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Noailly J, Sadozaï L, Hurtaud-Roux MF, Naudin J, Bonnefoy R, Farnoux C, Kwon T, Bourdon O, Prot-Labarthe S. [Enoxaparin and tinzaparin in pediatrics: Impact of recommendation on prescription quality and anti-Xa levels]. ANNALES PHARMACEUTIQUES FRANÇAISES 2021; 79:710-719. [PMID: 33675741 DOI: 10.1016/j.pharma.2021.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/27/2021] [Accepted: 02/24/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES A protocol has been written and distributed in May 2017 to all prescribers in a pediatric hospital to standardize and to secure the prescriptions of enoxaparin and tinzaparin considered as two high risk medications. The aim of this study is to evaluate the impact of the protocol on those prescriptions in a pediatric population. METHODS This is a monocentric retrospective study comparing prescriptions of this two low-molecular-weight heparins for patients under 18 years old in 2016 and 2018, thus before and after the protocol redaction. RESULTS In 2016, 2246 prescriptions of enoxaparin and tinzaparin were analyzed for 627 patients. Among them, 142 (22.6%) patients have had at least one anti-Xa level dosed. On the other hand, in 2018, 2061 prescriptions were written for 628 patients including 96 (15.3%) who have had at least one anti-Xa level dosed. The conformity rate of the first dose in IU/kg/administration of the first enoxaparin prescription goes from 36.3% before protocol to 52.1% after (P=0.03*). Concerning tinzaparin, the conformity rate goes from 69.2% to 83.3%. (P=0.19). The rate of first anti-Xa level in the range 0.4 to 1.2 IU/ml increase between 2016 and 2018 from 27.7% to 43.8% (P<0.001*). CONCLUSION This protocol enabled to improve the quality of prescriptions in terms of: dosage written in IU/kg/administration, frequency of administration, dilution conformity, and result of the first anti-Xa level. Some efforts must be made in writing the dose in IU not in mg or ml.
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Affiliation(s)
- J Noailly
- Service de Pharmacie, AP-HP, Hôpital Robert-Debré, Paris, France
| | - L Sadozaï
- Service de Pharmacie, AP-HP, Hôpital Robert-Debré, Paris, France
| | - M-F Hurtaud-Roux
- Service d'Hématologie Biologique, AP-HP, Hôpital Robert-Debré, Paris, France
| | - J Naudin
- Service de Réanimation et surveillance continue Pédiatrique, AP-HP, Hôpital Robert-Debré, Paris, France
| | - R Bonnefoy
- Service de Cardiologie Pédiatrique, AP-HP, Hôpital Robert-Debré, Paris, France
| | - C Farnoux
- Service de Néonatologie, AP-HP, Hôpital Robert-Debré, Paris, France
| | - T Kwon
- Service de Néphrologie Pédiatrique, AP-HP, Hôpital Robert-Debré, Paris, France
| | - O Bourdon
- Service de Pharmacie, AP-HP, Hôpital Robert-Debré, Paris, France; Département de pharmacie clinique, Université Paris Descartes, Paris, France; Laboratoire Educations et Pratiques de Santé, Université Paris XIII, Bobigny, France
| | - S Prot-Labarthe
- Service de Pharmacie, AP-HP, Hôpital Robert-Debré, Paris, France; Université de Paris, ECEVE, Inserm, 75010 Paris, France.
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Medley TL, Miteff C, Andrews I, Ware T, Cheung M, Monagle P, Mandelstam S, Wray A, Pridmore C, Troedson C, Dale RC, Fahey M, Sinclair A, Walsh P, Stojanovski B, Mackay MT. Australian Clinical Consensus Guideline: The diagnosis and acute management of childhood stroke. Int J Stroke 2018; 14:94-106. [DOI: 10.1177/1747493018799958] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke is among the top 10 causes of death in children and survivors carry resulting disabilities for decades, at substantial cost to themselves and their families. Children are not currently able to access reperfusion therapies, due to limited evidence supporting safety and efficacy and long diagnostic delays. The Australian Clinical Consensus Guideline for the Diagnosis and Acute Management of Childhood Stroke was developed to minimize unwarranted variations in care and document best evidence on the risk factors, etiologies, and conditions mimicking stroke that differ from adults. Clinical questions were formulated to inform systematic database searches from 2007 to 2017, limited to English and pediatric studies. SIGN methodology and the National Health and Medical Research Council system were used to screen and classify the evidence. The Grades of Recommendation, Assessment, Development, and Evaluation system (GRADE) was used to grade evidence as strong or weak. The Guideline provides more than 60 evidence-based recommendations to assist prehospital and acute care clinicians in the rapid identification of childhood stroke, choice of initial investigation, to confirm diagnosis, determine etiology, selection of the most appropriate interventions to salvage brain at risk, and prevent recurrence. Recommendations include advice regarding the management of intracranial pressure and congenital heart disease. Implementation of the Guideline will require reorganization of prehospital and emergency care systems, including the development of regional stroke networks, pediatric Code Stroke, rapid magnetic resonance imaging and accreditation of primary pediatric stroke centers with the capacity to offer reperfusion therapies. The Guideline will allow auditing to benchmark timelines of care, access to acute interventions, and outcomes. It will also facilitate the development of an Australian childhood stroke registry, with data linkage to international registries, to allow for accurate data collection on stroke incidence, treatment, and outcomes.
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Affiliation(s)
- Tanya L Medley
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
| | | | - Ian Andrews
- Sydney Children's Hospital, School of Women's and Children's Health, University of New South Wales, Sydney, Australia
| | - Tyson Ware
- Royal Hobart Hospital, Hobart, Australia
| | - Michael Cheung
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Department of Cardiology Royal Children's Hospital, Melbourne, Australia
| | - Paul Monagle
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | - Simone Mandelstam
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | - Alison Wray
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | | | - Christopher Troedson
- Children's Hospital at Westmead, Discipline of Child and Adolescent Health, University of Sydney, Sydney, Australia
| | - Russell C Dale
- Children's Hospital at Westmead and University of Sydney, Sydney Australia
| | - Michael Fahey
- Department of Paediatrics Monash University, Department of Medicine Melbourne University, and Monash Children's Hospital, Melbourne, Australia
| | - Adriane Sinclair
- Lady Cilento Children's Hospital, University of Queensland, Brisbane, Australia
| | | | - Belinda Stojanovski
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | - Mark T Mackay
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Department of Neurology Royal Children's Hospital, Melbourne Australia
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3
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Azab SF, Akeel NE, Abdalhady MA, Elhewala AA, Ali ASA, Amin EK, Sarhan DT, Almalky MAA, Elhindawy EM, Salam MMA, Soliman AA, Abdellatif SH, Ismail SM, Elsamad NA, Hashem MIA, Aziz KA, Elazouni OMA, Arafat MS. Serum Hepcidin Levels in Childhood-Onset Ischemic Stroke: A Case-Control Study. Medicine (Baltimore) 2016; 95:e2921. [PMID: 26945394 PMCID: PMC4782878 DOI: 10.1097/md.0000000000002921] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Recently, hepcidin, an antimicrobial-like peptide hormone, has evolved as the master regulator of iron homeostasis. Despite the growing evidence of iron imbalance in childhood-onset ischemic stroke, serum hepcidin level in those patients has not yet been researched. In this study, we aimed to estimate serum (hepcidin) level in acute ischemic stroke (AIS) patients and to investigate whether subcutaneous enoxaparin sodium, which is a low-molecular-weight heparin (LMWH) derivative, could modulate serum hepcidin level in those patients. This was a case-control study included 60 (AIS) cases, and 100 healthy children with comparable age and gender as control group. For all subjects' serum hepcidin, interleukin-6 (IL-6), and soluble transferrin receptor [sTfR]) levels were assessed by (enzyme-linked immunosorbent assay [ELISA] method). Iron parameters including (serum iron, ferritin, transferrin, and total iron binding capacity [TIBC]) were also measured. The patients were subdivided according to treatment with an LMWH derivative into 2 groups and serum hepcidin levels were assessed initially and 1 week after stroke onset for all cases. We found that AIS cases had higher serum iron, ferritin, and IL6 levels compared to the control group (all P < 0.01). Serum hepcidin was significantly higher in AIS cases (median, 36[15-73]ng/mL) compared to the control group (median, 24[10-41]ng/mL; P < 0.01). On the 1st day of AIS diagnosis, serum hepcidin levels were similar in both stroke subgroups (P > 0.05). However, on the 7th day of diagnosis serum hepcidin level decreased significantly in AIS cases treated with LMWH (group 1) (median, 36 vs 21 ng/mL; P < 0.01, respectively). Meanwhile, no significant change was observed in serum hepcidin level in AIS cases not treated with LMWH (group 2) (P > 0.05). Serum hepcidin showed significant positive correlations with serum iron, transferrin saturation, ferritin, and IL6 (r = 0.375, P < 0.05; r = 0.453, P < 0.05; r = 0.687, P < 0.01; r = 0.515, P < 0.01; respectively). Our data brought a novel observation of elevated serum hepcidin level in pediatric AIS patients and pointed out that treatment with LMWH could modulate hepcidin level in those patients.
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Affiliation(s)
- Seham F Azab
- From the Faculty of Medicine, Zagazig University, Al Sharqia Governorate (SFA, NEA, MAA, AAE, ASAA, EKA, DTS, MAAA, EME, MMAS, AAS, SHA, SMI, NAE, MIAH, KAA, OMAE); and Faculty of Medicine, Mansoura University Student hospital, Dakahlia Governorate,Egypt (MSA)
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4
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Improving evidence on anticoagulant therapies for venous thromboembolism in children: key challenges and opportunities. Blood 2015; 126:2541-7. [DOI: 10.1182/blood-2015-06-651539] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 10/11/2015] [Indexed: 12/25/2022] Open
Abstract
Abstract
Venous thromboembolism (VTE) is increasingly diagnosed in pediatric patients, and anticoagulant use in this population has become common, despite the absence of US Food and Drug Administration (FDA) approval for this indication. Guidelines for the use of anticoagulants in pediatrics are largely extrapolated from large randomized controlled trials (RCTs) in adults, smaller dose-finding and observational studies in children, and expert opinion. The recently FDA-approved direct oral anticoagulants (DOACs), such as dabigatran, rivaroxaban, apixaban, and edoxaban, provide potential advantages over oral vitamin K antagonists and subcutaneous low-molecular-weight heparins (LMWHs). However, key questions arise regarding their potential off-label clinical application in pediatric thromboembolic disease. In this Perspective, we provide background on the use of LMWHs such as enoxaparin as the mainstay of treatment of pediatric provoked VTE; identify key questions and challenges with regard to DOAC trials and future DOAC therapy in pediatric VTE; and discuss applicable lessons learned from the recent pilot/feasibility phase of a large multicenter RCT of anticoagulant duration in pediatric VTE. The challenges and lessons learned present opportunities to improve evidence for anticoagulant therapies in pediatric VTE through future clinical trials.
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5
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Gulsen S. Successful Heart Transplantation Following Decompressive Craniectomy in a Patient with Restrictive Cardiomyopathy and Extensive Stroke in the Region of the Right Middle Cerebral Artery. Open Access Maced J Med Sci 2014. [DOI: 10.3889/oamjms.2014.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Restrictive cardiomyopathy (RCM) in children is associated with a greater risk of embolic stroke than are other congenital heart diseases. After diagnosis, 50% of children with RCM die within 2 years without heart transplantation. As such, all RCM patients are placed on the heart transplantation list and must wait for an appropriate heart for transplantation. Every type of embolic stroke can occur while waiting for a donor heart; therefore, the cardiovascular team must initiate antithrombotic therapy at time RCM is diagnosed. Some pediatric RCM patients experience embolic stroke (50% are the cerebral type) despite antithrombotic therapy, including acetylsalicylic acid, warfarin, and heparine. Neurosurgeons working in hospitals that perform organ transplantation expect to see RCM cases with restrictive large cerebral infarct. We think that decompressive craniectomy should be performed as soon as possible after determining the clinical condition of any patient with RCM and a large right middle cerebral artery (MCA) infarct.
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6
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Abstract
Stroke is a rare but increasingly recognized disorder in children. Current therapies for arterial ischemic stroke include thrombolytic, antithrombotic and antiplatelet agents, blood transfusion and surgery. Adult studies, pediatric case studies and expert opinion form the basis for these treatment strategies. Thrombolytic agents are increasingly used but, as in adults, the majority of arterial ischemic strokes in children are treated with antiplatelet and antithrombotic agents. Sickle-cell patients, a distinct subset of the pediatric stroke population, are treated primarily with transfusion therapy. Pediatric arterial ischemic stroke studies are needed to determine the most appropriate course of treatment. An international study is currently in progress to formally study the incidence, risk factors, treatment strategies and outcomes of stroke in children.
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Affiliation(s)
- Jessica Carpenter
- Children's National Medical Center, Department of Neurology, Washington, DC 20010, USA.
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7
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Amlie-Lefond C, Gill JC. Approach to acute ischemic stroke in childhood. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:276. [PMID: 24390791 DOI: 10.1007/s11936-013-0276-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OPINION STATEMENT Acute ischemic stroke in childhood is a medical emergency. Prompt recognition and intervention is necessary to rescue potentially viable brain tissue, prevent complications, and minimize the risk of recurrent stroke. Conditions that could result in recurrent stroke such as cardiac thrombus or cervical artery dissection need to be identified and treated promptly. Although the care of childhood stroke is based largely on extrapolation from adults, an organized approach to the care of these children is critical to optimize outcome.
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Affiliation(s)
- Catherine Amlie-Lefond
- Department of Neurology, Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, 4800 Sand Point Way NE, MB 7.462, Seattle, WA, 98105, USA,
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9
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Abstract
The aim of this review is to summarize the existing literature on therapy and management of cerebrovascular insults in children and adolescents. As data sources, studies were identified by MEDLINE, PubMed, Cochrane Library, and relevant bibliographies for the topic "pediatric stroke." We also reviewed guidelines for "stroke in adults." As a result, pediatric stroke is underestimated. The annual incidence for all stroke entities (cerebral venous thrombosis and hemorrhagic and arterial ischemic stroke) is as high as for pediatric brain tumors, 3-15/100.000 children per year. A distinct etiology can be determined only in a minority of them. Underlying risk factors are multiple, mainly vasculopathies, congential heart diseases, coagulopathies, lipometabolic disorders, and sickle cell anemia. Current recommendations for therapy are based on adult studies, are preliminary, and discussed controversially. Antithrombotic therapy is uniformly recommended for the acute stage of pediatric stroke; no consensus exists on antiplatelet therapy with acetylsalicylic acid (ASA, aspirin) (5 mg/d), with ultra-fractionated or low-molecular-weight heparin. Thrombolysis using recombinant tissue plasminogen activator is not advised, despite the fact that current practice takes a different approach. None of the guidelines specify the duration of ASA for secondary prevention. Additional supportive therapy measures are osmotherapy and decompressive craniectomy. Oxygen in the absence of hypoxemia, intensive insulin therapy, antiepileptic drugs in the absence of clinical or electrographic seizures, corticosteroids, and GP-IIb/IIIa-receptor antagonists should not be used outside clinical trials. In conclusions, current therapeutic guidelines for pediatric stoke are still based on consensus and expert and society opinions and differ between countries. Consensus prevails on the need for acute anticoagulation using either antiplatelets or heparin. Long-term treatment with acetylsalicylic acid in all or only high-risk patients and for how long remains the subject of debate. Lifelong secondary prevention has never been investigated in children or adults. All guidelines agree that there is no indication for thrombolysis in children outside clinical trials, although clinical practice in large centers differs.
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10
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Titomanlio L, Zanin A, Sachs P, Khaled J, Elmaleh M, Blanc R, Piotin M. Pediatric ischemic stroke: acute management and areas of research. J Pediatr 2013; 162:227-35.e1. [PMID: 23153863 DOI: 10.1016/j.jpeds.2012.09.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Revised: 08/08/2012] [Accepted: 09/10/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Luigi Titomanlio
- Pediatric Emergency Department, APHP, Robert Debré Hospital, Paris Diderot University, Paris, France.
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11
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Monagle P, Chan AKC, Goldenberg NA, Ichord RN, Journeycake JM, Nowak-Göttl U, Vesely SK. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e737S-e801S. [PMID: 22315277 DOI: 10.1378/chest.11-2308] [Citation(s) in RCA: 958] [Impact Index Per Article: 79.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Neonates and children differ from adults in physiology, pharmacologic responses to drugs, epidemiology, and long-term consequences of thrombosis. This guideline addresses optimal strategies for the management of thrombosis in neonates and children. METHODS The methods of this guideline follow those described in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. RESULTS We suggest that where possible, pediatric hematologists with experience in thromboembolism manage pediatric patients with thromboembolism (Grade 2C). When this is not possible, we suggest a combination of a neonatologist/pediatrician and adult hematologist supported by consultation with an experienced pediatric hematologist (Grade 2C). We suggest that therapeutic unfractionated heparin in children is titrated to achieve a target anti-Xa range of 0.35 to 0.7 units/mL or an activated partial thromboplastin time range that correlates to this anti-Xa range or to a protamine titration range of 0.2 to 0.4 units/mL (Grade 2C). For neonates and children receiving either daily or bid therapeutic low-molecular-weight heparin, we suggest that the drug be monitored to a target range of 0.5 to 1.0 units/mL in a sample taken 4 to 6 h after subcutaneous injection or, alternatively, 0.5 to 0.8 units/mL in a sample taken 2 to 6 h after subcutaneous injection (Grade 2C). CONCLUSIONS The evidence supporting most recommendations for antithrombotic therapy in neonates and children remains weak. Studies addressing appropriate drug target ranges and monitoring requirements are urgently required in addition to site- and clinical situation-specific thrombosis management strategies.
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Affiliation(s)
- Paul Monagle
- Haematology Department, The Royal Children's Hospital, Department of Paediatrics, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Anthony K C Chan
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Neil A Goldenberg
- Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplantation and Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, Aurora, CO
| | - Rebecca N Ichord
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Janna M Journeycake
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
| | - Ulrike Nowak-Göttl
- Thrombosis and Hemostasis Unit, Institute of Clinical Chemistry, University Hospital Kiel, Kiel, Germany
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK.
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Abstract
Abstract
Pediatric arterial ischemic stroke (AIS) is increasingly diagnosed and carries significant risks of recurrence, morbidity, and mortality. Anticoagulant therapy (ACT) is commonly prescribed in childhood AIS. Hemorrhagic complication rates in pediatric stroke are unknown, and adult safety data are of limited applicability. We analyzed a prospectively enrolled cohort of children (aged 1 month-18 years) with acute AIS selected using standardized criteria for protocol-based ACT over14-year period. We assessed ACT-associated intracranial hemorrhage (ICH), including frequency, clinical and radiologic characteristics, predictors, and outcome. Among 215 children with AIS, 123 received ACT within 7 days after diagnosis. During anticoagulation, 14 (11%) children developed new or increased ICH, all within 26 days from diagnosis. ICH was symptomatic in 5 (4%), asymptomatic in 9 (7%), and mild (European Cooperative Acute Stroke Study grades HI1 or HI2) in all but 1 child (ECASS PH-2). Long-term neurologic outcomes after ACT-associated ICH in survivors were abnormal in 73% (8/11). Comparably, 12 of 75 (16%) children treated without anticoagulation developed new or increased ICH on follow-up imaging (P = .3507). We conclude that ACT is relatively safe in children with AIS, with a 4% risk of symptomatic ICH. Based on the safety of ACT in our study, clinical trials of ACT in childhood AIS are warranted.
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13
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Lyle CA, Bernard TJ, Goldenberg NA. Childhood arterial ischemic stroke: a review of etiologies, antithrombotic treatments, prognostic factors, and priorities for future research. Semin Thromb Hemost 2011; 37:786-93. [PMID: 22187401 DOI: 10.1055/s-0031-1297169] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Childhood arterial ischemic stroke (AIS) is a rare, but serious, medical condition, which is fatal in approximately 3% and associated with both acute and long-term neurologic impairment in over 70% of cases. Common etiologies include sickle cell disease, congenital heart disease, arterial dissection, prothrombotic conditions, and preceding viral infections; however, one in four cases is considered idiopathic. To date, no randomized controlled clinical trials (RCTs) have been conducted to establish evidence for current therapeutic strategies outside of sickle cell disease, thus, treatment strategies are largely shaped by consensus-based guidelines, in which, beyond the acute period, aspirin is the mainstay of therapy and anticoagulation is reserved for select circumstances. In recent years, evidence on prognostic factors has accumulated, helping to inform the future design of prognostically stratified RCTs. In this narrative review, we discuss the current understanding of etiologies, consensus-based treatment recommendations, contemporary treatment data, and prognostic factors in childhood AIS. We also identify priorities for future research.
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Affiliation(s)
- Courtney A Lyle
- Division of Hematology/Oncology, Department of Pediatrics, University of California, San Diego, California, USA.
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14
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Ciccone S, Cappella M, Borgna-Pignatti C. Ischemic stroke in infants and children: practical management in emergency. Stroke Res Treat 2011; 2011:736965. [PMID: 21776365 PMCID: PMC3138064 DOI: 10.4061/2011/736965] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 04/27/2011] [Accepted: 05/02/2011] [Indexed: 11/20/2022] Open
Abstract
Stroke is a rare disease in children, with an estimated incidence 13/100000 and a significant impact on morbidity and mortality. Clinical presentation and risk factors, present in almost half of pediatric patients, are not the same as in adults. The diagnosis of stroke in children is often delayed because signs and symptoms can be subtle and nonspecific. History and clinical examination should exclude underlying diseases or predisposing factors. Neuroimaging is crucial in defining diagnosis. Other tests might be necessary, according to the clinical picture. We present here the most recent practical directions on how to diagnose and manage arterial stroke in children, according to different international guidelines on the subject.
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Affiliation(s)
- Sara Ciccone
- Department of Clinical and Experimental Medicine-Pediatrics, University of Ferrara, 44121 Ferrara, Italy
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15
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Fan HC, Hu CF, Juan CJ, Chen SJ. Current proceedings of childhood stroke. Stroke Res Treat 2011; 2011:432839. [PMID: 21331325 PMCID: PMC3038616 DOI: 10.4061/2011/432839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 12/04/2010] [Indexed: 12/24/2022] Open
Abstract
Stroke is a sudden onset neurological deficit due to a cerebrovascular event. In children, the recognition of stroke is often delayed due to the low incidence of stroke and the lack of specific assessment measures to this entity. The causes of pediatric stroke are significantly different from that of adult stroke. The lack of safety and efficiency data in the treatment is the challenge while facing children with stroke. Nearly half of survivors of pediatric stroke may have neurologic deficits affecting functional status and quality of life. They may cause a substantial burden on health care resources. Hence, an accurate history, including onset and duration of symptoms, risk factors, and a complete investigation, including hematologic, neuroimaging, and metabolic studies is the key to make a corrective diagnosis. A prompt and optimal treatment without delay may minimize the damage to the brain.
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Affiliation(s)
- Hueng-Chuen Fan
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Neihu, Taipei 114, Taiwan
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16
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Adams HP, Davis PH. Antithrombotic Therapy for Treatment of Acute Ischemic Stroke. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10050-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Monagle P, Newall F, Campbell J. Anticoagulation in neonates and children: Pitfalls and dilemmas. Blood Rev 2010; 24:151-62. [PMID: 20663595 DOI: 10.1016/j.blre.2010.06.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Anticoagulation in children is problematic for many reasons, related to the patient population as well as the anticoagulant drugs themselves. This paper describes the multitude of reasons why providing anticoagulation therapy in children is different from anticoagulation therapy in adults, and hence why dedicated paediatric anticoagulant services are the ideal structure to provide this service. The paper then describes the three most common anticoagulants used in children, and details specifically what is and is not known about them in the paediatric population. Finally the paper addresses the issue of how best to introduce newer anticoagulant drugs into the paediatric population. There remains much research to be done in this field, in the meantime clinicians need to carefully consider the evidence available to them and manage each individual patient accordingly.
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Affiliation(s)
- Paul Monagle
- Department of Clinical Haematology, Royal Children's Hospital, Parkville, Victoria 3052, Australia.
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18
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Abstract
In recent years, there has been increasing recognition of the impact of childhood stroke and interest in the role of drugs in the acute, chronic, and prophylactic management of this condition. Most treatment strategies are based on studies in adults with stroke, and the relative infrequency of stroke and the heterogeneity of etiologies in childhood compared with adults present significant challenges in study design for childhood stroke studies. The presence of thrombophilia has been associated with stroke in children, strengthening the concept that antithrombotic, antiplatelet, and even thrombolytic agents have a role in stroke treatment and prevention. There are several potential roles for drugs in the treatment of childhood stroke including hyperacute therapy, antithrombotic medication, antiplatelet medication, and disease-specific medications. Herein, we review the use and rationale of these medications in childhood arterial ischemic stroke.
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Sachdev A, Sharma R, Gupta D. Cerebrovascular complications in pediatric intensive care unit. Indian J Crit Care Med 2010; 14:129-40. [PMID: 21253346 PMCID: PMC3021828 DOI: 10.4103/0972-5229.74171] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Cerebrovascular complications are being frequently recognized in the pediatric intensive care unit in the recent few years. The epidemiology and risk factors for pediatric stroke are different from that of the adults. The incidence of ischemic stroke is almost slightly more than that of hemorrhagic stroke. The list of diagnostic causes is increasing with the availability of newer imaging modalities and laboratory tests. The diagnostic work up depends on the age of the child and the rapidity of presentation. Magnetic resonance imaging, computerized tomography and arteriography and venography are the mainstay of diagnosis and to differentiate between ischemic and hemorrhagic events. Very sophisticated molecular diagnostic tests are required in a very few patients. There are very few pediatric studies on the management of stroke. General supportive management is as important as the specific treatment. Most of the treatment guidelines and suggestions are extrapolated from the adult studies. Few guidelines are available for the use of anticoagulants and thrombolytic agents in pediatric patients. So, our objective was to review the available literature on the childhood stroke and to provide an insight into the subject for the pediatricians and critical care providers.
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Affiliation(s)
- Anil Sachdev
- From: Department of Pediatrics, Sir Ganga Ram Hospital, New Rajinder Nagar, New Delhi, India
| | - Rachna Sharma
- Department of Pediatrics, Dr. B. L. Kapoor Memorial Hospital, Pusa Road, New Delhi, India
| | - Dhiren Gupta
- From: Department of Pediatrics, Sir Ganga Ram Hospital, New Rajinder Nagar, New Delhi, India
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Ignjatovic V, Najid S, Newall F, Summerhayes R, Monagle P. Dosing and monitoring of enoxaparin (Low molecular weight heparin) therapy in children. Br J Haematol 2010; 149:734-8. [DOI: 10.1111/j.1365-2141.2010.08163.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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21
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Papp J, Dorsey ST. A Preschool-Age Child With First-Time Seizure and Ataxia. J Emerg Med 2009; 36:30-3. [DOI: 10.1016/j.jemermed.2007.02.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2005] [Revised: 07/18/2006] [Accepted: 11/16/2006] [Indexed: 11/25/2022]
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22
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Low-Molecular-Weight Heparin Use in a Case of Noncardiogenic Multifocal Perinatal Thromboembolic Stroke. Adv Hematol 2009; 2009:153643. [PMID: 19946420 PMCID: PMC2778868 DOI: 10.1155/2009/153643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Accepted: 01/13/2009] [Indexed: 11/17/2022] Open
Abstract
A full-term neonate suffered multifocal cerebral infarctions due to multiple large vessel thrombi. Thrombophilia and cardiovascular assessments were negative, but due to the severity of the lesions and the concern for expansion of the thrombi or future embolic events, treatment with low-molecular-weight heparin (LMWH) was initiated. No complications from treatment were experienced. We present this severe case in order to highlight difficult management decisions for newborns with multifocal perinatal thromboembolic stroke and to stress the need for further practice guidelines and research in this area.
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Roach ES, Golomb MR, Adams R, Biller J, Daniels S, Deveber G, Ferriero D, Jones BV, Kirkham FJ, Scott RM, Smith ER. Management of Stroke in Infants and Children. Stroke 2008; 39:2644-91. [PMID: 18635845 DOI: 10.1161/strokeaha.108.189696] [Citation(s) in RCA: 743] [Impact Index Per Article: 46.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Monagle P, Chalmers E, Chan A, deVeber G, Kirkham F, Massicotte P, Michelson AD. Antithrombotic therapy in neonates and children: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:887S-968S. [PMID: 18574281 DOI: 10.1378/chest.08-0762] [Citation(s) in RCA: 415] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
This chapter about antithrombotic therapy in neonates and children is part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs, and Grade 2 suggests that individual patient values may lead to different choices (for a full understanding of the grading, see Guyatt et al in this supplement, pages 123S-131S). In this chapter, many recommendations are based on extrapolation of adult data, and the reader is referred to the appropriate chapters relating to guidelines for adult populations. Within this chapter, the majority of recommendations are separate for neonates and children, reflecting the significant differences in epidemiology of thrombosis and safety and efficacy of therapy in these two populations. Among the key recommendations in this chapter are the following: In children with first episode of venous thromboembolism (VTE), we recommend anticoagulant therapy with either unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) [Grade 1B]. Dosing of IV UFH should prolong the activated partial thromboplastin time (aPTT) to a range that corresponds to an anti-factor Xa assay (anti-FXa) level of 0.35 to 0.7 U/mL, whereas LMWH should achieve an anti-FXa level of 0.5 to 1.0 U/mL 4 h after an injection for twice-daily dosing. In neonates with first VTE, we suggest either anticoagulation or supportive care with radiologic monitoring and subsequent anticoagulation if extension of the thrombosis occurs during supportive care (Grade 2C). We recommend against the use of routine systemic thromboprophylaxis for children with central venous lines (Grade 1B). For children with cerebral sinovenous thrombosis (CSVT) without significant intracranial hemorrhage (ICH), we recommend anticoagulation initially with UFH, or LMWH and subsequently with LMWH or vitamin K antagonists (VKAs) for a minimum of 3 months (Grade 1B). For children with non-sickle-cell disease-related acute arterial ischemic stroke (AIS), we recommend UFH or LMWH or aspirin (1 to 5 mg/kg/d) as initial therapy until dissection and embolic causes have been excluded (Grade 1B). For neonates with a first AIS, in the absence of a documented ongoing cardioembolic source, we recommend against anticoagulation or aspirin therapy (Grade 1B).
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Affiliation(s)
- Paul Monagle
- From the Haematology Department, The Royal Children's Hospital and Department of Pathology, The University of Melbourne, Melbourne, VIC, Australia.
| | - Elizabeth Chalmers
- Consultant Pediatric Hematologist, Royal Hospital for Sick Children, Glasgow, UK
| | | | - Gabrielle deVeber
- Division of Neurology, Hospital for Sick Children, Toronto, ON, Canada
| | | | - Patricia Massicotte
- Department of Pediatrics, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Alan D Michelson
- Center for Platelet Function Studies, University of Massachusetts Medical School, Worcester, MA
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Bernard TJ, Goldenberg NA, Armstrong-Wells J, Amlie-Lefond C, Fullerton HJ. Treatment of childhood arterial ischemic stroke. Ann Neurol 2008; 63:679-96. [DOI: 10.1002/ana.21406] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Nowak-Göttl U, Bidlingmaier C, Krümpel A, Göttl L, Kenet G. Pharmacokinetics, efficacy, and safety of LMWHs in venous thrombosis and stroke in neonates, infants and children. Br J Pharmacol 2007; 153:1120-7. [PMID: 17906688 PMCID: PMC2275453 DOI: 10.1038/sj.bjp.0707447] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Since the early nineties it has been shown that low molecular weight heparin (LMWH) has significant advantages over unfractionated heparin and oral anticoagulants for both the treatment and the prevention of thrombosis, not only in adults, but also in children. The present review was based on an 'EMBASE', 'Medline' and 'PubMed' search including literature published in any language since 1980 on LMWH in neonates, infants and children. It included paediatric pharmacokinetic studies, the use of LMWH in children with venous thrombosis, LMWH administration in paediatric patients with ischaemic stroke, and its use in order to prevent symptomatic thromboembolism in children at risk. An increasing rate of off-label use of LMWH in children has been reported, showing that LMWHs offer important benefits to children with symptomatic thromboembolic events and poor venous access. Two well-conducted pharmacokinetic studies in this age group showed that neonates and younger infants require higher LMWH doses than older children to achieve the targeted anti-Xa levels, due to an increased extra vascular clearance. Recurrent symptomatic thromboses under LMWH occur in approximately 4% of children treated for venous thrombosis, and in 7% of children treated for stroke; major bleed was documented in 3% of children with therapeutic target LMWH anti-Xa levels, whereas minor bleeding was reported in approximately 23% of children receiving either therapeutic or prophylactic doses, respectively. Further randomized controlled trials are recommended to evaluate the optimum duration and application for different LMWH indications in children.
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Affiliation(s)
- U Nowak-Göttl
- Department of Paediatric Haematology and Oncology, University of Münster, Münster, Germany.
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Abstract
Evidence-based therapeutic interventions for pediatric ischemic cerebrovascular disease are beginning to emerge. The primary therapeutic target is usually the pathological prothrombotic disturbance that underlies the majority of pediatric stroke. A battle between anticoagulation and anti-platelet therapies continues to provide controversy and is the inspiration for upcoming randomized trials. Supportive care and neuroprotective strategies are an important consideration in children with stroke. Attempts to determine the safety of acute thrombolytic interventions are also underway. Finally, unique medical and surgical treatments for specific diseases leading to stroke in children continue to evolve. After briefly summarizing the epidemiology, pathophysiology, diagnosis, and outcomes of ischemic strokes in children, treatment approaches and alternatives will be reviewed in detail with emphasis placed on current areas of controversy and future directions for clinical research.
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Affiliation(s)
- Adam Kirton
- Children’s Stroke Program, Department of Pediatrics, Division of Neurology, Faculty of Medicine, University of Toronto, Hospital for Sick Children, M5G 1X8 Toronto, ON Canada
| | - Gabrielle deVeber
- Children’s Stroke Program, Department of Pediatrics, Division of Neurology, Faculty of Medicine, University of Toronto, Hospital for Sick Children, M5G 1X8 Toronto, ON Canada
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Kuhle S, Mitchell L, Andrew M, Chan AK, Massicotte P, Adams M, deVeber G. Urgent Clinical Challenges in Children With Ischemic Stroke. Stroke 2006; 37:116-22. [PMID: 16322494 DOI: 10.1161/01.str.0000195044.44442.e0] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Clinical trials are lacking in pediatric stroke. As a result, physicians caring for children with stroke face significant challenges. The patient characteristics and specific nature of clinical challenges facing practicing clinicians can inform the design of and priorities for developing relevant clinical trials.
Methods—
Physicians consulted the 1-800-NOCLOTS toll-free pediatric stroke telephone consultation service on children (birth to 18 years) with ischemic stroke. Pediatric neurologist or hematologists provided telephone consultation and documented caller and patient characteristics, antithrombotic treatments and callers’ questions for entry into a computerized database. Children referred from January 1, 1995 to January 1, 2004, comprised the study cohort.
Results—
Stroke consults were completed on 1065 children located predominantly in the United States (76%). Children had arterial ischemic stroke (AIS; 679; 64%) or cerebral sinovenous thrombosis (CSVT; 386; 36%) and were 54% male and 16% neonates. Risk factors and antithrombotic agents (none, aspirin, warfarin, and heparins) differed by stroke type. In 60% of patients, callers had not initiated antithrombotic therapy. Callers’ questions for both stroke types usually concerned treatment selection (83%), but for AIS, questions more frequently (
P
<0.0001) concerned the selection and interpretation of etiological investigations.
Conclusions—
Research is urgently needed in pediatric stroke to provide direction for management in “real-life” settings. Research efforts should address the unique challenges within different stroke types and include observational studies addressing investigation of the child with AIS. For AIS and CSVT, randomized controlled trials investigating the efficacy of antithrombotic treatment are urgently needed.
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Affiliation(s)
- Stefan Kuhle
- Department of Pediatrics, Thrombosis Program, Stollery Children's Hospital, Edmonton, Alberta, Canada
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Abstract
BACKGROUND Arterial ischaemic stroke and cerebral sinovenous thrombosis are increasingly seen in infants and children. Incidence ranges from two to six per 100,000 children a year. Adverse outcome including death, neurological deficits, and reduced quality of life affect most children with stroke. Residual neurological deficits last many decades, for the rest of a patient's life. Of major concern is the risk of recurrent stroke, which affects up to 25% of children who have arterial ischaemic stroke after the newborn period. Children with ischaemic stroke are empirically treated with antithrombotics including antiplatelet (aspirin and clopidogrel) and anticoagulant (heparins and warfarin) drugs. No randomised controlled trials have been done besides those in patients with sickle-cell disease and adult trial data are not directly applicable to paediatric stroke due to maturational differences in coagulation and vascular systems as well as different stroke mechanisms. RECENT DEVELOPMENTS National and international networks of clinical and basic researchers focused on paediatric stroke are now developing. Recently published cohort and case-controlled studies are elucidating stroke mechanisms, outcomes, and treatment safety in children. Two sets of guidelines have been published in the past 6 months. These guidelines differ both in the scope of treatments and subgroups of patients with stroke they cover; however, both focus on ischaemic stroke beyond the newborn period. There are areas of agreement-for children with sickle-cell disease and stroke, both guidelines recommend initial and maintenance transfusion therapy to reduce the proportion of sickle-cell haemoglobin to less than 30%. For children with sinovenous thrombosis or arterial stroke due to dissection or cardiac embolism, both guidelines recommend anticoagulant therapy with warfarin or low molecular weight heparin for 3-6 months. However, the guidelines diverge in their recommendations for the initial treatment of non-haemorrhagic arterial ischaemic stroke, one recommending aspirin and the other 5-7 days of anticoagulants. The guidelines also differ in their recommendations for long-term treatment of children after arterial ischaemic stroke, one set recommending maintenance aspirin in all patients and the other only in children with vasculopathy. These differences arise from both a lack of sufficient evidence and the differing views of neurologists and haematologists in the treatment of paediatric cerebral thrombosis. WHERE NEXT?: Multicentre studies and networks provide increasingly precise data regarding mechanisms, outcomes, and treatment safety in paediatric stroke. These data and networks will enable clinical trials to address areas of divergent opinion and improve the outcome from childhood stroke in the near future.
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Affiliation(s)
- Gabrielle DeVeber
- Division of Neurology, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G1X8, Canada.
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Adams H, Adams R, Del Zoppo G, Goldstein LB. Guidelines for the Early Management of Patients With Ischemic Stroke. Stroke 2005; 36:916-23. [PMID: 15800252 DOI: 10.1161/01.str.0000163257.66207.2d] [Citation(s) in RCA: 335] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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