Swallowing, Oral Motor, Motor Speech, and Language Impairments Following Acute Pediatric Ischemic Stroke

BACKGROUND AND PURPOSE

Following adult stroke, dysphagia, dysarthria, and aphasia are common sequelae. Little is known about these impairments in pediatric stroke. We assessed frequencies, co-occurrence and associations of dysphagia, oral motor, motor speech, language impairment, and caregiver burden in pediatric stroke.

METHODS

Consecutive acute patients from term birth-18 years, hospitalized for arterial ischemic stroke (AIS), and cerebral sinovenous thrombosis, from January 2013 to November 2018 were included. Two raters reviewed patient charts to detect documentation of in-hospital dysphagia, oral motor dysfunction, motor speech and language impairment, and caregiver burden, using a priori operational definitions for notation and assessment findings. Other variables abstracted included demographics, preexisting conditions, stroke characteristics, and discharge disposition. Impairment frequencies were obtained by univariate and bivariate analysis and associations by simple logistic regression.

RESULTS

A total of 173 patients were stratified into neonates (N=67, mean age 2.9 days, 54 AIS, 15 cerebral sinovenous thrombosis) and children (N=106, mean age 6.5 years, 73 AIS, 35 cerebral sinovenous thrombosis). Derived frequencies of impairments included dysphagia (39% neonates, 41% children); oral motor (6% neonates, 41% children); motor speech (37% children); and language (31% children). Common overlapping impairments included oral motor and motor speech (24%) and dysphagia and motor speech (23%) in children. Associations were found only in children between stroke type (AIS over cerebral sinovenous thrombosis) and AIS severity (more severe deficit at presentation) for all impairments except feeding impairment alone. Caregiver burden was present in 58% patients.

CONCLUSIONS

For the first time, we systematically report the frequencies and associations of dysphagia, oral motor, motor speech, and language impairment during acute presentation of pediatric stroke, ranging from 30% to 40% for each impairment. Further research is needed to determine long-term effects of these impairments and to design standardized age-specific assessment protocols for early recognition following stroke.

Characteristics and Outcome in Children With Craniectomy Following Acute Ischemic Stroke in the International Pediatric Stroke Study

The outcome of children with acute ischemic stroke treated with craniectomy has not been thoroughly examined. In adults, hemicraniectomy after middle cerebral artery territory stroke and posterior decompression after posterior circulation stroke has been shown to improve outcome. Pediatric cases of hemicraniectomy for middle cerebral artery stroke and posterior decompression following posterior circulation stroke suggest relatively good outcome. There are no published data in adults or children with craniectomy after cerebral sinovenous thrombosis. Our aim was to determine the outcome of children with acute ischemic stroke treated with craniectomy in the International Pediatric Stroke Study (IPSS). We included children enrolled who had a craniectomy following stroke presentation. Of 4294 patients in IPSS, 38 children (1%) were found to have craniectomy following an ischemic stroke. Of 38 craniectomy cases, 29 had anterior circulation strokes, 5 had posterior circulation strokes, and 4 had cerebral sinovenous thromboses. The mortality rate was 8%. Overall, children who have craniectomies have significant neurologic deficits. Prospective studies are needed to examine long-term morbidity following craniectomy.

Dyslipidemia in Children With Arterial Ischemic Stroke: Prevalence and Risk Factors

BACKGROUND

Risk factors for pediatric stroke are poorly understood and require study to improve prevention. Total cholesterol and triglyceride values peak to near-adult levels before puberty, a period of increased stroke incidence. The role of lipids in childhood arterial ischemic stroke has been minimally investigated.

METHODS

We performed a cross-sectional analysis of lipid and Lp(a) concentrations in children with arterial ischemic stroke in the International Pediatric Stroke Study to compare the prevalence of dyslipidemia and high- or low-ranking lipid values in our dataset with reported population values. We analyzed sex, body mass index, race, ethnicity, family history, and stroke risk factors for associations with dyslipidemia, high non-high-density lipoprotein cholesterol, and hypertriglyceridemia.

RESULTS

Compared with the National Health and Nutrition Examination Survey, a higher proportion of children ≥5 years with arterial ischemic stroke had dyslipidemia (38.4% versus 21%), high total cholesterol (10.6% versus 7.4%), high non-high-density lipoprotein cholesterol (23.1% versus 8.4%), and low high-density lipoprotein cholesterol (39.8% versus 13.4%). The lipid values that corresponded to one standard deviation above the mean (84th percentile) in multiple published national studies generally corresponded to a lower ranking percentile in children aged five years or older with arterial ischemic stroke. Dyslipidemia was more likely associated with an underweight, overweight, or obese body mass index compared with a healthy weight. Ethnic background and an acute systemic illness were also associated with abnormal lipids.

CONCLUSIONS

Dyslipidemia and hypertriglyceridemia may be more prevalent in children with arterial ischemic stroke compared with stroke-free children.

Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines, update 2015

Stroke rehabilitation is a progressive, dynamic, goal-orientated process aimed at enabling a person with impairment to reach their optimal physical, cognitive, emotional, communicative, social and/or functional activity level. After a stroke, patients often continue to require rehabilitation for persistent deficits related to spasticity, upper and lower extremity dysfunction, shoulder and central pain, mobility/gait, dysphagia, vision, and communication. Each year in Canada 62,000 people experience a stroke. Among stroke survivors, over 6500 individuals access in-patient stroke rehabilitation and stay a median of 30 days (inter-quartile range 19 to 45 days). The 2015 update of the Canadian Stroke Best Practice Recommendations: Stroke Rehabilitation Practice Guidelines is a comprehensive summary of current evidence-based recommendations for all members of multidisciplinary teams working in a range of settings, who provide care to patients following stroke. These recommendations have been developed to address both the organization of stroke rehabilitation within a system of care (i.e., Initial Rehabilitation Assessment; Stroke Rehabilitation Units; Stroke Rehabilitation Teams; Delivery; Outpatient and Community-Based Rehabilitation), and specific interventions and management in stroke recovery and direct clinical care (i.e., Upper Extremity Dysfunction; Lower Extremity Dysfunction; Dysphagia and Malnutrition; Visual-Perceptual Deficits; Central Pain; Communication; Life Roles). In addition, stroke happens at any age, and therefore a new section has been added to the 2015 update to highlight components of stroke rehabilitation for children who have experienced a stroke, either prenatally, as a newborn, or during childhood. All recommendations have been assigned a level of evidence which reflects the strength and quality of current research evidence available to support the recommendation. The updated Rehabilitation Clinical Practice Guidelines feature several additions that reflect new research areas and stronger evidence for already existing recommendations. It is anticipated that these guidelines will provide direction and standardization for patients, families/caregiver(s), and clinicians within Canada and internationally.

Predictors of cholesterol and lipoprotein(a) testing in children with arterial ischemic stroke

BACKGROUND

Professional societies recommend screening lipids in healthy children. Dyslipidemia and elevated lipoprotein(a) are risk factors for adult cardiovascular disease and stroke. Their role in childhood arterial ischemic stroke is unexplored. Inconsistencies in testing limit analysis of existing lipid data. The objective of this study is to identify predictors and modifiable barriers to lipid testing in pediatric stroke.

METHODS

In this cross-sectional analysis, children (28 days-18 years) with arterial ischemic stroke were identified from the International Pediatric Stroke Study registry (January 2003-April 2012). Analyzed predictors of recorded lipid or lipoprotein a (Lp(a)) testing were age, sex, race, ethnicity, body mass index (BMI) category, other stroke risk factors, country, US region, and recurrent thrombosis.

RESULTS

Among 1652 participants (median, 6 years [interquartile range, 1.7-12.7]; 59.0% male; 40.8% white; 7.0% black), at least 1 lipid parameter or Lp (a) was available for 461 (27.9%). Compared with infants, testing was incrementally higher for older age categories. Compared with whites, testing was lower in blacks (adjusted odds ratio [OR], .5; 95% confidence interval [CI], .4-.5; P < .0001). Hispanic ethnicity only predicted testing within the United States (OR, 2.2; 95% CI, 1.4-3.4; P = .001]. Testing was lower in the United States and Australia and higher in Chile. Any thrombotic recurrence and recurrent symptomatic arterial ischemic stroke were associated with testing, unlike male sex, BMI, other stroke risk factors, and region in the United States.

CONCLUSIONS

Only a quarter of children with stroke had recorded lipid testing. Older age, white race, and recurrence predicted testing. In future study adjusting for these predictors may be necessary. Standardized lipid testing in children with arterial ischemic stroke may further our understanding of this potential risk factor.

Consensus definitions of complications for accurate recording and comparisons of surgical outcomes in pediatric neurosurgery

OBJECT

Monitoring and recording of complications in pediatric neurosurgery are important for quality assurance and in particular for improving outcomes. Lack of accurate or mutually agreed upon definitions hampers this process and makes comparisons between centers, which is an important method to improve outcomes, difficult. Therefore, the Canadian Pediatric Neurosurgery Study Group created definitions of complications in pediatric neurosurgery with consensus among 13 Canadian pediatric neurosurgical centers.

METHODS

Definitions of complications were extracted from randomized trials, prospective data collection studies, and the medical literature. The definitions were presented at an annual meeting and were subsequently recirculated for anonymous comment and revision, assembled by a third party, and re-presented to the group for consensus.

RESULTS

Widely used definitions of shunt failure were extracted from previous randomized trials and prospective studies. Definitions for wound infections were extracted from the definitions from the Centers for Disease Control and Prevention. Postoperative neurological deficits were based on the Pediatric Stroke Outcome Measure. Other definitions were created and modified by consensus. These definitions are now currently in use across the Canadian Pediatric Neurosurgery Study Group centers in Morbidity and Mortality data collection and for subsequent comparison studies.

CONCLUSIONS

Coming up with consensus definitions of complications in pediatric neurosurgery is a first step in improving the quality of outcomes. It is a dynamic process, and further refinements are anticipated. Center to center comparison will hopefully allow significant variations in outcomes to be identified and acted upon.

Towards a consensus-based classification of childhood arterial ischemic stroke

BACKGROUND AND PURPOSE

The implementation of uniform nomenclature and classification in adult arterial ischemic stroke (AIS) has been critical for defining outcomes and recurrence risks according to etiology and in developing risk-stratified treatments. In contrast, current classification and nomenclature in childhood AIS are often overlapping or contradictory. Our purpose was to develop a comprehensive consensus-based classification system for childhood AIS.

METHODS

Using a modified-Delphi method, members of the International Pediatric Stroke Study (IPSS) developed the Childhood AIS Standardized Classification And Diagnostic Evaluation (CASCADE) criteria. Two groups of pediatric stroke specialists from the IPSS classified 7 test cases using 2 methods each: (1) classification typical of the individual clinician's current clinical practice; and (2) classification based on the CASCADE criteria. Group 1 underwent in-person training in the utilization of the CASCADE criteria. Group 2 classified the same cases via an online survey, including definitions but without training. Inter-rater reliability (IRR) was assessed via multi-rater unweighted κ-statistic.

RESULTS

In Group 1 (with training), IRR was improved using CASCADE criteria (κ=0.78, 95% CI=[0.49, 0.94]), compared with typical clinical practice (κ=0.40, 95% CI=[0.11, 0.60]). In Group 2 (without training), IRR was lower than among trained raters (κ=0.61, 95% CI=[0.29, 0.77]), but higher than current practice (κ=0.23, 95% CI=[0.03, 0.36]).

CONCLUSIONS

A new, consensus-based classification system for childhood AIS, the CASCADE criteria, can be used to classify cases with good IRR. These preliminary findings suggest that the CASCADE criteria may be particularity useful in the setting of prospective multicenter studies in childhood-onset AIS, where standardized training of investigators is feasible.

Concurrent validity and reliability of retrospective scoring of the Pediatric National Institutes of Health Stroke Scale

BACKGROUND AND PURPOSE

The Pediatric National Institutes of Health Stroke Scale (PedNIHSS), an adaptation of the adult National Institutes of Health Stroke Scale, is a quantitative measure of stroke severity shown to be reliable when scored prospectively. The ability to calculate the PedNIHSS score retrospectively would be invaluable in the conduct of observational pediatric stroke studies. The study objective was to assess the concurrent validity and reliability of estimating the PedNIHSS score retrospectively from medical records.

METHODS

Neurological examinations from medical records of 75 children enrolled in a prospective PedNIHSS validation study were photocopied. Four neurologists of varying training levels blinded to the prospective PedNIHSS scores reviewed the records and retrospectively assigned PedNIHSS scores. Retrospective scores were compared among raters and to the prospective scores.

RESULTS

Total retrospective PedNIHSS scores correlated highly with total prospective scores (R(2)=0.76). Interrater reliability for the total scores was "excellent" (intraclass correlation coefficient, 0.95; 95% CI, 0.94-0.97). Interrater reliability for individual test items was "substantial" or "excellent" for 14 of 15 items.

CONCLUSIONS

The PedNIHSS score can be scored retrospectively from medical records with a high degree of concurrent validity and reliability. This tool can be used to improve the quality of retrospective pediatric stroke studies.

Placental pathology in neonatal stroke

OBJECTIVE

Neonatal stroke is increasingly recognized, and risk factors have been identified. The placenta has been implicated as a potential contributor to neonatal stroke; however, pathology has not been previously described. This case series systematically evaluates prenatal, maternal, and neonatal risk factors and describes placental pathology in 12 cases of neonatal stroke.

PATIENTS AND METHODS

We reviewed the Canadian Pediatric Ischemic Stroke Registry from 1992 to 2006, which consists of 186 neonatal stroke patients. Twelve patients with symptomatic cerebral arterial ischemic stroke or sinovenous thrombosis had their placenta available for pathologic examination. Clinical presentation; maternal, prenatal, and neonatal risk factors for stroke; and patient outcome were collected retrospectively from patient charts. Gross and microscopic placental pathology was described and classified into 4 pathologic categories.

RESULTS

Of 12 patients studied, 10 patients were male, 5 patients had arterial ischemic stroke, and 7 patients had sinovenous thrombosis. Maternal risk factors were identified in 5 cases, prenatal risk factors in 10 cases, and neonatal risk factors in 10 cases. Placental lesions were present in 10 cases and were classified as thromboinflammatory process in 6 cases, sudden catastrophic event in 5 cases, decreased placental reserve in 3 cases, and stressful intrauterine environment in 2 cases.

CONCLUSIONS

This study reviews detailed placental pathology in a selected cohort of patients presenting near the time of delivery and correlates this with clinical presentation, outcome, and risk factors for neonatal stroke. Our results suggest that multiple risk factors are involved in neonatal stroke, and placental pathology may be a contributing factor. The implications of specific placental lesions remain to be determined with larger, case-controlled studies.

Health-related quality of life in children and adolescents with stroke, self-report and parent/proxy report: Cross sectional investigation

Background

Aim of the present study was to assess health-related quality of life (HR-QoL) by self and proxy-parent assessment in children and adolescents who survived a first stroke episode.

Methods

We investigated HR-QoL in 133 pediatric stroke survivors (71 preschool children (G1) aged 4 to < 8 years and 62 school children/adolescents (G2) aged 8 to 21 years) and in 169 healthy controls aged 4 – 16 years. HR-QoL was assessed with the generic KINDL-R questionnaire exploring overall well-being and 6 sub-dimensions (physical well-being, psychological well-being, self-esteem, family-related well-being, friend-related well-being, and school-related well-being. Proxy-parent reports explored overall well-being and sub-dimensions. Results were compared within groups between cases and controls. In pediatric stroke survivors the neurological long-term outcome was measured with the standardized Pediatric Stroke Outcome Measure.

Results

65% of stroke survivors exhibited at least one motor-sensor/cognitive disability. G1 and G2 stroke survivors reported lower overall well-being compared with healthy controls. In G2 stroke survivors, friend-related well-being was significantly reduced compared with healthy controls, 85.0 vs. 73.0 points, p < 0.001. Parents/proxys of both G1 and G2 stroke survivors rated the overall well-being and all sub-dimensions (except family-related and school-related well-being and in G1 stroke survivors physical functioning) lower compared with parent/proxys of healthy children/adolescents.

Inpretation

Our results suggest that the KINDL-R questionnaire is a useful tool in the assessment of HR-QoL in pediatric stroke survivors. Compared with healthy controls, all pediatric/adolescent stroke survivors are strongly affected regarding their overall well-being and older children/adolescents regarding their well-being with peers.

Low detection rate of craniocervical arterial dissection in children using time-of-flight magnetic resonance angiography: causes and strategies to improve diagnosis

Craniocervical arterial dissection is a frequent cause of childhood arterial ischemic stroke requiring prompt diagnosis and treatment. However, there is no universal guideline for diagnostic cerebrovascular imaging in children. We assessed the role of time-of-flight magnetic resonance angiography in diagnosing craniocervical arterial dissection. We included children (1 month to 18 years) with craniocervical arterial dissection and ischemic stroke from January 1998 to June 2007. Institutional protocol required magnetic resonance imaging (MRI)/ magnetic resonance angiography for all ischemic stroke cases and conventional cerebral angiography if magnetic resonance angiography showed any arteriopathy. Among 233 ischemic stroke cases, craniocervical arterial dissection was diagnosed in 13 patients (5.6%; 10 males), with a mean age of 7.5 years. Initial time-of-flight magnetic resonance angiography missed dissection in 8 patients (61.5%) because the neck vessels were not scanned (n = 2), of suboptimal technique (n = 3), and of diagnostic error (n = 3). T1 fat-saturated MRI and contrast-enhanced magnetic resonance angiography were not performed in 12 patients. If suspicion for arterial dissection is high, T1 fat-saturated neck imaging and contrast-enhanced magnetic resonance angiography should be considered to maximize detection.

Predictors of cerebral arteriopathy in children with arterial ischemic stroke: results of the International Pediatric Stroke Study

BACKGROUND

Cerebral arteriopathies, including an idiopathic focal cerebral arteriopathy of childhood (FCA), are common in children with arterial ischemic stroke and strongly predictive of recurrence. To better understand these lesions, we measured predictors of arteriopathy within a large international series of children with arterial ischemic stroke.

METHODS AND RESULTS

Between January 2003 and July 2007, 30 centers within the International Pediatric Stroke Study enrolled 667 children (age, 29 days to 19 years) with arterial ischemic stroke and abstracted clinical and radiographic data. Cerebral arteriopathy and its subtypes were defined using published definitions; FCA was defined as cerebral arterial stenosis not attributed to specific diagnoses such as moyamoya, arterial dissection, vasculitis, or postvaricella angiopathy. We used multivariate logistic regression techniques to determine predictors of arteriopathy and FCA among those subjects who received vascular imaging. Of 667 subjects, 525 had known vascular imaging results, and 53% of those (n=277) had an arteriopathy. The most common arteriopathies were FCA (n=69, 25%), moyamoya (n=61, 22%), and arterial dissection (n=56, 20%). Predictors of arteriopathy include early school age (5 to 9 years), recent upper respiratory infections, and sickle cell disease, whereas prior cardiac disease and sepsis reduced the risk of arteriopathy. The only predictor of FCA was recent upper respiratory infection.

CONCLUSIONS

Arteriopathy is prevalent among children with arterial ischemic stroke, particularly those presenting in early school age, and those with a history of sickle cell disease. Recent upper respiratory infection predicted cerebral arteriopathy and FCA in particular, suggesting a possible role for infection in the pathogenesis of these lesions.

Ischemic stroke complicating pediatric cardiovascular disease

BACKGROUND

After a year of unsuccessful treatment for hypertension, a young boy underwent a stenting procedure for aortic hypoplasia and awoke with hemiparesis and language deficits.

INVESTIGATIONS

Neuroimaging, echocardiography, craniocervical vascular imaging and prothrombotic testing.

DIAGNOSIS

Procedure-related acute arterial ischemic stroke and malignant cerebral edema with herniation.

MANAGEMENT

Anticoagulation with heparin, seizure prophylaxis and neuroprotective care, including external cooling for hyperthermia. Medical management of increased intracranial pressure and hemicraniectomy at 48 h for malignant cerebral edema. Treatment of deep vein thrombosis with inferior vena cava filter was also required. Long term treatments included extensive rehabilitation, aspirin, antiepileptics, antidyskinetics, antidepressants, antihypertensives and cosmetic skull reconstruction.

Angiography of primary central nervous system angiitis of childhood: conventional angiography versus magnetic resonance angiography at presentation

BACKGROUND AND PURPOSE

To systematically analyze conventional angiographic (CA) features of children with primary central nervous system angiitis (cPACNS), to compare and correlate CA and MR angiography (MRA) lesion characteristics, and to define the sensitivity and specificity of MRA with CA as a reference standard.

METHODS

A retrospective, single-center cohort study of consecutive patients with cPACNS was performed. Patients with CA and MRA studies at diagnosis were included. Imaging studies were blindly reviewed by 2 neuroradiologists using a standard analysis protocol. CA and MRA studies were compared using nonparametric analysis.

RESULTS

Of 45 patients with MRA at diagnosis, there were 25 for whom CA and MRA studies were performed within 1 month of each other. These comprised the study group. The CA distribution of lesions was multifocal (76%) and proximal (86%) (P < .05) with a trend toward unilaterality (P = .06) with anterior circulation involvement (P = .08). The sensitivity and specificity of MRA for CA abnormality was 70% and 98%, respectively. There was no significant difference between MRA and CA for lesion detection or characterization (P = .87), and the modalities showed a fair correlation (kappa = 0.4).

CONCLUSION

Angiographic lesions are multifocal and occur proximally and unilaterally within the anterior circulation. There is no significant difference in the ability of MRA to detect and characterize lesions when compared with CA.

Mode of onset predicts etiological diagnosis of arterial ischemic stroke in children

BACKGROUND AND PURPOSE

In children, early differentiation among various etiologies of arterial ischemic stroke (AIS) is important. Cerebral arteriopathy is a frequently identified cause of childhood stroke. Children with arteriopathies require a different therapeutic approach from children with AIS of nonarteriopathic origin. We aimed to investigate the association between temporal features of the onset of neurological symptoms and stroke etiology in children with AIS.

METHODS

From a consecutive cohort of children (6 months to 18 years) with a confirmed diagnosis of AIS at one center, we selected all patients with transient cerebral arteriopathy (n=10), postvaricella angiopathy (n=20), dissection (n=8), cardio-embolic (n=8), and cryptogenic stroke (n=10). We retrospectively reviewed medical charts for mode of onset and classified the onset as either abrupt, reaching maximum severity of symptoms within 30 minutes, or nonabrupt, including a progressing, stuttering, or recurring course. We compared the mode of onset in patients with known cerebral arteriopathy to those with nonarteriopathic stroke using multivariate logistic regression modeling.

RESULTS

There were no significant differences for age, gender, location of infarction, seizures, and headache between the arteriopathic and nonarteriopathic group. Most children with nonarteriopathic AIS had an abrupt onset (72%), compared with 32% in children with arteriopathic stroke. With nonabrupt onset, the odds of having an arteriopathic etiology was 6.1 (95% CI, 1.6 to 22.8; P=0.007) after correction for possible confounders.

CONCLUSIONS

Mode of onset predicts etiological diagnosis of childhood AIS and may guide prioritization of ancillary investigations and choice of treatment. A nonabrupt onset of symptoms is associated with arteriopathic stroke, particularly with presumed inflammatory arteriopathies.

Pediatric stroke: Opportunities and challenges in planning clinical trials

A conference entitled "Towards the establishment of clinical trials in pediatric and newborn stroke" assembled stroke animal model researchers, pediatric stroke researchers, adult stroke trialists, and members of the Food and Drug Administration and National Institute of Neurological Disorders and Stroke to focus on the obstacles and opportunities for conducting randomized trials in pediatric stroke. The need for good prospective clinical data in newborn and pediatric stroke in regard to outcome and recurrence risk was stressed. For clinical trials, there should be a scientific rationale. Preclinical data should be as promising and as complete as possible. Adult data should be explored, both positive and negative. For medication trials, reasonable safety and bioavailability data for the agent in question should be available. Commitment of researchers, collaboration with colleagues in primary care, emergency rooms, and intensive care units, and most importantly the willingness to participate of children and their families will all be crucial. Most children with cancer in the United States are enrolled in clinical trials and have an outcome superior to the adult patient with cancer, who is less likely to be enrolled in a trial. We should strive for enrollment and outcome results in pediatric stroke similar to those found in pediatric oncology trials.

Infantile spasms as an adverse outcome of neonatal cortical sinovenous thrombosis

Cerebral sinovenous thrombosis is a rare but potentially serious condition often occurring in children with nonspecific presenting features. Much remains to be learned about the long-term outcome of infants with cerebral sinovenous thrombosis. We report a series of four patients taken from a prospective database of neonates with sinovenous thrombosis who subsequently developed infantile spasms, three with hypsarrythmia on electroencephalography and one with multiple independent spike foci. The first patient presented at 2 weeks of age with hypernatremia, dehydration, and seizures. He was found to have extensive thrombosis and hemorrhagic infarction of the right basal ganglia. The second patient presented at 5 weeks of life and was found to have sagittal sinus thrombosis with bilateral intracranial hemorrhage. The third patient presented with seizures on day 1 of life and was found to have venous thrombosis involving the torcular, extending into the sagittal sinus. The fourth patient presented at 3 weeks with lethargy and seizures. He was diagnosed with bacterial meningitis and also had extensive sinus thrombosis. All patients developed infantile spasms at ages 9, 7, 11, and 10 months, respectively. This is the first report in the English literature describing infantile spasms as a possible outcome of sinovenous thrombosis in early infancy.

In pursuit of evidence-based treatments for paediatric stroke: the UK and Chest guidelines

BACKGROUND

Arterial ischaemic stroke and cerebral sinovenous thrombosis are increasingly seen in infants and children. Incidence ranges from two to six per 100,000 children a year. Adverse outcome including death, neurological deficits, and reduced quality of life affect most children with stroke. Residual neurological deficits last many decades, for the rest of a patient's life. Of major concern is the risk of recurrent stroke, which affects up to 25% of children who have arterial ischaemic stroke after the newborn period. Children with ischaemic stroke are empirically treated with antithrombotics including antiplatelet (aspirin and clopidogrel) and anticoagulant (heparins and warfarin) drugs. No randomised controlled trials have been done besides those in patients with sickle-cell disease and adult trial data are not directly applicable to paediatric stroke due to maturational differences in coagulation and vascular systems as well as different stroke mechanisms.

RECENT DEVELOPMENTS

National and international networks of clinical and basic researchers focused on paediatric stroke are now developing. Recently published cohort and case-controlled studies are elucidating stroke mechanisms, outcomes, and treatment safety in children. Two sets of guidelines have been published in the past 6 months. These guidelines differ both in the scope of treatments and subgroups of patients with stroke they cover; however, both focus on ischaemic stroke beyond the newborn period. There are areas of agreement-for children with sickle-cell disease and stroke, both guidelines recommend initial and maintenance transfusion therapy to reduce the proportion of sickle-cell haemoglobin to less than 30%. For children with sinovenous thrombosis or arterial stroke due to dissection or cardiac embolism, both guidelines recommend anticoagulant therapy with warfarin or low molecular weight heparin for 3-6 months. However, the guidelines diverge in their recommendations for the initial treatment of non-haemorrhagic arterial ischaemic stroke, one recommending aspirin and the other 5-7 days of anticoagulants. The guidelines also differ in their recommendations for long-term treatment of children after arterial ischaemic stroke, one set recommending maintenance aspirin in all patients and the other only in children with vasculopathy. These differences arise from both a lack of sufficient evidence and the differing views of neurologists and haematologists in the treatment of paediatric cerebral thrombosis. WHERE NEXT?: Multicentre studies and networks provide increasingly precise data regarding mechanisms, outcomes, and treatment safety in paediatric stroke. These data and networks will enable clinical trials to address areas of divergent opinion and improve the outcome from childhood stroke in the near future.

Childhood acute myelomonocytic leukemia (AML-M4) presenting as catastrophic antiphospholipid antibody syndrome

: The authors describe a 15-year-old girl presenting with a cerebral ischemic stroke as the first manifestation of catastrophic antiphospholipid antibody syndrome secondary to acute myeloid leukemia (AML). Despite treatment with anticoagulants, therapeutic plasma exchange, and chemotherapy, the patient developed multiorgan thromboses and failure, eventually culminating in death. This unusual presentation of AML has not been previously described in children. Clinical features of antiphospholipid antibody syndrome and current knowledge regarding its association with malignancies are reviewed.

Anticoagulation for cerebral sinus thrombosis

BACKGROUND

Treatment of cerebral sinus thrombosis with anticoagulants has been controversial. Anticoagulants may prevent new venous infarcts, neurologic deterioration, and pulmonary embolism but may also promote haemorrhages.

OBJECTIVES

To review the available evidence regarding the effectiveness and safety of anticoagulant therapy in patients with confirmed cerebral sinus thrombosis.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched 18 March 2002). We also searched MEDLINE (1966-Oct 2001), EMBASE (1980-Feb 2002) and the Cochrane Controlled Trials Register (Cochrane Library, 2002 Issue 1) and contacted authors to identify additional published and unpublished studies.

SELECTION CRITERIA

Unconfounded randomised controlled trials in which anticoagulant therapy was compared with placebo or open control in patients with cerebral sinus thrombosis (confirmed by intra-arterial contrast or magnetic resonance angiography).

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted outcomes for each of the two treatment groups (anticoagulant treatment and control). The outcome data for each patient are analysed in the treatment group to which the patient was originally allocated ('intention to treat' analysis). A weighted estimate of the treatment effects across trials (relative risk, absolute risk reduction) is calculated using the Cochrane statistical software.

MAIN RESULTS

Two small trials involving 79 patients fulfilled the inclusion criteria. One trial (20 patients) examined the efficacy of intravenous, adjusted dose unfractionated heparin. The other trial (59 patients) examined high dose, body weight adjusted, subcutaneous, low-molecular weight heparin (Nadroparin). Anticoagulant therapy was associated with a pooled relative risk of death of 0.33 (95 % CI 0.08 to 1.21) and of death or dependency of 0.46 (95 % CI 0.16 to 1.31). No new symptomatic intracerebral haemorrhages were observed. One major gastro-intestinal haemorrhage occurred after anticoagulant treatment. Two control patients (placebo) had a diagnosis of probable pulmonary embolism (one fatal).

REVIEWER'S CONCLUSIONS

Based upon the limited evidence available, anticoagulant treatment for cerebral sinus thrombosis appeared to be safe and was associated with a potentially important reduction in the risk of death or dependency which did not reach statistical significance.

Report of the National Institute of Neurological Disorders and Stroke workshop on perinatal and childhood stroke

The National Institute of Neurological Disorders and Stroke and the Office of Rare Disorders sponsored a workshop on perinatal and childhood stroke in Bethesda, Maryland, on September 18 and 19, 2000. This was an international workshop to bring together experts in the field of perinatal and childhood stroke. Topics covered included epidemiology, animal models, risk factors, outcome and prognosis, and areas of future research for perinatal and childhood stroke. Stroke in infants and children is an important cause of morbidity and mortality and an emerging area for clinical and translational research. Currently, there is no consensus on the classification, evaluation, outcome measurement, or treatment of perinatal and childhood stroke. Pediatric stroke registries are needed to generate data regarding risk factors, recurrence, and outcome. The impact of maternal and perinatal factors on risk and outcome of neonatal stroke needs to be studied. This information is essential to identifying significant areas for future treatment and prevention.

Successful treatment of systemic blastomycosis with high-dose ketoconazole in a renal transplant recipient

A case of disseminated blastomycosis in a male renal transplant recipient is presented. Discontinuation of immunosuppressive therapy and treatment with high-dose ketoconazole was successful in treating the patient's cutaneous and pulmonary disease initially. Ketoconazole was discontinued after 12 months of chronic therapy, but 2 weeks after discontinuation, blastomycosis recurred. High-dose ketoconazole was again effective; the patient remains asymptomatic presently on chronic suppressive therapy with ketoconazole.

Serum gonadotropin patterns in patients with chronic renal failure on hemodialysis

A clinical model to study gonadotropin patterns when minimal or no kidney function persists is available in patients demonstrating chronic renal failure and maintained on hemodialysis. Hemodialysis does not alter the serum level of FSH and LH. In 9 premenopausal women, 3 serum patterns of FSH and LH were observed. The most common serum pattern of gonadotropin is a normal concentration of FSH and a moderately elevated level of LH, wherein LH/FSH is 4:1. This pattern was also observed in 4 male patients maintained on hemodialysis. The serum gonadotropin pattern in oophorectomized women on hemodialysis is the same as in post-menopausal women with normal renal function (i.e. high LH and high FSH). Serum estrogen levels are below normal in all female patients studied. Renal failure does not induce a suppression in the hypothalamic-pituitary control of gonadotropin release. Renal failure is not associated with an unique serum pattern of FSH and LH. This suggests that kidney excretion is not the only mechanism for clearing gonadotropin from blood.