Short-term intellectual outcome after arterial ischemic stroke and sinovenous thrombosis in childhood and infancy

Neurological and Functional Outcomes after Pediatric Stroke

Pediatric stroke results in life-long morbidity for many patients, but the outcomes can vary depending on factors such as age of injury, or mechanism, size, and location of stroke. In this review, we summarize the current understanding of outcomes in different neurological domains (eg, motor, cognitive, language) for children with stroke of different mechanisms (ie, arterial ischemic stroke, cerebral sinus venous thrombosis, and hemorrhagic stroke), but with a focus on World Health Organization International Classification for Functioning, Disability, and Health (ICF-CY) framework for measuring health and disability for children and youth. We describe outcomes for the population as a whole and certain factors that may further refine prognostication.

Bevacizumab and Sinus Venous Thrombosis: A Literature Review

Pediatric glioma treatment can be confounded by eloquent anatomical location and pathologic and genetic characteristics. Current literature suggests that the vascular endothelial growth factor (VEGF) inhibitor bevacizumab has been linked to enhancing disease control; however, its safety and effectiveness are unknown. Bevacizumab has been linked with an increased incidence of intratumoral hemorrhage as well as arterial and venous thromboembolism. A rare adverse effect of chemotherapeutic treatment with bevacizumab is sinus venous thrombosis (SVT), with only a few cases reported to date. This review highlights the pathophysiology of bevacizumab, its rare and life-threatening side effect of SVT, and future recommendations.

Social Cognitive Dysfunction Following Pediatric Arterial Ischemic Stroke: Evidence From a Prospective Cohort Study

[Figure: see text].

A study on the distinctive clinical profile and thrombophilia in pediatric cerebral venous sinus thrombosis

Aim:

The objective of the study was to systematically bring out the clinical presentations, neuro-imaging features, treatment given, and long-term outcomes of children with cerebral venous sinus thrombosis (CVST).

Materials and Methods:

Data were obtained by retrospective analysis of electronic records spanning 13 years, of children (<18 years) with a confirmed diagnosis of CVST based on magnetic resonance imaging of the brain and managed at a tertiary care children’s hospital in the UK.

Results:

Seventeen patients with pediatric CVST were identified over a 13-year study period, highlighting the uncommon prevalence of this entity. This study comprised 10 males and seven females. The age range at presentation was between 2 days and 17 years with a median age of 5.5 years. Headache was the commonest presenting symptom in 10 of 17 children and focal neurological signs were seen in 11 of 17 patients. Among risk factors, six patients had an antecedent infection of the ear/mastoid, three children had acute leukemia, and two patients had central venous catheters. Para-infectious CVST (seven of 17 patients) responded well to appropriate antibiotic therapy. Thrombophilia screens were available in 10 of 17 patients with noninfectious CVST and returned abnormal in four patients (two with Factor V Leiden mutations and one each with deficiency of protein C and anti-thrombin III). Anticoagulants were used in only six of 17 cases and were generally well tolerated. Follow-up data revealed, 11 of 17 patients had a complete recovery and four of 17 patients had residual neurological deficits. Two children died in the entire cohort.

Conclusion:

Pediatric CVST is uncommon and has a different spectrum from adults, with unique clinical triggers and thrombophilic states. Management varies significantly among clinicians, due to the paucity of trial evidence and also due to the heterogeneity of this condition in children.

Long-term cognitive outcomes after cerebral sinovenous thrombosis in childhood

AIM

To assess long-term cognitive function in children after cerebral sinovenous thrombosis (CSVT).

METHOD

Children with CSVT, who had neuropsychological testing for intellectual ability, executive function, attention, language, or behavior, were included in a prospective observational study. Outcomes were compared with normative means using one-sample t-tests. Predictors of abnormal function were examined using logistic regression.

RESULTS

Fifty children with CSVT were included (median age at diagnosis 2y 10mo, interquartile range 7d-6y 10mo; 35 males, 15 females). The median follow-up time was 4 years 2 months (interquartile range 2y 8mo-6y 4mo). Compared with normative means, children with CSVT had lower mean (± standard deviation) full-scale IQ, working memory, and processing speed scores (93.3±16, p=0.01; 93.6±16, p=0.04; 93.7±15.3, p=0.02 respectively). They also had lower scores in executive function, attention, and language domains. Refractory seizure at presentation was associated with a trend in behavioral problems (odds ratio [OR] 6.3, 95% confidence interval [CI] 0.9-46, p=0.07). Females were less likely to experience processing speed difficulties (OR 0.22, 95% CI 0.04-1.3, p=0.09). Incomplete recanalization was associated with a greater risk of abnormal verbal comprehension (OR 5.3, 95% CI 0.93-30.5, p=0.059).

INTERPRETATION

Children with CSVT as a group performed below age expectations on standardized neuropsychological tests, although there was variability across individuals and cognitive domains. Larger studies are needed to evaluate predictors of cognitive deficits in children with CSVT.

Cerebral sinovenous thrombosis in pediatric hemolytic uremic syndrome

Hemolytic uremic syndrome (HUS) may result in thrombotic central nervous system complications. We present a child with diarrhea-associated HUS who developed new-onset focal seizures secondary to cerebral sinovenous thrombosis (CSVT). Her CSVT was treated with low-molecular-weight heparin. The patient's seizures were controlled with levetiracetam, and her HUS was managed supportively with hemodialysis. Repeat imaging nearly 6 months following presentation and initiation of anticoagulation demonstrated cerebral sinus enlargement and persistent intraluminal webbing. Anticoagulation was discontinued after 6 months, and she did not experience long-term gross neurologic sequelae. CSVT is a complication of HUS that has not been previously described. In this report, we summarize the thrombotic central nervous system complications of pediatric HUS.

Cognitive and Academic Outcomes Following Childhood Cortical Stroke

The majority of pediatric neuropsychological stroke research has focused on perinatal stroke outcomes given its relative frequency. Meanwhile, childhood-onset stroke is under-represented in the literature, resulting in limited knowledge about its neurocognitive sequelae. This retrospective study examined cognitive outcomes in children and youth (n = 27) with childhood arterial ischemic stroke (stroke occurring between 29 days and 18 years of life) isolated to the cortical region. Intellectual, academic, language, visual-perception, visual-motor integration, fine motor coordination, and executive function scores were examined relative to normative means. Results indicate that although these children are doing well in terms of general intellectual ability, they demonstrate lower scores on tasks of processing speed and fine motor coordination. Exploratory analysis also revealed that of the personal and neurologic factors examined, age at stroke was positively correlated with perceptual reasoning and fine motor control, age at assessment was negatively correlated with math calculation abilities, and maternal education was positively correlated with working memory and parent-reported behavioral regulation and impulse inhibition abilities. While neurologic variables were not predictive of cognitive neuropsychological outcomes, those with significant poorer performance had higher rates of medium/large, right-sided lesions with frontal lobe involvement. Our results highlight the overall resilience of the injured developing brain but also the vulnerability of specific cognitive skills within this unique population.

[Cerebral venous thrombosis in children: about a series of 12 cases]

La thrombose veineuse cérébrale (TVC) est rare chez l'enfant. Sa présentation clinique et ses étiologies sont variables. Le pronostic des patients reste redoutable devant le risque de décès et des séquelles neurosensorielles. L'objectif était d'étudier le profil clinique, radiologique et étiologique des TVC de l'enfant, et évaluer l'intérêt du traitement anti thrombotique. L'étude rétrospective menée au service de pédiatrie et de réanimation pédiatrique au CHU Med VI de Marrakech, Maroc, sur une période de 9 ans 10 mois (janvier 2008 à octobre 2018), colligeant tous les cas de TVC confirmés à l'imagerie, ayant un âge entre 1 mois et 15 ans. Nous avons recensé 12 cas. L'âge moyen était de 6,4 ans. Le sexe ratio était de 1.4. Le mode de début était aigu dans 7 cas. Les principales présentations cliniques étaient les convulsions (7 cas), les signes neurologiques focaux (7 cas), et les signes d'hypertension intracrânienne (HTIC) (6 cas). La tomodensitométrie (TDM) et / ou l'imagerie par résonance magnétique (IRM), ont révélé une atteinte du réseau veineux superficiel dans 8 cas, étendue dans 3 cas. L'étiologie était infectieuse chez 6 patients avec un cas de déshydratation, deux cas de maladie de système et une homocystinurie. Cependant, l'étiologie restait inconnue chez deux patients. Le traitement anti-thrombotique instaurait chez 7 enfants, avait permis une bonne évolution clinico-radiologique dans 5 cas. Le décès était survenu chez 2 enfants, et 3 autres avaient des séquelles neurologiques. Les TVCs chez l'enfant sont caractérisées par la grande diversité de leur présentation clinique et de leurs étiologies. L'impact des anticoagulants a été prouvé malgré l'absence de protocole thérapeutique standardisé.

Improving cognitive outcomes for pediatric stroke

PURPOSE OF REVIEW

The past 20 years have seen a 35% increase in prevalence of pediatric stroke. Contrary to widely held views, children do not recover better than adults. This review explores the impact of pediatric stroke on cognitive domains, including intellectual and executive functions, memory and behavior, and the influence of age, lesion characteristics, and comorbidities on outcome.

RECENT FINDINGS

Cognitive problems occur in up to half of ischemic and hemorrhagic stroke survivors. Single-center studies have shown intelligence quotient scores skewed to the lower end of the average range, with greater impairment in performance than verbal domains. Executive function, such as attention and processing speed are particularly vulnerable to the effects of pediatric stroke. Age at stroke, larger infarct size, cortical/subcortical lesion location, epilepsy, and comorbid physical deficits are associated with poorer cognitive outcomes.

SUMMARY

Cognitive impairment occurs relatively frequently following pediatric stroke but the nature, severity, and predictors of specific deficits are not well defined. Improving understanding of outcomes following pediatric stroke is a key priority for families but a paucity of data limits the ability to develop targeted disease, and age-specific pediatric rehabilitation strategies to optimize cognitive outcomes following pediatric stroke.

Clinical Predictors of Attention and Executive Functioning Outcomes in Children After Perinatal Arterial Ischemic Stroke

BACKGROUND

Children with perinatal arterial ischemic stroke (PAIS) are at risk for later neurocognitive and behavioral deficits, yet the clinical predictors of these outcomes are understudied. We examined the influence of clinical and infarct characteristics on attention and executive functioning in children following PAIS.

METHODS

Forty children born at term (≥37 weeks' gestation) with PAIS (28 with neonatal arterial ischemic stroke and 12 with presumed PAIS) underwent a comprehensive neuropsychological battery at age three to 16 years (median age 7.2 years; 58% male) to assess attention and executive functioning. Parents also completed questionnaires regarding real-world functioning. Clinical variables including perinatal stroke subtype, infarct characteristics (location, laterality, and volume), and the presence of comorbid epilepsy were ascertained from the medical record.

RESULTS

Presumed PAIS, larger infarct volume, and comorbid epilepsy negatively influenced the performance on attention and executive functioning measures. These clinical variables were also associated with greater functional problems on parent reports, including a higher frequency of attention-deficit/hyperactivity disorder symptoms and greater difficulties in some subdomains of executive functioning. Infarct location and laterality were not associated with performance measures or parental report of functioning.

CONCLUSION

Although all children with PAIS are at risk for later deficits in attention and executive functioning, those with presumed PAIS, larger infarct size, and comorbid epilepsy appear to be the most vulnerable. As they approach and reach school age, these children should undergo neuropsychological assessment to ensure timely implementation of therapeutic interventions and behavioral strategies.

Moral Reasoning in Children with Focal Brain Insults to Frontotemporal Regions

Neuroscientific evidence indicates that human social functioning is supported by a distributed network of frontal and temporal brain regions that undergoes significant development during childhood and adolescence. Clinical studies of individuals with early brain insults (EBI) to frontotemporal regions suggest that such lesions may interfere with the maturation of sociocognitive skills and lead to increased sociobehavioural problems. However, little attention has focussed on the direct assessment of sociocognitive skills, such as moral reasoning, following focal EBI. In the present study, the performance of 15 patients with focal EBI (8–16 years) was compared to that of 15 demographically matched controls on basic neuropsychological measures (IQ and executive functions), sociocognitive tasks (moral reasoning, moral decision-making and empathy) and parent reports of sociobehavioural problems and social adaptive skills. Patients with focal EBI had significantly lower levels of moral reasoning maturity, moral decision-making, and empathy than their matched controls, but did not differ on more general measures of cognition. Their parents also reported increased sociobehavioural problems. These findings suggest that focal EBI to frontotemporal regions can result in reduced sociocognitive capacities, more specifically moral reasoning, and increased vulnerability to sociobehavioural problems.

Evaluation of cases with cerebral thrombosis in children

AIM

We aimed to evaluate the patients who were followed up in our clinic with a diagnosis of cerebral sinovenous thrombosis in terms of age, sex, clinical findings, etiology, thrombophilic factors, imaging findings, treatment and prognosis.

MATERIAL AND METHODS

The files of 11 patients who were followed up in our pediatric neurology clinic with a diagnosis of cerebral thrombosis between 1 December 2010 and 31 December 2014 were retrospectively analyzed.

RESULTS

Seven of 11 patients were male (63.6%). The median age was 14 years (2-17 years). Six (54%) of the patients presented with a complaint of headache. Other complaints at presentation included diplopia (n:3), weakness and difficulty in speaking (n:1) and seizure (n:1). A diagnosis of pseudotumor cerebri was made in eight of the patients (72.7%). In the etiology, mastoiditis was found in three patients, mastoiditis and meningitis were found in combination in one patient, Behçet's disease was found in three patients and head trauma was found in one patient. In 3 patients, only prothrombotic genetic risk factors were present; one patient had deficiency of protein C and S, one patient had deficiency of antithrombin III and one patient had hyperhomosisteinemia in association with vitamin B12 deficiency. 1A homozygous MTFHR A1298C mutation was detected in the patient who had mastoiditis and meningitis and protein S deficiency and lupus anticoagulant were found in another patient who had mastoiditis. All patients received anticoagulant treatment and all patients recovered without neurological sequelae except one.

CONCLUSIONS

Cerebral sinovenous thrombosis should be considered in patients who present with headache and focal neurological deficits. Appropriate utilization of imaging studies is necessary for the diagnosis. Detailed ear, nose and throat examination should be performed to detect mastoiditis. It is recommended that genetic risk factors should be investigated, because hereditary thrombophilis factors may have a role in children. Behçet's disease which is relatively common in our country should be considered in differential diagnosis.

Cognitive outcomes following arterial ischemic stroke in infants and children

This study sought to investigate cognitive outcomes following pediatric arterial ischemic stroke and explore predictors. Participants included 36 children with perinatal or childhood arterial ischemic stroke and a comparison group of 15 children with asthma. Outcomes included cognitive ability, executive functions, and neurological function (Pediatric Stroke Outcome Measure). Magnetic resonance imaging measured lesion location and volume. Mean cognitive scores were at the low end of the average range. Children with arterial ischemic stroke performed significantly below normative populations and significantly below the asthma group on inhibitory control (Cohen's d = .68). Both the Pediatric Stroke Outcome Measure and lesion volume were negatively correlated with cognitive outcome (Spearman r = -.01 to -.42 Pediatric Stroke Outcome Measure; r =-.14 to -.32 Volume). Following arterial ischemic stroke, children performed at the low end of the average range on measures of cognitive functioning. Cognitive outcomes depend on a variety of factors.

Functioning and disability after stroke in children: using the ICF-CY to classify health outcome and inform future clinical research priorities

AIM

The International Classification of Functioning Disability and Health, Child-Youth version (ICF-CY) provides a framework for describing and evaluating health, intervention outcomes, and needs assessment. It can, however, also serve as a system for classifying the focus of outcome studies and identification of gaps in current knowledge.

METHOD

The paediatric arterial ischaemic stroke (AIS) population was targeted. Multiple databases were systematically searched for AIS outcome studies focussing on functioning or disability. Findings were rated using the ICF-CY framework.

RESULTS

Twenty-eight studies were identified. Most were cross-sectional and age range at assessment varied widely. Sixty-seven different standardized measures were used, predominantly evaluating body functions. The most common domains of activity and participation reported were learning and applying knowledge, general tasks and demands, and self-care skills. Health-related quality of life was measured in nine papers. Environmental factors were rarely evaluated.

INTERPRETATION

AIS outcome studies addressing the relationship between body structures and functions (e.g. brain lesion characteristics, neurological examination findings) and activities, participation, and quality of life have emerged in recent years. Comparison of findings across studies is complicated by design and tool selection. The relationship between components of activity limitation and participation restriction is rarely explored.

Congenital brain damage: cognitive development correlates with lesion and electroencephalographic features

The purpose of this study was to assess cognitive development in 26 children with congenital focal brain lesion and unilateral spastic cerebral palsy first diagnosed and followed up for rehabilitation at our institution. Mean intelligence quotients (IQs) were correlated not only to the different features of the cerebral lesions, but also to the different types of electroencephalographic abnormalities. We also examined individual scores. We found that about 70% of the children had values of Full-Scale, Verbal, and Performance IQs within the normal range. No differences were found between left and right injured children. Different Verbal IQ-Performance IQ profiles were observed. Larger lesions and some electroencephalographic features, mainly signal slowing/attenuation as signs of structural brain damage, were significantly associated with lower intellectual abilities. The role of other factors, including genetic and environmental background variability, as well as rehabilitative treatments, on cognitive sequelae in such patients was discussed.

Caring for cerebral venous sinus thrombosis in children

Cerebral venous sinus thrombosis in children is increasingly recognized as diagnostic tools and clinical awareness has improved. It is a multifactorial disease where prothrombotic risk factors and predisposing clinical conditions usually in combination constitute the underlying etiology. Clinical features range from headache, seizures to comatose state. Although symptomatic treatment involving control of infections, seizures and intracranial hypertension is uniform, use of anticoagulation and local thrombolytic therapy is still controversial. Morbidity and mortality can be significant and long-term neurological sequelae include developmental delay, sensorimotor and visual deficits and epilepsy.

Der Einfluss von Schlaganfällen im Kindes- und Jugendalter auf die kognitive Entwicklung

Schlaganfälle ereignen sich im Kindesalter nur selten, haben jedoch für betroffene Kinder große Auswirkungen auch auf kognitive Fähigkeiten. Die vorliegende Studie analysiert die Intelligenzleistung von 103 Kindern nach einem Schlaganfall im Versorgungsgebiet der Arteria cerebri media. Dabei zeigt sich, dass das Alter zum Zeitpunkt der Schädigung einen großen Einfluss auf das Leistungsniveau hat. Kinder mit perinatalen Schlaganfällen schneiden in den Intelligenztestskalen insgesamt am schlechtesten ab. Dabei weist eine antikonvulsive Medikation zur Epilepsiebehandlung einen zusätzlichen Effekt auf. Ereignet sich der Schlaganfall nach dem sechsten Lebensjahr, können lateralisierte Effekte sichtbar gemacht werden: nach linkshemisphärischen Infarkten zeigen sich Sprachleistungen reduziert, rechtshemisphärische Schlaganfälle wirken sich auf visuell-räumliche Leitungen aus. Die Ergebnisse weisen auf die Notwendigkeit langfristiger neuropsychologischer Begleitung der Kinder und Jugendlichen hin.

Long-term cognitive outcomes after pediatric stroke

This study assessed neurocognitive and neurologic outcomes of children with neonatal and childhood strokes. Twenty-one children with neonatal (mean age, 6.86 years) and 10 children with childhood (mean age, 8.21 years) strokes, identified via the Estonian Pediatric Stroke Database (1995-2006), participated. A developmental neuropsychologic assessment was used for neurocognitive outcomes, and the Paediatric Stroke Outcome Measure for neurologic outcomes. Neuromotor impairment was evident in 62% of children with neonatal strokes, and in 70% of children with childhood strokes. Compared with control subjects, children with strokes exhibited worse attention, language, memory, and sensorimotor functions. The sensorimotor domain comprised the most impaired neurocognitive area, whereas executive functions remained intact in both stroke groups. A well-preserved executive function may account for the normal range of intelligence in children with strokes. More severe impairment in neurocognitive skills was evident after neonatal strokes, and the visuospatial domain was more impaired than in children from the childhood group. Prognoses were worse after left hemisphere strokes associated with epilepsy. Our results on emerging neurocognitive deficits in several areas underline the importance of neuropsychologic testing and the follow-up of children with pediatric strokes.

Cerebral venous sinus (sinovenous) thrombosis in children

Cerebral venous sinus (sinovenous) thrombosis (CSVT) in childhood is a rare, but underrecognized, disorder, typically of multifactorial etiology, with neurologic sequelae apparent in up to 40% of survivors and mortality approaching 10%. There is an expanding spectrum of perinatal brain injury associated with neonatal CSVT. Although there is considerable overlap in risk factors for CSVT in neonates and older infants and children, specific differences exist between the groups. Clinical symptoms are frequently nonspecific, which may obscure the diagnosis and delay treatment. While morbidity and mortality are significant, CSVT recurs less commonly than arterial ischemic stroke in children. Appropriate management may reduce the risk of recurrence and improve outcome, however there are no randomized controlled trials to support the use of anticoagulation in children. Although commonly employed in many centers, this practice remains controversial, highlighting the continued need for high-quality studies. This article reviews the literature pertaining to pediatric venous sinus thrombosis.

Cerebral sinus venous thrombosis in Swiss children

AIMo describe the characteristics of paediatric cerebral sinus venous thrombosis (CSVT) in Switzerland.

METHOD

data on clinical features, neuroimaging, risk factors, and treatment were collected for all children in Switzerland younger than 16 years of age who had CSVT between January 2000 and December 2008. A follow-up examination and a cognitive assessment were performed (mean follow-up period 26mo). Differences between neonates and children (patients older than 28d) were assessed and predictors of outcome were determined.

RESULTS

twenty-one neonates (14 males, seven females; mean age 9d, SD 8d) and 44 children (30 males, 14 females; mean age 8y 7mo, SD 4y 5mo) were reported. The incidence of paediatric CSVT in Switzerland was 0.558 per 100000 per year. In neonates, the deep venous system was more often involved and parenchymal injuries were more common. The strongest predictor of poor outcome was neonatal age (odds ratio 17.8, 95% confidence interval 0.847-372.353). Most children showed global cognitive abilities within the normal range, but impairments in single cognitive subdomains were frequent.

INTERPRETATION

paediatric CSVT is rare. Its outcome is poor in neonates. Most children have good neurological outcomes, but some patients have individual neuropsychological impairments.

Neonatal Cerebral Sinovenous Thrombosis From Symptom to Outcome

Background and Purpose— Cerebral sinovenous thrombosis is a rare disease with severe neurological sequelae. The aim of this retrospective multicenter study was to investigate the clinical course, possible risk factors, and outcome of a cohort of neonatal patients with sinovenous thrombosis and, second, to estimate the incidence in The Netherlands.

Methods— From January 1999 to March 2009, a review of all neonatal patients with sinovenous thrombosis from 6 tertiary neonatal intensive care units was performed. Population characteristics, clinical presentation, (prothrombotic) risk factors, neuroimaging, interventions, and neurodevelopment were evaluated. An estimated incidence was calculated based on the Netherlands Perinatal Registry.

Results— Fifty-two neonates were included (39 boys) with a median gestational age of 39 weeks (range, 30 to 42 weeks; 5 preterm). An assisted or complicated delivery occurred in 32 of 52. Presenting symptoms developed at a median postnatal age of 1.5 days (range, 0 to 28 days) and consisted mainly of seizures (29 of 52). All sinovenous thrombosis cases were confirmed with MRI/MR venography. Multisinus thrombosis was most common followed by superior sagittal sinus thrombosis. FII G20210A mutation was present in 2 of 18 tested neonates (11%). Anticoagulation therapy (in 22 of 52) did not result in hemorrhagic complications. At follow-up (median age, 19 months; range, 3 to 72 months), moderate to severe neurological sequelae were present in 38%. The mortality was 10 of 52 (19%). A variable, although high yearly incidence of 1.4 to 12 per 100 000 term newborns was found.

Conclusions— Neonatal sinovenous thrombosis is a multifactorial disease. The estimated incidence in The Netherlands seems higher than reported elsewhere.

Paediatric arterial ischaemic stroke: functional outcome and risk factors

AIM

To study functional outcome in children aged 1 month to 18 years after paediatric arterial ischaemic stroke (PAIS) and to identify risk factors influencing their quality of life.

METHOD

In a consecutive series of 76 children (35 males 41 females, median age at diagnosis 2y 6mo, range 1mo-17y 2mo; median length of follow-up 2y 4mo, range [7mo-10y 6mo]) with PAIS diagnosed at the Erasmus Medical Centre Sophia Children's Hospital between 1997 and 2006, we collected clinical, biochemical, and radiological data prospectively. In 66 children surviving at least 1 year after PAIS, functional outcome could be evaluated with the World Health Organization's International Classification of Impairments, Disabilities and Handicaps.

RESULTS

Significant risk factors at presentation for a poor neurological outcome were young age, infarction in the right middle cerebral artery territory, and fever at presentation. Fifty-four % of children had severe neurological impairments at 12 months after PAIS, and at last follow-up more than half needed remedial teaching, special education, or institutionalization. Health-related quality of life (HRQOL) questionnaires showed a significantly lower HRQOL in all age groups. Children with a longer follow-up had a lower HRQOL in the cognitive functioning domain.

INTERPRETATION

Our study shows significant morbidity and mortality and a reduced HRQOL after PAIS depending on age, fever at presentation, and infarction in the right middle cerebral artery territory.

Early cognitive outcome after neonatal stroke

The purpose of this study was to assess the cognitive development of 27 children with nonhemorrhagic neonatal stroke (occurring within the first 28 days of life). The cognitive evaluation consisted of the Bayley Scales of Infant Development, administered at 12 and/or 24 months poststroke. Compared with the normative sample, children with neonatal stroke obtained significantly lower scores on the Bayley Psychomotor Development Index at 12 months poststroke and on the Bayley Mental and Psychomotor Development Indices at 24 months poststroke. Outcome did not differ based on stroke type or laterality of infarct. However, there was a trend toward higher scores on the Bayley Psychomotor Development Index at 24 months in the left hemisphere group compared to the right hemisphere group. Overall, children with neonatal stroke evidenced significant impairment within the first 2 years poststroke. Further research is required to confirm whether cognitive impairments in these children resolve, remain in the low-average range, or increase with development as more complex skills are learned.

Diffusion-weighted imaging of the brain in infants and children

During the last decade, diffusion-weighted imaging (DWI) has become an important tool in the evaluation of a variety of disorders of the central nervous system in children. DWI relies on variability in the diffusivity of water molecules in the presence of a supplemental diffusion-sensitizing gradient to produce image contrast. Pathologic states alter the diffusion characteristics of brain water in a reproducible fashion. In this review, the DWI appearances of a number of common abnormalities of the brain in infants and children are presented.

AE. Hemorrhagic stroke in children

Hemorrhagic stroke accounts for approximately half of stroke in childhood. Unlike arterial ischemic stroke, there are no consensus guidelines to assist in the evaluation and treatment of these children. This article reviews the literature on the evaluation, treatment, etiology, and neurologic outcome of hemorrhagic stroke in children. Important differences between pediatric and adult hemorrhage are highlighted, as treatment guidelines for adults may not be applicable in all cases. Required future research and potential therapies are also discussed.