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Hausman-Kedem M, Krishnan P, Dlamini N. Cerebral arteriopathies of childhood and stroke - A focus on systemic arteriopathies and pediatric fibromuscular dysplasia (FMD). Vasc Med 2024; 29:328-341. [PMID: 38898630 PMCID: PMC11188572 DOI: 10.1177/1358863x241254796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Systemic vascular involvement in children with cerebral arteriopathies is increasingly recognized and often highly morbid. Fibromuscular dysplasia (FMD) represents a cerebral arteriopathy with systemic involvement, commonly affecting the renal and carotid arteries. In adults, FMD diagnosis and classification typically relies on angiographic features, like the 'string-of-beads' appearance, following exclusion of other diseases. Pediatric FMD (pFMD) is considered equivalent to adult FMD although robust evidence for similarities is lacking. We conducted a comprehensive literature review on pFMD and revealed inherent differences between pediatric and adult-onset FMD across various domains including epidemiology, natural history, histopathophysiology, clinical, and radiological features. Although focal arterial lesions are often described in children with FMD, the radiological appearance of 'string-of-beads' is highly nonspecific in children. Furthermore, children predominantly exhibit intimal-type fibroplasia, common in other childhood monogenic arteriopathies. Our findings lend support to the notion that pFMD broadly reflects an undefined heterogenous group of monogenic systemic medium-or-large vessel steno-occlusive arteriopathies rather than a single entity. Recognizing the challenges in categorizing complex morphologies of cerebral arteriopathy using current classifications, we propose a novel term for describing children with cerebral and systemic vascular involvement: 'cerebral and systemic arteriopathy of childhood' (CSA-c). This term aims to streamline patient categorization and, when coupled with advanced vascular imaging and high-throughput genomics, will enhance our comprehension of etiology, and accelerate mechanism-targeted therapeutic developments. Lastly, in light of the high morbidity in children with cerebral and systemic arteriopathies, we suggest that investigating for systemic vascular involvement is important in children with cerebral arteriopathies.
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Affiliation(s)
- Moran Hausman-Kedem
- Pediatric Neurology Institute, Tel Aviv Medical Center, Tel Aviv, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pradeep Krishnan
- Department of Pediatric Neuroradiology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Nomazulu Dlamini
- Division of Neurology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Neurosciences and Mental Health Program, The Hospital for Sick Children, Toronto, ON, Canada
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Slavova N, Muenger R, Sanchez-Albisua I, Regényi M, Oesch G, Fluss J, Hackenberg A, Lebon S, Maier O, Datta AN, Bigi S, Grunt S, Steinlin M. Inflammatory Type Focal Cerebral Arteriopathy of the Posterior Circulation in Children: A Comparative Cohort Study. Stroke 2024; 55:1006-1014. [PMID: 38445467 PMCID: PMC10962439 DOI: 10.1161/strokeaha.123.043562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 01/08/2024] [Accepted: 01/18/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Inflammatory type focal cerebral arteriopathy (FCA-i) in the anterior circulation (AC) is well characterized, and the focal cerebral arteriopathy severity score (FCASS) reflects the severity of the disease. We identified cases of FCA-i in the posterior circulation (PC) and adapted the FCASS to describe these cases. METHODS In this comparative cohort study, patients from the Swiss NeuroPaediatric Stroke Registry with ischemic stroke due to FCA-i between January 2000 and December 2018 were analyzed. A comparison between PC and AC cases regarding pediatric National Institutes of Health Stroke Scale score and pediatric stroke outcome measure and FCASS was performed. We estimated infarct size by the modified pediatric Alberta Stroke Program Early Computed Tomography Score in children with AC stroke and the adapted Bernese posterior diffusion-weighted imaging score in the PC. RESULTS Thirty-five children with a median age of 6.3 (interquartile range, 2.7-8.2 [95% CI, 0.9-15.6]; 20 male; 57.1%) years with FCA-i were identified. The total incidence rate was 0.15/100 000/year (95% CI, 0.11-0.21). Six had PC-FCA-i. Time to final FCASS was longer in the PC compared with AC; the evolution of FCASS did not differ. Initial pediatric National Institutes of Health Stroke Scale score was higher in children with FCA-i in the PC with a median of 10.0 (interquartile range, 5.75-21.0) compared with 4.5 (interquartile range, 2.0-8.0) in those with AC-FCA-i. Different from the anterior cases, PC infarct volume did not correlate with higher discharge, maximum, or final FCASS scores (Pearson correlation coefficient [r], 0.25, 0.35, and 0.54). CONCLUSIONS FCA-i also affects the PC. These cases should be included in future investigations into FCA-i. Although it did not correlate with clinical outcomes in our cohort, the modified FCASS may well serve as a marker for the evolution of the arteriopathy in posterior FCA-i.
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Affiliation(s)
- Nedelina Slavova
- Support Center for Advanced Neuroimaging, Institute of Diagnostic and Interventional Neuroradiology (N.S.), Inselspital, Bern University Hospital, University of Bern, Switzerland
- Pediatric Radiology, University of Basel Children’s Hospital and University of Basel, Switzerland (N.S.)
- Department of Neurology, University Hospital Bern (N.S.), University of Bern, Switzerland
| | - Robin Muenger
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics (R.M., I.S.-A., M.R., G.O., S.G., M.S.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Iciar Sanchez-Albisua
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics (R.M., I.S.-A., M.R., G.O., S.G., M.S.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Maria Regényi
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics (R.M., I.S.-A., M.R., G.O., S.G., M.S.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Gabriela Oesch
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics (R.M., I.S.-A., M.R., G.O., S.G., M.S.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Joël Fluss
- Department of Pediatrics, Gynecology and Obstetrics, Pediatric Neurology Unit, University Hospitals of Geneva, Switzerland (J.F.)
| | - Annette Hackenberg
- Department of Pediatric Neurology, University Children’s Hospital, Zürich, Switzerland (A.H.)
| | - Sébastien Lebon
- Pediatric Neurology and Neurorehabilitation Unit, Lausanne University Hospital, Switzerland (S.L.)
| | - Oliver Maier
- Division of Child Neurology, Department of Pediatrics, Children’s Hospital, St. Gallen, Switzerland (O.M.)
| | - Alexandre N. Datta
- Department of Pediatric Neurology and Developmental Medicine, University of Basel Children’s Hospital, Switzerland (A.D.)
| | - Sandra Bigi
- Institute of Social and Preventive Medicine (S.B.), University of Bern, Switzerland
- Division of Pediatric Neurology, Department of Pediatrics, Children’s Hospital Lucerne, Switzerland (S.B.)
| | - Sebastian Grunt
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics (R.M., I.S.-A., M.R., G.O., S.G., M.S.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Maja Steinlin
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics (R.M., I.S.-A., M.R., G.O., S.G., M.S.), Inselspital, Bern University Hospital, University of Bern, Switzerland
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Oesch G, Münger R, Steinlin M. Be aware of childhood stroke: Proceedings from EPNS Webinar. Eur J Paediatr Neurol 2024; 49:82-94. [PMID: 38447504 DOI: 10.1016/j.ejpn.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/11/2023] [Accepted: 02/05/2024] [Indexed: 03/08/2024]
Abstract
Childhood arterial ischaemic stroke (AIS) is a significant health concern with increasing incidence. This review aims to provide an overview of the current understanding of childhood AIS. The incidence of childhood AIS is on the rise especially in developing countries, likely due to improved awareness and diagnostic capabilities. Aetiology of childhood AIS is multifactorial, with both modifiable risk factors and genetic predisposition playing important roles. Identifying and addressing these risk factors, such as infection, sickle cell disease, and congenital heart defects, is essential in prevention and management. Identifying underlying conditions through genetic testing is important for appropriate management and long-term prognosis. Clinically, distinguishing stroke from stroke mimics can be challenging. Awareness of important stroke mimics, including migraines, seizures, and metabolic disorders, is crucial to avoid misdiagnosis and ensure appropriate treatment. The diagnostic approach to childhood AIS involves a comprehensive "chain of care," including initial assessment, neuroimaging, and laboratory investigations. National guidelines play a pivotal role in standardizing and streamlining the diagnostic process, ensuring prompt and accurate management. Early intervention is critical in the management of childhood AIS. Due to the critical time window, the question if mechanical thrombectomy is feasible and beneficial should be addressed as fast as possible. Early initiation of antiplatelet or anticoagulation therapy and, in select cases, thrombolysis can help restore blood flow and minimize long-term neurological damage. Additionally, rehabilitation should start as soon as possible to optimize recovery and improve functional outcomes. In conclusion, childhood AIS is a growing concern. Understanding the increasing incidence, age distribution, risk factors, clinical presentation, diagnostic approach, and management strategies is crucial for optimized management of these patients.
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Affiliation(s)
- Gabriela Oesch
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Robin Münger
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Switzerland
| | - Maja Steinlin
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland.
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Younger DS. Primary central nervous system vasculitis and headache: Ten themes. Curr Opin Neurol 2023; 36:647-658. [PMID: 37865827 PMCID: PMC10624409 DOI: 10.1097/wco.0000000000001225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
PURPOSE OF REVIEW The primary central nervous system (CNS) vasculitides refers to clinicopathologic disorders that share the histopathology of inflammation of cerebral or spinal blood vessels. Unrecognized and therefore untreated, vasculitis of the CNS results in irreversible injury and disability making these disorders of paramount importance to clinicians. RECENT FINDINGS Headache is an important clue to vasculitic involvement of CNS vessels. CNS vasculitis can be primary, in which only intracranial or spinal vessels are involved in the inflammatory process, or secondary to another known disorder with overlapping systemic involvement. The suspicion of vasculitis based on the history, clinical examination, and laboratory studies warrants prompt evaluation and treatment to prevent cerebral ischemia or infarction. SUMMARY Primary CNS vasculitides can be diagnosed with certainty after intensive evaluation that includes tissue confirmation whenever possible. As in its systemic counterparts, clinicians must choose from among the available immune modulating, suppressive, and targeted immunotherapies to induce and maintain remission status and prevent relapse, tempered by anticipated medication adverse effects.
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Affiliation(s)
- David S Younger
- Department of Medicine, Section of Neuroscience, City University of New York School of Medicine, New York; Department of Neurology, White Plains Hospital, White Plains, New York, USA
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Goktas OA, Bektas O, Yıldırım M, Sahap SK, Yuksel MF, Sahın S, Fıtoz OS, Teber ST. Clinical and Imaging Clues of Arteriopathy-Related Pediatric Arterial Ischemic Stroke: A Single Center Experience. Ann Indian Acad Neurol 2023; 26:917-926. [PMID: 38229616 PMCID: PMC10789414 DOI: 10.4103/aian.aian_315_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/25/2023] [Accepted: 07/15/2023] [Indexed: 01/18/2024] Open
Abstract
Background and Purpose Arteriopathy is a common etiology for childhood arterial ischemic stroke (AIS). In this study, we aimed to address clinical, demographic, and neuroimaging characteristics and the reversibility of vasculopathy in patients with childhood stroke due to arteriopathy by classifying them according to Childhood AIS Standardized Classification and Diagnostic Evaluation (CASCADE) criteria. Methods We included 15 patients with AIS due to arteriopathy presented between 2013 and 2018. All patients were diagnosed and followed up using magnetic resonance imaging (MRI) studies. All acute AIS patients were classified by acute CASCADE criteria (1-4). Moreover, each group was categorized according to the chronic CASCADE criteria, including progressive, stable, reversible, and indeterminate courses. Results In the study population, CASCADE 2 patients were the most common group, and basal ganglia involvement was the most common involvement in CASCADE 2 patients. Of CASCADE 2 patients, 71.4% received steroids, which was compatible with a favorable outcome. In the study, trauma was present in 33.3% of patients, 60% of which was related to CASCADE 4. In the control visit on month 24, there were neuromotor sequelae of 60%, including hemiparesis, facial paralysis, and decreased fine motor skills; furthermore, the recurrence rate was 20%. Conclusion We strongly emphasize that arteriopathy should be kept in mind in school-age children presenting with hemiparesis and headache. Moyamoya disease must be considered in the differential diagnosis with anterior circulation involvement, while focal cerebral arteriopathy (FCA) in patients with basal ganglia involvement was detected on MRI and dissection in the patients with a history of head-neck injury. We think that steroids have positive influences on neurologic prognosis in patients with FCA.
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Affiliation(s)
- Ozben Akıncı Goktas
- Department of Pediatrics, Division of Pediatric Neurology, Ataturk Sanatoryum Training and Research Hospital, Ankara, Turkey
| | - Omer Bektas
- Department of Pediatrics, Division of Pediatric Neurology, Ankara University School of Medicine, Ankara, Turkey
| | - Mirac Yıldırım
- Department of Pediatrics, Division of Pediatric Neurology, Ankara University School of Medicine, Ankara, Turkey
| | - Seda Kaynak Sahap
- Department of Pediatric Radiology, Ankara University School of Medicine, Ankara, Turkey
| | - Merve Feyza Yuksel
- Department of Pediatrics, Division of Pediatric Neurology, Recep Tayyıp Erdogan Training and Research Hospital, Rize, Turkey
| | - Suleyman Sahın
- Department of Pediatrics, Division of Pediatric Neurology, Ankara University School of Medicine, Ankara, Turkey
| | - Omer Suat Fıtoz
- Department of Pediatric Radiology, Ankara University School of Medicine, Ankara, Turkey
| | - Serap Tıraş Teber
- Department of Pediatrics, Division of Pediatric Neurology, Ankara University School of Medicine, Ankara, Turkey
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Hui AWH, Yau MLY, Fung ELW, Chan KC, Lai BMH, Wang K, Chu WCW. Focal cerebral arteriopathy-inflammatory type in a child - MR diagnosis using vessel wall imaging technique with review of classification and diagnostic evaluation criteria. Radiol Case Rep 2023; 18:3169-3174. [PMID: 37404224 PMCID: PMC10315924 DOI: 10.1016/j.radcr.2023.05.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/14/2023] [Accepted: 05/28/2023] [Indexed: 07/06/2023] Open
Abstract
Acute ischemic stroke (AIS) in childhood is defined by a stroke occurring after 28 days of life to 18 years of age. This presents a distinct clinical challenge in terms of both diagnosis and treatment. The overlapping clinical presentations of acute ischemic stroke and its mimics such as migraine with aura, seizure with Todd paresis and encephalitis renders early accurate diagnosis of this time-sensitive condition difficult, with a change in the final diagnosis in up to 40% of patients. Identification of the etiology after establishing the diagnosis of ischemic stroke is paramount for prognostication and treatment decisions. These include cardioembolic, arteriopathy, thrombophilia and inflammatory causes. Magnetic resonance imaging (MRI) plays an indispensable role towards tackling the initial diagnostic dilemma and subsequent evaluation of the underlying etiology, particularly in patients with arteriopathy. Here we present the MRI findings including vessel wall imaging with longitudinal follow-up, which support the diagnosis of focal cerebral arteriopathy-inflammatory type (FCAi) in a pediatric patient.
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Affiliation(s)
- Anselm Wang Hei Hui
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, New Territories, Hong Kong
| | - Maggie Lo Yee Yau
- Department of Pediatrics, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Eva Lai Wah Fung
- Department of Pediatrics, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Ka Chi Chan
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, New Territories, Hong Kong
| | - Billy Ming Hei Lai
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, New Territories, Hong Kong
| | - Ki Wang
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, New Territories, Hong Kong
| | - Winnie Chiu Wing Chu
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, New Territories, Hong Kong
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Osteraas ND, Dafer RM. Advances in Management of the Stroke Etiology One-Percenters. Curr Neurol Neurosci Rep 2023; 23:301-325. [PMID: 37247169 PMCID: PMC10225785 DOI: 10.1007/s11910-023-01269-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2023] [Indexed: 05/30/2023]
Abstract
PURPOSE OF REVIEW Uncommon causes of stroke merit specific attention; when clinicians have less common etiologies of stoke in mind, the diagnosis may come more easily. This is key, as optimal management will in many cases differs significantly from "standard" care. RECENT FINDINGS Randomized controlled trials (RCT) on the best medical therapy in the treatment of cervical artery dissection (CeAD) have demonstrated low rates of ischemia with both antiplatelet and vitamin K antagonism. RCT evidence supports the use of anticoagulation with vitamin K antagonism in "high-risk" patients with antiphospholipid antibody syndrome (APLAS), and there is new evidence supporting the utilization of direct oral anticoagulation in malignancy-associated thrombosis. Migraine with aura has been more conclusively linked not only with increased risk of ischemic and hemorrhagic stroke, but also with cardiovascular mortality. Recent literature has surprisingly not provided support the utilization of L-arginine in the treatment of patients with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS); however, there is evidence at this time that support use of enzyme replacement in patients with Fabry disease. Additional triggers for reversible cerebral vasoconstriction syndrome (RCVS) have been identified, such as capsaicin. Imaging of cerebral blood vessel walls utilizing contrast-enhanced MRA is an emerging modality that may ultimately prove to be very useful in the evaluation of patients with uncommon causes of stroke. A plethora of associations between cerebrovascular disease and COVID-19 have been described. Where pertinent, authors provide additional tips and guidance. Less commonly encountered conditions with updates in diagnosis, and management along with clinical tips are reviewed.
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Affiliation(s)
| | - Rima M Dafer
- Rush University Medical Center, Chicago, IL, USA.
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison St., Suite 1118, Chicago, IL, 60612, USA.
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Dorschel KB, Wanebo JE. Physiological and pathophysiological mechanisms of the molecular and cellular biology of angiogenesis and inflammation in moyamoya angiopathy and related vascular diseases. Front Neurol 2023; 14:661611. [PMID: 37273690 PMCID: PMC10236939 DOI: 10.3389/fneur.2023.661611] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 01/16/2023] [Indexed: 06/06/2023] Open
Abstract
Rationale The etiology and pathophysiological mechanisms of moyamoya angiopathy (MMA) remain largely unknown. MMA is a progressive, occlusive cerebrovascular disorder characterized by recurrent ischemic and hemorrhagic strokes; with compensatory formation of an abnormal network of perforating blood vessels that creates a collateral circulation; and by aberrant angiogenesis at the base of the brain. Imbalance of angiogenic and vasculogenic mechanisms has been proposed as a potential cause of MMA. Moyamoya vessels suggest that aberrant angiogenic, arteriogenic, and vasculogenic processes may be involved in the pathophysiology of MMA. Circulating endothelial progenitor cells have been hypothesized to contribute to vascular remodeling in MMA. MMA is associated with increased expression of angiogenic factors and proinflammatory molecules. Systemic inflammation may be related to MMA pathogenesis. Objective This literature review describes the molecular mechanisms associated with cerebrovascular dysfunction, aberrant angiogenesis, and inflammation in MMA and related cerebrovascular diseases along with treatment strategies and future research perspectives. Methods and results References were identified through a systematic computerized search of the medical literature from January 1, 1983, through July 29, 2022, using the PubMed, EMBASE, BIOSIS Previews, CNKI, ISI web of science, and Medline databases and various combinations of the keywords "moyamoya," "angiogenesis," "anastomotic network," "molecular mechanism," "physiology," "pathophysiology," "pathogenesis," "biomarker," "genetics," "signaling pathway," "blood-brain barrier," "endothelial progenitor cells," "endothelial function," "inflammation," "intracranial hemorrhage," and "stroke." Relevant articles and supplemental basic science articles almost exclusively published in English were included. Review of the reference lists of relevant publications for additional sources resulted in 350 publications which met the study inclusion criteria. Detection of growth factors, chemokines, and cytokines in MMA patients suggests the hypothesis of aberrant angiogenesis being involved in MMA pathogenesis. It remains to be ascertained whether these findings are consequences of MMA or are etiological factors of MMA. Conclusions MMA is a heterogeneous disorder, comprising various genotypes and phenotypes, with a complex pathophysiology. Additional research may advance our understanding of the pathophysiology involved in aberrant angiogenesis, arterial stenosis, and the formation of moyamoya collaterals and anastomotic networks. Future research will benefit from researching molecular pathophysiologic mechanisms and the correlation of clinical and basic research results.
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Affiliation(s)
- Kirsten B. Dorschel
- Medical Faculty, Heidelberg University Medical School, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Germany
| | - John E. Wanebo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
- Department of Neuroscience, HonorHealth Research Institute, Scottsdale, AZ, United States
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Das S, Ray BK, Mishra L, Chatterjee K, Mondal G, Paul DK. The Spectrum of Pediatric Infection-Associated Intracranial Arteriopathies and Acute Ischemic Stroke at 2 Eastern Indian Tertiary Care Centres. J Child Neurol 2023; 38:422-434. [PMID: 37138497 DOI: 10.1177/08830738231171800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
INTRODUCTION Major and minor pediatric infections may cause intracranial arteriopathies, the long-term outcome of which we investigated and identified the factors influencing the progression/resolution of arteriopathies. METHODS We collected the clinical and radiological data of children aged 1 month-15 years who had ischemic stroke with definite arteriopathy following a recent febrile infection. Repeated neuroimaging was done over the next year to ascertain recurrent strokes and the progression and resolution of arteriopathies. RESULTS The anterior circulation was more frequently affected (83.33%), predominantly involving the middle cerebral artery (41.67%), resolving in 20.84% of cases and progressing in 33.33% of cases. Lesions were commonly unilateral (54.17%) and stenotic (75%), resulting predominantly in cortical infarcts (45.83%), with hemiparesis being the most common neurodeficiency. Apart from tubercular meningitis patients, others had a good functional outcome. CONCLUSION Lower age, minor infections, and unilateral arteriopathies had a significantly higher chance of resolution. Postviral arteriopathies had a significantly lower chance of progression compared with those following bacterial infections. Progressive and bilateral arteriopathies were significantly associated with worse outcomes and recurrent strokes.
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Affiliation(s)
- Suman Das
- Department of Neurology, North Bengal Medical College, Shusrutnagar, Darjeeling, West Bengal, India
| | - Biman Kanti Ray
- Department of Neurology, Bangur Institute of Neurology, Kolkata, West Bengal, India
| | | | - Kaushani Chatterjee
- Dr. B C Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
| | - Gobinda Mondal
- Dr. B C Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
| | - Dilip Kumar Paul
- Dr. B C Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
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Gupta N, Hiremath SB, Aviv RI, Wilson N. Childhood Cerebral Vasculitis : A Multidisciplinary Approach. Clin Neuroradiol 2023; 33:5-20. [PMID: 35750917 PMCID: PMC9244086 DOI: 10.1007/s00062-022-01185-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 06/02/2022] [Indexed: 11/26/2022]
Abstract
Cerebral vasculitis is increasingly recognized as a common cause of pediatric arterial stroke. It can present with focal neurological deficits, psychiatric manifestations, seizures, and encephalopathy. The etiopathogenesis of childhood cerebral vasculitis (CCV) is multifactorial, making an inclusive classification challenging. In this review, we describe the common and uncommon CCV with a comprehensive discussion of etiopathogenesis, the role of various imaging modalities, and advanced techniques in diagnosing CCV. We also highlight the implications of relevant clinical, laboratory, and genetic findings to reach the final diagnosis. Based on the clinicoradiological findings, a stepwise diagnostic approach is proposed to facilitate CCV diagnosis and rule out potential mimics. Identification of key clinical manifestations, pertinent blood and cerebrospinal fluid results, and evaluation of central nervous system vessels for common and disease-specific findings will be emphasized. We discuss the role of magnetic resonance imaging, MR angiography, and vessel wall imaging as the imaging investigation of choice, and reservation of catheter angiography as a problem-solving tool. We emphasize the utility of brain and leptomeningeal biopsy for diagnosis and exclusion of imitators and masqueraders.
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Affiliation(s)
- Neetika Gupta
- Department of Medical Imaging, Children’s Hospital of Eastern Ontario (CHEO), University of Ottawa, Ottawa, Ontario Canada
- Clinical Fellow—Pediatric Radiology, Department of Medical Imaging, Children’s Hospital of Eastern Ontario (CHEO), University of Ottawa, Ottawa, Ontario Canada
| | - Shivaprakash B. Hiremath
- Department of Medical Imaging, Division of Neuroradiology, Civic and General Campus, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario Canada
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario Canada
| | - Richard I. Aviv
- Department of Medical Imaging, Division of Neuroradiology, Civic and General Campus, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario Canada
| | - Nagwa Wilson
- Department of Medical Imaging, Children’s Hospital of Eastern Ontario (CHEO), University of Ottawa, Ottawa, Ontario Canada
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Yoshii S, Fukui R, Hattori S, Yamaguchi R, Fujimoto R, Aoyama H, Omata T. MR vessel wall enhancement in a pediatric focal cerebral arteriopathy. Brain Dev 2023; 45:354-359. [PMID: 36806407 DOI: 10.1016/j.braindev.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 01/22/2023] [Accepted: 02/05/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Focal cerebral arteriopathy (FCA) is a common cause of childhood arterial ischemic stroke in previously healthy children. Although its mechanisms are poorly understood, recent studies have suggested inflammatory processes. Magnetic resonance vessel wall imaging (VWI) is a potential imaging biomarker of inflammation. CASE DESCRIPTION We describe the case of a 7-year-old Japanese girl with right hemiplegia and dysarthria for 3 days. Brain MRI showed acute infarct in the left basal ganglia, and MRA and conventional cerebral angiogram detected vascular stenosis in the left distal internal carotid artery, left M1 and A1 segments. VWI revealed marked vessel wall enhancement and thickening in the left carotid artery, M1, and A2 segments. Based on imaging findings, she was diagnosed with acute ischemic stroke caused by FCA. Because VWI findings were thought to suggest vessel wall inflammation, high-dose steroid therapy was administered in addition to neuroprotective care and antithrombotic therapy. Although her clinical symptoms improved immediately, cerebral arteriopathy worsened on MRA a month after the onset. Subsequently, after 3 months of steroid therapy, vessel wall enhancement on VWI decreased, while arterial stenosis partially improved. At the follow-up 9 months after the onset, she had no recurrent stroke, her arteriopathy had stabilized. DISCUSSION Definitive evidence of inflammatory mechanisms in FCA is limited, and appropriate management and treatment strategies for FCA are undefined. VWI attempts to demonstrate pathologic processes within the vessel wall, and reversible wall enhancement observed in our patient suggested the presence of inflammation. VWI would help in the evaluation of disease activity in FCA. CONCLUSION VWI may contribute to the appropriate diagnosis and treatment for FCA to reflect active inflammation. Further work is needed to assess the utility of VWI in pediatric FCA.
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Affiliation(s)
- Shoko Yoshii
- Division of Child Neurology, Chiba Children's Hospital, Chiba, Japan
| | - Rina Fukui
- Department of Radiology, Chiba Children's Hospital, Chiba, Japan
| | - Shinya Hattori
- Department of Radiology, Chiba University Hospital, Chiba, Japan
| | - Ryo Yamaguchi
- Division of Child Neurology, Chiba Children's Hospital, Chiba, Japan
| | - Ryo Fujimoto
- Division of Child Neurology, Chiba Children's Hospital, Chiba, Japan
| | - Hiromi Aoyama
- Division of Child Neurology, Chiba Children's Hospital, Chiba, Japan
| | - Taku Omata
- Division of Child Neurology, Chiba Children's Hospital, Chiba, Japan.
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12
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Amlie-Lefond C. Pediatric Stroke-Are We Asking the Right Questions? The 2022 Sidney Carter Award Lecture. Neurology 2023; 100:192-198. [PMID: 36347625 DOI: 10.1212/wnl.0000000000201487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/14/2022] [Indexed: 11/11/2022] Open
Abstract
Over the past few decades, robust clinical and research collaborations among pediatric stroke researchers have informed and improved the care of children with stroke. Risk factors and presentation of childhood stroke have been described, and the acute and chronic burden of childhood stroke has been better delineated. Nevertheless, high-quality data for the treatment of children with stroke is dwarfed by that available for adult stroke, and it is therefore tempting to extend research questions and treatment trials from adults to children. A trial designed to answer a question about stroke in adults may yield useful information about stroke in childhood, but a trial that incorporates the unique neurodevelopmental and etiologic aspects of childhood stroke is more likely to truly advance care. Research questions and study design in childhood stroke must capture the complexity of stroke mechanisms and medical comorbidities in children who suffer stroke, the impact on the developing nervous system, and the role of normal and aberrant neurodevelopment in recovery.
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Affiliation(s)
- Catherine Amlie-Lefond
- From the Department of Neurology and Department of Neurosurgery, University of Washington, Seattle, WA.
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13
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Esin RG, Fatykhova AF, Esin OR. [Vasculitis as a cause of stroke]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:5-11. [PMID: 38148691 DOI: 10.17116/jnevro20231231225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
The review considers the clinical picture, key aspects of the diagnosis and treatment of vasculitis that are the causes of strokes (giant cell arteritis, polyarteritis nodosa, varicella zoster virus vasculopathy, cerebrovascular pathology caused by herpes simplex virus types 1 and 2, primary CNS angiitis, adenosine deaminase-2 deficiency).
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Affiliation(s)
- R G Esin
- Kazan (Volga region) Federal University, Kazan, Russia
- Kazan State Medical Academy, Kazan, Russia
| | - A F Fatykhova
- Kazan (Volga region) Federal University, Kazan, Russia
| | - O R Esin
- Kazan (Volga region) Federal University, Kazan, Russia
- Clinic of Otorhinolaryngology, Kazan, Russia
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14
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Younger DS. Adult and childhood vasculitis. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:653-705. [PMID: 37562892 DOI: 10.1016/b978-0-323-98818-6.00008-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system leads to pervasive injury and disability, making this a disorder of paramount importance to all clinicians. There has been remarkable progress in the pathogenesis, diagnosis, and treatment of primary CNS and PNS vasculitides, predicated on achievement in primary systemic forms. Primary neurological vasculitides can be diagnosed with assurance after intensive evaluation that incudes tissue confirmation whenever possible. Clinicians must choose from among the available immune modulating, suppressive, and targeted immunotherapies to induce and maintain remission status and prevent relapse, unfortunately without the benefit of RCTs, and tempered by the recognition of anticipated medication side effects. It may be said that efforts to define a disease are attempts to understand the very concept of the disease. This has been especially evident in systemic and neurological disorders associated with vasculitis. For the past 100 years, since the first description of granulomatous angiitis of the brain, the CNS vasculitides have captured the attention of generations of clinical investigators around the globe to reach a better understanding of vasculitides involving the central and peripheral nervous system. Since that time it has become increasingly evident that this will necessitate an international collaborative effort.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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15
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Wilseck ZM, Lin LY, Chaudhary N, Rivas-Rodriguez F. Newer Updates in Pediatric Vascular Diseases. Semin Roentgenol 2023; 58:110-130. [PMID: 36732006 DOI: 10.1053/j.ro.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 09/18/2022] [Indexed: 11/05/2022]
Abstract
Pediatric neurovascular pathology directly involves or is in close proximity to the central nervous system (CNS). These vascular pathologies can occur in isolation or in association with broader syndromes. While some vascular pathologies are unique to the pediatric population, the full spectrum of adult neurovascular lesions can also affect children however, may present differently both clinically and on diagnostic imaging. Non-invasive (Ultrasound, CT, MRI) imaging plays a critical role in the diagnosis, treatment planning, and follow-up of vascular lesions involving the CNS. The modality can be chosen based on the age of the child, urgency of diagnosis, and local availability. Each modality has sensitivities and specificities which vary based on the location and imaging findings of a specific neurovascular pathology. In addition to non-invasive options, digital subtraction angiography (DSA) may be used as both a diagnostic and therapeutic imaging method for pediatric vascular lesions of the central nervous system. The diagnosis and management of pediatric cerebrovascular disease requires the close collaboration between pediatricians and pediatric specialists including neuroradiologists, neurologists, neurosurgeons, cardiologists, neurointerventionalists, and anesthesiologists among others. A detailed understanding of imaging findings, natural history, and treatment options is essential to guide and monitor imaging and treatment. The goal of this review is to provide the reader with an overview on pediatric neurovascular pathologies, provide examples of pathognomonic imaging findings, and present a brief review of endovascular treatment options, if applicable.
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Affiliation(s)
| | - Leanne Y Lin
- Department of Radiology, University of Michigan, Ann Arbor, MI
| | - Neeraj Chaudhary
- Department of Radiology, University of Michigan, Ann Arbor, MI; Department of Neurosurgery, University of Michigan, Ann Arbor, MI; Department of Otorhinolaryngology, University of Michigan, Ann Arbor, MI; Department of Neurology, University of Michigan, Ann Arbor, MI
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16
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Persa L, Shaw DW, Amlie-Lefond C. Why Would a Child Have a Stroke? J Child Neurol 2022; 37:907-915. [PMID: 36214173 DOI: 10.1177/08830738221129916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Identifying the etiology of childhood arterial ischemic stroke helps prevent stroke recurrence. In addition, stroke may herald a serious underlying condition requiring treatment, such as acquired heart disease, malignancy, or autoimmune disorder. Evidence-based guidelines exist for adults to identify and treat common risk factors for primary and secondary stroke, including hypertension, diabetes, elevated lipids, atrial fibrillation, and sleep apnea, which are rarely relevant in children. However, guidelines do not exist in pediatrics. Identifying the cause of childhood stroke may be straightforward or may require extensive clinical and neuroimaging expertise, serial evaluations, and reassessment based on the evolving clinical picture. Risk factors may be present but not necessarily causative, or not causative until a triggering event such as infection or anemia occurs. Herein, we describe strategies to determine stroke etiology, including challenges and potential pitfalls.
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Affiliation(s)
- Laurel Persa
- Department of Neurology, 7274Seattle Children's Hospital, Seattle, Washington, USA
| | - Dennis Ww Shaw
- Department of Radiology, 7274Seattle Children's Hospital, Seattle, Washington, USA
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17
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Arteriell ischämischer Schlaganfall im Kindes- und Jugendalter. DER NERVENARZT 2022; 93:1258-1270. [PMCID: PMC9667834 DOI: 10.1007/s00115-022-01409-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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18
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Ba’Omar M, Chhetri S, Pandak N, Khamis F, Al-Balushi Z, Al-Hajri A, Abouelhamd H, Al-Fahdi Z. Varicella Zoster Virus Vasculopathy; an HIV adult presenting with multiple strokes. IDCases 2022; 30:e01641. [PMID: 36388851 PMCID: PMC9649954 DOI: 10.1016/j.idcr.2022.e01641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 10/23/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
Abstract
VZV vasculopathy has been associated with granulomatous vasculitis where there is vessel wall damage and transmural inflammation. VZV vasculopathy has been previously called granulomatous angiitis, VZV vasculitis or post-varicella arteriopathy. Intracerebral VZV vasculopathy can occur in children and adults, either after primary infection or after viral reactivation. Where-as varicella primary infection is a common cause of stroke in children, in adults there is an increased risk of stroke after herpes zoster. Here we present a 38-year-old immunocompromised patient who presents to us with multiple cerebral infarcts post primary infection and imaging showing distribution similar to those in children.
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Affiliation(s)
- Muna Ba’Omar
- Department of Infectious Disease, The Royal Hospital, Oman
- Corresponding author
| | | | - Nenad Pandak
- Department of Infectious Disease, The Royal Hospital, Oman
| | - Faryal Khamis
- Department of Infectious Disease, The Royal Hospital, Oman
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19
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Acute Hospital Management of Pediatric Stroke. Semin Pediatr Neurol 2022; 43:100990. [PMID: 36344020 DOI: 10.1016/j.spen.2022.100990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 08/13/2022] [Accepted: 08/14/2022] [Indexed: 11/24/2022]
Abstract
The field of pediatric stroke has historically been hampered by limited evidence and small patient cohorts. However the landscape of childhood stroke is rapidly changing due in part to increasing awareness of the importance of pediatric stroke and the emergence of dedicated pediatric stroke centers, care pathways, and alert systems. Acute pediatric stroke management hinges on timely diagnosis confirmed by neuroimaging, appropriate consideration of recanalization therapies, implementation of neuroprotective measures, and attention to secondary prevention. Because pediatric stroke is highly heterogenous in etiology, management strategies must be individualized. Determining a child's underlying stroke etiology is essential to appropriately tailoring hyperacute stroke management and determining best approach to secondary prevention. Herein, we review the methods of recognition, diagnosis, management, current knowledge gaps and promising research for pediatric stroke.
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20
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Cersosimo A, Riccardi M, Amore L, Cimino G, Arabia G, Metra M, Vizzardi E. Varicella zoster virus and cardiovascular diseases. Monaldi Arch Chest Dis 2022; 93. [PMID: 36128930 DOI: 10.4081/monaldi.2022.2414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/03/2022] [Indexed: 01/20/2023] Open
Abstract
Varicella zoster virus (VZV) is a Herpesviridae family double-stranded DNA virus that only affects humans. The first clinical manifestation appears to be varicella, typical of childhood. VZV, on the other hand, becomes latent in ganglion neurons throughout the neuroaxis after primary infection. The VZV reactivates and travels along peripheral nerve fibers in the elderly and immunocompromised individuals, resulting in Zoster. It can, however, spread centrally and infect cerebral and extracranial arteries, resulting in vasculopathy, which can lead to transient ischemic attacks, strokes, aneurysms, cavernous sinus thrombosis, giant cell arteritis, and granulomatous aortitis. Although the mechanisms of virus-induced pathological vascular remodeling are not fully understood, recent research indicates that inflammation and dysregulation of ligand-1 programmed death play a significant role. Few studies, on the other hand, have looked into the role of VZV in cardiovascular disease. As a result, the purpose of this review is to examine the relationship between VZV and cardiovascular disease, the efficacy of the vaccine as a protective mechanism, and the target population of heart disease patients who could benefit from vaccination.
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21
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Moyamoya disease emerging as an immune-related angiopathy. Trends Mol Med 2022; 28:939-950. [DOI: 10.1016/j.molmed.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 11/22/2022]
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22
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Nakamura Y, Mineharu Y, Kamata T, Funaki T, Miyamoto S, Koizumi A, Harada KH. Lack of Association between Seropositivity of Vasculopathy-Related Viruses and Moyamoya Disease. J Stroke Cerebrovasc Dis 2022; 31:106509. [PMID: 35500358 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 04/05/2022] [Accepted: 04/08/2022] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES Although the association between genetic factors, such as RNF213 mutations, and moyamoya disease (MMD) has been well investigated, environmental factors are largely undetermined. Thus, we aimed to examine whether viral infection increases the risk of MMD. MATERIALS AND METHODS To eliminate the effect of presence or absence of the RNF213 p.R4810K mutation, the entire study population was positive for this mutation. We collected whole blood from 111 patients with MMD (45 familial and 66 sporadic cases) and 67 healthy volunteers, and we measured the immunoglobulin G titer of 11 viruses (cytomegalovirus, varicella-zoster virus, measles virus, rubella virus, herpes simplex virus, mumps virus, Epstein-Barr virus, human parvovirus B19, human herpesvirus 6 [HHV6], human herpesvirus 8, and John Cunningham virus) that were presumed to be associated with vasculopathy using the enzyme-linked immunosorbent assay. Positivity for past viral infection was determined by cut-off values obtained from previous reports and the manufacturer's instructions, and the positive rate was compared between cases and age- and sex-matched controls. We performed familial case-specific and sporadic case-specific analyses, as well as a case-control analysis. RESULTS There was no significant difference in the positive rate between the case group and the control group in any of the analyses. A significant difference was only observed in the combined case-control analysis for HHV6 (p = 0.046), but the viral antibody-positive rate in control individuals was higher than in MMD cases. CONCLUSIONS Our cross-sectional study suggest that the investigated 11 viruses including HHV6 are unlikely to have an impact on MMD development.
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Affiliation(s)
- Yasuhisa Nakamura
- Department of Health and Environmental Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yohei Mineharu
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan; Department of Artificial Intelligence in Healthcare and Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Takahiko Kamata
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Funaki
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akio Koizumi
- Social Health Medicine Welfare Laboratory, Public Interest Incorporated Association Kyoto Hokenkai, Kyoto, Japan
| | - Kouji H Harada
- Department of Health and Environmental Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan.
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23
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Gerstl L, Borggräfe I, Heinen F, Olivieri M. Arteriell ischämischer Schlaganfall im Kindes- und Jugendalter. Monatsschr Kinderheilkd 2022; 170:458-471. [PMID: 35465384 PMCID: PMC9020421 DOI: 10.1007/s00112-022-01465-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 11/27/2022]
Abstract
Der arteriell ischämische Schlaganfall im Kindes- und Jugendalter gehört zu den zeitkritischsten pädiatrischen Notfällen, wird aber häufig erst mit prognostisch relevanter Zeitverzögerung diagnostiziert. Gründe sind geringe „Awareness“, die zuweilen unspezifische klinische Präsentation mit einer Breite an kritischen Differenzialdiagnosen und in der Fläche noch wenig verzahnte Akutversorgungsstrukturen. Die beim Erwachsenen etablierten Revaskularisationsstrategien zeigen auch beim Kind mögliche, z. T. spektakuläre Erfolge. Diese sind daher nach Möglichkeit auch betroffenen Kindern zur Verfügung zu stellen, auch wenn hier derzeit keine annähernd vergleichbare Evidenz vorliegt. Postakut ist die ätiologische Aufarbeitung aufgrund zu bedenkender Risikofaktoren komplex, muss aber das individuelle Risikoprofil mit Sekundärprophylaxe, Rezidivrisiko und Outcome präzise identifizieren. Die Langzeitbetreuung im multiprofessionellen, interdisziplinären Team muss die bio-psycho-sozialen Aspekte des Kindes in seiner jeweiligen Entwicklungsphase berücksichtigen.
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Affiliation(s)
- L. Gerstl
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Abteilung für Pädiatrische Neurologie, Entwicklungsneurologie und Sozialpädiatrie, LMU Zentrum für Entwicklung und komplex chronisch kranke Kinder – iSPZ Hauner, LMU Klinikum München, Campus Innenstadt, Lindwurmstr. 4, 80337 München, Deutschland
| | - I. Borggräfe
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Abteilung für Pädiatrische Neurologie, Entwicklungsneurologie und Sozialpädiatrie, LMU Zentrum für Entwicklung und komplex chronisch kranke Kinder – iSPZ Hauner, LMU Klinikum München, Campus Innenstadt, Lindwurmstr. 4, 80337 München, Deutschland
| | - F. Heinen
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Abteilung für Pädiatrische Neurologie, Entwicklungsneurologie und Sozialpädiatrie, LMU Zentrum für Entwicklung und komplex chronisch kranke Kinder – iSPZ Hauner, LMU Klinikum München, Campus Innenstadt, Lindwurmstr. 4, 80337 München, Deutschland
| | - M. Olivieri
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Abteilung für Pädiatrische Hämostaseologie, LMU Klinikum München, Campus Innenstadt, München, Deutschland
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Abteilung für Kinderintensivmedizin und Notfallmedizin, LMU Klinikum München, Campus Innenstadt, München, Deutschland
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24
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Gupta S, Biswas A, Chandra A, Ray BK, Dutta A, Pandit A. Post-Varicella Neurological Complications: A Preliminary Observation from a Tertiary Care Centre of Eastern India. Ann Indian Acad Neurol 2022; 25:207-213. [PMID: 35693688 PMCID: PMC9175418 DOI: 10.4103/aian.aian_270_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/20/2021] [Accepted: 08/25/2021] [Indexed: 11/16/2022] Open
Abstract
Objectives: The objective of this study is to analyse detailed clinical presentations, imaging findings, and outcome in a series of 17 cases (n = 17) with neurological complications following acute varicella infection. Methods: It is an observational study on the patients who presented to the neurology outpatient department of our institute with neurological abnormalities following acute varicella infection within the last 3 months. Results: Neuroimaging, either computed tomography or magnetic resonance imaging, cerebrospinal fluid analysis, electroencephalography and nerve conduction studies were performed in all the patients along with other specialized investigations as per clinical context. The age of presentation varied from childhood to middle age (median age was 23 years) and range of clinical spectrum was also wide. Peripheral nervous system involvement was more common in the form of Guillain–Barré syndrome (29.4%) and isolated lower motor neuron facial nerve palsy (23.5%) compared to central nervous system (CNS) involvement. CNS involvement was documented in the form of ataxia (11.76%), myelopathy (17.6%), stroke (5.88%) and encephalitis (5.88%). Conclusion: Chickenpox is a common viral disease and most patients recover without any complication. Although rare, neurological complications following acute varicella infection may have myriad presentations ranging from lower motor neuron facial palsy to life-threatening encephalitis. Compared to other studies, varicella encephalitis and ataxia were not so common in our study group. Response to therapy was uniformly good except in the patients presenting with ataxia. Response was particularly good to central and peripheral demyelinating disorders.
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Affiliation(s)
- Subhadeep Gupta
- Department of Neuromedicine, Bangur Institute of Neurosciences, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - Atanu Biswas
- Department of Neuromedicine, Bangur Institute of Neurosciences, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - Atanu Chandra
- Department of Internal Medicine, RG Kar Medical College and Hospital, Kolkata, West Bengal, India
| | - Biman Kanti Ray
- Department of Neuromedicine, Bangur Institute of Neurosciences, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - Arpan Dutta
- Department of Neuromedicine, Bangur Institute of Neurosciences, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - Alak Pandit
- Department of Neuromedicine, Bangur Institute of Neurosciences, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
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25
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Kuribara T, Akiyama Y, Mikami T, Komatsu K, Kimura Y, Takahashi Y, Sakashita K, Chiba R, Mikuni N. Macrohistory of Moyamoya Disease Analyzed Using Artificial Intelligence. Cerebrovasc Dis 2022; 51:413-426. [PMID: 35104814 DOI: 10.1159/000520099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 10/06/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Moyamoya disease is characterized by progressive stenotic changes in the terminal segment of the internal carotid artery and the development of abnormal vascular networks called moyamoya vessels. The objective of this review was to provide a holistic view of the epidemiology, etiology, clinical findings, treatment, and pathogenesis of moyamoya disease. A literature search was performed in PubMed using the term "moyamoya disease," for articles published until 2021. RESULTS Artificial intelligence (AI) clustering was used to classify the articles into 5 clusters: (1) pathophysiology (23.5%); (2) clinical background (37.3%); (3) imaging (13.2%); (4) treatment (17.3%); and (5) genetics (8.7%). Many articles in the "clinical background" cluster were published from the 1970s. However, in the "treatment" and "genetics" clusters, the articles were published from the 2010s through 2021. In 2011, it was confirmed that a gene called Ringin protein 213 (RNF213) is a susceptibility gene for moyamoya disease. Since then, tremendous progress in genomic, transcriptomic, and epigenetic profiling (e.g., methylation profiling) has resulted in new concepts for classifying moyamoya disease. Our literature survey revealed that the pathogenesis involves aberrations of multiple signaling pathways through genetic mutations and altered gene expression. CONCLUSION We analyzed the content vectors in abstracts using AI, and reviewed the pathophysiology, clinical background, radiological features, treatments, and genetic peculiarity of moyamoya disease.
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Affiliation(s)
| | - Yukinori Akiyama
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Takeshi Mikami
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Katsuya Komatsu
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Yusuke Kimura
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | | | - Kyoya Sakashita
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Ryohei Chiba
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Nobuhiro Mikuni
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
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Gerstl L, Olivieri M, Heinen F, Bidlingmaier C, Schroeder AS, Reiter K, Hoffmann F, Kurnik K, Liebig T, Trumm CG, Haas NA, Jakob A, Borggraefe I. Notfall-Neuropädiatrie – Der arteriell ischämische Schlaganfall als einer der zeitkritischsten Notfälle bei Kindern und Jugendlichen. DER NERVENARZT 2022; 93:158-166. [PMID: 35072763 PMCID: PMC8785019 DOI: 10.1007/s00115-021-01252-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/06/2021] [Indexed: 11/21/2022]
Abstract
Der arteriell ischämische Schlaganfall im Kindes- und Jugendalter gehört zu den zeitkritischsten Notfällen in der Pädiatrie. Dennoch wird er häufig mit einer oft prognostisch relevanten Zeitverzögerung diagnostiziert. Gründe dafür liegen neben der geringen Awareness auch in der zuweilen unspezifischen klinischen Präsentation mit einer herausfordernden Breite kritischer Differenzialdiagnosen sowie in der Fläche noch wenig verzahnter Akutversorgungsstrukturen. Gleichwohl zeigen grundsätzlich die beim Erwachsenen etablierten Revaskularisationsstrategien auch beim Kind ihre möglichen, zum Teil spektakulären Erfolge. Es gilt also, diese nach Möglichkeit auch den betroffenen Kindern zur Verfügung zu stellen, auch wenn hier derzeit ein nicht annähernd vergleichbarer Grad an Evidenz erreicht ist. Postakut ist die ätiologische Aufarbeitung durch die größere Bandbreite zu bedenkender Risikofaktoren besonders komplex, muss aber in der Lage sein, das individuelle Risikoprofil mit Sekundärprophylaxe, Rezidivrisiko und Outcome präzise zu identifizieren. Die Langzeitbetreuung im multiprofessionellen, interdisziplinären Team muss die biopsychosozialen Aspekte des Kindes in seiner jeweiligen Entwicklungsphase berücksichtigen und damit eine bestmögliche Integration des Kindes in sein soziales und schulisches, später berufliches Umfeld realisieren.
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High-resolution intracranial vessel wall imaging in cerebral viral infections evaluations. Neuroradiology 2021; 64:915-924. [PMID: 34657167 PMCID: PMC8520459 DOI: 10.1007/s00234-021-02831-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/08/2021] [Indexed: 11/30/2022]
Abstract
Purpose Vascular complications can be seen in various viral CNS infections. Variable neuro-imaging findings have been described in the literature elucidating the parenchymal changes with vascular involvement. Vessel wall imaging (VWI) can help to detect these vascular involvements. We aimed to describe the role and usefulness of VWI in the evaluation of various viral CNS infections. Methods In this prospective study, we included 15 cases of various diagnosed viral CNS infections (varicella, HIV encephalopathy, HSV encephalitis, Japanese encephalitis, dengue, COVID-19). VWI and time-of-flight MR angiography (TOF MRA) were included in imaging protocol. All cases were evaluated for the presence of cerebral parenchymal changes, vascular enhancement, and vascular stenosis. Results We found infarctions in all 5 cases of varicella, 1 case of HIV encephalopathy, and 1 case of COVID-19 encephalopathy. All these cases also showed vascular enhancement and stenosis on VWI. The rest of the cases, including 1 case of HIV encephalopathy, 3 cases of herpes encephalitis, 2 cases of dengue, and 2 cases of Japanese encephalitis did not have any vascular complication, and also did not show vascular enhancement or stenosis. Conclusion VWI can be useful in the detection of vascular involvement in various viral infections of CNS which show a relatively higher cerebrovascular complication rate like varicella, HIV encephalopathy, and COVID-19. However, VWI may not be useful in the routine evaluation of other viral infections like herpes, dengue, and Japanese encephalitis, which have a very low rate of cerebrovascular complication rate.
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Mineharu Y, Miyamoto S. RNF213 and GUCY1A3 in Moyamoya Disease: Key Regulators of Metabolism, Inflammation, and Vascular Stability. Front Neurol 2021; 12:687088. [PMID: 34381413 PMCID: PMC8350054 DOI: 10.3389/fneur.2021.687088] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 06/24/2021] [Indexed: 12/24/2022] Open
Abstract
Moyamoya disease is an idiopathic chronically progressive cerebrovascular disease, which causes both ischemic and hemorrhagic stroke. Genetic studies identified RNF213/Mysterin and GUCY1A3 as disease-causing genes. They were also known to be associated with non-moyamoya intracranial large artery disease, coronary artery disease and pulmonary artery hypertension. This review focused on these two molecules and their strong linker, calcineurin/NFAT signaling and caveolin to understand the pathophysiology of moyamoya disease and related vascular diseases. They are important regulators of lipid metabolism especially lipotoxicity, NF-κB mediated inflammation, and nitric oxide-mediated vascular protection. Although intimal thickening with fibrosis and damaged vascular smooth muscle cells are the distinguishing features of moyamoya disease, origin of the fibrous tissue and the mechanism of smooth muscle cell damages remains not fully elucidated. Endothelial cells and smooth muscle cells have long been a focus of interest, but other vascular components such as immune cells and extracellular matrix also need to be investigated in future studies. Molecular research on moyamoya disease would give us a clue to understand the mechanism preserving vascular stability.
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Affiliation(s)
- Yohei Mineharu
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Cellerini M, Princiotta C, Menozzi R, Capurri G, Russo R, Bergui M. Letter-to-the Editor: Focal cerebral arteriopathy and acute ischaemic stroke in children: A diagnostic-therapeutical conundrum. Eur J Radiol 2021; 142:109846. [PMID: 34247031 DOI: 10.1016/j.ejrad.2021.109846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 06/29/2021] [Accepted: 07/02/2021] [Indexed: 11/16/2022]
Abstract
Acute ischaemic stroke (AIS) in children is generally considered an up-to-date and controversial topic because its presents significant peculiarities. Focal cerebral arteriopathies (FCA) are a possible cause of AIS in children characterized by an unilateral lesion of the terminal internal cerebral artery (ICA) and proximal segment (M1) of middle cerebral artery (MCA), leading to subocclusion, occasionally with a typical "striate" pattern and a tendency to stability or regression at follow-up. It is unclear whether in FCA the basic lesion is an inflammatory or a dissective arterial pathology. Herein we report a small series of children (<16 yo) with AIS from a FCA who underwent mechanical thrombectomy (MT). We speculate on the angiographic findings suggesting an aetiology of the lesion, and on indications and limits of the currently available treatments.
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Affiliation(s)
- Martino Cellerini
- Department of Neuroradiology, Bellaria Hospital, IRCCS Istituto delle Scienze Neurologiche di Bologna, Italy.
| | - Ciro Princiotta
- Department of Neuroradiology, Bellaria Hospital, IRCCS Istituto delle Scienze Neurologiche di Bologna, Italy
| | | | | | - Riccardo Russo
- Department of Neuroradiology, Città della Salute University Hospital, Torino, Italy
| | - Mauro Bergui
- Department of Neuroradiology, Città della Salute University Hospital, Torino, Italy
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31
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Mallick AA. Pediatric arterial ischemic stroke in the scientific literature. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Oesch G, Perez FA, Wainwright MS, Shaw DWW, Amlie-Lefond C. Focal Cerebral Arteriopathy of Childhood: Clinical and Imaging Correlates. Stroke 2021; 52:2258-2265. [PMID: 34039030 DOI: 10.1161/strokeaha.120.031880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Gabriela Oesch
- Department of Pediatric Neurology, University Children's Hospital, Zurich, Switzerland (G.O.)
| | - Francisco A Perez
- Department of Radiology, Seattle Children's and University of Washington (F.A.P., D.W.W.S.)
| | - Mark S Wainwright
- Department of Neurology, Seattle Children's Hospital and University of Washington (M.S.W., C.A.-L.)
| | - Dennis W W Shaw
- Department of Radiology, Seattle Children's and University of Washington (F.A.P., D.W.W.S.)
| | - Catherine Amlie-Lefond
- Department of Neurology, Seattle Children's Hospital and University of Washington (M.S.W., C.A.-L.)
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Abstract
Neurovascular disorders are an important cause of brain injury in the paediatric population, leading to substantial mortality and morbidity. These include ischaemic, haemorrhagic strokes, and cerebral venous sinus thromboses. Despite remarkable improvements in our understanding and management of strokes in general, and in the quality of immediate care and rehabilitation, the outcomes in childhood strokes lag far behind adult strokes. This is a multifaceted problem. There remain several challenges including delays in recognition due to vague clinical presentations, a failure to consider strokes in many cases, delays in obtaining imaging and inadequate imaging when performed, as well as limited evidence and availability for hyper acute intervention in children. Stroke in children is also a vastly different entity to adult strokes, with a unique set of risk factors and often with an underlying cause to be found. This review is by no means exhaustive, but instead aims to provide an overview of the epidemiology, sub-classification and aetiology of paediatric neurovascular disorders, mainly ischaemic, haemorrhagic strokes and cerebral venous sinus thrombosis. We also focus on the risk factors for each of these, the clinical presentation, recommended diagnostic protocol, pertinent imaging findings, as well as the current treatment and follow-up practices.
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Affiliation(s)
- Richa Sinha
- Department of Neuroradiology, Royal Preston Hospital, Preston, UK
| | - Saipriya Ramji
- Department of Neuroradiology, Charing Cross Hospital, London, UK
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35
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Ali N, Al-Chalabi M, Salahuddin H. Successful Mechanical Thrombectomy for Basilar Artery Occlusion in a Seven-Year-Old Male. Cureus 2021; 13:e13950. [PMID: 33884225 PMCID: PMC8053644 DOI: 10.7759/cureus.13950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Acute arterial strokes in children are rare but can potentially cause lasting and often permanent neurological deficits. Mechanical thrombectomy has a well-established efficacy and safety profile in adult stroke management, but in the pediatric population, it is yet to be proven efficacious and safe. We present a case of a seven-year-old male who presented with multiple episodes of generalized tonic-clonic seizures after sustaining a neck injury by falling from a trampoline. National Institutes of Health (NIH) on presentation was 21. Neurological exam revealed dilated nonreactive pupils, dysconjugate gaze, severe dysarthria, bilateral ptosis, and movement of upper and lower extremities only to noxious stimuli. Magnetic resonance imaging (MRI) of brain without contrast revealed infarcted areas in the left pons, midbrain, and cerebellar regions. Computed tomographic angiogram (CTA) of head demonstrated left vertebral artery dissection with associated complete occlusion of the distal basilar artery. Successful recanalization was achieved with mechanical thrombectomy six hours after presentation. Mechanical thrombectomy treatment resulted in a significant neurological recovery with NIH of 1. This case supports the growing evidence of the efficacy and safety of mechanical thrombectomy in children.
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Affiliation(s)
- Nasar Ali
- Department of Neurology, University of Toledo, Toledo, USA
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36
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AbdelRazek MA, Hillis JM, Guo Y, Martinez-Lage M, Gholipour T, Sloane J, Cho T, Matiello M. Unilateral Relapsing Primary Angiitis of the CNS: An Entity Suggesting Differences in the Immune Response Between the Cerebral Hemispheres. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/2/e936. [PMID: 33402525 PMCID: PMC7862090 DOI: 10.1212/nxi.0000000000000936] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/22/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To determine whether studying patients with strictly unilateral relapsing primary angiitis of the CNS (UR-PACNS) can support hemispheric differences in immune response mechanisms, we reviewed characteristics of a group of such patients. METHODS We surveiled our institution for patients with UR-PACNS, after characterizing one such case. We defined UR-PACNS as PACNS with clinical and radiographic relapses strictly recurring in 1 brain hemisphere, with or without hemiatrophy. PACNS must have been biopsy proven. Three total cases were identified at our institution. A literature search for similar reports yielded 4 additional cases. The combined 7 cases were reviewed for demographic, clinical, imaging, and pathologic trends. RESULTS The median age at time of clinical onset among the 7 cases was 26 years (range 10-49 years); 5 were male (71%). All 7 patients presented with seizures. The mean follow-up duration was 7.5 years (4-14.1 years). The annualized relapse rate ranged between 0.2 and 1. UR-PACNS involved the left cerebral hemisphere in 5 of the 7 patients. There was no consistent relationship between the patient's dominant hand and the diseased side. When performed (5 cases), conventional angiogram was nondiagnostic. CSF examination showed nucleated cells and protein levels in normal range in 3 cases and ranged from 6 to 11 cells/μL and 49 to 110 mg/dL in 4 cases, respectively. All cases were diagnosed with lesional biopsy, showing lymphocytic type of vasculitis of the small- and medium-sized vessels. Patients treated with steroids alone showed progression. Induction therapy with cyclophosphamide or rituximab followed by a steroid sparing agent resulted in the most consistent disease remission. CONCLUSIONS Combining our 3 cases with others reported in the literature allows better clinical understanding about this rare and extremely puzzling disease entity. We hypothesize that a functional difference in immune responses, caused by such discrepancies as basal levels of cytokines, asymmetric distribution of microglia, and differences in modulation of the systemic immune functions, rather than a structural antigenic difference, between the right and left brain may explain this phenomenon, but this is speculative.
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Affiliation(s)
- Mahmoud A AbdelRazek
- From the Neurology Department (M.A.A.), Mount Auburn Hospital, Harvard Medical School, Cambridge, MA; Neurology Department (J.M.H., M.M.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (Y.G.), Beijing Tongren Hospital, Capital Medical University, China; Department of Pathology (M.M.-L.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (T.G.), The George Washington University, DC; Neurology Department (J.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Neurology Department (T.C.), University of Iowa.
| | - James M Hillis
- From the Neurology Department (M.A.A.), Mount Auburn Hospital, Harvard Medical School, Cambridge, MA; Neurology Department (J.M.H., M.M.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (Y.G.), Beijing Tongren Hospital, Capital Medical University, China; Department of Pathology (M.M.-L.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (T.G.), The George Washington University, DC; Neurology Department (J.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Neurology Department (T.C.), University of Iowa
| | - Yanjun Guo
- From the Neurology Department (M.A.A.), Mount Auburn Hospital, Harvard Medical School, Cambridge, MA; Neurology Department (J.M.H., M.M.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (Y.G.), Beijing Tongren Hospital, Capital Medical University, China; Department of Pathology (M.M.-L.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (T.G.), The George Washington University, DC; Neurology Department (J.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Neurology Department (T.C.), University of Iowa
| | - Maria Martinez-Lage
- From the Neurology Department (M.A.A.), Mount Auburn Hospital, Harvard Medical School, Cambridge, MA; Neurology Department (J.M.H., M.M.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (Y.G.), Beijing Tongren Hospital, Capital Medical University, China; Department of Pathology (M.M.-L.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (T.G.), The George Washington University, DC; Neurology Department (J.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Neurology Department (T.C.), University of Iowa
| | - Taha Gholipour
- From the Neurology Department (M.A.A.), Mount Auburn Hospital, Harvard Medical School, Cambridge, MA; Neurology Department (J.M.H., M.M.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (Y.G.), Beijing Tongren Hospital, Capital Medical University, China; Department of Pathology (M.M.-L.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (T.G.), The George Washington University, DC; Neurology Department (J.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Neurology Department (T.C.), University of Iowa
| | - Jacob Sloane
- From the Neurology Department (M.A.A.), Mount Auburn Hospital, Harvard Medical School, Cambridge, MA; Neurology Department (J.M.H., M.M.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (Y.G.), Beijing Tongren Hospital, Capital Medical University, China; Department of Pathology (M.M.-L.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (T.G.), The George Washington University, DC; Neurology Department (J.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Neurology Department (T.C.), University of Iowa
| | - Tracey Cho
- From the Neurology Department (M.A.A.), Mount Auburn Hospital, Harvard Medical School, Cambridge, MA; Neurology Department (J.M.H., M.M.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (Y.G.), Beijing Tongren Hospital, Capital Medical University, China; Department of Pathology (M.M.-L.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (T.G.), The George Washington University, DC; Neurology Department (J.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Neurology Department (T.C.), University of Iowa
| | - Marcelo Matiello
- From the Neurology Department (M.A.A.), Mount Auburn Hospital, Harvard Medical School, Cambridge, MA; Neurology Department (J.M.H., M.M.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (Y.G.), Beijing Tongren Hospital, Capital Medical University, China; Department of Pathology (M.M.-L.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (T.G.), The George Washington University, DC; Neurology Department (J.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Neurology Department (T.C.), University of Iowa
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Bertamino M, Signa S, Vagelli G, Caorsi R, Zanetti A, Volpi S, Losurdo G, Amico G, Dodi I, Prato G, Ronchetti AB, Di Rocco M, Nagel M, Severino M. An atypical case of post-varicella stroke in a child presenting with hemichorea followed by late-onset inflammatory focal cerebral arteriopathy. Quant Imaging Med Surg 2021; 11:463-471. [PMID: 33392044 DOI: 10.21037/qims-20-628] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Marta Bertamino
- Rehabilitation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Sara Signa
- Department of Neuroscience, Ophthalmology, Genetics and Maternal Infantile Sciences (DINOGMI), University of Genoa, Genoa, Italy.,Autoinflammatory Diseases and Immunodeficiencies Center, IRCCS Istituto Gianina Gaslini, Genoa, Italy
| | - Giulia Vagelli
- Department of Neuroscience, Ophthalmology, Genetics and Maternal Infantile Sciences (DINOGMI), University of Genoa, Genoa, Italy
| | - Roberta Caorsi
- Autoinflammatory Diseases and Immunodeficiencies Center, IRCCS Istituto Gianina Gaslini, Genoa, Italy
| | - Alice Zanetti
- Rehabilitation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Stefano Volpi
- Department of Neuroscience, Ophthalmology, Genetics and Maternal Infantile Sciences (DINOGMI), University of Genoa, Genoa, Italy.,Autoinflammatory Diseases and Immunodeficiencies Center, IRCCS Istituto Gianina Gaslini, Genoa, Italy
| | - Giuseppe Losurdo
- Infectious Diseases Unit, IRCCS Istituto Gianina Gaslini, Genoa, Italy
| | - Giulia Amico
- Department of Neuroscience, Ophthalmology, Genetics and Maternal Infantile Sciences (DINOGMI), University of Genoa, Genoa, Italy.,Laboratory of Genetic and Genomics of Rare Disease, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Icilio Dodi
- Emergency Unit, Pietro Barilla Children Hospital, Parma, Italy
| | - Giulia Prato
- Child Neuropsychiatry Unit, IRCCS Istituto Gianina Gaslini, Genoa, Italy
| | | | - Maja Di Rocco
- Rare Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Maria Nagel
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
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Lampros A, Caumes E, Psimaras D, Galanaud D, Clarençon F, Peyre M, Deltour S, Bielle F, Lhote R, Haroche J, Amoura Z, Cohen Aubart F. [Infection associated cerebral vasculitis]. Rev Med Interne 2020; 42:258-268. [PMID: 32868117 DOI: 10.1016/j.revmed.2020.05.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 04/26/2020] [Accepted: 05/07/2020] [Indexed: 12/11/2022]
Abstract
Infections are a frequent cause of cerebral vasculitis, important to diagnose because a specific treatment may be required. Infection-associated vasculitis can be caused by angiotropic pathogens (varicella zoster virus, syphilis, aspergillus). They can be associated with subarachnoidal meningitis (tuberculosis, pyogenic meningitis, cysticercosis). They can appear contiguously to sinuses or orbital infection (aspergillosis, mucormycosis). Finally, they also may be due to an immune mechanism in the context of chronic infections (hepatitis B virus, hepatitis C virus, human immunodeficiency virus). Cerebral vasculitis are severe conditions and their prognosis is directly linked to early recognition and diagnosis. Infectious causes must therefore be systematically considered ahead of cerebral vasculitis, and the appropriate investigations must be determined according to the patient's clinical context. We propose here an update on the infectious causes of cerebral vasculitis, their diagnosis modalities, and therapeutic options.
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Affiliation(s)
- A Lampros
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de Médecine Interne 2, Centre de Référence Maladies systémiques rares et Histiocytoses, 75013 Paris, France
| | - E Caumes
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service des maladies infectieuses et tropicales, 75013 Paris, France
| | - D Psimaras
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de Neurologie 2, 75013 Paris, France
| | - D Galanaud
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de Neuroradiologie, 75013 Paris, France
| | - F Clarençon
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de Neuroradiologie, 75013 Paris, France
| | - M Peyre
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de Neurochirurgie, 75013 Paris, France
| | - S Deltour
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service des Urgences cérébro-vasculaires, 75013 Paris, France
| | - F Bielle
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de Neuropathologie, 75013 Paris, France
| | - R Lhote
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de Médecine Interne 2, Centre de Référence Maladies systémiques rares et Histiocytoses, 75013 Paris, France
| | - J Haroche
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de Médecine Interne 2, Centre de Référence Maladies systémiques rares et Histiocytoses, 75013 Paris, France
| | - Z Amoura
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de Médecine Interne 2, Centre de Référence Maladies systémiques rares et Histiocytoses, 75013 Paris, France
| | - F Cohen Aubart
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de Médecine Interne 2, Centre de Référence Maladies systémiques rares et Histiocytoses, 75013 Paris, France.
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Slavova N, Fullerton HJ, Hills NK, Breiding PS, Mackay MT, Steinlin M. Validation of the focal cerebral arteriopathy severity score (FCASS) in a Swiss cohort: Correlation with infarct volume and outcome. Eur J Paediatr Neurol 2020; 28:58-63. [PMID: 32826156 DOI: 10.1016/j.ejpn.2020.07.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/09/2020] [Accepted: 07/27/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Focal cerebral arteriopathy (FCA), a major cause of childhood arterial ischemic stroke (AIS), can progress and lead to increased infarct size and/or recurrent stroke. Evaluating treatment options depends on the ability to quantify reliably the degree of stenosis in FCA. AIMS We validated the recently introduced FCA severity score (FCASS) in an independent cohort from the Swiss Neuro-Paediatric Stroke Registry (SNPSR). MATERIALS AND METHODS We included children with FCA who had MR or CT angiography and a Pediatric Stroke Outcome Measure (PSOM) at 6-months and 2-years post-stroke. A paediatric neuroradiologist applied the FCASS and the modified pediatric Alberta Stroke Program Early Computed Tomography Score (ASPECTS), a measure of infarct volume, to all available imaging. Two senior paediatric stroke neurologists and a neuroradiology fellow independently assigned FCASS scores to test interrater reliability. Pairwise correlations between FCASS, pedASPECTS, and PSOM were examined. RESULTS Thirty-two children [median (IQR) age = 5.9 (1.8, 9.6), 19 males] were included. The median maximum FCASS score at any time was 9 (IQR 6, 12; range 3, 16). Larger infarct volume scores correlated with both higher maximum FCASS scores and worse post-stroke outcomes, although we found no direct correlation between FCASS and outcomes. Stroke neurologists tended to assign lower FCASS scores than the neuroradiologist, but interrater reliability was predominantly good. CONCLUSIONS In this independent validation cohort, higher maximum FCASS correlated with greater infarct volume scores that also correlated with worse neurological outcomes. Scoring by non-imaging specialists seems to be valuable, although differences are present.
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Affiliation(s)
- Nedelina Slavova
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Inselspital, and University of Bern, Switzerland; Department of Interventional, Pediatric and Diagnostic Radiology, Inselspital, University Hospital, and University of Bern, Switzerland.
| | | | - Nancy K Hills
- Department of Neurology, University of California, San Francisco, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
| | - Philipe S Breiding
- Department of Diagnostic and Interventional Radiology, Kantonsspital Frauenfeld, Switzerland
| | - Mark T Mackay
- Royal Children's Hospital and Murdoch Children's Research Institute, University of Melbourne, Australia
| | - Maja Steinlin
- Division of Neuropaediatrics, University Hospital Inselspital, and University of Bern, Switzerland
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Associations between Lesion Locations and Stroke Recurrence in Survivors of First-ever Ischemic Stroke: A Prospective Cohort Study. Curr Med Sci 2020; 40:708-718. [PMID: 32862382 DOI: 10.1007/s11596-020-2240-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 05/14/2020] [Indexed: 02/05/2023]
Abstract
Several studies have indicated that stroke survivors with multiple lesions or with larger lesion volumes have a higher risk of stroke recurrence. However, the relationship between lesion locations and stroke recurrence is unclear. We conducted a prospective cohort study of first-ever ischemic stroke survivors who were consecutively enrolled from January 2010 to December 2015. Stroke recurrence was assessed every 3 months after post-discharge via telephone interviews by trained interviewers. Lesion locations were obtained from hospital-based MRI or CT scans and classified using two classification systems that were based on cerebral hemisphere or vascular territory and brain anatomical structures. Flexible parametric survival models using the proportional hazards scale (PH model) were used to analyze the time-to-event data. Among 633 survivors, 63.51% (n=402) had anterior circulation ischemia (ACI), and more than half of all ACIs occurred in the subcortex. After a median follow-up of 2.5 years, 117 (18.48%) survivors developed a recurrent stroke. The results of the multivariate PH model showed that survivors with non-brain lesions were at higher risk of recurrence than those with right-side lesions (HR, 2.79; 95%CI, 1.53, 5.08; P=0.001). There was no increase in risk among survivors with left-side lesions (HR, 0.97; 95%CI, 0.53, 1.75; P=0.914) or both-side lesions (HR, 1.24; 95%CI, 0.75, 2.07; P=0.401) compared to those with right-side lesions. Additionally, there were no associations between stroke recurrence and lesion locations that were classified based on vascular territory and brain anatomical structures. It was concluded that first-ever ischemic stroke survivors with non-brain lesion had higher recurrence risk than those with right-side lesion, although no significant associations were found when the lesion locations were classified by vascular territory and brain anatomical structures.
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Rafay MF, Shapiro KA, Surmava AM, deVeber GA, Kirton A, Fullerton HJ, Amlie-Lefond C, Weschke B, Dlamini N, Carpenter JL, Mackay MT, Rivkin M, Linds A, Bernard TJ. Spectrum of cerebral arteriopathies in children with arterial ischemic stroke. Neurology 2020; 94:e2479-e2490. [PMID: 32457211 DOI: 10.1212/wnl.0000000000009557] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 11/25/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine that children with arterial ischemic stroke (AIS) due to an identifiable arteriopathy are distinct from those without arteriopathy and that each arteriopathy subtype has unique and recognizable clinical features. METHODS We report a large, observational, multicenter cohort of children with AIS, age 1 month to 18 years, enrolled in the International Pediatric Stroke Study from 2003 to 2014. Clinical and demographic differences were compared by use of the Fisher exact test, with linear step-up permutation min-p adjustment for multiple comparisons. Exploratory analyses were conducted to evaluate differences between cases of AIS with and without arteriopathy and between arteriopathy subtypes. RESULTS Of 2,127 children with AIS, 725 (34%) had arteriopathy (median age 7.45 years). Arteriopathy subtypes included dissection (27%), moyamoya (24.5%), focal cerebral arteriopathy-inflammatory subtype (FCA-i; 15%), diffuse cerebral vasculitis (15%), and nonspecific arteriopathy (18.5%). Children with arteriopathic AIS were more likely to present between 6 and 9 years of age (odds ratio [OR] 1.93, p = 0.029) with headache (OR 1.55, p = 0.023), multiple infarctions (OR 2.05, p < 0.001), sickle cell anemia (OR 2.9, p = 0.007), and head/neck trauma (OR 1.93, p = 0.018). Antithrombotic use and stroke recurrence were higher in children with arteriopathy. Among arteriopathy subtypes, dissection was associated with male sex, older age, headache, and anticoagulant use; FCA-i was associated with hemiparesis and single infarcts; moyamoya was associated with seizures and recurrent strokes; and vasculitis was associated with bilateral infarctions. CONCLUSION Specific clinical profiles are associated with cerebral arteriopathies in children with AIS. These observations may be helpful indicators in guiding early diagnosis and defining subgroups who may benefit most from future therapeutic trials.
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Affiliation(s)
- Mubeen F Rafay
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver.
| | - Kevin A Shapiro
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Ann-Marie Surmava
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Gabrielle A deVeber
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Adam Kirton
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Heather J Fullerton
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Catherine Amlie-Lefond
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Bernhard Weschke
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Nomazulu Dlamini
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Jessica L Carpenter
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Mark T Mackay
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Michael Rivkin
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Alexandra Linds
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
| | - Timothy J Bernard
- From the Section of Pediatric Neurology (M.F.R.), Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Department of Neurology and Pediatrics (K.A.S., H.J.F.), University of California, San Francisco; University of Toronto (A.-M.S.); Division of Neurology (G.A.d.V., N.D., A.L.), The Hospital for Sick Children, University of Toronto, Ontario; Department of Pediatrics and Clinical Neurosciences (A.K.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (C.A.-L.), University of Washington, Seattle; Department of Neuropediatrics (B.W.), Charité University Medicine Berlin, Germany; Department of Neurology (J.L.C.), George Washington University, Washington, DC; Department of Neurology (M.T.M.), Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Australia; Boston Children's Hospital (M.R.), Harvard Medical School, Boston, MA; and Division of Child Neurology (T.J.B.), Department of Pediatrics and the Hemophilia and Thrombosis Center, University of Colorado, Denver
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Abstract
Background and Purpose- Focal cerebral arteriopathy is monophasic inflammatory stenosis of the distal internal carotid artery or the proximal segment of the middle cerebral artery. It is one of the most common causes of acute arterial ischemic stroke in young children but is a less familiar entity for adult neurologists. Methods- We retrospectively reviewed stroke service radiology records at a tertiary referral center from January 2013 to December 2014. Focal cerebral arteriopathy was defined as nonprogressive unifocal and unilateral stenosis/irregularity of the distal internal carotid artery or its proximal branches. Only patients aged 16 to 55 years with stroke were included. Results- There were 5 cases of focal cerebral arteriopathy: 2 males and 3 females. Three cases were from the cohort of 123 acute presentations of young stroke, and 2 cases were outpatient referrals. The mean age (range) was 43 (32-55) years. The majority presented with recurrent transient ischemic attacks/minor strokes within a single vascular territory over days to weeks. All cases had characteristic radiological features. Interval imaging demonstrated resolution in 1 case and improvement in 3 cases. Functional outcome was excellent with discharge modified Rankin Scale score ranging from 0 to 1. Recurrence occurred in 1 case. Conclusions- Focal cerebral arteriopathy is a rare cause of arterial ischemic stroke in young adults. Follow-up intracranial imaging is essential to differentiate from progressive arteriopathies. Evidence-based treatment warrants further investigation. Prognosis is favorable.
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Affiliation(s)
- Mary Clare McKenna
- From the Department of Neurology (M.C.M., S.C.), Cork University Hospital, Ireland
| | - Noel Fanning
- Department of Neurointerventional Radiology (N.F.), Cork University Hospital, Ireland
| | - Simon Cronin
- From the Department of Neurology (M.C.M., S.C.), Cork University Hospital, Ireland
- Department of Clinical Neuroscience, College of Medicine and Health, University College Cork, Ireland (S.C.)
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Arterial ischemic stroke in non-neonate children: Diagnostic and therapeutic specificities. Rev Neurol (Paris) 2020; 176:20-29. [DOI: 10.1016/j.neurol.2019.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/13/2019] [Accepted: 03/14/2019] [Indexed: 12/12/2022]
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Smitka M, Bruck N, Engellandt K, Hahn G, Knoefler R, von der Hagen M. Clinical Perspective on Primary Angiitis of the Central Nervous System in Childhood (cPACNS). Front Pediatr 2020; 8:281. [PMID: 32719754 PMCID: PMC7349935 DOI: 10.3389/fped.2020.00281] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 05/04/2020] [Indexed: 12/21/2022] Open
Abstract
Non-arteriosclerotic arteriopathies have emerged as important underlying pathomechanism in pediatric arterial ischemic stroke (AIS). The pathogenesis and classification of cerebral arteriopathies in childhood are heterogeneous. Different classifications base on (i) the anatomic site; (ii) the distribution and size of the affected vessel; (iii) the time course, for example, transient vs. progressive, monophasic vs. recurrent; (iv) the putative pathogenesis; (v) the magnetic resonance imaging morphology of the vasculopathies. Inflammation affecting the cerebral vessels is increasingly recognized as common cause of pediatric AIS. Primary cerebral vasculitis or primary angiitis of the central nervous system (CNS) in childhood (cPACNS) is an important differential diagnosis in pediatric AIS. Primary angiitis of the CNS is a rare disorder, and the pathogenesis is poorly understood so far. The current classification of cPACNS is based on the affected cerebral vessel size, the disease course, and angiographic pattern. Two large subtypes are currently recognized comprising large- and medium-sized vessel CNS vasculitis referred to as angiography-positive cPACNS and angiography-negative small vessel cPACNS. As the clinical manifestations of cPACNS are rather diverse, precise diagnosis can be challenging for the treating pediatrician because of the lack of vital laboratory tests or imaging features. Initial misdiagnosis is common because of overlapping phenotypes and pediatric AIS mimics. As untreated cPACNS is associated with a high morbidity and mortality, timely diagnosis, and induction of immunomodulatory and symptomatic therapy are essential. Survival and neurological outcome depend on early diagnosis and prompt therapy. Primary angiitis of the central nervous system in childhood differs in several aspects from primary cerebral angiitis in adults. The aim of this article is to give a brief comprehensive summary on pediatric primary cerebral vasculitis focusing on the clinical perspective regarding the classification, the putative pathogenesis, the disease course, the diagnostic tools, and emerging treatment options. A modified terminology for clinical practice is discussed.
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Affiliation(s)
- Martin Smitka
- Abteilung Neuropädiatrie, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Normi Bruck
- Klinik für Kinder und Jugendmedizin, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Kay Engellandt
- Department of Neuroradiology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Gabriele Hahn
- Bereich Kinderradiologie, Medizinische Fakultät Carl Gustav Carus, Institut und Poliklinik für Radiologische Diagnostik, Technische Universität Dresden, Dresden, Germany
| | - Ralf Knoefler
- Klinik für Kinder und Jugendmedizin, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Maja von der Hagen
- Abteilung Neuropädiatrie, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Bakradze E, Kirchoff KF, Antoniello D, Springer MV, Mabie PC, Esenwa CC, Labovitz DL, Liberman AL. Varicella Zoster Virus Vasculitis and Adult Cerebrovascular Disease. Neurohospitalist 2019; 9:203-208. [PMID: 31534609 PMCID: PMC6739663 DOI: 10.1177/1941874419845732] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The role of Varicella zoster virus (VZV) in neurological illness, particularly cerebrovascular disease, has been increasingly recognized. Primary infection by VZV causes varicella (chickenpox), after which the virus remains latent in neuronal ganglia. Later, during aging or immunosuppression, the virus can reactivate causing zoster (shingles). Virus reactivation can also spread to cerebral arteries causing vasculitis and stroke. Zoster is a recognized risk factor for stroke, but stroke can occur without preceding zoster rash. The diagnosis of VZV cerebral vasculitis is established by abnormal brain imaging and confirmed by presence of viral DNA or anti-VZV antibodies in cerebrospinal fluid. Treatment with acyclovir with or without prednisone is usually recommended. VZV vasculitis is a unique and uncommon stroke mechanism that has been under recognized. Careful diagnostic investigation may be warranted in a subgroup of patients with ischemic stroke to detect VZV vasculitis and initiate appropriate therapy. In the following review, we detail the clinical presentation of VZV vasculitis, diagnostic challenges in VZV detection, and suggest the ways to enhance recognition and treatment of this uncommon disease.
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Affiliation(s)
- Ekaterina Bakradze
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kathryn F. Kirchoff
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Daniel Antoniello
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Peter C. Mabie
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Neurology, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Charles C. Esenwa
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Daniel L. Labovitz
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ava L. Liberman
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Fullerton HJ, Stence N, Hills NK, Jiang B, Amlie-Lefond C, Bernard TJ, Friedman NR, Ichord R, Mackay MT, Rafay MF, Chabrier S, Steinlin M, Elkind MSV, deVeber GA, Wintermark M. Focal Cerebral Arteriopathy of Childhood: Novel Severity Score and Natural History. Stroke 2019; 49:2590-2596. [PMID: 30355212 DOI: 10.1161/strokeaha.118.021556] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Focal cerebral arteriopathy (FCA)-a common cause of arterial ischemic stroke in previously healthy children-often progresses over days to weeks, increasing the risk of recurrent stroke. We developed a novel severity scoring system designed to quantify FCA progression and correlate with clinical outcomes. Methods- The VIPS study (Vascular Effects of Infection in Pediatric Stroke) prospectively enrolled 355 children with arterial ischemic stroke (2010-2014), including 41 with centrally confirmed FCA. Two neuroradiologists independently reviewed FCA cerebrovascular imaging, assigning a graded severity score of zero (no involvement) to 4 (occlusion) to individual arterial segments. The FCA severity score (FCASS) was the unweighted sum. In an iterative process, we modeled scores derived from different combinations of arterial segments to identify the model that optimized correlation with clinical outcome, simplicity, and reliability. Results- The optimal FCASS summed scores from 5 arterial segments: supraclinoid internal carotid artery, A1, A2, M1, and M2. The median (interquartile range) baseline FCASS was 4 (2-6). Of 33 children with follow-up imaging, the maximum FCASS (at any time point) was 7 (5-9). Twenty-four (73%) had FCA progression on follow-up with their maximum FCASS at a median of 8 (5-35.5) days poststroke; their median FCASS increase was 4 (2.5-6). FCASS did not correlate with recurrent arterial ischemic stroke. Maximum (but not baseline) FCASS correlated with 1-year pediatric stroke outcome measures ( P=0.037). Conclusions- Our novel scoring system for FCA severity correlates with neurological outcomes in the VIPS cohort and provides a tool for FCA treatment trials under development.
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Affiliation(s)
- Heather J Fullerton
- From the Department of Neurology (H.J.F., N.K.H.), University of California, San Francisco.,Department of Pediatrics (H.J.F.), University of California, San Francisco
| | - Nicholas Stence
- Department of Radiology (N.S.), University of Colorado, Denver
| | - Nancy K Hills
- From the Department of Neurology (H.J.F., N.K.H.), University of California, San Francisco.,Department of Biostatistics and Epidemiology (N.K.H.), University of California, San Francisco
| | - Bin Jiang
- Division of Neuroradiology, Department of Radiology, Stanford University, CA (B.J., M.W.)
| | | | | | - Neil R Friedman
- Center for Pediatric Neurosciences, Neurological Institute, Cleveland Clinic, OH (N.R.F.)
| | - Rebecca Ichord
- Department of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine of the University of Pennsylvania (R.I.)
| | - Mark T Mackay
- Department of Paediatrics, Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne, Victoria, Australia (M.T.M.)
| | - Mubeen F Rafay
- Department of Pediatrics and Child Health, Children's Hospital, University of Manitoba, Winnipeg, Canada (M.F.R.)
| | - Stéphane Chabrier
- INSERM, UMR1059 Sainbiose, University of Lyon, CHU Saint-Étienne, France (S.C.)
| | - Maja Steinlin
- Department of Pediatric Neurology, University Children's Hospital, University of Bern, Switzerland (M.S.)
| | - Mitchell S V Elkind
- Department of Epidemiology, Mailman School of Public Health (M.S.V.E.), Columbia University, New York, NY.,Department of Neurology, Vagelos College of Physicians and Surgeons (M.S.V.E.), Columbia University, New York, NY
| | | | - Max Wintermark
- Division of Neuroradiology, Department of Radiology, Stanford University, CA (B.J., M.W.)
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Fink M, Slavova N, Grunt S, Perret E, Regényi M, Steinlin M, Bigi S. Posterior Arterial Ischemic Stroke in Childhood. Stroke 2019; 50:2329-2335. [DOI: 10.1161/strokeaha.119.025154] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Literature on the clinical manifestation and neuroradiological findings in pediatric patients with posterior circulation arterial ischemic stroke is scarce. This study aims to describe epidemiological features, clinical characteristics, and neuroimaging data on pediatric posterior circulation arterial ischemic stroke in Switzerland using the population-based Swiss Neuropediatric Stroke Registry.
Methods—
Children aged from 1 month to 16 years presenting with an isolated posterior circulation arterial ischemic stroke between 2000 and 2016 were included. Epidemiology, clinical manifestation, stroke cause, and neuroradiological features were summarized using descriptive statistics. Stroke severity was assessed using the pediatric National Institutes of Health Stroke Scale. Correlation analysis was performed using the Spearman correlation coefficient.
Results—
Forty-three children with posterior circulation arterial ischemic stroke were included (27 boys [62.8%], median age 7.9 years, interquartile range, 5 to 11.7 years). The incidence of posterior circulation arterial ischemic stroke is Switzerland was 0.183/100 000 and represented 16% of all childhood arterial ischemic strokes. Most patients presented with nonspecific neurological complaints, such as headache (58.1%) and nausea/vomiting (46.5%). The most frequent clinical manifestations were ataxia (58.1%) and motor/sensory hemisyndrome (53.5%/51.2%). Unilateral focal cerebral arteriopathy was the most common cause (11 children, 25.6%). Most infarcts were located in the cerebellum (46.5%) and thalamus (39.5%). A shorter diagnostic delay correlated with more severe stroke symptoms at presentation (rho= −0.365,
P
=0.016).
Conclusions—
Pediatric posterior circulation arterial ischemic stroke was caused by focal cerebral arteriopathy in one quarter of the patients in our cohort. The frequently reported nonspecific clinical symptoms, especially when associated with mild neurological findings, risk delaying the diagnosis of stroke. A high index of suspicion and increased awareness are required for timely diagnosis and treatment initiation.
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Affiliation(s)
- Mirjam Fink
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
| | - Nedelina Slavova
- Department of Neuroradiology, Bern University Hospital, University of Bern, Switzerland (N.S.)
| | - Sebastian Grunt
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
| | - Eveline Perret
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
| | - Maria Regényi
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
| | - Maja Steinlin
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
| | - Sandra Bigi
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
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Gerstl L, Weinberger R, Heinen F, Bonfert MV, Borggraefe I, Schroeder AS, Tacke M, Landgraf MN, Vill K, Kurnik K, Sorg AL, Olivieri M. Arterial ischemic stroke in infants, children, and adolescents: results of a Germany-wide surveillance study 2015–2017. J Neurol 2019; 266:2929-2941. [DOI: 10.1007/s00415-019-09508-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 08/01/2019] [Accepted: 08/13/2019] [Indexed: 12/13/2022]
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[Childhood stroke : What are the special features of childhood stroke?]. DER NERVENARZT 2019; 88:1367-1376. [PMID: 29063260 DOI: 10.1007/s00115-017-0435-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Childhood arterial ischemic stroke differs in essential aspects from adult stroke. It is rare, often relatively unknown among laypersons and physicians and the wide variety of age-specific differential diagnoses (stroke mimics) as well as less established care structures often lead to a considerable delay in the diagnosis of stroke. The possible treatment options in childhood are mostly off-label. Experiences in well-established acute treatment modalities in adult stroke, such as thrombolysis and mechanical thrombectomy are therefore limited in children and only based on case reports and case series. The etiological clarification is time-consuming due to the multitude of risk factors which must be considered. Identifying each child's individual risk profile is mandatory for acute treatment and secondary prevention strategies and has an influence on the individual outcome. In addition to the clinical neurological outcome the residual neurological effects of stroke on cognition and behavior are decisive for the integration of the child into its educational, later professional and social environment.
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