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Goktas OA, Bektas O, Yıldırım M, Sahap SK, Yuksel MF, Sahın S, Fıtoz OS, Teber ST. Clinical and Imaging Clues of Arteriopathy-Related Pediatric Arterial Ischemic Stroke: A Single Center Experience. Ann Indian Acad Neurol 2023; 26:917-926. [PMID: 38229616 PMCID: PMC10789414 DOI: 10.4103/aian.aian_315_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/25/2023] [Accepted: 07/15/2023] [Indexed: 01/18/2024] Open
Abstract
Background and Purpose Arteriopathy is a common etiology for childhood arterial ischemic stroke (AIS). In this study, we aimed to address clinical, demographic, and neuroimaging characteristics and the reversibility of vasculopathy in patients with childhood stroke due to arteriopathy by classifying them according to Childhood AIS Standardized Classification and Diagnostic Evaluation (CASCADE) criteria. Methods We included 15 patients with AIS due to arteriopathy presented between 2013 and 2018. All patients were diagnosed and followed up using magnetic resonance imaging (MRI) studies. All acute AIS patients were classified by acute CASCADE criteria (1-4). Moreover, each group was categorized according to the chronic CASCADE criteria, including progressive, stable, reversible, and indeterminate courses. Results In the study population, CASCADE 2 patients were the most common group, and basal ganglia involvement was the most common involvement in CASCADE 2 patients. Of CASCADE 2 patients, 71.4% received steroids, which was compatible with a favorable outcome. In the study, trauma was present in 33.3% of patients, 60% of which was related to CASCADE 4. In the control visit on month 24, there were neuromotor sequelae of 60%, including hemiparesis, facial paralysis, and decreased fine motor skills; furthermore, the recurrence rate was 20%. Conclusion We strongly emphasize that arteriopathy should be kept in mind in school-age children presenting with hemiparesis and headache. Moyamoya disease must be considered in the differential diagnosis with anterior circulation involvement, while focal cerebral arteriopathy (FCA) in patients with basal ganglia involvement was detected on MRI and dissection in the patients with a history of head-neck injury. We think that steroids have positive influences on neurologic prognosis in patients with FCA.
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Affiliation(s)
- Ozben Akıncı Goktas
- Department of Pediatrics, Division of Pediatric Neurology, Ataturk Sanatoryum Training and Research Hospital, Ankara, Turkey
| | - Omer Bektas
- Department of Pediatrics, Division of Pediatric Neurology, Ankara University School of Medicine, Ankara, Turkey
| | - Mirac Yıldırım
- Department of Pediatrics, Division of Pediatric Neurology, Ankara University School of Medicine, Ankara, Turkey
| | - Seda Kaynak Sahap
- Department of Pediatric Radiology, Ankara University School of Medicine, Ankara, Turkey
| | - Merve Feyza Yuksel
- Department of Pediatrics, Division of Pediatric Neurology, Recep Tayyıp Erdogan Training and Research Hospital, Rize, Turkey
| | - Suleyman Sahın
- Department of Pediatrics, Division of Pediatric Neurology, Ankara University School of Medicine, Ankara, Turkey
| | - Omer Suat Fıtoz
- Department of Pediatric Radiology, Ankara University School of Medicine, Ankara, Turkey
| | - Serap Tıraş Teber
- Department of Pediatrics, Division of Pediatric Neurology, Ankara University School of Medicine, Ankara, Turkey
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Phelps K, Silos C, De La Torre S, Moreno A, Lapus R, Sanghani N, Koenig M, Savitz S, Green C, Fraser S. Establishing a pediatric acute stroke protocol: experience of a new pediatric stroke program and predictors of acute stroke. Front Neurol 2023; 14:1194990. [PMID: 37273694 PMCID: PMC10232855 DOI: 10.3389/fneur.2023.1194990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/27/2023] [Indexed: 06/06/2023] Open
Abstract
Introduction Pediatric stroke is among the top 10 causes of death in pediatrics. Rapid recognition and treatment can improve outcomes in select patients, as evidenced by recent retrospective studies in pediatric thrombectomy. We established a collaborative protocol involving the vascular neurology and pediatric neurology division in our institution to rapidly diagnose and treat pediatric suspected stroke. We also prospectively collected data to attempt to identify predictors of acute stroke in pediatric patients. Methods IRB approval was obtained to prospectively collect clinical data on pediatric code stroke activations based on timing metrics in resident-physician note templates. The protocol emphasized magnetic resonance imaging over computed tomography imaging when possible. We analyzed performance of the system with descriptive statistics. We then performed a Bayesian statistical analysis to search for predictors of pediatric stroke. Results There were 40 pediatric code strokes over the 2.5-year study period with a median age of 10.8 years old. 12 (30%) of patients had stroke, and 28 (70%) of code stroke patients were diagnosed with a stroke mimic. Median time from code stroke activation to completion of imaging confirming or ruling out stroke was 1 h. In the Bayesian analysis, altered mental status, hemiparesis, and vasculopathy history were associated with increased odds of stroke, though credible intervals were wide due to the small sample size. Conclusion A trainee developed and initiated pediatric acute stroke protocol quickly implemented a hospital wide change in management that led to rapid diagnosis and triage of pediatric stroke and suspected stroke. No additional personnel or resources were needed for this change, and we encourage other hospitals and emergency departments to implement similar systems. Additionally, hemiparesis and altered mental status were predictors of stroke for pediatric acute stroke activation in our Bayesian statistical analysis. However credible intervals were wide due to the small sample size. Further multicenter data collection could more definitively analyze predictors of stroke, as well as the help in the creation of diagnostic tools for clinicians in the emergency setting.
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Affiliation(s)
- Kamal Phelps
- University of Texas McGovern Medical School, Houston, TX, United States
| | - Christin Silos
- School of Biomedical Informatics, The University of Texas Health Science Center Houston, Houston, TX, United States
- The UTHealth Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center, Houston, TX, United States
| | - Susan De La Torre
- Department of Internal Medicine, University of Illinois College of Medicine, Chicago, IL, United States
| | - Amee Moreno
- Baylor University Louise Herrington School of Nursing, Dallas, TX, United States
| | - Robert Lapus
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, The University of Texas McGovern Medical School, Houston, TX, United States
| | - Nipa Sanghani
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, The University of Texas McGovern Medical School, Houston, TX, United States
| | - Mary Koenig
- Division of Child and Adolescent Neurology, Department of Pediatrics, The University of Texas McGovern Medical School, Houston, TX, United States
| | - Sean Savitz
- The UTHealth Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center, Houston, TX, United States
| | - Charles Green
- The UTHealth Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center, Houston, TX, United States
| | - Stuart Fraser
- The UTHealth Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center, Houston, TX, United States
- Division of Child and Adolescent Neurology, Department of Pediatrics, The University of Texas McGovern Medical School, Houston, TX, United States
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Abstract
PURPOSE OF REVIEW The purpose of this review is to review recent findings regarding stroke epidemiology, etiologies, and treatment in children and young adults. RECENT FINDINGS Incidence in young adults is increasing, and incidence, recurrence, and survival is worse in patients with cryptogenic stroke and in developing countries. Careful consideration of patent foramen ovale closure is now recommended in young adults with cryptogenic stroke. Thrombectomy has recently been extended to carefully selected children with acute ischemic stroke, and two recent publications strongly suggest that it can be beneficial for children. Sickle cell is also an important global contributor to stroke burden, but hydroxyurea can be a cost effective medication for stroke prevention in children. Recent advances in genetic testing and treatments may improve outcomes for patients with monogenic causes of stroke, such as deficiency of adenosine deaminase 2, hemophilia, and Fabry's disease. SUMMARY Stroke in children and young adults is a morbid disease responsible for enormous indirect societal costs and a high burden of years with disability per affected patient. Recent advances have improved access to care for children with large vessel occlusion and adults with rare causes of stroke. Future research may bring effective treatments for other monogenic causes of stroke as well as increasing access to hyperacute therapies for young stroke patients.
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Affiliation(s)
- Stuart Fraser
- Division of Child and Adolescent Neurology, Department of Pediatrics, The University of Texas McGovern Medical School
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center Houston, Houston, Texas
| | - Lisa Pabst
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Fiona Smith
- Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, Texas and Houston Methodist Sugar Land Hospital, Sugar Land, Texas
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Acute Hospital Management of Pediatric Stroke. Semin Pediatr Neurol 2022; 43:100990. [PMID: 36344020 DOI: 10.1016/j.spen.2022.100990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 08/13/2022] [Accepted: 08/14/2022] [Indexed: 11/24/2022]
Abstract
The field of pediatric stroke has historically been hampered by limited evidence and small patient cohorts. However the landscape of childhood stroke is rapidly changing due in part to increasing awareness of the importance of pediatric stroke and the emergence of dedicated pediatric stroke centers, care pathways, and alert systems. Acute pediatric stroke management hinges on timely diagnosis confirmed by neuroimaging, appropriate consideration of recanalization therapies, implementation of neuroprotective measures, and attention to secondary prevention. Because pediatric stroke is highly heterogenous in etiology, management strategies must be individualized. Determining a child's underlying stroke etiology is essential to appropriately tailoring hyperacute stroke management and determining best approach to secondary prevention. Herein, we review the methods of recognition, diagnosis, management, current knowledge gaps and promising research for pediatric stroke.
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Alcolumbre Tobelem FL, de Andrade GALR, Paschoal JKSF, de Oliveira Cardoso MDS, Sarmento Trindade SM, Paschoal EHA, Paschoal-Jr FM, Bor-Seng-Shu E. Cerebral Vasculopathy in Children With Sickle Cell Disease in an Amazonian Population. J Child Neurol 2022; 37:8830738221100088. [PMID: 35611504 DOI: 10.1177/08830738221100088] [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: 11/17/2022]
Abstract
Introduction: Sickle cell disease is the most prevalent hereditary disease in the country. The aim of this study was to use transcranial Doppler as a screening method for identifying cerebral vasculopathy in children with sickle cell disease. Methods: An epidemiologic, descriptive, and cross-sectional study was conducted. Patients aged 2-16 years with sickle cell disease and followed at a neurology referral service between January 2014 and March 2020 underwent transcranial Doppler and complementary examinations to screen for cerebral vasculopathy. Results: Screening and confirmatory examinations diagnosed 14 of 164 patients (8.5%) with cerebral vasculopathy. Regarding stroke risk, as measured by cerebral blood flow velocity, 2 of 14 patients (14.2%) were classified as conditional risk (170-199 cm/s) and 12 of 14 (85.7%) as high risk of stroke. Conclusion: Complementary examinations should be performed in all patients with changes on transcranial Doppler to confirm cerebral vasculopathy. Further studies, particularly genetic, are needed to better understand the relationship between sickle cell disease and cerebral vasculopathy.
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Affiliation(s)
| | | | - Joelma Karin Sagica Fernandes Paschoal
- Amazônia Neurovascular Research Group, Federal University of Pará, Belém, Brazil
- Department of Neurology, Federal University of Pará Medical School, Belém, Brazil
| | - Maria do Socorro de Oliveira Cardoso
- Department of Hematology, Federal University of Pará Medical School, Belém, Brazil
- Foundation Center of Hematology and Hemotherapy of Pará (HEMOPA), Belém, Brazil
| | | | - Eric Homero Albuquerque Paschoal
- Amazônia Neurovascular Research Group, Federal University of Pará, Belém, Brazil
- Department of Neurosurgery, Federal University of Pará, Belém, Brazil
| | - Fernando M Paschoal-Jr
- Amazônia Neurovascular Research Group, Federal University of Pará, Belém, Brazil
- Department of Neurology, Federal University of Pará Medical School, Belém, Brazil
| | - Edson Bor-Seng-Shu
- Laboratory for Neurosonology and Cerebral Hemodynamics, Division of Neurological Surgery, Hospital das Clinicas, São Paulo University Medical School, São Paulo, Brazil
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Aihara Y, Kashiwase S, Chiba K, Yamaguchi K, Okada Y, Kimura T, Kawamata T. Aspirin use and platelet aggregation in ischemic onset-type pediatric moyamoya patients with intractable headaches (moya-ache). Childs Nerv Syst 2021; 37:1649-1657. [PMID: 33404716 DOI: 10.1007/s00381-020-04991-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 11/30/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND NSAIDs (nonsteroidal anti-inflammatory drugs) were administered to patients with ischemic onset-type moyamoya disease who experience headaches, but their therapeutic effect was very poor and resulted in a drop in quality of life (QOL). On the other hand, patients who were administered aspirin initially to prevent transient ischemic attacks (TIA) were observed to have a better QOL with the absence of headaches. Here, we report on patients with ischemic onset-type moyamoya disease experiencing headaches who received aspirin in order to verify its safety and effectiveness. METHODS From October 2012 to July 2014, 35 patients (male: 19, female: 16 average age: 10.5 ± 3.9) with ischemic onset-type pediatric moyamoya disease and who were admitted or commuted to hospital and had surgical treatment were evaluated for background, moyamoya staging (Suzuki), presence/absence of TIA, and platelet aggregation activity by adenosine diphosphate (ADP)/collagen turbidity test. The patients were divided into four groups depending on the intensity of headache prior to being administered aspirin, and the Kruskal-Wallis test was carried out for platelet aggregation activity and moyamoya staging. Also, the 4 × 2 χ2 test was carried out for the presence/absence of TIA. Next, the items which were significant in these tests were used as independent variables to analyze the risk of headache onset, using logistic regression analysis. RESULTS One item with statistical significance was the platelet aggregation test(PAT) value (on collagen) (P < 0.0001). A logistic regression analysis was carried out, using this value as an independent variable and headache intensity-as a dependent variable. As a result, an increase in PAT value by 1 translated into 4.43 times higher risk of the onset of intractable headache, and the onset of intractable headaches was predicted at 58.8% with collagen. The risk of developing a headache decreased as a result of aspirin administration, and the decrease was dependent on the collagen-induced aggregation suppression effect of aspirin. Aspirin was administered in the range of 1.6~9.5 mg/kg/day, and the PAT value decreasing rate was 42.9% on average. One case alone experienced nasal bleeding, and all cases showed an improvement in the intractable headaches. CONCLUSIONS In patients with ischemic onset-type pediatric moyamoya disease who experience headaches, the platelet aggregation activity is accelerated, and aspirin administration is effective in alleviating headaches by inhibiting platelet activation, detected by the collagen PAT.
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Affiliation(s)
- Yasuo Aihara
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Shinobu Kashiwase
- Department of Pharmacy, Tokyo Women's Medical University, Tokyo, Japan
| | - Kentaro Chiba
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Koji Yamaguchi
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yoshikazu Okada
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Toshimi Kimura
- Department of Pharmacy, Tokyo Women's Medical University, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho Shinjuku-ku, Tokyo, 162-8666, Japan
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Abstract
The diagnosis and management of neurologic conditions are more complex at the extremes of age than in the average adult. In the pediatric population, neurologic emergencies are somewhat rare and some may require emergent consultation. In older adults, geriatric physiologic changes with increased comorbidities leads to atypical presentations and worsened outcomes. The unique considerations regarding emergency department presentation and management of stroke and altered mental status in both age groups is discussed, in addition to seizures and intracranial hemorrhage in pediatrics, and Parkinson's disease and meningitis in the geriatric population.
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Affiliation(s)
- Danya Khoujah
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S Paca St, 6th Floor, Suite 200, Baltimore, MD 21201, USA; Department of Emergency Medicine, MedStar Franklin Square Medical Center, 9000 Franklin Square Dr, Baltimore, MD 21237, USA.
| | - Megan J Cobb
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S Paca St, 6th Floor, Suite 200, Baltimore, MD 21201, USA; Maryland Emergency Medicine Network, Upper Chesapeake Emergency Medicine, 500 Upper Chesapeake Drive, Bel Air, MD 21014, USA
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