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Cavicchiolo ME, Brigiari G, Nosadini M, Pin JN, Vincenti A, Toldo I, Ancona C, Simioni P, D Errico I, Baraldi E, Sartori S. Cerebral venous thrombosis and deep medullary vein thrombosis: Padua experience over the last two decades. Eur J Pediatr 2024; 183:3461-3470. [PMID: 38780653 DOI: 10.1007/s00431-024-05602-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Cerebral venous thrombosis (CVT) is a cerebrovascular disorder that accounts for 20% of perinatal strokes. CVT incidence ranges from 0.67 to 1.12 per 100,000 newborns, while the incidence of "deep medullary vein thrombosis" (DMVT), a subtype of CVT, cannot be accurately estimated. This study aims to analyze the case history of CVT in the neonatal period, with a specific focus on DMVT. MATERIALS AND METHODS Newborns diagnosed with CVT, with or without DMVT, between January 2002 and April 2023, were collected using the Italian Registry of Infantile Thrombosis (RITI). Cerebral MRIs were reviewed by an expert neuroradiologist following a standardized protocol. RESULTS Forty-two newborns with CVT were identified, of which 27/42 (64%) had CVT, and the remaining 15/42 (36%) had DMVT (isolated DMVT in 9/15). Symptom onset occurred in the first week of life (median 8 days, IQR 4-14) with a male prevalence of 59%. The most common risk factors for CVT were complicated delivery (38%), prematurity (40%), congenital heart diseases (48%), and infections (40%). Seizures were the predominant presenting symptom in 52% of all cases. Hemorrhagic infarction was higher in cases with isolated DMVT (77%) compared to patients with CVT without DMVT (p = 0.013). Antithrombotic treatment was initiated in 36% of patients. Neurological impairment was observed in 48% of cases at discharge, while 18 out of 31 infants (58%) presented one or more neurological deficits at long term follow up. Conclusion: DMVT occurs in over a third of neonates with CVT. Multicentric studies are essential to establish standardized protocols for therapy, neuroimaging, and follow-up in these patients.
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Affiliation(s)
- Maria Elena Cavicchiolo
- Neonatal Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Via Giustiniani 3, 35128, Padua, Italy.
| | - Gloria Brigiari
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Margherita Nosadini
- Pediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | - Jacopo Norberto Pin
- Division of Neuropediatrics, Institute of Pediatrics of Southern Switzerland, Bellinzona, Switzerland
| | - Arianna Vincenti
- Pediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | - Irene Toldo
- Pediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | - Claudio Ancona
- Pediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | - Paolo Simioni
- General Internal Medicine and Thrombotic and Haemorrhagic Unit, Department of Medicine, University Hospital of Padova, Padova, Italy
| | - Ignazio D Errico
- Neuroradiology Unit, Department of Neuroscience, University Hospital of Padua, Padova, Italy
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Via Giustiniani 3, 35128, Padua, Italy
| | - Stefano Sartori
- Pediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
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Song Y, Li S, Hao L, Han Y, Wu W, Fan Y, Gao X, Li X, Ren C, Chen Y. Risk factors of neonatal stroke from different origins: a systematic review and meta-analysis. Eur J Pediatr 2024; 183:3073-3083. [PMID: 38661815 DOI: 10.1007/s00431-024-05531-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/12/2024] [Accepted: 03/17/2024] [Indexed: 04/26/2024]
Abstract
Given the persistent ambiguity regarding the etiology of neonatal stroke across diverse origins, our objective was to conduct a comprehensive evaluation of both qualitative and quantitative risk factors. An exhaustive search of eight databases was executed to amass all pertinent observational studies concerning risk factors for neonatal stroke from various origins. Subsequent to independent screening, data extraction, and bias assessment by two researchers, a meta-analysis was conducted utilizing RevMan and Stata software. Nineteen studies, encompassing a total of 30 factors, were incorporated into this analysis. Beyond established risk factors, our investigation unveiled gestational diabetes (OR, 5.51; P < 0.00001), a history of infertility (OR, 2.44; P < 0.05), placenta previa (OR, 3.92; P = 0.02), postdates (OR, 2.07; P = 0.01), preterm labor (OR, 2.32; P < 0.00001), premature rupture of membranes (OR, 3.02; P = 0.007), a prolonged second stage of labor (OR, 3.94; P < 0.00001), and chorioamnionitis (OR, 4.35; P < 0.00001) as potential risk factors for neonatal cerebral arterial ischemic stroke. Additionally, postdates (OR, 4.31; P = 0.003), preterm labor (OR, 1.60; P < 0.00001), an abnormal CTG tracing (OR, 9.32; P < 0.0001), cesarean section (OR, 4.29; P = 0.0004), male gender (OR, 1.73; P = 0.02), and vaginal delivery (OR, 1.39; P < 0.00001) were associated with an elevated risk for neonatal hemorrhagic stroke. CONCLUSIONS This study provides a succinct overview and comparative analysis of maternal, perinatal, and additional risk factors associated with neonatal cerebral artery ischemic stroke and neonatal hemorrhagic stroke, furnishing critical insights for healthcare practitioners involved in the diagnosis and prevention of neonatal stroke. This research also broadens the conceptual framework for future investigations. WHAT IS KNOWN • Research indicates that prenatal, perinatal, and neonatal risk factors can elevate the risk of neonatal arterial ischemic stroke (NAIS). However, the risk factors for neonatal cerebral arterial ischemic stroke remain contentious, and those for neonatal hemorrhagic stroke (NHS) and neonatal cerebral venous sinus thrombosis (CVST) are still not well-defined. WHAT IS NEW • This study is the inaugural comprehensive review and meta-analysis encompassing 19 studies that explore maternal, perinatal, and various risk factors linked to neonatal stroke of differing etiologies. Notably, our analysis elucidates eight risk factors associated with NAIS: gestational diabetes mellitus, a history of infertility, placenta previa, postdates, preterm birth, premature rupture of membranes, a prolonged second stage of labor, and chorioamnionitis. Furthermore, we identify six risk factors correlated with NHS: postdates, preterm birth, an abnormal CTG, the method of delivery, male gender, and vaginal delivery. Additionally, our systematic review delineates risk factors associated with CVST.
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Affiliation(s)
- Yankun Song
- Department of Pediatrics, First Affifiliated Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, 050000, China
| | - Shangbin Li
- Department of Pediatrics, First Affifiliated Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, 050000, China
| | - Ling Hao
- Department of Pediatrics, First Affifiliated Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, 050000, China
| | - Yiwei Han
- Department of Pediatrics, First Affifiliated Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, 050000, China
| | - Wenhui Wu
- Department of Pediatrics, First Affifiliated Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, 050000, China
| | - Yuqing Fan
- Department of Pediatrics, First Affifiliated Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, 050000, China
| | - Xiong Gao
- Department of Pediatrics, First Affifiliated Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, 050000, China
| | - Xueying Li
- Department of Pediatrics, First Affifiliated Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, 050000, China
| | - Changjun Ren
- Department of Pediatrics, First Affifiliated Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, 050000, China.
| | - Yuan Chen
- Department of Pediatrics, the Second Hospital of Hebei medical university, Hebei Medical University, Shijiazhuang, 050000, China.
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Munster CB, El-Shibiny H, Szakmar E, Yang E, Walsh BH, Inder TE, El-Dib M. Magnetic resonance venography to evaluate cerebral sinovenous thrombosis in infants receiving therapeutic hypothermia. Pediatr Res 2023; 93:985-989. [PMID: 35854084 DOI: 10.1038/s41390-022-02195-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 06/14/2022] [Accepted: 06/28/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The incidence of cerebral sinovenous thrombosis (CSVT) in infants receiving therapeutic hypothermia for neonatal encephalopathy remains controversial. The aim of this study was to identify if the routine use of magnetic resonance venography (MRV) in term-born infants receiving hypothermia is associated with diagnostic identification of CSVT. METHODS We performed a retrospective review of 291 infants who received therapeutic hypothermia from January 2014 to March 2020. Demographic and clinical data, as well as the incidence of CSVT, were compared between infants born before and after adding routine MRV to post-rewarming magnetic resonance imaging (MRI). RESULTS Before routine inclusion of MRV, 209 babies were cooled, and 25 (12%) underwent MRV. Only one baby (0.5%) was diagnosed with CSVT in that period, and it was detected by structural MRI, then confirmed with MRV. After the inclusion of routine MRV, 82 infants were cooled. Of these, 74 (90%) had MRV and none were diagnosed with CSVT. CONCLUSION CSVT is uncommon in our cohort of infants receiving therapeutic hypothermia for neonatal encephalopathy. Inclusion of routine MRV in the post-rewarming imaging protocol was not associated with increased detection of CSVT in this population. IMPACT Cerebral sinovenous thrombosis (CSVT) in infants with NE receiving TH may not be as common as previously indicated. The addition of MRV to routine post-rewarming imaging protocol did not lead to increased detection of CSVT in infants with NE. Asymmetry on MRV of the transverse sinus is a common anatomic variant. MRI alone may be sufficient in indicating the presence of CSVT.
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Affiliation(s)
- Chelsea B Munster
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Hoda El-Shibiny
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Eniko Szakmar
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Edward Yang
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Brian H Walsh
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
| | - Terrie E Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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Xia Q, Yang Z, Xie Y, Zhu Y, Yang Z, Hei M, Ding Y, Kong W, Kang L, Yang S, Mei Y, Feng Z, Zhang L, Lei Y, Wang P, Dong J, Yang L, Ju J, Chang H, Zhan S, Yu J, Zhang P, Wang R, Guo H, Liu X, Tan H, Liu Y, Zhang Z, Zhen L, Yan J, Liu Z, Yang C, Wang Q, Wang J, Sun L, Zeng H, Li J, Qu W, Wang X, Liu G, Yang X, Liu X, Zhang X, Xu X, Gu Y, Long H, Zhang L, Liu L, Tang Z, Hou X. The Incidence and Characteristics of Perinatal Stroke in Beijing: A Multicenter Study. Front Public Health 2022; 10:783153. [PMID: 35400054 PMCID: PMC8987304 DOI: 10.3389/fpubh.2022.783153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 01/31/2022] [Indexed: 02/05/2023] Open
Abstract
ObjectiveTo assess the incidence, risk factors, and clinical characteristics of perinatal stroke in Beijing.MethodsThis multicenter prospective study included all the live births from 17 representative maternal delivery hospitals in Beijing from March 1, 2019 to February 29, 2020. Neonates with a stroke were assigned to the study group. Clinical data, including general information, clinical manifestations, and risk factors, were collected. Up until 18 months after birth, neonates were routinely assessed according to the Ages and Stages Questionnaire (ASQ) and/or the Bayley scale. Statistical analysis was done using the chi-squared, t-tests, and logistic regression analysis using SPSS version 26.0.OutcomesIn total, 27 cases were identified and the incidence of perinatal stroke in Beijing was 1/2,660 live births, including 1/5,985 for ischemic stroke and 1/4,788 for hemorrhagic stroke. Seventeen cases (62.96%) of acute symptomatic stroke and convulsions within 72 h (10 cases, 37.04%) were the most common presentations. Ten patients showed no neurological symptoms and were found to have had a stroke through routine cranial ultrasonography after being hospitalized for non-neurological diseases. The risk factors include primiparity, placental or uterine abruption/acute chorioamnionitis, intrauterine distress, asphyxia, and severe infection. In the study group, 11.1% (3/27) of patients had adverse neurodevelopmental outcomes. The patients in the study group had lower scores for the ASQ than those in the control group in the communication, gross, and fine motor dimensions.ConclusionThe incidence of perinatal stroke in Beijing was consistent with that in other countries. Routine neuroimaging of infants with risk factors may enable identification of asymptomatic strokes in more patients. Patients who have suffered from a stroke may have neurological sequelae; therefore, early detection, treatment, and regular follow-ups are beneficial for improving their recovery outcomes.
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Affiliation(s)
- Qianqian Xia
- Pediatric Department, Peking University First Hospital, Beijing, China
| | - Zhao Yang
- Pediatric Department, Peking University First Hospital, Beijing, China
| | - Yao Xie
- Pediatric Department, Peking University First Hospital, Beijing, China
| | - Ying Zhu
- Pediatric Department, Peking University First Hospital, Beijing, China
| | - Zixin Yang
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Mingyan Hei
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yingxue Ding
- Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Weijing Kong
- Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Limin Kang
- Department of Neonatology, Children's Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Shengnan Yang
- Department of Neonatology, Children's Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Yabo Mei
- Neonatal Intensive Care Unit of Faculty of Pediatrics, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Zhichun Feng
- Neonatal Intensive Care Unit of Faculty of Pediatrics, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Li Zhang
- Pediatric Department, Haidian Maternal and Child Health Hospital, Beijing, China
| | - Yanzhe Lei
- Pediatric Department, Haidian Maternal and Child Health Hospital, Beijing, China
| | - Ping Wang
- Department of Neonatology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Jingyu Dong
- Pediatric Department, Tongzhou Maternal and Child Health Hospital, Beijing, China
| | - Li Yang
- Pediatric Department, Tongzhou Maternal and Child Health Hospital, Beijing, China
| | - Jun Ju
- Pediatric Department, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Hesheng Chang
- Pediatric Department, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Shina Zhan
- Pediatric Department, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, Beijing, China
| | - Jinqian Yu
- Pediatric Department, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, Beijing, China
| | - Peng Zhang
- Pediatric Department, Beijing Miyun Maternal and Child Health Hospital, Beijing, China
| | - Ran Wang
- Pediatric Department, Beijing Miyun Maternal and Child Health Hospital, Beijing, China
| | - Hui Guo
- Pediatric Department, Fengtai Maternal and Child Health Hospital, Beijing, China
| | - Xinli Liu
- Pediatric Department, Fengtai Maternal and Child Health Hospital, Beijing, China
| | - Huaqing Tan
- Pediatric Department, Beijing Daxing Maternal and Child Care Hospital, Beijing, China
| | - Yakun Liu
- Pediatric Department, Beijing Daxing Maternal and Child Care Hospital, Beijing, China
| | - Zhenzong Zhang
- Pediatric Department, The First Hospital of Fangshan, Beijing, China
| | - Lixia Zhen
- Pediatric Department, The First Hospital of Fangshan, Beijing, China
| | - Jinting Yan
- Pediatric Department, Beijing Mentougou Hospital, Beijing, China
| | - Zhan Liu
- Pediatric Department, Beijing Mentougou Hospital, Beijing, China
| | - Chunxia Yang
- Pediatric Department, Changping Women and Children Health Care Hospital, Beijing, China
| | - Qingqing Wang
- Pediatric Department, Changping Women and Children Health Care Hospital, Beijing, China
| | - Jinfeng Wang
- Beijing Pinggu Maternal and Child Health Hospital, Beijing, China
| | - Lifang Sun
- Beijing Pinggu Maternal and Child Health Hospital, Beijing, China
| | - Huihui Zeng
- Pediatric Department, Huairou Maternal and Child Health Care Hospital, Beijing, China
| | - Jing Li
- Pediatric Department, Huairou Maternal and Child Health Care Hospital, Beijing, China
| | - Wenwen Qu
- Department of Pediatrics, Peking University Shougang Hospital and Capital Medical University, Beijing, China
| | - Xuemei Wang
- Department of Pediatrics, Peking University Shougang Hospital and Capital Medical University, Beijing, China
- General Respiratory Department of Beijing Jingdu Children's Hospital, Beijing, China
| | - Guiying Liu
- Department of Pediatrics, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xi Yang
- Department of Pediatrics, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xinxin Liu
- Pediatric Department, Fifth Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Xuefeng Zhang
- Pediatric Department, Fifth Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Xiaojing Xu
- Pediatric Department, The First Hospital of Tsinghua University, Beijing, China
| | - Yanan Gu
- Pediatric Department, The First Hospital of Tsinghua University, Beijing, China
| | - Hui Long
- Department of Pediatrics, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Li Zhang
- Department of Pediatrics, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Lili Liu
- Pediatric Department, Peking University First Hospital, Beijing, China
- *Correspondence: Lili Liu
| | - Zezhong Tang
- Pediatric Department, Peking University First Hospital, Beijing, China
- Zezhong Tang
| | - Xinlin Hou
- Pediatric Department, Peking University First Hospital, Beijing, China
- Xinlin Hou
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Bedetti L, Poluzzi S, Guidotti I, Lucaccioni L, Rota C, Cavalleri F, Pugliese M, Iughetti L, Lugli L, Berardi A. Multiple thrombosis of the cerebral venous sinuses, neonatal seizures, and minor parenchymal lesions: a case report and a review of the literature. J Matern Fetal Neonatal Med 2022; 35:8507-8510. [PMID: 35135398 DOI: 10.1080/14767058.2021.1986480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Cerebral sinovenous thrombosis (CSVT) is a rare disease with potential catastrophic consequences. However, neonatal brain damage after venous injury and long-term neurologic outcomes have been poorly investigated. Some found an association between site and number of sinus occlusions, severity of lesions, clinical presentation and the neurodevelopmental outcome. CASE PRESENTATION We describe the case of a term newborn girl with multiple CSVT who presented with clonic seizures and who received early treatment with heparin. MRI scans showed a progressive recanalization of deep venous system, and only minor cerebral lesions were present at 3 months of life. Neurocognitive outcome was normal at 12 months of life. CONCLUSIONS This case demonstrates that multiple CSVT presenting with severe seizures does not necessarily underlie major cerebral lesions or lead to severely abnormal neurodevelopmental outcome.
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Affiliation(s)
- Luca Bedetti
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy.,Neonatal Intensive Care Unit, Women's and Children's Health Department, University Hospital of Modena, Modena, Italy
| | - Silvia Poluzzi
- Maternal and Child Department, Pediatric Postgraduate School, University of Modena and Reggio Emilia, Modena, Italy
| | - Isotta Guidotti
- Neonatal Intensive Care Unit, Women's and Children's Health Department, University Hospital of Modena, Modena, Italy
| | - Laura Lucaccioni
- Pediatrics, Women's and Children's Health Department, University Hospital of Modena, Modena, Italy
| | - Claudio Rota
- Department of Pediatrics, Nuovo Ospedale Civile, Sassuolo, Italy
| | | | - Marisa Pugliese
- Neonatal Intensive Care Unit, Women's and Children's Health Department, University Hospital of Modena, Modena, Italy
| | - Lorenzo Iughetti
- Maternal and Child Department, Pediatric Postgraduate School, University of Modena and Reggio Emilia, Modena, Italy.,Pediatrics, Women's and Children's Health Department, University Hospital of Modena, Modena, Italy
| | - Licia Lugli
- Neonatal Intensive Care Unit, Women's and Children's Health Department, University Hospital of Modena, Modena, Italy
| | - Alberto Berardi
- Neonatal Intensive Care Unit, Women's and Children's Health Department, University Hospital of Modena, Modena, Italy
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Sun J, Chen D, Mao J. Research advances in neonatal cerebral sinovenous thrombosis. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:860-866. [PMID: 34511178 DOI: 10.7499/j.issn.1008-8830.2105146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Neonatal cerebral sinovenous thrombosis (CSVT) is a cerebrovascular disease with a seriously underestimated incidence rate. Due to a lack of specific clinical manifestations and the low sensitivity of conventional imaging examinations, it has long been considered a rare disease in neonates. In recent years, the development of magnetic resonance technology has improved the diagnostic rate of CSVT. This article reviews the research advances in intracranial venous anatomy of neonates and clinical manifestations, imaging features, treatment, and prognosis of CSVT and deep venous thrombosis, in order to improve the understanding and to make correct diagnosis and treatment of neonatal CSVT.
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Affiliation(s)
- Jing Sun
- Department of Neonatology, Shengjing Hospital, China Medical University, Shenyang 110004, China
| | - Dan Chen
- Department of Neonatology, Shengjing Hospital, China Medical University, Shenyang 110004, China
| | - Jian Mao
- Department of Neonatology, Shengjing Hospital, China Medical University, Shenyang 110004, China
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Clinical Profile and Long-Term Outcome in Neonatal Cerebral Sinus Venous Thrombosis. Pediatr Neurol 2021; 121:20-25. [PMID: 34126318 DOI: 10.1016/j.pediatrneurol.2021.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/20/2021] [Accepted: 05/01/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Neonatal cerebral sinus venous thrombosis (CSVT) causes high morbidity and mortality. Factors associated with either favorable or unfavorable long-term outcomes have not been clearly established. This study aimed to determine the factors involved in long-term neurological outcomes in patients with neonatal CSVT. METHODS This was a retrospective cohort study of patients with neonatal CSVT at a single institution. Clinical factors associated with long-term neurological outcomes were examined. RESULTS A total of 67 patients met study inclusion criteria for radiologically confirmed neonatal CSVT. The mean patient follow-up duration was four years (range one week to 16 years, median six years). We observed a favorable neurological outcome defined by a pediatric stroke outcome measures (PSOM) score of 0 to 0.5 in 26 (53%) of osurviving patients at follow-up. An unfavorable neurological outcome as defined by PSOM score >0.5 was observed in 23 survivors (47%). Death was reported in 18 (27%) patients, of which 10 patients died due to direct complications of CSVT. Congential heart disease and genetic disease were associated with significantly increased odds for all-cause death. Cardiorespiratory failure and altered mental status during the initial neurological examination were significantly associated with increased odds of death due to CSVT. Among surviving patients, higher PSOM scores were associated with premature birth (i.e., gestational age < 37 weeks), traumatic birth, site of thrombosis in the straight sinus, site of thrombosis in the internal cerebral veins, and hemorrhagic infarct. In contrast, lower PSOM scores were associated with a normal neurological examination at presentation, thrombosis in only superficial sinuses, and hemorrhage without infarct. There was no statistically significant association between the type and duration of CSVT treatment. CONCLUSIONS The major factors influencing outcome of neonates following CSVT included comorbid medical conditions, abnormal neurological examination at presentation, location of venous thrombosis, and type of cerebral injury. These results can help guide further studies in neonatal CSVT aiming to decrease morbidity and mortality with the goal of improving long-term neurological outcomes.
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Sorg AL, Von Kries R, Klemme M, Gerstl L, Beyerlein A, Lack N, Felderhoff-Müser U, Dzietko M. Incidence and risk factors of cerebral sinovenous thrombosis in infants. Dev Med Child Neurol 2021; 63:697-704. [PMID: 33506500 DOI: 10.1111/dmcn.14816] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2020] [Indexed: 12/16/2022]
Abstract
AIM To describe the incidence of term and preterm neonatal cerebral sinovenous thrombosis (CSVT) and identify perinatal risk factors. METHOD This was a national capture-recapture calculation-corrected surveillance and nested case-control study. Infants born preterm and at term with magnetic resonance imaging-confirmed neonatal CSVT were identified by surveillance in all paediatric hospitals in Germany (2015-2017). Incidence was corrected for underreporting using a capture-recapture method in one federal state and then extrapolated nationwide. We reviewed PubMed for comparisons with previously reported incidence estimators. We used a population-based perinatal database for quality assurance to select four controls per case and applied univariate and multivariable regression for risk factor analysis. RESULTS Fifty-one newborn infants (34 males, 17 females; 14 born preterm) with neonatal CSVT were reported in the 3-year period. The incidence of term and preterm neonatal CSVT was 6.6 (95% confidence interval [CI] 4.4-8.7) per 100 000 live births. Median age at time of confirmation of the diagnosis was 9.95 days (range 0-39d). In the univariate analysis, male sex, preterm birth, hypoxia and related indicators (umbilical artery pH <7.1; 5-minute Apgar score <7; intubation/mask ventilation; perinatal asphyxia), operative vaginal delivery, emergency Caesarean section, and pathological fetal Doppler sonography were associated (p<0.05) with neonatal CSVT. Multivariable regression yielded hypoxia (odds ratio=20.3; 95% CI 8.1-50.8) as the independent risk factor. INTERPRETATION Incidence of neonatal CSVT was within the range of other population-based studies. The results suggest that hypoxia is an important perinatal risk factor for the aetiology of neonatal CSVT.
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Affiliation(s)
- Anna-Lisa Sorg
- Institute of Social Paediatrics and Adolescent Medicine, Division of Paediatric Epidemiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Rüdiger Von Kries
- Institute of Social Paediatrics and Adolescent Medicine, Division of Paediatric Epidemiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Mathias Klemme
- Department of Neonatology, University Children's Hospital and Perinatal Centre, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Lucia Gerstl
- Department of Paediatric Neurology, University Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Andreas Beyerlein
- Institute of Computational Biology, Helmholtz Zentrum München, Neuherberg, Germany
| | - Nicholas Lack
- Bavarian Quality Assurance for In-Patient Medical Care, Munich, Germany
| | | | - Mark Dzietko
- Department of Paediatrics I, Neonatology, University Duisburg-Essen, Essen, Germany
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Sellers A, Meoded A, Quintana J, Jallo G, Amankwah E, Nguyen ATH, Betensky M, Mills K, Goldenberg N, Shimony N. Risk factors for pediatric cerebral sinovenous thrombosis: A case-control study with case validation. Thromb Res 2020; 194:8-15. [PMID: 32554256 DOI: 10.1016/j.thromres.2020.06.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/09/2020] [Accepted: 06/06/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Cerebral sinovenous thrombosis (CSVT) represents the second most common type of venous thromboembolism (VTE) in children. Current literature includes limited evidence on risk factors for CSVT, particularly in the pediatric population. We sought to determine risk factors for CSVT in pediatric patients through a single-institutional case-control study. In addition, we evaluated thrombophilias, treatments and outcomes in CSVT among cases. METHODS A case-control study was performed at Johns Hopkins All Children's Hospital on patients admitted from March 31, 2006 through April 1, 2018. Cases were identified using diagnostic codes and confirmed based on electronic health record (EHR) and neuroimaging review. Controls were matched in a 2:1 fashion accounting for the month and year of admission. RESULTS A total of 60 CSVT cases and 120 controls were identified. Median (range) age was 4.8 years (0-21.3 years) for cases and 5.6 years (0-20.0 years) for controls. Factors putatively associated with CSVT in unadjusted analyses were: corticosteroid use, presence of a central venous catheter, mechanical ventilation, systemic infection, head/neck infection, head/neck trauma, and chronic inflammatory disease. In the multivariable model, head/neck infection (OR: 13.8, 95% CI: 4.87-38.7; P < 0.01), head/neck trauma (OR: 12.7, 95% CI: 2.88-56.2; P < 0.01), and mechanical ventilation (OR: 9.32, 95% CI: 2.35-36.9; P = 0.01) remained independent, statistically-significant risk factors. 61% of patients were subacutely treated with anticoagulants and of those, only two developed relevant bleeding after initiation of therapy. CONCLUSIONS This single-institutional case-control study reveals that head/neck infection, head/neck trauma, and mechanical ventilation are independent risk factors for pediatric CSVT. These findings will be further investigated via a cooperative registry of pediatric hospital-acquired VTE, by which a risk model for pediatric CSVT will be developed and validated, in order to inform future preventive strategies in at-risk pediatric patients.
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Affiliation(s)
- Austin Sellers
- Office of Medical Education, Lake Erie College of Osteopathic Medicine, Bradenton, FL, USA; Johns Hopkins All Children's Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Avner Meoded
- Department of Radiology, Division of Pediatric Neuroradiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Javier Quintana
- Department of Radiology, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA; Johns Hopkins Medicine Pediatric Thrombosis Program, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA; Johns Hopkins All Children's Stroke Program, St. Petersburg, FL, USA
| | - George Jallo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins All Children's Institute for Brain Protection Sciences, St. Petersburg, FL, USA
| | - Ernest Amankwah
- Johns Hopkins All Children's Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA; Department of Oncology, Division of Pediatric Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Epidemiology and Biostatistics Unit, Johns Hopkins All Children's Health Informatics, St. Petersburg, FL, USA
| | - Anh Thy H Nguyen
- Epidemiology and Biostatistics Unit, Johns Hopkins All Children's Health Informatics, St. Petersburg, FL, USA
| | - Marisol Betensky
- Johns Hopkins All Children's Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA; Department of Pediatrics, Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins All Children's Cancer and Blood Disorders Institute, St. Petersburg, FL, USA
| | - Katie Mills
- Johns Hopkins All Children's Cancer and Blood Disorders Institute, St. Petersburg, FL, USA
| | - Neil Goldenberg
- Johns Hopkins All Children's Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA; Johns Hopkins Medicine Pediatric Thrombosis Program, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA; Johns Hopkins All Children's Stroke Program, St. Petersburg, FL, USA; Johns Hopkins All Children's Institute for Brain Protection Sciences, St. Petersburg, FL, USA; Department of Pediatrics, Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins All Children's Cancer and Blood Disorders Institute, St. Petersburg, FL, USA; Department of Medicine, Division of Hematology, Johns Hopkins School of Medicine, Baltimore, MD, USA; Johns Hopkins Medicine Pediatric Thrombosis Program, Johns Hopkins Children's Center, Baltimore, MD, USA.
| | - Nir Shimony
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins All Children's Institute for Brain Protection Sciences, St. Petersburg, FL, USA; Department of Neurosurgery, Geisinger Medical Center, Danville, PA, USA; Department of Neuroscience, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
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10
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Mineyko A, Kirton A, Billinghurst L, Tatishvili NN, Wintermark M, deVeber G, Fox C. Seizures and Outcome One Year After Neonatal and Childhood Cerebral Sinovenous Thrombosis. Pediatr Neurol 2020; 105:21-26. [PMID: 31882182 PMCID: PMC7071986 DOI: 10.1016/j.pediatrneurol.2019.08.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/16/2019] [Accepted: 08/20/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pediatric cerebral sinovenous thrombosis is a treatable cause of brain injury, acute symptomatic seizures, and remote epilepsy. Our objective was to prospectively study epilepsy and outcomes in neonates and children one year after cerebral sinovenous thrombosis diagnosis. METHODS Patients with cerebral sinovenous thrombosis were enrolled prospectively from 21 international sites through the Seizures in Pediatric Stroke Study. Clinical data, including acute symptomatic seizures and cerebral sinovenous thrombosis risk factors, were collected at diagnosis. A neuroradiologist who was unaware of the diagnosis reviewed acute imaging. At one year, outcomes including seizure recurrence, epilepsy diagnosis, antiepileptic drug use, and modified Engel score were collected. Outcomes were assessed using the modified Rankin score and the King's Outcome Scale for Childhood Head Injury. RESULTS Twenty-four participants with cerebral sinovenous thrombosis were enrolled (67% male, 21% neonates). Headache was the most common presenting symptom in non-neonates (47%, nine of 19). Nine (37.5%) presented with acute symptomatic seizures. Six (25%; 95% confidence interval, 10% to 47%) developed epilepsy by one-year follow-up. No clinical predictors associated with epilepsy were identified. King's Outcome Scale for Childhood Head Injury and modified Rankin scores at one year were favorable in 71%. Half of the patients who developed epilepsy (three of six) did not have infarcts, hemorrhage, or seizures identified during the acute hospitalization. CONCLUSION Our study provides a prospective estimate that epilepsy occurs in approximately one-quarter of patients by one year after diagnosis of cerebral sinovenous thrombosis. Later epilepsy can develop in the absence of acute seizures or parenchymal injury associated with the acute presentation.
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Affiliation(s)
- Aleksandra Mineyko
- Section of Neurology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Section of Neurology, Department Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Adam Kirton
- Section of Neurology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Section of Neurology, Department Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lori Billinghurst
- Division of Neurology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nana Nino Tatishvili
- Department of Neurosciences, D. Tvildiani Medical University, M. Iashvili Central Children Hospital, Tbilis, Georgia
| | - Max Wintermark
- Neuroimaging and Neurointervention Division, Department of Radiology, Stanford University Hospital, Stanford, California
| | - Gabrielle deVeber
- Neurology Division, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Christine Fox
- Department of Neurology, University of California San Francisco, San Francisco, California; Department of Pediatrics, University of California San Francisco, San Francisco, California
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11
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Abstract
Perinatal stroke is a heterogeneous syndrome resulting from brain injury of vascular origin that occurs between 20 weeks of gestation and 28 days of postnatal life. The incidence of perinatal stroke is estimated to be between 1:1600 and 1:3000 live births (approximately 2500 children per year in the United States), though its actual incidence is difficult to estimate because it is likely underdiagnosed. Perinatal arterial ischemic stroke (PAIS) accounts for approximately 70% of cases of perinatal stroke. Cerebral sinovenous thrombosis, while less common, also accounts for a large proportion of the morbidity and mortality seen with perinatal stroke. Hemorrhagic stroke leads to disruption of neurologic function due to intracerebral hemorrhage that is nontraumatic in origin. While most cases of PAIS fall into one of these three categories, other patterns of injury should also be considered perinatal stroke. In some cases, the etiology of PAIS is not known but is idiopathic. This chapter will review the classification, risk factors, pathogenesis, clinical presentation, management, and long-term sequelae of perinatal stroke.
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Affiliation(s)
- Emmett E Whitaker
- Department of Anesthesiology, University of Vermont Larner College of Medicine, Burlington, VT, United States; Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, United States.
| | - Marilyn J Cipolla
- Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, United States; Department of Obstetrics, Gynecology & Reproductive Sciences, University of Vermont Larner College of Medicine, Burlington, VT, United States; Department of Pharmacology, University of Vermont Larner College of Medicine, Burlington, VT, United States
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12
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Abstract
Perinatal strokes are a diverse but specific group of focal cerebrovascular injuries that occur early in brain development and affect an estimated 5 million people worldwide. The objective of this review is to describe the epidemiology, clinical presentations, pathophysiology, outcomes, and management for the 6 subtypes of perinatal stroke. Some perinatal strokes are symptomatic in the first days of life, typically with seizures, including neonatal arterial ischemic stroke, neonatal hemorrhagic stroke, and cerebral sinovenous thrombosis. The remaining subtypes present in the first year of life or later, usually with motor asymmetry and include arterial presumed perinatal ischemic stroke, presumed perinatal hemorrhagic stroke, and in utero periventricular venous infarction. The consequences of these injuries include cerebral palsy, epilepsy, and cognitive and behavioral challenges, in addition to the psychosocial impact on families. While there have been significant advances in understanding mechanisms of both injury and recovery, there is still a great deal to learn regarding causation and the optimization of outcomes.
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Affiliation(s)
- Mary Dunbar
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; Calgary Pediatric Stroke Program, University of Calgary, Calgary, AB, Canada
| | - Adam Kirton
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada; Department of Clinical Neuroscience, University of Calgary, Calgary, AB, Canada; Department of Radiology, Faculty of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, Calgary, AB, Canada; Hotchkiss Brain Institute, Calgary, AB, Canada; Calgary Pediatric Stroke Program, University of Calgary, Calgary, AB, Canada.
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13
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Garrido-Barbero M, Arnaez J, Loureiro B, Arca G, Agut T, Garcia-Alix A. The Role of Factor V Leiden, Prothrombin G20210A, and MTHFR C677T Mutations in Neonatal Cerebral Sinovenous Thrombosis. Clin Appl Thromb Hemost 2019; 25:1076029619834352. [PMID: 31025572 PMCID: PMC6714919 DOI: 10.1177/1076029619834352] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Little is known about the pathogenesis of cerebral sinovenous thrombosis (CSVT) in the
neonate. Although thrombophilia has been described as increasing the risk of CSVT in
adults, it remains controversial in pediatric patients, and prospective case–control
studies regarding neonatal CSVT are lacking. From 2008 to 2017, all 26 consecutive newborn
infants ≥35 weeks of gestation diagnosed with neonatal CSVT, and their mothers, were
tested for factor V Leiden (FV) G1691A, FII G20210A, and methylenetetrahydrofolate
reductase C677T (MTHFR C677T) mutations. Eighty-five mother–infant pairs were recruited as
controls. All infants except 1 with CSVT were suspected due to clinical symptoms, mainly
seizures (22/25). Magnetic resonance imaging was performed in 24/26 infants. Heterozygous
FV G1691A, FII G20210A, and homozygous MTHFR C677T mutations were present in 1/26, 3/26,
and 3/20 infants with CSVT, respectively. FII (odds ratio: 10.96; 95% confidence interval
[CI]: 1.09-110.35) and male sex (3.93; 95% CI: 1.43-10.76) were associated with CSVT. When
FII G20210A analysis was adjusted for sex, the OR for FII G20210A was 6.70 (95% CI:
0.65-69.22). No differences were found for FV G1691A or homozygous MTHFR mutations between
neonates with CSVT and their mothers, compared to controls.
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Affiliation(s)
| | - Juan Arnaez
- Unidad Neonatal, Hospital Universitario de Burgos, Burgos, Spain
- Fundación NeNe, Spain
- Juan Arnaez, Neonatologia, Hospital Universitario de
Burgos, Islas Baleares, 3, 09006 Burgos, Spain.
| | - Begoña Loureiro
- Unidad Neonatal, Hospital Universitario Cruces, Vizcaya, Spain
| | - Gemma Arca
- Unidad Neonatal, Hospital Universitario Clinic Maternitat, Barcelona,
Spain
| | - Thais Agut
- Fundación NeNe, Spain
- Unidad Neonatal, Institut de Recerca Pediatrica Sant Joan de Dèu, Hospital
Sant Joan de Dèu, Barcelona, Spain
| | - Alfredo Garcia-Alix
- Fundación NeNe, Spain
- Unidad Neonatal, Institut de Recerca Pediatrica Sant Joan de Dèu, Hospital
Sant Joan de Dèu, Barcelona, Spain
- Universitat de Barcelona, Barcelona, Spain
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14
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Fluss J, Dinomais M, Chabrier S. Perinatal stroke syndromes: Similarities and diversities in aetiology, outcome and management. Eur J Paediatr Neurol 2019; 23:368-383. [PMID: 30879961 DOI: 10.1016/j.ejpn.2019.02.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 02/04/2019] [Accepted: 02/24/2019] [Indexed: 01/09/2023]
Abstract
With a birth-prevalence of 37-67/100,000 (mostly term-born), perinatal stroke encompasses distinct disease-states with diverse causality, mechanism, time of onset, mode of presentation and outcome. Neonatal primary haemorrhagic stroke and ischemic events (also divided into neonatal arterial ischemic stroke and neonatal cerebral sinus venous thrombosis) that manifest soon after birth are distinguished from presumed perinatal - ischemic or haemorrhagic - stroke. Signs of the latter become apparent only beyond the neonatal period, most often with motor asymmetry or milestones delay, and occasionally with seizures. Acute or remote MRI defines the type of stroke and is useful for prognosis. Acute care relies on homeostatic maintenance. Seizures are often self-limited and anticonvulsant agents might be discontinued before discharge. Prolonged anticoagulation for a few weeks is an option in some cases of sinovenous thrombosis. Although the risk of severe impairment is low, many children develop mild to moderate multimodal developmental issues that require a multidisciplinary approach.
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Affiliation(s)
- Joel Fluss
- Pediatric Neurology Unit, Geneva Children's Hospital, 6 rue Willy-Donzé, 1211 Genève 4, Switzerland
| | - Mickaël Dinomais
- CHU Angers, Département de Médecine Physique et de Réadaptation, CHU Angers-Capucins, F-49933, Angers, France; Université d'Angers, Laboratoire Angevin de Recherche en Ingénierie des Systèmes (LARIS) EA7315, F-49000, Angers, France
| | - Stéphane Chabrier
- CHU Saint-Étienne, French Centre for Paediatric Stroke, Paediatric Physical and Rehabilitation Medicine Department, INSERM, CIC 1408, F-42055, Saint-Étienne, France; INSERM, U1059 Sainbiose, Univ Saint-Étienne, Univ Lyon, F-42023, Saint-Étienne, France.
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15
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Abstract
Cerebral sinovenous thrombosis (CSVT) is a focal or diffuse disruption of cerebral blood flow secondary to occlusion of cerebral veins and/or sinuses. The challenge of CSVT during the neonatal age has led to a great interest in this condition among neonatologists, child neurologists, and pediatric neuroradiologists. The highly variable clinical spectra, etiologies, and prognosis require fine medical skills and a high level of suspicion. Nevertheless, the diagnosis is often delayed or missed altogether. Differences in brain vulnerability at different stages of maturation may explain the spectrum of associated brain lesions, which varies with gestational age. Treatment is controversial and reported clinical outcomes vary widely. The controversial treatment of CSVT with anticoagulant therapy is based only on case series and expert consensus, there is lack of safety data.
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Affiliation(s)
- Luca A Ramenghi
- Neonatal Intensive Care Unit, Giannina Gaslini Children's Hospital, Genova, Italy.
| | - Valentina Cardiello
- Neonatal Intensive Care Unit, Giannina Gaslini Children's Hospital, Genova, Italy
| | - Andrea Rossi
- Neonatal Intensive Care Unit, Giannina Gaslini Children's Hospital, Genova, Italy
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16
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Perinataler Schlaganfall und Sinusvenenthrombose: Klinik, Diagnostik und therapeutische Ansätze. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-016-0132-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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17
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Lolli V, Molinari F, Pruvo JP, Soto Ares G. Radiological and clinical features of cerebral sinovenous thrombosis in newborns and older children. J Neuroradiol 2016; 43:280-9. [PMID: 26970861 DOI: 10.1016/j.neurad.2015.12.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 12/08/2015] [Accepted: 12/19/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE Cerebral sinovenous thrombosis (CSVT) represents an increasingly recognized cause of pediatric stroke. Our purpose was to assess gender and age differences in the etiology, clinical presentation, and imaging features of CSVT in neonates and older children. METHODS Subjects aged newborn to 18 years diagnosed with CSVT at the Lille university hospital between 2011 and 2014 were included. RESULTS Eleven neonates and 16 non-neonates constituted the study population. The incidence of CSVT was significantly higher in male newborns. Clinical presentation did not vary significantly between the groups. Risk factors were age-dependent, with acute systemic illnesses significantly predominating in neonates (54%), whereas local infections, prothrombotic conditions, and trauma were more common in older children (36, 27, and 27% respectively). No predisposing factor could be identified in 36% of the neonates as compared to less than 5% of the non-neonates. Thrombosis of the deep venous structures was documented in 73% of the neonates whereas involvement of the superficial sinuses was significantly more frequent in the non-neonates group. Venous infarctions and extraparenchymal hemorrhages were significantly more frequent in the neonates group. CONCLUSION Male patients are at higher risk for CSVT than females. In neonates, involvement of the deep venous structures is significantly more common. Brain parenchymal and extraparenchymal changes occur more frequently in this age group than in older children.
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Affiliation(s)
- Valentina Lolli
- Radiology department, Erasmus university hospital, 808, route de Lennik, 1070 Brussels, Belgium.
| | | | - Jean-Pierre Pruvo
- Neuroradiology department, Roger-Salengro hospital, 59037 Lille, France
| | - Gustavo Soto Ares
- Neuroradiology department, Roger-Salengro hospital, 59037 Lille, France
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18
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Abstract
Abstract
Stroke is more likely to occur in the perinatal period than any other time in childhood, and these events can lead to a lifetime of intellectual and motor disabilities, epilepsy, and behavioral challenges. This review describes the epidemiology and natural history of perinatal arterial ischemic stroke (PAIS) and cerebral sinovenous thrombosis (CSVT), risk factors for these complications, recent evidence regarding treatment strategies, and current gaps in knowledge. Existing evidence demonstrates the multifactorial etiology of symptomatic ischemic stroke in neonates, which includes a combination of maternal, delivery, and neonatal factors. The importance of inherited thrombophilia in the pathophysiology and long-term outcomes of perinatal stroke requires additional study. At this time, there is no evidence to support routine extensive thrombophilia screening outside of a research setting. Despite the frequency of perinatal stroke and its association with substantial morbidity, treatment strategies are currently limited, and prevention strategies are nonexistent. Anticoagulation is rarely indicated in PAIS, and more work needs to focus on neuroprotective prevention and alternate treatment strategies. Anticoagulation does appear to be safe in CSVT and may prevent thrombus progression but clinical equipoise remains, and clinical trials are needed to obtain evidence regarding short- and long-term efficacy outcomes.
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19
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Perinatal brain damage: The term infant. Neurobiol Dis 2015; 92:102-12. [PMID: 26409031 PMCID: PMC4915441 DOI: 10.1016/j.nbd.2015.09.011] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/27/2015] [Accepted: 09/22/2015] [Indexed: 12/21/2022] Open
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Yurttutan S, Oncel MY, Yurttutan N, Degirmencioglu H, Uras N, Dilmen U. A novel association between cerebral sinovenous thrombosis and nonketotic hyperglycinemia in a neonate. KOREAN JOURNAL OF PEDIATRICS 2015. [PMID: 26213552 PMCID: PMC4510357 DOI: 10.3345/kjp.2015.58.6.230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Lethargy in newborns usually indicates central nervous system dysfunction, and many conditions such as cerebrovascular events, infections, and metabolic diseases should be considered in the differential diagnosis. Nonketotic hyperglycinemia is an autosomal recessive error of glycine metabolism, characterized by myoclonic jerks, hypotonia, hiccups, apnea, and progressive lethargy that may progress to encephalopathy or even death. Cerebral sinovenous thrombosis is a rare condition with various clinical presentations such as seizures, cerebral edema, lethargy, and encephalopathy. Here, we report the case of a newborn infant who presented with progressive lethargy. An initial diagnosis of cerebral venous sinus thrombosis was followed by confirmation of the presence of nonketotic hyperglycinemia.
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Affiliation(s)
- Sadık Yurttutan
- Neonatal Intensive Care Unit, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | - Mehmet Yekta Oncel
- Neonatal Intensive Care Unit, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | | | - Halil Degirmencioglu
- Neonatal Intensive Care Unit, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | - Nurdan Uras
- Neonatal Intensive Care Unit, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | - Ugur Dilmen
- Department of Pediatrics, Yıldırım Beyazıt University Hospital, Ankara, Turkey
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21
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De Carolis MP, Salvi S, Botta A, Cocca C, Garufi C, Lanzone A, De Carolis S. Cerebral sinovenous thrombosis in neonatal antiphospholipid syndrome: a new entity? Lupus 2014; 24:231-4. [DOI: 10.1177/0961203314560207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neonatal antiphospholipid syndrome (neonatal APS) seems to be exceedingly rare, as the antiphospholipid antibodies (aPL) related thrombosis in the neonatal period. The pathogenesis of perinatal aPL related thrombosis may be explained both by the transplacental passage of the maternal antibodies and by the production of de novo antibodies by the neonate. However, few cases of neonatal APS are reported in the literature, especially regarding arterial thrombotic events. In particular, only two cases of neonatal aPL related isolated cerebral sinovenous thrombosis (CSVT) are described in the literature. Despite its frequency, CSVT results in significant mortality and morbidity, probably also due to the difficulty in early diagnosis and then in correct managing in the neonatal period. A diagnosis of neonatal APS should be considered in the evaluation of neonates with CSVT, as well as in any case of neonatal thrombosis, to correctly manage the affected neonates and counsel the mother for future pregnancies.
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Affiliation(s)
- M P De Carolis
- Division of Neonatology, Department of Obstetrics, Gynaecology and Paediatrics, Catholic University of the Sacred Heart, Rome, Italy
| | - S Salvi
- Department of Obstetrics, Gynaecology and Paediatrics, Catholic University of Sacred Heart, Rome Italy
| | - A Botta
- Department of Obstetrics, Gynaecology and Paediatrics, Catholic University of Sacred Heart, Rome Italy
| | - C Cocca
- Division of Neonatology, Department of Obstetrics, Gynaecology and Paediatrics, Catholic University of the Sacred Heart, Rome, Italy
| | - C Garufi
- Division of Rheumatology, Sapienza Universita’ di Roma, Italy
| | - A Lanzone
- Department of Obstetrics, Gynaecology and Paediatrics, Catholic University of Sacred Heart, Rome Italy
| | - S De Carolis
- Department of Obstetrics, Gynaecology and Paediatrics, Catholic University of Sacred Heart, Rome Italy
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22
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van der Aa NE, Benders MJNL, Groenendaal F, de Vries LS. Neonatal stroke: a review of the current evidence on epidemiology, pathogenesis, diagnostics and therapeutic options. Acta Paediatr 2014; 103:356-64. [PMID: 24428836 DOI: 10.1111/apa.12555] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/02/2014] [Accepted: 01/10/2014] [Indexed: 12/26/2022]
Abstract
UNLABELLED Neonatal stroke, including perinatal arterial ischaemic stroke and cerebral sinovenous thrombosis, remains a serious problem in the neonate. This article reviews the current evidence on epidemiology, pathogenesis, diagnostics and therapeutic options. CONCLUSION Although our understanding of the underlying mechanisms and possible risk factors has improved, little progress has been made towards therapeutic options. Considering the high incidence of neurological sequelae, the need for therapeutic options is high and should be the focus of future research.
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Affiliation(s)
- NE van der Aa
- Department of Neonatology; Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht The Netherlands
| | - MJNL Benders
- Department of Neonatology; Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht The Netherlands
| | - F Groenendaal
- Department of Neonatology; Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht The Netherlands
| | - LS de Vries
- Department of Neonatology; Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht The Netherlands
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23
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Bektaş Ö, Teber S, Akar N, Uysal LZ, Arsan S, Atasay B, Deda G. Cerebral Sinovenous Thrombosis in Children and Neonates. Clin Appl Thromb Hemost 2014; 21:777-82. [DOI: 10.1177/1076029614523491] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Our aim is to present the etiology and risk factors for cerebral sinovenous thrombosis (CSVT) and the radiological findings, anticoagulant therapy used, and treatment outcome of patients with CSVT. This study included 12 patients who were treated for CSVT at the Ankara University, School of Medicine, Department of Pediatric Neurology. This study included 5 girls (41.7%) and 7 boys (58.3%) with a mean age of symptom onset of 5.2 ± 6.29 years (range: 0-18 years), who were followed at our institution for a mean of 1.8 ± 1.73 years (range: 0-6.5 years). Among the patients, 3 had no risk factors, 2 had 1 risk factor, and 7 had multiple risk factors. Anticoagulant therapy was administered to 4 patients, of which 1 had neurological sequelae; neurological sequelae or exitus occurred in 4 of the 8 patients who did not receive anticoagulant therapy. The present findings showed that appropriate prophylaxis in appropriately selected patients reduced the rate of recurrence of CSVT.
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Affiliation(s)
- Ömer Bektaş
- Department of Pediatric Neurology, Ankara University Medical School, Ankara, Turkey
| | - Serap Teber
- Department of Pediatric Neurology, Ankara University Medical School, Ankara, Turkey
| | - Nejat Akar
- Department of Pediatric Molecular Genetics, TOBB ETU Hospital, Ankara, Turkey
| | - Leyla Zümrüt Uysal
- Department of Pediatric Hematology, Ankara University Medical School, Ankara, Turkey
| | - Saadet Arsan
- Department of Neonatology, Ankara University Medical School, Ankara, Turkey
| | - Begüm Atasay
- Department of Neonatology, Ankara University Medical School, Ankara, Turkey
| | - Gülhis Deda
- Department of Pediatric Neurology, Ankara University Medical School, Ankara, Turkey
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24
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Oulmaati A, Babakhoya A, Chaouki S, Hida M, Bouharrou A. Apport de l’échographie transfontanellaire dans le diagnostic précoce des thromboses veineuses cérébrales néonatales : à propos de trois cas. Arch Pediatr 2014; 21:214-8. [DOI: 10.1016/j.arcped.2013.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 07/09/2013] [Accepted: 11/26/2013] [Indexed: 11/29/2022]
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25
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Mortimer AM, Bradley MD, O'Leary S, Renowden SA. Endovascular treatment of children with cerebral venous sinus thrombosis: a case series. Pediatr Neurol 2013; 49:305-12. [PMID: 24139531 DOI: 10.1016/j.pediatrneurol.2013.07.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 07/06/2013] [Accepted: 07/11/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cerebral venous sinus thrombosis is a potentially serious condition affecting 0.56 to 0.67 per 100,000 children annually; adverse outcomes are common. The standard of care is anticoagulation with heparin. A proportion of patients, however, remain in a severe clinical condition and in these, endovascular therapy is an alternative treatment. There is little published literature on the use of endovascular treatments in children with cerebral venous sinus thrombosis. METHODS We retrospectively reviewed case notes and imaging in a consecutive series of nine children treated using endovascular therapy after diagnosis of cerebral venous sinus thrombosis. Clinical presentation, decision to escalate therapy, methods of recanalization, and clinical outcome were assessed. RESULTS Nine children were treated (age range 18 months to 16 years). Diagnosis was made by computed tomography, computed tomography venography, magnetic resonance imaging, or magnetic resonance venography. Seven children were in a coma; one had signs of raised intracranial pressure with progressive cranial nerve palsies; and one was drowsy with a fluctuating hemiparesis. Eight children had been treated with heparin without improvement. Several endovascular methods were used including local tissue plasminogen activator, microguidewire and catheter disruption, balloon angioplasty, and thromboaspiration using the Penumbra device. Eight children had good functional outcomes. One child died as a result of uncontrolled intracranial hypertension secondary to cerebral venous sinus thrombosis. CONCLUSION Endovascular therapy may have a role in the treatment of cerebral venous sinus thrombosis in children when medical therapy has failed and the patient is in a poor clinical condition.
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Affiliation(s)
- Alex M Mortimer
- Department of Neuroradiology, Frenchay Hospital, Bristol, United Kingdom.
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26
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Moharir MD, Shroff M, Pontigon AM, Askalan R, Yau I, MacGregor D, deVeber GA. A prospective outcome study of neonatal cerebral sinovenous thrombosis. J Child Neurol 2011; 26:1137-44. [PMID: 21628696 PMCID: PMC3695693 DOI: 10.1177/0883073811408094] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Neonatal cerebral sinovenous thrombosis is a frequent contributor to neonatal mortality and morbidity. Treatment is controversial, and reported clinical outcomes vary widely. Newborns with radiologically confirmed neonatal cerebral sinovenous thrombosis from 1992 to 2009 were prospectively followed in our Children's Stroke Clinic for standardized outcomes, including the Pediatric Stroke Outcome Measure. Outcomes were available in 90 of 104 (87%) neonates. Early outcomes included cerebral sinovenous thrombosis-associated death (5) and thrombus propagation (15 [6 associated with new venous infarcts]). Lack of anticoagulation predicted propagation (RR = 13; P = .0007). Complete thrombus recanalization occurred in 90% by 3 months. Late outcomes (median, 2.5 years) were epilepsy (15) and neurological disability (50), which included moderate-severe language (43), sensorimotor (38), and cognitive/behavioral (24) deficits. Overall, 61% had poor outcome (death/any deficit). Concurrent neurological comorbidity at diagnosis (odds ratio = 2.8; P = .029) predicted poor outcome. Clinical trials are urgently needed to establish more effective treatment strategies.
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Affiliation(s)
| | - Manohar Shroff
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ann-Marie Pontigon
- Department of Population Health Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rand Askalan
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ivanna Yau
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Daune MacGregor
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gabrielle A. deVeber
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Population Health Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
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27
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Kersbergen KJ, Groenendaal F, Benders MJNL, de Vries LS. Neonatal cerebral sinovenous thrombosis: neuroimaging and long-term follow-up. J Child Neurol 2011; 26:1111-20. [PMID: 21693652 PMCID: PMC3674555 DOI: 10.1177/0883073811408090] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Neonates are known to have a higher risk of cerebral sinovenous thrombosis than children of other age groups. The exact incidence in neonates remains unknown and is likely to be underestimated, as clinical presentation is nonspecific and diagnosis can only be made when dedicated neuroimaging techniques, including computed tomographic venography or magnetic resonance venography, are performed. Associated intracranial lesions are common and some, such as a unilateral thalamic hemorrhage, should suggest cerebral sinovenous thrombosis as the underlying etiology. Neurodevelopmental outcome is poor in approximately 50% of these infants and is adversely affected by associated parenchymal lesions. Anticoagulation therapy will limit propagation of the clot and possibly the development or enhancement of parenchymal lesions. Multicenter randomized clinical trials are urgently needed to address many of these important issues.
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Affiliation(s)
- Karina J Kersbergen
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, the Netherlands
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28
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Cerebral venous thrombosis in the mediterranean area in children. Mediterr J Hematol Infect Dis 2011; 3:e2011029. [PMID: 21869915 PMCID: PMC3152451 DOI: 10.4084/mjhid.2011.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Accepted: 06/12/2011] [Indexed: 11/08/2022] Open
Abstract
Cerebral Venous Sinus (sinovenous) Thrombosis (CSVT) is a serious and rare disorder, increasingly recognized and diagnosed in pediatric patients. The etiology and pathophisiology has not yet been completely clarified, and unlike adults with CSVT, management in children and neonates remains controversial. However, morbidity and mortality are significant, highlighting the continued need for high-quality studies within this field. The following review will highlight aspects of CSVT in the mediteranian area in children.
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29
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Grunt S, Wingeier K, Wehrli E, Boltshauser E, Capone A, Fluss J, Gubser-Mercati D, Jeannet PY, Keller E, Marcoz JP, Schmitt-Mechelke T, Weber P, Weissert M, Steinlin M. Cerebral sinus venous thrombosis in Swiss children. Dev Med Child Neurol 2010; 52:1145-50. [PMID: 20573178 DOI: 10.1111/j.1469-8749.2010.03722.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
UNLABELLED AIMo describe the characteristics of paediatric cerebral sinus venous thrombosis (CSVT) in Switzerland. METHOD data on clinical features, neuroimaging, risk factors, and treatment were collected for all children in Switzerland younger than 16 years of age who had CSVT between January 2000 and December 2008. A follow-up examination and a cognitive assessment were performed (mean follow-up period 26mo). Differences between neonates and children (patients older than 28d) were assessed and predictors of outcome were determined. RESULTS twenty-one neonates (14 males, seven females; mean age 9d, SD 8d) and 44 children (30 males, 14 females; mean age 8y 7mo, SD 4y 5mo) were reported. The incidence of paediatric CSVT in Switzerland was 0.558 per 100000 per year. In neonates, the deep venous system was more often involved and parenchymal injuries were more common. The strongest predictor of poor outcome was neonatal age (odds ratio 17.8, 95% confidence interval 0.847-372.353). Most children showed global cognitive abilities within the normal range, but impairments in single cognitive subdomains were frequent. INTERPRETATION paediatric CSVT is rare. Its outcome is poor in neonates. Most children have good neurological outcomes, but some patients have individual neuropsychological impairments.
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Affiliation(s)
- Sebastian Grunt
- Department of Neuropaediatrics, University Children's Hospital, Inselspital, Berne, Switzerland
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30
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Yang JYK, Chan AKC, Callen DJA, Paes BA. Neonatal cerebral sinovenous thrombosis: sifting the evidence for a diagnostic plan and treatment strategy. Pediatrics 2010; 126:e693-700. [PMID: 20696732 DOI: 10.1542/peds.2010-1035] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Although cerebral sinovenous thrombosis (CSVT) is an uncommon disorder in neonates, the incumbent morbidity, mortality, and adverse neurodevelopmental sequelae highlight the importance of establishing an early diagnosis with an appropriate therapeutic plan. The clinical signs and symptoms of the condition are subtle and invariably masquerade under the umbrella of a broad spectrum of neonatal illnesses. A high index of diagnostic suspicion is essential for investigating and initiating treatment in a timely fashion before major complications ensue. Recent advances in accessible radiographic techniques with reduced radiation exposure have facilitated rapid diagnosis of thrombosis in both the superficial and deep plexuses of the cerebral venous systems. The absence of large-scale randomized trials and solid prospective smaller-sample-sized studies of neonates with CSVT has compromised our ability to develop efficacious treatment decisions. In this review of the scientific literature we offer understanding of the complex etiology of CSVT and inherent problems involved in the diagnosis and treatment of the disorder and focus on the limitations in current follow-up. An approach to neonatal CSVT is proposed on the basis of the available evidence from guidelines, registries, prospective and retrospective infant studies, and case series.
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Affiliation(s)
- Janet Y K Yang
- Department of Pediatrics, Room 3A, McMaster University, 1200 Main St W, Hamilton, Ontario, Canada L8S 4J9
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31
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Berfelo FJ, Kersbergen KJ, van Ommen CH, Govaert P, van Straaten HL, Poll-The BT, van Wezel-Meijler G, Vermeulen RJ, Groenendaal F, de Vries LS, de Haan TR. Neonatal Cerebral Sinovenous Thrombosis From Symptom to Outcome. Stroke 2010; 41:1382-8. [DOI: 10.1161/strokeaha.110.583542] [Citation(s) in RCA: 138] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background and Purpose—
Cerebral sinovenous thrombosis is a rare disease with severe neurological sequelae. The aim of this retrospective multicenter study was to investigate the clinical course, possible risk factors, and outcome of a cohort of neonatal patients with sinovenous thrombosis and, second, to estimate the incidence in The Netherlands.
Methods—
From January 1999 to March 2009, a review of all neonatal patients with sinovenous thrombosis from 6 tertiary neonatal intensive care units was performed. Population characteristics, clinical presentation, (prothrombotic) risk factors, neuroimaging, interventions, and neurodevelopment were evaluated. An estimated incidence was calculated based on the Netherlands Perinatal Registry.
Results—
Fifty-two neonates were included (39 boys) with a median gestational age of 39 weeks (range, 30 to 42 weeks; 5 preterm). An assisted or complicated delivery occurred in 32 of 52. Presenting symptoms developed at a median postnatal age of 1.5 days (range, 0 to 28 days) and consisted mainly of seizures (29 of 52). All sinovenous thrombosis cases were confirmed with MRI/MR venography. Multisinus thrombosis was most common followed by superior sagittal sinus thrombosis. FII G20210A mutation was present in 2 of 18 tested neonates (11%). Anticoagulation therapy (in 22 of 52) did not result in hemorrhagic complications. At follow-up (median age, 19 months; range, 3 to 72 months), moderate to severe neurological sequelae were present in 38%. The mortality was 10 of 52 (19%). A variable, although high yearly incidence of 1.4 to 12 per 100 000 term newborns was found.
Conclusions—
Neonatal sinovenous thrombosis is a multifactorial disease. The estimated incidence in The Netherlands seems higher than reported elsewhere.
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Affiliation(s)
- Florieke J. Berfelo
- From the Department of Neurology (F.J.B.), Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (K.J.K., F.G., L.S.d.V.), Wilhelmina Children’s Hospital, University Medical Center, Utrecht, The Netherlands; the Department of Pediatric Haematology (C.H.v.O.), Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (P.G.), Sophia Children’s Hospital, Erasmus Academic Medical Center, Rotterdam, The Netherlands; the
| | - Karina J. Kersbergen
- From the Department of Neurology (F.J.B.), Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (K.J.K., F.G., L.S.d.V.), Wilhelmina Children’s Hospital, University Medical Center, Utrecht, The Netherlands; the Department of Pediatric Haematology (C.H.v.O.), Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (P.G.), Sophia Children’s Hospital, Erasmus Academic Medical Center, Rotterdam, The Netherlands; the
| | - C. H.(Heleen) van Ommen
- From the Department of Neurology (F.J.B.), Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (K.J.K., F.G., L.S.d.V.), Wilhelmina Children’s Hospital, University Medical Center, Utrecht, The Netherlands; the Department of Pediatric Haematology (C.H.v.O.), Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (P.G.), Sophia Children’s Hospital, Erasmus Academic Medical Center, Rotterdam, The Netherlands; the
| | - Paul Govaert
- From the Department of Neurology (F.J.B.), Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (K.J.K., F.G., L.S.d.V.), Wilhelmina Children’s Hospital, University Medical Center, Utrecht, The Netherlands; the Department of Pediatric Haematology (C.H.v.O.), Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (P.G.), Sophia Children’s Hospital, Erasmus Academic Medical Center, Rotterdam, The Netherlands; the
| | - H. L.M.(Irma) van Straaten
- From the Department of Neurology (F.J.B.), Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (K.J.K., F.G., L.S.d.V.), Wilhelmina Children’s Hospital, University Medical Center, Utrecht, The Netherlands; the Department of Pediatric Haematology (C.H.v.O.), Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (P.G.), Sophia Children’s Hospital, Erasmus Academic Medical Center, Rotterdam, The Netherlands; the
| | - Bwee-Tien Poll-The
- From the Department of Neurology (F.J.B.), Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (K.J.K., F.G., L.S.d.V.), Wilhelmina Children’s Hospital, University Medical Center, Utrecht, The Netherlands; the Department of Pediatric Haematology (C.H.v.O.), Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (P.G.), Sophia Children’s Hospital, Erasmus Academic Medical Center, Rotterdam, The Netherlands; the
| | - Gerda van Wezel-Meijler
- From the Department of Neurology (F.J.B.), Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (K.J.K., F.G., L.S.d.V.), Wilhelmina Children’s Hospital, University Medical Center, Utrecht, The Netherlands; the Department of Pediatric Haematology (C.H.v.O.), Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (P.G.), Sophia Children’s Hospital, Erasmus Academic Medical Center, Rotterdam, The Netherlands; the
| | - R. Jeroen Vermeulen
- From the Department of Neurology (F.J.B.), Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (K.J.K., F.G., L.S.d.V.), Wilhelmina Children’s Hospital, University Medical Center, Utrecht, The Netherlands; the Department of Pediatric Haematology (C.H.v.O.), Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (P.G.), Sophia Children’s Hospital, Erasmus Academic Medical Center, Rotterdam, The Netherlands; the
| | - Floris Groenendaal
- From the Department of Neurology (F.J.B.), Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (K.J.K., F.G., L.S.d.V.), Wilhelmina Children’s Hospital, University Medical Center, Utrecht, The Netherlands; the Department of Pediatric Haematology (C.H.v.O.), Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (P.G.), Sophia Children’s Hospital, Erasmus Academic Medical Center, Rotterdam, The Netherlands; the
| | - Linda S. de Vries
- From the Department of Neurology (F.J.B.), Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (K.J.K., F.G., L.S.d.V.), Wilhelmina Children’s Hospital, University Medical Center, Utrecht, The Netherlands; the Department of Pediatric Haematology (C.H.v.O.), Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (P.G.), Sophia Children’s Hospital, Erasmus Academic Medical Center, Rotterdam, The Netherlands; the
| | - Timo R. de Haan
- From the Department of Neurology (F.J.B.), Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (K.J.K., F.G., L.S.d.V.), Wilhelmina Children’s Hospital, University Medical Center, Utrecht, The Netherlands; the Department of Pediatric Haematology (C.H.v.O.), Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands; the Department of Neonatology (P.G.), Sophia Children’s Hospital, Erasmus Academic Medical Center, Rotterdam, The Netherlands; the
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Crossing the blood-brain barrier: clinical interactions between neurologists and hematologists in pediatrics - advances in childhood arterial ischemic stroke and cerebral venous thrombosis. Curr Opin Pediatr 2010; 22:20-7. [PMID: 19996969 PMCID: PMC2836322 DOI: 10.1097/mop.0b013e3283350d94] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The past year has marked a period of growing awareness of the need for improved diagnosis and treatment in children with arterial ischemic stroke (AIS) and cerebral sinus venous thrombosis (CSVT). Here we review these conditions, highlighting the importance of the intersection between hematologic abnormalities and pediatric stroke as they impact clinical management. RECENT FINDINGS Recent multicenter cohort studies are beginning to clarify the incidence, risk factors, clinical course and outcomes of AIS and CSVT in children. Key findings include: diagnosis rests on adequate neuroimaging and is often delayed more than 24 h after symptom onset; multiple risk factors and inciting events are often involved; one or more prothrombotic risk factors are common; recurrence is common; and selected groups of patients benefit from anticoagulation, and less frequently, thrombolytic therapies. SUMMARY Progress in caring for children with AIS and CSVT requires greatly improved awareness of cerebrovascular disease among primary providers, who are most often the first point of contact, more rapid and specific diagnosis using appropriate advanced neuroimaging technologies, comprehensive hematologic evaluation for inherited and acquired thrombophilias, and multidisciplinary approaches to treatment. Additional large cohort studies and clinical trials are greatly needed to further clarify these issues.
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Ramenghi LA, Govaert P, Fumagalli M, Bassi L, Mosca F. Neonatal cerebral sinovenous thrombosis. Semin Fetal Neonatal Med 2009; 14:278-83. [PMID: 19699161 DOI: 10.1016/j.siny.2009.07.010] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cerebral sinovenous thrombosis (CSVT) is an uncommon condition among paediatric patients involving major sinuses, with a preponderant occurrence in neonates. The clinical presentation is unspecific, either early, within 48h from birth, or later. An early presentation may be accompanied by several comorbidities (respiratory distress, poor tone, fetal distress, asphyxia), whereas a later presentation is more often associated with conventional neurological signs such as seizures, lethargy, apnoea and poor feeding. These differences in clinical presentation render the neuroradiological diagnosis difficult, in particular before the introduction of magnetic resonance imaging. The interest in CSVT is based on the complex pathogenesis, often resulting from a combination of inherited and acquired thrombophilic patterns. In addition, the course of CSVT can be influenced by medical treatment, currently based on the consensus of experts more than on randomised trials.
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Affiliation(s)
- Luca A Ramenghi
- Neonatal Intensive Care Unit-Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, IRCCS, University of Milan, Via Commenda 12, 20122 Milan, Italy.
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Kersbergen KJ, de Vries LS, van Straaten HL, Benders MJ, Nievelstein RA, Groenendaal F. Anticoagulation Therapy and Imaging in Neonates With a Unilateral Thalamic Hemorrhage Due to Cerebral Sinovenous Thrombosis. Stroke 2009; 40:2754-60. [DOI: 10.1161/strokeaha.109.554790] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Cerebral sinovenous thrombosis is a rare disorder with a high risk of an adverse neurodevelopmental outcome. Until now, anticoagulation therapy has been restricted to neonates without an associated parenchymal hemorrhage. In this study, we describe sequential neuroimaging findings and use of anticoagulation therapy in newborn infants with a unilateral thalamic hemorrhage due to cerebral sinovenous thrombosis.
Methods—
Ten neonates with a unilateral thalamic hemorrhage and cerebral sinovenous thrombosis were studied. Diagnosis was suspected using cranial ultrasound and confirmed with MRI/MR venography. Eight infants had a repeat MRI at 3 to 7 months. Neurodevelopmental outcome was assessed from 3 months until 5 years.
Results—
One infant died. Seven infants were treated with low-molecular-weight heparin. No side affects were noted. MRI showed involvement of multiple sinuses, additional intraventricular hemorrhage, and white matter lesions in all infants. Recanalization was present on the repeat MRI at 3 months in all infants. Treatment was delayed in one infant and anticoagulation was started only after extension of the thalamic hemorrhage. He required a ventriculoperitoneal drain for posthemorrhagic ventricular dilatation and developed cerebral visual impairment and global delay. Two other infants showed global delay and one of them also developed postneonatal epilepsy. Mild asymmetry in tone was present in 4 children.
Conclusions—
Cerebral sinovenous thrombosis was found in 10 neonates with unilateral thalamic hemorrhage. Diagnosis was suspected on cranial ultrasound and confirmed with MRI/MR venography. Treatment with low-molecular-weight heparin in newborn infants with a thalamic hemorrhage due to cerebral sinovenous thrombosis appears to be safe and should be considered. Long-term follow-up will be needed to assess cognitive outcome.
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Affiliation(s)
- Karina J. Kersbergen
- From the Department of Neonatology (K.J.K., L.S.d.V., M.J.N.L.B., F.G.), Wilhelmina Children’s Hospital, University Medical Center, Utrecht, The Netherlands; the Department of Radiology (R.A.J.N.), University Medical Center, Utrecht, The Netherlands; and the Department of Neonatology (H.L.M.v.S.), Isala Clinics, Zwolle, The Netherlands
| | - Linda S. de Vries
- From the Department of Neonatology (K.J.K., L.S.d.V., M.J.N.L.B., F.G.), Wilhelmina Children’s Hospital, University Medical Center, Utrecht, The Netherlands; the Department of Radiology (R.A.J.N.), University Medical Center, Utrecht, The Netherlands; and the Department of Neonatology (H.L.M.v.S.), Isala Clinics, Zwolle, The Netherlands
| | - H. L.M.(Irma) van Straaten
- From the Department of Neonatology (K.J.K., L.S.d.V., M.J.N.L.B., F.G.), Wilhelmina Children’s Hospital, University Medical Center, Utrecht, The Netherlands; the Department of Radiology (R.A.J.N.), University Medical Center, Utrecht, The Netherlands; and the Department of Neonatology (H.L.M.v.S.), Isala Clinics, Zwolle, The Netherlands
| | - Manon J.N.L. Benders
- From the Department of Neonatology (K.J.K., L.S.d.V., M.J.N.L.B., F.G.), Wilhelmina Children’s Hospital, University Medical Center, Utrecht, The Netherlands; the Department of Radiology (R.A.J.N.), University Medical Center, Utrecht, The Netherlands; and the Department of Neonatology (H.L.M.v.S.), Isala Clinics, Zwolle, The Netherlands
| | - Rutger A.J. Nievelstein
- From the Department of Neonatology (K.J.K., L.S.d.V., M.J.N.L.B., F.G.), Wilhelmina Children’s Hospital, University Medical Center, Utrecht, The Netherlands; the Department of Radiology (R.A.J.N.), University Medical Center, Utrecht, The Netherlands; and the Department of Neonatology (H.L.M.v.S.), Isala Clinics, Zwolle, The Netherlands
| | - Floris Groenendaal
- From the Department of Neonatology (K.J.K., L.S.d.V., M.J.N.L.B., F.G.), Wilhelmina Children’s Hospital, University Medical Center, Utrecht, The Netherlands; the Department of Radiology (R.A.J.N.), University Medical Center, Utrecht, The Netherlands; and the Department of Neonatology (H.L.M.v.S.), Isala Clinics, Zwolle, The Netherlands
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Millichap JG. Presentation of Neonatal Sinovenous Thrombosis. Pediatr Neurol Briefs 2008. [DOI: 10.15844/pedneurbriefs-22-9-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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