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Singh J, Krishnan P, Slim M, Pontigon AM, Paterson J, Moharir M, MacGregor D, Dlamini N, Westmacott R, deVeber G. Abstract WMP120: The Role of Age, Lesion Location and Volume in Predicting Long-Term Neurological Outcomes in Pediatric Ischemic Stroke. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wmp120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
The balance of plasticity versus vulnerability to acute ischemic injury in the immature brain across development remains controversial. We aimed to investigate the relationship between age at stroke and lesion location and volume with long-term outcomes following arterial ischaemic stroke (AIS).
Hypothesis:
Age at stroke onset interacts with lesion location and volume to predict long-term neurological outcomes.
Methods:
In a single-centre prospective study, children aged term birth to 18 years with acute symptomatic AIS from 1992 to 2016 who underwent neuroimaging (CT/MRI) within 14 days of stroke onset were studied. Long term outcomes were assessed with the Pediatric Stroke Outcome Measure (PSOM). Outcomes were defined as normal (score 0-0.5 on 1-5 PSOM subscales), otherwise abnormal. AIS lesions were classified based on major (anterior, middle, posterior, other) cerebral arteries and branch sub-territories (e.g. MCA-lateral lenticulostriate). For each vascular territory, the proportion of infarcted brain was estimated as ‘small’ (≤50% territory) or ‘large’ (>50% territory). Factors predictive of long term outcomes were evaluated using logistic regression models.
Results:
Among 285 children, median age at stroke onset was 22 months (IQR: 0.03-101), 41% were females. PSOM scoring at median 9 years (IQR: 4-15) post-stroke was normal in 61%. Abnormal outcome was associated with age 1-4 years (OR=2.2, 95% CI: 1.02-4.9), ‘large’ proportion infarcts involving cortex within any major artery territory (OR=6.1, 95% CI: 2.6-14.4), and subcortical infarcts: OR= 2.7 (95% CI: 1.4-5.4) for small proportion infarcts; OR=8.3 (95% CI: 4.2-16.6) for large proportion infarcts in either medial or lateral lenticulostriate arteries; OR=15.8 (95% CI: 5-50.3) for large volume lesions in both lenticulostriate territories. In multivariate logistic regression, age, cortical and subcortical infarcts predicted long-term neurologic outcomes.
Conclusions:
In addition to age at stroke onset, infarct location including volume plays a key role in predicting long-term neurological outcomes in children. While the relationship between age and neurological outcomes seems to be bimodal, a linear effect of lesion volume on stroke outcomes is evident.
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deVeber G, Kirkham F, Shannon K, Brandão L, Sträter R, Kenet G, Clausnizer H, Moharir M, Kausch M, Askalan R, MacGregor D, Stoll M, Torge A, Dlamini N, Ganesan V, Prengler M, Singh J, Nowak-Göttl U. Recurrent stroke: the role of thrombophilia in a large international pediatric stroke population. Haematologica 2019; 104:1676-1681. [PMID: 30679327 PMCID: PMC6669164 DOI: 10.3324/haematol.2018.211433] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/22/2019] [Indexed: 12/04/2022] Open
Abstract
Risk factors for arterial ischemic stroke in children include vasculopathy and prothrombotic risk factors but their relative importance to recurrent stroke is uncertain. Data on recurrent stroke from databases held in Canada (Toronto), Germany (Kiel-Lübeck/Münster), and the UK (London/Southampton) were pooled. Data were available from 894 patients aged 1 month to 18 years at first stroke (median age, 6 years) with a median follow-up of 35 months. Among these 894 patients, 160 (17.9%) had a recurrence between 1 day and 136 months after the first stroke (median, 3.1 months). Among 288 children with vasculopathy, recurrence was significantly more common [hazard ratio (HR) 2.5, 95% confidence interval (95% CI) 1.92-3.5] compared to the rate in children without vasculopathy. Adjusting for vasculopathy, isolated antithrombin deficiency (HR 3.9; 95% CI: 1.4-10.9), isolated elevated lipoprotein (a) (HR 2.3; 95% CI: 1.3-4.1), and the presence of more than one prothrombotic risk factor (HR 1.9; 95% CI: 1.12-3.2) were independently associated with an increased risk of recurrence. Recurrence rates calculated per 100 person-years were 10 (95% CI: 3-24) for antithrombin deficiency, 6 (95% CI: 4-9) for elevated lipoprotein (a), and 13 (95% CI: 7-20) for the presence of more than one prothrombotic risk factor. Identifying children at increased risk of a second stroke is important in order to intensify measures aimed at preventing such recurrences.
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Surmava AM, Maclagan LC, Khan F, Kapral MK, Hall RE, deVeber G. Incidence and Current Treatment Gaps in Pediatric Stroke and TIA: An Ontario-Wide Population-Based Study. Neuroepidemiology 2019; 52:119-127. [PMID: 30654369 DOI: 10.1159/000493140] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 08/21/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Reported incidence rates of pediatric stroke and transient ischemic attack (TIA) range widely. Treatment gaps are poorly characterized. We sought to evaluate in -Ontario, the incidence and characteristics of pediatric stroke and TIA including care gaps and the predictive value of International Classification of Diseases (ICD) codes. METHODS A retrospective chart review was conducted at 147 Ontario pediatric and adult acute care hospitals. Pediatric stroke and TIA cases (age < 18 years) were identified using ICD-10 code searches in the 2010/11 Canadian Institute for Health Information's Discharge Abstract Database (CIHI-DAD) and National Ambulatory Care Reporting System (NACRS) databases in the Ontario Stroke Audit. RESULTS Among 478 potential pediatric stroke and TIA cases identified in the CIHI-DAD and NACRS databases, 163 were confirmed as cases of stroke and TIA during the 1-year study period. The Ontario stroke and TIA incidence rate was 5.9 per 100,000 children (3.3 ischemic, 1.8 hemorrhagic and 0.8 TIA). Mean age was 6.4 years (16% neonate). Nearly half were not imaged within 24 h of arrival in emergency and only 56% were given antithrombotic treatment. At discharge, 83 out of 121 (69%) required health care services post-discharge. Overall positive predictive value (PPV) of ICD-10 stroke and TIA codes was 31% (range 5-74%) and yield ranged from 2.4 to 29% for acute stroke or TIA event; code I63 achieved maximal PPV and yield. CONCLUSION Our population-based study yielded a higher incidence rate than prior North-American studies. Important care gaps exist including delayed diagnosis, lack of expert care, and departure from published treatment guidelines. Variability in ICD PPV and yield underlines the need for prospective data collection and for improving the pediatric stroke and TIA coding processes.
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Kouzmitcheva E, Andrade A, Muthusami P, Shroff M, MacGregor DL, deVeber G, Dlamini N, Moharir M. Anatomical Venous Variants in Children With Cerebral Sinovenous Thrombosis. Stroke 2019; 50:178-180. [PMID: 30580715 DOI: 10.1161/strokeaha.118.023482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Literature is sparse on the frequency and significance of anatomical venous variants (AVVs) in pediatric cerebral sinovenous thrombosis (CSVT). Methods- We retrospectively reviewed children with CSVT and controls undergoing computed tomography/magnetic resonance venography from January 2008 to 2014. Clinical features examined included raised intracranial pressure, risk factors, and treatment. Radiological features examined included CSVT location, presence and type of AVVs, hemorrhagic venous infarction, and venous collateralization. Clinical outcome was measured by the pediatric stroke outcome measure and radiological outcome by thrombus recanalization. Results- Fifty-one children with CSVT were identified. Twenty-two (43%) had AVVs at presentation. Nineteen (86%) had hypoplasia/absence of major dural sinus, 5 (23%) had persistent fetal structures, 3 (14%) had duplications/fenestrations, and 1 (5%) had disconnected superficial and deep venous systems. Controls had a slightly higher but nonsignificant prevalence 26 (51%) of AVVs. No significant clinical and radiological differences were observed between children with CSVT and AVVs compared with those with typical venous anatomy. Conclusions- AVVs are seen in many children with and without CSVT and do not seem to alter the presentation or clinical course. The influence of these variations on the brain's ability to tolerate venous congestion because of thrombosis merits further study.
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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: 836] [Impact Index Per Article: 139.3] [Reference Citation Analysis] [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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Deotto A, Westmacott R, Fuentes A, deVeber G, Desrocher M. Does stroke impair academic achievement in children? The role of metacognition in math and spelling outcomes following pediatric stroke. J Clin Exp Neuropsychol 2018; 41:257-269. [DOI: 10.1080/13803395.2018.1533528] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Kouzmitcheva E, Krishnan P, Dlamini N, deVeber G, MacGregor DL, Moharir M. Child Neurology: Mimics of cerebral sinovenous thrombosis: A pediatric case series. Neurology 2018; 91:e1545-e1548. [PMID: 30323079 DOI: 10.1212/wnl.0000000000006363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Westmacott R, McDonald KP, Roberts SD, deVeber G, MacGregor D, Moharir M, Dlamini N, Williams TS. Predictors of Cognitive and Academic Outcome following Childhood Subcortical Stroke. Dev Neuropsychol 2018; 43:708-728. [PMID: 30321060 DOI: 10.1080/87565641.2018.1522538] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Childhood arterial ischemic stroke often involves basal ganglia and thalamus but little is known about neuropsychological outcomes in this group. We examined intellectual ability, academics, attention, executive function, and psychological diagnoses in children and adolescents (6-20 years of age) with childhood stroke involving the basal ganglia (n = 32) or thalamus (n = 12). Intellectual ability was age-appropriate but working memory was significantly lower than expected. Compared to the normative mean, the stroke group exhibited significantly weaker performance in reading comprehension, math fluency, attention, and greater challenges with executive function. Children with basal ganglia stroke had weaker working memory and were more likely to receive diagnoses of Attention Deficit Hyperactivity Disorder and Anxiety Disorder than those with thalamic stroke. Lesion size was most important in predicting working memory ability, whereas age at stroke and age at test were important in predicting academic ability.
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Dlamini N, Shah-Basak P, Leung J, Kirkham F, Shroff M, Kassner A, Robertson A, Dirks P, Westmacott R, deVeber G, Logan W. Breath-Hold Blood Oxygen Level-Dependent MRI: A Tool for the Assessment of Cerebrovascular Reserve in Children with Moyamoya Disease. AJNR Am J Neuroradiol 2018; 39:1717-1723. [PMID: 30139753 DOI: 10.3174/ajnr.a5739] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 06/10/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE There is a critical need for a reliable and clinically feasible imaging technique that can enable prognostication and selection for revascularization surgery in children with Moyamoya disease. Blood oxygen level-dependent MR imaging assessment of cerebrovascular reactivity, using voluntary breath-hold hypercapnic challenge, is one such simple technique. However, its repeatability and reliability in children with Moyamoya disease are unknown. The current study sought to address this limitation. MATERIALS AND METHODS Children with Moyamoya disease underwent dual breath-hold hypercapnic challenge blood oxygen level-dependent MR imaging of cerebrovascular reactivity in the same MR imaging session. Within-day, within-subject repeatability of cerebrovascular reactivity estimates, derived from the blood oxygen level-dependent signal, was computed. Estimates were associated with demographics and intellectual function. Interrater reliability of a qualitative and clinically applicable scoring scheme was assessed. RESULTS Twenty children (11 males; 12.1 ± 3.3 years) with 30 MR imaging sessions (60 MR imaging scans) were included. Repeatability was "good" on the basis of the intraclass correlation coefficient (0.70 ± 0.19). Agreement of qualitative scores was "substantial" (κ = 0.711), and intrarater reliability of scores was "almost perfect" (κ = 0.83 and 1). Younger participants exhibited lower repeatability (P = .027). Repeatability was not associated with cognitive function (P > .05). However, abnormal cerebrovascular reactivity was associated with slower processing speed (P = .015). CONCLUSIONS Breath-hold hypercapnic challenge blood oxygen level-dependent MR imaging is a repeatable technique for the assessment of cerebrovascular reactivity in children with Moyamoya disease and is reliably interpretable for use in clinical practice. Standardization of such protocols will allow further research into its application for the assessment of ischemic risk in childhood cerebrovascular disease.
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Andrew M, David M, deVeber G, Brooker LA. Arterial Thromboembolic Complications in Paediatric Patients. Thromb Haemost 2018. [DOI: 10.1055/s-0038-1657618] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Fox CK, Jordan LC, Beslow LA, Armstrong J, Mackay MT, deVeber G. Children with post-stroke epilepsy have poorer outcomes one year after stroke. Int J Stroke 2018; 13:820-823. [PMID: 29956597 DOI: 10.1177/1747493018784434] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Epilepsy is a common complication of pediatric stroke. Aim In this study, we aim to measure the association between epilepsy and neurologic outcome after childhood arterial ischemic stroke. Methods Prospective cohort study of children (29 days-19 years) enrolled after an acute arterial ischemic stroke at 21 international pediatric stroke centers and followed to identify epilepsy. One year post-stroke, outcomes were scored using the examination-based Pediatric Stroke Outcome Measure (range = 0-10); higher values reflect greater disability. Ordinal logistic regression was used to measure the association of Pediatric Stroke Outcome Measure scores (categorized as 0-1, 1.5-3, 3.5-6, 6.5-10) with epilepsy. Results Investigators enrolled 86 children (median age = 6.1 years, interquartile range (IQR) = 1.4-12.2 years) with acute stroke. At 1 year, 18/80 (23%) remained on an anticonvulsant including 8/80 (10%) with epilepsy. Among the 70 with Pediatric Stroke Outcome Measure scored, the median was 0.5 (IQR = 0-1.5) for children without epilepsy ( n = 63), and 6 (IQR = 0.5-10) for children with epilepsy ( n = 7). In univariable analyses, poorer 1-year outcome was associated with middle cerebral artery stroke, cortical infarcts, hemorrhagic transformation, hospital disposition not to home, and epilepsy. In multivariable analysis, middle cerebral artery stroke (odds ratio (OR) = 4.9, 95% confidence intervals (CI) = 1.1-21.3) and epilepsy (OR = 24.1, CI = 1.5-380) remained associated with poorer outcome. Conclusions Children who developed epilepsy during the first year post-stroke had poorer neurologic outcomes than those without epilepsy.
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Beslow LA, Dowling MM, Hassanein SMA, Lynch JK, Zafeiriou D, Sun LR, Kopyta I, Titomanlio L, Kolk A, Chan A, Biller J, Grabowski EF, Abdalla AA, Mackay MT, deVeber G. Mortality After Pediatric Arterial Ischemic Stroke. Pediatrics 2018; 141:peds.2017-4146. [PMID: 29695585 DOI: 10.1542/peds.2017-4146] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2018] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES Cerebrovascular disease is among the top 10 causes of death in US children, but risk factors for mortality are poorly understood. Within an international registry, we identify predictors of in-hospital mortality after pediatric arterial ischemic stroke (AIS). METHODS Neonates (0-28 days) and children (29 days-<19 years) with AIS were enrolled from January 2003 to July 2014 in a multinational stroke registry. Death during hospitalization and cause of death were ascertained from medical records. Logistic regression was used to analyze associations between risk factors and in-hospital mortality. RESULTS Fourteen of 915 neonates (1.5%) and 70 of 2273 children (3.1%) died during hospitalization. Of 48 cases with reported causes of death, 31 (64.6%) were stroke-related, with remaining deaths attributed to medical disease. In multivariable analysis, congenital heart disease (odds ratio [OR]: 3.88; 95% confidence interval [CI]: 1.23-12.29; P = .021), posterior plus anterior circulation stroke (OR: 5.36; 95% CI: 1.70-16.85; P = .004), and stroke presentation without seizures (OR: 3.95; 95% CI: 1.26-12.37; P = .019) were associated with in-hospital mortality for neonates. Hispanic ethnicity (OR: 3.12; 95% CI: 1.56-6.24; P = .001), congenital heart disease (OR: 3.14; 95% CI: 1.75-5.61; P < .001), and posterior plus anterior circulation stroke (OR: 2.71; 95% CI: 1.40-5.25; P = .003) were associated with in-hospital mortality for children. CONCLUSIONS In-hospital mortality occurred in 2.6% of pediatric AIS cases. Most deaths were attributable to stroke. Risk factors for in-hospital mortality included congenital heart disease and posterior plus anterior circulation stroke. Presentation without seizures and Hispanic ethnicity were also associated with mortality for neonates and children, respectively. Awareness and study of risk factors for mortality represent opportunities to increase survival.
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Dlamini N, Yau I, Muthusami P, Mikulis DJ, Elbers J, Slim M, Askalan R, MacGregor D, deVeber G, Shroff M, Moharir M. Arterial Wall Imaging in Pediatric Stroke. Stroke 2018; 49:891-898. [DOI: 10.1161/strokeaha.117.019827] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/02/2018] [Accepted: 01/25/2018] [Indexed: 11/16/2022]
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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] [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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Felling RJ, Rafay MF, Bernard T, Carpenter JL, Dlamini N, Hassanein SM, Jordan LC, Noetzel MJ, Rivkin MJ, Shapiro K, deVeber G. Abstract TMP102: Predicting Recovery and Outcome After Pediatric Stroke. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.tmp102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We aimed to characterize the timing of recovery and predictors of outcome following pediatric stroke, with the hypothesis that the recovery pattern after stroke is influenced by age. While the immature brain is often presumed to have an increased capacity for neuroplasticity, there is little direct data examining how recovery differs in children of different ages. We reviewed data for children with arterial ischemic stroke (AIS) who were enrolled in the International Pediatric Stroke Study, a prospective registry of children with stroke. Inclusion criteria included a diagnosis of AIS and the availability of outcome at two years after the index stroke event. A subset of these patients who had multiple assessments over time were used to study longitudinal patterns of recovery. We investigated demographic, clinical, and radiologic associations with both early outcome at discharge and long term outcome at two years using multinomial logistic regression. Categorical outcomes at each timepoint were defined by Pediatric Stroke Outcome Measure (PSOM). We studied longitudinal recovery using time-to-event (survival) analysis. 614 out of 4,294 patients met our inclusion criteria. 202 patients had perinatal AIS while 412 had childhood AIS. Perinatal AIS was associated with significant worsening between discharge and two years, as neurologic impairment became more apparent, but with better outcomes at both timepoints compared with childhood AIS (moderate/severe: 14% vs 49% at discharge, 47% vs 54% at 2 years). Predictors of severe deficits in univariate analyses included age at stroke (perinatal vs. childhood), hemiparesis or decreased consciousness at presentation, anterior circulation, and large vessel involvement. In longitudinal analysis, improvement in PSOM occurred for a longer time after stroke onset in younger children compared to older children. Although age has a strong influence on recovery after pediatric stroke, all children had the capacity to demonstrate recovery over extended periods of time. Understanding the timing and predictors of recovery will allow us to better target therapies to the appropriate windows of opportunity, thereby improving outcomes after pediatric stroke.
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Beslow LA, Dowling MM, Hassanein SM, Zafeiriou D, Sun LR, Kopyta IA, Chan AK, Biller J, Lynch JK, Grabowski EF, Titomanlio L, Kolk A, Abdalla AA, Mackay MT, deVeber G. Abstract 15: Mortality After Pediatric Arterial Ischemic Stroke: Results From the International Paediatric Stroke Study. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Stroke is reported among the top 10 causes of death in children in the US. In the Kids’ Inpatient Database, older age and Hispanic ethnicity were risk factors for mortality after pediatric ICH. Limited data is available regarding risk factors for death after pediatric arterial ischemic stroke (AIS).
Objective:
To identify predictors of in-hospital mortality in pediatric patients hospitalized with AIS.
Methods:
Neonates (0-28 days) and children (29 days- <19 years) with AIS were enrolled from 1/2003 to 7/2014 in the IPSS multinational stroke registry. Death prior to hospital discharge and cause of death was ascertained from medical records. Logistic regression was used to analyze associations between risk factors and in-hospital mortality.
Results:
Fourteen of 915 neonates (1.5%) and 74/2,285 children (3.2%) died during hospitalization. Of 54 cases with reported causes of death, 32 (59%) were related to AIS (herniation 2, brain death 10, ICH/hemorrhagic transformation 5, care withdrawal due to stroke severity 15), with the remaining deaths attributed to underlying medical disease. Of 356 children with Pediatric NIH Stroke Scale (PedNIHSS) scores, median PedNIHSS was 19 (IQR 14-27) among the 13 children who died and 7 (IQR 3-12) among the 343 children who did not die. In multivariable analysis, congenital heart disease (OR 4.1, 95%CI 1.3-13, p=0.018) and posterior plus anterior circulation stroke (OR 4.3, 95%CI 1.3-14, p=0.017) were associated with in-hospital mortality for neonates, while higher PedNIHSS [OR 1.11 (per 1 point PedNIHSS increase), 95%CI 1.03-1.19, p=0.004], Hispanic ethnicity (OR 7.6, 95%CI 1.8-32.3, p=0.006), and cardiac disease (OR 7.5, 95%CI 1.5-38.6, p=0.015) were associated with in-hospital mortality for children.
Conclusions:
In-hospital mortality occurred in about 2% of pediatric AIS cases with nearly 60% attributable to stroke. Risk factors for in-hospital mortality included cardiac disease and stroke severity, factors also associated with mortality in adults. Hispanic ethnicity, a factor associated with mortality in childhood ICH, was also associated with mortality after childhood AIS; the underlying reasons are unclear. Additional information is needed on stroke-related deaths after hospitalization.
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Guiliams KP, Dowling MM, Zafeiriou DI, Friedman N, deVeber G, Fox CK. Abstract 18: Anticonvulsant Medication Practice Varies After Pediatric Arterial Ischemic Stroke. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Acute symptomatic seizures are common after pediatric arterial ischemic stroke (AIS). We sought to analyze practice variation in anticonvulsant medication treatment (ACM) after AIS. We hypothesized that ACM practice varies but is related to age, acute seizure frequency and duration, cortical involvement, and hemorrhagic conversion.
Methods:
Seizures in Pediatric Stroke (SIPS), an international, prospective study, enrolled neonatal (<28 days) and childhood (<19 years) acute AIS patients 3/2011-8/2012. Seizures and ACM were recorded. Among patients with acute seizures (<7 days post-stroke), we used univariate Spearman’s correlations to determine association between ACM and clinical predictors at both discharge and 12-month time points. Variables with p <0.05 at univariate analysis were entered into a logistic regression model.
Results:
Among 116 patients, 27 neonates and 31 children (ages 0.2-17 years) had an acute seizure. In neonates, 24 (89%) had ACM continued after discharge, but only 4 (15%) remained on ACM at 12 m (3 having had post-discharge seizure). Phenobarbital was the most common ACM in neonates at discharge (n=14) and 12m (n=2, levetiracetam = 2). In children, 23 (74%) had ACM at discharge, and 17 (57%) remained on ACM at 12m (7 having had a post-discharge seizure). All patients in study with post-discharge seizure were discharged on ACM. Two neonates and 1 child with post-discharge seizure were not on ACM at 12m. Levetiracetam was the most common ACM in children at discharge (n=11) and 12m (n=9). No single variable correlated with discharge ACM (Table). ACM at 12 m correlated with neonatal stroke, >10 seizures in acute period, and post-discharge seizure. In logistic regression, all variables remained significant.
Conclusion:
ACM management after acute post-stroke seizures varies widely in pediatric stroke. Neonates rarely, but children frequently, are continued on ACM up to 1 year, even without further seizures.
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Abstract
SummaryThe past decade has seen a dramatic increase in pediatric stroke research. However few studies have addressed anti-thrombotic safety or effectiveness. Three paediatric stroke guidelines combining research data with expert consensus have been published in the past five years. For most patients treatment recommendations are consistent. Newborns with arterial ischaemic stroke (AIS) rarely require antithrombotic treatment given their extremely low risk of recurrence. In children with AIS a substantial recurrence risk means that antithrombotic treatment is required unless contraindicated. Anticoagulation (heparins, warfarin) is recommended for possible or established dissection and cardiogenic embolism. Antiplatelet treatment is recommended for other children with AIS. For neonatal cerebral sinovenous thrombosis (CSVT) most centers provide initial anticoagulation in the absence of haemorrhagic contra indications, and otherwise, monitor for propagation. Children with CSVT, even with haemorrhagic infarction, more consistently receive anticoagulation, as in adults. While more studies are necessary, current treatment guidelines offer an interim option for guiding the treatment of paediatric stroke.
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Lee S, Rivkin MJ, Kirton A, deVeber G, Elbers J. Moyamoya Disease in Children: Results From the International Pediatric Stroke Study. J Child Neurol 2017; 32:924-929. [PMID: 28715924 DOI: 10.1177/0883073817718730] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study aimed to describe children with moyamoya disease from an international multicenter stroke database, and explore risk factors for stroke recurrence. We reviewed data of children >28-days old with moyamoya disease enrolled in the International Pediatric Stroke Study from January 2003 to March 2013. A total of 174 children from 32 sites and 14 countries had moyamoya disease; median age 7.4 years, 49% male. Of these, 90% presented with ischemic stroke, 7.5% with transient ischemic attack, and 2.5% with hemorrhagic stroke. One-third of patients had moyamoya syndrome. Stroke recurrence was 20% over median follow-up of 13 months; 9% had multiple recurrences. Children treated with surgical revascularization were less likely to have stroke recurrence ( P = .046). Moyamoya disease accounted for 8% of arterial strokes in this international pediatric stroke registry. One-third of pediatric patients with moyamoya disease have an underlying syndromic condition. Surgical revascularization is effective at reducing the incidence of stroke recurrence.
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Pandian JD, William AG, Kate MP, Norrving B, Mensah GA, Davis S, Roth GA, Thrift AG, Kengne AP, Kissela BM, Yu C, Kim D, Rojas-Rueda D, Tirschwell DL, Abd-Allah F, Gankpé F, deVeber G, Hankey GJ, Jonas JB, Sheth KN, Dokova K, Mehndiratta MM, Geleijnse JM, Giroud M, Bejot Y, Sacco R, Sahathevan R, Hamadeh RR, Gillum R, Westerman R, Akinyemi RO, Barker-Collo S, Truelsen T, Caso V, Rajagopalan V, Venketasubramanian N, Vlassovi VV, Feigin VL. Strategies to Improve Stroke Care Services in Low- and Middle-Income Countries: A Systematic Review. Neuroepidemiology 2017; 49:45-61. [DOI: 10.1159/000479518] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 07/11/2017] [Indexed: 01/10/2023] Open
Abstract
Background: The burden of stroke in low- and middle-income countries (LMICs) is large and increasing, challenging the already stretched health-care services. Aims and Objectives: To determine the quality of existing stroke-care services in LMICs and to highlight indigenous, inexpensive, evidence-based implementable strategies being used in stroke-care. Methods: A detailed literature search was undertaken using PubMed and Google scholar from January 1966 to October 2015 using a range of search terms. Of 921 publications, 373 papers were shortlisted and 31 articles on existing stroke-services were included. Results: We identified efficient models of ambulance transport and pre-notification. Stroke Units (SU) are available in some countries, but are relatively sparse and mostly provided by the private sector. Very few patients were thrombolysed; this could be increased with telemedicine and governmental subsidies. Adherence to secondary preventive drugs is affected by limited availability and affordability, emphasizing the importance of primary prevention. Training of paramedics, care-givers and nurses in post-stroke care is feasible. Conclusion: In this systematic review, we found several reports on evidence-based implementable stroke services in LMICs. Some strategies are economic, feasible and reproducible but remain untested. Data on their outcomes and sustainability is limited. Further research on implementation of locally and regionally adapted stroke-services and cost-effective secondary prevention programs should be a priority.
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Williams TS, McDonald KP, Roberts SD, Dlamini N, deVeber G, Westmacott R. Prevalence and Predictors of Learning and Psychological Diagnoses Following Pediatric Arterial Ischemic Stroke. Dev Neuropsychol 2017; 42:309-322. [DOI: 10.1080/87565641.2017.1353093] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Westmacott R, McDonald KP, deVeber G, MacGregor D, Moharir M, Dlamini N, Askalan R, Williams TS. Neurocognitive outcomes in children with unilateral basal ganglia arterial ischemic stroke and secondary hemidystonia. Child Neuropsychol 2017; 24:923-937. [DOI: 10.1080/09297049.2017.1353073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Kassebaum N, Kyu HH, Zoeckler L, Olsen HE, Thomas K, Pinho C, Bhutta ZA, Dandona L, Ferrari A, Ghiwot TT, Hay SI, Kinfu Y, Liang X, Lopez A, Malta DC, Mokdad AH, Naghavi M, Patton GC, Salomon J, Sartorius B, Topor-Madry R, Vollset SE, Werdecker A, Whiteford HA, Abate KH, Abbas K, Damtew SA, Ahmed MB, Akseer N, Al-Raddadi R, Alemayohu MA, Altirkawi K, Abajobir AA, Amare AT, Antonio CAT, Arnlov J, Artaman A, Asayesh H, Avokpaho EFGA, Awasthi A, Ayala Quintanilla BP, Bacha U, Betsu BD, Barac A, Bärnighausen TW, Baye E, Bedi N, Bensenor IM, Berhane A, Bernabe E, Bernal OA, Beyene AS, Biadgilign S, Bikbov B, Boyce CA, Brazinova A, Hailu GB, Carter A, Castañeda-Orjuela CA, Catalá-López F, Charlson FJ, Chitheer AA, Choi JYJ, Ciobanu LG, Crump J, Dandona R, Dellavalle RP, Deribew A, deVeber G, Dicker D, Ding EL, Dubey M, Endries AY, Erskine HE, Faraon EJA, Faro A, Farzadfar F, Fernandes JC, Fijabi DO, Fitzmaurice C, Fleming TD, Flor LS, Foreman KJ, Franklin RC, Fraser MS, Frostad JJ, Fullman N, Gebregergs GB, Gebru AA, Geleijnse JM, Gibney KB, Gidey Yihdego M, Ginawi IAM, Gishu MD, Gizachew TA, Glaser E, Gold AL, Goldberg E, Gona P, Goto A, Gugnani HC, Jiang G, Gupta R, Tesfay FH, Hankey GJ, Havmoeller R, Hijar M, Horino M, Hosgood HD, Hu G, Jacobsen KH, Jakovljevic MB, Jayaraman SP, Jha V, Jibat T, Johnson CO, Jonas J, Kasaeian A, Kawakami N, Keiyoro PN, Khalil I, Khang YH, Khubchandani J, Ahmad Kiadaliri AA, Kieling C, Kim D, Kissoon N, Knibbs LD, Koyanagi A, Krohn KJ, Kuate Defo B, Kucuk Bicer B, Kulikoff R, Kumar GA, Lal DK, Lam HY, Larson HJ, Larsson A, Laryea DO, Leung J, Lim SS, Lo LT, Lo WD, Looker KJ, Lotufo PA, Magdy Abd El Razek H, Malekzadeh R, Markos Shifti D, Mazidi M, Meaney PA, Meles KG, Memiah P, Mendoza W, Abera Mengistie M, Mengistu GW, Mensah GA, Miller TR, Mock C, Mohammadi A, Mohammed S, Monasta L, Mueller U, Nagata C, Naheed A, Nguyen G, Nguyen QL, Nsoesie E, Oh IH, Okoro A, Olusanya JO, Olusanya BO, Ortiz A, Paudel D, Pereira DM, Perico N, Petzold M, Phillips MR, Polanczyk GV, Pourmalek F, Qorbani M, Rafay A, Rahimi-Movaghar V, Rahman M, Rai RK, Ram U, Rankin Z, Remuzzi G, Renzaho AMN, Roba HS, Rojas-Rueda D, Ronfani L, Sagar R, Sanabria JR, Kedir Mohammed MS, Santos IS, Satpathy M, Sawhney M, Schöttker B, Schwebel DC, Scott JG, Sepanlou SG, Shaheen A, Shaikh MA, She J, Shiri R, Shiue I, Sigfusdottir ID, Singh J, Silpakit N, Smith A, Sreeramareddy C, Stanaway JD, Stein DJ, Steiner C, Sufiyan MB, Swaminathan S, Tabarés-Seisdedos R, Tabb KM, Tadese F, Tavakkoli M, Taye B, Teeple S, Tegegne TK, Temam Shifa G, Terkawi AS, Thomas B, Thomson AJ, Tobe-Gai R, Tonelli M, Tran BX, Troeger C, Ukwaja KN, Uthman O, Vasankari T, Venketasubramanian N, Vlassov VV, Weiderpass E, Weintraub R, Gebrehiwot SW, Westerman R, Williams HC, Wolfe CDA, Woodbrook R, Yano Y, Yonemoto N, Yoon SJ, Younis MZ, Yu C, Zaki MES, Zegeye EA, Zuhlke LJ, Murray CJL, Vos T. Child and Adolescent Health From 1990 to 2015: Findings From the Global Burden of Diseases, Injuries, and Risk Factors 2015 Study. JAMA Pediatr 2017; 171:573-592. [PMID: 28384795 PMCID: PMC5540012 DOI: 10.1001/jamapediatrics.2017.0250] [Citation(s) in RCA: 250] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 01/16/2017] [Indexed: 01/06/2023]
Abstract
Importance Comprehensive and timely monitoring of disease burden in all age groups, including children and adolescents, is essential for improving population health. Objective To quantify and describe levels and trends of mortality and nonfatal health outcomes among children and adolescents from 1990 to 2015 to provide a framework for policy discussion. Evidence Review Cause-specific mortality and nonfatal health outcomes were analyzed for 195 countries and territories by age group, sex, and year from 1990 to 2015 using standardized approaches for data processing and statistical modeling, with subsequent analysis of the findings to describe levels and trends across geography and time among children and adolescents 19 years or younger. A composite indicator of income, education, and fertility was developed (Socio-demographic Index [SDI]) for each geographic unit and year, which evaluates the historical association between SDI and health loss. Findings Global child and adolescent mortality decreased from 14.18 million (95% uncertainty interval [UI], 14.09 million to 14.28 million) deaths in 1990 to 7.26 million (95% UI, 7.14 million to 7.39 million) deaths in 2015, but progress has been unevenly distributed. Countries with a lower SDI had a larger proportion of mortality burden (75%) in 2015 than was the case in 1990 (61%). Most deaths in 2015 occurred in South Asia and sub-Saharan Africa. Global trends were driven by reductions in mortality owing to infectious, nutritional, and neonatal disorders, which in the aggregate led to a relative increase in the importance of noncommunicable diseases and injuries in explaining global disease burden. The absolute burden of disability in children and adolescents increased 4.3% (95% UI, 3.1%-5.6%) from 1990 to 2015, with much of the increase owing to population growth and improved survival for children and adolescents to older ages. Other than infectious conditions, many top causes of disability are associated with long-term sequelae of conditions present at birth (eg, neonatal disorders, congenital birth defects, and hemoglobinopathies) and complications of a variety of infections and nutritional deficiencies. Anemia, developmental intellectual disability, hearing loss, epilepsy, and vision loss are important contributors to childhood disability that can arise from multiple causes. Maternal and reproductive health remains a key cause of disease burden in adolescent females, especially in lower-SDI countries. In low-SDI countries, mortality is the primary driver of health loss for children and adolescents, whereas disability predominates in higher-SDI locations; the specific pattern of epidemiological transition varies across diseases and injuries. Conclusions and Relevance Consistent international attention and investment have led to sustained improvements in causes of health loss among children and adolescents in many countries, although progress has been uneven. The persistence of infectious diseases in some countries, coupled with ongoing epidemiologic transition to injuries and noncommunicable diseases, require all countries to carefully evaluate and implement appropriate strategies to maximize the health of their children and adolescents and for the international community to carefully consider which elements of child and adolescent health should be monitored.
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Dlamini N, Wintermark M, Fullerton H, Strother S, Lee W, Bjornson B, Guilliams KP, Miller S, Kirton A, Filippi CG, Linds A, Askalan R, deVeber G. Harnessing Neuroimaging Capability in Pediatric Stroke: Proceedings of the Stroke Imaging Laboratory for Children Workshop. Pediatr Neurol 2017; 69:3-10. [PMID: 28259513 DOI: 10.1016/j.pediatrneurol.2017.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 01/05/2017] [Accepted: 01/06/2017] [Indexed: 12/22/2022]
Abstract
On June 5, 2015 the International Pediatric Stroke Study and the Stroke Imaging Laboratory for Children cohosted a unique workshop focused on developing neuroimaging research in pediatric stroke. Pediatric neurologists, neuroradiologists, interventional neuroradiologists, physicists, nurse practitioners, neuropsychologists, and imaging research scientists from around the world attended this one-day meeting. Our objectives were to (1) establish a group of experts to collaborate in advancing pediatric neuroimaging for stroke, (2) develop consensus clinical and research magnetic resonance imaging protocols for pediatric stroke patients, and (3) develop imaging-based research strategies in pediatric ischemic stroke. This article provides a summary of the meeting proceedings focusing on identified challenges and solutions and outcomes from the meeting. Further details on the workshop contents and outcomes are provided in three additional articles in the current issue of Pediatric Neurology.
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Dlamini N, Yau I, Westmacott R, Shroff M, Armstrong D, Logan W, Mikulis D, deVeber G, Kassner A. Cerebrovascular Reactivity and Intellectual Outcome in Childhood Stroke With Transient Cerebral Arteriopathy. Pediatr Neurol 2017; 69:71-78. [PMID: 28258787 DOI: 10.1016/j.pediatrneurol.2017.01.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 01/02/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hypercapnic-challenge blood oxygen level-dependent magnetic resonance imaging cerebrovascular reactivity (CVR), measures the regional perfusion response to altered carbon dioxide. CVR correlates with the tissue-level microvascular dysfunction and ischemic risk. Among children with arterial ischemic stroke, transient cerebral arteriopathy (TCA) is a frequent, nonprogressive unilateral intracranial arteriopathy, which typically results in basal ganglia infarction and chronic cerebral artery stenosis. Therefore TCA provides a model for studying the consequences of chronic nonprogressive stenosis using CVR and intellectual outcome. We hypothesized that children with TCA and chronic nonprogressive intracranial artery stenosis have impaired CVR distal to the stenosis and associated cognitive impairment. METHODS We studied children with a prior diagnosis of TCA as defined by infarction limited to the basal ganglia, internal capsule, or both; and significant (greater than 50% diameter) residual stenosis of the supraclinoid internal carotid artery, its proximal branches or both. All children had CVR, intellectual function, and infarct volumes quantified. RESULTS We performed CVR studies in five children at mean 8.96 years (3.33 to 14.58 years) poststroke. Impaired CVR was limited to the infarct zone and adjacent white matter in most children. Intellectual function was broadly average in all but one subject. CONCLUSIONS In children with typical TCA, ipsilateral cortical CVR and intellectual function seem to be preserved despite persistent arterial stenosis in the majority. These findings suggest that chronic revascularization strategies in these children may not be indicated and require further exploration in a larger cohort of children.
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