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Lesion size and long-term cognitive outcome after pediatric stroke: A comparison between two techniques to assess lesion size. Eur J Paediatr Neurol 2023; 42:126-132. [PMID: 36641854 DOI: 10.1016/j.ejpn.2023.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 11/25/2022] [Accepted: 01/02/2023] [Indexed: 01/09/2023]
Abstract
BACKGROUND There is little consensus on how lesion size impacts long-term cognitive outcome after pediatric arterial ischemic stroke (AIS). This study, therefore, compared two techniques to assessed lesion size in the chronic phase after AIS and determined their measurement agreement in relation to cognitive functions in patients after pediatric stroke. METHODS Twenty-five patients after pediatric AIS were examined in the chronic phase (>2 years after stroke) in respect to intelligence, memory, executive functions, visuo-motor functions, motor abilities, and disease-specific outcome. Lesion size was measured using the ABC/2 formula and segmentation technique (3D Slicer). Correlation analysis determined the association between volumetry techniques and outcome measures in respect to long-term cognitive outcome. RESULTS The measurements from the ABC/2 and segmentation technique were strongly correlated (r = 0.878, p < .001) and displayed agreement in particular for small lesions. Lesion size from both techniques was significantly correlated with disease-specific outcome (p < .001) and processing speed (p < .005) after controlling for age at stroke and multiple comparison. CONCLUSION The two techniques showed convergent validity and were both significantly correlated with long-term outcome after pediatric AIS. Compared to the time-consuming segmentation technique, ABC/2 facilitates clinical and research work as it requires relatively little time and is easy to apply.
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Jiang B, Mackay MT, Stence N, Domi T, Dlamini N, Lo W, Wintermark M. Neuroimaging in Pediatric Stroke. Semin Pediatr Neurol 2022; 43:100989. [PMID: 36344022 DOI: 10.1016/j.spen.2022.100989] [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: 05/04/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 11/30/2022]
Abstract
Pediatric stroke is unfortunately not a rare condition. It is associated with severe disability and mortality because of the complexity of potential clinical manifestations, and the resulting delay in seeking care and in diagnosis. Neuroimaging plays an important role in the multidisciplinary response for pediatric stroke patients. The rapid development of adult endovascular thrombectomy has created a new momentum in health professionals caring for pediatric stroke patients. Neuroimaging is critical to make decisions of identifying appropriate candidates for thrombectomy. This review article will review current neuroimaging techniques, imaging work-up strategies and special considerations in pediatric stroke. For resources limited areas, recommendation of substitute imaging approaches will be provided. Finally, promising new techniques and hypothesis-driven research protocols will be discussed.
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Affiliation(s)
- Bin Jiang
- Department of Radiology, Neuroradiology Section, Stanford University, Stanford, CA.
| | - Mark T Mackay
- Murdoch Children's Research Institute, Royal Children's Hospital and Department of Paediatrics, University of Melbourne, Victoria, Australia.
| | - Nicholas Stence
- Department of Radiology, pediatric Neuroradiology Section, University of Colorado School of Medicine, Aurora, CO
| | - Trish Domi
- Department of Neurology, Hospital for Sick Children, Toronto, Canada.
| | - Nomazulu Dlamini
- Department of Neurology, Hospital for Sick Children, Toronto, Canada.
| | - Warren Lo
- Department of Pediatrics and Neurology, The Ohio State University & Nationwide Children's Hospital, Columbus, OH.
| | - Max Wintermark
- Department of Neuroradiology, University of Texas MD Anderson Center, Houston, TX.
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Maternal Undernutrition Modulates Neonatal Rat Cerebrovascular Structure, Function, and Vulnerability to Mild Hypoxic-Ischemic Injury via Corticosteroid-Dependent and -Independent Mechanisms. Int J Mol Sci 2021; 22:ijms22020680. [PMID: 33445547 PMCID: PMC7827870 DOI: 10.3390/ijms22020680] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 12/31/2020] [Accepted: 01/07/2021] [Indexed: 12/27/2022] Open
Abstract
The present study explored the hypothesis that an adverse intrauterine environment caused by maternal undernutrition (MUN) acted through corticosteroid-dependent and -independent mechanisms to program lasting functional changes in the neonatal cerebrovasculature and vulnerability to mild hypoxic-ischemic (HI) injury. From day 10 of gestation until term, MUN and MUN-metyrapone (MUN-MET) group rats consumed a diet restricted to 50% of calories consumed by a pair-fed control; and on gestational day 11 through term, MUN-MET groups received drinking water containing MET (0.5 mg/mL), a corticosteroid synthesis inhibitor. P9/P10 pups underwent unilateral carotid ligation followed 24 h later by 1.5 h exposure to 8% oxygen (HI treatment). An ELISA quantified MUN-, MET-, and HI-induced changes in circulating levels of corticosterone. In P11/P12 pups, MUN programming promoted contractile differentiation in cerebrovascular smooth muscle as determined by confocal microscopy, modulated calcium-dependent contractility as revealed by cerebral artery myography, enhanced vasogenic edema formation as indicated by T2 MRI, and worsened neurobehavior MUN unmasked HI-induced improvements in open-field locomotion and in edema resolution, alterations in calcium-dependent contractility and promotion of contractile differentiation. Overall, MUN imposed multiple interdependent effects on cerebrovascular smooth muscle differentiation, contractility, edema formation, flow-metabolism coupling and neurobehavior through pathways that both required, and were independent of, gestational corticosteroids. In light of growing global patterns of food insecurity, the present study emphasizes that infants born from undernourished mothers may experience greater risk for developing neonatal cerebral edema and sensorimotor impairments possibly through programmed changes in neonatal cerebrovascular function.
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Automated Estimation of Acute Infarct Volume from Noncontrast Head CT Using Image Intensity Inhomogeneity Correction. Int J Biomed Imaging 2019; 2019:1720270. [PMID: 31531008 PMCID: PMC6719274 DOI: 10.1155/2019/1720270] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/15/2019] [Accepted: 07/31/2019] [Indexed: 11/25/2022] Open
Abstract
Identification of early ischemic changes (EIC) on noncontrast head CT scans performed within the first few hours of stroke onset may have important implications for subsequent treatment, though early stroke is poorly delimited on these studies. Lack of sharp lesion boundary delineation in early infarcts precludes manual volume measures, as well as measures using edge-detection or region-filling algorithms. We wished to test a hypothesis that image intensity inhomogeneity correction may provide a sensitive method for identifying the subtle regional hypodensity which is characteristic of early ischemic infarcts. A digital image analysis algorithm was developed using image intensity inhomogeneity correction (IIC) and intensity thresholding. Two different IIC algorithms (FSL and ITK) were compared. The method was evaluated using simulated infarcts and clinical cases. For synthetic infarcts, measured infarct volumes demonstrated strong correlation to the true lesion volume (for 20% decreased density “infarcts,” Pearson r = 0.998 for both algorithms); both algorithms demonstrated improved accuracy with increasing lesion size and decreasing lesion density. In clinical cases (41 acute infarcts in 30 patients), calculated infarct volumes using FSL IIC correlated with the ASPECTS scores (Pearson r = 0.680) and the admission NIHSS (Pearson r = 0.544). Calculated infarct volumes were highly correlated with the clinical decision to treat with IV-tPA. Image intensity inhomogeneity correction, when applied to noncontrast head CT, provides a tool for image analysis to aid in detection of EIC, as well as to evaluate and guide improvements in scan quality for optimal detection of EIC.
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Dlamini N, Wintermark M, Fullerton H, Strother S, Lee W, Bjornson B, Guilliams KP, Miller S, Kirton A, Filippi CG, Linds A, Askalan R, deVeber G. Harnessing Neuroimaging Capability in Pediatric Stroke: Proceedings of the Stroke Imaging Laboratory for Children Workshop. Pediatr Neurol 2017; 69:3-10. [PMID: 28259513 DOI: 10.1016/j.pediatrneurol.2017.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 01/05/2017] [Accepted: 01/06/2017] [Indexed: 12/22/2022]
Abstract
On June 5, 2015 the International Pediatric Stroke Study and the Stroke Imaging Laboratory for Children cohosted a unique workshop focused on developing neuroimaging research in pediatric stroke. Pediatric neurologists, neuroradiologists, interventional neuroradiologists, physicists, nurse practitioners, neuropsychologists, and imaging research scientists from around the world attended this one-day meeting. Our objectives were to (1) establish a group of experts to collaborate in advancing pediatric neuroimaging for stroke, (2) develop consensus clinical and research magnetic resonance imaging protocols for pediatric stroke patients, and (3) develop imaging-based research strategies in pediatric ischemic stroke. This article provides a summary of the meeting proceedings focusing on identified challenges and solutions and outcomes from the meeting. Further details on the workshop contents and outcomes are provided in three additional articles in the current issue of Pediatric Neurology.
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Affiliation(s)
- Nomazulu Dlamini
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - Max Wintermark
- Division of Neuroradiology, Department of Radiology, Stanford University, Stanford, California
| | - Heather Fullerton
- Department of Neurology, University of California, San Francisco, San Francisco, California; Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Stephen Strother
- Department of Medical Biophysics, Rotman Research Institute at Baycrest, University of Toronto, Toronto, Ontario, Canada
| | - Wayne Lee
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Bruce Bjornson
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Developmental Neurosciences and Child Health, Child and Family Research Institute, Vancouver, British Columbia, Canada
| | - Kristin P Guilliams
- Division of Pediatric Neurology, Department of Neurology, Washington University in St. Louis, St. Louis, Missouri; Division of Critical Care Medicine, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Steven Miller
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Adam Kirton
- Department of Pediatrics, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Clinical Neurosciences, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher G Filippi
- Department of Radiology, Northwell Health, Manhasset, New York; Department of Neurology, University of Vermont Medical Center, Burlington, Vermont
| | - Alexandra Linds
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Rand Askalan
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Gabrielle deVeber
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Abstract
Despite being as common as brain tumors in children, lack of awareness of pediatric stroke presents unique challenges, both in terms of diagnosis and management. Due to diverse and overlapping risk factors, as well as variable clinical presentations, the diagnosis can be either missed or frequently delayed. Early recognition and treatment of pediatric stroke is however critical in optimizing long-term functional outcomes, reducing morbidity and mortality, and preventing recurrent stroke. Neuroimaging plays a vital role in achieving this goal. The advancements in imaging over the last two decades have allowed for multiple modality options for suspected stroke with more accurate diagnosis, as well as quicker turnaround time in imaging diagnosis, especially at primary stroke centers. However, with the multiple imaging possibilities, referring physicians can be overwhelmed with the best option for each clinical situation and what the literature recommends. Here the authors review the etiology of pediatric stroke in the settings of arterial ischemia, hemorrhage, and cerebral sinovenous thrombosis (CSVT), with emphasis on the best diagnostic tools available, including advanced imaging techniques.
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Affiliation(s)
- Aashim Bhatia
- Department of Diagnostic Radiology, Monroe Carell, Jr. Children's Hospital at Vanderbilt, Nashville, TN, 37232, USA
| | - Sumit Pruthi
- Department of Diagnostic Radiology, Monroe Carell, Jr. Children's Hospital at Vanderbilt, Nashville, TN, 37232, USA.
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