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Colovic H, Zlatanovic D, Zivkovic V, Jankovic M, Radosavljevic N, Ducic S, Ducic J, Stojkovic J, Jovanovic K, Nikolic D. A Review of Current Perspectives on Motoric Insufficiency Rehabilitation following Pediatric Stroke. Healthcare (Basel) 2024; 12:149. [PMID: 38255037 PMCID: PMC10815565 DOI: 10.3390/healthcare12020149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 12/30/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Pediatric stroke (PS) is an injury caused by the occlusion or rupture of a blood vessel in the central nervous system (CNS) of children, before or after birth. Hemiparesis is the most common motoric deficit associated with PS in children. Therefore, it is important to emphasize that PS is a significant challenge for rehabilitation, especially since the consequences may also appear during the child's growth and development, reducing functional capacity. The plasticity of the child's CNS is an important predecessor of recovery, but disruption of the neural network, specific to an immature brain, can have harmful and potentially devastating consequences. In this review, we summarize the complexity of the consequences associated with PS and the possibilities and role of modern rehabilitation. An analysis of the current literature reveals that Constraint-Induced Movement Therapy, forced-use therapy, repetitive transcranial magnetic stimulation, functional electrical stimulation and robot-assisted therapy have demonstrated at least partial improvements in motor domains related to hemiparesis or hemiplegia caused by PS, but they are supported with different levels of evidence. Due to the lack of randomized controlled studies, the optimal rehabilitation treatment is still debatable, and therefore, most recommendations are primarily based on expert consensuses, opinions and an insufficient level of evidence.
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Affiliation(s)
- Hristina Colovic
- Department for Physical Medicine and Rehabilitation, Faculty of Medicine, University of Niš, 18000 Niš, Serbia; (D.Z.); (V.Z.)
- Clinic for Physical Medicine and Rehabilitation, University Clinical Center Niš, 18000 Niš, Serbia
| | - Dragan Zlatanovic
- Department for Physical Medicine and Rehabilitation, Faculty of Medicine, University of Niš, 18000 Niš, Serbia; (D.Z.); (V.Z.)
- Clinic for Physical Medicine and Rehabilitation, University Clinical Center Niš, 18000 Niš, Serbia
| | - Vesna Zivkovic
- Department for Physical Medicine and Rehabilitation, Faculty of Medicine, University of Niš, 18000 Niš, Serbia; (D.Z.); (V.Z.)
- Clinic for Physical Medicine and Rehabilitation, University Clinical Center Niš, 18000 Niš, Serbia
| | - Milena Jankovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.J.); (S.D.); (J.D.); (J.S.); (D.N.)
- Neurology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Natasa Radosavljevic
- Department of Biomedical Sciences, State University of Novi Pazar, 36300 Novi Pazar, Serbia;
| | - Sinisa Ducic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.J.); (S.D.); (J.D.); (J.S.); (D.N.)
- Department of Pediatric Surgery, University Children’s Hospital, 11000 Belgrade, Serbia
| | - Jovan Ducic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.J.); (S.D.); (J.D.); (J.S.); (D.N.)
| | - Jasna Stojkovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.J.); (S.D.); (J.D.); (J.S.); (D.N.)
- Department of Physical Medicine and Rehabilitation, University Children’s Hospital, 11000 Belgrade, Serbia
| | - Kristina Jovanovic
- Department of Pediatrics, University Children’s Hospital, 11000 Belgrade, Serbia;
| | - Dejan Nikolic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.J.); (S.D.); (J.D.); (J.S.); (D.N.)
- Department of Physical Medicine and Rehabilitation, University Children’s Hospital, 11000 Belgrade, Serbia
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Mastej EJ, Leppert MH, Poisson S, Ritchey Z, Barry M, Rundek T, Liebeskind DS, Mirsky D, Bernard TJ, Stence NV. Thalamic Volume Loss Is Greater in Children Than in Adults Following Middle Cerebral Artery Territory Arterial Ischemic Stroke. J Child Neurol 2022; 37:882-888. [PMID: 36069041 PMCID: PMC9560991 DOI: 10.1177/08830738221118807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Younger stroke patients may suffer worse outcomes than older patients; however, the extent to which age at stroke impacts remote areas of the brain remains unclear. The objective of this study was to determine thalamic volume changes ipsilateral to middle cerebral artery territory strokes based on age at acute ischemic stroke onset. Methods: Acute ischemic stroke patients <9 years, 9-18 years, and >18 years old were retrospectively recruited from a large quaternary care system. Each subject underwent an acute (<72 hours from AIS) and chronic (>90 days) magnetic resonance imaging (MRI) scan. Manual thalamic segmentation was performed. Results: Younger and older children had significantly greater stroke-side thalamic volume loss compared to adults (48.2%, P = .022; 40.7%, P = .044, respectively). Conclusions: Stroke-side thalamic volumes decreased across the age spectrum but to a greater degree in pediatric patients. This observation can affect functional and cognitive outcomes post stroke and warrants further research.
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Affiliation(s)
- Emily J. Mastej
- Computational Bioscience Program, University of Colorado Anschutz, Aurora, CO
| | - Michelle H. Leppert
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO
| | - Sharon Poisson
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO
| | - Zak Ritchey
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO
| | - Megan Barry
- Section of Child Neurology, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Tatjana Rundek
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL
| | - David S. Liebeskind
- Department of Neurology, University of California Los Angeles, Los Angeles, CA
| | - David Mirsky
- Department of Radiology, Children’s Hospital Colorado, Medicine, Aurora, CO
| | - Timothy J. Bernard
- Section of Child Neurology, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Nicholas V. Stence
- Department of Radiology, Children’s Hospital Colorado, Medicine, Aurora, CO
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Sundelin HEK, Walås A, Söderling J, Bang P, Ludvigsson JF. Long-Term Mortality in Children With Ischemic Stroke: A Nationwide Register-Based Cohort Study. Stroke 2021; 53:837-844. [PMID: 34875844 DOI: 10.1161/strokeaha.121.034797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND PURPOSE Ischemic stroke is a common cause of death in adults, however, mortality after pediatric ischemic stroke is not well explored. We investigate long-term and cause-specific mortality in children with ischemic stroke and their first-degree relatives. METHODS Through nationwide Swedish registers, we identified 1606 individuals <18 years old with ischemic stroke between 1969 and 2016 and their first-degree relatives (n=5714). Each individual with ischemic stroke was compared with 10 reference individuals (controls) matched for age, sex, and county of residence. Our main analysis examined 1327 children with ischemic stroke still alive 1 week after the event. First-degree relatives to children with ischemic stroke were compared with first-degree relatives to the reference individuals. Using a Cox proportional hazard regression model, the risk of overall and cause-specific mortality was computed in individuals with pediatric ischemic stroke and their first-degree relatives. RESULTS The mortality rate in the first 6 months was 40.1 (95% CI, 24.7-55.6) per 1000 person-years compared with 1.1/1000 in controls (95% CI, 0.3-1.9). The overall mortality risk was hazard ratio (HR)=10.8 (95% CI, 8.1-14.3) and remained elevated beyond 20 years (HR=3.9 [95% CI, 2.1-7.1]). Children with ischemic stroke were at increased risk of death from neurological diseases (HR=29.9 [95% CI, 12.7-70.3]), cardiovascular diseases (HR=6.2 [95% CI, 1.8-22.2]), cancers (HR=6.5 [95% CI, 2.6-15.9]) and endocrine, nutritional and metabolic diseases (HR=49.2 [95% CI, 5.7-420.8]). First-degree relatives to children with ischemic stroke had an increased mortality risk (HR=1.21 [95% CI, 1.05-1.39]), with the highest risk among siblings (HR=1.52 [95% CI, 1.09-2.11]) and relatives to individuals with ischemic stroke >28 days of age (HR=1.23 [95% CI, 1.06-1.42]) compared with the relatives of the controls. CONCLUSIONS Long-term mortality increased after pediatric ischemic stroke, even 20 years later, with neurological diseases as the most frequent cause of death.
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Affiliation(s)
- Heléne E K Sundelin
- Division of Children's and Women's Health, Department of Biomedical and Clinical Sciences, Linköping University, Sweden (H.E.K.S., A.W., P.B.).,Neuropediatric Unit, Department of Women's and Children's Health, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden. (H.E.K.S.)
| | - Anna Walås
- Division of Children's and Women's Health, Department of Biomedical and Clinical Sciences, Linköping University, Sweden (H.E.K.S., A.W., P.B.)
| | - Jonas Söderling
- Clinical Epidemiology Division, Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden. (J.S.)
| | - Peter Bang
- Division of Children's and Women's Health, Department of Biomedical and Clinical Sciences, Linköping University, Sweden (H.E.K.S., A.W., P.B.)
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden. (J.F.L.).,Department of Pediatrics, Örebro University Hospital, Sweden (J.F.L.).,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, United Kingdom (J.F.L.).,Department of Medicine, Columbia University, NY (J.F.L.)
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Endovascular and thrombolytic treatment eligibility in childhood arterial ischemic stroke. Eur J Paediatr Neurol 2021; 34:99-104. [PMID: 34454335 DOI: 10.1016/j.ejpn.2021.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/04/2021] [Accepted: 08/23/2021] [Indexed: 01/02/2023]
Abstract
AIM To describe factors affecting eligibility for, and rates of utilization of, hyperacute therapy in children with acute ischemic stroke (AIS) following establishment of our institutional acute stroke treatment pathway in 2005. METHODS A retrospective analysis of a prospectively enrolled, single-center cohort was performed including children age 2 - <18 years with acute AIS from 2005 through 2017. Descriptive statistics were used to summarize clinical characteristics, presentation data, and Pediatric NIH Stroke Scale (PedNIHSS) scores that were abstracted from medical records. Assessment for eligibility and administration of hyperacute therapy was determined at the time of presentation according to the institutional stroke pathway. RESULTS Of 90 children (median age at presentation 11.3 years, 36% female) with acute AIS, 5 (6%) received hyperacute therapy: 3 received intravenous tissue plasminogen activator (IV-tPA) alone, 1 received endovascular therapy (EVT) alone, and 1 received IV-tPA and EVT. Of 54 children (60%) who presented within 4.5 h of time last seen well, 6 had PedNIHSS scores 6-24, no medical contraindication to IV-tPA, and a partial or complete vessel occlusion. Of 7 children >3 years old who presented after EVT became available at our hospital and within 6 h of time last seen well with a PedNIHSS score 6-24, 3 (43%) had a large vessel occlusion (LVO). Two patients underwent EVT and the other patient was not transferred until >6 h from time last seen well. CONCLUSIONS Delay to presentation and diagnosis of childhood acute AIS, mild neurologic deficits at presentation, medical contraindications to IV-tPA, and lack of vessel occlusion on acute neuroimaging contribute to low rates of hyperacute treatment in children with acute AIS.
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Kopyta I, Cebula A, Sarecka-Hujar B. Early Deaths after Arterial Ischemic Stroke in Pediatric Patients: Incidence and Risk Factors. CHILDREN-BASEL 2021; 8:children8060471. [PMID: 34204895 PMCID: PMC8228712 DOI: 10.3390/children8060471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 05/29/2021] [Accepted: 05/31/2021] [Indexed: 01/02/2023]
Abstract
In developed countries, cerebrovascular diseases are among the 10 most common causes of death in both the pediatric and adult population. The prevalence of fatal outcomes following arterial ischemic stroke (AIS) in various groups of pediatric patients ranges from 1% to almost 32%. However, a constant improvement in stroke mortality among children has been observed. The extent of the decline differs among studies (from nearly tenfold to twofold decline), as it depends on the study population. While a portion of this variability might be explained by factors such as health care access, population age, diseases related to ethnicity, and different etiologies of stroke in studied populations, the understanding of such differences is still insufficient. Risk factors for death in the early stages of the disease are poorly understood and are usually based on the clinical presentations of relatively small groups of pediatric patients. Familiarity with these factors may be of significant importance for prognosis, but also for the early selection of patients requiring careful supervision. The present study aimed to analyze and discuss the current literature data on the incidence of early death and risk factors for early death in children suffering from stroke.
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Affiliation(s)
- Ilona Kopyta
- Department of Paediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia in Katowice, Medykow Str 16, 40-752 Katowice, Poland; (I.K.); (A.C.)
| | - Agnieszka Cebula
- Department of Paediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia in Katowice, Medykow Str 16, 40-752 Katowice, Poland; (I.K.); (A.C.)
| | - Beata Sarecka-Hujar
- Department of Basic Biomedical Science, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia in Katowice, Kasztanowa Str 3, 41-200 Sosnowiec, Poland
- Correspondence:
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Short-term outcomes after a neonatal arterial ischemic stroke. Childs Nerv Syst 2021; 37:1249-1254. [PMID: 33064213 DOI: 10.1007/s00381-020-04931-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/12/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The purpose of this study is to determine the frequency and radiological predictors of recurrent acute symptomatic seizures (RASS) and motor impairment at discharge after a neonatal arterial ischemic stroke (NAIS). METHODS In a nonconcurrent cohort study, 33 full-term newborns with NAIS confirmed by MRI are admitted into our hospital between January 2003 and December 2012. Stroke size, calculated as stroke volume divided by whole brain volume (WBV), was categorized as > or < 3.3% of WBV. A univariate analysis of categorical variables was performed using Fisher's exact test. A multivariate analysis was performed using logistic regression models including all variables with a p value < 0.1 in the univariate analysis. RESULTS The median age at NAIS was 2 days (IQR, 1-5.6), 36.4% were girls. The stroke size was > 3.3 of WBV in 48.5% of the cases, and 54.5% showed multifocal lesions. Involvement of the cerebral cortex (54.5%), thalamus (48.5%), posterior limb of the internal capsule (36.4%), basal ganglia (36.4%), and brainstem (28.2%) were found. At discharge, 45.5% of newborns had a motor deficit, and 27.3% had at least two seizures. Multivariate analyses revealed that stroke size > 3.3% of WBV (OR: 8.1, CI: 1.2-53.9) and basal ganglia involvement (OR: 12.8, CI: 1.7-95.4) predicted motor impairment at discharge. Cortical involvement of temporal and frontal lobes (OR: 14, CI: 2.2-88.1; and OR: 9.1, CI: 1.2-72.6) were predictive of RASS. CONCLUSION Stroke size and location are independent risk factors for adverse short-term neurological outcomes in full-term newborns following a NAIS.
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Does the Occurrence of Particular Symptoms and Outcomes of Arterial Ischemic Stroke Depend on Sex in Pediatric Patients?-A Pilot Study. Brain Sci 2020; 10:brainsci10110881. [PMID: 33233638 PMCID: PMC7699743 DOI: 10.3390/brainsci10110881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/06/2020] [Accepted: 11/19/2020] [Indexed: 12/23/2022] Open
Abstract
Arterial ischemic stroke (AIS) in childhood is reported to occur more frequently in boys, which may lead to the assumption that the prevalence of post-stroke deficits is sex related. The present study aimed to evaluate sex-related differences in functional outcomes (hemiparesis, seizures, aphasia, and motor disturbances other than hemiparesis) in pediatric patients with AIS. A total of 89 children (52 boys and 37 girls; mean age at stroke onset: 8.4 ± 5.6 years) were evaluated retrospectively based on data from medical records. The patients were divided into subgroups according to age (i.e., infants and toddlers, children, and adolescents), stroke subtype (i.e., lacunar anterior circulation infarct (LACI), total anterior circulation infarct (TACI), partial anterior circulation infarct (PACI), posterior circulation infarct (POCI)) and stroke location (i.e., anterior stroke, posterior stroke). Significant differences in the prevalence of stroke subtypes between girls and boys were observed (p = 0.034). POCI stroke were found to be more frequent in boys than in girls (OR = 8.57 95%CI 1.05–70.23, p = 0.023). Males predominated in the total group and in all analyzed age subgroups. The proportions of boys within the subgroups according to stroke subtype were extremely high for the POCI and TACI stroke subgroups. On the other hand, girls predominated in the LACI stroke subgroup. Frequency of central type facial nerve palsy and other symptoms of AIS were found to significantly differ between male subgroups according to stroke subtype (p = 0.050 and p < 0.001, respectively), as well as between children with anterior stroke and those with posterior stroke (p = 0.059 and p < 0.001, respectively). Post-stroke seizures appeared significantly more commonly in girls with TACI and POCI stroke than in girls with LACI and PACI stroke (p = 0.022). In turn, the prevalence of post-stroke hemiparesis differed between stroke subtypes in boys (p = 0.026). In conclusion, sex may have an impact in predisposing to a certain type of AIS in the patient. Post-stroke seizure may be related to stroke subtype in girls and hemiparesis in boys. However, further studies are needed to confirm the results.
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Polat İ, Yiş U, Ayanoğlu M, Okur D, Edem P, Paketçi C, Bayram E, Hız Kurul S. Risk Factors of Post-Stroke Epilepsy in Children; Experience from a Tertiary Center and a Brief Review of the Literature. J Stroke Cerebrovasc Dis 2020; 30:105438. [PMID: 33197802 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105438] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 10/02/2020] [Accepted: 10/29/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Acute seizures and post-stroke epilepsy have been reported more frequently in patients with pediatric stroke than adults. Acute seizures in the first days of a stroke may deteriorate stroke and ischemia-related neurodegeneration and contribute to the development of post-stroke epilepsy. In this study, we aimed to investigate risk factors for the development of post-stroke epilepsy in children with arterial ischemic stroke. MATERIALS AND METHODS We recruited 86 children with arterial ischemic stroke. We analyzed variables, including age at admission, gender, complaints at presentation, focal or diffuse neurologic signs, neurologic examination findings, laboratory investigations that were conducted at admission with stroke (complete blood cell count, biochemical-infectious-metabolic-immunological investigations, vitamin B12 levels, vitamin D levels), neuroimaging results, etiologies, time of the first seizure, time of remote seizures, and development of neurologic deficit retrospectively. Seizures during the first six hours after stroke onset were defined as 'very early seizures'. 'Early seizures' were referred to seizures during the first 48 h. Patients who experienced two or more seizures that occurred after the acute phase of seizures were classified as 'epileptic.' A binary logistic regression analysis was used to estimate risk factors. RESULTS An acute seizure was detected in 59% and post-stroke epilepsy developed in 41% of our cohort. Binary logistic regression analysis demonstrated that 'very early seizures' increased epilepsy risk six-fold. Epilepsy was 16 times higher in patients with 'early seizures'. Low vitamin D levels were defined as a risk factor for post-stroke epilepsy. CONCLUSION Seizures in the very early period (within the first six hours) are the most significant risk factors for the development of post-stroke epilepsy Further studies regarding seizure prevention and neuroprotective therapies are needed because post-stroke epilepsy will affect long term prognosis in patients with pediatric stroke.
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Affiliation(s)
- İpek Polat
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Uluç Yiş
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Müge Ayanoğlu
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Derya Okur
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Pınar Edem
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Cem Paketçi
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Erhan Bayram
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Semra Hız Kurul
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
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Malone LA, Felling RJ. Pediatric Stroke: Unique Implications of the Immature Brain on Injury and Recovery. Pediatr Neurol 2020; 102:3-9. [PMID: 31371122 PMCID: PMC6959511 DOI: 10.1016/j.pediatrneurol.2019.06.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 06/17/2019] [Accepted: 06/26/2019] [Indexed: 02/07/2023]
Abstract
Pediatric stroke causes significant morbidity for children resulting in lifelong neurological disability. Although hyperacute recanalization therapies are available for pediatric patients, most patients are ineligible for these treatments. Therefore the mainstay for pediatric stroke treatment relies on rehabilitation to improve outcomes. Little is known about the ideal rehabilitation therapies for pediatric patients with stroke and the unique interplay between the developing brain and our models of stroke recovery. In this review, we first discuss the consequences of pediatric stroke. Second, we examine the scientific evidence that exists between the mechanisms of recovery and how they are different in the pediatric developing brain. Finally, we evaluate potential interventions that could improve outcomes.
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Affiliation(s)
- Laura A. Malone
- Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, MD 21287, United States
| | - Ryan J. Felling
- Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, MD 21287, United States
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Abstract
The aim of this study was to evaluate the clinical characteristics, risk factors, treatment, and outcomes of pediatric stroke cases. A total of 118 patients diagnosed with arterial ischemic stroke (AIS), hemorrhagic stroke, and sinovenous thrombosis (SVT) between January 2000 and December 2011 were included. Neonatal cases were excluded. Demographic and clinical findings were retrospectively examined from medical records. We identified 118 patients with stroke. The age of the patients ranged from 1 to 215 months (17.92 y), with a mean age of 5.19±5.25 years. AIS accounted for the majority of cases (n=69, 58.5%), and the major etiology was cardiac disease (17%). Hemorrhagic stroke accounted for 19.5% (n=23) of the cases, and late hemorrhagic disease of the newborn was the major etiology (43%, n=10). SVT accounted for 22% (n=26) of the cases, and the major etiology was otitis media-mastoiditis (27%, n=7). Hemiplegia and headache were the most frequent symptoms for AIS and SVT, respectively. Stroke is rare in children compared with adults; however, it is detected more frequently with better imaging techniques and increased awareness. We found that children with AIS presented more commonly with hemiplegia and children with SVT with headache and strabismus. We did not find an association between thrombophilia and stroke.
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Marchi A, Pennaroli D, Lagarde S, McGonigal A, Bonini F, Carron R, Lépine A, Villeneuve N, Trebuchon A, Pizzo F, Scavarda D, Bartolomei F. Epileptogenicity and surgical outcome in post stroke drug resistant epilepsy in children and adults. Epilepsy Res 2019; 155:106155. [DOI: 10.1016/j.eplepsyres.2019.106155] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 06/04/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022]
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Lopez-Espejo M, Hernandez-Chavez M, Huete I. Risk factors for in-hospital and follow-up mortality after childhood arterial ischemic stroke. J Neurol 2019; 266:1526-1532. [DOI: 10.1007/s00415-019-09293-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 03/19/2019] [Accepted: 03/21/2019] [Indexed: 01/10/2023]
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13
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Dingman AL, Rodgers KM, Dietz RM, Hickey SP, Frazier AP, Clevenger AC, Yonchek JC, Traystman RJ, Macklin WB, Herson PS. Oligodendrocyte Progenitor Cell Proliferation and Fate after White Matter Stroke in Juvenile and Adult Mice. Dev Neurosci 2019; 40:1-16. [PMID: 30861520 DOI: 10.1159/000496200] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 12/06/2018] [Indexed: 11/19/2022] Open
Abstract
The incidence of stroke in children is 2.4 per 100,000 person-years and results in long-term motor and cognitive disability. In ischemic stroke, white matter (WM) is frequently injured, but is relatively understudied compared to grey matter injury. Previous research suggests that the cellular response to WM ischemic injury is different at different ages. Little is known about whether WM repair mechanisms differ in children and adults. We utilized a model of focal ischemic WM injury to determine the oligodendrocyte (OL) response to focal WM ischemic injury in juvenile and adult mice. Methods: Juvenile (21-25 days of age) versus adult (2-3 months of age) mice underwent stereotaxic injection of the potent vasoconstrictor N5-(1-iminoethyhl)-L-ornithine (L-NIO) into the lateral corpus callosum (CC). Animals were sacrificed on postoperative day 3 (acute) or 21 (chronic). Cell birth-dating was performed acutely after WM stroke with 5-ethynyl-2-deoxyuridine (EdU) injected intraperitoneally. Immunohistochemistry was performed, as well as stereology, to measure injury volume. The acute oligodendrocyte progenitor cell (OPC) proliferation and the chronic OL cell fate were determined with immunohistochemistry. Compound action potentials were measured in the CC at acute and chronic time points. Results: Acutely WM injury volume was smaller in juveniles. There was significantly greater OPC proliferation in juvenile animals (acute) compared to adults, but newly born OLs did not survive and mature into myelinating cells at chronic time points. In addition, juveniles did not have improved histological or functional recovery when compared to adults. Protecting newly born OPCs is a potential therapeutic target in children with ischemic stroke.
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Affiliation(s)
- Andra L Dingman
- Division of Child Neurology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA,
| | - Krista M Rodgers
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Robert M Dietz
- Division of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Sean P Hickey
- Department of Cell and Developmental Biology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Alexandra P Frazier
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Amy C Clevenger
- Division of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Joan C Yonchek
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Richard J Traystman
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Wendy B Macklin
- Department of Cell and Developmental Biology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Paco S Herson
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
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14
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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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15
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Clinical and radiological risk factors for poststroke epilepsy in childhood. Epilepsy Behav 2018; 88:113-116. [PMID: 30253308 DOI: 10.1016/j.yebeh.2018.08.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 08/09/2018] [Accepted: 08/12/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND There are few studies evaluating risk factors for poststroke epilepsy (PSE) after an arterial ischemic stroke (AIS) in childhood. This study aimed to evaluate clinical and radiological predictors for PSE in a cohort of children with a first-ever AIS. METHODS A retrospective analysis of a single-center prospective consecutive cohort of children beyond neonatal age with a first-ever AIS admitted at the Pontifical Catholic University of Chile's Clinical Hospital between 2003 and 2013. All participants had a brain magnetic resonance imaging at the time of diagnosis. All children underwent follow-up for at least three years with an annual clinical evaluation. We used the current epilepsy definition of the International League Against Epilepsy. Studied variables include demographics, clinical manifestations at onset, stroke risk factors, and radiological characteristics of AIS. Cox proportional hazards regression analysis was used to evaluate PSE risk adjusted for clinical and radiological variables. RESULTS Among 98 children who met the study criteria, 41 (41.8%) with PSE. Following multivariate analysis, it was determined that the predictors of PSE include young age at AIS (hazard ratio [HR] = 0.91; confidence interval [CI] = 0.84-0.99), the occurrence of acute symptomatic seizures (HR = 3.29; CI = 1.35-8.01), cortical infarction (HR = 5.01; CI = 2.00-12.6), and multifocal infarction (HR = 3.27; CI = 1.01-10.8). CONCLUSION Seizures, young age, cortical lesions, and multiple infarction at the time of stroke are independent risk factors for PSE in children following a first-ever AIS.
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16
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Beslow LA, Dowling MM, Hassanein SMA, Lynch JK, Zafeiriou D, Sun LR, Kopyta I, Titomanlio L, Kolk A, Chan A, Biller J, Grabowski EF, Abdalla AA, Mackay MT, deVeber G. Mortality After Pediatric Arterial Ischemic Stroke. Pediatrics 2018; 141:peds.2017-4146. [PMID: 29695585 DOI: 10.1542/peds.2017-4146] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2018] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES Cerebrovascular disease is among the top 10 causes of death in US children, but risk factors for mortality are poorly understood. Within an international registry, we identify predictors of in-hospital mortality after pediatric arterial ischemic stroke (AIS). METHODS Neonates (0-28 days) and children (29 days-<19 years) with AIS were enrolled from January 2003 to July 2014 in a multinational stroke registry. Death during hospitalization and cause of death were ascertained from medical records. Logistic regression was used to analyze associations between risk factors and in-hospital mortality. RESULTS Fourteen of 915 neonates (1.5%) and 70 of 2273 children (3.1%) died during hospitalization. Of 48 cases with reported causes of death, 31 (64.6%) were stroke-related, with remaining deaths attributed to medical disease. In multivariable analysis, congenital heart disease (odds ratio [OR]: 3.88; 95% confidence interval [CI]: 1.23-12.29; P = .021), posterior plus anterior circulation stroke (OR: 5.36; 95% CI: 1.70-16.85; P = .004), and stroke presentation without seizures (OR: 3.95; 95% CI: 1.26-12.37; P = .019) were associated with in-hospital mortality for neonates. Hispanic ethnicity (OR: 3.12; 95% CI: 1.56-6.24; P = .001), congenital heart disease (OR: 3.14; 95% CI: 1.75-5.61; P < .001), and posterior plus anterior circulation stroke (OR: 2.71; 95% CI: 1.40-5.25; P = .003) were associated with in-hospital mortality for children. CONCLUSIONS In-hospital mortality occurred in 2.6% of pediatric AIS cases. Most deaths were attributable to stroke. Risk factors for in-hospital mortality included congenital heart disease and posterior plus anterior circulation stroke. Presentation without seizures and Hispanic ethnicity were also associated with mortality for neonates and children, respectively. Awareness and study of risk factors for mortality represent opportunities to increase survival.
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Affiliation(s)
- Lauren A Beslow
- Division of Neurology, Children's Hospital of Philadelphia, and Departments of Neurology and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania;
| | - Michael M Dowling
- Departments of Pediatrics and Neurology, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - John K Lynch
- Section on Stroke Diagnostics and Therapeutics, National Institute of Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Dimitrios Zafeiriou
- Division of Child Neurology and Developmental Pediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lisa R Sun
- Department of Neurology, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Ilona Kopyta
- Department of Pediatric Neurology, School of Medicine, Medical University of Silesia, Katowice, Poland
| | - Luigi Titomanlio
- Pediatric Emergency Département, Hôpital Robert Debré, Paris, France
| | - Anneli Kolk
- Department of Neuropsychology, University of Tartu, Tartu, Estonia
| | - Anthony Chan
- Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Canada
| | - Jose Biller
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | - Eric F Grabowski
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Abdalla A Abdalla
- Department of Neurosciences, Al Jalila Children's Hospital, Dubai, United Arab Emirates
| | - Mark T Mackay
- Department of Neurology, The Royal Children's Hospital, Melbourne, Australia; and
| | - Gabrielle deVeber
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
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