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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. Pediatrics 2024; 154:e2024066855. [PMID: 38932719 DOI: 10.1542/peds.2024-066855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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2
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Lambea-Gil Á, Martínez-de-Morentín-Narvarcorena AL, Tejada-Meza H, Zapatero-González D, Madurga-Revilla P, Bestué-Cardiel M. Paediatric stroke in the northern Spanish region of Aragon: incidence, clinical characteristics, and outcomes. Neurologia 2024; 39:474-485. [PMID: 35691906 DOI: 10.1016/j.nrleng.2021.10.004] [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] [Received: 03/17/2021] [Accepted: 10/17/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Recent years have seen considerable changes in the prevention and treatment of acute ischaemic stroke in adult patients. However, the low incidence of paediatric stroke makes the development of specific guidelines more challenging. This study aims to clarify the situation of these children in our region in order to establish a regional protocol to improve the care provided to these patients. METHODS We performed a regional incidence study of pediatric stroke (≤ 15 years of age) in Aragon, Spain (1308728 population, 15% aged ≤ 15 years) between 2008 and 2019. Data were obtained from hospital discharge records, including deaths, from the regional health service of Aragón, according to ICD codes for cerebrovascular disease. We analysed demographic, clinical, diagnostic/therapeutic, and prognostic variables. RESULTS A total of 21 events were recorded: 8 ischaemic (38.1%) and 13 haemorrhagic strokes (61.9%). The mean age (SD) was 9.3 years (1.0). The sample included 12 boys and nine girls. No statistically significant differences were found between ischaemic and haemorrhagic strokes, except in the chief complaint (language and motor impairment in ischaemic stroke and headache in haemorrhagic stroke). None of the patients with ischaemic stroke received reperfusion therapies. Including the 3 patients who died during hospitalisation, eight patients (42.1%) had modified Rankin Scale scores > 2 at 12 months. Motor deficits were the most common sequela (n=9). CONCLUSION Though infrequent, paediatric stroke has an important functional impact. In Spain, Madrid was the first region to adapt the existing code stroke care networks for adult patients. In Aragon, this review has enabled us to work closely with the different stakeholders to offer a care plan for acute paediatric ischaemic stroke. Nevertheless, prospective national registries would be valuable to continue improving the care provided to these patients.
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Affiliation(s)
- Á Lambea-Gil
- Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, Spain; Grupo de Investigación en Neurociencias, Instituto de Investigación Sanitaria (IIS) Aragón, Aragón, Spain.
| | | | - H Tejada-Meza
- Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, Spain; Grupo de Investigación en Neurociencias, Instituto de Investigación Sanitaria (IIS) Aragón, Aragón, Spain
| | - D Zapatero-González
- Servicio de Estrategias en Salud de la Dirección General de Sanidad, Gobierno de Aragón, Aragón, Spain
| | - P Madurga-Revilla
- Servicio de Pediatría, Hospital Materno Infantil - Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - M Bestué-Cardiel
- Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, Spain; Servicio de Estrategias en Salud de la Dirección General de Sanidad, Gobierno de Aragón, Aragón, Spain
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3
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. J Am Coll Radiol 2024; 21:e37-e69. [PMID: 38944445 DOI: 10.1016/j.jacr.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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4
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Lammert DB, Miller JL, Atkinson MA, Sun LR. Single-center Incidence and Patterns of Stroke in Early Renal Anhydramnios after Serial Amnioinfusions. J Pediatr 2024:114053. [PMID: 38615944 DOI: 10.1016/j.jpeds.2024.114053] [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] [Received: 01/26/2024] [Revised: 03/25/2024] [Accepted: 04/08/2024] [Indexed: 04/16/2024]
Abstract
The Renal Anhydramnios Fetal Therapy (RAFT) trial is a study of serial amnioinfusions to prevent lethal neonatal pulmonary hypoplasia from early renal anhydramnios. Infant neurologic outcomes were not originally evaluated. We describe the high incidence of stroke observed among infants in the treatment arm of the trial at our center.
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Affiliation(s)
- Dawn B Lammert
- Johns Hopkins School of Medicine, Department of Neurology, Division of Child Neurology, Baltimore, Maryland;.
| | - Jena L Miller
- Johns Hopkins School of Medicine, Department of Obstetrics and Gynecology, Johns Hopkins Center for Fetal Therapy, Baltimore, MD
| | - Meredith A Atkinson
- Johns Hopkins School of Medicine, Department of Pediatrics, Division of Pediatric Nephrology, Baltimore, MD
| | - Lisa R Sun
- Johns Hopkins School of Medicine, Department of Neurology, Division of Child Neurology, Baltimore, Maryland
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Barbadora J, Chun A, Yarimi JM, Shukla N, Lee-Kim Y, Kralik S, Little-Wienert K. A 6-Year-Old Girl With Fever, Weakness, and Ataxia. Pediatrics 2024; 153:e2023064171. [PMID: 38321939 DOI: 10.1542/peds.2023-064171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 02/08/2024] Open
Affiliation(s)
- Jennifer Barbadora
- Department of Pediatrics, Division of Cardiology, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, Ohio
- Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
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6
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Colovic H, Zlatanovic D, Zivkovic V, Jankovic M, Radosavljevic N, Ducic S, Ducic J, Stojkovic J, Jovanovic K, Nikolic D. A Review of Current Perspectives on Motoric Insufficiency Rehabilitation following Pediatric Stroke. Healthcare (Basel) 2024; 12:149. [PMID: 38255037 PMCID: PMC10815565 DOI: 10.3390/healthcare12020149] [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: 12/11/2023] [Revised: 12/30/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Pediatric stroke (PS) is an injury caused by the occlusion or rupture of a blood vessel in the central nervous system (CNS) of children, before or after birth. Hemiparesis is the most common motoric deficit associated with PS in children. Therefore, it is important to emphasize that PS is a significant challenge for rehabilitation, especially since the consequences may also appear during the child's growth and development, reducing functional capacity. The plasticity of the child's CNS is an important predecessor of recovery, but disruption of the neural network, specific to an immature brain, can have harmful and potentially devastating consequences. In this review, we summarize the complexity of the consequences associated with PS and the possibilities and role of modern rehabilitation. An analysis of the current literature reveals that Constraint-Induced Movement Therapy, forced-use therapy, repetitive transcranial magnetic stimulation, functional electrical stimulation and robot-assisted therapy have demonstrated at least partial improvements in motor domains related to hemiparesis or hemiplegia caused by PS, but they are supported with different levels of evidence. Due to the lack of randomized controlled studies, the optimal rehabilitation treatment is still debatable, and therefore, most recommendations are primarily based on expert consensuses, opinions and an insufficient level of evidence.
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Affiliation(s)
- Hristina Colovic
- Department for Physical Medicine and Rehabilitation, Faculty of Medicine, University of Niš, 18000 Niš, Serbia; (D.Z.); (V.Z.)
- Clinic for Physical Medicine and Rehabilitation, University Clinical Center Niš, 18000 Niš, Serbia
| | - Dragan Zlatanovic
- Department for Physical Medicine and Rehabilitation, Faculty of Medicine, University of Niš, 18000 Niš, Serbia; (D.Z.); (V.Z.)
- Clinic for Physical Medicine and Rehabilitation, University Clinical Center Niš, 18000 Niš, Serbia
| | - Vesna Zivkovic
- Department for Physical Medicine and Rehabilitation, Faculty of Medicine, University of Niš, 18000 Niš, Serbia; (D.Z.); (V.Z.)
- Clinic for Physical Medicine and Rehabilitation, University Clinical Center Niš, 18000 Niš, Serbia
| | - Milena Jankovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.J.); (S.D.); (J.D.); (J.S.); (D.N.)
- Neurology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Natasa Radosavljevic
- Department of Biomedical Sciences, State University of Novi Pazar, 36300 Novi Pazar, Serbia;
| | - Sinisa Ducic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.J.); (S.D.); (J.D.); (J.S.); (D.N.)
- Department of Pediatric Surgery, University Children’s Hospital, 11000 Belgrade, Serbia
| | - Jovan Ducic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.J.); (S.D.); (J.D.); (J.S.); (D.N.)
| | - Jasna Stojkovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.J.); (S.D.); (J.D.); (J.S.); (D.N.)
- Department of Physical Medicine and Rehabilitation, University Children’s Hospital, 11000 Belgrade, Serbia
| | - Kristina Jovanovic
- Department of Pediatrics, University Children’s Hospital, 11000 Belgrade, Serbia;
| | - Dejan Nikolic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.J.); (S.D.); (J.D.); (J.S.); (D.N.)
- Department of Physical Medicine and Rehabilitation, University Children’s Hospital, 11000 Belgrade, Serbia
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Brandt AE, Rø TB, Finnanger TG, Hypher RE, Lien E, Lund B, Catroppa C, Andersson S, Risnes K, Stubberud J. Intelligence and executive function are associated with age at insult, time post-insult, and disability following chronic pediatric acquired brain injury. Front Neurol 2024; 14:1192623. [PMID: 38249741 PMCID: PMC10796693 DOI: 10.3389/fneur.2023.1192623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 12/05/2023] [Indexed: 01/23/2024] Open
Abstract
Background Pediatric acquired brain injury (pABI) profoundly affects cognitive functions, encompassing IQ and executive functions (EFs). Particularly, young age at insult may lead to persistent and debilitating deficits, affecting daily-life functioning negatively. This study delves into the intricate interplay of age at insult, time post-insult, and their associations with IQ and EFs during chronic (>1 year) pABI. Additionally, we investigate cognitive performance across different levels of global function, recognizing the multifaceted nature of developmental factors influencing outcomes. Methods Drawing upon insult data and baseline information analyzing secondary outcomes from a multicenter RCT, including comprehensive medical and neuropsychological assessments of participants aged 10 to 17 years with pABI and parent-reported executive dysfunctions. The study examined associations between age at insult (early, EI; ≤7y vs. late, LI; > 7y) and time post-insult with IQ and EFs (updating, shifting, inhibition, and executive attention). Additionally, utilizing the Pediatric Glasgow Outcome Scale-Extended, we explored cognitive performance across levels of global functioning. Results Seventy-six participants, median 8 years at insult and 5 years post-insult, predominantly exhibiting moderate disability (n = 38), were included. Notably, participants with LI demonstrated superior IQ, executive attention, and shifting compared to EI, [adjusted mean differences with 95% Confidence Intervals (CIs); 7.9 (1.4, 14.4), 2.48 (0.71, 4.24) and 1.73 (0.03, 3.43), respectively]. Conversely, extended post-insult duration was associated with diminished performances, evident in mean differences with 95% CIs for IQ, updating, shifting, and executive attention compared to 1-2 years post-insult [-11.1 (-20.4, -1.7), -8.4 (-16.7, -0.1), -2.6 (-4.4, -0.7), -2.9 (-4.5, -1.2), -3.8 (-6.4, -1.3), -2.6 (-5.0, -0.3), and -3.2 (-5.7, -0.8)]. Global function exhibited a robust relationship with IQ and EFs. Conclusion Early insults and prolonged post-insult durations impose lasting tribulations in chronic pABI. While confirmation through larger studies is needed, these findings carry clinical implications, underscoring the importance of vigilance regarding early insults. Moreover, they dispel the notion that children fully recover from pABI; instead, they advocate equitable rehabilitation offerings for pABI, tailored to address cognitive functions, recognizing their pivotal role in achieving independence and participation in society. Incorporating disability screening in long-term follow-up assessments may prove beneficial.
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Affiliation(s)
- Anne Elisabeth Brandt
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Children’s Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Torstein B. Rø
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Children’s Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Torun G. Finnanger
- Children’s Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Ruth E. Hypher
- Department of Clinical Neurosciences for Children, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Espen Lien
- Children’s Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Bendik Lund
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Children’s Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Cathy Catroppa
- Brain and Mind, Clinical Sciences, Murdoch Children’s Research Institute, Melbourne, VIC, Australia
- Department of Psychology, Royal Children’s Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, VIC, Australia
| | | | - Kari Risnes
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Children’s Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Jan Stubberud
- Department of Clinical Neurosciences for Children, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Department of Psychology, University of Oslo, Oslo, Norway
- Department of Research, Lovisenberg Diaconal Hospital, Oslo, Norway
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8
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Bogavac I, Jeličić L, Marisavljević M, Bošković Matić T, Subotić M. Arterial Presumed Perinatal Ischemic Stroke: A Mini Review and Case Report of Cognitive and Speech-Language Profiles in a 5-Year-Old Girl. CHILDREN (BASEL, SWITZERLAND) 2023; 11:33. [PMID: 38255347 PMCID: PMC10814911 DOI: 10.3390/children11010033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/16/2023] [Accepted: 12/20/2023] [Indexed: 01/24/2024]
Abstract
Arterial presumed perinatal ischemic stroke is a type of perinatal stroke that emerges due to late or delayed diagnostics of perinatal or neonatal arterial ischemic stroke. It is usually recognized before one year of life due to hemiparesis. This injury may lead to cognitive, behavioral, or motor symptoms, and life-long neurodevelopmental disabilities. In this case report, we describe a five-year-old girl with a history of arterial presumed perinatal ischemic stroke in the left hemisphere, which adversely affected her cognitive and language outcomes. The girl's cognitive development has been uneven, ranging from below average to average, and she had specific language acquisition deficits in comprehension, vocabulary, morphology, use of complex syntax, and narrative structure. The obtained results point to the specificity of each child whose development is influenced not only by the timing of the brain lesion and the degree of damage, but also by the child's neurobiological capacity. In addition, we provide an updated review of the literature that includes information on epidemiology, risk factors, diagnostics, clinical manifestations, outcomes, and potential therapies. The present article highlights the importance of early intervention and systematic monitoring of children with perinatal stroke with the aim of improving the child's development.
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Affiliation(s)
- Ivana Bogavac
- Cognitive Neuroscience Department, Research and Development Institute “Life Activities Advancement Institute”, 11000 Belgrade, Serbia; (I.B.); (M.M.); (M.S.)
- Department of Speech, Language and Hearing Sciences, Institute for Experimental Phonetics and Speech Pathology, 11000 Belgrade, Serbia
| | - Ljiljana Jeličić
- Cognitive Neuroscience Department, Research and Development Institute “Life Activities Advancement Institute”, 11000 Belgrade, Serbia; (I.B.); (M.M.); (M.S.)
- Department of Speech, Language and Hearing Sciences, Institute for Experimental Phonetics and Speech Pathology, 11000 Belgrade, Serbia
| | - Maša Marisavljević
- Cognitive Neuroscience Department, Research and Development Institute “Life Activities Advancement Institute”, 11000 Belgrade, Serbia; (I.B.); (M.M.); (M.S.)
- Department of Speech, Language and Hearing Sciences, Institute for Experimental Phonetics and Speech Pathology, 11000 Belgrade, Serbia
| | - Tatjana Bošković Matić
- Department of Neurology, Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia;
- Clinic of Neurology, University Clinical Centre of Kragujevac, 34000 Kragujevac, Serbia
| | - Miško Subotić
- Cognitive Neuroscience Department, Research and Development Institute “Life Activities Advancement Institute”, 11000 Belgrade, Serbia; (I.B.); (M.M.); (M.S.)
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Pero G, Ruggieri F, Macera A, Piano M, Gladin CR, Motto C, Cervo A, Chieregato A. Endovascular treatment of acute ischemic stroke in childhood: A comprehensive literature review based on the experience of a single center. Eur J Radiol Open 2023; 11:100528. [PMID: 37840654 PMCID: PMC10569978 DOI: 10.1016/j.ejro.2023.100528] [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: 07/26/2023] [Revised: 09/24/2023] [Accepted: 09/30/2023] [Indexed: 10/17/2023] Open
Abstract
Acute ischemic stroke (AIS) in childhood is a relatively rare but significant condition that can result in long-term disabilities. There is a lack of standardized strategies for diagnosing and treating pediatric AIS due to limited evidence-based data on thrombolytic and endovascular treatments in children. This comprehensive literature review focuses on the experience of a single center in Italy and aims to highlight the main peculiarities of endovascular treatment (EVT) for AIS in childhood. The review covers the diagnostic workup, the endovascular procedures, and the need for a specific thrombectomy program for pediatric AIS. The review discusses the indications and considerations for thrombectomy in children, including the risk of complications and the challenges of extrapolating results from adult studies. The diagnostic protocols for pediatric AIS are also discussed, emphasizing the use of MRI to avoid X-ray and contrast medium exposure in children. The combination of intravenous thrombolysis and mechanical thrombectomy has been examined, considering the differences between pediatric and adult thrombi. Technical considerations related to the size of pediatric patients are addressed, including the use of large bore catheters and potential concerns with access points. The organization of a thrombectomy program for pediatric AIS is discussed, emphasizing the need for specialized facilities and expertise. Although evidence for EVT in the pediatric population is based on case series, the importance of specialized centers and the lack of validated guidelines are evident.
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Affiliation(s)
- Guglielmo Pero
- Department of Neuroradiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Ruggieri
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonio Macera
- Department of Neuroradiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Mariangela Piano
- Department of Neuroradiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Caroline Regna Gladin
- Department of Neuroradiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Cristina Motto
- Neurology Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Amedeo Cervo
- Department of Neuroradiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Arturo Chieregato
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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10
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Ostrem BEL, Godfrey D, Caruso PA, Musolino PL. Monogenic Causes of Cerebrovascular Disease in Childhood: A Case Series. Pediatr Neurol 2023; 149:39-43. [PMID: 37776659 DOI: 10.1016/j.pediatrneurol.2023.08.026] [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: 02/20/2023] [Revised: 08/16/2023] [Accepted: 08/18/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Despite an increase in the number of genes associated with pediatric stroke, imaging phenotypes in children have not been well reported. Guidelines are needed to facilitate the identification and treatment of patients with monogenic causes of cerebrovascular disorders. METHODS We performed a retrospective review of imaging and medical records of patients aged zero to 21 years with monogenic causes of vascular malformations, small or large vessel disease, transient ischemic attacks, and/or ischemic or hemorrhagic stroke. We classified patients according to their imaging phenotype and reviewed neurological and systemic features and management strategies. We reviewed the literature to identify genes associated with cerebrovascular disorders presenting in childhood. RESULTS We identified 18 patients with monogenic causes of cerebrovascular disorders and classified each patient as belonging to one or more of three cerebrovascular phenotypes according to predominant imaging characteristics: small vessel disease, large vessel disease, and/or vascular malformations. Preventative treatments included aspirin, N-acetylcysteine, tocilizumab, therapeutic low-molecular-weight heparin, and resection of vascular malformations. CONCLUSIONS Classifying pediatric patients with cerebrovascular disorders by imaging phenotype can aid in determining the next steps in genetic testing and treatment.
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Affiliation(s)
- Bridget E L Ostrem
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts; Department of Neurology, University of California, San Francisco, San Francisco, California.
| | - Deena Godfrey
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Paul A Caruso
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Lenox Hill Radiology and Medical Imaging Associates, New York, New York
| | - Patricia L Musolino
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
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11
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Stadulni ARP, Sleifer P, Berticelli AZ, Riesgo R, Rocha-Muniz CN, Schochat E. Stroke in children and adolescents: Analysis of electrophysiological and behavioral assessment findings of auditory processing. Clinics (Sao Paulo) 2023; 78:100286. [PMID: 37812955 PMCID: PMC10569949 DOI: 10.1016/j.clinsp.2023.100286] [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: 03/09/2023] [Revised: 08/25/2023] [Accepted: 09/06/2023] [Indexed: 10/11/2023] Open
Abstract
PURPOSE This study aimed to analyze the auditory processing behavior of children and adolescents diagnosed with stroke and compare it with that of typically developing individuals. METHODS This was an analytical cross-sectional study involving 48 participants aged between 7 and 17 years with adequate schooling for age and grade, allocated equally to two groups: Stroke (SG) and Control Groups (CG). For the SG, cases identified between 2003 and 2018 were considered. In the CG, school-aged participants with typical development were randomized. After screening for differential audiological assessment and confirmation of auditory pathway integrity at the brainstem level, binaural analyses of the auditory processing behavior were conducted using the Dichotic Digit Test (DDT), Frequency Pattern Test (FPT), and electrophysiological assessment (P300). The Shapiro-Wilk test for normality was conducted, followed by the T and Mann-Whitney tests, with a 95 % confidence level and significance offset at p < 0.05, using the SPSS software (IBM®, v. 22.) RESULTS: The CG performed better in terms of auditory processing. These differences were significant (p < 0.0001) for the binaural integration of DDT, FPT humming and Labeling, and P300 latency. The P300 results were similar; however, with a greater amplitude in the SG. CONCLUSION This study showed that children and adolescents with stroke performed worse in electrophysiological and behavioral tests of auditory processing assessed using the auditory evoked potentials. These data reinforce the hypothesis that stroke-related lesions compromise the neural mechanisms underlying auditory processing.
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Affiliation(s)
- Andréia Rodrigues Parnoff Stadulni
- Department of Physiotherapy, Speech Therapy and Occupational Therapy, Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo, SP, Brazil.
| | - Pricila Sleifer
- Department of Health and Human Communication, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Amanda Zanatta Berticelli
- Graduate Program in Child and Adolescent Health, Faculdade de Medicina da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Rudimar Riesgo
- Graduate Program in Child and Adolescent Health, Faculdade de Medicina da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Hospital de Clínicas (HCPA), Porto Alegre, RS, Brazil
| | - Carolina Nunes Rocha-Muniz
- Department of Physiotherapy, Speech Therapy and Occupational Therapy, Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | - Eliane Schochat
- Department of Physiotherapy, Speech Therapy and Occupational Therapy, Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo, SP, Brazil
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12
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Marquez-Ortiz RA, Tesic V, Hernandez DR, Akhter B, Aich N, Boudreaux PM, Clemons GA, Wu CYC, Lin HW, Rodgers KM. Neuroimmune Support of Neuronal Regeneration and Neuroplasticity following Cerebral Ischemia in Juvenile Mice. Brain Sci 2023; 13:1337. [PMID: 37759938 PMCID: PMC10526826 DOI: 10.3390/brainsci13091337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
Ischemic damage to the brain and loss of neurons contribute to functional disabilities in many stroke survivors. Recovery of neuroplasticity is critical to restoration of function and improved quality of life. Stroke and neurological deficits occur in both adults and children, and yet it is well documented that the developing brain has remarkable plasticity which promotes increased post-ischemic functional recovery compared with adults. However, the mechanisms underlying post-stroke recovery in the young brain have not been fully explored. We observed opposing responses to experimental cerebral ischemia in juvenile and adult mice, with substantial neural regeneration and enhanced neuroplasticity detected in the juvenile brain that was not found in adults. We demonstrate strikingly different stroke-induced neuroimmune responses that are deleterious in adults and protective in juveniles, supporting neural regeneration and plasticity. Understanding age-related differences in neuronal repair and regeneration, restoration of neural network function, and neuroimmune signaling in the stroke-injured brain may offer new insights for the development of novel therapeutic strategies for stroke rehabilitation.
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Affiliation(s)
- Ricaurte A. Marquez-Ortiz
- Department of Cellular Biology and Anatomy, Louisiana State University, Health Sciences Center, Shreveport, LA 70803, USA (B.A.)
| | - Vesna Tesic
- Department of Neurology, Louisiana State University, Health Sciences Center, Shreveport, LA 70803, USA
| | - Daniel R. Hernandez
- Department of Cellular Biology and Anatomy, Louisiana State University, Health Sciences Center, Shreveport, LA 70803, USA (B.A.)
| | - Bilkis Akhter
- Department of Cellular Biology and Anatomy, Louisiana State University, Health Sciences Center, Shreveport, LA 70803, USA (B.A.)
| | - Nibedita Aich
- Department of Cellular Biology and Anatomy, Louisiana State University, Health Sciences Center, Shreveport, LA 70803, USA (B.A.)
| | - Porter M. Boudreaux
- Department of Cellular Biology and Anatomy, Louisiana State University, Health Sciences Center, Shreveport, LA 70803, USA (B.A.)
| | - Garrett A. Clemons
- Department of Cellular Biology and Anatomy, Louisiana State University, Health Sciences Center, Shreveport, LA 70803, USA (B.A.)
| | - Celeste Yin-Chieh Wu
- Department of Neurology, Louisiana State University, Health Sciences Center, Shreveport, LA 70803, USA
| | - Hung Wen Lin
- Department of Cellular Biology and Anatomy, Louisiana State University, Health Sciences Center, Shreveport, LA 70803, USA (B.A.)
- Department of Neurology, Louisiana State University, Health Sciences Center, Shreveport, LA 70803, USA
- Department of Pharmacology, Toxicology, and Neuroscience, Louisiana State University, Health Sciences Center, Shreveport, LA 70803, USA
| | - Krista M. Rodgers
- Department of Cellular Biology and Anatomy, Louisiana State University, Health Sciences Center, Shreveport, LA 70803, USA (B.A.)
- Department of Neurology, Louisiana State University, Health Sciences Center, Shreveport, LA 70803, USA
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13
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Carlhan-Ledermann A, Bartoli A, Gebistorf F, Beghetti M, Sologashvili T, Rebollo Polo M, Fluss J. Decompressive hemicraniectomy in pediatric malignant arterial ischemic stroke: a case-based review. Childs Nerv Syst 2023; 39:2377-2389. [PMID: 37493722 PMCID: PMC10432330 DOI: 10.1007/s00381-023-06086-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/15/2023] [Indexed: 07/27/2023]
Abstract
PURPOSE Malignant stroke is a life-threatening emergency, with a high mortality rate (1-3). Despite strong evidence showing decreased morbidity and mortality in the adult population, decompressive hemicraniectomy (DCH) has been scarcely reported in the pediatric stroke population, and its indication remains controversial, while it could be a potential lifesaving option. METHODS AND RESULTS We performed an extensive literature review on pediatric malignant arterial ischemic stroke (pmAIS) and selected 26 articles reporting 97 cases. Gathering the data together, a 67% mortality rate is observed without decompressive therapy, contrasting with a 95.4% survival rate with it. The median modified Rankin score (mRS) is 2.1 after surgery with a mean follow-up of 31.8 months. For the 33% of children who survived without surgery, the mRS is 3 at a mean follow-up of 19 months. As an illustrative case, we report on a 2-year-old girl who presented a cardioembolic right middle cerebral artery stroke with subsequent malignant edema and ongoing cerebral transtentorial herniation in the course of a severe myocarditis requiring ECMO support. A DCH was done 32 h after symptom onset. At the age of 5 years, she exhibits an mRS of 3. CONCLUSION Pediatric stroke with malignant edema is a severe condition with high mortality rate if left untreated and often long-lasting consequences. DCH might minimize the vicious circle of cerebral swelling, increasing intracranial pressure and brain ischemia. Our literature review underscores DCH as an efficient therapeutic measure management of pmAIS even when performed after a significant delay; however, long-lasting morbidities remain high.
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Affiliation(s)
- Audrey Carlhan-Ledermann
- Neonatology and Pediatric Intensive Care Unit, Department of Woman, Child and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Andrea Bartoli
- Neurosurgery Unit, Department of Clinical Neuroscience, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Fabienne Gebistorf
- Neonatology and Pediatric Intensive Care Unit, Department of Woman, Child and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Maurice Beghetti
- Pediatric Cardiology Unit, Department of Woman, Child and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Tornike Sologashvili
- Cardiovascular Surgery Unit, Department of Surgery, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Monica Rebollo Polo
- Pediatric Radiology Unit, Department of Radiology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Joel Fluss
- Pediatric Neurology Unit, Department of Woman, Child and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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14
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Krleza JL, Coen Herak D, Đakovic I, Vulin K, Roic G, Tripalo Batoš A, Čeri A, Zadro R, Đuranovic V. Inherited Thrombophilia Associated With Ischemic Pediatric Stroke in Parent-Child Pairs. Pediatr Neurol 2023; 146:119-128. [PMID: 37480820 DOI: 10.1016/j.pediatrneurol.2023.06.017] [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] [Received: 08/01/2022] [Revised: 04/16/2023] [Accepted: 06/19/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND We aimed to examine inherited thrombophilia frequencies by extending genetic profile to previously rarely or not investigated polymorphisms in children with ischemic pediatric stroke (IPS) and their parents. METHODS The study included 33 children: 23 with perinatal arterial ischemic stroke (PAIS), eight with childhood arterial ischemic stroke (CAIS), and two with sinovenous thrombosis and their parents (33 mother-child, 12 father-child, and 12 mother-father-child pairs). Genotyping of FV-Leiden, FV-H1299R, FII-G20210A, β-fibrinogen-455G>A, FXIII-A-Val34Leu, PAI-1(4G/5G), HPA-1, MTHFR-C677T, MTHFR-A1298C, ACE(I/D), and APOE(ε2-4) was performed using CVD Strip assay (ViennaLab, Austria). RESULTS At least one and up to seven simultaneously present polymorphisms were observed in all children with IPS, mothers, and fathers. More than five simultaneously present polymorphisms were identified threefold more frequently in children with IPS (10 of 33; 30%) compared with the child control group (17 of 150; 11%), yielding a statistically significant difference between the two groups (odds ratio [OR] = 3.40; 95% confidence interval [CI] = 1.39 to 8.35; P = 0.012). Stronger association was revealed for PAIS (OR = 4.17; 95% CI = 1.55 to 11.29; P = 0.008) and CAIS subgroups (OR = 7.82; 95% CI = 1.79 to 34.20; P = 0.012). Complete match of polymorphisms was not identified in any parent-child pair. A partial match (one to four mutual polymorphisms) was found in 11 of 12 parent-child pairs where until three mutual polymorphisms was present in 11 of 12 (91.7%) father-child compared with 21 of 33 (63.6%) mother-child pairs. CONCLUSIONS According to obtained results the simultaneous presence of more than five polymorphisms is associated with a higher risk for IPS occurrence, suggesting the risk enhancement for PAIS in the presence of pregnancy complications or for CAIS in conjunction with maternal comorbidity and positive family history. The presence of up to three mutual polymorphisms more frequently in father-child than mother-child pairs suggests significant paternal contribution of inherited thrombophilia to increased risk of IPS.
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Affiliation(s)
- Jasna Lenicek Krleza
- Department of Laboratory Diagnostcs, Children's Hospital Zagreb, Zagreb, Croatia; Universitas Studiorum Catholica Croatica, Zagreb, Croatia; University of Applied Health Sciences Zagreb, Zagreb, Croatia.
| | - Desiree Coen Herak
- University of Applied Health Sciences Zagreb, Zagreb, Croatia; Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Zagreb, Croatia; Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | - Ivana Đakovic
- Department of Neuropediatrics, Children's Hospital Zagreb, Zagreb, Croatia
| | - Katarina Vulin
- Department of Medical Genetics and Reproductive Health, Children's Hospital Zagreb, Zagreb, Croatia
| | - Goran Roic
- University of Applied Health Sciences Zagreb, Zagreb, Croatia; Department of Pediatric Radiology, Children's Hospital Zagreb, Zagreb, Croatia; Faculty of Medicine of the University of Rijeka, Rijeka, Croatia
| | - Ana Tripalo Batoš
- University of Applied Health Sciences Zagreb, Zagreb, Croatia; Department of Pediatric Radiology, Children's Hospital Zagreb, Zagreb, Croatia
| | - Andrea Čeri
- Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | - Renata Zadro
- Medical Biochemistry Laboratory, St Catherine Specialty Hospital, Zagreb, Croatia
| | - Vlasta Đuranovic
- University of Applied Health Sciences Zagreb, Zagreb, Croatia; Department of Neuropediatrics, Children's Hospital Zagreb, Zagreb, Croatia; Faculty of Medicine of the University of Rijeka, Rijeka, Croatia
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15
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Liu J, Wu Y, Jia W, Han M, Chen Y, Li J, Wu B, Yin S, Zhang X, Chen J, Yu P, Luo H, Tu J, Zhou F, Cheng X, Yi Y. Prediction of recurrence of ischemic stroke within 1 year of discharge based on machine learning MRI radiomics. Front Neurosci 2023; 17:1110579. [PMID: 37214402 PMCID: PMC10192708 DOI: 10.3389/fnins.2023.1110579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 03/06/2023] [Indexed: 05/24/2023] Open
Abstract
Purpose This study aimed to investigate the value of a machine learning-based magnetic resonance imaging (MRI) radiomics model in predicting the risk of recurrence within 1 year following an acute ischemic stroke (AIS). Methods The MRI and clinical data of 612 patients diagnosed with AIS at the Second Affiliated Hospital of Nanchang University from March 1, 2019, to March 5, 2021, were obtained. The patients were divided into recurrence and non-recurrence groups according to whether they had a recurrent stroke within 1 year after discharge. Randomized splitting was used to divide the data into training and validation sets using a ratio of 7:3. Two radiologists used the 3D-slicer software to label the lesions on brain diffusion-weighted (DWI) MRI sequences. Radiomics features were extracted from the annotated images using the pyradiomics software package, and the features were filtered using the Least Absolute Shrinkage and Selection Operator (LASSO) regression analysis. Four machine learning algorithms, logistic regression (LR), Support Vector Classification (SVC), LightGBM, and Random forest (RF), were used to construct a recurrence prediction model. For each algorithm, three models were constructed based on the MRI radiomics features, clinical features, and combined MRI radiomics and clinical features. The sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve (AUC) were used to compare the predictive efficacy of the models. Results Twenty features were selected from 1,037 radiomics features extracted from DWI images. The LightGBM model based on data with three different features achieved the best prediction accuracy from all 4 models in the validation set. The LightGBM model based solely on radiomics features achieved a sensitivity, specificity, and AUC of 0.65, 0.671, and 0.647, respectively, and the model based on clinical data achieved a sensitivity, specificity, and AUC of 0.7, 0.799, 0.735, respectively. The sensitivity, specificity, and AUC of the LightGBM model base on both radiomics and clinical features achieved the best performance with a sensitivity, specificity, and AUC of 0.85, 0.805, 0.789, respectively. Conclusion The ischemic stroke recurrence prediction model based on LightGBM achieved the best prediction of recurrence within 1 year following an AIS. The combination of MRI radiomics features and clinical data improved the prediction performance of the model.
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Affiliation(s)
- Jianmo Liu
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yifan Wu
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- School of Public Health, Jiangxi Provincial Key Laboratory of Preventive Medicine, Nanchang University, Nanchang, China
| | - Weijie Jia
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- School of Public Health, Jiangxi Provincial Key Laboratory of Preventive Medicine, Nanchang University, Nanchang, China
| | - Mengqi Han
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- School of Public Health, Jiangxi Provincial Key Laboratory of Preventive Medicine, Nanchang University, Nanchang, China
| | - Yongsen Chen
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- School of Public Health, Jiangxi Provincial Key Laboratory of Preventive Medicine, Nanchang University, Nanchang, China
| | - Jingyi Li
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- School of Public Health, Jiangxi Provincial Key Laboratory of Preventive Medicine, Nanchang University, Nanchang, China
| | - Bin Wu
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- School of Public Health, Jiangxi Provincial Key Laboratory of Preventive Medicine, Nanchang University, Nanchang, China
| | - Shujuan Yin
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- School of Public Health, Jiangxi Provincial Key Laboratory of Preventive Medicine, Nanchang University, Nanchang, China
| | - Xiaolin Zhang
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- School of Public Health, Jiangxi Provincial Key Laboratory of Preventive Medicine, Nanchang University, Nanchang, China
| | - Jibiao Chen
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- School of Public Health, Jiangxi Provincial Key Laboratory of Preventive Medicine, Nanchang University, Nanchang, China
| | - Pengfei Yu
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Haowen Luo
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jianglong Tu
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Fan Zhou
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xuexin Cheng
- Biological Resource Center, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yingping Yi
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, China
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16
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Feldman SJ, Beslow LA, Felling RJ, Malone LA, Waak M, Fraser S, Bakeer N, Lee JEM, Sherman V, Howard MM, Cavanaugh BA, Westmacott R, Jordan LC. Consensus-Based Evaluation of Outcome Measures in Pediatric Stroke Care: A Toolkit. Pediatr Neurol 2023; 141:118-132. [PMID: 36812698 PMCID: PMC10042484 DOI: 10.1016/j.pediatrneurol.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/08/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023]
Abstract
Following a pediatric stroke, outcome measures selected for monitoring functional recovery and development vary widely. We sought to develop a toolkit of outcome measures that are currently available to clinicians, possess strong psychometric properties, and are feasible for use within clinical settings. A multidisciplinary group of clinicians and scientists from the International Pediatric Stroke Organization comprehensively reviewed the quality of measures in multiple domains described in pediatric stroke populations including global performance, motor and cognitive function, language, quality of life, and behavior and adaptive functioning. The quality of each measure was evaluated using guidelines focused on responsiveness and sensitivity, reliability, validity, feasibility, and predictive utility. A total of 48 outcome measures were included and were rated by experts based on the available evidence within the literature supporting the strengths of their psychometric properties and practical use. Only three measures were found to be validated for use in pediatric stroke: the Pediatric Stroke Outcome Measure, the Pediatric Stroke Recurrence and Recovery Questionnaire, and the Pediatric Stroke Quality of Life Measure. However, multiple additional measures were deemed to have good psychometric properties and acceptable utility for assessing pediatric stroke outcomes. Strengths and weaknesses of commonly used measures including feasibility are highlighted to guide evidence-based and practicable outcome measure selection. Improving the coherence of outcome assessment will facilitate comparison of studies and enhance research and clinical care in children with stroke. Further work is urgently needed to close the gap and validate measures across all clinically significant domains in the pediatric stroke population.
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Affiliation(s)
- Samantha J Feldman
- Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lauren A Beslow
- Division of Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ryan J Felling
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Laura A Malone
- Johns Hopkins University School of Medicine and the Kennedy Krieger Institute, Baltimore, Maryland
| | - Michaela Waak
- Pediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Queensland, Australia; Pediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - Stuart Fraser
- Division of Vascular Neurology, Department of Pediatrics, University of Texas Health Science Center, Houston, Texas
| | - Nihal Bakeer
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana
| | - Jo Ellen M Lee
- Department of Neurology, Nationwide Children's Hospital, Columbus, Ohio
| | | | - Melissa M Howard
- Casa Colina Hospital and Centers for Healthcare, Pomona, California
| | - Beth Anne Cavanaugh
- Division of Pediatric Neurology, Department of Pediatrics, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Robyn Westmacott
- Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.
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17
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Sun LR, Lynch JK. Advances in the Diagnosis and Treatment of Pediatric Arterial Ischemic Stroke. Neurotherapeutics 2023; 20:633-654. [PMID: 37072548 PMCID: PMC10112833 DOI: 10.1007/s13311-023-01373-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/20/2023] Open
Abstract
Though rare, stroke in infants and children is an important cause of mortality and chronic morbidity in the pediatric population. Neuroimaging advances and implementation of pediatric stroke care protocols have led to the ability to rapidly diagnose stroke and in many cases determine the stroke etiology. Though data on efficacy of hyperacute therapies, such as intravenous thrombolysis and mechanical thrombectomy, in pediatric stroke are limited, feasibility and safety data are mounting and support careful consideration of these treatments for childhood stroke. Recent therapeutic advances allow for targeted stroke prevention efforts in high-risk conditions, such as moyamoya, sickle cell disease, cardiac disease, and genetic disorders. Despite these exciting advances, important knowledge gaps persist, including optimal dosing and type of thrombolytic agents, inclusion criteria for mechanical thrombectomy, the role of immunomodulatory therapies for focal cerebral arteriopathy, optimal long-term antithrombotic strategies, the role of patent foramen ovale closure in pediatric stroke, and optimal rehabilitation strategies after stroke of the developing brain.
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Affiliation(s)
- Lisa R Sun
- Divisions of Pediatric Neurology and Cerebrovascular Neurology, Department of Neurology, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Ste 2158, Baltimore, MD, 21287, USA.
| | - John K Lynch
- Acute Stroke Research Section, Stroke Branch (SB), National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
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18
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Harrar DB, Sun LR, Segal JB, Lee S, Sansevere AJ. Neuromonitoring in Children with Cerebrovascular Disorders. Neurocrit Care 2023; 38:486-503. [PMID: 36828980 DOI: 10.1007/s12028-023-01689-2] [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: 04/29/2022] [Accepted: 01/31/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Cerebrovascular disorders are an important cause of morbidity and mortality in children. The acute care of a child with an ischemic or hemorrhagic stroke or cerebral sinus venous thrombosis focuses on stabilizing the patient, determining the cause of the insult, and preventing secondary injury. Here, we review the use of both invasive and noninvasive neuromonitoring modalities in the care of pediatric patients with arterial ischemic stroke, nontraumatic intracranial hemorrhage, and cerebral sinus venous thrombosis. METHODS Narrative review of the literature on neuromonitoring in children with cerebrovascular disorders. RESULTS Neuroimaging, near-infrared spectroscopy, transcranial Doppler ultrasonography, continuous and quantitative electroencephalography, invasive intracranial pressure monitoring, and multimodal neuromonitoring may augment the acute care of children with cerebrovascular disorders. Neuromonitoring can play an essential role in the early identification of evolving injury in the aftermath of arterial ischemic stroke, intracranial hemorrhage, or sinus venous thrombosis, including recurrent infarction or infarct expansion, new or recurrent hemorrhage, vasospasm and delayed cerebral ischemia, status epilepticus, and intracranial hypertension, among others, and this, is turn, can facilitate real-time adjustments to treatment plans. CONCLUSIONS Our understanding of pediatric cerebrovascular disorders has increased dramatically over the past several years, in part due to advances in the neuromonitoring modalities that allow us to better understand these conditions. We are now poised, as a field, to take advantage of advances in neuromonitoring capabilities to determine how best to manage and treat acute cerebrovascular disorders in children.
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Affiliation(s)
- Dana B Harrar
- Division of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA.
| | - Lisa R Sun
- Divisions of Pediatric Neurology and Vascular Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J Bradley Segal
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Arnold J Sansevere
- Division of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
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19
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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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20
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Rawanduzy CA, Earl E, Mayer G, Lucke-Wold B. Pediatric Stroke: A Review of Common Etiologies and Management Strategies. Biomedicines 2022; 11:biomedicines11010002. [PMID: 36672510 PMCID: PMC9856134 DOI: 10.3390/biomedicines11010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/12/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
Pediatric stroke is an important cause of mortality and morbidity in children. There is a paucity of clinical trials pertaining to pediatric stroke management, and solidified universal guidelines are not established for children the way they are for the adult population. Diagnosis of pediatric stroke can be challenging, and it is often delayed or mischaracterized, which can result in worse outcomes. Understanding risks and appropriate therapy is paramount to improving care.
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Affiliation(s)
| | - Emma Earl
- School of Medicine, University of Utah, Salt Lake City, UT 84112, USA
| | - Greg Mayer
- School of Medicine, University of Utah, Salt Lake City, UT 84112, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
- Correspondence:
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Tanisaka LS, Oliveira FR, de Alcantara Sousa LV, de Abreu LC, Adami F, da Silva Paiva L. Changes in childhood stroke mortality from 1990 to 2019 in Brazil and its federative units. Sci Rep 2022; 12:20757. [PMID: 36456606 PMCID: PMC9715677 DOI: 10.1038/s41598-022-24761-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 11/21/2022] [Indexed: 12/03/2022] Open
Abstract
This research analyzed the temporal trend of stroke mortality in children aged 0-14 years, from 1990 to 2019, in Brazil and its federative units. This ecological study used data from the Global Burden of Disease, a study led by the Institute for Health Metrics and Evaluation. Stroke definition considered the International Classification of Diseases according to codes G45, G46, and I60-I69. Age-standardized mortality rates and the mean annual percentage change (APC) in mortality rates were estimated. Stroke mortality trends decreased, with an APC of - 3.9% (95% CI - 4.5; - 3.3; p < 0.001). Reducing trends were found in all but two states, where they were stationary. Maranhão (- 6.5%; 95% CI - 7.6; - 5.4; p < 0.001) had the greatest reduction and Rondônia, the smallest (- 1.2%; 95% CI - 2.3; - 0.1, p = 0.027). Decrease was more important in children < 5 (- 5.8%; 95% CI - 6.3; - 5.2; p < 0.001) compared to 5-14 years old (- 2.1%; 95% CI - 2.9; - 1.3; p < 0.001); additionally, it was greater in girls (- 4.1%; 95% CI - 4.6; - 3.5; p < 0.001) than in boys (- 3.8%; 95% IC - 4.5; - 3.1; p < 0.001). Ischemic stroke had the highest APC (- 6.1%; 95% CI - 6.8; - 5.3; p < 0.001), followed by intracranial hemorrhage (- 5.3%; 95% CI - 6.1; - 4.5; p < 0.001) and subarachnoid hemorrhage (- 2.7%; 95% CI - 3.3; - 2.1; p < 0.001). Largest reductions were seen in states with more vulnerable socioeconomic contexts. The stationary trends and lowest APCs were concentrated in the northern region, which had greater impact of diseases and less favorable outcomes.
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Affiliation(s)
- Laura Silveira Tanisaka
- Present Address: Laboratório de Epidemiologia e Análise de Dados do Centro Universitário FMABC, Avenida Lauro Gomes, 2000 – Vila Sacadura Cabral, Santo André, SP 09060-870 Brazil
| | - Fernando Rocha Oliveira
- grid.11899.380000 0004 1937 0722Faculdade de Saúde Pública da Universidade de São Paulo, São Paulo, SP Brazil
| | - Luiz Vinicius de Alcantara Sousa
- Present Address: Laboratório de Epidemiologia e Análise de Dados do Centro Universitário FMABC, Avenida Lauro Gomes, 2000 – Vila Sacadura Cabral, Santo André, SP 09060-870 Brazil
| | - Luiz Carlos de Abreu
- grid.10049.3c0000 0004 1936 9692School of Medicine, University of Limerick, Limerick, Ireland ,Present Address: Laboratório de Epidemiologia e Análise de Dados do Centro Universitário FMABC, Avenida Lauro Gomes, 2000 – Vila Sacadura Cabral, Santo André, SP 09060-870 Brazil
| | - Fernando Adami
- Present Address: Laboratório de Epidemiologia e Análise de Dados do Centro Universitário FMABC, Avenida Lauro Gomes, 2000 – Vila Sacadura Cabral, Santo André, SP 09060-870 Brazil
| | - Laércio da Silva Paiva
- grid.11899.380000 0004 1937 0722Faculdade de Saúde Pública da Universidade de São Paulo, São Paulo, SP Brazil
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Al-Qahtani S, Jalal Z, Paudyal V, Mahmood S, Mason J. The Role of Pharmacists in Providing Pharmaceutical Care in Primary and Secondary Prevention of Stroke: A Systematic Review and Meta-Analysis. Healthcare (Basel) 2022; 10:healthcare10112315. [PMID: 36421639 PMCID: PMC9691113 DOI: 10.3390/healthcare10112315] [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: 09/03/2022] [Revised: 11/05/2022] [Accepted: 11/13/2022] [Indexed: 11/22/2022] Open
Abstract
Pharmacists deliver pharmaceutical care in many different healthcare settings and are well-placed to support the prevention of stroke. However, their role and impact in this area is ill-defined. This systematic review aims to explore the pharmacists’ role in stroke prevention. Nine databases were searched for studies reporting pharmacist interventions in the management of primary and secondary ischaemic stroke prevention. Study quality was evaluated through Cochrane Risk of Bias and Joanna Briggs Institute (JBI) appraisal tools where possible. A narrative review was conducted and meta-analysis performed for studies with comparable outcomes. Of the 834 initial articles, 31 met inclusion criteria. Study designs were varied and included controlled trials, observational studies, audit reports and conference abstracts. Seven studies addressed the pharmacists’ role in primary prevention and 24 in secondary prevention. Pharmacist interventions reported were diverse and often multifactorial. Overall, 20 studies reported significant improvement in outcomes. Meta-analysis showed pharmacist interventions in emergency care significantly improved the odds of achieving thrombolytic therapy door to needle (DTN) times ≤45 min, odds ratio: 2.69 (95% confidence interval (CI): 1.95−3.72); p < 0.001. The pharmacists’ role is varied and spans the stroke treatment pathway, with the potential for a positive impact on a range of health-related outcomes.
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Affiliation(s)
- Saeed Al-Qahtani
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK
- School of Pharmacy, Jazan University, Jazan 45142, Saudi Arabia
- Correspondence: ; Tel.: +966-560742224
| | - Zahraa Jalal
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Vibhu Paudyal
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Sajid Mahmood
- Department of Pharmacy, Quaid-i-Azam University, Islamabad 45320, Pakistan
| | - Julie Mason
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK
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23
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An exploratory study to identify neonatal arterial ischemic stroke: A single-center study. Brain Dev 2022; 44:672-680. [PMID: 36058756 DOI: 10.1016/j.braindev.2022.08.005] [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] [Received: 05/11/2022] [Revised: 08/03/2022] [Accepted: 08/18/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Neonatal arterial ischemic stroke (NAIS) presents as seizures, including convulsions, subtle seizures, and apnea, and most patients experience neurological sequelae. Diagnosis is often delayed owing to low test sensitivity. The present study aimed to identify the early clinical diagnostic factors for NAIS in neonates with seizures. METHODS The present study included 54 patients born at ≥36 weeks of gestation during the last 15 years who presented to the neonatal intensive care unit with neonatal seizures and underwent brain magnetic resonance imaging (MRI), 6 of whom were diagnosed with NAIS. Maternal background, clinical characteristics, and transcranial pulsed Doppler sonography results were retrospectively reviewed. RESULTS Of the 24 patients who presented with convulsions or subtle seizures, 3 (13%) were diagnosed with NAIS and 3 of 30 patients (10%) presented with apnea. Maternal premature ventricular contraction complications were higher in the NAIS group than in the non-NAIS group (p = 0.01). NAIS group showed lower mean middle cerebral artery (MCA) resistance index (RI) was lower the non-NAIS group (p = 0.009), while the left-right RI difference (p = 0.019), mean MCA blood velocity (MnV; p = 0.04), and left-right MnV difference (p < 0.001) in cerebral blood flow velocities (CBFVs) were higher in the NAIS group. CONCLUSIONS Our results revealed that maternal arrhythmia may be a diagnostic factor for NAIS in neonates with seizures. Early brain MRI is essential in neonates with seizures and findings of low MCA-RI, high MCA-MnV, or high left-right difference in CBFVs to distinguish between NAIS and non-NAIS.
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24
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Kumar R, Sun LR, Rodriguez V, Sankar A, Sharma M, Meoded A, Brandão LR, Goldenberg NA. Hemostatic and Thrombotic Considerations in the Diagnosis and Management of Childhood Arterial Ischemic Stroke: A Narrative Review. Semin Pediatr Neurol 2022; 43:101003. [PMID: 36344025 DOI: 10.1016/j.spen.2022.101003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/12/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
Abstract
Although rare in children, arterial ischemic stroke (AIS) is associated with increased mortality and neurological morbidity. The incidence of AIS after the neonatal period is approximately 1-2/100,000/year, with an estimated mortality of 3-7%. A significant proportion of children surviving AIS experience life-long neurological deficits including hemiparesis, epilepsy, and cognitive delays. The low incidence of childhood AIS coupled with atypical clinical-presentation and lack of awareness contribute to delay in diagnosis and consequently, the early initiation of treatment. While randomized-clinical trials have demonstrated the efficacy and safety of reperfusion therapies including thrombolysis and endovascular thrombectomy in appropriately-selected adult patients, similar data for children are unavailable. Consequently, clinical decisions surrounding reperfusion therapy in childhood AIS are either extrapolated from adult data or based on local experience. The etiology of childhood AIS is multifactorial, often occurring in the setting of both acquired and congenital risk-factors including thrombophilia. While multiple studies have investigated the association of thrombophilia with incident childhood AIS, its impact on stroke recurrence and therefore duration and intensity of antithrombotic therapy is less clear. Despite these limitations, a significant progress has been made over the last decade in the management of childhood AIS. This progress can be attributed to international consortiums, and in selected cohorts to federally-funded clinical trials. In this narrative review, the authors have systematically appraised the literature and summarize the hemostatic and thrombotic considerations in the diagnosis and management of childhood AIS focusing on the evidence supporting reperfusion therapies, relevance of thrombophilia testing, and duration and drug choices for secondary-prophylaxis.
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Affiliation(s)
- Riten Kumar
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - Lisa R Sun
- Division of Pediatric Neurology, Johns Hopkins School of Medicine, Baltimore, MD; Division of Cerebrovascular Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Amanda Sankar
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Mukta Sharma
- Division of Hematology, Children's Mercy Hospital, Kansas City, MO
| | - Avner Meoded
- Edward B. Singleton, Department of Radiology, Texas Children's Hospital, Houston, TX
| | - Leonardo R Brandão
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON; Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Neil A Goldenberg
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL; Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Stroke in pediatric ECMO patients: analysis of the National Inpatient Sample (NIS) database. Pediatr Res 2022; 92:754-761. [PMID: 35505077 DOI: 10.1038/s41390-022-02088-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/30/2022] [Accepted: 04/07/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The rates, outcomes, and long-term trends of stroke complicating the use of extracorporeal membrane oxygenation (ECMO) have been inconsistently reported. We compared the outcomes of pediatric ECMO patients with and without stroke and described the frequency trends between 2000 and 2017. METHODS Using the National Inpatient Sample (NIS) database, pediatric patients (age ≤18 years) who received ECMO were identified using ICD-9&10 codes. Binary, regression, and trend analyses were performed to compare patients with and without stroke. RESULTS A total of 114,477,997 records were reviewed. Overall, 28,695 (0.025%) ECMO patients were identified of which 2982 (10.4%) had stroke, which were further classified as hemorrhagic (n = 1464), ischemic (n = 1280), or combined (n = 238). Mortality was higher in the hemorrhagic and combined groups compared to patients with ischemic stroke and patients without stroke. Length of stay (LOS) was significantly longer in stroke vs. no-stroke patients. Hypertension and septicemia were more encountered in the hemorrhagic group, whereas the combined group demonstrated higher frequency of cardiac arrest and seizures. CONCLUSIONS Over the years, there is an apparent increase in the diagnosis of stroke. All types of stroke in ECMO patients are associated with increased LOS, although mortality is increased in hemorrhagic and combined stroke only. IMPACT Stroke is a commonly seen complication in pediatric patients supported by ECMO. Understanding the trends will help in identifying modifiable risk factors that predict poor outcomes in this patient population.
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26
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Goli SG, Pal R, Lee S, Lee MO. Infantile ischemic stroke secondary to profound arteriopathy. J Am Coll Emerg Physicians Open 2022; 3:e12768. [PMID: 35813523 PMCID: PMC9255893 DOI: 10.1002/emp2.12768] [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: 02/06/2022] [Revised: 05/24/2022] [Accepted: 05/31/2022] [Indexed: 11/10/2022] Open
Abstract
Pediatric arterial ischemic stroke (AIS) is an uncommon emergency department (ED) presentation. We share the case of a 4‐month‐old female with a chief complaint of irritability and difficulty feeding. During ED evaluation, she developed lateral gaze deviation, tongue deviation, and rhythmic leg movements. Computed tomography of the head revealed a right‐sided hypodensity concerning for ischemic infarct without hemorrhagic conversion. Subsequent brain magnetic resonance imaging and arteriography confirmed a large right‐sided cerebral infarct and demonstrated narrowing and tortuosity of almost all extra‐ and intracranial vessels. Comprehensive pediatric AIS workup, including echocardiogram and laboratory tests for anemia, hypercoagulability, inflammatory, and genetic panels, were non‐diagnostic. This case highlights the difficulty in diagnosis of pediatric AIS due to low clinical suspicion, limited neurologic examination, and non‐specific presentations that may suggest stroke mimics. Maintenance of clinical suspicion and early recognition of pediatric AIS can result in earlier initiation of neuroprotective measures and optimization of imaging strategies for better outcomes.
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Affiliation(s)
- Shubhi G. Goli
- Department of Emergency Medicine Stanford University School of Medicine Stanford University Stanford California USA
| | - Ria Pal
- Division of Child Neurology Department of Neurology Stanford University School of Medicine Stanford University Stanford California USA
| | - Sarah Lee
- Division of Child Neurology Department of Neurology Stanford University School of Medicine Stanford University Stanford California USA
- Department of Neurology Stanford Stroke Center Stanford University School of Medicine Stanford California USA
| | - Moon O. Lee
- Department of Emergency Medicine Stanford University School of Medicine Stanford University Stanford California USA
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27
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Sharma S, Suthar R, Dhawan SR, Ahuja CK, Bhatia P, Baranwal AK, Sankhyan N. Aetiological Profile and Short-Term Neurological Outcome of Haemorrhagic Stroke in Children. J Trop Pediatr 2022; 68:6625780. [PMID: 35776488 DOI: 10.1093/tropej/fmac040] [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: 11/14/2022]
Abstract
BACKGROUND Haemorrhagic stroke (HS) accounts for nearly half of the paediatric strokes. The aetiology of HS in childhood is not well defined in the Indian context. OBJECTIVES To study the aetiological profile and short-term neurological outcome of children with HS from North India. METHODS In a prospective observational study, consecutive patients >28 days to <12 years of age admitted with a diagnosis of HS were enrolled. Demography, clinical, radiological details and investigations were recorded. Short-term outcomes were assessed at three months follow-up with the Paediatric Cerebral Performance Category scale and Paediatric Stroke Outcome Measure (PSOM). RESULTS A total of 48 children with HS were enrolled. The median age was 6 months (1-58 months), and 33 (69%) were <2 years old. Vitamin K deficiency-related bleeding disorder (VKDB, 44%), central nervous system infections (19%), arteriovenous malformations (13%) and inherited coagulation disorders (8%) were the most common risk factors for HS. VKDB and inherited coagulation disorders were more frequent in children <2 years of age, and arteriovenous malformations were more frequent in children >2 years of age (p = 0.001). During hospitalization, 21 (44%) children died. Older age, low Glasgow coma score (<8) at admission and paediatric intracerebral haemorrhage score ≥2 were associated with mortality at discharge (p = <0.05). Among survivors, 15 (56%) children had neurological deficits (PSOM >0.5) at three month follow-up. CONCLUSION VKDB, inherited coagulation disorders, central nervous system infections and arteriovenous malformations were the most common risk factors for HS. VKDB is the single most important preventable risk factor for HS in infants.
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Affiliation(s)
- Sunil Sharma
- Pediatric Neurology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Renu Suthar
- Pediatric Neurology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Sumeet R Dhawan
- Pediatric Neurology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Chirag Kamal Ahuja
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Prateek Bhatia
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Arun Kumar Baranwal
- Pediatric Emergency and Intensive Care Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Naveen Sankhyan
- Pediatric Neurology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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28
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Chopra T, Neuberger I, Prince E, White C, Maloney J, Stence N, Mirsky D. Age-related changes in the completeness of the circle of Willis in children. Childs Nerv Syst 2022; 38:1181-1184. [PMID: 35394211 DOI: 10.1007/s00381-022-05505-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/16/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The circle of Willis is a circulatory anastomosis that supplies blood to the brain. If any of the bridging segments are hypoplastic or absent, the capacity for collateral flow in the setting of large vessel occlusion may be decreased. Outside of the neonatal period, the prevalence of a complete circle of Willis (CoW) in the pediatric population has not been well described. Our objectives include determining the prevalence of a complete CoW in children and identifying if there is an age-related "loss" of arterial segments. METHODS Following IRB approval, angiograms of the CoW performed on a 3-T MR platform from 2016 to 2020 on patients 21 years or younger were retrospectively reviewed. Any patient with underlying arterial pathology that may affect the CoW was excluded. Patient age and gender at the time of imaging were obtained. RESULTS In total, 592 pediatric CoW were assessed. Frequencies of completeness were calculated in two different fashions: scenario 1 where a CoW was characterized as complete even if it contained hypoplastic vessels (88.8%), and scenario 2 where it was characterized as complete after excluding hypoplastic vessels (44.0%). In both scenarios, our data showed that older age was more associated with an incomplete CoW (p < 0.0001). In addition, we found a higher percentage of males with an incomplete CoW compared with females (p < 0.0001). CONCLUSIONS The presence of a complete CoW is greater in our pediatric population than what has been reported in adults. The prevalence of an incomplete circle of Willis also increases significantly with age.
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Affiliation(s)
- Tavishi Chopra
- Creighton University School of Medicine, AZ, Phoenix, USA.
| | | | - Eric Prince
- University of Colorado Anschutz Medical Campus, Aurora, USA
| | | | - John Maloney
- Neuroradiology, Children's Hospital Colorado, Aurora, USA
| | | | - David Mirsky
- Neuroradiology, Children's Hospital Colorado, Aurora, USA
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29
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Szewczyk AK, Mitosek-Szewczyk K, Dworzańska E. Where words are powerless to express: Use of music in paediatric neurology. J Pediatr Rehabil Med 2022; 16:179-194. [PMID: 35599509 DOI: 10.3233/prm-200802] [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: 11/15/2022] Open
Abstract
Music is an art form that strongly affects people and can elicit many different emotions at the same time, including happiness, anxiety, sadness, and even ecstasy. What is it about music that causes such a strong reaction from each of us? Music engages many senses, which in turn can produce a multiplicity of responses and help create more extensive neuronal connections, as well as influence behaviour through structural and functional changes in the brain. Music-based interventions as a therapeutic tool in rehabilitation are becoming more common. It is said that the impact of music on the human body is positive. However, what impact does music have on the young nervous system, especially the affected one? This review presents the advantages and disadvantages of the use of music in paediatric neurology to treat dyslexia, cerebral palsy, and stroke, among others. Potential negative impacts such as musicogenic epilepsy and hallucinations will be discussed.
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Affiliation(s)
- Anna K Szewczyk
- Department of Neurology, Medical University of Lublin, Lublin, Poland.,Doctoral School, Medical University of Lublin, Lublin, Poland
| | | | - Ewa Dworzańska
- Department of Child Neurology, Medical University of Lublin, Lublin, Poland
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30
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Hutchinson ML, Nash KB, Abend NS, Moharir M, Wells E, Messer RD, Palaganas J, Helbig I, Wietstock SO, Suslovic W, Gonzalez AK, Kaufman MC, Press CA, Piantino J. Multicenter Study of the Impact of COVID-19 Shelter-In-Place on Tertiary Hospital-based Care for Pediatric Neurologic Disease. Neurohospitalist 2022; 12:218-226. [PMID: 35414846 PMCID: PMC8814588 DOI: 10.1177/19418744211063075] [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] [Indexed: 01/18/2023] Open
Abstract
Objective To describe changes in hospital-based care for children with neurologic diagnoses during the initial 6 weeks following regional Coronavirus 2019 Shelter-in-Place orders. Methods This retrospective cross-sectional study of 7 US and Canadian pediatric tertiary care institutions included emergency and inpatient encounters with a neurologic primary discharge diagnosis code in the initial 6 weeks of Shelter-in-Place (COVID-SiP), compared to the same period during the prior 3 years (Pre-COVID). Patient demographics, encounter length, and neuroimaging and electroencephalography use were extracted from the medical record. Results 27,900 encounters over 4 years were included. Compared to Pre-COVID, there was a 54% reduction in encounters during Shelter-in-Place. COVID-SiP patients were younger (median 5 years vs 7 years). The incidence of encounters for migraine fell by 72%, and encounters for acute diagnoses of status epilepticus, infantile spasms, and traumatic brain injury dropped by 53%, 55%, and 56%, respectively. There was an increase in hospital length of stay, relative utilization of intensive care, and diagnostic testing (long-term electroencephalography, brain MRI, and head CT (all P<.01)). Conclusion During the initial 6 weeks of SiP, there was a significant decrease in neurologic hospital-based encounters. Those admitted required a high level of care. Hospital-based neurologic services are needed to care for acutely ill patients. Precise factors causing these shifts are unknown and raise concern for changes in care seeking of patients with serious neurologic conditions. Impacts of potentially delayed diagnosis or treatment require further investigation.
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Affiliation(s)
- Melissa L. Hutchinson
- Department of Pediatrics, Neurology
Division, The Ohio State University College of
Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Kendall B. Nash
- Departments of Neurology and
Pediatrics, Division of Child Neurology, University of California, San
Francisco, Benioff Children’s Hospital San Francisco, San Francisco,
CA, USA
| | - Nicholas S. Abend
- Departments of Neurology and
Pediatrics, Children’s Hospital of Philadelphia
and the University of Pennsylvania, Philadelphia PA, USA
| | - Mahendranath Moharir
- Division of Neurology, Department
of Pediatrics, The Hospital for Sick Children and
University of Toronto, Ontario, Canada
| | - Elizabeth Wells
- Center for Neuroscience and
Behavioral Medicine, Children’s National Hospital and the
George Washington University School of Medicine and Health
Sciences, Washington, DC, USA
| | - Ricka D. Messer
- Department of Pediatrics, Section
of Child Neurology, University of Colorado, Aurora, CO, USA
| | - Jamie Palaganas
- Department of Pediatrics, Division
of Child Neurology, Weill Cornell Medicine, New York Presbyterian
Hospital, New York, NY, USA
| | - Ingo Helbig
- Division of Neurology, Children’s Hospital of
Philadelphia, Philadelphia PA, USA
| | - Sharon O. Wietstock
- The Epilepsy NeuroGenetics
Initiative (ENGIN), Department of Biomedical and Health Informatics (DBHi),
Department of Neurology, University of
Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - William Suslovic
- Department of Neurology, Children’s National
Hospital, Washington, DC, USA
| | - Alexander K. Gonzalez
- The Epilepsy NeuroGenetics
Initiative (ENGIN). Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of
Philadelphia, Philadelphia PA, USA 1
| | - Michael C. Kaufman
- The Epilepsy NeuroGenetics
Initiative (ENGIN). Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of
Philadelphia, Philadelphia PA, USA 1
| | - Craig A. Press
- Departments of Neurology and
Pediatrics, Children’s Hospital of Philadelphia
and the University of Pennsylvania, Philadelphia PA, USA
| | - Juan Piantino
- Department of Pediatrics, Section
of Child Neurology, Oregon Health & Science
University, Portland, OR, USA,Juan A. Piantino, Department of Pediatrics,
Section of Child Neurology, Oregon Health & Science University, MCR CDRC-P
707 SW Gaines St, Portland, OR 97239, USA.
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31
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Dicpinigaitis AJ, Gandhi CD, Pisapia J, Muh CR, Cooper JB, Tobias M, Mohan A, Nuoman R, Overby P, Santarelli J, Hanft S, Bowers C, Yaghi S, Mayer SA, Al-Mufti F. Endovascular Thrombectomy for Pediatric Acute Ischemic Stroke. Stroke 2022; 53:1530-1539. [PMID: 35272483 DOI: 10.1161/strokeaha.121.036361] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Evidence regarding the utilization and outcomes of endovascular thrombectomy (EVT) for pediatric ischemic stroke is limited, and justification for its use is largely based on extrapolation from clinical benefits observed in adults. METHODS Weighted discharge data from the National Inpatient Sample were queried to identify pediatric patients with ischemic stroke (<18 years old) during the period of 2010 to 2019. Complex samples statistical methods were used to characterize the profiles and clinical outcomes of EVT-treated patients. Propensity adjustment was performed to address confounding by indication for EVT based on disparities in baseline characteristics between EVT-treated patients and those medically managed. RESULTS Among 7365 pediatric patients with ischemic stroke identified, 190 (2.6%) were treated with EVT. Utilization significantly increased in the post-EVT clinical trial era (2016-2019; 1.7% versus 4.0%; P<0.001), while the use of decompressive hemicraniectomy decreased (2.8% versus 0.7%; P<0.001). On unadjusted analysis, 105 (55.3%) EVT-treated patients achieved favorable functional outcomes at discharge (home or to acute rehabilitation), while no periprocedural iatrogenic complications or instances of contrast-induced kidney injury were reported. Following propensity adjustment, EVT-treated patients demonstrated higher absolute but nonsignificant rates of favorable functional outcomes in comparison with medically managed patients (55.3% versus 52.8%; P=0.830; adjusted hazard ratio, 1.01 [95% CI, 0.51-2.03]; P=0.972 for unfavorable outcome). Among patients with baseline National Institutes of Health Stroke Scale score >11 (75th percentile of scores in cohort), EVT-treated patients trended toward higher rates of favorable functional outcomes compared with those treated medically only (71.4% versus 55.6%; P=0.146). In a subcohort assessment of EVT-treated patients, those administered preceding thrombolytic therapy (n=79, 41.6%) trended toward higher rates of favorable functional outcomes (63.3% versus 49.5%; P=0.060). CONCLUSIONS This cross-sectional evaluation of the clinical course and short-term outcomes of pediatric patients with ischemic stroke treated with EVT demonstrates that EVT is likely a safe modality which confers high rates of favorable functional outcomes.
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Affiliation(s)
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Jared Pisapia
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Carrie R Muh
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Jared B Cooper
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Michael Tobias
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Avinash Mohan
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Rolla Nuoman
- Department of Neurology, Westchester Medical Center, Valhalla, NY. (R.N., P.O., S.A.M., F.A.-M.)
| | - Philip Overby
- Department of Neurology, Westchester Medical Center, Valhalla, NY. (R.N., P.O., S.A.M., F.A.-M.)
| | - Justin Santarelli
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Simon Hanft
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Christian Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque (C.B.)
| | - Shadi Yaghi
- Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (S.Y.)
| | - Stephan A Mayer
- Department of Neurology, Westchester Medical Center, Valhalla, NY. (R.N., P.O., S.A.M., F.A.-M.)
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.).,Department of Neurology, Westchester Medical Center, Valhalla, NY. (R.N., P.O., S.A.M., F.A.-M.)
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Jankovic M, Petrovic B, Novakovic I, Brankovic S, Radosavljevic N, Nikolic D. The Genetic Basis of Strokes in Pediatric Populations and Insight into New Therapeutic Options. Int J Mol Sci 2022; 23:ijms23031601. [PMID: 35163523 PMCID: PMC8835808 DOI: 10.3390/ijms23031601] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/27/2022] [Accepted: 01/28/2022] [Indexed: 02/04/2023] Open
Abstract
Strokes within pediatric populations are considered to be the 10th leading cause of death in the United States of America, with over half of such events occurring in children younger than one year of life. The multifactorial etiopathology that has an influence on stroke development and occurrence signify the importance of the timely recognition of both modifiable and non-modifiable factors for adequate diagnostic and treatment approaches. The early recognition of a stroke and stroke risk in children has the potential to advance the application of neuroprotective, thrombolytic, and antithrombotic interventions and rehabilitation strategies to the earliest possible timepoints after the onset of a stroke, improving the outcomes and quality of life for affected children and their families. The recent development of molecular genetic methods has greatly facilitated the analysis and diagnosis of single-gene disorders. In this review, the most significant single gene disorders associated with pediatric stroke are presented, along with specific therapeutic options whenever they exist. Besides monogenic disorders that may present with stroke as a first symptom, genetic polymorphisms may contribute to the risk of pediatric and perinatal stroke. The most frequently studied genetic risk factors are several common polymorphisms in genes associated with thrombophilia; these genes code for proteins that are part of the coagulation cascade, fibrolysis, homocystein metabolism, lipid metabolism, or platelets. Single polymorphism frequencies may not be sufficient to completely explain the stroke causality and an analysis of several genotype combinations is a more promising approach. The recent steps forward in our understanding of the disorders underlying strokes has given us a next generation of therapeutics and therapeutic targets by which to improve stroke survival, protect or rebuild neuronal connections in the brain, and enhance neural function. Advances in DNA sequencing and the development of new tools to correct human gene mutations have brought genetic analysis and gene therapy into the focus of investigations for new therapeutic options for stroke patients.
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Affiliation(s)
- Milena Jankovic
- Neurology Clinic, Clinical Center of Serbia, 11000 Belgrade, Serbia;
| | - Bojana Petrovic
- Clinic of Gynecology and Obstetrics, Clinical Center of Serbia, 11000 Belgrade, Serbia;
| | - Ivana Novakovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Slavko Brankovic
- Faculty of Sciences and Mathematics, University of Priština in Kosovska Mitrovica, 38220 Kosovska Mitrovica, Serbia;
| | - Natasa Radosavljevic
- Department of Physical Medicine and Rehabilitation, King Abdulaziz Specialist Hospital, Taif 26521, Saudi Arabia;
| | - Dejan Nikolic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
- Physical Medicine and Rehabilitation Department, University Children’s Hospital, 11000 Belgrade, Serbia
- Correspondence:
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Lambea-Gil Á, Martínez-de-Morentín-Narvarcorena A, Tejada-Meza H, Zapatero-González D, Madurga-Revilla P, Bestué-Cardiel M. Ictus pediátrico en Aragón: incidencia, características y resultados en salud. Neurologia 2022. [DOI: 10.1016/j.nrl.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Garza-Alatorre G, Carrion-Garcia AL, Falcon-Delgado A, Garza-Davila EC, Martinez-Ponce de Leon AR, Botello-Hernandez E. Characteristics of Pediatric Stroke and Association of Delayed Diagnosis with Mortality in a Mexican Tertiary Care Hospital. Neuropediatrics 2021; 52:499-503. [PMID: 34261144 DOI: 10.1055/s-0041-1731802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Pediatric cerebrovascular disease carries significant morbidity and mortality. Early recognition of a pediatric stroke as well and its most common risk factors are important, but that diagnosis is often delayed. It is believed that the incidence in our center is higher than it appears. This study aims to assess the incidence and characteristics of the pediatric stroke in our university hospital. Likewise, this study seeks to evaluate if a longer symptoms-to-diagnosis time is associated with mortality in patients with ischemic stroke. METHODS A retrospective study including children with stroke admitted to the UANL University Hospital from January 2013 to December 2016. RESULTS A total of 41 patients and 46 stroke episodes were admitted. About 45.7% had an ischemic stroke and 54.3% had a hemorrhagic stroke. A mortality of 24.4% and a morbidity of 60.9% were recorded. Regarding ischemic and hemorrhagic stroke, an increased symptoms-to-diagnosis time and a higher mortality were obtained with a relative risk of 2.667 (95% confidence interval [CI]: 1.09-6.524, p = 0.013) and 8.0 (95% CI: 2.18-29.24, p = < 0.0001), respectively. A continuous increase in the incidence rate, ranging from 4.57 to 13.21 per 1,000 admissions comparing the first period (2013) versus the last period (2016), p = 0.02, was found in our center. CONCLUSIONS Pediatric stroke is a rare disease; however, its incidence shows a continuous increase. More awareness toward pediatric stroke is needed.
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Affiliation(s)
- Gerardo Garza-Alatorre
- Pediatric Intensive Therapy Unit, Facultad de Medicina y Hospital Universitario "Dr. Jose Eleuterio Gonzalez," Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico.,Pediatrics Department, Facultad de Medicina y Hospital Universitario "Dr. Jose Eleuterio Gonzalez," Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico
| | - Ana Luisa Carrion-Garcia
- Pediatrics Department, Facultad de Medicina y Hospital Universitario "Dr. Jose Eleuterio Gonzalez," Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico
| | - Alfredo Falcon-Delgado
- Pediatrics Department, Facultad de Medicina y Hospital Universitario "Dr. Jose Eleuterio Gonzalez," Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico
| | - Elda Carolina Garza-Davila
- Pediatrics Department, Facultad de Medicina y Hospital Universitario "Dr. Jose Eleuterio Gonzalez," Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico
| | - Angel R Martinez-Ponce de Leon
- Neurosurgery and Endovascular Neurological Therapy Department, Facultad de Medicina y Hospital Universitario "Dr. Jose Eleuterio Gonzalez," Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico
| | - Edgar Botello-Hernandez
- Facultad de Medicina y Hospital Universitario "Dr. Jose Eleuterio Gonzalez," Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico
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Definitive Diagnostic Evaluation of the Child With Arterial Ischemic Stroke and Approaches to Secondary Stroke Prevention. Top Magn Reson Imaging 2021; 30:225-230. [PMID: 34613945 DOI: 10.1097/rmr.0000000000000272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT In children with arterial ischemic stroke (AIS), the definitive diagnosis of stroke subtype and confirmation of stroke etiology is necessary to mitigate stroke morbidity and prevent recurrent stroke. The common causes of AIS in children are sharply differentiated from the common causes of adult AIS. A comprehensive, structured diagnostic approach will identify the etiology of stroke in most children. Adequate diagnostic evaluation relies on advanced brain imaging and vascular imaging studies. A variety of medical and surgical secondary stroke prevention strategies directed at the underlying cause of stroke are available. This review aims to outline strategies for definitive diagnosis and secondary stroke prevention in children with AIS, emphasizing the critical role of neuroimaging.
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Trollmann R. Neuromonitoring bei zerebralen Anfällen im Neugeborenenalter – Chancen und Herausforderungen. KLIN NEUROPHYSIOL 2021. [DOI: 10.1055/a-1438-1828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Angesichts der vielen Kinder mit neonatalen Risikofaktoren für erworbene ZNS-Läsionen und zerebrale Anfälle ist das EEG zunehmend relevant für eine optimierte Diagnostik und Therapieüberwachung 1
2. Folgender Artikel gibt einen Überblick über Besonderheiten des neonatalen EEG und über aktuelle Empfehlungen zum Stellenwert des Langzeit-EEG-Monitorings bei neonatalen Anfällen und epileptischen Enzephalopathien im Früh- und Neugeborenalter.
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Endovascular and thrombolytic treatment eligibility in childhood arterial ischemic stroke. Eur J Paediatr Neurol 2021; 34:99-104. [PMID: 34454335 DOI: 10.1016/j.ejpn.2021.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/04/2021] [Accepted: 08/23/2021] [Indexed: 01/02/2023]
Abstract
AIM To describe factors affecting eligibility for, and rates of utilization of, hyperacute therapy in children with acute ischemic stroke (AIS) following establishment of our institutional acute stroke treatment pathway in 2005. METHODS A retrospective analysis of a prospectively enrolled, single-center cohort was performed including children age 2 - <18 years with acute AIS from 2005 through 2017. Descriptive statistics were used to summarize clinical characteristics, presentation data, and Pediatric NIH Stroke Scale (PedNIHSS) scores that were abstracted from medical records. Assessment for eligibility and administration of hyperacute therapy was determined at the time of presentation according to the institutional stroke pathway. RESULTS Of 90 children (median age at presentation 11.3 years, 36% female) with acute AIS, 5 (6%) received hyperacute therapy: 3 received intravenous tissue plasminogen activator (IV-tPA) alone, 1 received endovascular therapy (EVT) alone, and 1 received IV-tPA and EVT. Of 54 children (60%) who presented within 4.5 h of time last seen well, 6 had PedNIHSS scores 6-24, no medical contraindication to IV-tPA, and a partial or complete vessel occlusion. Of 7 children >3 years old who presented after EVT became available at our hospital and within 6 h of time last seen well with a PedNIHSS score 6-24, 3 (43%) had a large vessel occlusion (LVO). Two patients underwent EVT and the other patient was not transferred until >6 h from time last seen well. CONCLUSIONS Delay to presentation and diagnosis of childhood acute AIS, mild neurologic deficits at presentation, medical contraindications to IV-tPA, and lack of vessel occlusion on acute neuroimaging contribute to low rates of hyperacute treatment in children with acute AIS.
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Bahrami R, Dastgheib SA, Mirjalili H, Setayesh S, Shaker SH, Mirjalili SR, Noorishadkam M, Neamatzadeh H. Association of SERPINE1 rs1799889 polymorphism with arterial ischemic stroke in children: a systematic review and meta-analysis. NUCLEOSIDES NUCLEOTIDES & NUCLEIC ACIDS 2021; 40:1018-1035. [PMID: 34429017 DOI: 10.1080/15257770.2021.1966798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Inherited thrombophilias are well-established predisposing factors for venous thromboembolism, but their role in arterial ischemic stroke (AIS) in children, remains unclear. The association between SERPINE1 rs1799889 polymorphism and AIS in children was evaluated by several studies, whereas the results were conflicting. Thus, we performed this meta-analysis to combine and analyze the available studies in order to provide a more accurate result on the association. PubMed, Scopus, EMBASE, SciELO, MedRxiv, China Biology Medicine Disk, DeepDyve, CNKI, and Web of Science were used to identify all relevant articles published up to 30 November 2020, without any restrictions on ethnicity. Summary odds ratios (ORs) with 95% confidence intervals (CIs) were used to determine the strength of the associations. A total of eight case-control studies with 600 cases and 2,156 controls were selected. No significant association between SERPINE1 rs1799889 polymorphism and AIS in children susceptibility was noted. In the stratified analyses by ethnicity, source of controls, genotyping methods, and age groups, there was still no significant association between SERPINE1 rs1799889 polymorphism and AIS risk in children. This study suggested that SERPINE1 rs1799889 polymorphism might be not related to etiology of AIS in children. Moreover, well-designed, large-scale and multicenter clinical studies are required to improve and validate these results.Supplemental data for this article is available online at https://doi.org/10.1080/15257770.2021.1966798 .
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Affiliation(s)
- Reza Bahrami
- Neonatal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Alireza Dastgheib
- Department of Medical Genetics, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Mirjalili
- Department of Emergency Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Sepideh Setayesh
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Hossein Shaker
- Department of Emergency Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Reza Mirjalili
- Mother and Newborn Health Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mahmood Noorishadkam
- Mother and Newborn Health Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Hossein Neamatzadeh
- Department of Emergency Medicine, Iran University of Medical Sciences, Tehran, Iran.,Department of Medical Genetics, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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Pediatric Patient with Ischemic Stroke: Initial Approach and Early Management. CHILDREN 2021; 8:children8080649. [PMID: 34438540 PMCID: PMC8394345 DOI: 10.3390/children8080649] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 02/05/2023]
Abstract
Acute Ischemic Stroke (AIS) in children is an acute neurologic emergency associated with significant morbidity and mortality. Although the incidence of AIS in pediatric patients is considerably lower than in adults, the overall cumulative negative impact of the quality of life could be even higher in children. The age-related variable clinical presentation could result in a delay in diagnosis and could negatively influence the overall outcome. The early management should be based on early recognition, acute transfer to pediatric AIS centre, standardised approach (ABCDE), early neurologic examination together with neuroimaging (preferable Magnetic Resonance Imaging—MRI). The treatment is based on supportive therapy (normoxemia, normocapnia, normotension and normoglycemia) in combination with intravenous/intraarterial thrombolytic therapy and/or mechanical thrombectomy in selected cases. Pediatric stroke centres, together with the implementation of local stroke management protocols, could further improve the outcome of pediatric patients with AIS.
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Molecular Analysis of Prothrombotic Gene Variants in Patients with Acute Ischemic Stroke and with Transient Ischemic Attack. ACTA ACUST UNITED AC 2021; 57:medicina57070723. [PMID: 34357004 PMCID: PMC8306646 DOI: 10.3390/medicina57070723] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/03/2021] [Accepted: 07/14/2021] [Indexed: 12/28/2022]
Abstract
Background and objectives: ischemic stroke (IS) is among the most frequent causes of death worldwide; thus, it is of paramount relevance to know predisposing factors that may help to identify and treat the high-risk subjects. Materials and Methods:we tested nine variants in genes involved in thrombotic pathway in 282 patients that experienced IS and 87 that had transient ischemic attacks (TIA) in comparison to 430 subjects from the general population (GP) of the same geographic area (southern Italy). We included cases of young and child IS to evaluate the eventual differences in the role of the analyzed variants. Results: we did not observe significant differences between TIA and the GP for any of the variants, while the allele frequencies of methylene-tetrahydrofolate reductase (MTHFR) C677T, beta-fibrinogen -455G>A and factor (FXIII) V34L were significantly higher in patients with IS than in the subjects from the GP. No significant interaction was observed with sex. Conclusions: the present data argue that some gene variants have a role in IS and this appears to be an interesting possibility to be pursued in large population studies to help design specific strategies for IS prevention.
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Internal Carotid Dissection as the Cause of Stroke in Childhood. Case Rep Pediatr 2021; 2021:5568827. [PMID: 34258095 PMCID: PMC8261171 DOI: 10.1155/2021/5568827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/21/2021] [Indexed: 11/17/2022] Open
Abstract
Internal carotid artery (ICA) dissection is a cause of stroke, but it is often underdiagnosed in children. ICAs' risk factors and pathogenic mechanisms are poorly understood, and the treatment is still empirical. We report the case of a previously healthy 9-year-old girl who presented with involuntary hypertonic closure of the right hand associated with transient difficulty for both fine movements of the right arm and speech. She had a history of minor cervical trauma occurring 20 days prior to our observation without other associated risk factors. Magnetic resonance imaging and magnetic resonance angiography showed ischemic lesions due to the left ICA dissection. Treatment with both acetylsalicylic acid and levetiracetam allowed recanalization of the ICA associated with the resolution of clinical signs. Our clinical case suggests that the ICA dissection must be suspected early whenever a child manifests mild neurologic deficits after a cervical trauma, especially if they are associated with headache and/or cervical pain. Moreover, the management of ICA dissection must be improved.
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Hollist M, Au K, Morgan L, Shetty PA, Rane R, Hollist A, Amaniampong A, Kirmani BF. Pediatric Stroke: Overview and Recent Updates. Aging Dis 2021; 12:1043-1055. [PMID: 34221548 PMCID: PMC8219494 DOI: 10.14336/ad.2021.0219] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/19/2021] [Indexed: 12/24/2022] Open
Abstract
Stroke can occur at any age or stage in life. Although it is commonly thought of as a disease amongst the elderly, it is important to highlight the fact that it also affects infants and children. In both populations, strokes have a high rate of morbidity and mortality. Arguably, it is more detrimental in the pediatric population given the occurrence at a younger age and therefore, a longer duration of disability, potentially over the entire lifespan. The high rate of morbidity and mortality in pediatrics is attributed to significant delays in diagnosis, as well as misdiagnosis. Acute stroke management is time dependent. Patients who receive acute treatment with either intravenous (IV) tissue plasminogen activator (tPA) or mechanical thrombectomy, have improved mortality and functional outcomes. Additionally, the earlier treatment is initiated, the higher the likelihood of preserving penumbra, restoring cerebral blood flow and potentially reversing symptoms, thereby limiting disability. Prompt identification is essential as it leads to improved patient care in such a narrow therapeutic window. It enhances the care received during hospitalization and reduces the risk of early stroke recurrence. Despite limited data and lack of large randomized clinical trials in pediatrics, both IV tPA and mechanical thrombectomy have been successfully used. Bridging the gap of acute stroke management in the pediatric population is an essential part of minimizing adverse outcomes. In this review, we discuss the epidemiology of pediatric stroke, the diverse etiologies, presentation as well as both acute and preventative management.
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Affiliation(s)
- Mary Hollist
- 1Memorial Healthcare Institute for Neurosciences, Owosso MI, USA
| | - Katherine Au
- 2George Washington University, School of Medicine & Health Sciences, Washington DC, USA
| | - Larry Morgan
- 3Bronson Neuroscience Center, Kalamazoo, MI, USA
| | - Padmashri A Shetty
- 4Ramaiah Medical College, M. S. Ramaiah Nagar, Bengaluru, Karnataka, India
| | - Riddhi Rane
- 7Texas A&M University College of Medicine, College Station, TX, USA
| | | | | | - Batool F Kirmani
- 7Texas A&M University College of Medicine, College Station, TX, USA.,8Endovascular Therapy & Interventional Stroke Program, Department of Neurology, CHI St. Joseph Health, Bryan, TX, USA
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Bahri R, Sharma RS, Jain V. Mineralizing angiopathy with basal ganglia stroke after minor head trauma; a clinical profile and follow up study of a large series of paediatric patients from North India. Eur J Paediatr Neurol 2021; 33:61-67. [PMID: 34077857 DOI: 10.1016/j.ejpn.2021.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND There is paucity of published literature on follow-up outcome of mineralizing angiopathy with basal ganglia stroke related to minor head trauma. This retrospective study aims to bridge this knowledge gap. METHODS Patients (1 months- 15 years), presenting with acute stroke over a 5-year period were recruited. From this cohort, basal ganglia strokes following minor head trauma were analysed in detail and outcome assessed using the Recovery and Recurrence Questionnaire (RRQ). RESULTS A total of 94 patients were eligible, 48 (51%) were basal ganglia stroke following minor head trauma [M: F 2.5:1; mean age 21 ± 8.5 (±SD months]. Further evaluation of this group revealed a median time of 60 min (range 0-96 h) from trauma to stroke onset. Nearly all had acute hemiparesis (45/48). Almost a third of patients (n = 13; 27%) had a transient hemi dystonia on the hemiparetic side after a median of 4 days (range 2-6 days) of symptom onset.Computed tomography (CT) head showed bilateral basal ganglia calcification in all; Most patients (31/48; 64.5%) were anaemic. Magnetic Resonance (MR) angiography, echocardiogram and thrombophilia screen was normal wherever they were performed (6/48).The median follow-up period - 14 months (Range 0-22months). Majority of patients (22/35; 63%) showed complete recovery at 18 months follow up, with maximum recovery occurring between 6 and 12 months. CONCLUSION Minor head trauma leading to basal ganglia stroke in children was the most common cause of paediatric stroke in our patients. In follow-up most patients had recovered fully, though a significant minority did not recover completely.
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Affiliation(s)
- Roshni Bahri
- Departments' of Paediatrics & Paediatric Neurology, Santokba Durlabhji Memorial Hospital, Jaipur, India; Norwich Medical School, University of East Anglia, Norwich, UK
| | - Radhe Shyam Sharma
- Departments' of Paediatrics & Paediatric Neurology, Santokba Durlabhji Memorial Hospital, Jaipur, India
| | - Vivek Jain
- Departments' of Paediatrics & Paediatric Neurology, Santokba Durlabhji Memorial Hospital, Jaipur, India.
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Pizzatto R, Resende LL, Lobo CFT, Neves YCS, Paz JAD, Alves CAPF, Leite CDC, Lucato LT. Arteriopathy in pediatric stroke: an underestimated clinical entity. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:321-333. [PMID: 34133513 DOI: 10.1590/0004-282x-anp-2020-0105] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/07/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pediatric arterial ischemic stroke (AIS), which was thought to be a rare disorder, is being increasingly recognized as an important cause of neurological morbidity, thanks to new advances in neuroimaging. OBJECTIVE The aim of this study was to review the main etiologies of stroke due to arteriopathy in children. METHODS Using a series of cases from our institution, we addressed its epidemiological aspects, physiopathology, imaging findings from CT, MR angiography, MR conventional sequences and MR DWI, and nuclear medicine findings. RESULTS Through discussion of the most recent classification for childhood AIS (Childhood AIS Standardized Classification and Diagnostic Evaluation, CASCADE), we propose a modified classification based on the anatomical site of disease, which includes vasculitis, varicella, arterial dissection, moyamoya, fibromuscular dysplasia, Takayasu's arteritis and genetic causes (such as ACTA-2 mutation, PHACE syndrome and ADA-2 deficiency). We have detailed each of these separately. Conclusions: Prompt recognition of AIS and thorough investigation for potential risk factors are crucial for a better outcome. In this scenario, neurovascular imaging plays an important role in diagnosing AIS and identifying children at high risk of recurrent stroke.
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Affiliation(s)
- Ronaldo Pizzatto
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Radiologia, São Paulo SP, Brazil
| | - Lucas Lopes Resende
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Radiologia, São Paulo SP, Brazil
| | - Carlos Felipe Teixeira Lobo
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Radiologia, São Paulo SP, Brazil
| | - Yuri Costa Sarno Neves
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Radiologia, São Paulo SP, Brazil
| | - José Albino da Paz
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Pediatria, São Paulo SP, Brazil
| | | | - Claudia da Costa Leite
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Radiologia, São Paulo SP, Brazil
| | - Leandro Tavares Lucato
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Radiologia, São Paulo SP, Brazil
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Olivieri M, Sorg AL, Weinberger R, Kurnik K, Bidlingmaier C, Juranek S, Hoffmann F, Reiter K, Bonfert M, Tacke M, Borggraefe I, Heinen F, Gerstl L. Recanalization strategies in childhood stroke in Germany. Sci Rep 2021; 11:13314. [PMID: 34172782 PMCID: PMC8233321 DOI: 10.1038/s41598-021-92533-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/11/2021] [Indexed: 12/21/2022] Open
Abstract
Childhood arterial ischemic stroke (CAIS) is a rare event. Diverse etiologies, risk factors, symptoms and stroke mimics hamper obtaining a fast diagnosis and implementing immediate recanalization strategies. Over a period of 3 years (2015–2017), the data of 164 pediatric patients (> 28 days of life-18 years) with a first episode of AIS were submitted to a hospital-based nationwide surveillance system for rare disorders (ESPED). We report a subgroup analysis of patients who have undergone recanalization therapy and compare these data with those of the whole group. Twenty-eight patients (17%) with a median age of 12.2 years (range 3.3–16.9) received recanalization therapy. Hemiparesis, facial weakness and speech disturbance were the main presenting symptoms. The time from onset of symptoms to confirmation of diagnosis was significantly shorter in the intervention group (4.1 h vs. 20.4 h, p ≤ 0.0001). Only in one patient occurred a minor bleed. Cardiac disease as predisposing risk factor was more common in the recanalization group. Recanalization therapies are feasible and increasingly applied in children with AIS. High awareness, timely diagnosis and a large amount of expertise may improve time to treatment and make hyperacute therapy an option for more patients.
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Affiliation(s)
- Martin Olivieri
- Pediatric Hemostasis and Thrombosis Unit, Department of Pediatrics, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany.
| | - Anna-Lisa Sorg
- Institute of Social Pediatrics and Adolescent Medicine, LMU Munich, Munich, Germany
| | - Raphael Weinberger
- Institute of Social Pediatrics and Adolescent Medicine, LMU Munich, Munich, Germany
| | - Karin Kurnik
- Pediatric Hemostasis and Thrombosis Unit, Department of Pediatrics, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Christoph Bidlingmaier
- Pediatric Hemostasis and Thrombosis Unit, Department of Pediatrics, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Sabrina Juranek
- Pediatric Hemostasis and Thrombosis Unit, Department of Pediatrics, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Florian Hoffmann
- Pediatric Intensive Care Unit, Department of Pediatrics, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Karl Reiter
- Pediatric Intensive Care Unit, Department of Pediatrics, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Michaela Bonfert
- Department of Pediatric Neurology and Developmental Medicine and LMU Center for Development and Children With Medical Complexity, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Moritz Tacke
- Department of Pediatric Neurology and Developmental Medicine and LMU Center for Development and Children With Medical Complexity, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Ingo Borggraefe
- Department of Pediatric Neurology and Developmental Medicine and LMU Center for Development and Children With Medical Complexity, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Florian Heinen
- Department of Pediatric Neurology and Developmental Medicine and LMU Center for Development and Children With Medical Complexity, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Lucia Gerstl
- Department of Pediatric Neurology and Developmental Medicine and LMU Center for Development and Children With Medical Complexity, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
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Kopyta I, Cebula A, Sarecka-Hujar B. Early Deaths after Arterial Ischemic Stroke in Pediatric Patients: Incidence and Risk Factors. CHILDREN-BASEL 2021; 8:children8060471. [PMID: 34204895 PMCID: PMC8228712 DOI: 10.3390/children8060471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 05/29/2021] [Accepted: 05/31/2021] [Indexed: 01/02/2023]
Abstract
In developed countries, cerebrovascular diseases are among the 10 most common causes of death in both the pediatric and adult population. The prevalence of fatal outcomes following arterial ischemic stroke (AIS) in various groups of pediatric patients ranges from 1% to almost 32%. However, a constant improvement in stroke mortality among children has been observed. The extent of the decline differs among studies (from nearly tenfold to twofold decline), as it depends on the study population. While a portion of this variability might be explained by factors such as health care access, population age, diseases related to ethnicity, and different etiologies of stroke in studied populations, the understanding of such differences is still insufficient. Risk factors for death in the early stages of the disease are poorly understood and are usually based on the clinical presentations of relatively small groups of pediatric patients. Familiarity with these factors may be of significant importance for prognosis, but also for the early selection of patients requiring careful supervision. The present study aimed to analyze and discuss the current literature data on the incidence of early death and risk factors for early death in children suffering from stroke.
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Affiliation(s)
- Ilona Kopyta
- Department of Paediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia in Katowice, Medykow Str 16, 40-752 Katowice, Poland; (I.K.); (A.C.)
| | - Agnieszka Cebula
- Department of Paediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia in Katowice, Medykow Str 16, 40-752 Katowice, Poland; (I.K.); (A.C.)
| | - Beata Sarecka-Hujar
- Department of Basic Biomedical Science, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia in Katowice, Kasztanowa Str 3, 41-200 Sosnowiec, Poland
- Correspondence:
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Kopyta I, Sarecka-Hujar B, Raczkiewicz D, Gruszczyńska K, Machnikowska-Sokołowska M. Assessment of Post-Stroke Consequences in Pediatric Ischemic Stroke in the Context of Neuroimaging Results-Experience from a Single Medical Center. CHILDREN-BASEL 2021; 8:children8040292. [PMID: 33917968 PMCID: PMC8068320 DOI: 10.3390/children8040292] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/25/2021] [Accepted: 04/06/2021] [Indexed: 11/16/2022]
Abstract
Arterial ischemic stroke (AIS) in children is a rare condition; its frequency is estimated at 0.58 to 7.9 new onsets in 100,000 children per year. The knowledge on risk factors, clinical outcomes and consequences of pediatric AIS is increasing. However, there are still many unknowns in the field. The aim of the study was to analyze the clinical presentation of pediatric AIS and its consequences according to the neuroimaging results and location of ischemia. The research was retrospective and observational. The analyzed group consisted of 75 AIS children (32 girls, 43 boys), whereby the age of the patients ranged from 9 months to 18 years at stroke onset. All the patients were diagnosed and treated in one tertiary center. The most frequent stroke subtype was total anterior circulation infarct (TACI) with most common ischemic focus location in temporal lobe and vascular pathology in middle cerebral artery (MCA). The location of ischemic focus in the brain correlated with post-stroke outcomes: intellectual delay and epilepsy, hemiparesis corresponded to the location of vascular pathology. A correlation found between ischemic lesion location and vascular pathology with post-stroke consequences in pediatric AIS may be important information and helpful in choosing proper early therapy. The expected results should lead to lesser severity of late post-stroke outcomes.
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Affiliation(s)
- Ilona Kopyta
- Department of Pediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia in Katowice, 40-752 Katowice, Poland;
| | - Beata Sarecka-Hujar
- Department of Basic Biomedical Science, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia in Katowice, 41-200 Sosnowiec, Poland;
| | - Dorota Raczkiewicz
- Department of Medical Statistics, School of Public Health, Center of Postgraduate Medical Education, 01-826 Warsaw, Poland
- Correspondence: ; Tel.: +48-605-313-261
| | - Katarzyna Gruszczyńska
- Department of Diagnostic Imaging, Radiology and Nuclear Medicine, Faculty of Medical Sciences in Katowice, Medical University of Silesia in Katowice, 40-752 Katowice, Poland; (K.G.); (M.M.-S.)
| | - Magdalena Machnikowska-Sokołowska
- Department of Diagnostic Imaging, Radiology and Nuclear Medicine, Faculty of Medical Sciences in Katowice, Medical University of Silesia in Katowice, 40-752 Katowice, Poland; (K.G.); (M.M.-S.)
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Sarecka-Hujar B, Kopyta I. The Impact of Sex on Arterial Ischemic Stroke in Young Patients: From Stroke Occurrence to Poststroke Consequences. CHILDREN-BASEL 2021; 8:children8030238. [PMID: 33803901 PMCID: PMC8003301 DOI: 10.3390/children8030238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/12/2021] [Accepted: 03/16/2021] [Indexed: 01/12/2023]
Abstract
The male sex has been suggested to predominate in paediatric patients with arterial ischemic stroke (AIS), especially in newborns. The explanation for this phenomenon remains unsatisfactory since it focuses on the analysis of the potential relationship with trauma and arterial dissection. In turn, in some populations of young adults, men suffer from AIS more frequently than women, which may be related to the protective role of oestrogen. On the other hand, certain data indicate that women dominate over men. Some of the disparities in the frequencies of particular symptoms of AIS and poststroke consequences in both children and young adults have been suggested; however, data are scarce. Unfortunately, the low number of studies on the subject does not allow certain conclusions to be drawn. For adults, more data are available for patients aged over 60 years, the results of which are more obvious. The present literature review aimed to discuss available data on the prevalence of AIS, its clinical presentations, and poststroke consequences in regard to the sex of young patients. We considered young patients to be children from birth up to the age of 19 years of life and young adults to be individuals up to the age of 55 years. The role of sex hormones in AIS and possible gender differences in genetic risk factors for AIS were also discussed briefly.
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Affiliation(s)
- Beata Sarecka-Hujar
- Department of Basic Biomedical Science, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia in Katowice, Kasztanowa Str 3, 41-200 Sosnowiec, Poland
- Correspondence: or ; Tel.: +48-32-269-98-30
| | - Ilona Kopyta
- Department of Pediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia in Katowice, Medykow Str 16, 40-752 Katowice, Poland;
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Barry M, Barry D, Kansagra AP, Hallam D, Abraham M, Amlie-Lefond C. Higher-Quality Data Collection Is Critical to Establish the Safety and Efficacy of Pediatric Mechanical Thrombectomy. Stroke 2021; 52:1213-1221. [PMID: 33719517 DOI: 10.1161/strokeaha.120.032009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE Because children often have lifelong morbidity after stroke, there is considerable enthusiasm to pursue mechanical thrombectomy in childhood stroke based on literature reports. However, current published data may reflect inconsistent reporting and publication bias, which limit the ability to assess safety and efficacy of mechanical thrombectomy in childhood stroke. METHODS This retrospective cohort study compared reporting quality and clinical outcomes for mechanical thrombectomy between a trial-derived cohort of 42 children treated with mechanical thrombectomy for acute stroke at study sites and 133 patients reported in the literature. National Institutes of Health Stroke Scale at baseline, 24 hours after mechanical thrombectomy, and at discharge were compared between study site patients and literature patients. Odds ratios (ORs) were used to compare reporting frequencies. Proportional odds logistic regression was used to compare outcomes. RESULTS Premechanical thrombectomy National Institutes of Health Stroke Scale was available in 93% of study patients compared with 74% of patients in the literature (OR, 4.42 [95% CI, 1.47-19.89]). Postmechanical thrombectomy National Institutes of Health Stroke Scale was available in 69% of study patients compared with 29% of literature cases at 24 hours (OR, 5.48 [95% CI, 2.62-12.06]), and 64% of study patients compared with 32% of cases at discharge (OR, 3.85 [95% CI, 1.87-8.19]). For study sites, median scores were 12 at baseline, 9 at 24 hours, and 5 at discharge. Median scores in case reports were 15 at baseline, 4 at 24 hours, and 3 at discharge. ORs for differences in outcomes between groups were 5.97 (95% CI, 2.28-15.59) at 24 hours and 3.68 (95% CI, 1.45-9.34) at discharge. CONCLUSIONS Study site patients had higher rates of National Institutes of Health Stroke Scale reporting and worse short-term outcomes compared with literature reports. Rigorous data collection is needed before treatment guidelines for pediatric mechanical thrombectomy can be developed.
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Affiliation(s)
- Megan Barry
- Section of Pediatric Neurology, Department of Pediatrics, University of Colorado, Aurora (M.B.)
| | - Dwight Barry
- Clinical Analytics (D.B.), Seattle Children's Hospital
| | - Akash P Kansagra
- Departments of Radiology, Neurological Surgery, and Neurology, Washington University School of Medicine in St Louis (A.P.K.)
| | - Danial Hallam
- Departments of Radiology and Neurological Surgery, University of Washington, Seattle (D.H.)
| | - Michael Abraham
- Departments of Neurology and Interventional Radiology, University of Kansas Medical Center (M.A.)
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Fragata I, Morais T, Silva R, Nunes AP, Loureiro P, Diogo Martins J, Pamplona J, Carvalho R, Baptista M, Reis J. Endovascular treatment of pediatric ischemic stroke: A single center experience and review of the literature. Interv Neuroradiol 2021; 27:16-24. [PMID: 32903115 PMCID: PMC7903541 DOI: 10.1177/1591019920958827] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 08/18/2020] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Mechanical thrombectomy is standard treatment for large vessel occlusion (LVO) in adults. There are no randomized controlled trials for the pediatric population. We report our single-center experience with thrombectomy of LVO in a series of pediatric patients, and perform a review of the literature. METHODS Retrospective review of consecutive pediatric thrombectomy cases between 2011 and 2018. Demographic variables, imaging data, technical aspects and clinical outcome were recorded. RESULTS In a period of 7 years, 7 children were treated for LVO at our center. Median age was 13 (2-17), and median Ped-NIHSS was 15 (3-24), and the median ASPECTS was 8 (2-10). Five patients had cardiac disease, and 2 of them were under external cardiac assistance. Median time from onset of symptoms to beginning of treatment was 7h06m (2h58m-21h38m). Five patients had middle cerebral artery occlusions. Thrombectomy was performed using a stentriever in 3 patients, aspiration in 3 patients, and combined technique in 1 patient. Six patients had good recanalization (TICI 2 b/3). There were no immediate periprocedural complications. At 3 months, 4 patients (57%) were independent (mRS score <3). Two patients died, one after haemorrhagic transformation of an extensive MCA infarct, and one due to extensive brainstem ischemia in the setting of varicella vasculitis. DISCUSSION Selected pediatric patients with LVO may be treated with mechanical thrombectomy safely. In patients under external cardiac assistance and under anticoagulation, thrombectomy is the only alternative for treatment of LVO. A multidisciplinary approach in specialized pediatric stroke centers with trained neurointerventionalists are essential for good results.
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Affiliation(s)
- Isabel Fragata
- Neuroradiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - Teresa Morais
- Neuroradiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - Rita Silva
- Pediatric Neurology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - Ana Paiva Nunes
- Stroke Unit, Centro Hospitalar Universitário Lisboa Central,
Lisboa, Portugal
| | - Petra Loureiro
- Pediatric Cardiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - José Diogo Martins
- Pediatric Cardiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - Jaime Pamplona
- Neuroradiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - Rui Carvalho
- Neuroradiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - Mariana Baptista
- Neuroradiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - João Reis
- Neuroradiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
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