49, 95% confidence interval 2.08-2.98). A risk score greater than 0 was associated with a 33.3% risk of stroke for patients with congenital heart disease (negative predictive value of 99%, sensitivity 69%, specificity 63%). Children with congenital heart disease are at increased risk for developing stroke, which is associated with increased mortality. Early identification of the most vulnerable patients may enable providers to implement preventative measures or rapid treatment strategies to prevent neurologic morbidity.
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Affiliation(s)
- Sarah E Gardner Yelton
- Division of Cardiology, Advocate Children's Hospital, Oak Lawn, IL, USA.
- Division of Critical Care, University of Chicago Comer Children's Hospital, Chicago, IL, USA.
| | - Saul Flores
- Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, House, TX, USA
- Department of Pediatrics, Baylor School of Medicine, Houston, TX, USA
| | - Lisa R Sun
- Division of Pediatric Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kristen Nelson-McMillan
- Division of Cardiology, Advocate Children's Hospital, Oak Lawn, IL, USA
- Division of Critical Care, University of Chicago Comer Children's Hospital, Chicago, IL, USA
| | - Rohit S Loomba
- Division of Cardiology, Advocate Children's Hospital, Oak Lawn, IL, USA
- Department of Pediatrics, Chicago Medical School/Rosalind Franklin University of Medicine and Science, Chicago, IL, USA
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Hill NM, Malone LA, Sun LR. Stroke in the Developing Brain: Neurophysiologic Implications of Stroke Timing, Location, and Comorbid Factors. Pediatr Neurol 2023; 148:37-43. [PMID: 37651976 DOI: 10.1016/j.pediatrneurol.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 08/02/2023] [Accepted: 08/07/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Pediatric stroke, which is unique in that it represents a static insult to a developing brain, often leads to long-term neurological disability. Neuroplasticity in infants and children influences neurophysiologic recovery patterns after stroke; therefore outcomes depend on several factors including the timing and location of stroke and the presence of comorbid conditions. METHODS In this review, we discuss the unique implications of stroke occurring in the fetal, perinatal, and childhood/adolescent time periods. First, we highlight the impact of the developmental stage of the brain at the time of insult on the motor, sensory, cognitive, speech, and behavioral domains. Next, we consider the influence of location of stroke on the presence and severity of motor and nonmotor outcomes. Finally, we discuss the impact of associated conditions on long-term outcomes and risk for stroke recurrence. RESULTS Hemiparesis is common after stroke at any age, although the severity of impairment differs by age group. Risk of epilepsy is elevated in all age groups compared with those without stroke. Outcomes in other domains vary by age, although several studies suggest worse cognitive outcomes when stroke occurs in early childhood compared with fetal and later childhood epochs. Conditions such as congenital heart disease, sickle cell disease, and moyamoya increase the risk of stroke and leave patients differentially vulnerable to neurodevelopmental delay, stroke recurrence, silent infarcts, and cognitive impairment. CONCLUSIONS A comprehensive understanding of the interplay of various factors is essential in guiding the clinical care of patients with pediatric stroke.
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Affiliation(s)
- Nayo M Hill
- Center for Movement Studies, Kennedy Krieger Institute, Baltimore, Maryland; Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Laura A Malone
- Center for Movement Studies, Kennedy Krieger Institute, Baltimore, Maryland; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lisa R Sun
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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7
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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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8
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Tan MA, Layug EJV, Singh BP, Parakh M. Diagnosis of Pediatric Stroke in Resource Limited Settings. Semin Pediatr Neurol 2022; 44:100997. [PMID: 36456040 DOI: 10.1016/j.spen.2022.100997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 09/01/2022] [Accepted: 09/07/2022] [Indexed: 10/14/2022]
Abstract
Global awareness of stroke as a significant cause of neurologic sequelae and death in children has increased over the years as more data in this field becomes available. However, most published literature on pediatric stroke have limited geographic representation. Data on childhood stroke from developing countries remains limited. Thus, this paper reviewed geographic/ethnic differences in pediatric stroke risk factors highlighting those reported in low- and middle-income countries, and proposes a childhood arterial ischemic stroke diagnostic algorithm for resource limited settings. Stroke risk factors include cardiac disorders, infectious diseases, cerebral arteriopathies, hematologic disorders, inflammatory diseases, thrombophilia and genetic conditions. Infection of the central nervous system particularly tuberculous meningitis, is a leading cause of pediatric arterial ischemic stroke in developing countries. Stroke should be considered in children with acute focal neurologic deficit especially in the presence of aforementioned risk factors. Cranial magnetic resonance imaging with angiography is the neuroimaging modality of choice but if unavailable, cranial computed tomography with angiography may be performed as an alternative. If both are not available, transcranial doppler together with neurologic exam may be used to screen children for arterial ischemic stroke. Etiological diagnosis follows with the aid of appropriate laboratory tests that are available in each level of care. International collaborative research on stroke risk factors that are prevalent in low and middle income countries will provide information for drafting of stroke care guidelines that are universal yet inclusive taking into consideration regional differences in available resources with the goal of reducing global stroke burden.
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Affiliation(s)
- Marilyn A Tan
- Division of Pediatric Neurology, Departments of Pediatrics and Neurosciences, University of the Philippines - Philippine General Hospital, Manila, Philippines.
| | - Elbert John V Layug
- Division of Pediatric Neurology, Departments of Pediatrics and Neurosciences, University of the Philippines - Philippine General Hospital, Manila, Philippines
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Arteriell ischämischer Schlaganfall im Kindes- und Jugendalter. DER NERVENARZT 2022; 93:1258-1270. [PMCID: PMC9667834 DOI: 10.1007/s00115-022-01409-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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10
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Mayne EW, Mailo JA, Pabst L, Pulcine E, Harrar DB, Waak M, Rafay MF, Hassanein SM, Amlie-Lefond C, Jordan LC. Pediatric Stroke and Cardiac Disease: Challenges in Recognition and Management. Semin Pediatr Neurol 2022; 43:100992. [PMID: 36344023 PMCID: PMC9719802 DOI: 10.1016/j.spen.2022.100992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/11/2022] [Accepted: 08/24/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Elizabeth W Mayne
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA.
| | - Janette A Mailo
- Division of Pediatric Neurology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa Pabst
- Department of Pediatrics, Division of Neurology, Nationwide Children's Hospital, Columbus, OH
| | - Elizabeth Pulcine
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Dana B Harrar
- Division of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Michaela Waak
- Pediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Queensland, Australia; Pediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - Mubeen F Rafay
- Children's Hospital Winnipeg, University of Manitoba, Children's Hospital Research Institute of Manitoba, Manitoba, Canada
| | - Sahar Ma Hassanein
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Catherine Amlie-Lefond
- Department of Neurology, Department of Neurological Surgery, University of Washington, Seattle, WA
| | - Lori C Jordan
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN
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Gerstl L, Borggräfe I, Heinen F, Olivieri M. Arteriell ischämischer Schlaganfall im Kindes- und Jugendalter. Monatsschr Kinderheilkd 2022; 170:458-471. [PMID: 35465384 PMCID: PMC9020421 DOI: 10.1007/s00112-022-01465-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 11/27/2022]
Abstract
Der arteriell ischämische Schlaganfall im Kindes- und Jugendalter gehört zu den zeitkritischsten pädiatrischen Notfällen, wird aber häufig erst mit prognostisch relevanter Zeitverzögerung diagnostiziert. Gründe sind geringe „Awareness“, die zuweilen unspezifische klinische Präsentation mit einer Breite an kritischen Differenzialdiagnosen und in der Fläche noch wenig verzahnte Akutversorgungsstrukturen. Die beim Erwachsenen etablierten Revaskularisationsstrategien zeigen auch beim Kind mögliche, z. T. spektakuläre Erfolge. Diese sind daher nach Möglichkeit auch betroffenen Kindern zur Verfügung zu stellen, auch wenn hier derzeit keine annähernd vergleichbare Evidenz vorliegt. Postakut ist die ätiologische Aufarbeitung aufgrund zu bedenkender Risikofaktoren komplex, muss aber das individuelle Risikoprofil mit Sekundärprophylaxe, Rezidivrisiko und Outcome präzise identifizieren. Die Langzeitbetreuung im multiprofessionellen, interdisziplinären Team muss die bio-psycho-sozialen Aspekte des Kindes in seiner jeweiligen Entwicklungsphase berücksichtigen.
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Affiliation(s)
- L. Gerstl
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Abteilung für Pädiatrische Neurologie, Entwicklungsneurologie und Sozialpädiatrie, LMU Zentrum für Entwicklung und komplex chronisch kranke Kinder – iSPZ Hauner, LMU Klinikum München, Campus Innenstadt, Lindwurmstr. 4, 80337 München, Deutschland
| | - I. Borggräfe
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Abteilung für Pädiatrische Neurologie, Entwicklungsneurologie und Sozialpädiatrie, LMU Zentrum für Entwicklung und komplex chronisch kranke Kinder – iSPZ Hauner, LMU Klinikum München, Campus Innenstadt, Lindwurmstr. 4, 80337 München, Deutschland
| | - F. Heinen
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Abteilung für Pädiatrische Neurologie, Entwicklungsneurologie und Sozialpädiatrie, LMU Zentrum für Entwicklung und komplex chronisch kranke Kinder – iSPZ Hauner, LMU Klinikum München, Campus Innenstadt, Lindwurmstr. 4, 80337 München, Deutschland
| | - M. Olivieri
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Abteilung für Pädiatrische Hämostaseologie, LMU Klinikum München, Campus Innenstadt, München, Deutschland
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Abteilung für Kinderintensivmedizin und Notfallmedizin, LMU Klinikum München, Campus Innenstadt, München, Deutschland
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Screening and Evaluation of Neurodevelopmental Impairments in Infants Under 6 Months of Age with Congenital Heart Disease. Pediatr Cardiol 2022; 43:489-496. [PMID: 35190880 DOI: 10.1007/s00246-021-02745-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/29/2021] [Indexed: 10/19/2022]
Abstract
Clinical evaluation of neurodevelopmental impairments before 6 months of age is needed in congenital heart disease (CHD) to promote early referral to developmental interventions. The objective was to identify the risk of cerebral palsy (CP) and to compare neurodevelopment outcomes in infants with and without CHD. In a longitudinal study, 30 infants with CHD and 15 infants without CHD were assessed at 1 month, 3 months, and 6 months of age. Included measures were General Movement Assessment (GMA), Test of Infant Motor Performance (TIMP) and the Bayley Scale of Infant Development, third edition (Bayley-III), selected to identify the risk of CP, document neurodevelopmental impairments and infants' eligibility for early intervention services. Abnormal GMA categories were found in the CHD group where 48% had poor repertoire and 15% were at high risk of CP. At 3 months of age, CHD group had significantly lower TIMP scores compared to infants without CHD [t(41) = 6.57, p = 0.01]. All infants in the study had higher Bayley-III scores at 6 months than at 3 months of age. Infants with CHD had lower gross motor, fine motor and cognitive Bayley-III scores compared to their peers without CHD. Over time infants without CHD outperformed the CHD group in the gross motor skills [F(1,41) = 11.76, p = .001]. Higher prevalence of abnormal GMs, lower TIMP and Bayley-III were found in infants with single ventricle physiology compared to two-ventricle physiology. The risk of CP exists in infants with CHD, and these infants have worse outcomes compared to their peers without CHD. These differences are intensified in the single ventricle population.Clinical Trial Registration National Institute of Health, Unique identifier: NCT03104751; Date of registration-April 7, 2017.
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Gerstl L, Olivieri M, Heinen F, Bidlingmaier C, Schroeder AS, Reiter K, Hoffmann F, Kurnik K, Liebig T, Trumm CG, Haas NA, Jakob A, Borggraefe I. Notfall-Neuropädiatrie – Der arteriell ischämische Schlaganfall als einer der zeitkritischsten Notfälle bei Kindern und Jugendlichen. DER NERVENARZT 2022; 93:158-166. [PMID: 35072763 PMCID: PMC8785019 DOI: 10.1007/s00115-021-01252-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/06/2021] [Indexed: 11/21/2022]
Abstract
Der arteriell ischämische Schlaganfall im Kindes- und Jugendalter gehört zu den zeitkritischsten Notfällen in der Pädiatrie. Dennoch wird er häufig mit einer oft prognostisch relevanten Zeitverzögerung diagnostiziert. Gründe dafür liegen neben der geringen Awareness auch in der zuweilen unspezifischen klinischen Präsentation mit einer herausfordernden Breite kritischer Differenzialdiagnosen sowie in der Fläche noch wenig verzahnter Akutversorgungsstrukturen. Gleichwohl zeigen grundsätzlich die beim Erwachsenen etablierten Revaskularisationsstrategien auch beim Kind ihre möglichen, zum Teil spektakulären Erfolge. Es gilt also, diese nach Möglichkeit auch den betroffenen Kindern zur Verfügung zu stellen, auch wenn hier derzeit ein nicht annähernd vergleichbarer Grad an Evidenz erreicht ist. Postakut ist die ätiologische Aufarbeitung durch die größere Bandbreite zu bedenkender Risikofaktoren besonders komplex, muss aber in der Lage sein, das individuelle Risikoprofil mit Sekundärprophylaxe, Rezidivrisiko und Outcome präzise zu identifizieren. Die Langzeitbetreuung im multiprofessionellen, interdisziplinären Team muss die biopsychosozialen Aspekte des Kindes in seiner jeweiligen Entwicklungsphase berücksichtigen und damit eine bestmögliche Integration des Kindes in sein soziales und schulisches, später berufliches Umfeld realisieren.
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14
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Calderon J, Newburger JW, Rollins CK. Neurodevelopmental and Mental Health Outcomes in Patients With Fontan Circulation: A State-of-the-Art Review. Front Pediatr 2022; 10:826349. [PMID: 35356444 PMCID: PMC8959547 DOI: 10.3389/fped.2022.826349] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
Children, adolescents and adults living with Fontan circulation face numerous neurological and developmental challenges. As the population with complex CHD increases thanks to outstanding improvement in medical and surgical care, the long-term developmental and mental health sequelae have become a public health priority in pediatric and congenital cardiology. Many patients with a Fontan circulation experience difficulty in areas of cognition related to attention and executive functioning, visual spatial reasoning and psychosocial development. They are also at high risk for mental health morbidities, particularly anxiety disorders and depression. Several hemodynamic risk factors, beginning during the fetal period, may influence outcomes and yield to abnormal brain growth and development. Brain injury such as white matter lesions, stroke or hemorrhage can occur before, during, or after surgery. Other sociodemographic and surgical risk factors such as multiple catheterizations and surgeries and prolonged hospital stay play a detrimental role in patients' neurodevelopmental prognosis. Prevention and intervention to optimize long-term outcomes are critical in the care of this vulnerable population with complex CHD.
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Affiliation(s)
- Johanna Calderon
- PhyMedExp, Université de Montpellier, National Institute of Health and Medical Research (INSERM), CNRS, Montpellier, France.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Caitlin K Rollins
- Department of Neurology, Boston Children's Hospital, Boston, MA, United States.,Department of Neurology, Harvard Medical School, Boston, MA, United States
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15
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Saharan S, Vettukattil J, Bhat A, Amula V, Bansal M, Chowdhury D, Dyamenahalli U, Gupta SK, Das B, Susheel Kumar TK, Muralidaran A, Trivedi K, Swaminathan S, Bansal N, Doshi U, Hoskoppal A, Balaji S. Patent foramen ovale in children: Unique pediatric challenges and lessons learned from adult literature. Ann Pediatr Cardiol 2022; 15:44-52. [PMID: 35847406 PMCID: PMC9280096 DOI: 10.4103/apc.apc_67_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/19/2021] [Accepted: 07/16/2021] [Indexed: 11/05/2022] Open
Abstract
A patent foramen ovale (PFO) is a frequent incidental finding during echocardiography in otherwise healthy children. In most healthy children with a diagnosis of isolated incidental PFO, no further follow-up or intervention is necessary. In some children, PFO is associated with certain clinical syndromes such as cryptogenic stroke, decompression sickness, migraine, and platypnea-orthodeoxia syndrome. This review discusses PFO anatomy, diagnostic imaging, PFO-associated clinical situations, management options, and the role of PFO in certain congenital heart disease. This review also highlights the current deficiency of pediatric data guiding management of these uncommon but important PFO-associated conditions. Future multicenter randomized controlled studies are necessary to guide the management of these unique and challenging PFO-associated conditions.
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Affiliation(s)
- Sunil Saharan
- Department of Pediatrics, Division of Cardiology, Hassenfeld Children's Hospital, New York University Langone Health, New York, NY, USA,Address for correspondence: Dr. Sunil Saharan, Department of Pediatrics, Division of Cardiology, New York University Langone Health, 550 First Avenue, New York, NY 10016, USA. E-mail:
| | - Joseph Vettukattil
- Department of Pediatrics, Division of Cardiology, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - Aarti Bhat
- Department of Pediatrics, Division of Pediatric Cardiology, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Venu Amula
- Department of Pediatrics, Division of Critical Care, Primary Children's Hospital and University of Utah, Salt Lake City, UT, USA
| | - Manish Bansal
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Houston, TX, USA
| | | | - Umesh Dyamenahalli
- Department of Pediatrics, Division of Pediatric Cardiology, University of Chicago, Chicago, IL, USA
| | - Saurabh Kumar Gupta
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Bibhuti Das
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - T. K. Susheel Kumar
- Department of Surgery, Section of Congenital and Pediatric Cardiac Surgery, New York University Langone Health, New York, NY, USA
| | - Ashok Muralidaran
- Department of Surgery, Section of Congenital and Pediatric Cardiac Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Kalyani Trivedi
- Department of Pediatrics, Heart and Vascular Institute, Arnot Health, Elmira, New York, USA
| | - Sethuraman Swaminathan
- Department of Pediatrics, Division of Cardiology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Neha Bansal
- Department of Pediatrics, Division of Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, New York, NY, USA
| | - Unnati Doshi
- Department of Pediatrics, Division of Cardiology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Arvind Hoskoppal
- Department of Pediatrics, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Seshadri Balaji
- Department of Pediatrics, Division of Cardiology, Oregon Health and Science University, Portland, OR, USA
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16
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Pulcine E, Seed M, Brandão LR, Slim M, Palasamudram S, Shroff M, Moharir M, deVeber G, Dlamini N. Hemorrhagic transformation and stroke recurrence in children with cardiac disease receiving antithrombotic therapy for secondary stroke prevention. J Thromb Haemost 2021; 19:2428-2439. [PMID: 34152075 DOI: 10.1111/jth.15428] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 05/20/2021] [Accepted: 06/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Antithrombotic therapy is currently recommended for stroke prevention in pediatric cardioembolic stroke where the recurrence risk is high; however, safety concerns remain. The primary objective of this study was to evaluate clinical and radiographic predictors of hemorrhagic transformation and stroke recurrence in children with cardiac disease to ascertain the safety and failure rates for secondary stroke prevention. METHODS This was a single-center, retrospective analysis of a prospectively enrolled cohort of children with radiologically confirmed cardioembolic stroke from January 2003 to December 2017 treated with institutional guidelines. RESULTS Eighty-two children met inclusion criteria (male 44 [54%]; neonates 23 [28%]; median age 0.43 years [0.08-4.23]). Hemorrhagic transformation occurred in 20 (24%) with the majority (75% of 20) being petechial and asymptomatic. One death (1%) was reported from hemorrhagic transformation. Four children (5%) had major extracranial hemorrhage. Most (95%) received antithrombic therapy, with anticoagulation being favored (82%). Greater stroke volume was associated with hemorrhagic transformation using the pediatric Alberta Stroke Program Early CT Score (6.1 ± 3.3 vs. 3.5 ± 2.3; p = .006). Stroke recurred in 11 (13%) children at a median 32 days (5.5-93) from the index event and the majority (90%) were on treatment at the time of recurrence. Children with univentricular physiology were less likely to have hemorrhagic transformation (RR 0.31; 95% CI 0.09-0.96, p = .04); however, they had higher rates of recurrent stroke before final palliative repair. CONCLUSIONS In spite of the 24% hemorrhagic transformation rate, antithrombotic therapy has a positive risk-balance in certain cardioembolic stroke subgroups, particularly in those with single-ventricle physiology, when accounting for stroke volume.
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Affiliation(s)
- Elizabeth Pulcine
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mike Seed
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Leonardo R Brandão
- Division of Haematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Mahmoud Slim
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sunitha Palasamudram
- Division of Diagnostic Imaging, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Manohar Shroff
- Division of Diagnostic Imaging, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mahendranath Moharir
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Gabrielle deVeber
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Nomazulu Dlamini
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
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17
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Initial Diagnostic Evaluation of the Child With Suspected Arterial Ischemic Stroke. Top Magn Reson Imaging 2021; 30:211-223. [PMID: 34613944 DOI: 10.1097/rmr.0000000000000276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
ABSTRACT Numerous factors make the initial diagnostic evaluation of children with suspected arterial ischemic stroke (AIS) a relatively unsettling challenge, even for the experienced stroke specialist. The low frequency of pediatric AIS, diversity of unique age-oriented stroke phenotypes, and unconventional approaches required for diagnosis and treatment all contribute difficulty to the process. This review aims to outline important features that differentiate pediatric AIS from adult AIS and provide practical strategies that will assist the stroke specialist with diagnostic decision making in the initial phase of care.
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18
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AlBassri T, Sheikho M, Chaikhouni F, Al Habshan F, Kabbani MS. Neurological complications in children with infective endocarditis: Incidence, risk factors, and outcome: A 10-year single-center experience. Int J Pediatr Adolesc Med 2021; 8:198-202. [PMID: 34350336 PMCID: PMC8319676 DOI: 10.1016/j.ijpam.2021.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/26/2020] [Accepted: 02/14/2021] [Indexed: 04/13/2023]
Abstract
BACKGROUND AND OBJECTIVE Despite improvement in medical management, infective endocarditis (IE) remains a serious disease that may affect children with and without preexisting cardiac conditions with significant morbidity and mortality. Neurological complications of IE represent the worst with guarded prognosis. The aim of this study is to describe the incidence, etiology, characteristics, risk factors, and outcome of children with neurological complications associated with IE. MATERIAL AND METHODS A retrospective cohort study was conducted from 2009 to 2019 where all pediatric patients who fulfilled the modified Duke criteria for IE were included. We divided the cases into 2 groups: IE with neurological complications and IE without neurological complications control group. We compared the two groups statistically and analyzed the results. RESULTS We identified 31 (17 male, 14 female) patients with IE. Neurological complications occurred in 7/31 (23%) patients, mainly in the form of a stroke. Gram-positive microbes were the main causative agents for IE (52%) followed by gram-negative (14%), then fungal organisms (3%). Univariate analysis identified the following risk factors for neurological complications: lower body weight, higher C- reactive protein (CRP) level, and left-sided valvular lesions with P values of (0.0003, 0.0001, and 0.04), respectively.Although mortality was higher in the neurological complications group, it was 43% in comparison to 21% in the control group and it did not reach statistical significance (P = .49). Large vegetation size (more than 10 mm) was seen in 57% of patients with neurological complications as compared to 16% in the control group (P = .052). CONCLUSION Neurological complications occurred in almost a quarter of children with IE. Possible risk factors include lower body weight, left-sided valvular lesion, and higher levels of inflammatory markers (CRP). Stroke was the most common neurological complication encountered with possible increased risk of mortality.
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Affiliation(s)
- Tala AlBassri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Maha Sheikho
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Farah Chaikhouni
- Division of Pediatric Cardiology, Department of Cardiac Sciences, King Abdulaziz Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Fahad Al Habshan
- Division of Pediatric Cardiology, Department of Cardiac Sciences, King Abdulaziz Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Mohamed S. Kabbani
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Division of Pediatric Cardiac Intensive Care, Department of Cardiac Sciences, King Abdulaziz Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- Corresponding author. Pediatric Cardiac ICU, MC 1423, King Abdulaziz Medical City, P.O. BOX 22490, Riyadh, 11426, Saudi Arabia.
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19
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Sporns PB, Fullerton HJ, Lee S, Kirton A, Wildgruber M. Current treatment for childhood arterial ischaemic stroke. THE LANCET CHILD & ADOLESCENT HEALTH 2021; 5:825-836. [PMID: 34331864 DOI: 10.1016/s2352-4642(21)00167-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/18/2021] [Accepted: 05/24/2021] [Indexed: 12/23/2022]
Abstract
Paediatric arterial ischaemic stroke is an important cause of neurological morbidity in children, with consequences including motor disorders, intellectual impairment, and epilepsy. The causes of paediatric arterial ischaemic stroke are unique compared with those associated with stroke in adulthood. The past decade has seen substantial advances in paediatric stroke research and clinical care, but many unanswered questions and controversies remain. Shortage of prospective evidence for the use of recanalisation therapies in patients with paediatric stroke has resulted in little standardisation of disease management. Substantial time delays in diagnosis and treatment continue to challenge best possible care. In this Review, we highlight on some of the most pressing and productive aspects of research in the treatment of arterial ischaemic stroke in children, including epidemiology and cause, rehabilitation, secondary stroke prevention, and treatment updates focusing on advances in hyperacute therapies such as intravenous thrombolysis, mechanical thrombectomy, and critical care. Finally, we provide a future perspective for improving outcomes and quality of life for affected children and their families.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heather J Fullerton
- Departments of Neurology and Pediatrics, Weill Institute of Neurosciences, University of California at San Francisco, San Francisco, CA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Adam Kirton
- Department of Pediatrics and Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Moritz Wildgruber
- Department of Radiology, University Hospital Munich, LMU Munich, Munich, Germany.
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20
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21
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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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22
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Pulcine E, deVeber G. Neurologic complications of pediatric congenital heart disease. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:1-13. [PMID: 33632428 DOI: 10.1016/b978-0-12-819814-8.00010-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Improved medical management and surgical outcomes have significantly decreased mortality in children with congenital heart disease; however, with increased survival, there is a greater lifetime exposure to neurologic complications with serious long-term neurodevelopmental consequences. Thus, recent focus has shifted to recognition and reduction of these extracardiac comorbidities. Vascular and infective complications, such as arterial ischemic stroke, infective endocarditis, and localization-related epilepsy are some of the most common neurologic comorbidities of congenital heart disease. In addition, it is now well recognized that congenital heart disease has an impact on overall brain development and contributes to adverse neurodevelopmental outcomes across multiple domains. The goal of this chapter is to summarize the most common neurologic comorbidities of congenital heart disease and its management.
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Affiliation(s)
- Elizabeth Pulcine
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
| | - Gabrielle deVeber
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada.
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23
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Tona C, Nosadini M, Pelizza MF, Pin JN, Baggio L, Boniver C, Gabrieli JD, Causin F, Toldo I, Sartori S. Cardiac Myxoma as a Rare Cause of Pediatric Arterial Ischemic Stroke: Case Report and Literature Review. Neuropediatrics 2020; 51:389-396. [PMID: 32369836 DOI: 10.1055/s-0040-1710338] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cardiac disorders are the second leading cause of pediatric arterial ischemic stroke (AIS). Limited literature is available on pediatric AIS caused by cardiac myxoma, a rare tumor in childhood. METHODS We describe a new case of pediatric AIS due to a previously unknown atrial myxoma and we conduct a literature review on children with AIS due to cardiac myxoma. RESULTS We identified 41 published pediatric cases of AIS and cardiac myxoma, including ours (56% males, median age at AIS was 11 years [range: 3-18]). AIS presentation was most frequently with hemiparesis/hemiplegia (89%). Multiple brain ischemic lesions were detected in 69% of patients, and arteriopathy in 91%. Seven patients underwent mechanical thrombectomy. At AIS presentation, 73% of children had one or more of the following clinical symptoms/signs suggesting a possible underlying cardiac myxoma: Carney's complex, cardiac auscultation abnormalities, extraneurological symptoms/signs, such as skin signs (12, 38, and 65%, respectively). Cardiac myxoma was diagnosed within 72 hours in 68% of cases. Death occurred in 11%, and 40% had persistent neurological deficits. CONCLUSION Neurological presentation of AIS due to cardiac myxoma is similar to that of AIS with other etiologies, although clues suggesting a possible underlying cardiac myxoma can be detected in most cases. A timely diagnosis of cardiac myxoma in patients with AIS may favor prompt identification of candidates for endovascular therapy. Therefore, we suggest that in otherwise-healthy children presenting with AIS, transthoracic echocardiography should be performed early after stroke presentation.
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Affiliation(s)
- Clarissa Tona
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | - Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | - Maria F Pelizza
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | - Jacopo N Pin
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | - Laura Baggio
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | - Clementina Boniver
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | | | - Francesco Causin
- Neuroradiology Unit, University Hospital of Padua, Padova, Italy
| | - Irene Toldo
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
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24
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Sun LR, Harrar D, Drocton G, Castillo-Pinto C, Felling R, Carpenter JL, Wernovsky G, McDougall CG, Gailloud P, Pearl MS. Mechanical Thrombectomy for Acute Ischemic Stroke: Considerations in Children. Stroke 2020; 51:3174-3181. [PMID: 32912096 DOI: 10.1161/strokeaha.120.029698] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The use of mechanical thrombectomy for the treatment of acute childhood arterial ischemic stroke with large vessel occlusion is increasing, with mounting evidence for its feasibility and safety. Despite this emerging evidence, clear guidelines for patient selection, thrombectomy technique, and postprocedure care do not exist for the pediatric population. Due to unique features of stroke in children, neurologists and interventionalists must consider differences in patient size, anatomy, collateral vessels, imaging parameters, and expected outcomes that may impact appropriate patient selection and timing criteria. In addition, different causes of stroke and comorbidities in children must be considered and may alter the safety and efficacy of thrombectomy. To optimize the success of endovascular intervention in children, a multidisciplinary team should take into account these nuanced considerations when determining patient eligibility, developing a procedural approach, and formulating a postprocedure neurological monitoring and therapeutic plan.
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Affiliation(s)
- Lisa R Sun
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD. (L.R.S., R.F.)
| | - Dana Harrar
- Department of Neurology, Children's National Hospital, Washington, DC. (D.H., C.C.P., J.L.C.)
| | - Gerald Drocton
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD. (G.D., P.G., M.S.P.)
| | - Carlos Castillo-Pinto
- Department of Neurology, Children's National Hospital, Washington, DC. (D.H., C.C.P., J.L.C.)
| | - Ryan Felling
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD. (L.R.S., R.F.)
| | - Jessica L Carpenter
- Department of Neurology, Children's National Hospital, Washington, DC. (D.H., C.C.P., J.L.C.)
| | - Gil Wernovsky
- Divisions of Cardiac Critical Care and Pediatric Cardiology, Children's National Hospital, Washington, DC. (G.W.)
| | - Cameron G McDougall
- Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, MD. (C.G.M.)
| | - Philippe Gailloud
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD. (G.D., P.G., M.S.P.)
| | - Monica S Pearl
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD. (G.D., P.G., M.S.P.).,Department of Radiology, Children's National Hospital, Washington, DC. (M.S.P.)
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25
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Luckman J, Chokron S, Michowiz S, Belenky E, Toledano H, Zahavi A, Goldenberg-Cohen N. The Need to Look for Visual Deficit After Stroke in Children. Front Neurol 2020; 11:617. [PMID: 32714272 PMCID: PMC7343911 DOI: 10.3389/fneur.2020.00617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 05/27/2020] [Indexed: 11/13/2022] Open
Abstract
Purpose: To evaluate the role of the ophthalmologist in the management of children with arterial stroke, at presentation and during follow-up. Methods: This retrospective case series comprised children with arterial stroke who were followed for at least 12 months in a tertiary pediatric medical center in 2005–2016. Demographic data and findings on radiological neuroimaging and ophthalmological and neurological examination were retrieved from the medical files. Results: The cohort included 26 children with stroke. Underlying disorders included metabolic syndrome (n = 5, 19.2%), cardiac anomaly or Fontan repair (n = 3 each, 11.5%), vascular anomaly (n = 3, 11.5%), head trauma with traumatic dissection (n = 3, 11.5%), and hypercoagulability (n = 1, 3.8%); in eight patients (30.8%), no apparent cause was found. Eleven patients (42.3%) had a non-ophthalmological neurological deficit as a result of the stroke. Eye examination was performed in nine patients (34.6%) during follow-up. Ophthalmological manifestations included hemianopic visual field defect in seven patients (7.7%) and complete blindness and poor visual acuity in one patient each (3.8%). At the last visit, no change in visual function was detected. Conclusion: The variable etiology and presentation of pediatric stroke may mask specific visual signs. Children with arterial stroke should be referred for early ophthalmological evaluation and visual rehabilitation.
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Affiliation(s)
- Judith Luckman
- Department of Radiology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel
| | - Sylvie Chokron
- Responsable de l'Unité Fonctionnelle Vision et Cognition Service de Neurologie Fondation Ophtalmologique Rothschild, Paris, France
| | - Shalom Michowiz
- Department of Neurosurgery, Hadassah Hebrew University, Jerusalem, Israel
| | - Eugenia Belenky
- Department of Neurosurgery, Hadassah Hebrew University, Jerusalem, Israel
| | - Helen Toledano
- Pediatric Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Alon Zahavi
- Department of Ophthalmology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Krieger Eye Research Laboratory, Felsenstein Medical Research Center, Rabin Medical Center, Petach Tikva, Israel
| | - Nitza Goldenberg-Cohen
- Krieger Eye Research Laboratory, Felsenstein Medical Research Center, Rabin Medical Center, Petach Tikva, Israel.,Department of Ophthalmology, Bnai Zion Medical Center, Haifa, Israel.,Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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26
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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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27
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Goeggel Simonetti B, Rafay MF, Chung M, Lo WD, Beslow LA, Billinghurst LL, Fox CK, Pagnamenta A, Steinlin M, Mackay MT. Comparative study of posterior and anterior circulation stroke in childhood: Results from the International Pediatric Stroke Study. Neurology 2019; 94:e337-e344. [PMID: 31857436 DOI: 10.1212/wnl.0000000000008837] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 08/07/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare risk factors, clinical presentation, and outcomes after posterior circulation arterial ischemic stroke (PCAIS) and anterior circulation arterial ischemic stroke (ACAIS) in neonates and children. METHODS In this international multicenter observational study including neonates and children up to 18 years of age with arterial ischemic stroke (AIS), we compared clinical and radiologic features according to stroke location. RESULTS Of 2,768 AIS cases, 507 (18%) were located in the posterior circulation, 1,931 (70%) in the anterior circulation, and 330 (12%) involved both. PCAIS was less frequent in neonates compared to children (8.8% vs 22%, p < 0.001). Children with PCAIS were older than children with ACAIS (median age 7.8 [interquartile range (IQR) 3.1-14] vs 5.1 [IQR 1.5-12] years, p < 0.001), and more often presented with headache (54% vs 32%, p < 0.001) and a lower Pediatric NIH Stroke Scale score (4 [IQR 2-8] vs 8 [IQR 3-13], p = 0.001). Cervicocephalic artery dissections (CCAD) were more frequent (20% vs 8.5%, p < 0.001), while cardioembolic strokes were less frequent (19% vs 32%, p < 0.001) in PCAIS. Case fatality rates were equal in both groups (2.9%). PCAIS survivors had a better outcome (normal neurologic examination at hospital discharge in 29% vs 21%, p = 0.002) than ACAIS survivors, although this trend was only observed in children and not in neonates. CONCLUSION PCAIS is less common than ACAIS in both neonates and children. Children with PCAIS are older and have a higher rate of CCAD, lower clinical stroke severity, and better outcome than children with ACAIS.
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Affiliation(s)
- Barbara Goeggel Simonetti
- From the Neurovascular Research Group, Department of Neurology (B.G.S.), and Division of Child Neurology, Department of Pediatrics (B.G.S., M.S.), Inselspital Bern, University Hospital, University of Bern; Pediatric Neurology (B.G.S.), Institute of Pediatrics of Southern Switzerland, San Giovanni Hospital Bellinzona, Ente Ospedaliero Cantonale, Switzerland; Section of Pediatric Neurology, Department of Pediatrics and Child Health (M.F.R.), University of Manitoba, Children's Hospital Research Institute of Manitoba, Canada; Division of Neurology, Department of Pediatrics (M.C., W.D.L.), The Ohio State University and Nationwide Children's Hospital, Columbus; Division of Neurology (L.A.B., L.L.B.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (L.A.B., L.L.B.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Departments of Neurology and Pediatrics (C.K.F.), University of California, San Francisco; Unit of Clinical Epidemiology (A.P.), Ente Ospedaliero Cantonale, Bellinzona; Division of Pneumology (A.P.), University of Geneva, Switzerland; and Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute Melbourne, Parkville, Victoria, Australia.
| | - Mubeen F Rafay
- From the Neurovascular Research Group, Department of Neurology (B.G.S.), and Division of Child Neurology, Department of Pediatrics (B.G.S., M.S.), Inselspital Bern, University Hospital, University of Bern; Pediatric Neurology (B.G.S.), Institute of Pediatrics of Southern Switzerland, San Giovanni Hospital Bellinzona, Ente Ospedaliero Cantonale, Switzerland; Section of Pediatric Neurology, Department of Pediatrics and Child Health (M.F.R.), University of Manitoba, Children's Hospital Research Institute of Manitoba, Canada; Division of Neurology, Department of Pediatrics (M.C., W.D.L.), The Ohio State University and Nationwide Children's Hospital, Columbus; Division of Neurology (L.A.B., L.L.B.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (L.A.B., L.L.B.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Departments of Neurology and Pediatrics (C.K.F.), University of California, San Francisco; Unit of Clinical Epidemiology (A.P.), Ente Ospedaliero Cantonale, Bellinzona; Division of Pneumology (A.P.), University of Geneva, Switzerland; and Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute Melbourne, Parkville, Victoria, Australia
| | - Melissa Chung
- From the Neurovascular Research Group, Department of Neurology (B.G.S.), and Division of Child Neurology, Department of Pediatrics (B.G.S., M.S.), Inselspital Bern, University Hospital, University of Bern; Pediatric Neurology (B.G.S.), Institute of Pediatrics of Southern Switzerland, San Giovanni Hospital Bellinzona, Ente Ospedaliero Cantonale, Switzerland; Section of Pediatric Neurology, Department of Pediatrics and Child Health (M.F.R.), University of Manitoba, Children's Hospital Research Institute of Manitoba, Canada; Division of Neurology, Department of Pediatrics (M.C., W.D.L.), The Ohio State University and Nationwide Children's Hospital, Columbus; Division of Neurology (L.A.B., L.L.B.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (L.A.B., L.L.B.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Departments of Neurology and Pediatrics (C.K.F.), University of California, San Francisco; Unit of Clinical Epidemiology (A.P.), Ente Ospedaliero Cantonale, Bellinzona; Division of Pneumology (A.P.), University of Geneva, Switzerland; and Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute Melbourne, Parkville, Victoria, Australia
| | - Warren D Lo
- From the Neurovascular Research Group, Department of Neurology (B.G.S.), and Division of Child Neurology, Department of Pediatrics (B.G.S., M.S.), Inselspital Bern, University Hospital, University of Bern; Pediatric Neurology (B.G.S.), Institute of Pediatrics of Southern Switzerland, San Giovanni Hospital Bellinzona, Ente Ospedaliero Cantonale, Switzerland; Section of Pediatric Neurology, Department of Pediatrics and Child Health (M.F.R.), University of Manitoba, Children's Hospital Research Institute of Manitoba, Canada; Division of Neurology, Department of Pediatrics (M.C., W.D.L.), The Ohio State University and Nationwide Children's Hospital, Columbus; Division of Neurology (L.A.B., L.L.B.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (L.A.B., L.L.B.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Departments of Neurology and Pediatrics (C.K.F.), University of California, San Francisco; Unit of Clinical Epidemiology (A.P.), Ente Ospedaliero Cantonale, Bellinzona; Division of Pneumology (A.P.), University of Geneva, Switzerland; and Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute Melbourne, Parkville, Victoria, Australia
| | - Lauren A Beslow
- From the Neurovascular Research Group, Department of Neurology (B.G.S.), and Division of Child Neurology, Department of Pediatrics (B.G.S., M.S.), Inselspital Bern, University Hospital, University of Bern; Pediatric Neurology (B.G.S.), Institute of Pediatrics of Southern Switzerland, San Giovanni Hospital Bellinzona, Ente Ospedaliero Cantonale, Switzerland; Section of Pediatric Neurology, Department of Pediatrics and Child Health (M.F.R.), University of Manitoba, Children's Hospital Research Institute of Manitoba, Canada; Division of Neurology, Department of Pediatrics (M.C., W.D.L.), The Ohio State University and Nationwide Children's Hospital, Columbus; Division of Neurology (L.A.B., L.L.B.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (L.A.B., L.L.B.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Departments of Neurology and Pediatrics (C.K.F.), University of California, San Francisco; Unit of Clinical Epidemiology (A.P.), Ente Ospedaliero Cantonale, Bellinzona; Division of Pneumology (A.P.), University of Geneva, Switzerland; and Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute Melbourne, Parkville, Victoria, Australia
| | - Lori L Billinghurst
- From the Neurovascular Research Group, Department of Neurology (B.G.S.), and Division of Child Neurology, Department of Pediatrics (B.G.S., M.S.), Inselspital Bern, University Hospital, University of Bern; Pediatric Neurology (B.G.S.), Institute of Pediatrics of Southern Switzerland, San Giovanni Hospital Bellinzona, Ente Ospedaliero Cantonale, Switzerland; Section of Pediatric Neurology, Department of Pediatrics and Child Health (M.F.R.), University of Manitoba, Children's Hospital Research Institute of Manitoba, Canada; Division of Neurology, Department of Pediatrics (M.C., W.D.L.), The Ohio State University and Nationwide Children's Hospital, Columbus; Division of Neurology (L.A.B., L.L.B.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (L.A.B., L.L.B.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Departments of Neurology and Pediatrics (C.K.F.), University of California, San Francisco; Unit of Clinical Epidemiology (A.P.), Ente Ospedaliero Cantonale, Bellinzona; Division of Pneumology (A.P.), University of Geneva, Switzerland; and Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute Melbourne, Parkville, Victoria, Australia
| | - Christine K Fox
- From the Neurovascular Research Group, Department of Neurology (B.G.S.), and Division of Child Neurology, Department of Pediatrics (B.G.S., M.S.), Inselspital Bern, University Hospital, University of Bern; Pediatric Neurology (B.G.S.), Institute of Pediatrics of Southern Switzerland, San Giovanni Hospital Bellinzona, Ente Ospedaliero Cantonale, Switzerland; Section of Pediatric Neurology, Department of Pediatrics and Child Health (M.F.R.), University of Manitoba, Children's Hospital Research Institute of Manitoba, Canada; Division of Neurology, Department of Pediatrics (M.C., W.D.L.), The Ohio State University and Nationwide Children's Hospital, Columbus; Division of Neurology (L.A.B., L.L.B.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (L.A.B., L.L.B.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Departments of Neurology and Pediatrics (C.K.F.), University of California, San Francisco; Unit of Clinical Epidemiology (A.P.), Ente Ospedaliero Cantonale, Bellinzona; Division of Pneumology (A.P.), University of Geneva, Switzerland; and Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute Melbourne, Parkville, Victoria, Australia
| | - Alberto Pagnamenta
- From the Neurovascular Research Group, Department of Neurology (B.G.S.), and Division of Child Neurology, Department of Pediatrics (B.G.S., M.S.), Inselspital Bern, University Hospital, University of Bern; Pediatric Neurology (B.G.S.), Institute of Pediatrics of Southern Switzerland, San Giovanni Hospital Bellinzona, Ente Ospedaliero Cantonale, Switzerland; Section of Pediatric Neurology, Department of Pediatrics and Child Health (M.F.R.), University of Manitoba, Children's Hospital Research Institute of Manitoba, Canada; Division of Neurology, Department of Pediatrics (M.C., W.D.L.), The Ohio State University and Nationwide Children's Hospital, Columbus; Division of Neurology (L.A.B., L.L.B.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (L.A.B., L.L.B.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Departments of Neurology and Pediatrics (C.K.F.), University of California, San Francisco; Unit of Clinical Epidemiology (A.P.), Ente Ospedaliero Cantonale, Bellinzona; Division of Pneumology (A.P.), University of Geneva, Switzerland; and Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute Melbourne, Parkville, Victoria, Australia
| | - Maja Steinlin
- From the Neurovascular Research Group, Department of Neurology (B.G.S.), and Division of Child Neurology, Department of Pediatrics (B.G.S., M.S.), Inselspital Bern, University Hospital, University of Bern; Pediatric Neurology (B.G.S.), Institute of Pediatrics of Southern Switzerland, San Giovanni Hospital Bellinzona, Ente Ospedaliero Cantonale, Switzerland; Section of Pediatric Neurology, Department of Pediatrics and Child Health (M.F.R.), University of Manitoba, Children's Hospital Research Institute of Manitoba, Canada; Division of Neurology, Department of Pediatrics (M.C., W.D.L.), The Ohio State University and Nationwide Children's Hospital, Columbus; Division of Neurology (L.A.B., L.L.B.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (L.A.B., L.L.B.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Departments of Neurology and Pediatrics (C.K.F.), University of California, San Francisco; Unit of Clinical Epidemiology (A.P.), Ente Ospedaliero Cantonale, Bellinzona; Division of Pneumology (A.P.), University of Geneva, Switzerland; and Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute Melbourne, Parkville, Victoria, Australia
| | - Mark T Mackay
- From the Neurovascular Research Group, Department of Neurology (B.G.S.), and Division of Child Neurology, Department of Pediatrics (B.G.S., M.S.), Inselspital Bern, University Hospital, University of Bern; Pediatric Neurology (B.G.S.), Institute of Pediatrics of Southern Switzerland, San Giovanni Hospital Bellinzona, Ente Ospedaliero Cantonale, Switzerland; Section of Pediatric Neurology, Department of Pediatrics and Child Health (M.F.R.), University of Manitoba, Children's Hospital Research Institute of Manitoba, Canada; Division of Neurology, Department of Pediatrics (M.C., W.D.L.), The Ohio State University and Nationwide Children's Hospital, Columbus; Division of Neurology (L.A.B., L.L.B.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (L.A.B., L.L.B.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Departments of Neurology and Pediatrics (C.K.F.), University of California, San Francisco; Unit of Clinical Epidemiology (A.P.), Ente Ospedaliero Cantonale, Bellinzona; Division of Pneumology (A.P.), University of Geneva, Switzerland; and Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute Melbourne, Parkville, Victoria, Australia
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28
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Chung MG, Guilliams KP, Wilson JL, Beslow LA, Dowling MM, Friedman NR, Hassanein SMA, Ichord R, Jordan LC, Mackay MT, Rafay MF, Rivkin M, Torres M, Zafeiriou D, deVeber G, Fox CK. Arterial Ischemic Stroke Secondary to Cardiac Disease in Neonates and Children. Pediatr Neurol 2019; 100:35-41. [PMID: 31371125 PMCID: PMC7034952 DOI: 10.1016/j.pediatrneurol.2019.06.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/05/2019] [Accepted: 06/08/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVE We describe the risk factors for peri-procedural and spontaneous arterial ischemic stroke (AIS) in children with cardiac disease. METHODS We identified children with cardiac causes of AIS enrolled in the International Pediatric Stroke Study registry from January 2003 to July 2014. Isolated patent foramen ovale was excluded. Peri-procedural AIS (those occurring during or within 72 hours of cardiac surgery, cardiac catheterization, or mechanical circulatory support) and spontaneous AIS that occurred outside of these time periods were compared. RESULTS We identified 672 patients with congenital or acquired cardiac disease as the primary risk factor for AIS. Among these, 177 patients (26%) had peri-procedural AIS and 495 patients (74%) had spontaneous AIS. Among non-neonates, spontaneous AIS occurred at older ages (median 4.2 years, interquartile range 0.97 to 12.4) compared with peri-procedural AIS (median 2.4 years, interquartile range 0.35 to 6.1, P < 0.001). About a third of patients in both groups had a systemic illness at the time of AIS. Patients who had spontaneous AIS were more likely to have a preceding thrombotic event (16 % versus 9 %, P = 0.02) and to have a moderate or severe neurological deficit at discharge (67% versus 33%, P = 0.01) compared to those with peri-procedural AIS. CONCLUSIONS Children with cardiac disease are at risk for AIS at the time of cardiac procedures but also outside of the immediate 72 hours after procedures. Many have acute systemic illness or thrombotic event preceding AIS, suggesting that inflammatory or prothrombotic conditions could act as a stroke trigger in this susceptible population.
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Affiliation(s)
- MG Chung
- Divisions of Critical Care Medicine and Neurology, Department of Pediatrics, The Ohio State University and Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, Ohio, USA
| | - KP Guilliams
- Departments of Neurology and Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St. Louis, Missouri, USA
| | - JL Wilson
- Division of Neurology, Department of Pediatrics, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR
| | - LA Beslow
- Division of Neurology, Children’s Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perlman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, USA
| | - MM Dowling
- Departments of Pediatrics, Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center at Dallas and Children’s Health Dallas, 5323 Harry Hines Blvd, Dallas, Texas, USA
| | - NR Friedman
- Center for Pediatric Neurosciences, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, Ohio, USA
| | - SMA Hassanein
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Egypt
| | - R Ichord
- Division of Neurology, Children’s Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perlman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, USA
| | - LC Jordan
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, Tennessee, USA
| | - MT Mackay
- Department of Neurology, Royal Children’s Hospital Melbourne, Murdoch Children’s Research Institute Melbourne, Flemington Rd, Parkville, Victoria, Australia
| | - MF Rafay
- Section of Pediatric Neurology, Department of Pediatrics and Child Health, University of Manitoba, Children’s Hospital Research Institute of Manitoba, 715 McDermot Ave, Winnipeg, Canada
| | - M Rivkin
- Departments of Neurology, Psychiatry, and Radiology, and the Stroke and Cerebrovascular Center, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA, USA
| | - M Torres
- Pediatric Hematology and Oncology, Cook Children’s Medical Center, 801 7 Ave, Fort Worth, Texas, USA
| | - D Zafeiriou
- 1 Department of Pediatrics, Aristotle University, “Hippokratio” General Hospital, Thessaloniki, Greece
| | - G deVeber
- Department of Neurology, The Hospital for Sick Children, 555 University Ave, Toronto, Canada
| | - CK Fox
- Departments of Neurology and Pediatrics, University of California San Francisco, 521 Parmassus Ave, San Francisco, California, USA
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29
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Stroke After Cardiac Catheterization in Children. Pediatr Neurol 2019; 100:42-48. [PMID: 31481331 DOI: 10.1016/j.pediatrneurol.2019.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/08/2019] [Accepted: 07/12/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Children with cardiac disease are at high risk for stroke. Approximately one-quarter of strokes in children with cardiac disease occur in the peri-procedural period; yet, the risk factors, clinical presentation, and treatment of post-catheterization stroke in children have not been well defined. METHODS We conducted a retrospective review of the medical records of patients aged zero to 18 years with a new clinically-apparent arterial ischemic stroke after cardiac catheterization at a tertiary children's hospital from 2006 to 2016. We excluded patients who had cardiac surgery, a cardiac arrest, extracorporeal membrane oxygenation, a ventricular assist device, or an arrhythmia proximate to their stroke. RESULTS Twenty children had a new clinically-apparent post-catheterization arterial ischemic stroke. The median age was one year (range, two days to 16 years). The most common procedures were balloon dilation for pulmonary vein stenosis (n = 6) and systemic pulmonary collateral closure (n = 5). The most common presenting symptoms were arm weakness (n = 10) and seizure (n = 8). The median time from catheterization to symptom discovery was 31.5 hours (interquartile range, 16.2 to 47.8 hours; n = 18). The median Pediatric Stroke Outcome Measure score 12 months post-stroke was 0.75 (range, 0 to 2; n = 6). CONCLUSIONS Although arterial ischemic stroke after cardiac catheterization is rare, better understanding this entity is important as children with cardiac disease and stroke have ongoing morbidity. Ameliorating this morbidity requires efforts aimed at preventing and rapidly detecting stroke, thereby enabling timely institution of neuroprotective measures and treatment with hyperacute therapies.
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30
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Abstract
PURPOSE OF REVIEW Although the clinical approach to the young adult stroke patient is similar to that of an older adult, several important differences exist. The purpose of this article is to concisely review the epidemiology, pathophysiology, risk factors, clinical manifestations, diagnostic methods and current treatment options for the young adult ischemic stroke patient. RECENT FINDINGS Evidence clearly indicates that the incidence ischemic stroke in young adults is on the rise. A variety of factors are implicated, including an increased burden of classic and emerging vascular risk factors, and improved stroke detection, among other causes. Improved awareness, prevention and successful treatment of the young adult stroke patient is of great importance, particularly given the major long-term socioeconomic impact strokes have on the patient, their family and society at large. SUMMARY In this review, we focus on the latest epidemiologic, diagnostic and treatment paradigms to improve physician awareness and optimize outcomes in young adult ischemic stroke patients. An overview of the clinical presentations of various stroke syndromes is described, emphasizing key causes physicians should consider, as well as providing recommendations regarding evaluation and treatment. Important causes including dissection and inflammatory and noninflammatory vasculopathies are emphasized. The diagnoses of cerebral venous thromboses, cardioembolic stroke and paradoxical emboli are also discussed. The effects of established and emerging risk factors on large and small vessel disease, as well as genetic contributions, are also highlighted.
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31
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Cao Q, Yang F, Zhang J, Liang H, Liu X, Wang H. Features of Childhood Arterial Ischemic Stroke in China. Fetal Pediatr Pathol 2019; 38:317-325. [PMID: 30890011 DOI: 10.1080/15513815.2019.1588438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective: The aim of this study was to identify the features and risk factors for arterial ischemic stroke (AIS) in children. Methods: We retrospectively analyzed the initial symptoms, clinical manifestations, risk factors, neuroradiological findings, and treatment data of 75 Chinese children aged between 1 month and 14 years (median 5.7 years) who were diagnosed with AIS in our hospital between 2013 and 2018. Results: Among these 75 cases of childhood AIS, 53 patients (70.67%) were male, and the male-to-female ratio was 2.41:1. A total of 55 cases (73.33%) had respiratory tract infection with fever. Seventy cases had lesions in the basal ganglia (46 left, 24 right). All patients were treated conservatively without thrombolytic therapy. Intravenous immunoglobulin treatment was given to children with fever and drowsiness. Conclusion: Infection was an important risk factor for children with AIS in China. Infection and thrombophilia risk factors were more likely to occur in isolation. The stroke lesions commonly occurred in the basal ganglia region.
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Affiliation(s)
- Qingjun Cao
- a Shengjing Hospital of China Medical University , Shenyang , China
| | - Fenghua Yang
- a Shengjing Hospital of China Medical University , Shenyang , China
| | - Junmei Zhang
- a Shengjing Hospital of China Medical University , Shenyang , China
| | - Huo Liang
- a Shengjing Hospital of China Medical University , Shenyang , China
| | - Xueyan Liu
- a Shengjing Hospital of China Medical University , Shenyang , China
| | - Hua Wang
- a Shengjing Hospital of China Medical University , Shenyang , China
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32
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Boucher AA, Taylor JM, Luchtman-Jones L. Aspirin in childhood acute ischemic stroke: The evidence for treatment and efficacy testing. Pediatr Blood Cancer 2019; 66:e27665. [PMID: 30762284 DOI: 10.1002/pbc.27665] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/17/2019] [Accepted: 01/30/2019] [Indexed: 12/17/2022]
Abstract
Aspirin is the most commonly prescribed antiplatelet agent worldwide, but evidence supporting its use varies by age and disease process. Despite its frequent use in childhood acute ischemic stroke prevention and management, major knowledge gaps exist about optimal pediatric aspirin use, particularly in this setting, where high-quality clinical trials are urgently needed. This review focuses upon the evidence for aspirin use in childhood acute ischemic stroke, includes a summary of aspirin pharmacology to highlight misconceptions and common clinical situations which may limit its efficacy, and discusses the techniques and potential role of laboratory monitoring of aspirin efficacy in children.
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Affiliation(s)
- Alexander A Boucher
- Department of Pediatrics, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital, Cincinnati, Ohio.,University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - J Michael Taylor
- University of Cincinnati College of Medicine, Cincinnati, Ohio.,Department of Pediatrics, Division of Neurology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Lori Luchtman-Jones
- Department of Pediatrics, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital, Cincinnati, Ohio.,University of Cincinnati College of Medicine, Cincinnati, Ohio
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[Childhood stroke : What are the special features of childhood stroke?]. DER NERVENARZT 2019; 88:1367-1376. [PMID: 29063260 DOI: 10.1007/s00115-017-0435-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Childhood arterial ischemic stroke differs in essential aspects from adult stroke. It is rare, often relatively unknown among laypersons and physicians and the wide variety of age-specific differential diagnoses (stroke mimics) as well as less established care structures often lead to a considerable delay in the diagnosis of stroke. The possible treatment options in childhood are mostly off-label. Experiences in well-established acute treatment modalities in adult stroke, such as thrombolysis and mechanical thrombectomy are therefore limited in children and only based on case reports and case series. The etiological clarification is time-consuming due to the multitude of risk factors which must be considered. Identifying each child's individual risk profile is mandatory for acute treatment and secondary prevention strategies and has an influence on the individual outcome. In addition to the clinical neurological outcome the residual neurological effects of stroke on cognition and behavior are decisive for the integration of the child into its educational, later professional and social environment.
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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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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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Warne RR, Ramji S, Chong WK. Pediatric Stroke and Radiological Approach. Clin Neuroradiol 2019. [DOI: 10.1007/978-3-319-68536-6_35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Pediatric Stroke and Radiological Approach. Clin Neuroradiol 2019. [DOI: 10.1007/978-3-319-61423-6_35-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Rajani NK, Pearce K, Campion T, Salpietro V, Planells M, Chong W, Patankar T, Mankad K. Pediatric stroke: current diagnostic and management challenges. Quant Imaging Med Surg 2018; 8:984-991. [PMID: 30598876 DOI: 10.21037/qims.2018.11.09] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Nikil K Rajani
- Department of Radiology, Imperial Healthcare NHS Trust, London, UK
| | - Kirsten Pearce
- Department of Radiology, Great Ormond Street Hospital, London, UK
| | - Tom Campion
- Department of Radiology, Great Ormond Street Hospital, London, UK
| | | | - Mariana Planells
- Department of Radiology, Hospital General Universitario de Alicante, Alicante, Spain
| | - Winston Chong
- Monash Imaging, Monash University, Melbourne, Australia
| | - Tufail Patankar
- Department of Neuroradiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital, London, UK
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Medley TL, Miteff C, Andrews I, Ware T, Cheung M, Monagle P, Mandelstam S, Wray A, Pridmore C, Troedson C, Dale RC, Fahey M, Sinclair A, Walsh P, Stojanovski B, Mackay MT. Australian Clinical Consensus Guideline: The diagnosis and acute management of childhood stroke. Int J Stroke 2018; 14:94-106. [DOI: 10.1177/1747493018799958] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke is among the top 10 causes of death in children and survivors carry resulting disabilities for decades, at substantial cost to themselves and their families. Children are not currently able to access reperfusion therapies, due to limited evidence supporting safety and efficacy and long diagnostic delays. The Australian Clinical Consensus Guideline for the Diagnosis and Acute Management of Childhood Stroke was developed to minimize unwarranted variations in care and document best evidence on the risk factors, etiologies, and conditions mimicking stroke that differ from adults. Clinical questions were formulated to inform systematic database searches from 2007 to 2017, limited to English and pediatric studies. SIGN methodology and the National Health and Medical Research Council system were used to screen and classify the evidence. The Grades of Recommendation, Assessment, Development, and Evaluation system (GRADE) was used to grade evidence as strong or weak. The Guideline provides more than 60 evidence-based recommendations to assist prehospital and acute care clinicians in the rapid identification of childhood stroke, choice of initial investigation, to confirm diagnosis, determine etiology, selection of the most appropriate interventions to salvage brain at risk, and prevent recurrence. Recommendations include advice regarding the management of intracranial pressure and congenital heart disease. Implementation of the Guideline will require reorganization of prehospital and emergency care systems, including the development of regional stroke networks, pediatric Code Stroke, rapid magnetic resonance imaging and accreditation of primary pediatric stroke centers with the capacity to offer reperfusion therapies. The Guideline will allow auditing to benchmark timelines of care, access to acute interventions, and outcomes. It will also facilitate the development of an Australian childhood stroke registry, with data linkage to international registries, to allow for accurate data collection on stroke incidence, treatment, and outcomes.
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Affiliation(s)
- Tanya L Medley
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
| | | | - Ian Andrews
- Sydney Children's Hospital, School of Women's and Children's Health, University of New South Wales, Sydney, Australia
| | - Tyson Ware
- Royal Hobart Hospital, Hobart, Australia
| | - Michael Cheung
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Department of Cardiology Royal Children's Hospital, Melbourne, Australia
| | - Paul Monagle
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | - Simone Mandelstam
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | - Alison Wray
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | | | - Christopher Troedson
- Children's Hospital at Westmead, Discipline of Child and Adolescent Health, University of Sydney, Sydney, Australia
| | - Russell C Dale
- Children's Hospital at Westmead and University of Sydney, Sydney Australia
| | - Michael Fahey
- Department of Paediatrics Monash University, Department of Medicine Melbourne University, and Monash Children's Hospital, Melbourne, Australia
| | - Adriane Sinclair
- Lady Cilento Children's Hospital, University of Queensland, Brisbane, Australia
| | | | - Belinda Stojanovski
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | - Mark T Mackay
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Department of Neurology Royal Children's Hospital, Melbourne Australia
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Gerstl L, Weinberger R, von Kries R, Heinen F, Schroeder AS, Bonfert MV, Borggraefe I, Tacke M, Vill K, Landgraf MN, Kurnik K, Olivieri M. Risk factors in childhood arterial ischaemic stroke: Findings from a population-based study in Germany. Eur J Paediatr Neurol 2018; 22:380-386. [PMID: 29370976 DOI: 10.1016/j.ejpn.2018.01.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 11/22/2017] [Accepted: 01/02/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Acute treatment of childhood arterial ischaemic stroke and prevention strategies for recurrent stroke episodes depend strongly on each child's individual risk profile. The aim of this study is to characterize risk factors for childhood stroke, their occurrence in isolation or combination, and to identify possible common risk factor patterns. METHODS This population-based study was conducted via ESPED, a surveillance unit for rare paediatric diseases in Germany. Children aged >28days and <18 years with an acute arterial ischaemic stroke occurring between January 2015 and December 2016 were included. RESULTS Among 99 reported children with arterial ischaemic stroke, 56 children were male. Male predominance was significant in adolescents from 12 years old onward. Arterial ischaemic stroke was more common in very young children <2 years of age and in adolescence. No risk factor was identified in 27 children. Hypercoagulable states (29%), cardiac disorders (24%), and arteriopathies (21%) were the most common risk factors. Some risk factor categories were more likely to be identified in isolation (i.e. cardiac disorders, prothrombotic abnormalities and chronic head and neck disorders) than others. The number of risk factors (n = 0-4) per patient and risk factor categories did not differ by age. CONCLUSION Although we could not identify common patterns of risk factor combinations, several risk factors occurred more likely in isolation than others. Further research should focus on the impact of isolated presumed childhood stroke risk factors like certain prothrombotic abnormalities, migraine or a patent foramen ovale. With regard to different age groups, stroke mechanisms in male adolescents require particular attention.
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Affiliation(s)
- Lucia Gerstl
- Department of Paediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337 Munich, Germany.
| | - Raphael Weinberger
- Institute of Social Paediatrics and Adolescent Medicine, Division of Epidemiology, Ludwig-Maximilians-University Munich, Haydnstr. 5, 80336, Munich, Germany
| | - Ruediger von Kries
- Institute of Social Paediatrics and Adolescent Medicine, Division of Epidemiology, Ludwig-Maximilians-University Munich, Haydnstr. 5, 80336, Munich, Germany
| | - Florian Heinen
- Department of Paediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337 Munich, Germany
| | - A Sebastian Schroeder
- Department of Paediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337 Munich, Germany
| | - Michaela V Bonfert
- Department of Paediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337 Munich, Germany
| | - Ingo Borggraefe
- Department of Paediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337 Munich, Germany
| | - Moritz Tacke
- Department of Paediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337 Munich, Germany
| | - Katharina Vill
- Department of Paediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337 Munich, Germany
| | - Mirjam N Landgraf
- Department of Paediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337 Munich, Germany
| | - Karin Kurnik
- Department of Paediatric Haemostaseolgy, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Martin Olivieri
- Department of Paediatric Haemostaseolgy, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337, Munich, Germany
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41
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Komarova IB, Zykov VP, Ushakova LV, Novikova EB, Shuleshko OV, Nazarova EK, Samigulina MG. [Clinical and neuroimaging signs of cardioembolic stroke in children]. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 117:13-22. [PMID: 29359715 DOI: 10.17116/jnevro201711711213-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To study clinical and neuroimaging signs of cardioembolic stroke (CES) in children. MATERIAL AND METHODS A group of 100 patients with arterial ischemic stroke (AIS), aged from 1 month to 15 years, was stratified into the main group (10 patients with CES) and the comparison group (90 patients with other subtypes of AIS). CT and MRI, MR-angiography, ultrasound study as well as assessment of clinical symptoms on PedNIHSS were performed. The duration of follow-up was from 2 month to 14 years. The follow-up allowed the assessment of occurrence of secondary strokes, severity of residual neurological symptoms on the PSOM and fatal outcomes. Special attention was drawn to the use of CASSADE criteria for CES. RESULTS AND CONCLUSION Clinical features that help to diagnose CES, even in the absence of adequate neuroimaging, in patients with heart disease, which is a potential high risk factor for cardioembolia, were established. These factors include early disease onset, acute development and progression of neurological deficit to the maximal level in the first 5 min., marked severity of the acute period (PedNIHSS > 15), early recovery of neurological functions, significant residual neurological symptoms (PSOM > 2). These symptoms should be used in addition to the CASCADE criteria in the diagnosis of CES of AIS type in children.
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Affiliation(s)
- I B Komarova
- Russian Medical Academy аor Continuing Professional Education, Moscow, Russia
| | - V P Zykov
- Russian Medical Academy аor Continuing Professional Education, Moscow, Russia
| | - L V Ushakova
- Kulakov Research Center of Obstetrics, Gynecology and Perinatology, Moscow, Russia
| | - E B Novikova
- Russian Medical Academy аor Continuing Professional Education, Moscow, Russia
| | - O V Shuleshko
- Bashlyaeva City Child Clinical Hospital, Moscow, Russia
| | - E K Nazarova
- Moscow Regional Consultating and Diagnostic Center, Moscow, Russia
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Ischaemic stroke in children with cardiopathy: An epidemiological study. NEUROLOGÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.nrleng.2016.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Abstract
OPINION STATEMENT Optimal diagnosis and management of stroke in young adults benefit from a multidisciplinary team, including a vascular neurology specialist. In addition to the "standard" vascular risk factors including smoking, hypertension, diabetes, and hyperlipidemia, one needs to consider alternative etiologies including substance abuse, carotid/vertebral artery dissections, and rare genetic conditions among others. Once a young patient is determined to have had a stroke, the next question a clinician should ask is why did this patient have a stroke? A "heart to head" diagnostic approach is recommended. A thorough history is performed, including a detailed family history with specific annotations on each family member. A thorough physical examination is necessary including a careful evaluation of the patient's general appearance, noting any joint laxity, and/or abnormalities of the skin, eyes, and heart. Findings across multiple organ systems in the patient and/or their family may indicate a genetic etiology. After an initial head CT rules out hemorrhagic stroke, additional testing should include a brain MRI, neck and cerebral vascular imaging (e.g., CTA for head and neck), transthoracic echocardiogram with a bubble study, telemetry monitoring, basic risk factor blood work (e.g., lipid panel, hemoglobin A1c, TSH, ESR, CRP, RPR, HIV, and toxicology screen), and, when appropriate, sickle screen and pregnancy test. There should be a low threshold to obtain blood cultures or a lumbar puncture. The acute treatment of ischemic stroke in young adult patients does not differ from treatment of older adults, using intravenous alteplase within 4.5 h, assuming no contraindications. In suspected proximal large artery occlusive disease, interventional clot extraction procedures should be employed in patients deemed eligible. Long-term secondary prevention strategies aimed to reduce recurrent stroke risk by targeting and modifying vascular risk factors should be instituted. The mainstay of preventative therapy is aspirin for most etiologies; however, for atrial fibrillation, anticoagulation is recommended. Statin therapy is another pharmacologic intervention recommended in most stroke patients. Other measures employed are blood pressure reduction, smoking cessation, optimal glucose control in diabetic patients, the initiation of a healthy diet and regular exercise, and lastly, substance abuse counseling in appropriate patients.
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Affiliation(s)
- Christopher A Stack
- Department of Neurology, University of Maryland Medical Center, 16 South Eutaw Street Suite 300, Baltimore, MD, 21201, USA
| | - John W Cole
- Department of Neurology, Baltimore VA Medical Center, University of Maryland School of Medicine, 12th Floor, Bressler Building, Room 12-006, 655 West Baltimore Street, Baltimore, MD, 21201-1559, USA.
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Vázquez López M, de Castro de Castro P, Barredo Valderrama E, Miranda Herrero MC, Gil Villanueva N, Alcaraz Romero AJ, Pascual Pascual SI. Outcome of arterial ischemic stroke in children with heart disease. Eur J Paediatr Neurol 2017; 21:730-737. [PMID: 28619364 DOI: 10.1016/j.ejpn.2017.05.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 01/02/2017] [Accepted: 05/24/2017] [Indexed: 01/19/2023]
Abstract
UNLABELLED Arterial ischemic strokes (AIS) are rare in childhood. Congenital and acquired heart diseases are one of the most important risk factors of AIS in children. OBJECTIVE Study the outcome of children with heart disease that have suffered AIS and the factors that influence on prognosis. PATIENTS AND METHODS We evaluated all children with heart disease who had suffered AIS between 2000 and 2014 in our hospital. RESULTS Seventy-four children with heart disease suffered an arterial ischemic stroke. 20% of them died and 10% had new AIS during the study period. Fifty-two patients were evaluated an average of six years after AIS. According to the Paediatric Stroke Outcome Scale (PSOM), most of the patients had some degree of impairment, mainly in sensorimotor and in cognitive-behavioural areas. The modified Rankin scale (mRS) showed an unfavourable outcome in 70% of patients (including patients that have died). Upper limb was more functionally impaired than lower limb. Strokes in neonatal period and early life were associated with poor prognosis. Size of stroke, cortical and subcortical involvement and basal ganglia stroke were associated with an unfavourable outcome. Fever in the acute phase and hemiparesis at presentation were also poor prognostic factors. Epilepsy at time of evaluation was also associated with unfavourable outcome. On the other hand, a normal electroencephalogram was associated with favourable outcome. CONCLUSIONS AIS in children with heart disease had an unfavourable outcome, with impairment in different areas. Epilepsy happened in one third of the patients.
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Komarova IB, Zykov VP, Ushakova LV, Nazarova EK, Novikova EB, Shuleshko OV, Samigulina MG. [Clinical and neuroimaging signs of cardioembolic stroke laboratory in children]. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 117:11-19. [PMID: 28665364 DOI: 10.17116/jnevro20171173211-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM To study clinical and neuroimaging signs of cardioembolic stroke (CES) in children. MATERIAL AND METHODS Ten children (mean age 3.5±3.5 years) were examined. Eight children met the diagnostic criteria of CES CASCADE, two children were diagnosed with CES based on the complex of symptoms. A comparison group consisted of 90 children with other subtypes of ischemic stroke (IS). The diagnosis was confirmed by MRI and magnetic-resonance angiography; symptom severity was assessed with PedNIHSS and PSOM. RESULTS AND CONCLUSION The PedNIHSS score in the acute stage of CES was higher (18.4±9.34) compared to patients with other subtypes of IS (12.6±6.2; p=0.0065). Six patients had large cerebral infarctions with the involvement of basal ganglia, internal capsule, white matter and cerebral cortex. In two patients, the infarction affected the cerebral cortex and underlying white matter, in one patient it affected the cortex from one side and the basal ganglia from the other. A damage of the cortex was noted in one patient. The frequency of recurrent CES was 30%, of fatal cases 20%. Recurrent IS and severe residual neurological deficit were more frequent in CES. CONCLUSION Early disease onset, acute development and progression of neurological deficit up to the maximal level in the first 5 min, marked severity of the acute stage (PedNIHSS score >15), early onset of neurological function recovery, marked residual neurological deficit (PSOM score >2) are the additional signs of CES.
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Affiliation(s)
- I B Komarova
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
| | - V P Zykov
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
| | - L V Ushakova
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
| | - E K Nazarova
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
| | - E B Novikova
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
| | - O V Shuleshko
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
| | - M G Samigulina
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
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46
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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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Madan N, Carvalho KS. Neurological Complications of Cardiac Disease. Semin Pediatr Neurol 2017; 24:3-13. [PMID: 28779863 DOI: 10.1016/j.spen.2017.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This article focuses on the complex interactions between the cardiovascular and neurologic systems. Initially, we focus on neurological complications in children with congenital heart disease both secondary to the underlying cardiac disease and complications of interventions. We later discuss diagnosis and management of common syncope syndromes with emphasis on vasovagal syncope. We also review the diagnosis, classification, and management of children and adolescents with postural orthostatic tachycardia syndrome. Lastly, we discuss long QT syndrome and sudden unexpected death in epilepsy (SUDEP), reviewing advances in genetics and current knowledge of pathophysiology of these conditions. This article attempts to provide an overview of these disorders with focus on pathophysiology, advances in molecular genetics, and current medical interventions.
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Affiliation(s)
- Nandini Madan
- From the Section of Cardiology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA.
| | - Karen S Carvalho
- Section of Neurology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA
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48
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Abstract
OBJECTIVES The objective of this article is to review the particular tendencies as well as specific concerns of bleeding and clotting in children with critical cardiac disease. DATA SOURCE MEDLINE and PubMed. CONCLUSION Children with critical heart disease are at particular risk for bleeding and clotting secondary to intrinsic as well as extrinsic factors. We hope that this review will aid the clinician in managing the unique challenges of bleeding and clotting in this patient population, and serve as a springboard for much needed research in this area.
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Khan R, Chan AK, Mondal TK, Paes BA. Patent foramen ovale and stroke in childhood: A systematic review of the literature. Eur J Paediatr Neurol 2016; 20:500-11. [PMID: 27169856 DOI: 10.1016/j.ejpn.2016.04.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 03/14/2016] [Accepted: 04/13/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Stroke in association with a patent foramen ovale (PFO) may be due to paradoxical embolization via a right to left intracardiac shunt but the exact contribution of PFO to stroke or stroke recurrence in childhood remains unclear. METHODS To review the relationship of a PFO with stroke, and evaluate associated co-morbidities. An electronic database literature search of Pubmed, Cochrane and EMBASE was performed from January 2000-December 2014. RESULTS 149 articles were retrieved, with overlap for diagnosis, management, treatment and outcome. 65 reports were utilized for the comprehensive review. Majority of childhood arterial ischemic stroke and transient ischemic attacks are associated with prothrombotic disorders or arteriopathy. Transthoracic echocardiography with a Valsalva maneuver is highly sensitive as a screening tool but may be falsely positive. Transthoracic echocardiography with color Doppler and a concurrent bubble contrast study are excellent for visualizing the atrial septum and PFO and identifying a right to left shunt. Current literature does not support PFO closure for cryptogenic stroke in young adults without an associated risk of thromboembolism. CONCLUSIONS High quality research in the pediatric population is lacking and most of the data is extrapolated from adults. Paradoxical embolism from a PFO as a cause of transient ischemic attack or stroke is a diagnosis of exclusion. PFO closure should be individualized based on significant shunting and risk factors such that maximum benefit is derived from the procedure. A young person with a PFO and stroke should be thoroughly investigated to rule out other etiologies.
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Affiliation(s)
- Rubeena Khan
- Division of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada.
| | - Anthony K Chan
- Division of Pediatric Hematology/Oncology, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada.
| | - Tapas K Mondal
- Division of Cardiology, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada.
| | - Bosco A Paes
- Division of Neonatology, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada.
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50
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Vázquez-López M, Castro-de Castro P, Barredo-Valderrama E, Miranda-Herrero MC, Gil-Villanueva N, Alcaraz-Romero AJ, Jiménez-de Domingo A, Pascual-Pascual SI. Ischaemic stroke in children with cardiopathy: An epidemiological study. Neurologia 2016; 32:602-609. [PMID: 27296499 DOI: 10.1016/j.nrl.2016.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 03/13/2016] [Accepted: 03/29/2016] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Ischaemic stroke is rare during childhood. Congenital and acquired heart diseases are one of the most important risk factors for arterial ischaemic stroke (AIS) in children. PATIENTS AND METHODS We conducted a retrospective study of all children with AIS and heart disease diagnosed between 2000 and 2014. RESULTS We included 74 children with heart disease who were eligible for inclusion. 60% were boys with a mean stroke age of 11 months. 20% of the patients died during the study period. 90% of the patients had a congenital heart disease, while cyanotic heart disease was identified in 60%. Hypoplastic left heart syndrome was the most frequent heart disease. In 70% of patients AIS was directly associated with heart surgery, catheterisation or ventricular assist devices. Most patients with AIS were in the hospital. Seizures and motor deficit were the most frequent symptoms. Most patient diagnoses were confirmed by brain CT. The AIS consisted of multiple infarcts in 33% of the cases, affected both hemispheres in 27%, and involved the anterior and posterior cerebral circulation in 10%. CONCLUSIONS Arterial ischaemic strokes were mainly associated with complex congenital heart diseases, and heart procedures and surgery (catheterisation). AIS presented when patients were in-hospital and most of the patients were diagnosed in the first 24hours.
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Affiliation(s)
- M Vázquez-López
- Sección de Neuropediatría, Hospital Materno Infantil Gregorio Marañón, Madrid, España.
| | - P Castro-de Castro
- Sección de Neuropediatría, Hospital Materno Infantil Gregorio Marañón, Madrid, España
| | - E Barredo-Valderrama
- Sección de Neuropediatría, Hospital Materno Infantil Gregorio Marañón, Madrid, España
| | - M C Miranda-Herrero
- Sección de Neuropediatría, Hospital Materno Infantil Gregorio Marañón, Madrid, España
| | - N Gil-Villanueva
- Sección de Cardiología Infantil, Hospital Materno Infantil Gregorio Marañón, Madrid, España
| | - A J Alcaraz-Romero
- Sección de Unidad de Cuidados Intensivos Pediátricos, Hospital Materno Infantil Gregorio Marañón, Madrid, España
| | - A Jiménez-de Domingo
- Sección de Neuropediatría, Hospital Materno Infantil Gregorio Marañón, Madrid, España
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