1
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Maher K, Amlie-Lefond C. Cow's Milk Anemia in Childhood Manifesting as Severe Cerebral Venous Sinus Thrombosis. J Child Neurol 2024:8830738241227064. [PMID: 38263607 DOI: 10.1177/08830738241227064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
We describe a series of 7 toddler-aged children with iron deficiency anemia from excessive cow's milk consumption who presented with cerebral venous sinus thrombosis and no other identifiable risk factors for thrombosis. The deep venous system was involved in 6 patients, 6 had venous infarcts, and 5 have significant neurocognitive sequelae.
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Affiliation(s)
- Kristin Maher
- Division of Hematology-Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Catherine Amlie-Lefond
- Departments of Neurology and Neurological Surgery, University of Washington School of Medicine, Seattle, WA, USA
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2
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Maher K, Persa L, Barry D, Lee-Eng J, Dichek H, Joshi S, Amlie-Lefond C. Thrombophilia screening in the routine clinical care of children with arterial ischemic stroke. Pediatr Blood Cancer 2023:e30381. [PMID: 37114761 DOI: 10.1002/pbc.30381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/09/2023] [Accepted: 04/02/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Current guidelines recommend thrombophilia evaluation in childhood arterial ischemic stroke, but the impact of screening on management is unknown. The objective of the current study is to report the incidence of thrombophilia identified as part of routine clinical care in the context of available literature reports, and to describe the impact of a diagnosis of thrombophilia on patient management. METHODS We conducted a single-institution retrospective chart review for all children with arterial ischemic stroke occurring between January 1, 2009 and January 1, 2021. We collected thrombophilia screening results, stroke etiology, and management. We also reviewed the literature of thrombophilia testing in childhood arterial ischemic stroke published prior to June 30, 2022. Meta-analysis methods were used to assess prevalence rates. RESULTS Among children with thrombophilia testing performed, 5% (six of 122 patients) were factor V Leiden heterozygous, 1% (one of 102 patients) were prothrombin gene mutation heterozygous, 1% (one of 122) had protein S deficiency, 20% (23/116 patients) had elevated lipoprotein(a), 3% (three of 110 patients) had elevated homocysteine levels, and 9% (10/112) had elevated antiphospholipid antibodies, only two of whom had persistently elevated levels. There was no change in stroke therapy due to these results. Literature review revealed a wide range of prevalence for most thrombophilia traits, with high cross-study heterogeneity in most cases. CONCLUSIONS The rates of thrombophilia in our cohort were consistent with that expected in the general population. The identification of thrombophilia did not alter stroke care. However, some of the results were actionable, prompting evaluation for lipid disorders and patient-specific counseling on cardiovascular risk and risk for venous thrombosis.
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Affiliation(s)
- Kristin Maher
- Division of Hematology-Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Laurel Persa
- Department of Neurology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Dwight Barry
- Clinical Analytics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jacqueline Lee-Eng
- Department of Neurology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Helen Dichek
- Division of Endocrinology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Sarita Joshi
- Division of Hematology-Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Catherine Amlie-Lefond
- Department of Neurology, University of Washington School of Medicine, Seattle, Washington, USA
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3
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Amlie-Lefond C. Pediatric Stroke-Are We Asking the Right Questions? The 2022 Sidney Carter Award Lecture. Neurology 2023; 100:192-198. [PMID: 36347625 DOI: 10.1212/wnl.0000000000201487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/14/2022] [Indexed: 11/11/2022] Open
Abstract
Over the past few decades, robust clinical and research collaborations among pediatric stroke researchers have informed and improved the care of children with stroke. Risk factors and presentation of childhood stroke have been described, and the acute and chronic burden of childhood stroke has been better delineated. Nevertheless, high-quality data for the treatment of children with stroke is dwarfed by that available for adult stroke, and it is therefore tempting to extend research questions and treatment trials from adults to children. A trial designed to answer a question about stroke in adults may yield useful information about stroke in childhood, but a trial that incorporates the unique neurodevelopmental and etiologic aspects of childhood stroke is more likely to truly advance care. Research questions and study design in childhood stroke must capture the complexity of stroke mechanisms and medical comorbidities in children who suffer stroke, the impact on the developing nervous system, and the role of normal and aberrant neurodevelopment in recovery.
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Affiliation(s)
- Catherine Amlie-Lefond
- From the Department of Neurology and Department of Neurosurgery, University of Washington, Seattle, WA.
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4
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Persa L, Shaw DW, Amlie-Lefond C. Why Would a Child Have a Stroke? J Child Neurol 2022; 37:907-915. [PMID: 36214173 DOI: 10.1177/08830738221129916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Identifying the etiology of childhood arterial ischemic stroke helps prevent stroke recurrence. In addition, stroke may herald a serious underlying condition requiring treatment, such as acquired heart disease, malignancy, or autoimmune disorder. Evidence-based guidelines exist for adults to identify and treat common risk factors for primary and secondary stroke, including hypertension, diabetes, elevated lipids, atrial fibrillation, and sleep apnea, which are rarely relevant in children. However, guidelines do not exist in pediatrics. Identifying the cause of childhood stroke may be straightforward or may require extensive clinical and neuroimaging expertise, serial evaluations, and reassessment based on the evolving clinical picture. Risk factors may be present but not necessarily causative, or not causative until a triggering event such as infection or anemia occurs. Herein, we describe strategies to determine stroke etiology, including challenges and potential pitfalls.
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Affiliation(s)
- Laurel Persa
- Department of Neurology, 7274Seattle Children's Hospital, Seattle, Washington, USA
| | - Dennis Ww Shaw
- Department of Radiology, 7274Seattle Children's Hospital, Seattle, Washington, USA
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5
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Benedetti GM, Amlie-Lefond C. Caring for Our Sickest Patients: The Expanding Role of the Pediatric Neurohospitalist. Neurology 2022; 99:781-782. [PMID: 36316123 DOI: 10.1212/wnl.0000000000201267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/01/2022] [Indexed: 06/16/2023] Open
Affiliation(s)
- Giulia M Benedetti
- From the Division of Pediatric Neurology, Seattle Children's Hospital, Department of Neurology, University of Washington.
| | - Catherine Amlie-Lefond
- From the Division of Pediatric Neurology, Seattle Children's Hospital, Department of Neurology, University of Washington
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6
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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7
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Ko PY, Khalatbari H, Hatt D, Coufal N, Barry D, Wainwright MS, Khanna PC, Amlie-Lefond C. Hemorrhagic Transformation Following Childhood Cardioembolic Stroke Is Not Increased in Anticoagulated Patients. J Child Neurol 2022; 37:273-280. [PMID: 35021919 DOI: 10.1177/08830738211025866] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To characterize the risk of hemorrhagic transformation following cardioembolic stroke in childhood, and whether anticoagulation impacts that risk. METHODS Ninety-five children (1 month-18 years) with cardioembolic arterial ischemic stroke between January 1, 2009, and December 31, 2019, at 2 institutions were identified for retrospective chart review. Neuroimaging was reviewed to assess for hemorrhagic transformation. RESULTS There were 11 cases of hemorrhagic transformation; 8 occurred within 2 days of stroke diagnosis. Risk of hemorrhagic transformation did not differ in patients with and without anticoagulation use (15% vs 9%, estimated risk difference 5%; CI -9%, 19%). Stroke size did not predict hemorrhagic transformation (OR 1.004, 95% CI 0.997, 1.010). Risk of hemorrhagic transformation was higher in strokes that occurred in the inpatient compared with the outpatient setting (16% vs 6%). CONCLUSION Hemorrhagic transformation occurred in 11% of pediatric cardioembolic ischemic stroke, usually within 2 days of stroke diagnosis, and was not associated with anticoagulation or stroke size.
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Affiliation(s)
- Pin-Yi Ko
- Department of Neurology, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Hedieh Khalatbari
- Department of Radiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Danielle Hatt
- Department of Pediatrics, University of California, San Diego, Rady Children's Hospital, San Diego, CA, USA
| | - Nicole Coufal
- Department of Pediatrics, University of California, San Diego, Rady Children's Hospital, San Diego, CA, USA
| | - Dwight Barry
- Department of Clinical Analytics, Seattle Children's Hospital, Seattle, WA, USA
| | - Mark S Wainwright
- Department of Neurology, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Paritosh C Khanna
- Department of Radiology, University of California, San Diego, Rady Children's Hospital, San Diego, CA, USA
| | - Catherine Amlie-Lefond
- Department of Neurology, Seattle Children's Hospital, University of Washington, Seattle, WA
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8
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Sheppard SE, Sanders VR, Srinivasan A, Finn LS, Adams D, Elton A, Amlie-Lefond C, Nelson Z, Dmyterko V, Jensen D, Zenner K, Perkins J, Bennett JT. Cerebrofacial vascular metameric syndrome is caused by somatic pathogenic variants in PIK3CA. Cold Spring Harb Mol Case Stud 2021; 7:mcs.a006147. [PMID: 34887309 PMCID: PMC8751408 DOI: 10.1101/mcs.a006147] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 09/30/2021] [Indexed: 12/26/2022] Open
Abstract
Disorganized morphogenesis of arteries, veins, capillaries, and lymphatic vessels results in vascular malformations. Most individuals with isolated vascular malformations have postzygotic (mosaic), activating pathogenic variants in a handful of oncogenes within the PI3K–RAS–MAPK pathway (Padia et al., Laryngoscope Investig Otolaryngol 4: 170–173 [2019]). Activating pathogenic variants in the gene PIK3CA, which encodes for the catalytic subunit of phosphatidylinositol 3-kinase, are present in both lymphatic and venous malformations as well as arteriovenous malformations in other complex disorders such as CLOVES syndrome (congenital, lipomatous, overgrowth, vascular malformations, epidermal anevi, scoliosis) (Luks et al., Pediatr Dev Pathol 16: 51 [2013]; Luks et al., J Pediatr 166: 1048–1054.e1–5 [2015]; Al-Olabi et al., J Clin Invest 128: 1496–1508 [2018]). These vascular malformations are part of the PIK3CA-related overgrowth spectrum, a spectrum of entities that have regionalized disordered growth due to the presence of tissue-restricted postzygotic PIK3CA pathogenic variants (Keppler-Noreuil et al., Am J Med Genet A 167A: 287–295 [2015]). Cerebrofacial vascular metameric syndrome (CVMS; also described as cerebrofacial arteriovenous metameric syndrome, Bonnet–Dechaume–Blanc syndrome, and Wyburn–Mason syndrome) is the association of retinal, facial, and cerebral vascular malformations (Bhattacharya et al., Interv Neuroradiol 7: 5–17 [2001]; Krings et al., Neuroimaging Clin N Am 17: 245–258 [2007]). The segmental distribution, the presence of tissue overgrowth, and the absence of familial recurrence are all consistent with CVMS being caused by a postzygotic mutation, which has been hypothesized by previous authors (Brinjiki et al., Am J Neuroradiol 39: 2103–2107 [2018]). However, the genetic cause of CVMS has not yet been described. Here, we present three individuals with CVMS and mosaic activating pathogenic variants within the gene PIK3CA. We propose that CVMS be recognized as part of the PIK3CA-related overgrowth spectrum, providing justification for future trials using pharmacologic PIK3CA inhibitors (e.g., alpelisib) for these difficult-to-treat patients.
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Affiliation(s)
- Sarah E Sheppard
- Division of Human Genetics, Department of Pediatrics, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.,Comprehensive Vascular Anomaly Program, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA
| | - Victoria R Sanders
- Division of Human Genetics, Department of Pediatrics, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.,Comprehensive Vascular Anomaly Program, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA
| | - Abhay Srinivasan
- Comprehensive Vascular Anomaly Program, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.,Division of Interventional Radiology, Department of Radiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA
| | - Laura S Finn
- Department of Pathology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA
| | - Denise Adams
- Comprehensive Vascular Anomaly Program, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.,Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA
| | - Andrew Elton
- University of Minnesota School of Medicine, Minneapolis, Minnesota 55455, USA
| | | | - Zoe Nelson
- Seattle Children's Hospital, Division of Genetic Medicine, Department of Pediatrics, University of Washington, Seattle, Washington 98105, USA
| | - Victoria Dmyterko
- Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute, Seattle, Washington 98101, USA
| | - Dana Jensen
- Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute, Seattle, Washington 98101, USA
| | - Kaitlyn Zenner
- Seattle Children's Hospital, Division of Pediatric Otolaryngology, Department of Otolaryngology/Head and Neck Surgery, University of Washington, Seattle, Washington 98105, USA.,Vascular Anomalies Program, Seattle Children's Hospital, Seattle, Washington 98105, USA
| | - Jonathan Perkins
- Seattle Children's Hospital, Division of Pediatric Otolaryngology, Department of Otolaryngology/Head and Neck Surgery, University of Washington, Seattle, Washington 98105, USA.,Vascular Anomalies Program, Seattle Children's Hospital, Seattle, Washington 98105, USA
| | - James T Bennett
- Seattle Children's Hospital, Division of Genetic Medicine, Department of Pediatrics, University of Washington, Seattle, Washington 98105, USA.,Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute, Seattle, Washington 98101, USA.,Vascular Anomalies Program, Seattle Children's Hospital, Seattle, Washington 98105, USA
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9
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Abstract
[Figure: see text].
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Affiliation(s)
- Gabriela Oesch
- Department of Pediatric Neurology, University Children's Hospital, Zurich, Switzerland (G.O.)
| | - Francisco A Perez
- Department of Radiology, Seattle Children's and University of Washington (F.A.P., D.W.W.S.)
| | - Mark S Wainwright
- Department of Neurology, Seattle Children's Hospital and University of Washington (M.S.W., C.A.-L.)
| | - Dennis W W Shaw
- Department of Radiology, Seattle Children's and University of Washington (F.A.P., D.W.W.S.)
| | - Catherine Amlie-Lefond
- Department of Neurology, Seattle Children's Hospital and University of Washington (M.S.W., C.A.-L.)
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10
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Barry M, Barry D, Kansagra AP, Hallam D, Abraham M, Amlie-Lefond C. Higher-Quality Data Collection Is Critical to Establish the Safety and Efficacy of Pediatric Mechanical Thrombectomy. Stroke 2021; 52:1213-1221. [PMID: 33719517 DOI: 10.1161/strokeaha.120.032009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE Because children often have lifelong morbidity after stroke, there is considerable enthusiasm to pursue mechanical thrombectomy in childhood stroke based on literature reports. However, current published data may reflect inconsistent reporting and publication bias, which limit the ability to assess safety and efficacy of mechanical thrombectomy in childhood stroke. METHODS This retrospective cohort study compared reporting quality and clinical outcomes for mechanical thrombectomy between a trial-derived cohort of 42 children treated with mechanical thrombectomy for acute stroke at study sites and 133 patients reported in the literature. National Institutes of Health Stroke Scale at baseline, 24 hours after mechanical thrombectomy, and at discharge were compared between study site patients and literature patients. Odds ratios (ORs) were used to compare reporting frequencies. Proportional odds logistic regression was used to compare outcomes. RESULTS Premechanical thrombectomy National Institutes of Health Stroke Scale was available in 93% of study patients compared with 74% of patients in the literature (OR, 4.42 [95% CI, 1.47-19.89]). Postmechanical thrombectomy National Institutes of Health Stroke Scale was available in 69% of study patients compared with 29% of literature cases at 24 hours (OR, 5.48 [95% CI, 2.62-12.06]), and 64% of study patients compared with 32% of cases at discharge (OR, 3.85 [95% CI, 1.87-8.19]). For study sites, median scores were 12 at baseline, 9 at 24 hours, and 5 at discharge. Median scores in case reports were 15 at baseline, 4 at 24 hours, and 3 at discharge. ORs for differences in outcomes between groups were 5.97 (95% CI, 2.28-15.59) at 24 hours and 3.68 (95% CI, 1.45-9.34) at discharge. CONCLUSIONS Study site patients had higher rates of National Institutes of Health Stroke Scale reporting and worse short-term outcomes compared with literature reports. Rigorous data collection is needed before treatment guidelines for pediatric mechanical thrombectomy can be developed.
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Affiliation(s)
- Megan Barry
- Section of Pediatric Neurology, Department of Pediatrics, University of Colorado, Aurora (M.B.)
| | - Dwight Barry
- Clinical Analytics (D.B.), Seattle Children's Hospital
| | - Akash P Kansagra
- Departments of Radiology, Neurological Surgery, and Neurology, Washington University School of Medicine in St Louis (A.P.K.)
| | - Danial Hallam
- Departments of Radiology and Neurological Surgery, University of Washington, Seattle (D.H.)
| | - Michael Abraham
- Departments of Neurology and Interventional Radiology, University of Kansas Medical Center (M.A.)
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11
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Lauzier DC, Galardi MM, Guilliams KP, Goyal MS, Amlie-Lefond C, Hallam DK, Kansagra AP. Pediatric Thrombectomy: Design and Workflow Lessons From Two Experienced Centers. Stroke 2021; 52:1511-1519. [PMID: 33691502 DOI: 10.1161/strokeaha.120.032268] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Endovascular thrombectomy has played a major role in advancing adult stroke care and may serve a similar role in pediatric stroke care. However, there is a need to develop better evidence and infrastructure for pediatric stroke care. In this work, we review 2 experienced pediatric endovascular thrombectomy programs and examine key design features in both care environments, including a formalized protocol and workflow, integration with an adult endovascular thrombectomy workflow, simplification and automation of workflow steps, pediatric adaptations of stroke imaging, advocacy of pediatric stroke care, and collaboration between providers, among others. These essential features transcend any single hospital environment and may provide an important foundation for other pediatric centers that aim to enhance the care of children with stroke.
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Affiliation(s)
- David C Lauzier
- Mallinckrodt Institute of Radiology (D.C.L., M.S.G., A.P.K.), Washington University School of Medicine, St Louis, MO
| | - Maria M Galardi
- Department of Neurology (M.M.G., K.P.G., M.S.G., A.P.K.), Washington University School of Medicine, St Louis, MO
| | - Kristin P Guilliams
- Department of Neurology (M.M.G., K.P.G., M.S.G., A.P.K.), Washington University School of Medicine, St Louis, MO.,Department of Pediatrics (K.P.G.), Washington University School of Medicine, St Louis, MO
| | - Manu S Goyal
- Mallinckrodt Institute of Radiology (D.C.L., M.S.G., A.P.K.), Washington University School of Medicine, St Louis, MO.,Department of Neurology (M.M.G., K.P.G., M.S.G., A.P.K.), Washington University School of Medicine, St Louis, MO.,Department of Neuroscience (M.S.G.), Washington University School of Medicine, St Louis, MO
| | | | - Danial K Hallam
- Department of Radiology (D.K.H.), University of Washington, Seattle.,Department of Neurological Surgery (D.K.H.), University of Washington, Seattle
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology (D.C.L., M.S.G., A.P.K.), Washington University School of Medicine, St Louis, MO.,Department of Neurology (M.M.G., K.P.G., M.S.G., A.P.K.), Washington University School of Medicine, St Louis, MO.,Department of Neurological Surgery (A.P.K.), Washington University School of Medicine, St Louis, MO
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12
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Lauzier DC, Galardi MM, Guilliams K, Goyal MS, Amlie-Lefond C, Hallam DK, Kansagra AP. Abstract P589: Pediatric Thrombectomy: Design And Workflow Lessons From Two Experienced Centers. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
While clinical trials have demonstrated the remarkable efficacy of endovascular thrombectomy (EVT) for treating adult patients suffering from acute ischemic stroke (AIS), benefits reaped from advances in adult stroke care have unfortunately not occurred in parallel with pediatric stroke care. Randomized trials of EVT in childhood stroke are unlikely given the low incidence of stroke in children compared to adults, and despite promising outcomes in small case reports and series, EVT in children remains an off-label procedure lacking established consensus guidelines. Along with a clear need to collect prospective pediatric EVT outcome data, there is a need to enhance pediatric stroke care infrastructure to provide high-quality care to children experiencing stroke.
Methods:
In this work, we review two successful pediatric thrombectomy programs, examining key workflow design features that are likely to be important for other programs that aspire to implement pediatric EVT capability.
Discussion:
While pediatric EVT workflows will vary between centers, we identify several key elements of programmatic success shared between the two reviewed stroke programs that may serve as foundational design considerations for centers aiming to develop their own pediatric EVT programs. These elements include a formalized protocol and workflow, integration with an adult EVT workflow, simplification and automation of workflow steps, pediatric adaptations of stroke imaging, advocacy of pediatric stroke care, and collaboration between providers, among others. These essential features transcend any single hospital environment and may provide an important foundation for other pediatric centers that aim to enhance the care of children with stroke.
Conclusion:
EVT shows promise in reducing stroke-associated morbidity in children. To maximize the efficacy of this intervention, workflow optimizations discussed here should be implemented by centers seeking to develop local pediatric EVT capability.
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Affiliation(s)
- David C Lauzier
- Mallinckrodt Institute of Radiology, Washington Univ in St. Louis, St. Louis, MO
| | - Maria M Galardi
- Dept of Neurology, Washington Univ in St. Louis, St. Louis, MO
| | - Kristin Guilliams
- Dept of Neurology, Dept of Pediatrics, Washington Univ in St. Louis, St. Louis, MO
| | - Manu S Goyal
- Mallinckrodt Institute of Radiology, Dept of Neurology, Dept of Neuroscience, Washington Univ in St. Louis, St. Louis, MO
| | | | - Danial K Hallam
- Dept of Radiology, Dept of Neurological Surgery, Univ of Washington, Seattle, WA
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Dept of Neurology, Dept of Neurological Surgery, Washington Univ in St. Louis, St. Louis, MO
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13
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Affiliation(s)
| | - Mark S Wainwright
- Division of Neurology, Seattle Children's Hospital, University of Washington
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14
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Rafay MF, Shapiro KA, Surmava AM, deVeber GA, Kirton A, Fullerton HJ, Amlie-Lefond C, Weschke B, Dlamini N, Carpenter JL, Mackay MT, Rivkin M, Linds A, Bernard TJ. Spectrum of cerebral arteriopathies in children with arterial ischemic stroke. Neurology 2020; 94:e2479-e2490. [PMID: 32457211 DOI: 10.1212/wnl.0000000000009557] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 11/25/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine that children with arterial ischemic stroke (AIS) due to an identifiable arteriopathy are distinct from those without arteriopathy and that each arteriopathy subtype has unique and recognizable clinical features. METHODS We report a large, observational, multicenter cohort of children with AIS, age 1 month to 18 years, enrolled in the International Pediatric Stroke Study from 2003 to 2014. Clinical and demographic differences were compared by use of the Fisher exact test, with linear step-up permutation min-p adjustment for multiple comparisons. Exploratory analyses were conducted to evaluate differences between cases of AIS with and without arteriopathy and between arteriopathy subtypes. RESULTS Of 2,127 children with AIS, 725 (34%) had arteriopathy (median age 7.45 years). Arteriopathy subtypes included dissection (27%), moyamoya (24.5%), focal cerebral arteriopathy-inflammatory subtype (FCA-i; 15%), diffuse cerebral vasculitis (15%), and nonspecific arteriopathy (18.5%). Children with arteriopathic AIS were more likely to present between 6 and 9 years of age (odds ratio [OR] 1.93, p = 0.029) with headache (OR 1.55, p = 0.023), multiple infarctions (OR 2.05, p < 0.001), sickle cell anemia (OR 2.9, p = 0.007), and head/neck trauma (OR 1.93, p = 0.018). Antithrombotic use and stroke recurrence were higher in children with arteriopathy. Among arteriopathy subtypes, dissection was associated with male sex, older age, headache, and anticoagulant use; FCA-i was associated with hemiparesis and single infarcts; moyamoya was associated with seizures and recurrent strokes; and vasculitis was associated with bilateral infarctions. CONCLUSION Specific clinical profiles are associated with cerebral arteriopathies in children with AIS. These observations may be helpful indicators in guiding early diagnosis and defining subgroups who may benefit most from future therapeutic trials.
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Affiliation(s)
- Mubeen F Rafay
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver.
| | - Kevin A Shapiro
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Ann-Marie Surmava
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Gabrielle A deVeber
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Adam Kirton
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Heather J Fullerton
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Catherine Amlie-Lefond
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Bernhard Weschke
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Nomazulu Dlamini
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Jessica L Carpenter
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Mark T Mackay
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Michael Rivkin
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Alexandra Linds
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Timothy J Bernard
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
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15
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Boos MD, Bozarth XL, Sidbury R, Cooper AB, Perez F, Chon C, Paras G, Amlie-Lefond C. Forehead location and large segmental pattern of facial port-wine stains predict risk of Sturge-Weber syndrome. J Am Acad Dermatol 2020; 83:1110-1117. [PMID: 32413446 DOI: 10.1016/j.jaad.2020.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/23/2020] [Accepted: 05/05/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Children with forehead port-wine stains (PWSs) are at risk of Sturge-Weber syndrome (SWS). However, most will not develop neurologic manifestations. OBJECTIVE To identify children at greatest risk of SWS. METHOD In this retrospective cohort study of children with a forehead PWS, PWSs were classified as "large segmental" (half or more of a contiguous area of the hemiforehead or median pattern) or "trace/small segmental" (less than half of the hemiforehead). The outcome measure was a diagnosis of SWS. RESULTS Ninety-six children had a forehead PWS. Fifty-one had a large segmental PWS, and 45 had a trace/small segmental PWS. All 21 children with SWS had large segmental forehead PWSs. Large segmental forehead PWSs had a higher specificity (0.71 vs 0.27, P < .0001) and a higher positive predictive value (0.41 vs 0.22, P < .0001) for SWS than any forehead involvement by a PWS. LIMITATIONS Retrospective study at a referral center. CONCLUSION Children with large segmental forehead PWSs are at highest risk of SWS.
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Affiliation(s)
- Markus D Boos
- Division of Dermatology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington.
| | - Xiuhua L Bozarth
- Division of Neurology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington
| | - Robert Sidbury
- Division of Dermatology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington
| | - Andrew B Cooper
- Enterprise Analytics, Seattle Children's Hospital, Seattle, Washington
| | - Francisco Perez
- Division of Radiology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington
| | - Connie Chon
- Departmentof Pedatrics, Seattle Children's Hospital, Seattle, Washington
| | - Gabrielle Paras
- University of Washington School of Medicine, Seattle, Washington
| | - Catherine Amlie-Lefond
- Division of Neurology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington
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16
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Amlie-Lefond C, Shaw DW, Cooper A, Wainwright MS, Kirton A, Felling RJ, Abraham MG, Mackay MT, Dowling MM, Torres M, Rivkin MJ, Grabowski EF, Lee S, Kurz JE, McMillan HJ, Barry D, Lee-Eng J, Ichord RN. Risk of Intracranial Hemorrhage Following Intravenous tPA (Tissue-Type Plasminogen Activator) for Acute Stroke Is Low in Children. Stroke 2020; 51:542-548. [DOI: 10.1161/strokeaha.119.027225] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Data regarding the safety and efficacy of intravenous tPA (tissue-type plasminogen activator) in childhood acute arterial ischemic stroke are inadequate. The TIPS trial (Thrombolysis in Pediatric Stroke; National Institutes of Health grant R01NS065848)—a prospective safety and dose-finding trial of intravenous tPA in acute childhood stroke—was closed for lack of accrual. TIPS sites have subsequently treated children with acute stroke in accordance with established institutional protocols supporting data collection on outcomes.
Methods—
Data on children treated with intravenous tPA for neuroimaging-confirmed arterial ischemic stroke were collected retrospectively from 16 former TIPS sites to establish preliminary safety data. Participating sites were required to report all children who were treated with intravenous tPA to minimize reporting bias. Symptomatic intracranial hemorrhage (SICH) was defined as ECASS (European Cooperative Acute Stroke Study) II parenchymal hematoma type 2 or any intracranial hemorrhage associated with neurological deterioration within 36 following tPA administration. A Bayesian beta-binomial model for risk of SICH following intravenous tPA was fit using a prior distribution based on the risk level in young adults (1.7%); to test for robustness, the model was also fit with uninformative and conservative priors.
Results—
Twenty-six children (age range, 1.1–17 years; median, 14 years; 12 boys) with stroke and a median pediatric National Institutes of Health Stroke Scale score of 14 were treated with intravenous tPA within 2 to 4.5 hours (median, 3.0 hours) after stroke onset. No patient had SICH. Two children developed epistaxis.
Conclusions—
The estimated risk of SICH after tPA in children is 2.1% (95% highest posterior density interval, 0.0%–6.7%; mode, 0.9%). Regardless of prior assumption, there is at least a 98% chance that the risk is <15% and at least a 93% chance that the risk is <10%. These results suggest that the overall risk of SICH after intravenous tPA in children with acute arterial ischemic stroke, when given within 4.5 hours after symptom onset, is low.
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Affiliation(s)
- Catherine Amlie-Lefond
- From the Department of Neurology (C.A.-L., M.S.W., J.L.-E), Seattle Children’s Hospital, WA
| | - Dennis W.W. Shaw
- Department of Radiology (D.W.W.S.), Seattle Children’s Hospital, WA
| | - Andrew Cooper
- Enterprise Analytics (A.C., D.B.), Seattle Children’s Hospital, WA
| | - Mark S. Wainwright
- From the Department of Neurology (C.A.-L., M.S.W., J.L.-E), Seattle Children’s Hospital, WA
| | - Adam Kirton
- Department of Neurology, Alberta Children’s Hospital, Calgary, Canada (A.K.)
| | - Ryan J. Felling
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD (R.J.F.)
| | | | - Mark T. Mackay
- Department of Neurology, The Royal Children’s Hospital, Melbourne, VIC, Australia (M.T.M.)
| | - Michael M. Dowling
- Department of Neurology, Children’s Medical Center at Dallas, TX (M.M.D.)
| | - Marcela Torres
- Department of Hematology, Cook Children’s Medical Center, Fort Worth, TX (M.T.)
| | | | - Eric F. Grabowski
- Department of Pediatric Hematology-Oncology, Massachusetts General Hospital, Boston (E.F.G.)
| | - Sarah Lee
- Department of Neurology, Stanford University, Palo Alto, CA (S.L.)
| | - Jonathan E. Kurz
- Department of Neurology, Ann & Robert H Lurie Children’s Hospital of Chicago, IL (J.E.K.)
| | - Hugh J. McMillan
- Department of Neurology, Children’s Hospital of Eastern Ontario, Ottawa, Canada (H.J.M.)
| | - Dwight Barry
- Enterprise Analytics (A.C., D.B.), Seattle Children’s Hospital, WA
| | - Jacqueline Lee-Eng
- From the Department of Neurology (C.A.-L., M.S.W., J.L.-E), Seattle Children’s Hospital, WA
| | - Rebecca N. Ichord
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.)
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Amlie-Lefond C, Barry D. Abstract 52: Case Reports of Short-Term Outcome Following Mechanical Thrombectomy for Childhood Stroke May Be Overly Optimistic. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Meta-analyses of case reports and case series of mechanical thrombectomy in childhood arterial ischemic stroke (AIS) suggest that mechanical thrombectomy is associated with good short-term outcomes in approximately three-quarters of children.
Methods:
Retrospective data on 38 children treated between 2010-2019 with mechanical thrombectomy for stroke were collected from former Thrombolysis in Pediatric Stroke (TIPS) sites. To minimize reporting bias, sites were required to report all patients ≤ 17 years treated with mechanical thrombectomy either at the study site or at an outside hospital prior to transfer. Short-term outcomes, defined as change in NIHSS prior to and following mechanical thrombectomy (MT), were compared with 85 children from case reports/case series published between 2010-2019.
Results:
The mean age of children from former TIPS sites was 11.9 years, 50% male, 34% treated with IV tPA prior to thrombectomy. The mean age of published cases was 10.4 years, 65% males, 19% treated with IV tPA prior to thrombectomy. Case reports had a wider distribution of before-MT NIHSS scores, and a steeper decrease in distributions of after-MT NIHSS scores than those from study sites within 24 hours of MT (Figure 1A; medians: 15 to 4 in published cases, 12 to 8 in cases from sites) and at discharge (Figure 1B; medians: 15 to 3 in published cases, 12 to 5 in cases from sites).
Conclusion:
Patients reported to former TIPS sites had discernably lower rates of good short-term outcomes compared with published case reports and case series, suggesting publication bias. Capturing key metrics of safety and effectiveness of MT in children with AIS, including variations in care delivery in actual practice, will be critical in the creation of evidence-based guidelines for acute management of pediatric AIS.
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Affiliation(s)
| | - Dwight Barry
- Enterprise Analytics, Seattle Childrens Hosp, Seattle, WA
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Amlie-Lefond C, Wainwright MS. Response by Amlie-Lefond and Wainwright to Letter Regarding Article, "Organizing for Acute Arterial Ischemic Stroke in Children". Stroke 2020; 51:e37. [PMID: 31948352 DOI: 10.1161/strokeaha.119.028380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Mark S Wainwright
- Division of Neurology, Seattle Children's Hospital, University of Washington
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Guilliams KP, Kirkham FJ, Holzhauer S, Pavlakis S, Philbrook B, Amlie-Lefond C, Noetzel MJ, Dlamini N, Sharma M, Carpenter JL, Fox CK, Torres M, Ichord RN, Jordan LC, Dowling MM. Arteriopathy Influences Pediatric Ischemic Stroke Presentation, but Sickle Cell Disease Influences Stroke Management. Stroke 2020; 50:1089-1094. [PMID: 31009343 DOI: 10.1161/strokeaha.118.022800] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Sickle cell disease (SCD) and arteriopathy are pediatric stroke risk factors that are not mutually exclusive. The relative contributions of sickled red blood cells and arteriopathy to stroke risk are unknown, resulting in unclear guidelines for primary and secondary stroke prevention when both risk factors are present. We hypothesized that despite similarities in clinical presentation and radiographic appearance of arteriopathies, stroke evaluation and management differ in children with SCD compared with those without SCD. Methods- We compared presentation and management of children with and without SCD enrolled in the IPSS (International Pediatric Stroke Study) with acute arterial ischemic stroke, according to SCD and arteriopathy status. Regression modeling determined relative contribution of SCD and arteriopathy in variables with significant frequency differences. Results- Among 930 childhood arterial ischemic strokes, there were 98 children with SCD, 67 of whom had arteriopathy, and 466 without SCD, 392 of whom had arteriopathy. Arteriopathy, regardless of SCD status, increased likelihood of hemiparesis (odds ratio [OR], 1.94; 95% CI, 1.46-2.56) and speech abnormalities (OR, 1.67; 95% CI, 1.29-2.19). Arteriopathy also increased likelihood of headache but only among those without SCD (OR, 1.89; 95% CI, 1.40-2.55). Echocardiograms were less frequently obtained in children with SCD (OR, 0.58; 95% CI, 0.37-0.93), but the frequency of identified cardiac abnormalities was similar in both groups ( P=0.57). Children with SCD were less likely to receive antithrombotic therapy, even in the presence of arteriopathy (OR, 0.14; 95% CI, 0.08-0.22). Arteriopathy was associated with a significantly higher likelihood of antithrombotic therapy in children without SCD (OR, 5.36; 95% CI, 3.55-8.09). Conclusions- Arteriopathy, and not SCD status, was most influential of stroke presentation. However, SCD status influenced stroke management because children with SCD were less likely to have echocardiograms or receive antithrombotic therapy. Further work is needed to determine whether management differences are warranted.
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Affiliation(s)
- Kristin P Guilliams
- From the Departments of Neurology and Pediatrics, Washington University School of Medicine, St Louis, MO (K.P.G., M.J.N.)
| | - Fenella J Kirkham
- Developmental Neurosciences and Biomedical Research Unit, UCL Great Ormond Street Institute of Child Health, London and Clinical and Experimental Sciences, University of Southampton, United Kingdom (F.J.K.)
| | - Susanne Holzhauer
- Department of Pediatric Hematology and Oncology Charité University Medicine, Berlin, Germany (S.H.)
| | - Steven Pavlakis
- Department of Pediatrics and Neurology, The Brooklyn Hospital Center, Icahn School of Medicine at Mount Sinai, Brooklyn, NY (S.P.)
| | - Bryan Philbrook
- Department of Pediatrics, Pediatric Neurology, Emory University, Children's Healthcare of Atlanta, GA (B.P.)
| | - Catherine Amlie-Lefond
- Department of Neurology, Seattle Children's Hospital, University of Washington, Seattle (C.A.-L.)
| | - Michael J Noetzel
- From the Departments of Neurology and Pediatrics, Washington University School of Medicine, St Louis, MO (K.P.G., M.J.N.)
| | - Nomazulu Dlamini
- Department of Neurology, The Hospital for Sick Children, Toronto, Canada (N.D.)
| | - Mukta Sharma
- Department of Pediatric Hematology Oncology, Children's Mercy Hospital, University of Missouri Kansas City School of Medicine (M.S.)
| | - Jessica L Carpenter
- Department of Pediatrics, Neurology, and Neuroscience, George Washington University, Children's National Medical Center, Washington DC (J.L.C.)
| | - Christine K Fox
- Departments of Neurology and Pediatrics, University of California San Francisco (C.K.F.)
| | - Marcela Torres
- Department of Pediatric Hematology Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.)
| | - Rebecca N Ichord
- Departments of Neurology and Pediatrics, Perlman School of Medicine at the University of Pennsylvania, Philadelphia (R.N.I.)
| | - Lori C Jordan
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN (L.C.J.)
| | - Michael M Dowling
- Departments of Pediatrics, Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center at Dallas and Children's Health Dallas (M.M.D.)
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Wilson JL, Amlie-Lefond C, Abruzzo T, Orbach DB, Rivkin MJ, deVeber GA, Pergami P. Survey of practice patterns and preparedness for endovascular therapy in acute pediatric stroke. Childs Nerv Syst 2019; 35:2371-2378. [PMID: 31482313 DOI: 10.1007/s00381-019-04358-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 08/23/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE Endovascular therapy benefits selected adults with acute stroke while data are lacking for children. The purpose of this study was to assess physician practice and institutional preparedness for endovascular therapy in pediatric stroke. METHODS A link to an anonymous online survey was sent to members of the International Pediatric Stroke Study (IPSS) group about physician experience with endovascular therapy, likelihood of treatment for provided clinical vignettes, and institutional readiness for the delivery of endovascular therapy to children. RESULTS Thirty-one pediatric physicians with a mean of 11 years (SD 7.1) of experience responded. All but two would consider endovascular therapy in a child, and 20 (64.5%) had recommended endovascular therapy for a child in the preceding year. Most (n = 19, 67.9%) did not commit to an age minimum for endovascular therapy. Sixteen (57.1%) would consider treatment up to 24 h after symptom onset with 19 (67.9%) respondents reporting that their practice changed after the 2018 American Heart Association guidelines extended the time window for endovascular therapy in adults. Seventeen (60.7%) preferred imaging that included perfusion in children presenting beyond 6 h. Nineteen (70.4%) had institutional endovascular therapy criteria. Physicians in larger pediatric groups had more "likely to treat" responses on the clinical vignettes than physicians working in smaller groups (11.7 vs. 6.1, p < 0.05). CONCLUSION Pediatric stroke physicians are largely willing to consider endovascular therapy with most changing their practice according to adult guidelines, though experience and selection criteria varied. These findings may help to inform consensus guidelines and clinical trial development.
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Affiliation(s)
- Jenny L Wilson
- Division of Pediatric Neurology, Oregon Health & Science University, 707 SW Gaines St, Portland, OR, 97239, USA.
| | - Catherine Amlie-Lefond
- Department of Neurology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Todd Abruzzo
- Department of Radiology, Phoenix Children's Hospital, Mayo Clinic College of Medicine and University of Arizona, Tucson, AZ, USA
| | - Darren B Orbach
- Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael J Rivkin
- Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, Boston, MA, USA
| | | | - Paola Pergami
- Pediatric Neurology, MedStar Georgetown University Hospital and Department of Neurology, Children's National Medical Center, Washington, DC, USA
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21
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Affiliation(s)
| | - Mark S. Wainwright
- Division of Neurology, Seattle Children’s Hospital, University of Washington
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22
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Abstract
Perinatal stroke is a significant cause of severe epilepsy, including epileptic spasms. Although epileptic spasms due to underlying structural lesion often respond poorly to treatment and evolve into drug-resistant epilepsy, outcomes are not uniformly poor, and predictors of outcomes are not well described. We performed a single-institution retrospective review of epileptic spasms following perinatal stroke to determine if outcome depended on vascular subtype. We identified 24 children with epileptic spasms due to perinatal ischemic stroke: 11 cases of perinatal arterial stroke and 13 cases of perinatal venous infarct. Initial response to treatment was similar between groups; however, although children with perinatal arterial stroke who responded to epileptic spasms therapy had high rates of seizure freedom, many children with perinatal venous infarct, regardless of initial response, had residual drug-resistant epilepsy. We consider whether the mechanism for epileptogenesis may be different between arterial and venous strokes, and whether these 2 groups should be monitored for epileptic spasms, and subsequent epilepsy, differently.
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Affiliation(s)
- Jason P Lockrow
- Department of Neurology, Section of Pediatric Neurology, University of Washington, Seattle, WA, USA
| | - Jason N Wright
- Department of Neurology, Section of Neuroradiology, University of Washington, Seattle, WA, USA
| | - Russell P Saneto
- Department of Neurology, Section of Pediatric Neurology, University of Washington, Seattle, WA, USA
| | - Catherine Amlie-Lefond
- Department of Neurology, Section of Pediatric Neurology, University of Washington, Seattle, WA, USA
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23
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Fullerton HJ, Stence N, Hills NK, Jiang B, Amlie-Lefond C, Bernard TJ, Friedman NR, Ichord R, Mackay MT, Rafay MF, Chabrier S, Steinlin M, Elkind MSV, deVeber GA, Wintermark M. Focal Cerebral Arteriopathy of Childhood: Novel Severity Score and Natural History. Stroke 2019; 49:2590-2596. [PMID: 30355212 DOI: 10.1161/strokeaha.118.021556] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Focal cerebral arteriopathy (FCA)-a common cause of arterial ischemic stroke in previously healthy children-often progresses over days to weeks, increasing the risk of recurrent stroke. We developed a novel severity scoring system designed to quantify FCA progression and correlate with clinical outcomes. Methods- The VIPS study (Vascular Effects of Infection in Pediatric Stroke) prospectively enrolled 355 children with arterial ischemic stroke (2010-2014), including 41 with centrally confirmed FCA. Two neuroradiologists independently reviewed FCA cerebrovascular imaging, assigning a graded severity score of zero (no involvement) to 4 (occlusion) to individual arterial segments. The FCA severity score (FCASS) was the unweighted sum. In an iterative process, we modeled scores derived from different combinations of arterial segments to identify the model that optimized correlation with clinical outcome, simplicity, and reliability. Results- The optimal FCASS summed scores from 5 arterial segments: supraclinoid internal carotid artery, A1, A2, M1, and M2. The median (interquartile range) baseline FCASS was 4 (2-6). Of 33 children with follow-up imaging, the maximum FCASS (at any time point) was 7 (5-9). Twenty-four (73%) had FCA progression on follow-up with their maximum FCASS at a median of 8 (5-35.5) days poststroke; their median FCASS increase was 4 (2.5-6). FCASS did not correlate with recurrent arterial ischemic stroke. Maximum (but not baseline) FCASS correlated with 1-year pediatric stroke outcome measures ( P=0.037). Conclusions- Our novel scoring system for FCA severity correlates with neurological outcomes in the VIPS cohort and provides a tool for FCA treatment trials under development.
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Affiliation(s)
- Heather J Fullerton
- From the Department of Neurology (H.J.F., N.K.H.), University of California, San Francisco.,Department of Pediatrics (H.J.F.), University of California, San Francisco
| | - Nicholas Stence
- Department of Radiology (N.S.), University of Colorado, Denver
| | - Nancy K Hills
- From the Department of Neurology (H.J.F., N.K.H.), University of California, San Francisco.,Department of Biostatistics and Epidemiology (N.K.H.), University of California, San Francisco
| | - Bin Jiang
- Division of Neuroradiology, Department of Radiology, Stanford University, CA (B.J., M.W.)
| | | | | | - Neil R Friedman
- Center for Pediatric Neurosciences, Neurological Institute, Cleveland Clinic, OH (N.R.F.)
| | - Rebecca Ichord
- Department of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine of the University of Pennsylvania (R.I.)
| | - Mark T Mackay
- Department of Paediatrics, Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne, Victoria, Australia (M.T.M.)
| | - Mubeen F Rafay
- Department of Pediatrics and Child Health, Children's Hospital, University of Manitoba, Winnipeg, Canada (M.F.R.)
| | - Stéphane Chabrier
- INSERM, UMR1059 Sainbiose, University of Lyon, CHU Saint-Étienne, France (S.C.)
| | - Maja Steinlin
- Department of Pediatric Neurology, University Children's Hospital, University of Bern, Switzerland (M.S.)
| | - Mitchell S V Elkind
- Department of Epidemiology, Mailman School of Public Health (M.S.V.E.), Columbia University, New York, NY.,Department of Neurology, Vagelos College of Physicians and Surgeons (M.S.V.E.), Columbia University, New York, NY
| | | | - Max Wintermark
- Division of Neuroradiology, Department of Radiology, Stanford University, CA (B.J., M.W.)
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Luat AF, Juhász C, Loeb JA, Chugani HT, Falchek SJ, Jain B, Greene-Roethke C, Amlie-Lefond C, Ball KL, Davis A, Pinto A. Neurological Complications of Sturge-Weber Syndrome: Current Status and Unmet Needs. Pediatr Neurol 2019; 98:31-38. [PMID: 31272784 DOI: 10.1016/j.pediatrneurol.2019.05.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 05/28/2019] [Accepted: 05/30/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE We aimed to identify the current status and major unmet needs in the management of neurological complications in Sturge-Weber syndrome. METHODS An expert panel consisting of neurologists convened during the Sturge-Weber Foundation Clinical Care Network conference in September 2018. Literature regarding current treatment strategies for neurological complications was reviewed. RESULTS Although strong evidence-based standards are lacking, the implementation of consensus-based standards of care and outcome measures to be shared across all Sturge-Weber Foundation Clinical Care Network Centers are needed. Each patient with Sturge-Weber syndrome should have an individualized seizure action plan. There is a need to determine the appropriate abortive and preventive treatment of migraine headaches in Sturge-Weber syndrome. Likewise, a better understanding and better diagnostic modalities and treatments are needed for stroke-like episodes. As behavioral problems are common, the appropriate screening tools for mental illnesses and the timing for screening should be established. Brain magnetic resonance imaging (MRI) preferably done after age one year is the primary imaging modality of choice to establish the diagnosis, although advances in MRI techniques can improve presymptomatic diagnosis to identify patients eligible for preventive drug trials. CONCLUSION We identified the unmet needs in the management of neurological complications in Sturge-Weber syndrome. We define a minimum standard brain MRI protocol to be used by Sturge-Weber syndrome centers. Future multicenter clinical trials on specific treatments of Sturge-Weber syndrome-associated neurological complications are needed. An improved national clinical database is critically needed to understand its natural course, and for retrospective and prospective measures of treatment efficacy.
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Affiliation(s)
- Aimee F Luat
- Department of Pediatrics, Wayne State University Children's Hospital of Michigan, Detroit, Michigan; Department of Neurology, Wayne State University Children's Hospital of Michigan, Detroit, Michigan
| | - Csaba Juhász
- Department of Pediatrics, Wayne State University Children's Hospital of Michigan, Detroit, Michigan; Department of Neurology, Wayne State University Children's Hospital of Michigan, Detroit, Michigan
| | - Jeffrey A Loeb
- Department of Neurology and Rehabilitation, University of Illinois, Chicago, Illinois
| | - Harry T Chugani
- Department of Neurology, New York University School of Medicine, New York, New York
| | - Stephen J Falchek
- Department of Neurology, Nemours duPont Hospital for Children, Wilmington, Delaware; Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Badal Jain
- Department of Neurology, Nemours duPont Hospital for Children, Wilmington, Delaware; Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Carol Greene-Roethke
- Department of Neurology, Nemours duPont Hospital for Children, Wilmington, Delaware; Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | | | - Amy Davis
- Department of Neurosciences, Cook Children's Healthcare System, Forth Worth, Texas
| | - Anna Pinto
- Department of Neurology, Harvard Medical School, Children's Hospital Boston, Boston, Massachusetts.
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25
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Barry M, Hallam DK, Bernard TJ, Amlie-Lefond C. What is the Role of Mechanical Thrombectomy in Childhood Stroke? Pediatr Neurol 2019; 95:19-25. [PMID: 30795888 DOI: 10.1016/j.pediatrneurol.2019.01.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 01/07/2019] [Accepted: 01/09/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Like adults, most children have lifelong morbidity after stroke. Revascularization therapies such as intravenous tissue plasminogen activator and mechanical thrombectomy may be options to decrease this morbidity in selected children, although currently there are no evidence-based recommendations to guide treatment. The utility and safety of mechanical thrombectomy in childhood stroke is unknown because of the lack of safety trials, case-controlled trials, and comprehensive retrospective studies. As such, the current rationale for the use of mechanical thrombectomy in childhood is based on extrapolation from adult experience, as well as consensus at individual institutions with many centers deciding care on a case-by-case basis. Nevertheless, the increasing use of recanalization therapies in appropriately selected adults with acute arterial ischemic stroke has led to an increase in consideration and use in childhood, and there are enough case reports and series, as well as experience, to suggest that some children with large vessel occlusion will likely benefit. METHODS We reviewed current literature regarding mechanical thrombectomy in childhood. RESULTS There are differences between pediatric and adult stroke which may impact safety, efficacy, and individual decision-making, including patient size, pathophysiology of stroke, deficit, experience, and lack of data regarding natural history of stroke in children. CONCLUSIONS Hospitals planning to perform mechanical thrombectomy in children should establish local procedures and guidelines for considering thrombectomy. In our experience, care is best provided through multidisciplinary teams including a pediatric vascular neurologist, neurointerventionalist with pediatric experience, and pediatric neurocritical care.
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Affiliation(s)
- Megan Barry
- Section of Pediatric Neurology, Department of Pediatrics, University of Colorado, Denver, Colorado
| | - Danial K Hallam
- Department of Radiology, University of Washington, Seattle, Washington; Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Timothy J Bernard
- Section of Pediatric Neurology, Department of Pediatrics, University of Colorado, Denver, Colorado; Hemophilia and Thrombosis Center, University of Colorado, Denver, Colorado
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Abstract
Moyamoya is a chronic, progressive steno-occlusive arteriopathy that typically affects the anterior circulation arteries of the circle of Willis. A network of deep thalamoperforating and lenticulostriate collaterals develop to by-pass the occlusion giving rise to the characteristic angiographic "puff of smoke" appearance. Moyamoya confers a lifelong risk of stroke and neurological demise, with peak age of presentation in childhood ranging between five and 10 years. Moyamoya disease refers to patients who do not have a comorbid condition, whereas moyamoya syndrome refers to patients in whom moyamoya occurs in association with an acquired or inherited disorder such as sickle cell disease, neurofibromatosis type-1 or trisomy 21. The incidence of moyamoya disease and moyamoya syndrome demonstrates geographic and ethnic variation, with a predominance of moyamoya disease in East-Asian populations. Antiplatelet therapy and surgical revascularization procedures are the mainstay of management, as there are no available treatments to slow the progression of the arteriopathy. Future research is required to address the major gaps that remain in our understanding of the pathologic basis, optimal timing for surgery, and determinants of outcome in this high-stroke risk condition of childhood.
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Affiliation(s)
- Nomazulu Dlamini
- Department of Neurology, The Hospital for Sick Children, Toronto, Canada.
| | - Prakash Muthusami
- Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada
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Feigin VL, Nguyen G, Cercy K, Johnson CO, Alam T, Parmar PG, Abajobir AA, Abate KH, Abd-Allah F, Abejie AN, Abyu GY, Ademi Z, Agarwal G, Ahmed MB, Akinyemi RO, Al-Raddadi R, Aminde LN, Amlie-Lefond C, Ansari H, Asayesh H, Asgedom SW, Atey TM, Ayele HT, Banach M, Banerjee A, Barac A, Barker-Collo SL, Bärnighausen T, Barregard L, Basu S, Bedi N, Behzadifar M, Béjot Y, Bennett DA, Bensenor IM, Berhe DF, Boneya DJ, Brainin M, Campos-Nonato IR, Caso V, Castañeda-Orjuela CA, Rivas JC, Catalá-López F, Christensen H, Criqui MH, Damasceno A, Dandona L, Dandona R, Davletov K, de Courten B, deVeber G, Dokova K, Edessa D, Endres M, Faraon EJA, Farvid MS, Fischer F, Foreman K, Forouzanfar MH, Gall SL, Gebrehiwot TT, Geleijnse JM, Gillum RF, Giroud M, Goulart AC, Gupta R, Gupta R, Hachinski V, Hamadeh RR, Hankey GJ, Hareri HA, Havmoeller R, Hay SI, Hegazy MI, Hibstu DT, James SL, Jeemon P, John D, Jonas JB, Jóźwiak J, Kalani R, Kandel A, Kasaeian A, Kengne AP, Khader YS, Khan AR, Khang YH, Khubchandani J, Kim D, Kim YJ, Kivimaki M, Kokubo Y, Kolte D, Kopec JA, Kosen S, Kravchenko M, Krishnamurthi R, Kumar GA, Lafranconi A, Lavados PM, Legesse Y, Li Y, Liang X, Lo WD, Lorkowski S, Lotufo PA, Loy CT, Mackay MT, Abd El Razek HM, Mahdavi M, Majeed A, Malekzadeh R, Malta DC, Mamun AA, Mantovani LG, Martins SCO, Mate KK, Mazidi M, Mehata S, Meier T, Melaku YA, Mendoza W, Mensah GA, Meretoja A, Mezgebe HB, Miazgowski T, Miller TR, Ibrahim NM, Mohammed S, Mokdad AH, Moosazadeh M, Moran AE, Musa KI, Negoi RI, Nguyen M, Nguyen QL, Nguyen TH, Tran TT, Nguyen TT, Anggraini Ningrum DN, Norrving B, Noubiap JJ, O’Donnell MJ, Olagunju AT, Onuma OK, Owolabi MO, Parsaeian M, Patton GC, Piradov M, Pletcher MA, Pourmalek F, Prakash V, Qorbani M, Rahman M, Rahman MA, Rai RK, Ranta A, Rawaf D, Rawaf S, Renzaho AMN, Robinson SR, Sahathevan R, Sahebkar A, Salomon JA, Santalucia P, Santos IS, Sartorius B, Schutte AE, Sepanlou SG, Shafieesabet A, Shaikh MA, Shamsizadeh M, Sheth KN, Sisay M, Shin MJ, Shiue I, Silva DAS, Sobngwi E, Soljak M, Sorensen RJD, Sposato LA, Stranges S, Suliankatchi RA, Tabarés-Seisdedos R, Tanne D, Nguyen CT, Thakur JS, Thrift AG, Tirschwell DL, Topor-Madry R, Tran BX, Nguyen LT, Truelsen T, Tsilimparis N, Tyrovolas S, Ukwaja KN, Uthman OA, Varakin Y, Vasankari T, Venketasubramanian N, Vlassov VV, Wang W, Werdecker A, Wolfe CDA, Xu G, Yano Y, Yonemoto N, Yu C, Zaidi Z, El Sayed Zaki M, Zhou M, Ziaeian B, Zipkin B, Vos T, Naghavi M, Murray CJL, Roth GA. Global, Regional, and Country-Specific Lifetime Risks of Stroke, 1990 and 2016. N Engl J Med 2018; 379:2429-2437. [PMID: 30575491 PMCID: PMC6247346 DOI: 10.1056/nejmoa1804492] [Citation(s) in RCA: 810] [Impact Index Per Article: 135.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The lifetime risk of stroke has been calculated in a limited number of selected populations. We sought to estimate the lifetime risk of stroke at the regional, country, and global level using data from a comprehensive study of the prevalence of major diseases. METHODS We used the Global Burden of Disease (GBD) Study 2016 estimates of stroke incidence and the competing risks of death from any cause other than stroke to calculate the cumulative lifetime risks of first stroke, ischemic stroke, or hemorrhagic stroke among adults 25 years of age or older. Estimates of the lifetime risks in the years 1990 and 2016 were compared. Countries were categorized into quintiles of the sociodemographic index (SDI) used in the GBD Study, and the risks were compared across quintiles. Comparisons were made with the use of point estimates and uncertainty intervals representing the 2.5th and 97.5th percentiles around the estimate. RESULTS The estimated global lifetime risk of stroke from the age of 25 years onward was 24.9% (95% uncertainty interval, 23.5 to 26.2); the risk among men was 24.7% (95% uncertainty interval, 23.3 to 26.0), and the risk among women was 25.1% (95% uncertainty interval, 23.7 to 26.5). The risk of ischemic stroke was 18.3%, and the risk of hemorrhagic stroke was 8.2%. In high-SDI, high-middle-SDI, and low-SDI countries, the estimated lifetime risk of stroke was 23.5%, 31.1% (highest risk), and 13.2% (lowest risk), respectively; the 95% uncertainty intervals did not overlap between these categories. The highest estimated lifetime risks of stroke according to GBD region were in East Asia (38.8%), Central Europe (31.7%), and Eastern Europe (31.6%), and the lowest risk was in eastern sub-Saharan Africa (11.8%). The mean global lifetime risk of stroke increased from 22.8% in 1990 to 24.9% in 2016, a relative increase of 8.9% (95% uncertainty interval, 6.2 to 11.5); the competing risk of death from any cause other than stroke was considered in this calculation. CONCLUSIONS In 2016, the global lifetime risk of stroke from the age of 25 years onward was approximately 25% among both men and women. There was geographic variation in the lifetime risk of stroke, with the highest risks in East Asia, Central Europe, and Eastern Europe. (Funded by the Bill and Melinda Gates Foundation.).
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Abstract
PURPOSE OF REVIEW This article provides an overview of stroke in neonates, infants, and children. RECENT FINDINGS Arterial ischemic stroke and cerebral venous sinus thrombosis are increasingly recognized in childhood as important causes of lifelong morbidity and mortality. Diagnosis of arterial ischemic stroke is frequently delayed, as acute neurologic deficits can be challenging to detect in the young child, and stroke is often not considered in the differential diagnosis. Neurologic sequelae following stroke are common, and strategies to minimize stroke size and optimize recovery are being developed. Recurrent arterial ischemic stroke is not uncommon, particularly in children with cerebral arteriopathy. Cerebral venous sinus thrombosis causes obstruction of venous outflow leading to venous infarcts. Complications include hemorrhagic conversion of infarcts and increased intracranial pressure. Without treatment, thrombus extension with increased symptoms is common. Robust guidelines of care that exist for adults do not exist for children, particularly for children with arterial ischemic stroke. SUMMARY The approach to stroke in infants and children can be informed by clinical experience in pediatric stroke and cerebral venous sinus thrombosis, the extensive literature on pediatric thrombosis, and extrapolation from data from adult patients.
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Affiliation(s)
| | | | | | - Ann J Melvin
- Department of Pediatrics Division of Infectious Disease Seattle Children's Hospital University of Washington Seattle, Washington
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30
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Rafay MF, Shapiro K, Kirton A, deVeber G, Fullerton H, Dowling M, Dlamini N, Amlie-Lefond C, Carpenter JL, Weschke B, Rivkin M, Mackay M, Bernard T. Abstract 19: Clinical and Neuroimaging Profile of Children With Arterial Ischemic Stroke Due to Cerebral Arteriopathy - Results From the International Pediatric Stroke Study (IPSS). Stroke 2018. [DOI: 10.1161/str.49.suppl_1.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Cerebral arteriopathies are frequently identified in children with arterial ischemic stroke (AIS), and are distinguished by high stroke recurrence. However, the clinical and neuroimaging profiles of AIS due to cerebral arteriopathy versus non- arteriopathy have not been compared.
Hypothesis:
We hypothesized that children with AIS due to arteriopathy would differ in their demographic, clinical, and radiographic presentation from those without arteriopathy.
Methods:
We report a large, prospective, multicentre cohort of children, 1 month - 17 years, with AIS, enrolled in the International Pediatric Stroke Study, 2003-2014. Those with arteriopathy including focal cerebral arteriopathy, dissection, moyamoya, vasculitis and non-specific arteriopathies, were compared to those with non-arteriopathic stroke etiologies.
Results:
Of 2127 children with AIS, 725(34%) had arteriopathy (58% male, mean age 8.1years). The remaining 1402(66%) had non-arteriopathic AIS. Arteriopathy was associated with older age, but not a specific gender or ethnicity. Geographic differences were observed. Children with arteriopathy were likely to present with hemiparesis, dysarthria, ataxia, headache, preceding/concurrent thromboembolic events and without seizures. Risk factors associated with arteriopathy included sickle anemia, head/neck trauma and lack of acute systemic disease. Radiological associations with arteriopathy included right sided unilateral or bilateral stroke, multiple infarcts and relative reduction in occurrence of intracranial hemorrhage. On multivariate analysis, headache (p=0.006), additional thromboembolic events (p=0.007), multiple infarcts (p=0.002) and lack of seizures (p=0.001) were independently associated with arteriopathy.
Conclusions:
Specific clinical profiles are associated with arteriopathy in children with AIS and may guide the clinician in early diagnostic evaluations and management.
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Affiliation(s)
- Mubeen F Rafay
- Pediatrics and Child Health, Children’s Hosp Winnipeg, Univ of Manitoba, Winnipeg, Canada
| | - Kevin Shapiro
- Pediatrics, Univ of California, San Fransisco, San Fransisco, CA
| | - Adam Kirton
- Pediatrics, Univ of Alberta, Calgary, Canada
| | | | | | | | | | | | | | - Bernhard Weschke
- Dept of Neuropediatrics, Charité Univ Medicine Berlin, Berlin, Germany
| | | | - Mark Mackay
- Pediatrics, Univ of Melbourne, Melbourne, Australia
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Mirsky DM, Beslow LA, Amlie-Lefond C, Krishnan P, Laughlin S, Lee S, Lehman L, Rafay M, Shaw D, Rivkin MJ, Wintermark M. Pathways for Neuroimaging of Childhood Stroke. Pediatr Neurol 2017; 69:11-23. [PMID: 28274641 DOI: 10.1016/j.pediatrneurol.2016.12.004] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 12/07/2016] [Accepted: 12/08/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND The purpose of this article is to aid practitioners in choosing appropriate neuroimaging for children who present with symptoms that could be caused by stroke. METHODS The Writing Group members participated in one or more pediatric stroke neuroimaging symposiums hosted by the Stroke Imaging Laboratory for Children housed at the Hospital for Sick Children in Toronto, Ontario, Canada. Through collaboration, literature review, and discussion among child neurologists with expertise diagnosing and treating childhood stroke and pediatric neuroradiologists and neuroradiologists with expertise in pediatric neurovascular disease, suggested imaging protocols are presented for children with suspected stroke syndromes including arterial ischemic stroke, cerebral sinovenous thrombosis, and hemorrhagic stroke. RESULTS This article presents information about the epidemiology and classification of childhood stroke with definitions based on the National Institutes of Health Common Data Elements. The role of imaging for the diagnosis of childhood stroke is examined in depth, with separate sections for arterial ischemic stroke, cerebral sinovenous thrombosis, and hemorrhagic stroke. Abbreviated neuroimaging protocols for rapid diagnosis are discussed. The Writing Group provides suggestions for optimal neuroimaging investigation of various stroke types in the acute setting and suggestions for follow-up neuroimaging. Advanced sequences such as diffusion tensor imaging, perfusion imaging, and vessel wall imaging are also discussed. CONCLUSIONS This article provides protocols for the imaging of children who present with suspected stroke.
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Affiliation(s)
- David M Mirsky
- Department of Radiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado.
| | - Lauren A Beslow
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Catherine Amlie-Lefond
- Department of Neurology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Pradeep Krishnan
- Division of Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Suzanne Laughlin
- Division of Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Lee
- Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, California
| | - Laura Lehman
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mubeen Rafay
- Section of Neurology, Children's Hospital, Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Dennis Shaw
- Department of Radiology, University of Washington School of Medicine, Seattle, Washington
| | - Michael J Rivkin
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Psychiatry, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Max Wintermark
- Division of Neuroradiology, Department of Radiology, Stanford University School of Medicine, Stanford, California
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Rivkin MJ, Bernard TJ, Dowling MM, Amlie-Lefond C. Corrigendum to 'Guidelines for Urgent Management of Stroke in Children' [Pediatric Neurology 56 (2016) 8-17]. Pediatr Neurol 2016; 64:105. [PMID: 27594203 DOI: 10.1016/j.pediatrneurol.2016.08.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Michael J Rivkin
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts; Department of Psychiatry, Boston Children's Hospital, Boston, Massachusetts; Department of Radiology, Boston Children's Hospital, Boston, Massachusetts; Department of Neurology, Harvard Medical School, Boston, Massachusetts.
| | - Timothy J Bernard
- Department of Pediatrics, Hemophilia and Thrombosis Center, Aurora, Colorado; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Michael M Dowling
- Division of Pediatric Neurology, University of Texas Southwestern Medical Center Dallas, Dallas, Texas; Department of Pediatrics, University of Texas Southwestern Medical Center Dallas, Dallas, Texas; Department of Neurology, University of Texas Southwestern Medical Center Dallas, Dallas, Texas
| | - Catherine Amlie-Lefond
- Department of Neurology, Seattle Children's Hospital, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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Bernard TJ, Beslow LA, Manco-Johnson MJ, Armstrong-Wells J, Boada R, Weitzenkamp D, Hollatz A, Poisson S, Amlie-Lefond C, Lo W, deVeber G, Goldenberg NA, Dowling MM, Roach ES, Fullerton HJ, Benseler SM, Jordan LC, Kirton A, Ichord RN. Inter-Rater Reliability of the CASCADE Criteria: Challenges in Classifying Arteriopathies. Stroke 2016; 47:2443-9. [PMID: 27633024 DOI: 10.1161/strokeaha.116.013544] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 06/16/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE There are limited data about the reliability of subtype classification in childhood arterial ischemic stroke, an issue that prompted the IPSS (International Pediatric Stroke Study) to develop the CASCADE criteria (Childhood AIS Standardized Classification and Diagnostic Evaluation). Our purpose was to determine the CASCADE criteria's reliability in a population of children with stroke. METHODS Eight raters from the IPSS reviewed neuroimaging and clinical records of 64 cases (16 cases each) randomly selected from a prospectively collected cohort of 113 children with arterial ischemic stroke and classified them using the CASCADE criteria. Clinical data abstracted included history of present illness, risk factors, and acute imaging. Agreement among raters was measured by unweighted κ statistic. RESULTS The CASCADE criteria demonstrated a moderate inter-rater reliability, with an overall κ statistic of 0.53 (95% confidence interval [CI]=0.39-0.67). Cardioembolic and bilateral cerebral arteriopathy subtypes had much higher agreement (κ=0.84; 95% CI=0.70-0.99; and κ=0.90; 95% CI=0.71-1.00, respectively) than cases of aortic/cervical arteriopathy (κ=0.36; 95% CI=0.01-0.71), unilateral focal cerebral arteriopathy of childhood (FCA; κ=0.49; 95% CI=0.23-0.76), and small vessel arteriopathy of childhood (κ=-0.012; 95% CI=-0.04 to 0.01). CONCLUSIONS The CASCADE criteria have moderate reliability when used by trained and experienced raters, which suggests that it can be used for classification in multicenter pediatric stroke studies. However, the moderate reliability of the arteriopathic subtypes suggests that further refinement is needed for defining subtypes. Such revisions may reduce the variability in the literature describing risk factors, recurrence, and outcomes associated with childhood arteriopathy.
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Affiliation(s)
- Timothy J Bernard
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.).
| | - Lauren A Beslow
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Marilyn J Manco-Johnson
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Jennifer Armstrong-Wells
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Richard Boada
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - David Weitzenkamp
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Amanda Hollatz
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Sharon Poisson
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Catherine Amlie-Lefond
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Warren Lo
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Gabrielle deVeber
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Neil A Goldenberg
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Michael M Dowling
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - E Steve Roach
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Heather J Fullerton
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Susanne M Benseler
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Lori C Jordan
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Adam Kirton
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Rebecca N Ichord
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
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Abstract
The child presenting with possible sentinel transient ischemic event or stroke requires prompt diagnosis so that strategies to limit injury and prevent recurrent stroke can be instituted. Cerebral arteriopathy is a potent risk factor for arterial ischemic stroke in childhood. Though acute imaging study in the setting of possible stroke is often a head computed tomography, when possible magnetic resonance imaging (MRI) is recommended as the first-line study as confirmation and imaging evaluation of ischemic stroke will typically require MRI. The MRI scanning approach should include diffusion-weighted imaging (DWI) early in the sequence order, since normal DWI excludes acute infarct with rare exception. In most cases, arterial imaging with time-of-flight (TOF) magnetic resonance angiography (MRA) is warranted. Dedicated MRA may not be possible in the acute setting, but should be pursued as promptly as possible, particularly in the child with findings and history suggestive of arteriopathy, given the high risk of recurrent stroke in these children. MRA can overestimate the degree of arterial compromise due to complex/turbulent flow, and be insensitive to subtle vessel irregularity due to resolution and complex flow. In cases with high imaging suspicion for dissection despite normal MRA findings, catheter angiogram is indicated. A thoughtful, stepwise approach to arterial neuroimaging is critical to optimize diagnosis, treatment, and primary and secondary prevention of childhood stroke.
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Affiliation(s)
| | - Dennis Shaw
- Department of Radiology, Seattle Children's Hospital, Seattle, WA, USA
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Mossa-Basha M, de Havenon A, Becker KJ, Hallam DK, Levitt MR, Cohen WA, Hippe DS, Alexander MD, Tirschwell DL, Hatsukami T, Amlie-Lefond C, Yuan C. Added Value of Vessel Wall Magnetic Resonance Imaging in the Differentiation of Moyamoya Vasculopathies in a Non-Asian Cohort. Stroke 2016; 47:1782-8. [PMID: 27272486 DOI: 10.1161/strokeaha.116.013320] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 05/11/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Although studies have evaluated the differential imaging of moyamoya disease and atherosclerosis, none have investigated the added value of vessel wall magnetic resonance imaging (MRI). This study evaluates the added diagnostic value of vessel wall MRI in differentiating moyamoya disease, atherosclerotic-moyamoya syndrome (A-MMS), and vasculitic-MMS (V-MMS) with a multicontrast protocol. METHODS We retrospectively reviewed the carotid artery territories of patients with clinically defined vasculopathies (moyamoya disease, atherosclerosis, and vasculitis) and steno-occlusive intracranial carotid disease. Two neuroradiologists, blinded to clinical data reviewed the luminal imaging of each carotid, evaluating collateral extent and making a presumed diagnosis with diagnostic confidence. After 3 weeks, the 2 readers reviewed the luminal imaging+vessel wall MRI for the presence, pattern and intensity of postcontrast enhancement, T2 signal characteristics, pattern of involvement, and presumed diagnosis and confidence. RESULTS Ten A-MMS, 3 V-MMS, and 8 moyamoya disease cases with 38 affected carotid segments were included. There was significant improvement in diagnostic accuracy with luminal imaging+vessel wall MRI when compared with luminal imaging (87% versus 32%, P<0.001). The most common vessel wall MRI findings for moyamoya disease were nonenhancing, nonremodeling lesions without T2 heterogeneity; for A-MMS eccentric, remodeling, and T2 heterogeneous lesions with mild/moderate and homogeneous/heterogeneous enhancement; and for V-MMS concentric lesions with homogeneous, moderate enhancement. Inter-reader agreement was moderate to substantial for all vessel wall MRI characteristics (κ=0.46-0.86) and fair for collateral grading (κ=0.35). There was 11% inter-reader agreement for diagnosis on luminal imaging when compared with 82% for luminal imaging+vessel wall MRI (P<0.001). CONCLUSIONS Vessel wall MRI can significantly improve the differentiation of moyamoya vasculopathies when combined with traditional imaging techniques.
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Affiliation(s)
- Mahmud Mossa-Basha
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.).
| | - Adam de Havenon
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
| | - Kyra J Becker
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
| | - Danial K Hallam
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
| | - Michael R Levitt
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
| | - Wendy A Cohen
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
| | - Daniel S Hippe
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
| | - Matthew D Alexander
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
| | - David L Tirschwell
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
| | - Thomas Hatsukami
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
| | - Catherine Amlie-Lefond
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
| | - Chun Yuan
- From the Departments of Radiology (M.M.-B., D.K.H., W.A.C., D.S.H., C.Y.), Neurology (K.J.B., D.L.T., C.A.-L.), Neurosurgery (M.R.L.), and Surgery (T.H.), University of Washington, Seattle, WA; Department of Neurology, University of Utah, Salt Lake City (A.d.H.); and Department of Radiology, University of California-San Francisco (M.D.A.)
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Hong CS, Wang AC, Bonow RH, Abecassis IJ, Amlie-Lefond C, Ellenbogen RG. Moyamoya Disease in a Patient with VACTERL Association. World Neurosurg 2016; 89:729.e7-729.e10. [DOI: 10.1016/j.wneu.2016.01.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 01/13/2016] [Accepted: 01/14/2016] [Indexed: 10/22/2022]
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Abstract
BACKGROUND Varicella zoster virus (VZV) is a neurotropic, exclusively human herpesvirus. Primary infection causes varicella (chickenpox), after which the virus becomes latent in ganglionic neurons along the entire neuraxis. As cell-mediated immunity to VZV declines with advancing age and immunosuppression, VZV reactivates to produce zoster (shingles). One of the most serious complications of zoster is VZV vasculopathy. METHODS We reviewed recent studies of stroke associated with varicella and zoster, how VZV vasculopathy is verified virologically, vaccination to prevent varicella and immunization to prevent zoster, and VZV in giant cell arteritis (GCA). FINDINGS We report recent epidemiological studies revealing an increased risk of stroke after zoster; the clinical, laboratory, and imaging features of VZV vasculopathy; that VZV vasculopathy is confirmed by the presence of either VZV DNA or anti-VZV IgG antibody in cerebrospinal fluid; special features of VZV vasculopathy in children; vaccination to prevent varicella and immunization to prevent zoster; and the latest evidence linking VZV to GCA. CONCLUSION In children and adults, VZV is a common cause of stroke.
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Affiliation(s)
- Catherine Amlie-Lefond
- Department of Neurology, Seattle Children's Hospital, University of Washington, Seattle, Washington.
| | - Don Gilden
- Departments of Neurology and Immunology and Microbiology, University of Colorado School of Medicine, Aurora, Colorado
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Amlie-Lefond C, Rivkin MJ, Friedman NR, Bernard TJ, Dowling MM, deVeber G. The Way Forward: Challenges and Opportunities in Pediatric Stroke. Pediatr Neurol 2016; 56:3-7. [PMID: 26803334 DOI: 10.1016/j.pediatrneurol.2015.10.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 10/28/2015] [Indexed: 10/22/2022]
Affiliation(s)
| | - Michael J Rivkin
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts; Department of Psychiatry, Boston Children's Hospital, Boston, Massachusetts; Department of Radiology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Timothy J Bernard
- Department of Neurology, Children's Hospital Colorado, Aurora, Colorado
| | | | - Gabrielle deVeber
- Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
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Bernard TJ, Friedman NR, Stence NV, Jones W, Ichord R, Amlie-Lefond C, Dowling MM, Rivkin MJ. Preparing for a "Pediatric Stroke Alert". Pediatr Neurol 2016; 56:18-24. [PMID: 26969238 DOI: 10.1016/j.pediatrneurol.2015.10.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 10/06/2015] [Accepted: 10/13/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Childhood arterial ischemic stroke is an important cause of morbidity and mortality in children. Hyperacute treatment strategies remain controversial and challenging, especially in the setting of increasingly proven medical and endovascular options in adults. Although national and international pediatric guidelines have given initial direction about acute therapy and management, pediatric centers have traditionally lacked the infrastructure to triage, diagnose, and treat childhood arterial ischemic stroke quickly. METHODS In the past 10 years, researchers in the International Pediatric Stroke Study and Thrombolysis in Pediatric Stroke study have initiated early strategies for establishing pediatric specific stroke alerts. RESULTS We review the rationale, process and components necessary for establishing a pediatric stroke alert. CONCLUSION Development of pediatric stroke protocols and pathways, with evidence-based acute management strategies and supportive care where possible, facilitates the evaluation, management, and treatment of an acute pediatric stroke.
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Affiliation(s)
- Timothy J Bernard
- Hemophilia and Thrombosis Center, University of Colorado School of Medicine, Aurora, Colorado; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado.
| | - Neil R Friedman
- Center for Pediatric Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicholas V Stence
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Department of Radiology, University of Colorado School of Medicine, Aurora, Colorado
| | - William Jones
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado
| | - Rebecca Ichord
- Department of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Catherine Amlie-Lefond
- Seattle Children's Hospital, Department of Neurology, University of Washington, Seattle, Washington
| | - Michael M Dowling
- Division of Pediatric Neurology, Department of Pediatrics and Neurology, University of Texas Southwestern Medical Center Dallas, Dallas, Texas
| | - Michael J Rivkin
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts; Department of Psychiatry, Boston Children's Hospital, Boston, Massachusetts; Department of Radiology, Boston Children's Hospital, Boston, Massachusetts; Department of Neurology, Harvard Medical School, Boston, Massachusetts
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Abstract
Stroke in children carries lasting morbidity. Once recognized, it is important to evaluate and treat children with acute stroke efficiently and accurately. All children should receive neuroprotective measures. It is reasonable to consider treatment with advanced thrombolytic and endovascular agents. Delivery of such care requires purposeful institutional planning and organization in pediatric acute care centers. Primary stroke centers established for adults provide an example of the multidisciplinary approach that can be applied to the evaluation and treatment of children who present with acute stroke. The organizational infrastructure of these centers can be employed and adapted for treatment of children with acute stroke. It is likely that care for children with acute stroke can best be delivered by regional pediatric primary stroke centers dedicated to the care of children with pediatric stroke.
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Affiliation(s)
- Michael J Rivkin
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts; Department of Psychiatry, Boston Children's Hospital, Boston, Massachusetts; Department of Radiology, Boston Children's Hospital, Boston, Massachusetts; Department of Neurology, Harvard Medical School, Boston, Massachusetts.
| | - Timothy J Bernard
- Department of Pediatrics, Hemophilia and Thrombosis Center, Aurora, Colorado; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Michael M Dowling
- Division of Pediatric Neurology, University of Texas Southwestern Medical Center Dallas, Dallas, Texas; Department of Pediatrics, University of Texas Southwestern Medical Center Dallas, Dallas, Texas; Department of Neurology, University of Texas Southwestern Medical Center Dallas, Dallas, Texas
| | - Catherine Amlie-Lefond
- Department of Neurology, Seattle Children's Hospital, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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Elkind MSV, Hills NK, Glaser CA, Lo WD, Amlie-Lefond C, Dlamini N, Kneen R, Hod EA, Wintermark M, deVeber GA, Fullerton HJ. Herpesvirus Infections and Childhood Arterial Ischemic Stroke: Results of the VIPS Study. Circulation 2016; 133:732-41. [PMID: 26813104 DOI: 10.1161/circulationaha.115.018595] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 01/11/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Epidemiological studies demonstrate that childhood infections, including varicella zoster virus, are associated with an increased risk of arterial ischemic stroke (AIS). Other herpesviruses have been linked to childhood AIS in case reports. We sought to determine whether herpesvirus infections, which are potentially treatable, increase the risk of childhood AIS. METHODS AND RESULTS We enrolled 326 centrally confirmed cases of AIS and 115 stroke-free controls with trauma (29 days to 18 years of age) with acute blood samples (≤3 weeks after stroke/trauma); cases had convalescent samples (7-28 days later) when feasible. Samples were tested by commercial enzyme-linked immunosorbent assay kits for immunoglobulin M/immunoglobulin G antibodies to herpes simplex virus 1 and 2, cytomegalovirus, Epstein-Barr virus, and varicella zoster virus. An algorithm developed a priori classified serological evidence of past and acute herpesvirus infection as dichotomous variables. The median (quartiles) age was 7.7 (3.1-14.3) years for cases and 10.7 (6.9-13.2) years for controls (P=0.03). Serological evidence of past infection did not differ between cases and controls. However, serological evidence of acute herpesvirus infection doubled the odds of childhood AIS, even after adjusting for age, race, and socioeconomic status (odds ratio, 2.2; 95% confidence interval, 1.2-4.0; P=0.007). Among 187 cases with acute and convalescent blood samples, 85 (45%) showed evidence of acute herpesvirus infection; herpes simplex virus 1 was found most often. Most infections were asymptomatic. CONCLUSIONS Herpesviruses may act as a trigger for childhood AIS, even if the infection is subclinical. Antivirals like acyclovir might have a role in the prevention of recurrent stroke if further studies confirm a causal relationship.
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Affiliation(s)
- Mitchell S V Elkind
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Nancy K Hills
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Carol A Glaser
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Warren D Lo
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Catherine Amlie-Lefond
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Nomazulu Dlamini
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Rachel Kneen
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Eldad A Hod
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Max Wintermark
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Gabrielle A deVeber
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - Heather J Fullerton
- From Department of Neurology Columbia University, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); Departments of Neurology (N.K.H., H.J.F.), Biostatistics & Epidemiology (N.K.H.), and Pediatrics (C.A.G., H.J.F.), University of California San Francisco, San Francisco, CA; Department of Pediatrics (Infectious Disease), Kaiser Permanente, Oakland, CA (C.A.G.); Departments of Pediatrics and Neurology, Ohio State University, Columbus OH (W.D.L.); Department of Neurology, University of Washington, Seattle, WA (C.A.-L,); Department of Neurology, Hospital for Sick Children, Toronto, Canada (N.D., G.A.deV.); Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, England (R.K.); Department of Pathology, Columbia University, New York, NY (E.A.H.); and Department of Radiology, Stanford University, Palo Alto, CA (M.W.).
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Schwarz AC, Amlie-Lefond C. A 15-Year-Old Boy With Trisomy 21 and Postoperative Weakness. JAMA Pediatr 2016; 170:85-6. [PMID: 26747074 DOI: 10.1001/jamapediatrics.2015.1677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Anisha Chandra Schwarz
- Department of Neurology, Seattle Children's Hospital and the University of Washington, Seattle
| | - Catherine Amlie-Lefond
- Department of Neurology, Seattle Children's Hospital and the University of Washington, Seattle
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Elbers J, Wainwright MS, Amlie-Lefond C. The Pediatric Stroke Code: Early Management of the Child with Stroke. J Pediatr 2015; 167:19-24.e1-4. [PMID: 25937428 DOI: 10.1016/j.jpeds.2015.03.051] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 03/09/2015] [Accepted: 03/26/2015] [Indexed: 02/04/2023]
Affiliation(s)
- Jorina Elbers
- Division of Child Neurology, Stanford Children's Health, Stanford University, Stanford, CA.
| | - Mark S Wainwright
- Division of Neurology, Department of Pediatrics, Northwestern University, Chicago, IL
| | - Catherine Amlie-Lefond
- Division of Pediatric Neurology, Department of Neurology, Seattle Children's Hospital, University of Washington, Seattle, WA
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Amlie-Lefond C, Amlie-Lefond C. Abstract T P378: Factors Associated with the Presentation of Moyamoya in Childhood. Stroke 2015. [DOI: 10.1161/str.46.suppl_1.tp378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Moyamoya accounts for approximately one fifth of cerebral arteriopathies in children presenting with acute stroke, however often is not diagnosed until stroke occurs, even in higher risk populations and often despite a history of transient ischemic attacks (TIA’s). The surgical management and outcome are well reported, but limited information exists regarding signs and symptoms preceding diagnosis. This study was undertaken to better define which groups of children are at risk for moyamoya and how these children present.
Methods:
With IRB approval, the charts of all patients with a diagnosis of moyamoya cared for between Jan 1, 1997 - Sept 26, 2013 were reviewed.
Results:
Of 54 children with moyamoya, the mean age at presentation was 7 ½ years. 56% were female. 32 (59 %) had predisposing medical conditions associated with moyamoya. 17 (31%) were of Asian descent. Only 11 children (20%) had no underlying predisposing condition identified, of whom 4 had underlying conditions not previously reported in association with moyamoya. 8 patients (15%) were Native American. 38 (70%) had a history of transient ischemic attacks. 26 (48%) presented with acute stroke, of whom ¾ had left and ¼ had right hemisphere strokes. 52% had a history of headache.
Discussion:
The mean age and female predominance in this series are consistent with previous reports. Most children with moyamoya in this series had an underlying predisposing condition, compared with other US series, where almost half had no predisposing condition identified. 15% of children in this series are American Indian or Alaska Native, compared with 1.3% of all patients served at this institution. In this series, fewer children (48% vs 68%) presented with stroke, more (70% vs 43%) had a history of TIAs, and more (52% vs 22%) had a history of headaches than in previous reports. In addition, the Native American population may be at higher risk of moyamoya than previously recognized.
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Rivkin MJ, deVeber G, Ichord RN, Kirton A, Chan AK, Hovinga CA, Gill JC, Szabo A, Hill MD, Scholz K, Amlie-Lefond C. Thrombolysis in pediatric stroke study. Stroke 2015; 46:880-5. [PMID: 25613306 DOI: 10.1161/strokeaha.114.008210] [Citation(s) in RCA: 156] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michael J Rivkin
- From the Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, and Department of Neurology, Harvard Medical School, Boston, MA (M.J.R.); Division of Neurology, Department of Pediatrics, Hospital for Sick Children Toronto, Ontario, Canada (G.d.V.); The Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.N.I.); Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada Alberta Children's Hospital (A.K.) and Department of Clinical Neurosciences and Hotchkiss Brain Institute (M.D.H.), University of Calgary, Alberta, Canada; Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.C.); Dell Children's Medical Center and University of Texas at Austin College of Pharmacy (C.A.H.); BloodCenter of Wisconsin and Department of Pediatrics (J.C.G.) and Division of Biostatistics (A.S.), Medical College of Wisconsin, Milwaukee; Center for Integrated Brain Research, Seattle Children's Research Institute, WA (K.S.); and Seattle Children's Hospital, Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Gabrielle deVeber
- From the Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, and Department of Neurology, Harvard Medical School, Boston, MA (M.J.R.); Division of Neurology, Department of Pediatrics, Hospital for Sick Children Toronto, Ontario, Canada (G.d.V.); The Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.N.I.); Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada Alberta Children's Hospital (A.K.) and Department of Clinical Neurosciences and Hotchkiss Brain Institute (M.D.H.), University of Calgary, Alberta, Canada; Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.C.); Dell Children's Medical Center and University of Texas at Austin College of Pharmacy (C.A.H.); BloodCenter of Wisconsin and Department of Pediatrics (J.C.G.) and Division of Biostatistics (A.S.), Medical College of Wisconsin, Milwaukee; Center for Integrated Brain Research, Seattle Children's Research Institute, WA (K.S.); and Seattle Children's Hospital, Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Rebecca N Ichord
- From the Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, and Department of Neurology, Harvard Medical School, Boston, MA (M.J.R.); Division of Neurology, Department of Pediatrics, Hospital for Sick Children Toronto, Ontario, Canada (G.d.V.); The Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.N.I.); Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada Alberta Children's Hospital (A.K.) and Department of Clinical Neurosciences and Hotchkiss Brain Institute (M.D.H.), University of Calgary, Alberta, Canada; Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.C.); Dell Children's Medical Center and University of Texas at Austin College of Pharmacy (C.A.H.); BloodCenter of Wisconsin and Department of Pediatrics (J.C.G.) and Division of Biostatistics (A.S.), Medical College of Wisconsin, Milwaukee; Center for Integrated Brain Research, Seattle Children's Research Institute, WA (K.S.); and Seattle Children's Hospital, Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Adam Kirton
- From the Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, and Department of Neurology, Harvard Medical School, Boston, MA (M.J.R.); Division of Neurology, Department of Pediatrics, Hospital for Sick Children Toronto, Ontario, Canada (G.d.V.); The Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.N.I.); Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada Alberta Children's Hospital (A.K.) and Department of Clinical Neurosciences and Hotchkiss Brain Institute (M.D.H.), University of Calgary, Alberta, Canada; Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.C.); Dell Children's Medical Center and University of Texas at Austin College of Pharmacy (C.A.H.); BloodCenter of Wisconsin and Department of Pediatrics (J.C.G.) and Division of Biostatistics (A.S.), Medical College of Wisconsin, Milwaukee; Center for Integrated Brain Research, Seattle Children's Research Institute, WA (K.S.); and Seattle Children's Hospital, Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Anthony K Chan
- From the Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, and Department of Neurology, Harvard Medical School, Boston, MA (M.J.R.); Division of Neurology, Department of Pediatrics, Hospital for Sick Children Toronto, Ontario, Canada (G.d.V.); The Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.N.I.); Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada Alberta Children's Hospital (A.K.) and Department of Clinical Neurosciences and Hotchkiss Brain Institute (M.D.H.), University of Calgary, Alberta, Canada; Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.C.); Dell Children's Medical Center and University of Texas at Austin College of Pharmacy (C.A.H.); BloodCenter of Wisconsin and Department of Pediatrics (J.C.G.) and Division of Biostatistics (A.S.), Medical College of Wisconsin, Milwaukee; Center for Integrated Brain Research, Seattle Children's Research Institute, WA (K.S.); and Seattle Children's Hospital, Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Collin A Hovinga
- From the Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, and Department of Neurology, Harvard Medical School, Boston, MA (M.J.R.); Division of Neurology, Department of Pediatrics, Hospital for Sick Children Toronto, Ontario, Canada (G.d.V.); The Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.N.I.); Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada Alberta Children's Hospital (A.K.) and Department of Clinical Neurosciences and Hotchkiss Brain Institute (M.D.H.), University of Calgary, Alberta, Canada; Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.C.); Dell Children's Medical Center and University of Texas at Austin College of Pharmacy (C.A.H.); BloodCenter of Wisconsin and Department of Pediatrics (J.C.G.) and Division of Biostatistics (A.S.), Medical College of Wisconsin, Milwaukee; Center for Integrated Brain Research, Seattle Children's Research Institute, WA (K.S.); and Seattle Children's Hospital, Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Joan Cox Gill
- From the Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, and Department of Neurology, Harvard Medical School, Boston, MA (M.J.R.); Division of Neurology, Department of Pediatrics, Hospital for Sick Children Toronto, Ontario, Canada (G.d.V.); The Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.N.I.); Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada Alberta Children's Hospital (A.K.) and Department of Clinical Neurosciences and Hotchkiss Brain Institute (M.D.H.), University of Calgary, Alberta, Canada; Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.C.); Dell Children's Medical Center and University of Texas at Austin College of Pharmacy (C.A.H.); BloodCenter of Wisconsin and Department of Pediatrics (J.C.G.) and Division of Biostatistics (A.S.), Medical College of Wisconsin, Milwaukee; Center for Integrated Brain Research, Seattle Children's Research Institute, WA (K.S.); and Seattle Children's Hospital, Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Aniko Szabo
- From the Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, and Department of Neurology, Harvard Medical School, Boston, MA (M.J.R.); Division of Neurology, Department of Pediatrics, Hospital for Sick Children Toronto, Ontario, Canada (G.d.V.); The Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.N.I.); Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada Alberta Children's Hospital (A.K.) and Department of Clinical Neurosciences and Hotchkiss Brain Institute (M.D.H.), University of Calgary, Alberta, Canada; Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.C.); Dell Children's Medical Center and University of Texas at Austin College of Pharmacy (C.A.H.); BloodCenter of Wisconsin and Department of Pediatrics (J.C.G.) and Division of Biostatistics (A.S.), Medical College of Wisconsin, Milwaukee; Center for Integrated Brain Research, Seattle Children's Research Institute, WA (K.S.); and Seattle Children's Hospital, Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Michael D Hill
- From the Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, and Department of Neurology, Harvard Medical School, Boston, MA (M.J.R.); Division of Neurology, Department of Pediatrics, Hospital for Sick Children Toronto, Ontario, Canada (G.d.V.); The Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.N.I.); Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada Alberta Children's Hospital (A.K.) and Department of Clinical Neurosciences and Hotchkiss Brain Institute (M.D.H.), University of Calgary, Alberta, Canada; Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.C.); Dell Children's Medical Center and University of Texas at Austin College of Pharmacy (C.A.H.); BloodCenter of Wisconsin and Department of Pediatrics (J.C.G.) and Division of Biostatistics (A.S.), Medical College of Wisconsin, Milwaukee; Center for Integrated Brain Research, Seattle Children's Research Institute, WA (K.S.); and Seattle Children's Hospital, Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Kelley Scholz
- From the Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, and Department of Neurology, Harvard Medical School, Boston, MA (M.J.R.); Division of Neurology, Department of Pediatrics, Hospital for Sick Children Toronto, Ontario, Canada (G.d.V.); The Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.N.I.); Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada Alberta Children's Hospital (A.K.) and Department of Clinical Neurosciences and Hotchkiss Brain Institute (M.D.H.), University of Calgary, Alberta, Canada; Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.C.); Dell Children's Medical Center and University of Texas at Austin College of Pharmacy (C.A.H.); BloodCenter of Wisconsin and Department of Pediatrics (J.C.G.) and Division of Biostatistics (A.S.), Medical College of Wisconsin, Milwaukee; Center for Integrated Brain Research, Seattle Children's Research Institute, WA (K.S.); and Seattle Children's Hospital, Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Catherine Amlie-Lefond
- From the Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, and Department of Neurology, Harvard Medical School, Boston, MA (M.J.R.); Division of Neurology, Department of Pediatrics, Hospital for Sick Children Toronto, Ontario, Canada (G.d.V.); The Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.N.I.); Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada Alberta Children's Hospital (A.K.) and Department of Clinical Neurosciences and Hotchkiss Brain Institute (M.D.H.), University of Calgary, Alberta, Canada; Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.C.); Dell Children's Medical Center and University of Texas at Austin College of Pharmacy (C.A.H.); BloodCenter of Wisconsin and Department of Pediatrics (J.C.G.) and Division of Biostatistics (A.S.), Medical College of Wisconsin, Milwaukee; Center for Integrated Brain Research, Seattle Children's Research Institute, WA (K.S.); and Seattle Children's Hospital, Department of Neurology, University of Washington, Seattle (C.A.-L.)
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Wainwright MS, Grimason M, Goldstein J, Smith CM, Amlie-Lefond C, Revivo G, Noah ZL, Harris ZL, Epstein LG. Building a pediatric neurocritical care program: a multidisciplinary approach to clinical practice and education from the intensive care unit to the outpatient clinic. Semin Pediatr Neurol 2014; 21:248-54. [PMID: 25727506 DOI: 10.1016/j.spen.2014.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
We describe our 10-year experience developing the Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program at Northwestern University Feinberg School of Medicine. The neurocritical care team includes intensivists, neurologists, and an advanced practice nurse who have expertise in critical care neurology and who continue care in long-term follow-up of intensive care unit patients in a dedicated neurocritical care outpatient clinic. Brain-directed critical care requires collaboration between intensivists and neurologists with specific expertise in neurocritical care, using protocol-directed consistent care, and physiological measures to protect brain function. The heterogeneity of neurologic disorders in the pediatric intensive care unit requires a background in the relevant basic science and pathophysiology that is beyond the scope of standard neurology or critical care fellowships. To address this need, we also created a fellowship in neurocritical care for intensivists, neurologists, and advanced practice nurses. Last, we discuss the implications for pediatric neurocritical care from the experience of management of pediatric stroke and the development of stroke centers.
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Affiliation(s)
- Mark S Wainwright
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Department of Pediatrics, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Neurology, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Critical Care, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Michele Grimason
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Department of Pediatrics, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Joshua Goldstein
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Department of Pediatrics, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Neurology, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Craig M Smith
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Department of Pediatrics, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Critical Care, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Gadi Revivo
- The Rehabilitation Institute of Chicago, Chicago, IL
| | - Zehava L Noah
- Division of Critical Care, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Zena L Harris
- Division of Critical Care, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Leon G Epstein
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Department of Pediatrics, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Neurology, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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Bernard TJ, Rivkin MJ, Scholz K, deVeber G, Kirton A, Gill JC, Chan AK, Hovinga CA, Ichord RN, Grotta JC, Jordan LC, Benedict S, Friedman NR, Dowling MM, Elbers J, Torres M, Sultan S, Cummings DD, Grabowski EF, McMillan HJ, Beslow LA, Amlie-Lefond C. Emergence of the primary pediatric stroke center: impact of the thrombolysis in pediatric stroke trial. Stroke 2014; 45:2018-23. [PMID: 24916908 PMCID: PMC4083478 DOI: 10.1161/strokeaha.114.004919] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE In adult stroke, the advent of thrombolytic therapy led to the development of primary stroke centers capable to diagnose and treat patients with acute stroke rapidly. We describe the development of primary pediatric stroke centers through preparation of participating centers in the Thrombolysis in Pediatric Stroke (TIPS) trial. METHODS We collected data from the 17 enrolling TIPS centers regarding the process of becoming an acute pediatric stroke center with capability to diagnose, evaluate, and treat pediatric stroke rapidly, including use of thrombolytic therapy. RESULTS Before 2004, <25% of TIPS sites had continuous 24-hour availability of acute stroke teams, MRI capability, or stroke order sets, despite significant pediatric stroke expertise. After TIPS preparation, >80% of sites now have these systems in place, and all sites reported increased readiness to treat a child with acute stroke. Use of a 1- to 10-Likert scale on which 10 represented complete readiness, median center readiness increased from 6.2 before site preparation to 8.7 at the time of site activation (P≤0.001). CONCLUSIONS Before preparing for TIPS, centers interested in pediatric stroke had not developed systematic strategies to diagnose and treat acute pediatric stroke. TIPS trial preparation has resulted in establishment of pediatric acute stroke centers with clinical and system preparedness for evaluation and care of children with acute stroke, including use of a standardized protocol for evaluation and treatment of acute arterial stroke in children that includes use of intravenous tissue-type plasminogen activator. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT01591096.
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Affiliation(s)
- Timothy J Bernard
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Michael J Rivkin
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Kelley Scholz
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Gabrielle deVeber
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Adam Kirton
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Joan Cox Gill
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Anthony K Chan
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Collin A Hovinga
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Rebecca N Ichord
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - James C Grotta
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Lori C Jordan
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Susan Benedict
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Neil R Friedman
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Michael M Dowling
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Jorina Elbers
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Marcela Torres
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Sally Sultan
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Dana D Cummings
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Eric F Grabowski
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Hugh J McMillan
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Lauren A Beslow
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.)
| | - Catherine Amlie-Lefond
- From the Department of Neurology, Children's Hospital Colorado, Aurora (T.J.B.); Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, MA (M.J.R.); Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.d.V.), Department of Neurology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada (A.K.); Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and BloodCenter of Wisconsin (J.C.G.); Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada (A.K.C.); Department of Pediatrics, Dell Children's Medical Center, Austin, TX (C.A.H.), Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.); Department of Neurology, Memorial Hermann Hospital, Houston, TX (J.C.G.); Division of Pediatric Neurology, Vanderbilt University, Nashville, TN (L.C.J.); Department of Neurology, Primary Children's Medical Center, Salt Lake City, UT (S.B.); Department of Neurology, Cleveland Clinic, OH (N.R.F.); Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas TX (M.M.D.); Department of Neurology, Stanford University, CA (J.E.); Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.); Department of Neurology, Columbia University Medical Center, New York, NY (S.S.); Division of Child Neurology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, PA (D.D.C.); Division of Pediatric Hematology/Oncology, Department of Pediatrics, Mass General Hospital for Children, and Massachusetts General Hospital, Boston (E.F.G.); Department of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (H.J.M.); Departments of Pediatrics and Neurology, Yale-New Haven Children's Hospital, CT (L.A.B.); Department of Neurology, Seattle Children's Hospital, WA (K.S., C.A.-L.); and Department of Neurology, University of Washington, Seattle (C.A.-L.).
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Abstract
OPINION STATEMENT Acute ischemic stroke in childhood is a medical emergency. Prompt recognition and intervention is necessary to rescue potentially viable brain tissue, prevent complications, and minimize the risk of recurrent stroke. Conditions that could result in recurrent stroke such as cardiac thrombus or cervical artery dissection need to be identified and treated promptly. Although the care of childhood stroke is based largely on extrapolation from adults, an organized approach to the care of these children is critical to optimize outcome.
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Affiliation(s)
- Catherine Amlie-Lefond
- Department of Neurology, Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, 4800 Sand Point Way NE, MB 7.462, Seattle, WA, 98105, USA,
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