Pediatric ischemic stroke: acute management and areas of research

Traumatic Vertebral Artery Dissection and Basilar Artery Occlusion/Stroke in a 7-Year-Old Child: A Case Report

Vertebral artery dissection (VAD) followed by basilar artery occlusion/stroke (BAO/BAS) is a rare but potentially life-threatening complication. We present a case report of a 7-year-old boy with VAD complicated by BAO/BAS 4 days after falling off a scooter. Symptoms included left-sided weakness and facial droop preceded by a 20-minute episode of altered sensorium. Magnetic resonance imaging showed ischemic changes in the left posterior inferior cerebellum and right pons. Computed tomography angiogram confirmed dissection of the left vertebral artery with occlusion/thrombosis of the basilar artery. Heparinization for 96 hours, followed by 6 months of low-molecular weight heparin injection, resulted in improvement of his neurological symptoms.

Neuroprotective Effect of IRL-1620, an Endothelin B Receptor Agonist, on a Pediatric Rat Model of Middle Cerebral Artery Occlusion

Objective: The purpose of this study was to determine the potential neuroprotective effect of endothelin B (ET_B) receptor agonist IRL-1620 treatment in a pediatric model of ischemic stroke. Design: A prospective, animal model study. Setting: An experimental laboratory. Subjects: Three-month-old male Wistar Han rats. Interventions: The rats underwent permanent middle cerebral artery occlusion (MCAO). At 2, 4, and 6 h post MCAO, they were treated with saline, IRL-1620 (5 μg/kg, IV), and/or ET_B antagonist BQ788 (1 mg/kg, IV). Measurements and Main Results: The rats were evaluated over the course of 7 days for neurological and motor deficit, cerebral blood flow (CBF), and infarct volume. Young rats treated with IRL-1620 following MCAO improved significantly in neurological and motor assessments as compared to the vehicle-treated group, as measured by neurological score (P = 0.00188), grip test (P < 0.0001), and foot-fault error (P = 0.0075). CBF in the infarcted hemisphere decreased by 45-50% in all groups immediately following MCAO. After 7 days, CBF in the infarcted hemisphere of the IRL-1620 group increased significantly (P = 0.0007) when compared to the vehicle-treated group (+2.3 ± 23.3 vs. -45.4 ± 10.2%). Additionally, infarct volume was significantly reduced in IRL-1620-treated rats as compared to vehicle-treated rats (P = 0.0035, 41.4 ± 35.4 vs. 115.4 ± 40.9 mm³). Treatment with BQ788 blocked the effects of IRL-1620. Conclusions: IRL-1620 significantly reduced neurological and motor deficit as well as infarct volume while increasing CBF in a pediatric rat model of cerebral ischemia. These results indicate that selective ET_B receptor stimulation may provide a novel therapeutic strategy in the treatment of pediatric ischemic stroke as has been demonstrated in adult ischemic stroke.

Carotid Artery Dissection and Ischemic Stroke After Severe Coughing

Vigorous coughing leading to internal carotid artery dissection has been described in the adult literature but has not been reported in the pediatric population. We describe an 8-year-old right-handed girl who had a 1-week history of increased work of breathing and vigorous coughing. She initially presented to her pediatrician's office for her respiratory symptoms which improved with steroid therapy and albuterol treatments. However, she developed evolving left-sided motor weakness over the course of 2 days and presented to our pediatric emergency department where she was found to have an ischemic stroke in the right corona radiata with a right internal carotid artery dissection.

Management of pediatric central nervous system emergencies: a review for general radiologists

TEACHING OBJECTIVES

To review the most common and most important diseases and disorders of the central nervous system (CNS) in pediatric emergencies, discussing the indications for different imaging tests in each context.

DISCUSSION

In pediatric patients, acute neurologic symptoms (seizures, deteriorating level of consciousness, focal neurologic deficits, etc.) can appear in diverse clinical situations (trauma, child abuse, meningoencephalitis, ischemia…). It is important to decide on the most appropriate neuroimaging diagnostic algorithm for each situation and age group, as well as to know the signs of the most typical lesions that help us in the etiological differential diagnosis. Pediatric patients' increased vulnerability to ionizing radiation and the possible need for sedation in studies that require more time are factors that should be taken into account when indicating an imaging test. It is essential to weigh the risks and benefits for the patient and to avoid unnecessary studies.

Pathophysiology and neuroprotection of global and focal perinatal brain injury: lessons from animal models

BACKGROUND

Arterial ischemic stroke occurs more frequently in term newborns than in the elderly, and brain immaturity affects mechanisms of ischemic injury and recovery. The susceptibility to injury of the brain was assumed to be lower in the perinatal period as compared with childhood. This concept was recently challenged by clinical studies showing marked motor disabilities after stroke in neonates, with the severity of motor and cortical sensory deficits similar in both perinatal and childhood ischemic stroke. Our understanding of the triggers and the pathophysiological mechanisms of perinatal stroke has greatly improved in recent years, but many factors remain incompletely understood.

METHODS

In this review, we focus on the pathophysiology of perinatal stroke and on therapeutic strategies that can protect the immature brain from the consequences of stroke by targeting inflammation and brain microenvironment.

RESULTS

Studies in neonatal rodent models of cerebral ischemia have suggested a potential role for soluble inflammatory molecules as important modulators of injury and recovery. A great effort is underway to investigate neuroprotective molecules based on our increasing understanding of the pathophysiology.

CONCLUSION

In this review, we provide a comprehensive summary of new insights concerning pathophysiology of focal and global perinatal brain injury and their implications for new therapeutic approaches.

Headache with focal neurologic signs in children at the emergency department

OBJECTIVE

To identify predictors of secondary headache in children consulting at the pediatric emergency department (ED) for headache with a focal neurologic deficit.

STUDY DESIGN

In this prospective cohort study, we enrolled children aged 6-18 years presenting to the ED of a tertiary care hospital with moderate to severe headache and focal neurologic deficit. Enrollment took place between March 2009 and February 2012. Children with a history of trauma, fever, or neurosurgical intervention were excluded from the study. The final diagnosis was made after 1 year of follow-up. Our primary aim was to identify any differences in the frequency of clinical signs between children with a final diagnosis of primary headache and those with a final diagnosis of secondary headache.

RESULTS

Of the 101 patients included in the study, 66% received a final diagnosis of primary headache (94% migraine with aura), and 34% received a final diagnosis of secondary headache (76.5% focal epilepsy). On multivariate analysis, children with bilateral localization of pain had a higher likelihood (aOR, 8.6; 95% CI, 3.2-23.2; P<.001) of having secondary headache.

CONCLUSION

Among children presenting to the ED with focal neurologic deficits, a bilateral headache location was associated with higher odds of having a secondary cause of headache. Additional longitudinal studies are needed to investigate whether our data can aid management in the ED setting.