Improving care for central nervous system tumours: a mood for change

Treatment challenges in pediatric stroke patients

Aim. In this study we presented our experience of 18 years on the etiology, risk factors, prophylactic and acute treatment, the effect of treatment to recurrence rate of patients with stroke. Methods. The population included 108 patients who had been treated for stroke at Pediatric Neurology Department of Ankara University with the diagnosis of arterial ischemic stroke and sinovenous thrombosis between January 1992 and August 2010. Forty-one girls (38%) and 67 boys (62%) with mean symptom age 3.1 ± 4.04 years, (0–18 years old) were followed up with a mean period of 4.9 ± 3.78 years (0–17 years). Results. 30 patients had no risk factors, 34 patients had only one risk factor and 44 patients had multiple risk factors. Recurrence was seen in three patients. There was no any statistical correlation between the recurrence of stroke and the existence of risk factors (P = .961). Seventeen patients received prophylactic treatment; 2 of them without any risk factors, 3 had one risk factor, 12 patients, who constituted the majority of our patients, had multiple risk factors (P = .024). Conclusion. With this study we showed that the right prophylaxis for right patients reduces the rate of recurrence.

Recurrent Thromboembolism in Infants and Children Suffering From Symptomatic Neonatal Arterial Stroke

Background and Purpose— The present study was performed to evaluate the rate of recurrent symptomatic thromboembolism with respect to prothrombotic risk factors and underlying clinical conditions.

Methods— In a series of 215 consecutively enrolled neonates with arterial ischemic stroke (AIS), the factor V G1691A mutation, factor II G20210A variant, methylenetetrahydrofolate reductase (MTHFR) T677T genotype, lipoprotein (Lp) (a), antithrombin, protein C, protein S, and anticardiolipin antibodies (ACA) were investigated. Patient median follow-up was 3.5 years (range, 1 to 8 years).

Results— During follow-up, 7 infants and children (3.3%) showed recurrent symptomatic thromboembolism (AIS, n=4; venous sinus thrombosis, n=2; deep vein thrombosis of the leg, n=1). The factor V mutation, factor II variant, elevated Lp(a) >30 mg/dL, protein C deficiency, and protein S or antithrombin deficiency were associated with first stroke onset. In 5 of 7 cases (71.4%), prothrombotic risk factors [MTHFR T677T, elevated Lp(a), hyperhomocysteinemia, protein C deficiency] were involved at the time of recurrence. Furthermore, a second thromboembolic event was triggered additionally by underlying diseases (71%), eg, cardiac malformation and immobilization, diarrhea, mastoiditis, and moyamoya syndrome.

Conclusions— Data shown here give evidence that symptomatic recurrent thromboembolism is not common in children with neonatal AIS. The risk of a second event, however, is increased when underlying diseases occur and prothrombotic risk factors are involved.

Magnetic resonance imaging in pediatric stroke

Pediatric stroke is a term that can be used to encompass everything from hypoxic-ischemic injury to the fetal central nervous system, and especially the premature neonate, to bland versus hemorrhagic infarction from arterial or venous causes in the infant and older child. Pediatric stroke is a chronically underrecognized and therefore underdiagnosed problem that may have significant economic implications. The risk factors for stroke in children are numerous and differ from those in adults. However, with adequate workup, the etiology can be identified in about 75% of cases. Cardiac disorders and hemoglobinopathy are the most common causes of ischemic infarction in children, whereas various congenital anomalies of the blood vessels or defects in coagulation or platelet function often are found in children with parenchymal hemorrhage. Magnetic resonance imaging provides a noninvasive method of investigating childhood stroke, aiding in both better diagnosis and management of this problem.

Symptomatic ischemic stroke in full-term neonates : role of acquired and genetic prothrombotic risk factors

BACKGROUND AND PURPOSE

The present multicenter case-control study was prospectively designed to assess the extent to which single and combined clotting factor abnormalities influence the onset of symptomatic ischemic stroke in full-term neonates.

METHODS

Lipoprotein (Lp)(a); the factor V (FV) G1691A mutation; the prothrombin (PT) G20210A variant; the methylenetetrahydrofolate reductase (MTHFR) T677T genotype; antithrombin; protein C; protein S; and anticardiolipin antibodies (ACAs) were investigated in 91 consecutively recruited neonatal stroke patients and 182 age- and sex-matched healthy controls.

RESULTS

Sixty-two of 91 stroke patients (68.1%) had at least 1 prothrombotic risk factor compared with 44 control subjects (24.2%) (odds ratio [OR]/95% confidence interval [CI], 6.70/3.84 to 11.67). An increased Lp(a) level (>30 mg/dL) was found in 20 patients and 10 controls (OR/95% CI, 4.84/2. 16 to 10.86); FV G1691A was present in 17 patients and 10 controls (OR/95% CI, 3.95/1.72 to 9.0); the PT G20210A variant was detected in 4 patients and 4 controls (OR/95% CI, 2.04/0.49 to 8.3); the MTHFR TT677 genotype was found in 15 patients and 20 controls (OR/95% CI, 1.59/0.77 to 3.29); and protein C type I deficiency was found in 6 neonates. Neither antithrombin deficiency nor protein S deficiency was found in the neonatal patients studied. Acquired IgG ACAs were found in 3 cases. Additional triggering factors, ie, asphyxia, septicemia, maternal diabetes, and perinatally acquired renal venous thrombosis, were reported in 54.0% of patients.

CONCLUSIONS

Besides acquired triggering factors, the data presented here suggest that genetic prothrombotic risk factors play a role in symptomatic neonatal stroke.

Standardized quantitative assessment of brain tumor survivors treated within clinical trials in childhood

Important morbidity and impairment of life quality arises from both the primary pathology and therapeutic interventions in children with central nervous system (CNS) tumors. Standardized and systematic collection of morbidity data is a prerequisite of clinical trials in this field. The perception of the survivor is paramount in the determination of quality of life as this variable is dependent on the beholder. Comprehensive assessment of outcome following therapeutic intervention should evaluate this in parallel with other physical and psycho-social outcome parameters. A structured, simple schema for the evaluation of survivors of childhood CNS tumors is presented. It is intended to be easily applicable by clinicians within the everyday clinical setting. Information relating to pre- and post-operative states, function, health status and emotional and psychological well-being is collected at regular intervals from diagnosis. Re-integration into society and independence are evaluated. Children self-complete health-status assessments where appropriate. Evidence to support this is presented. The schema is intended to provide a basic framework for the monitoring of health status following treatment of CNS tumors in childhood. Regular assessments may identify individuals in need of more detailed investigation and further understanding of the evolution of morbidity in this cohort. Survivors' perception of the impact of documented dysfunction on their health-related quality of life will be determined. Optimization of the planning of future clinical service provision and therapies will result.