1
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Bhagat I, Sarkar R, Bapuraj JR, Sarkar S. Routine Echocardiography is not Required in Neonates with Arterial Ischemic Stroke. Am J Perinatol 2024; 41:e1-e5. [PMID: 38171384 DOI: 10.1055/a-2237-8711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
OBJECTIVE Current guidelines suggest routine echocardiography (ECHO) in the acute phase to exclude a cardiac source for neonatal arterial ischemic stroke (NAIS). However, the commonly assumed embolic origin from a cardiac source for NAIS is challenged and the need for ECHO in NAIS remains questionable, especially during the era of standard fetal anomaly scanning. Our hypothesis is that any complex cardiac defects potentially causing NAIS would likely be detected during routine prenatal scans, thus possibly making routine postnatal ECHO redundant. This study aimed to determine the prevalence of significant cardiac risk factors and evaluate the necessity of routine postnatal ECHO in NAIS during the routine use of prenatal fetal sonography. STUDY DESIGN Retrospective review of 54 infants diagnosed with NAIS via brain magnetic resonance imaging who underwent an ECHO evaluation during the acute period to exclude potential cardiac origins for NAIS. RESULTS Postnatal ECHO revealed no intracardiac thrombus or vegetation, and only identified structural heart anomalies in three (5%) infants. Interestingly, these three cases had already been diagnosed with syndromic conditions or chromosomal malformations prenatally. In the remaining infants, postnatal ECHO was either normal or showed minor abnormalities unlikely to have contributed to the stroke. The detection rates of complex cardiac anomalies from prenatal scans and postnatal ECHO were statistically similar (p = 0.617). CONCLUSION The probability of ECHO to exclude cardiac sources for NAIS is so low that in the era of standard fetal anomaly scanning, routine postnatal ECHO may not be necessary for all NAIS infants, except when chromosomal malformations are detected. KEY POINTS · Guidelines recommend an acute phase ECHO to identify a cardiac source of NAIS.. · ECHO not effective at excluding NAIS's cardiac origin for infants with normal fetal scans.. · Routine postnatal ECHO is unnecessary in NAIS infants, except with genetic abnormalities..
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Affiliation(s)
- Indira Bhagat
- Division of Neonatal-Perinatal Medicine, Central Michigan University, Mount Pleasant, Michigan
| | - Rohan Sarkar
- Research Volunteer, Michigan State University, East Lansing, Michigan
| | | | - Subrata Sarkar
- Division of Neonatal-Perinatal Medicine, University of Michigan, Ann Arbor, Michigan
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2
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Oesch G, Münger R, Steinlin M. Be aware of childhood stroke: Proceedings from EPNS Webinar. Eur J Paediatr Neurol 2024; 49:82-94. [PMID: 38447504 DOI: 10.1016/j.ejpn.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/11/2023] [Accepted: 02/05/2024] [Indexed: 03/08/2024]
Abstract
Childhood arterial ischaemic stroke (AIS) is a significant health concern with increasing incidence. This review aims to provide an overview of the current understanding of childhood AIS. The incidence of childhood AIS is on the rise especially in developing countries, likely due to improved awareness and diagnostic capabilities. Aetiology of childhood AIS is multifactorial, with both modifiable risk factors and genetic predisposition playing important roles. Identifying and addressing these risk factors, such as infection, sickle cell disease, and congenital heart defects, is essential in prevention and management. Identifying underlying conditions through genetic testing is important for appropriate management and long-term prognosis. Clinically, distinguishing stroke from stroke mimics can be challenging. Awareness of important stroke mimics, including migraines, seizures, and metabolic disorders, is crucial to avoid misdiagnosis and ensure appropriate treatment. The diagnostic approach to childhood AIS involves a comprehensive "chain of care," including initial assessment, neuroimaging, and laboratory investigations. National guidelines play a pivotal role in standardizing and streamlining the diagnostic process, ensuring prompt and accurate management. Early intervention is critical in the management of childhood AIS. Due to the critical time window, the question if mechanical thrombectomy is feasible and beneficial should be addressed as fast as possible. Early initiation of antiplatelet or anticoagulation therapy and, in select cases, thrombolysis can help restore blood flow and minimize long-term neurological damage. Additionally, rehabilitation should start as soon as possible to optimize recovery and improve functional outcomes. In conclusion, childhood AIS is a growing concern. Understanding the increasing incidence, age distribution, risk factors, clinical presentation, diagnostic approach, and management strategies is crucial for optimized management of these patients.
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Affiliation(s)
- Gabriela Oesch
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Robin Münger
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Switzerland
| | - Maja Steinlin
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland.
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3
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Sun LR, Lynch JK. Advances in the Diagnosis and Treatment of Pediatric Arterial Ischemic Stroke. Neurotherapeutics 2023; 20:633-654. [PMID: 37072548 PMCID: PMC10112833 DOI: 10.1007/s13311-023-01373-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/20/2023] Open
Abstract
Though rare, stroke in infants and children is an important cause of mortality and chronic morbidity in the pediatric population. Neuroimaging advances and implementation of pediatric stroke care protocols have led to the ability to rapidly diagnose stroke and in many cases determine the stroke etiology. Though data on efficacy of hyperacute therapies, such as intravenous thrombolysis and mechanical thrombectomy, in pediatric stroke are limited, feasibility and safety data are mounting and support careful consideration of these treatments for childhood stroke. Recent therapeutic advances allow for targeted stroke prevention efforts in high-risk conditions, such as moyamoya, sickle cell disease, cardiac disease, and genetic disorders. Despite these exciting advances, important knowledge gaps persist, including optimal dosing and type of thrombolytic agents, inclusion criteria for mechanical thrombectomy, the role of immunomodulatory therapies for focal cerebral arteriopathy, optimal long-term antithrombotic strategies, the role of patent foramen ovale closure in pediatric stroke, and optimal rehabilitation strategies after stroke of the developing brain.
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Affiliation(s)
- Lisa R Sun
- Divisions of Pediatric Neurology and Cerebrovascular Neurology, Department of Neurology, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Ste 2158, Baltimore, MD, 21287, USA.
| | - John K Lynch
- Acute Stroke Research Section, Stroke Branch (SB), National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
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4
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Mayne EW, Mailo JA, Pabst L, Pulcine E, Harrar DB, Waak M, Rafay MF, Hassanein SM, Amlie-Lefond C, Jordan LC. Pediatric Stroke and Cardiac Disease: Challenges in Recognition and Management. Semin Pediatr Neurol 2022; 43:100992. [PMID: 36344023 PMCID: PMC9719802 DOI: 10.1016/j.spen.2022.100992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/11/2022] [Accepted: 08/24/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Elizabeth W Mayne
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA.
| | - Janette A Mailo
- Division of Pediatric Neurology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa Pabst
- Department of Pediatrics, Division of Neurology, Nationwide Children's Hospital, Columbus, OH
| | - Elizabeth Pulcine
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Dana B Harrar
- Division of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Michaela Waak
- Pediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Queensland, Australia; Pediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - Mubeen F Rafay
- Children's Hospital Winnipeg, University of Manitoba, Children's Hospital Research Institute of Manitoba, Manitoba, Canada
| | - Sahar Ma Hassanein
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Catherine Amlie-Lefond
- Department of Neurology, Department of Neurological Surgery, University of Washington, Seattle, WA
| | - Lori C Jordan
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN
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5
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Tona C, Nosadini M, Pelizza MF, Pin JN, Baggio L, Boniver C, Gabrieli JD, Causin F, Toldo I, Sartori S. Cardiac Myxoma as a Rare Cause of Pediatric Arterial Ischemic Stroke: Case Report and Literature Review. Neuropediatrics 2020; 51:389-396. [PMID: 32369836 DOI: 10.1055/s-0040-1710338] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cardiac disorders are the second leading cause of pediatric arterial ischemic stroke (AIS). Limited literature is available on pediatric AIS caused by cardiac myxoma, a rare tumor in childhood. METHODS We describe a new case of pediatric AIS due to a previously unknown atrial myxoma and we conduct a literature review on children with AIS due to cardiac myxoma. RESULTS We identified 41 published pediatric cases of AIS and cardiac myxoma, including ours (56% males, median age at AIS was 11 years [range: 3-18]). AIS presentation was most frequently with hemiparesis/hemiplegia (89%). Multiple brain ischemic lesions were detected in 69% of patients, and arteriopathy in 91%. Seven patients underwent mechanical thrombectomy. At AIS presentation, 73% of children had one or more of the following clinical symptoms/signs suggesting a possible underlying cardiac myxoma: Carney's complex, cardiac auscultation abnormalities, extraneurological symptoms/signs, such as skin signs (12, 38, and 65%, respectively). Cardiac myxoma was diagnosed within 72 hours in 68% of cases. Death occurred in 11%, and 40% had persistent neurological deficits. CONCLUSION Neurological presentation of AIS due to cardiac myxoma is similar to that of AIS with other etiologies, although clues suggesting a possible underlying cardiac myxoma can be detected in most cases. A timely diagnosis of cardiac myxoma in patients with AIS may favor prompt identification of candidates for endovascular therapy. Therefore, we suggest that in otherwise-healthy children presenting with AIS, transthoracic echocardiography should be performed early after stroke presentation.
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Affiliation(s)
- Clarissa Tona
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | - Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | - Maria F Pelizza
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | - Jacopo N Pin
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | - Laura Baggio
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | - Clementina Boniver
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | | | - Francesco Causin
- Neuroradiology Unit, University Hospital of Padua, Padova, Italy
| | - Irene Toldo
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
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6
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Chung MG, Guilliams KP, Wilson JL, Beslow LA, Dowling MM, Friedman NR, Hassanein SMA, Ichord R, Jordan LC, Mackay MT, Rafay MF, Rivkin M, Torres M, Zafeiriou D, deVeber G, Fox CK. Arterial Ischemic Stroke Secondary to Cardiac Disease in Neonates and Children. Pediatr Neurol 2019; 100:35-41. [PMID: 31371125 PMCID: PMC7034952 DOI: 10.1016/j.pediatrneurol.2019.06.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/05/2019] [Accepted: 06/08/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVE We describe the risk factors for peri-procedural and spontaneous arterial ischemic stroke (AIS) in children with cardiac disease. METHODS We identified children with cardiac causes of AIS enrolled in the International Pediatric Stroke Study registry from January 2003 to July 2014. Isolated patent foramen ovale was excluded. Peri-procedural AIS (those occurring during or within 72 hours of cardiac surgery, cardiac catheterization, or mechanical circulatory support) and spontaneous AIS that occurred outside of these time periods were compared. RESULTS We identified 672 patients with congenital or acquired cardiac disease as the primary risk factor for AIS. Among these, 177 patients (26%) had peri-procedural AIS and 495 patients (74%) had spontaneous AIS. Among non-neonates, spontaneous AIS occurred at older ages (median 4.2 years, interquartile range 0.97 to 12.4) compared with peri-procedural AIS (median 2.4 years, interquartile range 0.35 to 6.1, P < 0.001). About a third of patients in both groups had a systemic illness at the time of AIS. Patients who had spontaneous AIS were more likely to have a preceding thrombotic event (16 % versus 9 %, P = 0.02) and to have a moderate or severe neurological deficit at discharge (67% versus 33%, P = 0.01) compared to those with peri-procedural AIS. CONCLUSIONS Children with cardiac disease are at risk for AIS at the time of cardiac procedures but also outside of the immediate 72 hours after procedures. Many have acute systemic illness or thrombotic event preceding AIS, suggesting that inflammatory or prothrombotic conditions could act as a stroke trigger in this susceptible population.
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Affiliation(s)
- MG Chung
- Divisions of Critical Care Medicine and Neurology, Department of Pediatrics, The Ohio State University and Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, Ohio, USA
| | - KP Guilliams
- Departments of Neurology and Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St. Louis, Missouri, USA
| | - JL Wilson
- Division of Neurology, Department of Pediatrics, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR
| | - LA Beslow
- Division of Neurology, Children’s Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perlman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, USA
| | - MM Dowling
- Departments of Pediatrics, Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center at Dallas and Children’s Health Dallas, 5323 Harry Hines Blvd, Dallas, Texas, USA
| | - NR Friedman
- Center for Pediatric Neurosciences, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, Ohio, USA
| | - SMA Hassanein
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Egypt
| | - R Ichord
- Division of Neurology, Children’s Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perlman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, USA
| | - LC Jordan
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, Tennessee, USA
| | - MT Mackay
- Department of Neurology, Royal Children’s Hospital Melbourne, Murdoch Children’s Research Institute Melbourne, Flemington Rd, Parkville, Victoria, Australia
| | - MF Rafay
- Section of Pediatric Neurology, Department of Pediatrics and Child Health, University of Manitoba, Children’s Hospital Research Institute of Manitoba, 715 McDermot Ave, Winnipeg, Canada
| | - M Rivkin
- Departments of Neurology, Psychiatry, and Radiology, and the Stroke and Cerebrovascular Center, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA, USA
| | - M Torres
- Pediatric Hematology and Oncology, Cook Children’s Medical Center, 801 7 Ave, Fort Worth, Texas, USA
| | - D Zafeiriou
- 1 Department of Pediatrics, Aristotle University, “Hippokratio” General Hospital, Thessaloniki, Greece
| | - G deVeber
- Department of Neurology, The Hospital for Sick Children, 555 University Ave, Toronto, Canada
| | - CK Fox
- Departments of Neurology and Pediatrics, University of California San Francisco, 521 Parmassus Ave, San Francisco, California, USA
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7
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Cardio-embolic stroke: Lessons from a single centre in Sub-Saharan Africa. Rev Neurol (Paris) 2019; 175:544-551. [PMID: 31155304 DOI: 10.1016/j.neurol.2019.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 01/05/2019] [Accepted: 02/13/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Limited information is available about cardio-embolic stroke (CES) in sub-Saharan Africa. The aim of this study was to describe the epidemiology, clinical features, etiology, the management and outcome of CES in our setting. METHODS A retrospective cohort study was carried out in the Douala General Hospital (DGH), using files of ischemic stroke patients admitted in the Neurological Unit and the Intensive Care Unit. Socio-demographic, clinical and paraclinical data were collected. After hospitalization, follow-up was performed with focus on mortality, stroke recurrence and the functional outcome assessed with Barthel score. Multivariate analysis was performed to determine the factors associated with death. RESULTS Of the 704 stroke cases included, 368 were ischemic with 86 (23.4%) of them being cardio-embolic. The mean age of patient with CES was 67±13.3 years. The main etiologies of CES were: atrial fibrillation (82.1%), dilated cardiomyopathy (12.8%), and rheumatic mitral stenosis (5.1%). Anti-platelet agents were the most prescribed anti-thrombotic drugs (50.7%). The in-hospital mortality rate was 23.3% with lesion in both internal carotid arteries [OR=110.3; 95% CI: 1.2-1040.7; P=0.043] and heart disease [OR=46.9; 95% CI: 1.2-1789.9; P=0.038] appeared to be predictive of this. Stroke recurrence was observed in 8 patients (12.1%) and the survival probability in 5 years was 10%. Functional outcome was progressively worse with the systolic blood pressure>140mmHg (P=0.025) been the associated factor. CONCLUSION CES accounted for 1/4 of ischemic stroke with a high risk of early death and long-term recurrence. Atrial fibrillation was the leading cause of CES. The association of VKA and anti-platelet agent should be avoided to reduce early death during acute stroke.
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8
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Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke 2019; 50:e51-e96. [DOI: 10.1161/str.0000000000000183] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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9
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Ndiaye M, Lengue F, Sagna SD, Sow AD, Fogany Y, Deme H, Basse AM, Diop-Sene MS, Diagne NS, Diop AG, Ndiaye O, Ndiaye MM. Childhood arterial ischemic stroke in Senegal (West Africa). Arch Pediatr 2018; 25:351-354. [PMID: 30143371 DOI: 10.1016/j.arcped.2018.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 06/07/2018] [Accepted: 06/30/2018] [Indexed: 01/09/2023]
Abstract
Etiological factors of childhood ischemic stroke depend on the epidemiological context. The purpose of this study was to determine the risk factors, the clinical and radiologic features, and the outcome of arterial ischemic stroke in a case series of Senegalese children. We carried out a retrospective registry-based study on arterial ischemic stroke in children hospitalized in the neurology department of Fann Teaching Hospital and Albert Royer Children's Hospital, from January 2005 to December 2015. We enrolled 116 cases with an age range from 2 months to 18 years. The mean age at stroke occurrence was 71.5 months. The most common manifestations were hemiparesis (84%), aphasia (19%), and partial motor seizures (10%). The middle cerebral artery was the most affected (81%). Risk factors were predominantly sickle cell disease (38%), embolic heart disease (9%), and anemia (3%). Twenty-eight percent of patients were lost to follow-up, 62% had neurological impairments, and 4% died. Secondary prevention was based on antithrombotic agents. Prevention must be prioritized and public health actions need to focus on sickle cell disease, rheumatismal disease, anemia, and related disorders. It will be necessary to set up policies that fight against consanguineous marriage, endemic infections, and argue for better nutrition.
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Affiliation(s)
- M Ndiaye
- Neurology department, Fann teaching hospital, BP 5035 Dakar, Senegal; Albert Royer Children Hospital, Dakar, Senegal.
| | - F Lengue
- Albert Royer Children Hospital, Dakar, Senegal
| | - S D Sagna
- Neurology department, Fann teaching hospital, BP 5035 Dakar, Senegal
| | - A D Sow
- Neurology department, Fann teaching hospital, BP 5035 Dakar, Senegal
| | - Y Fogany
- Neurology department, Fann teaching hospital, BP 5035 Dakar, Senegal
| | - H Deme
- Albert Royer Children Hospital, Dakar, Senegal
| | - A M Basse
- Neurology department, Fann teaching hospital, BP 5035 Dakar, Senegal
| | - M S Diop-Sene
- Neurology department, Fann teaching hospital, BP 5035 Dakar, Senegal
| | - N S Diagne
- Neurology department, Fann teaching hospital, BP 5035 Dakar, Senegal
| | - A G Diop
- Neurology department, Fann teaching hospital, BP 5035 Dakar, Senegal
| | - O Ndiaye
- Albert Royer Children Hospital, Dakar, Senegal
| | - M M Ndiaye
- Neurology department, Fann teaching hospital, BP 5035 Dakar, Senegal
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10
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Panagopoulos D, Loukopoulou S, Karanasios E, Grigoriadou G, Eleftherakis N. Cerebral hemorrhagic infarction as the initial manifestation of deep venous thrombosis in a child with patent foramen ovale. Glob Cardiol Sci Pract 2018; 2018:17. [PMID: 30083547 PMCID: PMC6062758 DOI: 10.21542/gcsp.2018.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Arterial ischemic stroke (AIS), with an estimated incidence of 1.1–4.3 per 100,000, is an important cause of morbidity and mortality in children and the risk of recurrence is high. We present the case of an 11-year-old child who presented with a symptomatology of acute ischemic stroke of unknown etiology. The radiological investigation did not reveal any underlying brain abnormality that could cause the event. The diagnostic work up included an echocardiogram, which revealed a thrombus in the right atrium, in conjunction with a patent foramen ovale. The patient was initiated immediately on anticoagulation therapy with low molecular weight heparin and warfarin, but two days later she suffered pulmonary emboli, diagnosed with spiral thorax computed tomography (CT) scan. An ultrasound study of the vessels of the lower extremitiesgcsp201817-main-client.xml revealed deep venous thrombosis (DVT), which was considered to be the underlying causative mechanism.
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Affiliation(s)
- Dimitrios Panagopoulos
- Pediatric Hospital of Athens, "Aglaia Kyriakou", Neurosurgical Department, Athens, Greece
| | - Sofia Loukopoulou
- Cardiology Department, Pediatric hospital "Agia Sophia", Athens, Greece
| | | | - Georgia Grigoriadou
- Pediatric Hospital of Athens, "Aglaia Kyriakou", Neurosurgical Department, Athens, Greece
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11
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Komarova IB, Zykov VP, Ushakova LV, Novikova EB, Shuleshko OV, Nazarova EK, Samigulina MG. [Clinical and neuroimaging signs of cardioembolic stroke in children]. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 117:13-22. [PMID: 29359715 DOI: 10.17116/jnevro201711711213-22] [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: 11/17/2022]
Abstract
AIM To study clinical and neuroimaging signs of cardioembolic stroke (CES) in children. MATERIAL AND METHODS A group of 100 patients with arterial ischemic stroke (AIS), aged from 1 month to 15 years, was stratified into the main group (10 patients with CES) and the comparison group (90 patients with other subtypes of AIS). CT and MRI, MR-angiography, ultrasound study as well as assessment of clinical symptoms on PedNIHSS were performed. The duration of follow-up was from 2 month to 14 years. The follow-up allowed the assessment of occurrence of secondary strokes, severity of residual neurological symptoms on the PSOM and fatal outcomes. Special attention was drawn to the use of CASSADE criteria for CES. RESULTS AND CONCLUSION Clinical features that help to diagnose CES, even in the absence of adequate neuroimaging, in patients with heart disease, which is a potential high risk factor for cardioembolia, were established. These factors include early disease onset, acute development and progression of neurological deficit to the maximal level in the first 5 min., marked severity of the acute period (PedNIHSS > 15), early recovery of neurological functions, significant residual neurological symptoms (PSOM > 2). These symptoms should be used in addition to the CASCADE criteria in the diagnosis of CES of AIS type in children.
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Affiliation(s)
- I B Komarova
- Russian Medical Academy аor Continuing Professional Education, Moscow, Russia
| | - V P Zykov
- Russian Medical Academy аor Continuing Professional Education, Moscow, Russia
| | - L V Ushakova
- Kulakov Research Center of Obstetrics, Gynecology and Perinatology, Moscow, Russia
| | - E B Novikova
- Russian Medical Academy аor Continuing Professional Education, Moscow, Russia
| | - O V Shuleshko
- Bashlyaeva City Child Clinical Hospital, Moscow, Russia
| | - E K Nazarova
- Moscow Regional Consultating and Diagnostic Center, Moscow, Russia
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12
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Risk Factors for Peri-Procedural Arterial Ischaemic Stroke in Children with Cardiac Disease. Pediatr Cardiol 2017; 38:1385-1392. [PMID: 28695245 DOI: 10.1007/s00246-017-1674-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 06/30/2017] [Indexed: 10/19/2022]
Abstract
Improved survival of children with congenital heart disease has led to increasing focus on neurodevelopmental outcome, as close to half of the infants undergoing cardiac surgery are affected by neurodevelopmental disability. Stroke is particularly important as it frequently results in permanent neurologic sequelae. The aim of this study was to investigate risk factors for peri-procedural arterial ischaemic stroke (AIS) in children with cardiac disease. A retrospective case-control analysis of children aged <18 years with radiologically confirmed AIS following a cardiac procedure admitted to the Royal Children's Hospital Melbourne between 1993 and 2010. Each case was matched with two controls with similar cardiac diagnosis, procedure type, age and date of procedure. Demographics and peri-procedural data were collected from medical records and departmental database. Fifty-two cases were identified. Multivariable analysis identified post-procedural infection (OR 6.1, CI 1.3-27, p = 0.017) and length of ICU stay (OR 4.0, CI 1.4-11, p = 0.009) as risk factors for AIS. Although the study is limited to a single-centre cohort, length of ICU stay and post-procedural infection were identified as risk factors for AIS. These findings demonstrate these factors to be important areas to focus attention for stroke prevention in children with cardiac disease.
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13
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Vázquez López M, de Castro de Castro P, Barredo Valderrama E, Miranda Herrero MC, Gil Villanueva N, Alcaraz Romero AJ, Pascual Pascual SI. Outcome of arterial ischemic stroke in children with heart disease. Eur J Paediatr Neurol 2017; 21:730-737. [PMID: 28619364 DOI: 10.1016/j.ejpn.2017.05.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 01/02/2017] [Accepted: 05/24/2017] [Indexed: 01/19/2023]
Abstract
UNLABELLED Arterial ischemic strokes (AIS) are rare in childhood. Congenital and acquired heart diseases are one of the most important risk factors of AIS in children. OBJECTIVE Study the outcome of children with heart disease that have suffered AIS and the factors that influence on prognosis. PATIENTS AND METHODS We evaluated all children with heart disease who had suffered AIS between 2000 and 2014 in our hospital. RESULTS Seventy-four children with heart disease suffered an arterial ischemic stroke. 20% of them died and 10% had new AIS during the study period. Fifty-two patients were evaluated an average of six years after AIS. According to the Paediatric Stroke Outcome Scale (PSOM), most of the patients had some degree of impairment, mainly in sensorimotor and in cognitive-behavioural areas. The modified Rankin scale (mRS) showed an unfavourable outcome in 70% of patients (including patients that have died). Upper limb was more functionally impaired than lower limb. Strokes in neonatal period and early life were associated with poor prognosis. Size of stroke, cortical and subcortical involvement and basal ganglia stroke were associated with an unfavourable outcome. Fever in the acute phase and hemiparesis at presentation were also poor prognostic factors. Epilepsy at time of evaluation was also associated with unfavourable outcome. On the other hand, a normal electroencephalogram was associated with favourable outcome. CONCLUSIONS AIS in children with heart disease had an unfavourable outcome, with impairment in different areas. Epilepsy happened in one third of the patients.
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Carey S, Wrogemann J, Booth FA, Rafay MF. Epidemiology, Clinical Presentation, and Prognosis of Posterior Circulation Ischemic Stroke in Children. Pediatr Neurol 2017; 74:41-50. [PMID: 28676245 DOI: 10.1016/j.pediatrneurol.2017.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 05/11/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Anterior and posterior circulation strokes are often different in terms of presentation and recurrence risk, but there are few studies that focused on posterior circulation stroke. METHODS We performed a longitudinal retrospective study of children, birth to 18 years, with posterior circulation ischemic stroke at the Children's Hospital Winnipeg from January 1992 to December 2012. Clinical and radiological features and outcomes were collected using standardized tools. RESULTS Of the 158 children with arterial ischemic stroke, 23 (14.5%) children, 21 non-neonates, and 11 males were identified. For posterior circulation ischemic stroke, mean crude incidence of 0.38 and crude mortality rate of 0.11 per 100,000 person-years was estimated. The crude total period prevalence rate for the study period was estimated as 8.1 per 100,000 children. Nonspecific symptoms before stroke presentation were present in 38% and impaired consciousness in 71%. Identifiable risk factors were present in two thirds: vasculopathy 24%, infection 19%, trauma 14%, and congenital heart disease 9.5%. Average Pediatric National Institutes of Health Stroke Scale score at presentation was 11. Poor outcome was noted in 45%. Outcome did not change significantly between 12 and 24 months. Aboriginal ethnicity (P = 0.01), high Pediatric National Institutes of Health Stroke Scale score (P = 0.001), bilateral infarction (P = 0.001), and large caliber artery territory infarction (P = 0.02) predicted poor outcome. CONCLUSIONS Our hospital-based incidence and outcome data provide valuable information to help direct treatment strategies and prognosticate children with posterior circulation ischemic stroke. Our study calls for close observation and early management of children with posterior circulation stroke, in particular with aboriginal ancestry and bilateral and large artery territory infarction.
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Affiliation(s)
| | - Jens Wrogemann
- Section of Pediatric Radiology, Department of Radiology, Manitoba, Canada
| | - Frances A Booth
- Section of Pediatric Neurology, Department of Pediatrics and Child Health, University of Manitoba, Manitoba, Canada
| | - Mubeen F Rafay
- Section of Pediatric Neurology, Department of Pediatrics and Child Health, University of Manitoba, Manitoba, Canada; Dr. M. Rafay Medical Corporation, Manitoba, Canada; Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada.
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15
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Lehman LL, Beaute J, Kapur K, Danehy AR, Bernson-Leung ME, Malkin H, Rivkin MJ, Trenor CC. Workup for Perinatal Stroke Does Not Predict Recurrence. Stroke 2017; 48:2078-2083. [DOI: 10.1161/strokeaha.117.017356] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/09/2017] [Accepted: 06/14/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Laura L. Lehman
- From the Stroke and Cerebrovascular Center (L.L.L., J.B., A.R.D., M.E.B.-L., H.M., M.J.R., C.C.T.), Departments of Neurology (L.L.L., J.B., K.K., M.E.B.-L., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J.R.), and Division of Hematology/Oncology (H.M., C.C.T.), Boston Children’s Hospital, Harvard Medical School, MA
| | - Jeanette Beaute
- From the Stroke and Cerebrovascular Center (L.L.L., J.B., A.R.D., M.E.B.-L., H.M., M.J.R., C.C.T.), Departments of Neurology (L.L.L., J.B., K.K., M.E.B.-L., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J.R.), and Division of Hematology/Oncology (H.M., C.C.T.), Boston Children’s Hospital, Harvard Medical School, MA
| | - Kush Kapur
- From the Stroke and Cerebrovascular Center (L.L.L., J.B., A.R.D., M.E.B.-L., H.M., M.J.R., C.C.T.), Departments of Neurology (L.L.L., J.B., K.K., M.E.B.-L., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J.R.), and Division of Hematology/Oncology (H.M., C.C.T.), Boston Children’s Hospital, Harvard Medical School, MA
| | - Amy R. Danehy
- From the Stroke and Cerebrovascular Center (L.L.L., J.B., A.R.D., M.E.B.-L., H.M., M.J.R., C.C.T.), Departments of Neurology (L.L.L., J.B., K.K., M.E.B.-L., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J.R.), and Division of Hematology/Oncology (H.M., C.C.T.), Boston Children’s Hospital, Harvard Medical School, MA
| | - Miya E. Bernson-Leung
- From the Stroke and Cerebrovascular Center (L.L.L., J.B., A.R.D., M.E.B.-L., H.M., M.J.R., C.C.T.), Departments of Neurology (L.L.L., J.B., K.K., M.E.B.-L., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J.R.), and Division of Hematology/Oncology (H.M., C.C.T.), Boston Children’s Hospital, Harvard Medical School, MA
| | - Hayley Malkin
- From the Stroke and Cerebrovascular Center (L.L.L., J.B., A.R.D., M.E.B.-L., H.M., M.J.R., C.C.T.), Departments of Neurology (L.L.L., J.B., K.K., M.E.B.-L., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J.R.), and Division of Hematology/Oncology (H.M., C.C.T.), Boston Children’s Hospital, Harvard Medical School, MA
| | - Michael J. Rivkin
- From the Stroke and Cerebrovascular Center (L.L.L., J.B., A.R.D., M.E.B.-L., H.M., M.J.R., C.C.T.), Departments of Neurology (L.L.L., J.B., K.K., M.E.B.-L., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J.R.), and Division of Hematology/Oncology (H.M., C.C.T.), Boston Children’s Hospital, Harvard Medical School, MA
| | - Cameron C. Trenor
- From the Stroke and Cerebrovascular Center (L.L.L., J.B., A.R.D., M.E.B.-L., H.M., M.J.R., C.C.T.), Departments of Neurology (L.L.L., J.B., K.K., M.E.B.-L., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J.R.), and Division of Hematology/Oncology (H.M., C.C.T.), Boston Children’s Hospital, Harvard Medical School, MA
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Komarova IB, Zykov VP, Ushakova LV, Nazarova EK, Novikova EB, Shuleshko OV, Samigulina MG. [Clinical and neuroimaging signs of cardioembolic stroke laboratory in children]. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 117:11-19. [PMID: 28665364 DOI: 10.17116/jnevro20171173211-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM To study clinical and neuroimaging signs of cardioembolic stroke (CES) in children. MATERIAL AND METHODS Ten children (mean age 3.5±3.5 years) were examined. Eight children met the diagnostic criteria of CES CASCADE, two children were diagnosed with CES based on the complex of symptoms. A comparison group consisted of 90 children with other subtypes of ischemic stroke (IS). The diagnosis was confirmed by MRI and magnetic-resonance angiography; symptom severity was assessed with PedNIHSS and PSOM. RESULTS AND CONCLUSION The PedNIHSS score in the acute stage of CES was higher (18.4±9.34) compared to patients with other subtypes of IS (12.6±6.2; p=0.0065). Six patients had large cerebral infarctions with the involvement of basal ganglia, internal capsule, white matter and cerebral cortex. In two patients, the infarction affected the cerebral cortex and underlying white matter, in one patient it affected the cortex from one side and the basal ganglia from the other. A damage of the cortex was noted in one patient. The frequency of recurrent CES was 30%, of fatal cases 20%. Recurrent IS and severe residual neurological deficit were more frequent in CES. CONCLUSION Early disease onset, acute development and progression of neurological deficit up to the maximal level in the first 5 min, marked severity of the acute stage (PedNIHSS score >15), early onset of neurological function recovery, marked residual neurological deficit (PSOM score >2) are the additional signs of CES.
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Affiliation(s)
- I B Komarova
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
| | - V P Zykov
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
| | - L V Ushakova
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
| | - E K Nazarova
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
| | - E B Novikova
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
| | - O V Shuleshko
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
| | - M G Samigulina
- Russian Medical Academy for Continuum Professional Education, Moscow, Russia
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