1
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Robertson D, Peirce HF, Nicpon MD, Otterson EM, O’Connor L, Rissmiller JG, Binder ZW. Face-off Droop: A Case Report of Pediatric Stroke. Clin Pract Cases Emerg Med 2024; 8:120-124. [PMID: 38869333 PMCID: PMC11166058 DOI: 10.5811/cpcem.6586] [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: 11/27/2023] [Revised: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 06/14/2024] Open
Abstract
Introduction Cerebrovascular accidents rarely occur in children; the incidence of ischemic stroke in patients <16 years of age is between 0.6-7.9/100,000. However, they are the fourth most common cause of acute neurological deficits in the pediatric population, and possible cases should be evaluated with a high index of suspicion to ensure timely intervention. Case Report We describe a previously healthy 17-year-old male who presented to the pediatric emergency department with a left facial droop and hemiparesis consistent with a stroke. The patient's age and lack of comorbidities made this an extremely uncommon presentation. Our patient's neurologic symptoms were believed to have been caused by a recent traumatic clavicular injury sustained two weeks prior, which subsequently led to vascular insult. Conclusion Cerebrovascular accidents are an important cause of morbidity and mortality in pediatric patients. Cerebrovascular accidents in children are most often secondary to congenital causes; however, care should be taken to assess for acquired causes, such as trauma to major blood vessels. While rarely implicated in traumatic injuries, arterial structures posterior to the medial clavicle can result in severe complications.
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Affiliation(s)
- Duncan Robertson
- University of Massachusetts, Chan Medical School, Department of Emergency Medicine, Worcester, Massachusetts
| | - Hayden F. Peirce
- University of Massachusetts, Chan Medical School, Department of Pediatrics, Worcester, Massachusetts
| | - Marek D. Nicpon
- University of Massachusetts, Chan Medical School, Department of Radiology, Worcester, Massachusetts
| | - Eric M. Otterson
- University of Massachusetts, Chan Medical School, Department of Emergency Medicine, Worcester, Massachusetts
| | - Laurel O’Connor
- University of Massachusetts, Chan Medical School, Department of Emergency Medicine, Worcester, Massachusetts
| | - Julia G. Rissmiller
- University of Massachusetts, Chan Medical School, Department of Radiology, Worcester, Massachusetts
| | - Zachary W. Binder
- University of Massachusetts, Chan Medical School, Department of Pediatrics, Worcester, Massachusetts
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2
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Oesch G, Münger R, Steinlin M. Be aware of childhood stroke: Proceedings from EPNS Webinar. Eur J Paediatr Neurol 2024; 49:82-94. [PMID: 38447504 DOI: 10.1016/j.ejpn.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/11/2023] [Accepted: 02/05/2024] [Indexed: 03/08/2024]
Abstract
Childhood arterial ischaemic stroke (AIS) is a significant health concern with increasing incidence. This review aims to provide an overview of the current understanding of childhood AIS. The incidence of childhood AIS is on the rise especially in developing countries, likely due to improved awareness and diagnostic capabilities. Aetiology of childhood AIS is multifactorial, with both modifiable risk factors and genetic predisposition playing important roles. Identifying and addressing these risk factors, such as infection, sickle cell disease, and congenital heart defects, is essential in prevention and management. Identifying underlying conditions through genetic testing is important for appropriate management and long-term prognosis. Clinically, distinguishing stroke from stroke mimics can be challenging. Awareness of important stroke mimics, including migraines, seizures, and metabolic disorders, is crucial to avoid misdiagnosis and ensure appropriate treatment. The diagnostic approach to childhood AIS involves a comprehensive "chain of care," including initial assessment, neuroimaging, and laboratory investigations. National guidelines play a pivotal role in standardizing and streamlining the diagnostic process, ensuring prompt and accurate management. Early intervention is critical in the management of childhood AIS. Due to the critical time window, the question if mechanical thrombectomy is feasible and beneficial should be addressed as fast as possible. Early initiation of antiplatelet or anticoagulation therapy and, in select cases, thrombolysis can help restore blood flow and minimize long-term neurological damage. Additionally, rehabilitation should start as soon as possible to optimize recovery and improve functional outcomes. In conclusion, childhood AIS is a growing concern. Understanding the increasing incidence, age distribution, risk factors, clinical presentation, diagnostic approach, and management strategies is crucial for optimized management of these patients.
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Affiliation(s)
- Gabriela Oesch
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Robin Münger
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Switzerland
| | - Maja Steinlin
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland.
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3
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Bandlamuri S, Custozzo A, Silva J, Bandlamuri SK, Qian J, Paul AR. Systematic Review and Case of Thrombectomy for Pediatric Stroke Due to Myxoma Embolism. World Neurosurg 2024; 183:e761-e771. [PMID: 38211812 DOI: 10.1016/j.wneu.2024.01.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/04/2024] [Indexed: 01/13/2024]
Abstract
BACKGROUND Stroke presentation secondary to a cardiac myxoma thromboembolism is rare in the pediatric population. Because of such rarity, the reported cases in the literature are primarily case reports. Additionally, general pediatric stroke management lacks evidence-based guidelines because of its low incidence and lack of clinical trials. In pediatric strokes identified from a cardiac myxoma, the incidence favors boys with the classical presentation of unilateral weakness and aphasia. We present a pediatric patient who presented with strokelike symptoms secondary to an intracranial embolus from a previously undiagnosed cardiac myxoma. METHODS We performed a systematic review by searching PubMed, Google Scholar, Web of Science, and Embase databases for cases of pediatric myxoma causing stroke (n = 2431) and identified 19 reported uses of surgical management in treating pediatric patients who present with stroke symptoms secondary to a cardiac myxoma thromboembolism. RESULTS The most common imaging modality was magnetic resonance imaging in 42% of cases, computed tomography in 36.8%, followed by computed tomography angiography in 31.6% of cases. Of these 19 children treated with procedures, 36.8% of pediatric patients aged between 4 and 14 years underwent neurosurgery (n = 7). CONCLUSIONS We describe an urgent mechanical thrombectomy and share preoperative and postoperative images and pathology slides confirming a stroke from myxoma origin. We provide added insight in the safe use of mechanical thrombectomy as treatment for pediatric strokes secondary to a thromboembolism.
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Affiliation(s)
- Sruti Bandlamuri
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - Amanda Custozzo
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - Jonathan Silva
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | | | - Jiang Qian
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, New York, USA
| | - Alexandra R Paul
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA.
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4
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Benedetti GM, Guerriero RM, Press CA. Review of Noninvasive Neuromonitoring Modalities in Children II: EEG, qEEG. Neurocrit Care 2023; 39:618-638. [PMID: 36949358 PMCID: PMC10033183 DOI: 10.1007/s12028-023-01686-5] [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: 07/28/2022] [Accepted: 01/30/2023] [Indexed: 03/24/2023]
Abstract
Critically ill children with acute neurologic dysfunction are at risk for a variety of complications that can be detected by noninvasive bedside neuromonitoring. Continuous electroencephalography (cEEG) is the most widely available and utilized form of neuromonitoring in the pediatric intensive care unit. In this article, we review the role of cEEG and the emerging role of quantitative EEG (qEEG) in this patient population. cEEG has long been established as the gold standard for detecting seizures in critically ill children and assessing treatment response, and its role in background assessment and neuroprognostication after brain injury is also discussed. We explore the emerging utility of both cEEG and qEEG as biomarkers of degree of cerebral dysfunction after specific injuries and their ability to detect both neurologic deterioration and improvement.
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Affiliation(s)
- Giulia M Benedetti
- Division of Pediatric Neurology, Department of Neurology, Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, WA, USA.
- Division of Pediatric Neurology, Department of Pediatrics, C.S. Mott Children's Hospital and the University of Michigan, 1540 E Hospital Drive, Ann Arbor, MI, 48109-4279, USA.
| | - Rejéan M Guerriero
- Division of Pediatric and Developmental Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Craig A Press
- Departments of Neurology and Pediatric, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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5
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Candelaresi P, Di Monaco C, Pisano E. Stroke chameleons: Diagnostic challenges. Eur J Radiol Open 2023; 11:100533. [PMID: 38028188 PMCID: PMC10652115 DOI: 10.1016/j.ejro.2023.100533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- P Candelaresi
- Neurology and Stroke Unit, AORN Antonio Cardarelli, Naples, Italy
| | - C Di Monaco
- Neurology and Stroke Unit, AORN Antonio Cardarelli, Naples, Italy
- Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University, Naples, Italy
| | - E Pisano
- Neurology and Stroke Unit, AORN Antonio Cardarelli, Naples, Italy
- Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University, Naples, Italy
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6
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Panova M, Pacheva I, Gaberova K, Iordanova R, Sotkova I, Galabova F, Tartova D, Dimitrova-Popova D, Ivanov I. Cases of acute hemiparesis in childhood. Folia Med (Plovdiv) 2023; 65:420-426. [PMID: 38351818 DOI: 10.3897/folmed.65.e81368] [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: 01/28/2022] [Accepted: 09/15/2022] [Indexed: 02/16/2024] Open
Abstract
INTRODUCTION Acute hemiparesis is an emergency of various etiologies and possible fatal outcome.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Ivan Ivanov
- Medical University of Plovdiv, Plovdiv, Bulgaria
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7
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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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8
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Wade CI, Kelly E, Kelly C, Braun J. A 22-year-old woman presenting with syncope and seizure. J Am Coll Emerg Physicians Open 2022; 3:e12855. [PMID: 36438647 PMCID: PMC9684682 DOI: 10.1002/emp2.12855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/30/2022] [Accepted: 10/26/2022] [Indexed: 09/08/2024] Open
Affiliation(s)
| | - Ethan Kelly
- Department of Emergency MedicineMadigan Army Medical CenterTacomaWashingtonUSA
| | - Connor Kelly
- Department of Emergency MedicineMadigan Army Medical CenterTacomaWashingtonUSA
| | - Jacob Braun
- Department of Emergency MedicineMadigan Army Medical CenterTacomaWashingtonUSA
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9
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Acute Hospital Management of Pediatric Stroke. Semin Pediatr Neurol 2022; 43:100990. [PMID: 36344020 DOI: 10.1016/j.spen.2022.100990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 08/13/2022] [Accepted: 08/14/2022] [Indexed: 11/24/2022]
Abstract
The field of pediatric stroke has historically been hampered by limited evidence and small patient cohorts. However the landscape of childhood stroke is rapidly changing due in part to increasing awareness of the importance of pediatric stroke and the emergence of dedicated pediatric stroke centers, care pathways, and alert systems. Acute pediatric stroke management hinges on timely diagnosis confirmed by neuroimaging, appropriate consideration of recanalization therapies, implementation of neuroprotective measures, and attention to secondary prevention. Because pediatric stroke is highly heterogenous in etiology, management strategies must be individualized. Determining a child's underlying stroke etiology is essential to appropriately tailoring hyperacute stroke management and determining best approach to secondary prevention. Herein, we review the methods of recognition, diagnosis, management, current knowledge gaps and promising research for pediatric stroke.
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10
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Sporns PB, Fullerton HJ, Lee S, Kim H, Lo WD, Mackay MT, Wildgruber M. Childhood stroke. Nat Rev Dis Primers 2022; 8:12. [PMID: 35210461 DOI: 10.1038/s41572-022-00337-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 01/09/2023]
Abstract
Stroke is an important cause of neurological morbidity in children; most survivors have permanent neurological deficits that affect the remainder of their life. Stroke in childhood, the focus of this Primer, is distinguished from perinatal stroke, defined as stroke before 29 days of age, because of its unique pathogenesis reflecting the maternal-fetal unit. Although approximately 15% of strokes in adults are haemorrhagic, half of incident strokes in children are haemorrhagic and half are ischaemic. The causes of childhood stroke are distinct from those in adults. Urgent brain imaging is essential to confirm the stroke diagnosis and guide decisions about hyperacute therapies. Secondary stroke prevention strongly depends on the underlying aetiology. While the past decade has seen substantial advances in paediatric stroke research, the quality of evidence for interventions, such as the rapid reperfusion therapies that have revolutionized arterial ischaemic stroke care in adults, remains low. Substantial time delays in diagnosis and treatment continue to challenge best possible care. Effective primary stroke prevention strategies in children with sickle cell disease represent a major success, yet barriers to implementation persist. The multidisciplinary members of the International Pediatric Stroke Organization are coordinating global efforts to tackle these challenges and improve the outcomes in children with cerebrovascular disease.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heather J Fullerton
- Departments of Neurology and Pediatrics, Benioff Children's Hospital, University of California at San Francisco, San Francisco, CA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Helen Kim
- Departments of Anesthesia and Perioperative Care, and Epidemiology and Biostatistics, Center for Cerebrovascular Research, University of California at San Francisco, San Francisco, CA, USA
| | - Warren D Lo
- Departments of Pediatrics and Neurology, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Mark T Mackay
- Department of Neurology, Royal Children's Hospital, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Moritz Wildgruber
- Department of Radiology, University Hospital Munich, LMU Munich, Munich, Germany.
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11
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Hosseini SA, Gharib MH, Mirheidari SB, Ghanbarzade B, Hosseini PS. Acute Ischemic Stroke in a 10-Month-Old Baby Recovered With Aspirin. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1722928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractAcute ischemic stroke is rare in children and often brings enduring and permanent morbidity in pediatric population. While there are numerous recommendations for initial treatment, evidence on effectiveness of different therapies among children is limited. Here, we describe a 10-month-old male child patient who presented with fever, restlessness, seizure and postictal left limb weakness. Examination revealed left hemiplegia and hemiparesthesia. Computed tomography (CT) head showed loss of gray–white matter distinction with diffuse hypodensity in the right temporoparietal lobes and right caudate nucleus. Magnetic resonance imaging (MRI) brain demonstrated diffusion restriction in favor of acute ischemic stroke in the right middle cerebral artery (MCA) territory. Brain MR angiography (MRA) demonstrated complete occlusion of proximal aspect of M1 segment of right MCA. Genetic testing determined a homozygous 4G/4G polymorphism of the PAI-1 gene. Antiplatelet therapy was started after diagnosis and continued for 8 days with antibiotic therapy. Stroke in children and infants is an infrequent condition associated with substantial morbidity and mortality that needs clinicians' care. This case highlights the significance of awareness about stroke in children and emphasizes on further research to compile evidence-based guidelines for acute stroke therapy in children.
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Affiliation(s)
- Seyed A. Hosseini
- Department of Pediatrics, Golestan University of Medical Sciences, Taleghani Hospital of Gorgan, Golestan, Iran
| | - Mohammad H. Gharib
- Department of Radiology, Golestan University of Medical Sciences, Taleghani Hospital of Gorgan, Golestan, Iran
| | - Seyed B. Mirheidari
- Department of Medicine, Golestan University of Medical Sciences, Taleghani Hospital of Gorgan, Golestan, Iran
| | - Bahar Ghanbarzade
- Golestan University of Medical Sciences, Taleghani Hospital of Gorgan, Golestan, Iran
| | - Parnian S. Hosseini
- Department of Medicine, Golestan University of Medical Sciences, Taleghani Hospital of Gorgan, Golestan, Iran
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12
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Mader EC, Losada V, Baity JC, McKinnies EM, Branch LA. Stroke-Onset Seizures During Midbrain Infarction in a Patient With Top of the Basilar Syndrome. J Investig Med High Impact Case Rep 2021; 8:2324709620940497. [PMID: 32646241 PMCID: PMC7357055 DOI: 10.1177/2324709620940497] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Risk factors for early-onset seizures in acute ischemic stroke include anterior circulation stroke, infarction of the cerebral cortex, large infarct size, and ischemic-to-hemorrhagic transformation. We define stroke-onset seizures as seizures occurring within 2 hours of stroke onset. A 64-year-old woman presented with top of the basilar artery syndrome-thalamic infarction occurred first and midbrain infarction 12 days later. She manifested stroke-onset seizures during midbrain infarction, which was heralded by stupor. Within 2 hours of the onset of stupor, she had a clonic seizure of the lower extremities, electroencephalography (EEG) revealed nonconvulsive status epilepticus, and an episode of convulsive movements of all extremities was recorded on video and on EEG. Continuous EEG recording showed epileptiform discharges that would appear, disappear, and reappear over a 3-week period. It took 3 weeks and 4 antiepileptic drugs to fully suppress cortical hyperexcitability, perhaps because injury to some midbrain structures resulted in global lowering of the seizure threshold. The most important risk factor for stroke-onset seizures appears to be posterior circulation stroke, particularly brainstem infarction. The difference in risk profile between stroke-onset seizures and other forms of early-onset seizures suggest that their pathophysiology is not exactly the same. Focusing some of the research spotlight on stroke-onset seizures can help us better understand their unique clinical, electrographic, radiologic, and pathophysiologic features.
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Affiliation(s)
- Edward C Mader
- Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Vaniolky Losada
- Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Jessica C Baity
- Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Ebony M McKinnies
- Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Lionel A Branch
- Louisiana State University Health Sciences Center, New Orleans, LA, USA
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13
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Griffith JL, Tomko ST, Guerriero RM. Continuous Electroencephalography Monitoring in Critically Ill Infants and Children. Pediatr Neurol 2020; 108:40-46. [PMID: 32446643 DOI: 10.1016/j.pediatrneurol.2020.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 12/15/2022]
Abstract
Continuous video electroencephalography (CEEG) monitoring of critically ill infants and children has expanded rapidly in recent years. Indications for CEEG include evaluation of patients with altered mental status, characterization of paroxysmal events, and detection of electrographic seizures, including monitoring of patients with limited neurological examination or conditions that put them at high risk for electrographic seizures (e.g., cardiac arrest or extracorporeal membrane oxygenation cannulation). Depending on the inclusion criteria and clinical characteristics of the population studied, the percentage of pediatric patients with electrographic seizures varies from 7% to 46% and with electrographic status epilepticus from 1% to 23%. There is also evidence that epileptiform and background CEEG patterns may provide important information about prognosis in certain clinical populations. Quantitative EEG techniques are emerging as a tool to enhance the value of CEEG to provide real-time bedside data for management and prognosis. Continued research is needed to understand the clinical value of seizure detection and identification of other CEEG patterns on the outcomes of critically ill infants and children.
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Affiliation(s)
- Jennifer L Griffith
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri.
| | - Stuart T Tomko
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Réjean M Guerriero
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
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14
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Current Status of Continuous Electroencephalographic Monitoring in Critically Ill Children. Pediatr Neurol 2019; 101:11-17. [PMID: 31493974 DOI: 10.1016/j.pediatrneurol.2019.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 06/13/2019] [Accepted: 07/26/2019] [Indexed: 11/21/2022]
Abstract
The utilization of continuous electroencephalographic monitoring in critical care units has increased significantly, and several consensus statements and guidelines have been published. The use of critical care electroencephalographic monitoring has become a standard of care in many centers in the United States and other countries. The most common indication is to detect electrographic seizures and status epilepticus. Other indications include monitoring treatment efficacy in patients with electrographic seizures and status epilepticus, evaluating the degree of disturbance of function in patients with encephalopathy, monitoring brain function in patients treated with sedation and neuromuscular blocking agents, and event characterization. The urgent initiation of critical care electroencephalographic monitoring is recommended in certain clinical populations, but varies among institutions. The consensus among neurologists is to start treatment after identifying electrographic seizures or electrographic status epilepticus with or without clinical signs. However, the optimal treatment of nonconvulsive and electrographic-only seizures remains controversial. Critical care electroencephalographic monitoring has significant impact on clinical management, but there is lack of clear evidence that treatment guided by critical care electroencephalographic monitoring leads to improvement of clinical and neurodevelopmental outcome. There are substantial discrepancies among institutions on personnel and technical support used for critical care electroencephalographic monitoring. The optimal critical care electroencephalographic monitoring team should include electroencephalographers with experience in critical care electroencephalographic monitoring interpretation and appropriately trained technologists certified in electroencephalography by the American Board of Registration of Electroencephalographic and Evoked Potential Technologists specializing in critical care electroencephalographic monitoring or long-term monitoring.
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15
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Souto Silva R, Rodrigues R, Reis Monteiro D, Tavares S, Pereira JP, Xavier J, Melo C, Ruano L. Acute Ischemic Stroke in a Child Successfully Treated with Thrombolytic Therapy and Mechanical Thrombectomy. Case Rep Neurol 2019; 11:47-52. [PMID: 31543785 PMCID: PMC6739694 DOI: 10.1159/000496535] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 01/02/2019] [Indexed: 11/19/2022] Open
Abstract
Acute ischemic stroke in the pediatric population is rare but carries lasting and often lifelong morbidity. Thrombolysis and mechanical thrombectomy are mainstays of care in adults, yet there is very little evidence for these treatments in children. We present the case of a 4-year-old boy with complex congenital heart disease, admitted 30 min after sudden onset of an aphasia and right hemiplegia, scoring 14 on the Pediatric National Institutes of Health Stroke Scale (PedNIHSS). Non-contrast brain computed tomography (CT) showed no evidence of acute ischemia. CT angiogram demonstrated a thrombus in the M1 segment of the left middle cerebral artery. Intravenous recombinant tissue plasminogen activator (rTPA) was infused 3.5 h after onset of symptoms. An improvement was observed in the hour after rTPA, with a PedNIHSS score of 7. Digital subtraction angiography was performed approximately 9 h from the onset of symptoms, showing a complete left M1 occlusion. The patient underwent successful mechanical thrombectomy and was discharged with a PedNIHSS score of 2. This case emphasizes the importance of early recognition to direct children towards rapid diagnosis and hyperacute treatment.
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Affiliation(s)
- Renata Souto Silva
- Neurology Department, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal
| | - Rita Rodrigues
- Neurology Department, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal
| | - Diana Reis Monteiro
- Pediatrics Department, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal
| | - Susana Tavares
- Pediatrics Department, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal
| | | | - João Xavier
- Neuroradiology Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Cláudia Melo
- Neuropediatric Unit, Pediatrics Department, Centro Hospitalar São João, Porto, Portugal
| | - Luís Ruano
- Neurology Department, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal.,Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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16
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Polymeris AA, Curtze S, Erdur H, Hametner C, Heldner MR, Groot AE, Zini A, Béjot Y, Dietrich A, Martinez-Majander N, von Rennenberg R, Gumbinger C, Schaedelin S, De Marchis GM, Thilemann S, Traenka C, Lyrer PA, Bonati LH, Wegener S, Ringleb PA, Tatlisumak T, Nolte CH, Scheitz JF, Arnold M, Strbian D, Nederkoorn PJ, Gensicke H, Engelter ST. Intravenous thrombolysis for suspected ischemic stroke with seizure at onset. Ann Neurol 2019; 86:770-779. [PMID: 31435960 DOI: 10.1002/ana.25582] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 08/06/2019] [Accepted: 08/18/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Seizure at onset (SaO) has been considered a relative contraindication for intravenous thrombolysis (IVT) in patients with acute ischemic stroke, although this appraisal is not evidence based. Here, we investigated the prognostic significance of SaO in patients treated with IVT for suspected ischemic stroke. METHODS In this multicenter, IVT-registry-based study we assessed the association between SaO and symptomatic intracranial hemorrhage (sICH, European Cooperative Acute Stroke Study II definition), 3-month mortality, and 3-month functional outcome on the modified Rankin Scale (mRS) using unadjusted and adjusted logistic regression, coarsened exact matching, and inverse probability weighted analyses. RESULTS Among 10,074 IVT-treated patients, 146 (1.5%) had SaO. SaO patients had significantly higher National Institutes of Health Stroke Scale score and glucose on admission, and more often female sex, prior stroke, and prior functional dependence than non-SaO patients. In unadjusted analysis, they had generally less favorable outcomes. After controlling for confounders in adjusted, matched, and weighted analyses, all associations between SaO and any of the outcomes disappeared, including sICH (odds ratio [OR]unadjusted = 1.53 [95% confidence interval (CI) = 0.74-3.14], ORadjusted = 0.52 [95% CI = 0.13-2.16], ORmatched = 0.68 [95% CI = 0.15-3.03], ORweighted = 0.95 [95% CI = 0.39-2.32]), mortality (ORunadjusted = 1.49 [95% CI = 1.00-2.24], ORadjusted = 0.98 [95% CI = 0.5-1.92], ORmatched = 1.13 [95% CI = 0.55-2.33], ORweighted = 1.17 [95% CI = 0.73-1.88]), and functional outcome (mRS ≥ 3/ordinal mRS: ORunadjusted = 1.33 [95% CI = 0.96-1.84]/1.35 [95% CI = 1.01-1.81], ORadjusted = 0.78 [95% CI = 0.45-1.32]/0.78 [95% CI = 0.52-1.16], ORmatched = 0.75 [95% CI = 0.43-1.32]/0.45 [95% CI = 0.10-2.06], ORweighted = 0.87 [95% CI = 0.57-1.34]/1.00 [95% CI = 0.66-1.52]). These results were consistent regardless of whether patients had an eventual diagnosis of ischemic stroke (89/146) or stroke mimic (57/146 SaO patients). INTERPRETATION SaO was not an independent predictor of poor prognosis. Withholding IVT from patients with assumed ischemic stroke presenting with SaO seems unjustified. ANN NEUROL 2019;86:770-779.
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Affiliation(s)
- Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sami Curtze
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hebun Erdur
- Department of Neurology, Charité-Universitaetsmedizin Berlin, Berlin, Germany
| | - Christian Hametner
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Adrien E Groot
- Department of Neurology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Andrea Zini
- IRCCS Istituto di Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Yannick Béjot
- University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France
| | - Annina Dietrich
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | | | | | - Christoph Gumbinger
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Sabine Schaedelin
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sebastian Thilemann
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Philippe A Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Peter A Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Turgut Tatlisumak
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Neurology, Sahlgrenska University Hospital and Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Christian H Nolte
- Department of Neurology, Charité-Universitaetsmedizin Berlin, Berlin, Germany
| | - Jan F Scheitz
- Department of Neurology, Charité-Universitaetsmedizin Berlin, Berlin, Germany
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Daniel Strbian
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Henrik Gensicke
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
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Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke 2019; 50:e51-e96. [DOI: 10.1161/str.0000000000000183] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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18
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Bhogal P, Hellstern V, AlMatter M, Ganslandt O, Bäzner H, Aguilar Pérez M, Henkes H. Mechanical thrombectomy in children and adolescents: report of five cases and literature review. Stroke Vasc Neurol 2018; 3:245-252. [PMID: 30637131 PMCID: PMC6312071 DOI: 10.1136/svn-2018-000181] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/01/2018] [Accepted: 10/03/2018] [Indexed: 12/20/2022] Open
Abstract
Background Paediatric arterial ischaemic stroke is an important cause of morbidity and mortality among children. Currently, there are no recommendations regarding mechanical thrombectomy in children despite overwhelming evidence of improved outcomes in adults. Therefore, the need for individual case reports and case series is important to highlight potential advantages and disadvantages in this approach. Case descriptions We retrospectively searched our prospectively maintained database of patients undergoing mechanical thrombectomy for ischaemic stroke. We describe five children, aged between 7 and 17, who underwent mechanical thrombectomy for acute ischaemic stroke. We provide an account of their clinical presentations, operative treatment and postoperative outcome. Discussion Mechanical thrombectomy in children, especially older children, can be performed safely and with existing devices. Although a randomised controlled trial would provide compelling evidence of the potential advantages to this technique, the lack of this should not prevent the use of this procedure by trained neurointerventionists.
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Affiliation(s)
- Pervinder Bhogal
- Department of Interventional Neuroradiology, Royal London Hospital, London, UK
| | - Victoria Hellstern
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Muhammad AlMatter
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Oliver Ganslandt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hansjörg Bäzner
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Marta Aguilar Pérez
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Duisburg, Germany
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19
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Abstract
Pediatric stroke is relatively rare, with approximately 1000 childhood strokes in the United States per year. However, the occurrence of stroke in children leads to significant morbidity and mortality, warranting the development proven screening tools, protocols, and treatment options. Because significant delays in seeking medical attention can occur, time to recognition of pediatric stroke in the emergency department is uniquely challenging and critical. Once recognized, a trained multidisciplinary team with a multifaceted approach is needed to provide the best possible outcome for the patient. Key elements of the pediatric stroke protocol should include recognition tools, stroke alert mechanism, stroke order sets, timely imaging, laboratory evaluation, and treatment options. Substantial advancements have been made in the field of pediatric stroke protocols mainly due to formation of international consortiums and clinical trial. Despite significant progress, treatment options remain controversial.
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20
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Lee J, Lee A, Kim H, Chang WH, Kim YH. Differences in motor network dynamics during recovery between supra- and infra-tentorial ischemic strokes. Hum Brain Mapp 2018; 39:4976-4986. [PMID: 30120859 DOI: 10.1002/hbm.24338] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/15/2018] [Accepted: 07/18/2018] [Indexed: 01/15/2023] Open
Abstract
Most previous stroke studies have been performed in heterogeneous patient populations. Moreover, the brain network might demonstrate different recovery dynamics according to lesion location. In this study, we investigated variation in motor network alterations according to lesion location. Forty patients with subcortical ischemic stroke were enrolled. Patients were divided into two groups: 21 patients with supratentorial stroke (STS) and 19 patients with infratentorial stroke (ITS). All patients underwent resting-state functional magnetic resonance imaging and behavioral assessment at 2 weeks and 3 months poststroke. Twenty-four healthy subjects participated as a control group. To compare altered connectivity between groups, measures used in previous studies to evaluate interhemispheric balance and global network reorganization were investigated and the relationship between network measures and motor functions were examined. Cortico-cerebellar connectivity was also extracted to investigate its relationship with interhemispheric connectivity. In the STS group, measures related to interhemispheric balance were disrupted compared to the control group 2 weeks poststroke, while this was not found in the ITS group. During recovery, measures related to global network reorganization in the STS group and measures related to interhemispheric balance in the ITS group demonstrated significant changes, respectively. Moreover, motor functions were correlated with altered network measures in both groups. There was an interactive relationship between cortico-cerebellar and interhemispheric cortical connectivity only in the ITS group. Different changes in the motor network were observed depending on the location of stroke lesions. These results might originate from differences in the interactions between cortico-cerebellar and interhemispheric connectivity.
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Affiliation(s)
- Jungsoo Lee
- Department of Physical and Rehabilitation Medicine, Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Department of Health Sciences and Technology, Department of Medical Device Management and Research, Department of Digital Health, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Ahee Lee
- Department of Health Sciences and Technology, Department of Medical Device Management and Research, Department of Digital Health, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Heegoo Kim
- Department of Health Sciences and Technology, Department of Medical Device Management and Research, Department of Digital Health, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Won Hyuk Chang
- Department of Physical and Rehabilitation Medicine, Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yun-Hee Kim
- Department of Physical and Rehabilitation Medicine, Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Department of Health Sciences and Technology, Department of Medical Device Management and Research, Department of Digital Health, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
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21
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Abstract
OBJECTIVES The aim was to describe clinical presentation, management, and outcomes of stroke in a tertiary emergency department (ED) of a developing country. METHODOLOGY Retrospective case series of patients aged 1 month to 18 years presenting to an ED with radiological confirmed acute stroke during a 7-year period were studied. RESULTS Ninety-five patients were identified. Twenty-five patients were excluded because of incomplete records (8) or not presenting via ED (17). Thirty-four (48.5%) were diagnosed with hemorrhagic stroke (HS), 30 (42.8%) with arterial ischemic stroke (AIS), and 6 (8.5%) with sinus venous thrombosis (SVT). Mean age was 5.3 years, and 55.3% were male. The median time from onset of symptoms to ED presentation was 24 hours (mean, 55 hours; interquartile range [IQR], 14-72) for AIS, 24 hours (mean, 46.9 hours; IQR, 9-48) for HS, and 120 hours (mean,112 hours; IQR, 72-168) for SVT. Congenital cardiac disease was the most common risk factor (9%). For AIS, the most common symptoms were focal numbness 56.6% (95% confidence interval [CI], 37.8%-75.4%), focal weakness 56.6% (95% CI, 37.8%-75.4%), and seizures 50% (95% CI, 31%-68.8%). For HS, the most common symptoms were headache 64.7% (95% CI, 47.7%-81.6%), vomiting 79.4 (95% CI, 65-93.7), and altered mental status 64.7% (95% CI, 47.7-81.6). Computed tomography scan was done in 100% of the patients and magnetic resonance imaging in 54%. Twenty-five (36%) patients were admitted to intensive care unit and required intubation. Long-term deficit was identified in 24 (36%) patients based on medium-term follow-up. CONCLUSIONS The spectrum of stroke in a developing country was similar to published series from developed countries in terms of final diagnosis, risk factors, and delay to ED presentation, neuroimaging, and long-term neurodeficits. No tropical diseases were identified as risk factors.
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22
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Dingman AL, Stence NV, O'Neill BR, Sillau SH, Chapman KE. Seizure Severity Is Correlated With Severity of Hypoxic-Ischemic Injury in Abusive Head Trauma. Pediatr Neurol 2018; 82:29-35. [PMID: 29625848 DOI: 10.1016/j.pediatrneurol.2017.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The objective of this study was to characterize hypoxic-ischemic injury and seizures in abusive head trauma. METHODS We studied 58 children with moderate or severe traumatic brain injury due to abusive head trauma. Continuous electroencephalograms and magnetic resonance images were scored. RESULTS Electrographic seizures (51.2%) and hypoxic-ischemic injury (77.4%) were common in our cohort. Younger age was associated with electrographic seizures (no seizures: median age 13.5 months, interquartile range five to 25 months, versus seizures: 4.5 months, interquartile range 3 to 9.5 months; P = 0.001). Severity of hypoxic-ischemic injury was also associated with seizures (no seizures: median injury score 1.0, interquartile range 0 to 3, versus seizures: 4.5, interquartile range 3 to 8; P = 0.01), but traumatic injury severity was not associated with seizures (no seizures: mean injury score 3.78 ± 1.68 versus seizures: mean injury score 3.83 ± 0.95, P = 0.89). There was a correlation between hypoxic-ischemic injury severity and seizure burden when controlling for patient age (rs=0.61, P < 0.001). The ratio of restricted diffusion volume to total brain volume (restricted diffusion ratio) was smaller on magnetic resonance imaging done early (median restricted diffusion ratio 0.03, interquartile range 0 to 0.23 on magnetic resonance imaging done within two days versus median restricted diffusion ratio 0.13, interquartile range 0.01 to 0.43 on magnetic resonance imaging done after two days, P = 0.03). CONCLUSIONS Electrographic seizures are common in children with moderate to severe traumatic brain injury from abusive head trauma, and therefore children with suspected abusive head trauma should be monitored with continuous electroencephalogram. Severity of hypoxic-ischemic brain injury is correlated with severity of seizures, and evidence of hypoxic-ischemic injury on magnetic resonance imaging may evolve over time. Therefore children with a high seizure burden should be reimaged to evaluate for evolving hypoxic-ischemic injury.
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Affiliation(s)
- Andra L Dingman
- Department of Pediatrics, Division of Child Neurology, University of Colorado Anschuts Medical Campus, Aurora, Colorado.
| | - Nicholas V Stence
- Department of Radiology, Division of Pediatric Radiology, University of Colorado Anschuts Medical Campus, Aurora, Colorado
| | - Brent R O'Neill
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Colorado Anschuts Medical Campus, Aurora, Colorado
| | - Stefan H Sillau
- Department of Neurology, University of Colorado Anschuts Medical Campus, Aurora, Colorado
| | - Kevin E Chapman
- Department of Pediatrics, Division of Child Neurology, University of Colorado Anschuts Medical Campus, Aurora, Colorado
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23
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Abstract
The occurrence of a stroke in children and adolescents constitutes a rare, critical event that is associated with substantial morbidity and mortality. In addition to the individual suffering for the young patient and the medical burden for the affected family, a stroke is also associated with high follow-up costs for the health system because of the necessary long-term rehabilitative treatment. Establishing an early and prompt diagnosis is of great therapeutic importance. Because of the rarity of the illness and the plethora of clinical manifestations, diagnosis is often delayed. The most frequent clinical presentation is an acute focal-neurological deficit, usually in the form of hemiparesis, but headache, seizures or alteration of consciousness may also be seen. Nowadays, the prompt performance of diffusion-weighted, blood-sensitive magnetic resonance imaging (MRI) constitutes the gold standard. The most relevant risk factors for the occurrence of a stroke in this age cohort are vasculopathies, infections, pathological cardiac conditions or coagulopathies. Recurrence of stroke is dependent on the underlying risk factors. In a substantial percentage of patients, residual neurological deficits are seen.Owing to a lack of randomized controlled trials in children and adolescents with stroke, the optimal treatment approach is still under debate. In addition to anti-platelet medication and heparinization, systematic intravenous thrombolysis and endovascular thrombectomy are other potentially effective treatment options. The long-term prognosis in children is dependent on establishing a correct, early diagnosis.
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24
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Cheng JH, Zhang Z, Ye Q, Ye ZS, Xia NG. Characteristics of the ischemic stroke patients whose seizures occur at stroke presentation at a single institution in Eastern China. J Neurol Sci 2018; 387:46-50. [PMID: 29571870 DOI: 10.1016/j.jns.2018.01.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 12/18/2017] [Accepted: 01/23/2018] [Indexed: 02/03/2023]
Abstract
PURPOSE We compared clinical characteristics and outcomes of the early-onset seizure post-stroke patients who had seizures occurring at stroke presentation (SSP) with other patients without SSP at a single institution in Eastern China. METHODS We reviewed 20,947 ischemic stroke patients in our hospital electronic medical records system from January 2007 to December 2016. Among them, there were 91 (0.43%) patients with early-onset seizure post-stroke. Among these 91 patients, there were 35 (0.16%) SSP patients and another 56 (0.27%) were designated as non SSP patients because they also had early-onset seizure post-stroke, but without SSP. We compared the clinical presentations of the SSP patients with those of the non SSP patients including baseline stroke risk factors, and 10-year Kaplan-Meier death risk after their first stroke. RESULTS In the SSP patients, 25.7% of them presented with posterior circulation infarction, whereas only 12.5% of the non SSP patients had this condition (P<0.05). In contrast, 17.1% of the SSP patients were being treated with antiepileptic drugs at discharge whereas 37.5% of the non SSP patients received such treatment (P<0.05). The percentage of SSP patients with temporal lobe lesions was less than in non SSP patients (P<0.05). However, brain stem and thalamus lesions were more frequently seen in SSP patients than non in SSP patients (P<0.05). The risk factors for ischemic stroke including a history of hypertension, diabetes mellitus, hyperlipidemia and atrial fibrillation were the same in these two groups (P>0.05). In the SSP patients group, the 10-year risk of death was 36.9% after the initial seizure incident, and in the non SSP patients group, the 10-year death risk was 40.1%, but this difference between the two groups was not significant (P>0.05). CONCLUSIONS Ischemic stroke patients with SSP had some unique signs that included a higher incidence of posterior circulation infarction than non SSP patients.
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Affiliation(s)
- Jian-Hua Cheng
- The Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China.
| | - Zheng Zhang
- The Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Qiang Ye
- The Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Zu-Sen Ye
- The Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Nian-Ge Xia
- The Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
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25
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Breitweg I, Stülpnagel CV, Pieper T, Lidzba K, Holthausen H, Staudt M, Kluger G. Early seizures predict the development of epilepsy in children and adolescents with stroke. Eur J Paediatr Neurol 2017; 21:465-467. [PMID: 28041798 DOI: 10.1016/j.ejpn.2016.12.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 07/12/2016] [Accepted: 12/12/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE To identify risk factors for the development of epilepsy after pediatric stroke. METHODS Retrospective analysis of hospital charts of 93 children and adolescents with post-neonatal non-traumatic stroke and a minimum follow-up of two years. Seizures during the first 48 h after onset of stroke symptoms were defined as "early seizures"; when two or more seizures occurred after this period, the patient was classified as "epileptic". RESULTS Early seizures, young age at stroke and MRI evidence of cortical involvement were observed more frequently in the children who developed epilepsy. These factors were, however, significantly interrelated; a stepwise multiple regression analysis in 46/93 patients with complete datasets identified only the occurrence of early seizures as a significant risk factor: 15/19 (79%) children with early seizures developed epilepsy, as opposed to only 7/53 (13%) without early seizures. CONCLUSION Children with stroke who show seizures during the first 48 h after onset of stroke symptoms have a high risk to develop post-stroke epilepsy, whereas in children without early seizures, post-stroke epilepsy is rare.
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Affiliation(s)
- Ina Breitweg
- Clinic for Neuropediatrics and Neurorehabilitation, Epilepsy Center for Children and Adolescents, Schön Klinik, Krankenhausstr. 20, D-83569 Vogtareuth, Germany; Department of Epileptology, Children's Center Munich, Center for Social Pediatrics, Heiglhofstr. 63, D-81377 Munich, Germany.
| | - Celina von Stülpnagel
- Clinic for Neuropediatrics and Neurorehabilitation, Epilepsy Center for Children and Adolescents, Schön Klinik, Krankenhausstr. 20, D-83569 Vogtareuth, Germany; Paracelsus Medical University, Strubergasse 21, A-5020 Salzburg, Austria
| | - Tom Pieper
- Clinic for Neuropediatrics and Neurorehabilitation, Epilepsy Center for Children and Adolescents, Schön Klinik, Krankenhausstr. 20, D-83569 Vogtareuth, Germany
| | - Karen Lidzba
- Dept. Pediatric Neurology and Developmental Medicine, University Children's Hospital, Hoppe-Seyler-Str. 1, D-72076 Tübingen, Germany
| | - Hans Holthausen
- Clinic for Neuropediatrics and Neurorehabilitation, Epilepsy Center for Children and Adolescents, Schön Klinik, Krankenhausstr. 20, D-83569 Vogtareuth, Germany
| | - Martin Staudt
- Clinic for Neuropediatrics and Neurorehabilitation, Epilepsy Center for Children and Adolescents, Schön Klinik, Krankenhausstr. 20, D-83569 Vogtareuth, Germany; Dept. Pediatric Neurology and Developmental Medicine, University Children's Hospital, Hoppe-Seyler-Str. 1, D-72076 Tübingen, Germany
| | - Gerhard Kluger
- Clinic for Neuropediatrics and Neurorehabilitation, Epilepsy Center for Children and Adolescents, Schön Klinik, Krankenhausstr. 20, D-83569 Vogtareuth, Germany; Paracelsus Medical University, Strubergasse 21, A-5020 Salzburg, Austria
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26
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Billinghurst LL, Beslow LA, Abend NS, Uohara M, Jastrzab L, Licht DJ, Ichord RN. Incidence and predictors of epilepsy after pediatric arterial ischemic stroke. Neurology 2017; 88:630-637. [PMID: 28087825 DOI: 10.1212/wnl.0000000000003603] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 11/23/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the cumulative incidence and clinical predictors of remote symptomatic seizures and epilepsy after pediatric arterial ischemic stroke (AIS). METHODS We performed a retrospective analysis of 218 participants with neonatal AIS (NAIS), presumed perinatal AIS (PPAIS), and childhood AIS (CAIS) from a single-center prospective consecutive cohort enrolled from 2006 to 2014. Medical records were reviewed for timing, semiology, and treatment of acute symptomatic seizures, remote symptomatic seizures (RSS), and epilepsy. Cumulative incidence of RSS and epilepsy were assessed using survival analysis. RESULTS Acute symptomatic seizures occurred in 94% of NAIS (n = 70/74) and 17% of CAIS (n = 18/105). Younger children were more likely to present with seizures at stroke ictus, and acute symptomatic seizures were predictive of later RSS and epilepsy in CAIS. Median follow-up for the entire cohort was 34 months, interquartile range 44.9 months (16.3-61.2). Estimated cumulative incidence of RSS at 2 years was 19% in NAIS, 24% in PPAIS, and 7% in CAIS. Estimated cumulative incidence of epilepsy at 2 years was 11% in NAIS, 19% in PPAIS, and 7% in CAIS. The median time to these outcomes was <2 years in all stroke subtypes. Among participants developing epilepsy (n = 34), seizures were often well-controlled at last follow-up with median Engel class of ≤2 (<1 seizure/month). CONCLUSIONS RSS and epilepsy are important neurologic sequelae of pediatric AIS. Children with perinatal stroke and CAIS with acute symptomatic seizures are at increased risk of these outcomes. These cohorts need further study to identify biomarkers and potential therapeutic targets for epileptogenesis.
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Affiliation(s)
- Lori L Billinghurst
- From the Division of Neurology (L.L.B., L.A.B., N.S.A., L.J., D.J.L., R.N.I.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; and Temple University School of Medicine (M.U.), Philadelphia, PA.
| | - Lauren A Beslow
- From the Division of Neurology (L.L.B., L.A.B., N.S.A., L.J., D.J.L., R.N.I.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; and Temple University School of Medicine (M.U.), Philadelphia, PA
| | - Nicholas S Abend
- From the Division of Neurology (L.L.B., L.A.B., N.S.A., L.J., D.J.L., R.N.I.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; and Temple University School of Medicine (M.U.), Philadelphia, PA
| | - Michael Uohara
- From the Division of Neurology (L.L.B., L.A.B., N.S.A., L.J., D.J.L., R.N.I.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; and Temple University School of Medicine (M.U.), Philadelphia, PA
| | - Laura Jastrzab
- From the Division of Neurology (L.L.B., L.A.B., N.S.A., L.J., D.J.L., R.N.I.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; and Temple University School of Medicine (M.U.), Philadelphia, PA
| | - Daniel J Licht
- From the Division of Neurology (L.L.B., L.A.B., N.S.A., L.J., D.J.L., R.N.I.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; and Temple University School of Medicine (M.U.), Philadelphia, PA
| | - Rebecca N Ichord
- From the Division of Neurology (L.L.B., L.A.B., N.S.A., L.J., D.J.L., R.N.I.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; and Temple University School of Medicine (M.U.), Philadelphia, PA
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Shack M, Andrade A, Shah-Basak PP, Shroff M, Moharir M, Yau I, Askalan R, MacGregor D, Rafay MF, deVeber GA. A pediatric institutional acute stroke protocol improves timely access to stroke treatment. Dev Med Child Neurol 2017; 59:31-37. [PMID: 28368092 DOI: 10.1111/dmcn.13214] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2016] [Indexed: 11/30/2022]
Abstract
AIM We aimed to evaluate whether an institutional acute stroke protocol (ASP) could accelerate the diagnosis and secondary treatment of pediatric stroke. METHOD We initiated an ASP in 2005. We compared 209 children (125 males, 84 females; median age 4.8y, interquartile range [IQR] 1.2-9.3y, range 0.09-17.7y) diagnosed with arterial ischemic stroke 'pre-protocol' (1992-2004) to 112 children (60 males, 52 females; median age 5.8y, IQR 1.0-11.4y, range 0.08-17.7y) diagnosed 'post-protocol' (2005-2012) for time-to-diagnosis, mode of diagnostic imaging, and time-to-treatment with antithrombotic medication (aspirin or anticoagulants). RESULTS Overall, the interval from symptom onset to diagnosis was similar post-protocol compared to pre-protocol (20.3 vs 22.7h; p=0.109), although mild strokes (Pediatric National Institute of Health Stroke Scale [PedNIHSS] 0-4), were diagnosed faster post-protocol (12.1 vs 36.3h; p=0.003). Magnetic resonance imaging (MRI) was the initial diagnostic modality more often post-protocol (25% vs 1.4%; p<0.001). Initial MRI was more accurate for diagnosing stroke than initial CT (100% vs 47%; p<0.001) with similar time-to-diagnosis. The proportion of children receiving antithrombotic medication within 24 hours doubled in the post-protocol period (83% vs 36%; p<0.001). INTERPRETATION A pediatric ASP accelerated time-to-treatment, time-to-diagnosis in children with subtle strokes, and increased MRI as initial imaging, reducing the need for computed tomography. Implementing optimized ASPs can facilitate more timely access to diagnosis and management of children with acute stroke.
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Affiliation(s)
- Melissa Shack
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Andrea Andrade
- Neurology Section, Department of Paediatrics, University of Western Ontario, London, ON, Canada
| | | | - Manohar Shroff
- Division of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Ivanna Yau
- Division of Neurology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Rand Askalan
- Division of Neurology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Daune MacGregor
- Division of Neurology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mubeen F Rafay
- Section of Neurology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
| | - Gabrielle A deVeber
- Division of Neurology, The Hospital for Sick Children, Toronto, ON, Canada.,Child Health Evaluative Sciences Program, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
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Fox CK, Mackay MT, Dowling MM, Pergami P, Titomanlio L, Deveber G. Prolonged or recurrent acute seizures after pediatric arterial ischemic stroke are associated with increasing epilepsy risk. Dev Med Child Neurol 2017; 59:38-44. [PMID: 27422813 PMCID: PMC7007772 DOI: 10.1111/dmcn.13198] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2016] [Indexed: 11/29/2022]
Abstract
AIM To determine epilepsy risk factors after pediatric stroke. METHOD A cohort of children with arterial ischemic stroke (birth-18y) was enrolled at 21 centers and followed for 1 year. Acute seizures (≤7d after stroke) and active epilepsy (at least one unprovoked remote seizure plus maintenance anticonvulsant at 1y) were identified. Predictors were determined using logistic regression. RESULTS Among 114 patients (28 neonates and 86 children) enrolled, 26 neonates (93%) and 32 children (37%) had an acute seizure. Acute seizures lasted longer than 5 minutes in 23 patients (40%) and were frequently recurrent: 33 (57%) had 2 to 10 seizures and 11 (19%) had more than 10. Among 109 patients with 1-year follow-up, 11 (10%) had active epilepsy. For each year younger, active epilepsy was 20% more likely (odds ratio [OR] 0.8, 95% confidence interval [CI] 0.6-0.99, p=0.041). Prolonged or recurrent acute seizures also increased epilepsy risk. Each additional 10 minutes of the longest acute seizure increased epilepsy risk fivefold (OR 4.7, 95% CI 1.7-13). Patients with more than 10 acute seizures had a 30-fold increased epilepsy risk (OR 30, 95% CI 2.9-305). INTERPRETATION Pediatric stroke survivors, especially younger children, have a high risk of epilepsy 1 year after stroke. Prolonged or recurrent acute seizures increase epilepsy risk in a dose-dependent manner.
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Affiliation(s)
- Christine K Fox
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Mark T Mackay
- Department of Neurology, Royal Children's Hospital, Melbourne, Vic., Australia
- Murdoch Children's Research Institute, Melbourne, Vic., Australia
| | - Michael M Dowling
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Paola Pergami
- Department of Neurology, Children's National Medical Center, Washington, DC, USA
| | - Luigi Titomanlio
- Pediatric Migraine and Neurovascular Diseases Clinic, Robert Debrè Hospital, Paris, France
| | - Gabrielle Deveber
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Andrade A, Bigi S, Laughlin S, Parthasarathy S, Sinclair A, Dirks P, Pontigon AM, Moharir M, Askalan R, MacGregor D, deVeber G. Association Between Prolonged Seizures and Malignant Middle Cerebral Artery Infarction in Children With Acute Ischemic Stroke. Pediatr Neurol 2016; 64:44-51. [PMID: 27663488 DOI: 10.1016/j.pediatrneurol.2016.08.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 08/17/2016] [Accepted: 08/18/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Malignant middle cerebral artery infarct syndrome is a potentially fatal complication of stroke that is poorly understood in children. We studied the frequency, associated characteristics, and outcomes of this condition in children. METHODS Children, aged two months to 18 years with acute middle cerebral artery infarct diagnosed at our center between January 2005 and December 2012 were studied. Associations with malignant middle cerebral artery infarct syndrome were sought, including age, seizures, neurological deficit severity (Pediatric National Institute of Health Stroke Severity Score), stroke etiology, fever, blood pressure, blood glucose, infarct location, infarct volume (modified pediatric Alberta Stroke Program Early Computed Tomography Score), and arterial occlusion. Death and neurological outcomes were determined. RESULTS Among 66 children with middle cerebral artery stroke, 12 (18%) developed malignant middle cerebral artery infarct syndrome, fatal in three. Prolonged seizures during the first 24 hours (odds ratio, 25.51; 95% confidence interval, 3.10 to 334.81; P = 0.005) and a higher Pediatric National Institute of Health Stroke Severity Score (odds ratio, 1.22; 95% confidence interval, 1.08 to 1.45; P = 0.006) were independently associated with malignant middle cerebral artery infarct syndrome. All children aged greater than two years with a Pediatric National Institute of Health Stroke Severity Score ≥8 and initial seizures ≥5 minutes duration developed malignant middle cerebral artery infarct syndrome (100%). CONCLUSIONS Malignant middle cerebral artery infarct syndrome affects nearly one in five children with acute middle cerebral artery stroke. Children with higher Pediatric National Institute of Health Stroke Severity Scores and prolonged initial seizures are at greatly increased risk for malignant middle cerebral artery infarct syndrome. Children with middle cerebral artery infarcts warrant intensive neuroprotective management and close monitoring to enable early referral for hemicraniectomy surgery.
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Affiliation(s)
- Andrea Andrade
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.
| | - Sandra Bigi
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Suzanne Laughlin
- Division of Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada; Division of Neuroradiology, Department of Medical Imaging, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Sujatha Parthasarathy
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Adriane Sinclair
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Peter Dirks
- Division of Neurosurgery, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Ann Marie Pontigon
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Mahendranath Moharir
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Rand Askalan
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Daune MacGregor
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Gabrielle deVeber
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences Program, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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30
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Cheng HH, Rajagopal S, McDavitt E, Wigmore D, Williams K, Thiagarajan R, Grant PE, Danehy A, Rivkin MJ. Stroke in Acquired and Congenital Heart Disease Patients and Its Relationship to Hospital Mortality and Lasting Neurologic Deficits. Pediatr Crit Care Med 2016; 17:976-983. [PMID: 27509364 DOI: 10.1097/pcc.0000000000000902] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To describe strokes in patients with acquired or congenital heart disease and investigate risk factors for in-hospital mortality and ongoing neurologic deficits. DESIGN Single-center, retrospective review of cardiac, neurologic, and radiologic patient databases. SETTING Tertiary care children's hospital. PATIENTS All patients with acquired or congenital heart disease admitted from January 2010 to October 2014 identified with stroke. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eighty-four stroke events were identified in 83 patients (median age, 5.9 mo; interquartile range, 0.8-33.4). Thirty-two patients (38%) had single ventricle congenital heart disease. Eight patients (9%) presented with symptoms at home, and the remainder was diagnosed while already admitted to the hospital. Forty patients (48%) presented with clinically evident neurologic deficits (e.g., weakness, seizures). Fifty-eight patients (69%) had arterial ischemic strokes, and 13 (15%) had parenchymal hemorrhages. At diagnosis, 54 patients (64%) were on inotropes. Twenty-nine patients (35%) had greater than or equal to 3 cardiac procedures during their hospitalization before stroke diagnosis. In-hospital mortality occurred in 28 patients (33%). Under multivariate analysis, inotropes, number of cardiac procedures, lack of seizure, and parenchymal hemorrhage were independently associated with in-hospital mortality (p < 0.05). Fifty-four percent of survivors with neurologic follow-up had ongoing neurologic deficits attributable to strokes (median follow-up, 15.3 mo; interquartile range, 7.0-29.9). With multivariate analysis, longer hospital stay (p = 0.02) was independently associated with ongoing deficits. CONCLUSIONS A majority of patients with acquired or congenital heart disease who suffer stroke present while hospitalized and without focal neurologic findings. In-hospital mortality is associated with inotropes, cardiac procedures, lack of seizure, and parenchymal hemorrhage. The majority of survivors have lasting neurologic deficits associated with longer hospital stay.
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Affiliation(s)
- Henry H Cheng
- 1Department of Cardiology, Boston Children's Hospital, Boston, MA.2Department of Clinical Research, Boston Children's Hospital, Boston, MA.3Department of Radiology, Boston Children's Hospital, Boston, MA.4Department of Psychiatry, Boston Children's Hospital, Boston, MA.5Department of Neurology, Boston Children's Hospital, Boston, MA
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Lvova OA, Shalkevich LV, Dron AN, Lukaschuk MY, Orlova EA, Gusev VV, Suleymanova EV, Sulimov AV, Kudlatch AI. [Predictors of epilepsy in children after ischemic stroke]. Zh Nevrol Psikhiatr Im S S Korsakova 2016; 116:4-8. [PMID: 27635604 DOI: 10.17116/jnevro2016116814-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To determine clinical/instrumental predictors of symptomatic epilepsy after ischemic stroke in children. MATERIAL AND METHODS One hundred and thirty-six patients, aged 0-15 years, with the diagnosis of ischemic stroke (ICD-10 I63.0-I63.9) were examined. The duration of the study was 18 months - 12 years. Patients were stratified into post-stroke (n=22) and control (n=114) groups, the latter included patients without epilepsy regardless of the presence of convulsive seizures in the acute stage of stroke. Predictors were determined based on EEG and characteristics of convulsive syndrome in the acute stage of stroke. RESULTS AND CONCLUSION The following prognostic criteria were found: generalized type of seizures, focal type of seizures with secondary generalization, epileptiform (peak and/or peak-wave) activity, focal character of epileptiform activity, generalized type of seizures in the combination with slow wave background activity on EEG, generalized type of seizures in the combination with slow wave activity and disorganized activity on EEG.
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Affiliation(s)
- O A Lvova
- The First President of Russia B.N. Yeltsin, Ural Federal University, Yekaterinburg, Russia
| | - L V Shalkevich
- Belarusian Medical Academy of Post-Graduate Education, Minsk, Republic of Belarus
| | - A N Dron
- Children City Clinical Hospital #9, Yekaterinburg, Russia
| | | | - E A Orlova
- Children City Clinical Hospital #9, Yekaterinburg, Russia
| | - V V Gusev
- Central City Hospital #23, Yekaterinburg, Russia
| | - E V Suleymanova
- The First President of Russia B.N. Yeltsin, Ural Federal University, Yekaterinburg, Russia
| | - A V Sulimov
- Children City Clinical Hospital #9, Yekaterinburg, Russia
| | - A I Kudlatch
- Belarusian Medical Academy of Post-Graduate Education, Minsk, Republic of Belarus
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32
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Li R, Xiao HF, Lyu JH, J.J. Wang D, Ma L, Lou X. Differential diagnosis of mitochondrial encephalopathy with lactic acidosis and stroke-like episodes (MELAS) and ischemic stroke using 3D pseudocontinuous arterial spin labeling. J Magn Reson Imaging 2016; 45:199-206. [PMID: 27348222 DOI: 10.1002/jmri.25354] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 06/09/2016] [Indexed: 01/16/2023] Open
Affiliation(s)
- Rui Li
- Department of Radiology; Chinese PLA General Hospital; Beijing China
- School of Medicine; Nankai University; Tianjin China
| | - Hua-feng Xiao
- Department of Radiology; Chinese PLA General Hospital; Beijing China
- Department of Radiology; Chinese PLA 302 Hospital; Beijing China
| | - Jin-hao Lyu
- Department of Radiology; Chinese PLA General Hospital; Beijing China
| | - Danny J.J. Wang
- Department of Neurology; University of California; Los Angeles California USA
| | - Lin Ma
- Department of Radiology; Chinese PLA General Hospital; Beijing China
| | - Xin Lou
- Department of Radiology; Chinese PLA General Hospital; Beijing China
- Department of Neurology; University of California; Los Angeles California USA
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33
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Nasiri J, Ariyana A, Yaghini O, Ghazavi MR, Keikhah M, Salari M. Neurological outcome after arterial ischemic stroke in children. Adv Biomed Res 2016; 5:107. [PMID: 27376046 PMCID: PMC4918203 DOI: 10.4103/2277-9175.183668] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/05/2015] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Stroke is an important cause of disability in children. Pediatric stroke may be due to significant permanent cognitive and motor handicap in children. In this study, we evaluated long-term outcomes of stroke in pediatric patients who have been discharged with definite diagnosis of stroke in Tehran Mofid children's Hospital and Imam Hossein children's Hospital located in Isfahan, Iran, from 2005 to 2012. MATERIALS AND METHODS A total of 53 children with stroke were included in the study. Stroke outcomes as motor disability, seizures, and cognitive dysfunctions were assessed. RESULTS After a median follow-up of 4 years, 15 (29%) patients experienced full recovery. Thirty-eight (71%) patients had some degree of neurological handicap. CONCLUSION Approximately 70% of children with arterial ischemic stroke suffer from long-term neurological disabilities including motor deficits, cognitive impairment, and late seizures. Stroke recurrence is the most important risk factor responsible for severe adverse neurological outcomes in pediatric stroke.
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Affiliation(s)
- Jafar Nasiri
- Department of Pediatric Neurology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran; Child Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alireza Ariyana
- Department of Pediatric Neurology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran; Child Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Omid Yaghini
- Department of Pediatric Neurology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Reza Ghazavi
- Department of Pediatric Neurology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mojtaba Keikhah
- Department of Pediatric Neurology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran; Child Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehri Salari
- Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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34
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Adil MM, Vidal G, Beslow LA. Weekend Effect in Children With Stroke in the Nationwide Inpatient Sample. Stroke 2016; 47:1436-43. [DOI: 10.1161/strokeaha.116.013453] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 03/18/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Malik M. Adil
- From the Department of Neurology, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, New Orleans, LA (M.M.A., G.V.); and Departments of Pediatrics and Neurology, Yale University School of Medicine, New Haven, CT (L.A.B.)
| | - Gabriel Vidal
- From the Department of Neurology, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, New Orleans, LA (M.M.A., G.V.); and Departments of Pediatrics and Neurology, Yale University School of Medicine, New Haven, CT (L.A.B.)
| | - Lauren A. Beslow
- From the Department of Neurology, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, New Orleans, LA (M.M.A., G.V.); and Departments of Pediatrics and Neurology, Yale University School of Medicine, New Haven, CT (L.A.B.)
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35
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Neville K, Lo W. Sensitivity and Specificity of an Adult Stroke Screening Tool in Childhood Ischemic Stroke. Pediatr Neurol 2016; 58:53-6. [PMID: 26973299 DOI: 10.1016/j.pediatrneurol.2016.02.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 12/15/2015] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND There are frequent delays in the diagnosis of acute pediatric ischemic stroke. A screening tool that could increase the suspicion of acute ischemic stroke could aid early recognition and might improve initial care. An earlier study reported that children with acute ischemic stroke have signs that can be recognized with two adult stroke scales. We tested the hypothesis that an adult stroke scale could distinguish children with acute ischemic stroke from children with acute focal neurological deficits not due to stroke. METHODS We retrospectively applied an adult stroke scale to the recorded examinations of 53 children with acute symptomatic acute ischemic stroke and 53 age-matched control subjects who presented with focal neurological deficits. We examined the sensitivity and specificity of the stroke scale and the occurrence of acute seizures as predictors of stroke status. RESULTS The total stroke scale did not differentiate children with acute ischemic stroke from those who had acute deficits from nonstroke causes; however, the presence of arm weakness was significantly associated with stroke cases. Acute seizures were significantly associated with stroke cases. CONCLUSIONS An adult stroke scale is not sensitive or specific to distinguish children with acute ischemic stroke from those with nonstroke focal neurological deficits. The development of a pediatric acute ischemic stroke screening tool should include arm weakness and perhaps acute seizures as core elements. Such a scale must account for the limitations of language in young or intellectually disabled children.
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Affiliation(s)
- Kerri Neville
- Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, Ohio
| | - Warren Lo
- Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, Ohio; Department of Neurology, The Ohio State University and Nationwide Children's Hospital, Columbus, Ohio.
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36
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Mallick AA, Ganesan V, Kirkham FJ, Fallon P, Hedderly T, McShane T, Parker AP, Wassmer E, Wraige E, Amin S, Edwards HB, Cortina-Borja M, O'Callaghan FJ. Outcome and recurrence 1 year after pediatric arterial ischemic stroke in a population-based cohort. Ann Neurol 2016; 79:784-793. [PMID: 26928665 DOI: 10.1002/ana.24626] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 02/24/2016] [Accepted: 02/25/2016] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Arterial ischemic stroke (AIS) is an important cause of acquired brain injury in children. Few prospective population-based studies of childhood AIS have been completed. We aimed to investigate the outcome of childhood AIS 12 months after the event in a population-based cohort. METHODS Children aged 29 days to < 16 years with radiologically confirmed AIS occurring over a 1-year period residing in southern England (population = 5.99 million children) were eligible for inclusion. Outcome was assessed during a home visit using the Pediatric Stroke Outcome Measure (PSOM). Parental impressions of recovery were assessed using the Pediatric Stroke Recurrence and Recovery Questionnaire. PSOM score was estimated via telephone interview or clinician interview whenever home visit was not possible. RESULTS Ninety-six children with AIS were identified. Two children were lost to follow-up. Nine of 94 (10%) children died before the 12-month follow-up. One child had an AIS recurrence. PSOM scores were available for 78 of 85 living children at follow-up. Thirty-nine of 78 (50%) had a good outcome (total PSOM score < 1), and 39 of 78 (50%) had a poor outcome. Seizures at onset of AIS were associated with a poor outcome (odds ratio = 3.5, 95% confidence interval = 1.16-10.6). Twenty-eight of 73 (38%) children were judged by their carers to have fully recovered. Ten of 84 (12%) children had recurrent seizures, and 17 of 84 (20%) reported recurrent headaches. INTERPRETATION AIS carries a significant risk of mortality and long-term neurological deficit. However, the rates of mortality, recurrence, and neurological impairment were markedly lower in this study than previously published figures in the United Kingdom. Ann Neurol 2016;79:784-793.
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Affiliation(s)
- Andrew A Mallick
- Department of Paediatric Neurology, Bristol Royal Hospital for Children, Bristol
| | - Vijeya Ganesan
- Neurosciences Unit, University College London Institute of Child Health, London
| | - Fenella J Kirkham
- Neurosciences Unit, University College London Institute of Child Health, London
- Department of Child Health, Southampton University Hospitals National Health Service Trust, Southampton
| | - Penny Fallon
- Department of Paediatric Neurology, St George's Hospital, London
| | - Tammy Hedderly
- Department of Paediatric Neurology, King's College Hospital National Health Service Foundation Trust, London
- Department of Paediatric Neurosciences, Evelina Children's Hospital, London
| | - Tony McShane
- Department of Paediatric Neurology, John Radcliffe Hospital, Oxford
| | - Alasdair P Parker
- Department of Paediatric Neurology, Addenbrooke's Hospital, Cambridge
| | - Evangeline Wassmer
- Department of Paediatric Neurology, Birmingham Children's Hospital, Birmingham
| | - Elizabeth Wraige
- Department of Paediatric Neurosciences, Evelina Children's Hospital, London
| | - Sam Amin
- Neurosciences Unit, University College London Institute of Child Health, London
| | - Hannah B Edwards
- School of Social and Community Medicine, University of Bristol, Bristol
| | - Mario Cortina-Borja
- Population, Policy, and Practice Programme, University College London Institute of Child Health, London
| | - Finbar J O'Callaghan
- Neurosciences Unit, University College London Institute of Child Health, London
- School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
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Marjan A, Mahtab R, Ehsan K, Hadi M. Generalized seizure, the only manifestation of a small ischemic atherothrombotic infarction. World J Emerg Med 2016; 7:71-3. [PMID: 27006744 DOI: 10.5847/wjem.j.1920-8642.2016.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND According to the literature, generalized seizure as a presenting sign of stroke is rare, and in the reported cases it was accompanied by a focal neurological deficit. Presentation of a small ischemic atherothrombotic brain infarction with convulsive generalized seizure is very rare. METHODS We reported a patient with acute small ischemic atherothrombotic infarction associated with an episode of generalized tonic-clonic seizure, a rare clinical manifestation in this type of stroke. The patient was treated with anti-epileptic therapy after admission. RESULTS The patient was discharged with oral administration of phenytoin 100 mg TDS, aspirin 80 mg daily, and atorvastatin 40 mg daily. CONCLUSION Small ischemic atherothrombotic infarction can present only with a seizure without any focal neurological deficit.
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Affiliation(s)
- Assadollahi Marjan
- Neurology Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ramezani Mahtab
- Neurology Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Karimialavijeh Ehsan
- Emergency Medicine Department, Tehran University of Medical Sciences, Tehran 14117-13137, Iran
| | - Mirfazaelian Hadi
- Emergency Medicine Department, Tehran University of Medical Sciences, Tehran 14117-13137, Iran
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38
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Rivkin MJ, Bernard TJ, Dowling MM, Amlie-Lefond C. Guidelines for Urgent Management of Stroke in Children. Pediatr Neurol 2016; 56:8-17. [PMID: 26969237 DOI: 10.1016/j.pediatrneurol.2016.01.016] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 01/18/2016] [Indexed: 01/09/2023]
Abstract
Stroke in children carries lasting morbidity. Once recognized, it is important to evaluate and treat children with acute stroke efficiently and accurately. All children should receive neuroprotective measures. It is reasonable to consider treatment with advanced thrombolytic and endovascular agents. Delivery of such care requires purposeful institutional planning and organization in pediatric acute care centers. Primary stroke centers established for adults provide an example of the multidisciplinary approach that can be applied to the evaluation and treatment of children who present with acute stroke. The organizational infrastructure of these centers can be employed and adapted for treatment of children with acute stroke. It is likely that care for children with acute stroke can best be delivered by regional pediatric primary stroke centers dedicated to the care of children with pediatric stroke.
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Affiliation(s)
- Michael J Rivkin
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts; Department of Psychiatry, Boston Children's Hospital, Boston, Massachusetts; Department of Radiology, Boston Children's Hospital, Boston, Massachusetts; Department of Neurology, Harvard Medical School, Boston, Massachusetts.
| | - Timothy J Bernard
- Department of Pediatrics, Hemophilia and Thrombosis Center, Aurora, Colorado; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Michael M Dowling
- Division of Pediatric Neurology, University of Texas Southwestern Medical Center Dallas, Dallas, Texas; Department of Pediatrics, University of Texas Southwestern Medical Center Dallas, Dallas, Texas; Department of Neurology, University of Texas Southwestern Medical Center Dallas, Dallas, Texas
| | - Catherine Amlie-Lefond
- Department of Neurology, Seattle Children's Hospital, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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39
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Mackay MT, Monagle P, Babl FE. Brain attacks and stroke in children. J Paediatr Child Health 2016; 52:158-63. [PMID: 27062619 DOI: 10.1111/jpc.13086] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 07/22/2015] [Accepted: 07/30/2015] [Indexed: 01/19/2023]
Abstract
Emergency physicians are often the first point of contact in children presenting with acute neurological disorders. Differentiating serious disorders, such as stroke, from benign disorders, such as migraine, can be challenging. Clinical assessment influences decision-making, in particular the need for emergent neuroimaging to confirm diagnosis. This review describes the spectrum of disorders causing 'brain attack' symptoms, or acute onset focal neurological dysfunction, with particular emphasis on childhood stroke, because early recognition is essential to improve access to thrombolytic treatments, which have improved outcomes in adults. Clues to diagnosis of specific conditions are discussed. Symptoms and signs, which discriminate stroke from mimics, are described, highlighting differences to adults. Haemorrhagic and ischaemic stroke have different presenting features, which influence choice of the most appropriate imaging modality to maximise diagnostic accuracy. Improvements in the care of children with brain attacks require coordinated approaches and system improvements similar to those developed in adults.
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Affiliation(s)
- Mark T Mackay
- Department of Neurology.,Murdoch Childrens Research Institute, Parkville, Australia.,Florey Institute of Neurosciences and Mental Health.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Paul Monagle
- Murdoch Childrens Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Franz E Babl
- Emergency Department, Royal Children's Hospital.,Murdoch Childrens Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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40
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Wilson CA. Continuous electroencephalogram detection of non-convulsive seizures in the pediatric intensive care unit: review of the utility and impact on management and outcomes. Transl Pediatr 2015; 4:283-9. [PMID: 26835390 PMCID: PMC4728999 DOI: 10.3978/j.issn.2224-4336.2015.10.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Non-convulsive seizures (NCS) are common among critically ill children with acute encephalopathy. Continuous electroencephalogram (CEEG) monitoring is an indispensable tool to detect NCS, which is essential to guiding management and assessing prognosis. Risk factors for NCS are highest in pediatric intensive care unit (PICU) patients with altered mental status (AMS) and a recently witnessed clinical seizure, acute changes on neuroimaging, and/or interictal abnormalities on CEEG. Screening for at least 24 hours in at risk pediatric populations is ideal, but around half of NCS may be detected within the first hour. Rapid treatment of prolonged seizures or status epilepticus is critical, as higher seizure burdens have been associated with poorer outcomes in critically ill children. This review integrates current information on critically ill children with AMS and the use of CEEGs, risk factors for NCS, duration of CEEG monitoring, and how the detection of NCS impacts management and outcomes.
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Affiliation(s)
- Carey A Wilson
- Department of Child Neurology, University of Utah School of Medicine, UT 84113, USA
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41
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Nguyen The Tich S, Cheliout-Heraut F. Continuous EEG monitoring in children in the intensive care unit (ICU). Neurophysiol Clin 2015; 45:75-80. [PMID: 25660126 DOI: 10.1016/j.neucli.2014.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 11/16/2014] [Indexed: 11/30/2022] Open
Abstract
Pediatric EEG in the intensive care unit (ICU) requires specific technical requirements in order to yield relevant data depending upon clinical scenario: diagnosis of electroclinical or subclinical seizures, their quantification before and after therapeutic changes and sometimes evaluation of severity of cortical dysfunction. The urgent nature of these indications implies the rapid set-up of the EEG system by qualified staff and possibility of maintaining the electrodes in place during long periods of time. Various techniques are available today for EEG monitoring, the interpretation of which depends on the contribution of an experienced physician. Among recent techniques, those most commonly used are trend curves obtained via signal analysis such as amplitude EEG (a-EEG) and density spectral array (DSA) or compressed spectral array (CSA). Trend curves enable the digital creation of a display graph containing several hours of transformed and compressed EEG recorded data. Visualized on one sole display graph, these trend curves can facilitate the identification of very slow changes in EEG background activity and their variation (alertness cycles, changes linked to treatment administrations) as well as seizure patterns and their quantification. In this chapter, we propose a brief overview of monitoring techniques, followed by a review of the various data yielded by EEG monitoring as well as the relevance of this type of management; finally, detailed clinical indications will be discussed after thorough analysis of the literature.
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Affiliation(s)
- S Nguyen The Tich
- Unité de Neurologie pédiatrique, CHU d'Angers, LARIS EA 7315, LUNAM, Angers, France.
| | - F Cheliout-Heraut
- Service de physiologie-explorations fonctionnelles, CHU de Garches, UVSQ, Garches, France
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Sinclair AJ, Fox CK, Ichord RN, Almond CS, Bernard TJ, Beslow LA, Chan AKC, Cheung M, deVeber G, Dowling MM, Friedman N, Giglia TM, Guilliams KP, Humpl T, Licht DJ, Mackay MT, Jordan LC. Stroke in children with cardiac disease: report from the International Pediatric Stroke Study Group Symposium. Pediatr Neurol 2015; 52:5-15. [PMID: 25532775 PMCID: PMC4936915 DOI: 10.1016/j.pediatrneurol.2014.09.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 09/17/2014] [Accepted: 09/22/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Cardiac disease is a leading cause of stroke in children, yet limited data support the current stroke prevention and treatment recommendations. A multidisciplinary panel of clinicians was convened in February 2014 by the International Pediatric Stroke Study group to identify knowledge gaps and prioritize clinical research efforts for children with cardiac disease and stroke. RESULTS Significant knowledge gaps exist, including a lack of data on stroke incidence, predictors, primary and secondary stroke prevention, hyperacute treatment, and outcome in children with cardiac disease. Commonly used diagnostic techniques including brain computed tomography and ultrasound have low rates of stroke detection, and diagnosis is frequently delayed. The challenges of research studies in this population include epidemiologic barriers to research such as small patient numbers, heterogeneity of cardiac disease, and coexistence of multiple risk factors. Based on stroke burden and study feasibility, studies involving mechanical circulatory support, single ventricle patients, early stroke detection strategies, and understanding secondary stroke risk factors and prevention are the highest research priorities over the next 5-10 years. The development of large-scale multicenter and multispecialty collaborative research is a critical next step. The designation of centers of expertise will assist in clinical care and research. CONCLUSIONS There is an urgent need for additional research to improve the quality of evidence in guideline recommendations for cardiogenic stroke in children. Although significant barriers to clinical research exist, multicenter and multispecialty collaboration is an important step toward advancing clinical care and research for children with cardiac disease and stroke.
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Affiliation(s)
- Adriane J Sinclair
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Christine K Fox
- Department of Neurology, University of California, San Francisco, San Francisco, California
| | - Rebecca N Ichord
- Departments of Neurology and Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher S Almond
- Department of Pediatrics, Stanford University, Lucile Packard Children's Hospital, Palo Alto, California
| | - Timothy J Bernard
- Pediatrics, Neurology and Child Neurology, University of Colorado, Aurora, Colorado
| | - Lauren A Beslow
- Department of Pediatric Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Anthony K C Chan
- Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Michael Cheung
- Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Gabrielle deVeber
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Michael M Dowling
- Department of Pediatrics and Neurology, UT Southwestern Medical Center, Dallas, Texas
| | - Neil Friedman
- Center for Pediatric Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Therese M Giglia
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kristin P Guilliams
- Division of Pediatric Neurology, Department of Neurology, Washington University in St. Louis, St. Louis, Missouri; Division of Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Tilman Humpl
- Division of Cardiac Critical Care, Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Daniel J Licht
- Departments of Neurology and Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark T Mackay
- Department of Neurology, Royal Children's Hospital, Melbourne, Victoria, Australia; Murdoch Children's Research Institute Melbourne, Parkville, Victoria, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.
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Abstract
PURPOSE OF REVIEW To discuss the use of continuous video-electroencephalographic (cEEG) monitoring among critically ill children at risk for electrographic seizures and status epilepticus. RECENT FINDINGS Recent reports have demonstrated the growing, but heterogeneous, use of cEEG monitoring among North American pediatric institutions, and provided evidence for the high prevalence of subclinical seizures, particularly among encephalopathic patients with acute brain injury. Increasing seizure burden and status epilepticus have been shown to be independently associated with worse short-term and long-term outcomes. SUMMARY Certain high-risk children frequently experience electrographic seizures and status epilepticus, often without clinical signs, necessitating the use of cEEG monitoring for their diagnosis and management. Although an increasing electrographic seizure burden and status epilepticus are independently associated with worse outcome, further studies are needed to determine whether aggressive use of antiepileptic drugs to reduce seizure burden can improve outcome.
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44
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[French guidelines on electroencephalogram]. Neurophysiol Clin 2014; 44:515-612. [PMID: 25435392 DOI: 10.1016/j.neucli.2014.10.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 10/07/2014] [Indexed: 12/11/2022] Open
Abstract
Electroencephalography allows the functional analysis of electrical brain cortical activity and is the gold standard for analyzing electrophysiological processes involved in epilepsy but also in several other dysfunctions of the central nervous system. Morphological imaging yields complementary data, yet it cannot replace the essential functional analysis tool that is EEG. Furthermore, EEG has the great advantage of being non-invasive, easy to perform and allows control tests when follow-up is necessary, even at the patient's bedside. Faced with the advances in knowledge, techniques and indications, the Société de Neurophysiologie Clinique de Langue Française (SNCLF) and the Ligue Française Contre l'Épilepsie (LFCE) found it necessary to provide an update on EEG recommendations. This article will review the methodology applied to this work, refine the various topics detailed in the following chapters. It will go over the summary of recommendations for each of these chapters and underline proposals for writing an EEG report. Some questions could not be answered by the review of the literature; in those cases, an expert advice was given by the working and reading groups in addition to the guidelines.
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45
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Mechanisms of perinatal arterial ischemic stroke. J Cereb Blood Flow Metab 2014; 34:921-32. [PMID: 24667913 PMCID: PMC4050239 DOI: 10.1038/jcbfm.2014.41] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 12/30/2013] [Accepted: 01/02/2014] [Indexed: 01/21/2023]
Abstract
The incidence of perinatal stroke is high, similar to that in the elderly, and produces a significant morbidity and severe long-term neurologic and cognitive deficits, including cerebral palsy, epilepsy, neuropsychological impairments, and behavioral disorders. Emerging clinical data and data from experimental models of cerebral ischemia in neonatal rodents have shown that the pathophysiology of perinatal brain damage is multifactorial. These studies have revealed that, far from just being a smaller version of the adult brain, the neonatal brain is unique with a very particular and age-dependent responsiveness to hypoxia-ischemia and focal arterial stroke. In this review, we discuss fundamental clinical aspects of perinatal stroke as well as some of the most recent and relevant findings regarding the susceptibility of specific brain cell populations to injury, the dynamics and the mechanisms of neuronal cell death in injured neonates, the responses of neonatal blood-brain barrier to stroke in relation to systemic and local inflammation, and the long-term effects of stroke on angiogenesis and neurogenesis. Finally, we address translational strategies currently being considered for neonatal stroke as well as treatments that might effectively enhance repair later after injury.
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Hsu CJ, Weng WC, Peng SSF, Lee WT. Early-Onset Seizures Are Correlated With Late-Onset Seizures in Children With Arterial Ischemic Stroke. Stroke 2014; 45:1161-3. [DOI: 10.1161/strokeaha.113.004015] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Early-onset seizures are common in children with arterial ischemic stroke, but the clinical features and effects on the outcome of early-onset seizures have been less studied in children.
Methods—
Children aged 1 month to 18 years presenting with first-time and image-confirmed arterial ischemic stroke were identified for analysis.
Results—
A total of 78 survivors of arterial ischemic stroke were enrolled. Twenty (25.6%) had early-onset seizures, and 90% were initial presentation. Younger children (mean, 3.4±3.9 versus 9.0±6.2 years;
P
<0.001) and cortical involvement (5% versus 63.8%;
P
=0.01) are more likely to have early-onset seizures. Thirteen of 20 survivors with early-onset seizures had late-onset seizures after the acute stage, and 12 of them were diagnosed as poststroke epilepsy.
Conclusions—
Early-onset seizures occurred in 25.6% of children with arterial ischemic stroke. Younger age and cortical involvement were risk factors for early-onset seizures. Sixty-five percent of children with early-onset seizures had late-onset seizures after the acute stage.
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Affiliation(s)
- Chen-Jui Hsu
- From the Department of Pediatrics, En Chu Kong Hospital, Taipei, Taiwan (C.-J.H.); and Departments of Pediatrics (W.-C.W., W.-T.L.) and Diagnostic Imaging (S.S.-F.P.), National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Chin Weng
- From the Department of Pediatrics, En Chu Kong Hospital, Taipei, Taiwan (C.-J.H.); and Departments of Pediatrics (W.-C.W., W.-T.L.) and Diagnostic Imaging (S.S.-F.P.), National Taiwan University Hospital, Taipei, Taiwan
| | - Steven Shinn-Feng Peng
- From the Department of Pediatrics, En Chu Kong Hospital, Taipei, Taiwan (C.-J.H.); and Departments of Pediatrics (W.-C.W., W.-T.L.) and Diagnostic Imaging (S.S.-F.P.), National Taiwan University Hospital, Taipei, Taiwan
| | - Wang-Tso Lee
- From the Department of Pediatrics, En Chu Kong Hospital, Taipei, Taiwan (C.-J.H.); and Departments of Pediatrics (W.-C.W., W.-T.L.) and Diagnostic Imaging (S.S.-F.P.), National Taiwan University Hospital, Taipei, Taiwan
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Freeman H, Patel J, Fernandez D, Sharples P, Ramanan AV. Fitting and flailing: recognition of paediatric antiphospholipid syndrome. Arch Dis Child Educ Pract Ed 2014; 99:28-36. [PMID: 24091699 DOI: 10.1136/archdischild-2012-302404] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune condition where the presence of antiphospholipid antibodies is thought to predispose to thrombotic events. It is uncommon in the paediatric population, but current diagnostic criteria are based on adult population studies, making assessment of its true paediatric prevalence difficult. We present two cases of paediatric APS, who presented with primary neurological events, and discuss approaches to diagnosis, interpretation of screening investigations, including antinuclear antibodies (ANA), anti-extractable nuclear antigen (ENA) antibodies and lupus anticoagulant. Possible approaches to the management of paediatric APS are discussed.
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Affiliation(s)
- H Freeman
- Department of Paediatrics, Raigmore Hospital, , Inverness, UK
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Abend NS, Wusthoff CJ, Goldberg EM, Dlugos DJ. Electrographic seizures and status epilepticus in critically ill children and neonates with encephalopathy. Lancet Neurol 2014; 12:1170-9. [PMID: 24229615 DOI: 10.1016/s1474-4422(13)70246-1] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Electrographic seizures are seizures that are evident on EEG monitoring. They are common in critically ill children and neonates with acute encephalopathy. Most electrographic seizures have no associated clinical changes, and continuous EEG monitoring is necessary for identification. The effect of electrographic seizures on outcome is the focus of active investigation. Studies have shown that a high burden of electrographic seizures is associated with worsened clinical outcome after adjustment for cause and severity of brain injury, suggesting that a high burden of such seizures might independently contribute to secondary brain injury. Further research is needed to determine whether identification and management of electrographic seizures reduces secondary brain injury and improves outcome in critically ill children and neonates.
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Affiliation(s)
- Nicholas S Abend
- Departments of Neurology and Pediatrics, The Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Amlie-Lefond C, Gill JC. Approach to acute ischemic stroke in childhood. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:276. [PMID: 24390791 DOI: 10.1007/s11936-013-0276-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OPINION STATEMENT Acute ischemic stroke in childhood is a medical emergency. Prompt recognition and intervention is necessary to rescue potentially viable brain tissue, prevent complications, and minimize the risk of recurrent stroke. Conditions that could result in recurrent stroke such as cardiac thrombus or cervical artery dissection need to be identified and treated promptly. Although the care of childhood stroke is based largely on extrapolation from adults, an organized approach to the care of these children is critical to optimize outcome.
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Affiliation(s)
- Catherine Amlie-Lefond
- Department of Neurology, Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, 4800 Sand Point Way NE, MB 7.462, Seattle, WA, 98105, USA,
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50
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Childhood arterial ischaemic stroke incidence, presenting features, and risk factors: a prospective population-based study. Lancet Neurol 2014; 13:35-43. [DOI: 10.1016/s1474-4422(13)70290-4] [Citation(s) in RCA: 240] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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