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Kumar R, Sun LR, Rodriguez V, Sankar A, Sharma M, Meoded A, Brandão LR, Goldenberg NA. Hemostatic and Thrombotic Considerations in the Diagnosis and Management of Childhood Arterial Ischemic Stroke: A Narrative Review. Semin Pediatr Neurol 2022; 43:101003. [PMID: 36344025 DOI: 10.1016/j.spen.2022.101003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/12/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
Abstract
Although rare in children, arterial ischemic stroke (AIS) is associated with increased mortality and neurological morbidity. The incidence of AIS after the neonatal period is approximately 1-2/100,000/year, with an estimated mortality of 3-7%. A significant proportion of children surviving AIS experience life-long neurological deficits including hemiparesis, epilepsy, and cognitive delays. The low incidence of childhood AIS coupled with atypical clinical-presentation and lack of awareness contribute to delay in diagnosis and consequently, the early initiation of treatment. While randomized-clinical trials have demonstrated the efficacy and safety of reperfusion therapies including thrombolysis and endovascular thrombectomy in appropriately-selected adult patients, similar data for children are unavailable. Consequently, clinical decisions surrounding reperfusion therapy in childhood AIS are either extrapolated from adult data or based on local experience. The etiology of childhood AIS is multifactorial, often occurring in the setting of both acquired and congenital risk-factors including thrombophilia. While multiple studies have investigated the association of thrombophilia with incident childhood AIS, its impact on stroke recurrence and therefore duration and intensity of antithrombotic therapy is less clear. Despite these limitations, a significant progress has been made over the last decade in the management of childhood AIS. This progress can be attributed to international consortiums, and in selected cohorts to federally-funded clinical trials. In this narrative review, the authors have systematically appraised the literature and summarize the hemostatic and thrombotic considerations in the diagnosis and management of childhood AIS focusing on the evidence supporting reperfusion therapies, relevance of thrombophilia testing, and duration and drug choices for secondary-prophylaxis.
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Affiliation(s)
- Riten Kumar
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - Lisa R Sun
- Division of Pediatric Neurology, Johns Hopkins School of Medicine, Baltimore, MD; Division of Cerebrovascular Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Amanda Sankar
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Mukta Sharma
- Division of Hematology, Children's Mercy Hospital, Kansas City, MO
| | - Avner Meoded
- Edward B. Singleton, Department of Radiology, Texas Children's Hospital, Houston, TX
| | - Leonardo R Brandão
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON; Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Neil A Goldenberg
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL; Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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AlBassri T, Sheikho M, Chaikhouni F, Al Habshan F, Kabbani MS. Neurological complications in children with infective endocarditis: Incidence, risk factors, and outcome: A 10-year single-center experience. Int J Pediatr Adolesc Med 2021; 8:198-202. [PMID: 34350336 PMCID: PMC8319676 DOI: 10.1016/j.ijpam.2021.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/26/2020] [Accepted: 02/14/2021] [Indexed: 04/13/2023]
Abstract
BACKGROUND AND OBJECTIVE Despite improvement in medical management, infective endocarditis (IE) remains a serious disease that may affect children with and without preexisting cardiac conditions with significant morbidity and mortality. Neurological complications of IE represent the worst with guarded prognosis. The aim of this study is to describe the incidence, etiology, characteristics, risk factors, and outcome of children with neurological complications associated with IE. MATERIAL AND METHODS A retrospective cohort study was conducted from 2009 to 2019 where all pediatric patients who fulfilled the modified Duke criteria for IE were included. We divided the cases into 2 groups: IE with neurological complications and IE without neurological complications control group. We compared the two groups statistically and analyzed the results. RESULTS We identified 31 (17 male, 14 female) patients with IE. Neurological complications occurred in 7/31 (23%) patients, mainly in the form of a stroke. Gram-positive microbes were the main causative agents for IE (52%) followed by gram-negative (14%), then fungal organisms (3%). Univariate analysis identified the following risk factors for neurological complications: lower body weight, higher C- reactive protein (CRP) level, and left-sided valvular lesions with P values of (0.0003, 0.0001, and 0.04), respectively.Although mortality was higher in the neurological complications group, it was 43% in comparison to 21% in the control group and it did not reach statistical significance (P = .49). Large vegetation size (more than 10 mm) was seen in 57% of patients with neurological complications as compared to 16% in the control group (P = .052). CONCLUSION Neurological complications occurred in almost a quarter of children with IE. Possible risk factors include lower body weight, left-sided valvular lesion, and higher levels of inflammatory markers (CRP). Stroke was the most common neurological complication encountered with possible increased risk of mortality.
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Affiliation(s)
- Tala AlBassri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Maha Sheikho
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Farah Chaikhouni
- Division of Pediatric Cardiology, Department of Cardiac Sciences, King Abdulaziz Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Fahad Al Habshan
- Division of Pediatric Cardiology, Department of Cardiac Sciences, King Abdulaziz Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Mohamed S. Kabbani
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Division of Pediatric Cardiac Intensive Care, Department of Cardiac Sciences, King Abdulaziz Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- Corresponding author. Pediatric Cardiac ICU, MC 1423, King Abdulaziz Medical City, P.O. BOX 22490, Riyadh, 11426, Saudi Arabia.
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Kirton A, Dowling M. Protocols and Guidelines for Stroke in Children: Point and Counterpoint. Pediatr Neurol 2019; 95:5-8. [PMID: 30686626 DOI: 10.1016/j.pediatrneurol.2018.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/18/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Adam Kirton
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Michael Dowling
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas
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Boucher AA, Taylor JM, Luchtman-Jones L. Aspirin in childhood acute ischemic stroke: The evidence for treatment and efficacy testing. Pediatr Blood Cancer 2019; 66:e27665. [PMID: 30762284 DOI: 10.1002/pbc.27665] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/17/2019] [Accepted: 01/30/2019] [Indexed: 12/17/2022]
Abstract
Aspirin is the most commonly prescribed antiplatelet agent worldwide, but evidence supporting its use varies by age and disease process. Despite its frequent use in childhood acute ischemic stroke prevention and management, major knowledge gaps exist about optimal pediatric aspirin use, particularly in this setting, where high-quality clinical trials are urgently needed. This review focuses upon the evidence for aspirin use in childhood acute ischemic stroke, includes a summary of aspirin pharmacology to highlight misconceptions and common clinical situations which may limit its efficacy, and discusses the techniques and potential role of laboratory monitoring of aspirin efficacy in children.
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Affiliation(s)
- Alexander A Boucher
- Department of Pediatrics, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital, Cincinnati, Ohio.,University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - J Michael Taylor
- University of Cincinnati College of Medicine, Cincinnati, Ohio.,Department of Pediatrics, Division of Neurology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Lori Luchtman-Jones
- Department of Pediatrics, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital, Cincinnati, Ohio.,University of Cincinnati College of Medicine, Cincinnati, Ohio
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Kissinger DB, Grover KS, Turner RC. Pediatric Stroke Caregiver Well-Being: A Holistic Wellness Perspective. REHABILITATION COUNSELING BULLETIN 2019. [DOI: 10.1177/0034355219846653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Evidence-based models are critical for understanding caregiver well-being and treatment interventions from a holistic perspective. This study introduces the Indivisible Self: An Evidence-Based Model of Wellness (IS-WEL) as a means for examining the holistic wellness of pediatric stroke caregivers. In this exploratory study, 161 participants completed a demographic survey and the Five-Factor Wellness Inventory (FF-WEL). Results indicate significant wellness score differences between the current sample of pediatric stroke caregivers and the FF-WEL norming sample on the higher order Total Wellness factor, the second-order wellness factors of Creative Self and Social Self, and the third-order wellness factors of thinking, emotions, control, positive humor, and love. These results support the veracity of the IS-WEL as an additional empirically sound holistic approach for understanding and addressing the well-being of stroke caregivers. The authors discuss practical clinical and research implications for utilizing the IS-WEL with pediatric stroke caregivers.
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Nonpharmacological rehabilitation interventions for motor and cognitive outcomes following pediatric stroke: a systematic review. Eur J Pediatr 2019; 178:433-454. [PMID: 30810821 DOI: 10.1007/s00431-019-03350-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 01/31/2019] [Accepted: 02/14/2019] [Indexed: 10/27/2022]
Abstract
The aim of this review was to evaluate the evidence for nonpharmacological rehabilitation interventions for motor and cognitive impairment following pediatric stroke. A literature search was conducted using multiple scientific databases. Studies were included if (1) the study population was > 50% pediatric (< 18 years) stroke, (2) a diagnosis of stroke was explicitly stated, (3) there were ≥ 3 pediatric stroke participants included in the study sample, and (4) motor or cognitive outcome measures were used to assess effect of treatment. Levels of evidence were assigned to each study to determine the strength of the evidence for each intervention. A total of 18 articles met inclusion criteria. Most studies (N = 14) examined rehabilitation of the upper limb, with constraint-induced movement therapy (CIMT) as the most common intervention. Overall, the evidence supports the use of CIMT, forced use therapy, repetitive transcranial magnetic stimulation, functional electrical stimulation, and robotics, but suggests no beneficial effect of transcranial direct current stimulation. Very few studies assessed interventions for the lower limb (N = 1) or cognitive impairment (N = 3).Conclusion: Effective rehabilitation approaches are important for optimizing outcomes in children who have had a stroke. Although the number of published clinical trials has increased in recent years, little evidence-based guidance exists for this clinical population. What is Known: • Pediatric stroke is a significant cause of disability in children that is often associated with long-term motor and cognitive sequelae. • There is a need to establish a knowledge base regarding available evidence-based rehabilitation therapies for this clinical population. What is New: • Most studies examining interventions for motor function focus on upper limb rehabilitation, whereas few studies have investigated interventions for improving lower limb or cognitive impairment. • An important gap exists regarding evidence-based rehabilitative treatment approaches for pediatric stroke.
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Onaolapo AY, Onaolapo OJ, Nathaniel TI. Cerebrovascular Disease in the Young Adult: Examining Melatonin's Possible Multiple Roles. J Exp Neurosci 2019; 13:1179069519827300. [PMID: 30783379 PMCID: PMC6366002 DOI: 10.1177/1179069519827300] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 01/09/2019] [Indexed: 12/11/2022] Open
Abstract
In the last decade or more, there have been reports suggesting a rise in the incidence of stroke in young adults. Presently, it appears that the risk factors associated with the cause of stroke in young adults remain relatively constant across different geographic regions of the world. Moreover, the endogenous rhythm of a neurohormone such as melatonin is known to play certain roles in the modulation of some of the risk factors that are associated with an increased risk of stroke in young people. Whereas animal studies have shown that melatonin plays diverse roles in stroke, only a limited number of human studies examined the roles of exogenous melatonin administration in the prevention of stroke, attenuation of neuronal damage, and improving outcome or well-being in stroke patients. In this review, first we summarize existing studies of stroke in the young adult and then provide insights on melatonin and stroke. Thereafter, we discuss the role of melatonin in models of stroke and how melatonin can be regulated to prevent stroke in young adults. Finally, we highlight the possible roles of melatonin in the management and outcome of stroke, especially in the young adult stroke population.
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Affiliation(s)
- Adejoke Yetunde Onaolapo
- Behavioural Neuroscience/Neurobiology Unit, Department of Anatomy, Ladoke Akintola University of Technology, Ogbomosho, Nigeria
| | - Olakunle James Onaolapo
- Behavioural Neuroscience/Neuropharmacology Unit, Department of Pharmacology, Ladoke Akintola University of Technology, Osogbo, Nigeria
| | - Thomas I Nathaniel
- School of Medicine Greenville, University of South Carolina, Greenville, SC, USA
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Rizzi M, Albisetti M. Treatment of arterial thrombosis in children: Methods and mechanisms. Thromb Res 2018; 169:113-119. [DOI: 10.1016/j.thromres.2018.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 07/05/2018] [Indexed: 12/17/2022]
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Abstract
OBJECTIVES The aim was to describe clinical presentation, management, and outcomes of stroke in a tertiary emergency department (ED) of a developing country. METHODOLOGY Retrospective case series of patients aged 1 month to 18 years presenting to an ED with radiological confirmed acute stroke during a 7-year period were studied. RESULTS Ninety-five patients were identified. Twenty-five patients were excluded because of incomplete records (8) or not presenting via ED (17). Thirty-four (48.5%) were diagnosed with hemorrhagic stroke (HS), 30 (42.8%) with arterial ischemic stroke (AIS), and 6 (8.5%) with sinus venous thrombosis (SVT). Mean age was 5.3 years, and 55.3% were male. The median time from onset of symptoms to ED presentation was 24 hours (mean, 55 hours; interquartile range [IQR], 14-72) for AIS, 24 hours (mean, 46.9 hours; IQR, 9-48) for HS, and 120 hours (mean,112 hours; IQR, 72-168) for SVT. Congenital cardiac disease was the most common risk factor (9%). For AIS, the most common symptoms were focal numbness 56.6% (95% confidence interval [CI], 37.8%-75.4%), focal weakness 56.6% (95% CI, 37.8%-75.4%), and seizures 50% (95% CI, 31%-68.8%). For HS, the most common symptoms were headache 64.7% (95% CI, 47.7%-81.6%), vomiting 79.4 (95% CI, 65-93.7), and altered mental status 64.7% (95% CI, 47.7-81.6). Computed tomography scan was done in 100% of the patients and magnetic resonance imaging in 54%. Twenty-five (36%) patients were admitted to intensive care unit and required intubation. Long-term deficit was identified in 24 (36%) patients based on medium-term follow-up. CONCLUSIONS The spectrum of stroke in a developing country was similar to published series from developed countries in terms of final diagnosis, risk factors, and delay to ED presentation, neuroimaging, and long-term neurodeficits. No tropical diseases were identified as risk factors.
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Pediatric Stroke in Southern Iran; Clinical Presentations, Etiologies and Outcomes: A Case-Series and Review of Literature. JOURNAL OF PEDIATRICS REVIEW 2018. [DOI: 10.5812/jpr.58356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Zhao M, Zhang D, Wang S, Zhang Y, Wang R, Zhao J. Transient Ischemic Attack in Pediatric Patients With Moyamoya Disease: Clinical Features, Natural History, and Predictors of Stroke. Pediatr Neurol 2017; 75:48-54. [PMID: 28778481 DOI: 10.1016/j.pediatrneurol.2017.06.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 06/26/2017] [Accepted: 06/30/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite being the most common presentation in children with moyamoya, transient ischemic attack (TIA) in children has rarely been described. The aim of this study is to describe the clinical characteristics of TIAs in children with moyamoya and explore the risk factors for stroke after TIA. METHODS We reviewed 696 consecutive patients with moyamoya vasculopathy (155 pediatric patients and 541 adults) admitted to our hospital from 2009 to 2015 to identify pediatric patients with moyamoya with an initial presentation of TIA. We defined recurrent TIAs that involve more types of symptoms or symptom extensions as symptom progression. The risk factors for subsequent stroke were analyzed using time-to-event analyses. RESULTS We identified 60 pediatric patients with moyamoya who had presented with TIA (initial presentation age, 10.0 ± 3.5 years). Motor weakness (n = 51 [85%]) was the most common initial presentation. During follow-up, 55 patients (91.7%) had recurrent TIAs and 14 (23.3%) had subsequent strokes. We identified female gender (hazard ratio, 5.08; 95% confidence interval, 1.40-18.47; P = 0.01), Suzuki grade greater than 3 (hazard ratio, 4.01; 95% confidence interval, 1.16-13.82; P = 0.03), and symptom progression (hazard ratio, 5.31; 95% confidence interval, 1.65-17.14; P = 0.01) as independent predictors of future stroke events. CONCLUSIONS Transient ischemic attacks have a relatively high recurrence rate in children with moyamoya and are associated with subsequent stroke. We identified the female sex, Suzuki grade greater than 3, and symptom progression as independent predictors of future strokes.
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Affiliation(s)
- Meng Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Yan Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Rong Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.
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Athale UH, Laverdiere C, Nayiager T, Delva YL, Foster G, Thabane L, Chan AKC. Evaluation for inherited and acquired prothrombotic defects predisposing to symptomatic thromboembolism in children with acute lymphoblastic leukemia: a protocol for a prospective, observational, cohort study. BMC Cancer 2017; 17:313. [PMID: 28472942 PMCID: PMC5418710 DOI: 10.1186/s12885-017-3306-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 04/27/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thromboembolism (TE) is a serious complication in children with acute lymphoblastic leukemia (ALL). The incidence of symptomatic thromboembolism is as high as 14% and case fatality rate of ~15%. Further, development of thromboembolism interferes with the scheduled chemotherapy with potential impact on cure rates. The exact pathogenesis of ALL-associated thromboembolism is unknown. Concomitant administration of asparaginase and steroids, two important anti-leukemic agents, is shown to increase the risk of ALL-associated TE. Dana-Farber Cancer Institute (DFCI) ALL studies reported ~10% incidence of thrombosis with significantly increased risk in older children (≥10 yrs.) and those with high-risk ALL. The majority (90%) of thromboembolic events occurred in the Consolidation phase of therapy with concomitant asparaginase and steroids when high-risk patients (including all older patients) receive higher dose steroids. Certain inherited and acquired prothrombotic defects are known to contribute to the development of TE. German investigators documented ~50% incidence of TE during therapy with concomitant asparaginase and steroids, in children with at least one prothrombotic defect. However, current evidence regarding the role of prothrombotic defects in the development of ALL-associated TE is contradictory. Although thromboprophylaxis can prevent thromboembolism, ALL and it's therapy can increase the risk of bleeding. For judicious use of thromboprophylaxis, identifying a population at high risk for TE is important. The risk factors, including prothrombotic defects, predisposing to thrombosis in children with ALL have not been defined. METHODS This prospective, observational cohort study aims to evaluate the prevalence of inherited prothrombotic defects in children with ALL treated on DFCI 05-01 protocol and the causal relationship of prothrombotic defects in combination with patient and disease-related factors to the development of TE. We hypothesize that the combination of prothrombotic defects and the intensive therapy with concomitant high dose steroids and asparaginase increases the risk of TE in older patients and patients with high-risk ALL. DISCUSSION The results of the proposed study will help design studies of prophylactic anticoagulant therapy. Thromboprophylaxis given to a targeted population will likely reduce the incidence of TE in children with ALL and ultimately improve their quality of life and prospects for cure.
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Affiliation(s)
- Uma H. Athale
- Division of Hematology/ Oncology, McMaster Children’s Hospital, Hamilton Health Sciences, 1280 Main Street West, Room HSC 3N27, Hamilton, ON L8S 4K1 Canada
- Department of Pediatrics, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
| | - Caroline Laverdiere
- Department of Pediatrics, Hematology Oncology Service, CHU Ste-Justine, University of Montréal, 3175, Côtes-Sainte-Catherine, Montréal, QC H3T 1C5 Canada
| | - Trishana Nayiager
- Department of Pediatrics, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
| | - Yves-Line Delva
- Department of Pediatrics, Hematology Oncology Service, CHU Ste-Justine, University of Montréal, 3175, Côtes-Sainte-Catherine, Montréal, QC H3T 1C5 Canada
| | - Gary Foster
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 50 Charlton Ave. E, Hamilton, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 50 Charlton Ave. E, Hamilton, Canada
| | - Anthony KC Chan
- Division of Hematology/ Oncology, McMaster Children’s Hospital, Hamilton Health Sciences, 1280 Main Street West, Room HSC 3N27, Hamilton, ON L8S 4K1 Canada
- Department of Pediatrics, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
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Darteyre S, Renaud C, Fluss J, Laporte S, Bertoletti L, Chabrier S. Secondary Prevention of Childhood Arterial Ischemic Stroke. J Child Neurol 2017; 32:488-493. [PMID: 28128037 DOI: 10.1177/0883073816686911] [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] [Indexed: 11/16/2022]
Abstract
This study aimed to know how frontline physicians in France, Belgium, and Switzerland implement guidelines regarding the secondary prevention of childhood arterial ischemic stroke and to introduce physicians' point of view on a clinical trial assessing the efficacy of aspirin as a preventive strategy. The authors conducted an online survey directed at specialists throughout dedicated networks and used a mixed method for data analysis. Overall, 63 physicians responded, and 88% prescribe aspirin when sickle cell disease, cardio-embolic stroke, and dissection of cervical arteries are excluded. Prescribing habits vary among respondents with respect to their specialty. A majority would choose placebo or a treatment given to historical controls to compare with an aspirin arm in a trial. In studied countries, there seems to be good adherence to guidelines regarding the secondary prevention of childhood stroke. A trial assessing the efficacy of aspirin could be well accepted if several factors regarding study design were taken into account.
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Affiliation(s)
- Stéphane Darteyre
- 1 INSERM, UMR 1059, SAINBIOSE, Dysfonction Vasculaire et Hémostase, Université Jean Monnet, Saint-Étienne, France
| | - Cyrille Renaud
- 2 CHU Saint-Étienne, French Center for Pediatric stroke and Pediatric Rehabilitation Unit, Saint-Étienne, France
| | - Joel Fluss
- 3 Pediatric Neurology Unit, Children's Hospital, Geneva, Switzerland
| | - Silvy Laporte
- 1 INSERM, UMR 1059, SAINBIOSE, Dysfonction Vasculaire et Hémostase, Université Jean Monnet, Saint-Étienne, France.,4 CHU Saint-Étienne, Unité de Recherche Clinique, Innovation, Pharmacologie, Hôpital Nord, Saint-Étienne France
| | - Laurent Bertoletti
- 1 INSERM, UMR 1059, SAINBIOSE, Dysfonction Vasculaire et Hémostase, Université Jean Monnet, Saint-Étienne, France.,5 INSERM, CIC1408, Saint-Étienne, France.,6 CHU Saint-Étienne, Service de Médecine Vasculaire et Thérapeutique, Hôpital Nord, Saint-Étienne, France
| | - Stéphane Chabrier
- 1 INSERM, UMR 1059, SAINBIOSE, Dysfonction Vasculaire et Hémostase, Université Jean Monnet, Saint-Étienne, France.,2 CHU Saint-Étienne, French Center for Pediatric stroke and Pediatric Rehabilitation Unit, Saint-Étienne, France.,5 INSERM, CIC1408, Saint-Étienne, France
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deVeber GA, Kirton A, Booth FA, Yager JY, Wirrell EC, Wood E, Shevell M, Surmava AM, McCusker P, Massicotte MP, MacGregor D, MacDonald EA, Meaney B, Levin S, Lemieux BG, Jardine L, Humphreys P, David M, Chan AKC, Buckley DJ, Bjornson BH. Epidemiology and Outcomes of Arterial Ischemic Stroke in Children: The Canadian Pediatric Ischemic Stroke Registry. Pediatr Neurol 2017; 69:58-70. [PMID: 28254555 DOI: 10.1016/j.pediatrneurol.2017.01.016] [Citation(s) in RCA: 175] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pediatric arterial ischemic stroke remains incompletely understood. Population-based epidemiological data inform clinical trial design but are scant in this condition. We aimed to determine age-specific epidemiological characteristics of arterial ischemic stroke in neonates (birth to 28 days) and older children (29 days to 18 years). METHODS We conducted a 16-year, prospective, national population-based study, the Canadian Pediatric Ischemic Stroke Registry, across all 16 Canadian acute care children's hospitals. We prospectively enrolled children with arterial ischemic stroke from January 1992 to December 2001 and documented disease incidence, presentations, risk factors, and treatments. Study outcomes were assessed throughout 2008, including abnormal clinical outcomes (stroke-related death or neurological deficit) and recurrent arterial ischemic stroke or transient ischemic attack. RESULTS Among 1129 children enrolled with arterial ischemic stroke, stroke incidence was 1.72/100,000/year, (neonates 10.2/100,000 live births). Detailed clinical and radiological information were available for 933 children (232 neonates and 701 older children, 55% male). The predominant clinical presentations were seizures in neonates (88%), focal deficits in older children (77%), and diffuse neurological signs (54%) in both. Among neonates, 44% had no discernible risk factors. In older children, arteriopathy (49% of patients with vascular imaging), cardiac disorders (28%), and prothrombotic disorders (35% of patients tested) predominated. Antithrombotic treatment increased during the study period (P < 0.001). Stroke-specific mortality was 5%. Outcomes included neurological deficits in 60% of neonates and 70% of older children. Among neonates, deficits emerged during follow-up in 39%. Overall, an initially decreased level of consciousness, a nonspecific systemic presentation, and the presence of stroke risk factors predicted abnormal outcomes. For neonates, predictors were decreased level of consciousness, nonspecific systemic presentation, and basal ganglia infarcts. For older children, predictors were initial seizures, nonspecific systemic presentation, risk factors, and lack of antithrombotic treatment. Recurrent arterial ischemic stroke or transient ischemic attack developed in 12% of older children and was predicted by arteriopathy, presentation without seizures, and lack of antithrombotic treatment. Emerging deficit was predicted by neonatal age at stroke and by cardiac disease. CONCLUSIONS This national data set provides a population-based disease incidence rate and demonstrates the protective effect of antithrombotic treatment in older children, and frequent long-term emerging deficits in neonates and in children with cardiac disorders. Further clinical trials are required to develop effective age-appropriate treatments for children with acute arterial ischemic stroke.
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Affiliation(s)
- Gabrielle A deVeber
- Division of Neurology, Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.
| | - Adam Kirton
- Department of Pediatrics, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Frances A Booth
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jerome Y Yager
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Ellen Wood
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael Shevell
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Ann-Marie Surmava
- Division of Neurology, Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Patricia McCusker
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Daune MacGregor
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - E Athen MacDonald
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
| | - Brandon Meaney
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Simon Levin
- Department of Pediatrics, University of Western Ontario, London, Ontario, Canada
| | - Bernard G Lemieux
- Department of Pediatrics, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Lawrence Jardine
- Department of Pediatrics, University of Western Ontario, London, Ontario, Canada
| | - Peter Humphreys
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Michèle David
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Anthony K C Chan
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - David J Buckley
- Department of Pediatrics, Janeway Children's Health and Rehabilitation Centre, St. John's, Newfoundland, Canada
| | - Bruce H Bjornson
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
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Onozuka D, Hagihara A, Nishimura K, Kada A, Nakagawara J, Ogasawara K, Ono J, Shiokawa Y, Aruga T, Miyachi S, Nagata I, Toyoda K, Matsuda S, Suzuki A, Kataoka H, Nakamura F, Kamitani S, Nishimura A, Kurogi R, Sayama T, Iihara K. Prehospital antiplatelet use and functional status on admission of patients with non-haemorrhagic moyamoya disease: a nationwide retrospective cohort study (J-ASPECT study). BMJ Open 2016; 6:e009942. [PMID: 27008684 PMCID: PMC4800148 DOI: 10.1136/bmjopen-2015-009942] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To elucidate the association between antiplatelet use in patients with non-haemorrhagic moyamoya disease before hospital admission and good functional status on admission in Japan. DESIGN Retrospective, multicentre, non-randomised, observational study. SETTING Nationwide registry data in Japan. PARTICIPANTS A total of 1925 patients with non-haemorrhagic moyamoya disease admitted between 1 April 2012 and 31 March 2014 in Japan. MAIN OUTCOME MEASURE We performed propensity score-matched analysis to examine the association between prehospital antiplatelet use and no significant disability on hospital admission, as defined by a modified Rankin Scale score of 0 or 1. RESULTS Propensity-matched patients who received prehospital antiplatelet drugs were associated with a good outcome on hospital admission (OR adjusted for all covariates, 3.82; 95% CI 1.22 to 11.99) compared with those who did not receive antiplatelet drugs prior to hospital admission. CONCLUSIONS Prehospital antiplatelet use was significantly associated with good functional status on hospital admission among patients with non-haemorrhagic moyamoya disease in Japan. Our results suggest that prehospital antiplatelet use should be considered when evaluating outcomes of patients with non-haemorrhagic moyamoya disease.
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Affiliation(s)
- Daisuke Onozuka
- Department of Health Communication, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akihito Hagihara
- Department of Health Communication, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Akiko Kada
- Clinical Research Center, Nagoya Medical Center, Aichi, Japan
| | - Jyoji Nakagawara
- Department of Integrative Stroke Imaging Center, National Cerebral and Cardiovascular Center, Osaka, Japan
| | | | | | | | | | - Shigeru Miyachi
- Department of Neurosurgery, Osaka Medical College, Osaka, Japan
| | | | - Kazunori Toyoda
- Department of Cerebrovascular Medicine and Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Akifumi Suzuki
- Akita Prefectural Hospital Organization Research Institute for Brain and Blood Vessels, Akita, Japan
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Fumiaki Nakamura
- Department of Public Health/Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Satoru Kamitani
- Department of Public Health/Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Ataru Nishimura
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryota Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tetsuro Sayama
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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16
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Masri A, Al-Ammouri I. Clinical presentation, etiology, and outcome of stroke in children: A hospital-based study. Brain Dev 2016; 38:204-8. [PMID: 26341288 DOI: 10.1016/j.braindev.2015.08.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 08/05/2015] [Accepted: 08/07/2015] [Indexed: 01/14/2023]
Abstract
AIM To describe clinical presentations, etiologies, and outcomes of stroke in Jordanian children. PATIENTS AND METHODS We retrospectively reviewed the medical records of children diagnosed with ischemic stroke who presented to our clinic from January 2001 to June 2014. Patients with onset of stroke in the neonatal period were excluded. RESULTS Twenty-four children (12 boys and 12 girls, with a male to female ratio of 1:1) were included in this study. The follow-up period ranged from 1 month to 9 years. Age at onset of the first stroke ranged from 1 month to 13 years. The most common initial clinical presentation was hemiparesis (58.3%). A known etiology was identified in 58.3% of patients. The most common etiologies were metabolic disorders, such as mitochondrial encephalopathy lactic acidosis and stroke (MELAS) and homocystinuria (25%), cardiac disorders (17%), and coagulopathy, such as a homozygous mutation in the MTHFR gene and a factor V Leiden mutation (17%). Recurrence of both clinical and silent strokes occurred in 46% of patients, residual motor weakness occurred in 58.3%, and residual epilepsy occurred in 29.2%. CONCLUSION Metabolic disorders, cardiac disorders, and coagulopathy are the causes of strokes in Jordanian children. Our results emphasized the importance of inherited disorders in Jordan.
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Affiliation(s)
- Amira Masri
- Department of Pediatrics, Division of Child Neurology, Faculty of Medicine, The University of Jordan, Jordan.
| | - Iyad Al-Ammouri
- Department of Pediatrics, Division of Pediatric Cardiology, Faculty of Medicine, The University of Jordan, Jordan
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17
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Makatsaria AD, Akin'shina SV, Bitsadze VO. [Thrombosis of the cerebral veins in gynecological practice]. Zh Nevrol Psikhiatr Im S S Korsakova 2016. [PMID: 28635764 DOI: 10.17116/jnevro20161168233-39] [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: 11/18/2022]
Abstract
The review presents literature data on the risk factors of cerebral venous thrombosis (CVT), a rare life threatening disorder. Currently, the diagnosis of CVT is made more often due to the possibility of using neuroimaging methods of cerebral structures. Pregnancy, postpartum period, use of oral contraceptives are risk factors of CVT. A role of thrombophilia, in particular Factor V Leiden mutations and the prothrombin G20210A polymorphism, in the CVT pathogenesis is confirmed. The development of CVT is an example of the interaction between persistent risk factors increasing the likelihood of thrombotic complications and acquired risk factors. A focal neurological deficit during pregnancy, delivery and postpartum period is the best indicator of CVT diagnosis. Possibilities of the use of anticoagulants in treatment and prevention of CVT are analyzed.
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Affiliation(s)
- A D Makatsaria
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - S V Akin'shina
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - V O Bitsadze
- Sechenov First Moscow State Medical University, Moscow, Russia
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18
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Tripathi P, Kar SK, Goyal P, Kumar D, Panda AK. Biological correlates of attention deficit hyperactivity disorder and specific learning disability, following stroke in a young child. Ind Psychiatry J 2015; 24:211-2. [PMID: 27212833 PMCID: PMC4866356 DOI: 10.4103/0972-6748.181716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Praveen Tripathi
- Department of Psychiatry, Institute of Human Behavior and Allied Sciences, New Delhi, India
| | - Sujita Kumar Kar
- Department of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Priyanka Goyal
- Department of Psychiatry, ESI Post Graduate Institute of Medical Sciences and Research, Basai Darapur, New Delhi, India
| | - Deepak Kumar
- Department of Psychiatry, Institute of Human Behavior and Allied Sciences, New Delhi, India
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19
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Elbers J, Wainwright MS, Amlie-Lefond C. The Pediatric Stroke Code: Early Management of the Child with Stroke. J Pediatr 2015; 167:19-24.e1-4. [PMID: 25937428 DOI: 10.1016/j.jpeds.2015.03.051] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 03/09/2015] [Accepted: 03/26/2015] [Indexed: 02/04/2023]
Affiliation(s)
- Jorina Elbers
- Division of Child Neurology, Stanford Children's Health, Stanford University, Stanford, CA.
| | - Mark S Wainwright
- Division of Neurology, Department of Pediatrics, Northwestern University, Chicago, IL
| | - Catherine Amlie-Lefond
- Division of Pediatric Neurology, Department of Neurology, Seattle Children's Hospital, University of Washington, Seattle, WA
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20
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Abstract
Stroke is a relatively rare but rather significant cause of short- and long-term morbidity and mortality in children. It can be divided into three categories: arterial ischemic stroke (AIS), hemorrhagic stroke (HS) and cerebral sinovenous thrombosis (CSVT). This review focuses on AIS. The etiologies of pediatric AIS are diverse and different from those in adult stroke, chief among these being congenital heart disease, vasculopathies, hematological disorders and prothrombotic states. Additional factors might be related to the age group, ethnicity and geographic factors. Early recognition enables initiation of prompt therapy thereby reducing risk of further recurrence and complications.
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21
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Chen S, Wang Y, Li S, Wang Y, Zhao M, Zhu H, Wu J, Peng S. Poly-α,β-aspartyl-Arg-Gly-Asp-Phe: a novel polymeric nanomedicine. MEDCHEMCOMM 2015. [DOI: 10.1039/c4md00331d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
High anti-thrombotic efficacy, action target and nano-structure of a novel nanomedicine were described.
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Affiliation(s)
- Shuangling Chen
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs
- Beijing Laboratory of Biomedical Materials
- Engineering Research Center of Endogenous Prophylactic of Ministry of Education of China
- College of Pharmaceutical Sciences of Capital Medical University
- Beijing 100069
| | - Yuji Wang
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs
- Beijing Laboratory of Biomedical Materials
- Engineering Research Center of Endogenous Prophylactic of Ministry of Education of China
- College of Pharmaceutical Sciences of Capital Medical University
- Beijing 100069
| | - Shan Li
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs
- Beijing Laboratory of Biomedical Materials
- Engineering Research Center of Endogenous Prophylactic of Ministry of Education of China
- College of Pharmaceutical Sciences of Capital Medical University
- Beijing 100069
| | - Yaonan Wang
- Engineering Research Center of Endogenous Prophylactic of Ministry of Education of China
- Medical Experiment and Test Center of Capital Medical University
- Beijing 100069
- P. R. China
| | - Ming Zhao
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs
- Beijing Laboratory of Biomedical Materials
- Engineering Research Center of Endogenous Prophylactic of Ministry of Education of China
- College of Pharmaceutical Sciences of Capital Medical University
- Beijing 100069
| | - Haimei Zhu
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs
- Beijing Laboratory of Biomedical Materials
- Engineering Research Center of Endogenous Prophylactic of Ministry of Education of China
- College of Pharmaceutical Sciences of Capital Medical University
- Beijing 100069
| | - Jianhui Wu
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs
- Beijing Laboratory of Biomedical Materials
- Engineering Research Center of Endogenous Prophylactic of Ministry of Education of China
- College of Pharmaceutical Sciences of Capital Medical University
- Beijing 100069
| | - Shiqi Peng
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs
- Beijing Laboratory of Biomedical Materials
- Engineering Research Center of Endogenous Prophylactic of Ministry of Education of China
- College of Pharmaceutical Sciences of Capital Medical University
- Beijing 100069
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22
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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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23
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24
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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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25
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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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Guidelines for Diagnosis and Treatment of Moyamoya Disease (Spontaneous Occlusion of the Circle of Willis). Neurol Med Chir (Tokyo) 2012; 52:245-66. [DOI: 10.2176/nmc.52.245] [Citation(s) in RCA: 601] [Impact Index Per Article: 50.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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27
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Tsze DS, Valente JH. Pediatric stroke: a review. Emerg Med Int 2011; 2011:734506. [PMID: 22254140 PMCID: PMC3255104 DOI: 10.1155/2011/734506] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2011] [Accepted: 09/16/2011] [Indexed: 01/07/2023] Open
Abstract
Stroke is relatively rare in children, but can lead to significant morbidity and mortality. Understanding that children with strokes present differently than adults and often present with unique risk factors will optimize outcomes in children. Despite an increased incidence of pediatric stroke, there is often a delay in diagnosis, and cases may still remain under- or misdiagnosed. Clinical presentation will vary based on the child's age, and children will have risk factors for stroke that are less common than in adults. Management strategies in children are extrapolated primarily from adult studies, but with different considerations regarding short-term anticoagulation and guarded recommendations regarding thrombolytics. Although most recommendations for management are extrapolated from adult populations, they still remain useful, in conjunction with pediatric-specific considerations.
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Affiliation(s)
- Daniel S. Tsze
- Department of Pediatrics, Division of Pediatric Emergency Medicine, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
| | - Jonathan H. Valente
- Department of Emergency Medicine and Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
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28
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Statler KD, Dong L, Nielsen DM, Bratton SL. Pediatric stroke: clinical characteristics, acute care utilization patterns, and mortality. Childs Nerv Syst 2011; 27:565-73. [PMID: 20922396 DOI: 10.1007/s00381-010-1292-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Accepted: 09/23/2010] [Indexed: 01/21/2023]
Abstract
PURPOSE Acute care utilization patterns are not well described but may help inform care coordination and treatment for pediatric stroke. The Kids Inpatient Database was queried to describe demographics and clinical characteristics of children with stroke, compare acute care utilization for hemorrhagic vs. ischemic stroke and Children's vs. non-Children's Hospitals, and identify factors associated with aggressive care and in-hospital mortality. METHODS Using a retrospective cohort of children hospitalized with stroke, demographics, predisposing conditions, and intensive (mechanical ventilation, advanced monitoring, and blood product administration) or aggressive (pharmacological therapy and/or invasive interventions) care were compared by stroke and hospital types. Factors associated with aggressive care or in-hospital mortality were explored using logistic regression. RESULTS Hemorrhagic stroke comprised 43% of stroke discharges, was more common in younger children, and carried greater mortality. Ischemic stroke was more common in older children and more frequently associated with a predisposing condition. Rates of intensive and aggressive care were low (30% and 15%), similar by stroke type, and greater at Children's Hospitals. Older age, hemorrhagic stroke, predisposing condition, and treatment at a Children's Hospital were associated with aggressive care. Hemorrhagic stroke and aggressive care were associated with in-hospital mortality. CONCLUSIONS Acute care utilization is similar by stroke type but both intensive and aggressive care are more common at Children's Hospitals. Mortality remains relatively high after pediatric stroke. Widespread implementation of treatment guidelines improved outcomes in adult stroke. Adoption of recently published treatment recommendations for pediatric stroke may help standardize care and improve outcomes.
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Affiliation(s)
- Kimberly D Statler
- Department of Pediatrics, University of Utah, PO Box 2581289, 295 Chipeta Way, Salt Lake City, UT 84158, USA.
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29
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Ng J, Ganesan V. Expert opinion on emerging drugs in childhood arterial ischemic stroke. Expert Opin Emerg Drugs 2011; 16:363-72. [DOI: 10.1517/14728214.2011.565050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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30
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Abstract
Stroke in children is rarely due to traditional stroke risk factors such as hypertension and diabetes. Rather, stroke in this patient group typically results from the simultaneous occurrence of multiple stroke risk factors, the presence of which necessitates a thorough evaluation to determine the cause of this disorder. Several challenges exist in the care of children with stroke. Of note, recognition of pediatric stroke onset by parents and caregivers is often delayed, highlighting the need for increased awareness of and education regarding this condition. Moreover, various neurological conditions resemble stroke in pediatric patients and a definite diagnosis of this disorder requires MRI; adding to the diagnostic challenge, young children may need to be sedated to undergo acute MRI. Perhaps the most significant challenge is the need for clinical research studies focusing on pediatric stroke treatment, so as to allow evidence-based treatment decision-making. A final challenge is the standardization of outcome assessment after stroke for a wide range of ages and developmental levels. In this Review, we examine recent findings and diagnostic issues pertaining to both arterial ischemic stroke and hemorrhagic stroke in children.
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Multiple Organ Infarctions Following Disseminated Intravascular Coagulation Precipitated by Sepsis in A Healthy Infant: A Case Report. Kaohsiung J Med Sci 2010; 26:663-8. [DOI: 10.1016/s1607-551x(10)70101-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Accepted: 04/27/2010] [Indexed: 11/17/2022] Open
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Kossorotoff M, Gonin-Flambois C, Gitiaux C, Quijano S, Boddaert N, Bahi-Buisson N, Barnerias C, Dulac O, Brunelle F, Desguerre I. A cognitive and affective pattern in posterior fossa strokes in children: a case series. Dev Med Child Neurol 2010; 52:626-31. [PMID: 20370817 DOI: 10.1111/j.1469-8749.2010.03616.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM Posterior fossa strokes account for about 10% of ischaemic strokes in children. Although motor and dysautonomic symptoms are common, to our knowledge cognitive and affective deficits have not been described in the paediatric literature. Our aim, therefore, was to describe these symptoms and deficits. METHOD In a retrospective study, we included all cases of posterior fossa strokes in children occurring at a single centre between 2005 and 2007, and investigated cognitive and affective deficits. RESULTS Five males aged 3 to 14 years met the inclusion criteria. They all presented very early with mood disturbances: outbursts of laughter and/or crying and alternating agitation or prostration that disappeared spontaneously within a few days. Persistent cognitive deficits were also diagnosed in all five: initial mutism, then anomia, followed by comprehension deficiency and deficiencies of planning ability, visual-spatial organization, and attention. Despite early and intensive rehabilitation, recovery from these cognitive deficits was slow and sometimes incomplete, and on follow-up they proved to be more disabling than the motor symptoms. INTERPRETATION These findings are similar to the cerebellar cognitive affective syndrome described in adults, and quite similar to the language and affective deficits observed in children after surgery for posterior fossa tumour. This is consistent with the role of the cerebellum and brainstem in affective and cognitive processes from early development.
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Affiliation(s)
- Manoelle Kossorotoff
- Paediatric Neurology Department, Hôpital Necker-Enfants Malades, APHP, 149 rue de Sévres, Paris, France.
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Sipahi T, Karademir S, Kuybulu A, Akar N. Diffuse Cerebral Infarct Associated With Factor V Leiden and Prothrombin 20210A Mutations in a Patient With Tetralogy of Fallot. Clin Appl Thromb Hemost 2009; 15:705-7. [DOI: 10.1177/1076029608319883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A 2-year-old girl with tetralogy of Fallot presented with diffuse cranial infarct after cardiac angiography. Heterozygosity for factor V Leiden and prothrombin 20210A mutations were detected. The authors suggest that if thrombosis develops in patients with congenital heart disease, genetic risk factors should be evaluated.
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Affiliation(s)
- Tansu Sipahi
- Department of Pediatric Hematology, Suleyman Demirel University, Faculty of Medicine, Isparta,
| | - Selmin Karademir
- Department of Pediatric Cardiology, Suleyman Demirel University, Faculty of Medicine, Isparta
| | - Ayça Kuybulu
- Department of Pediatric Cardiology Suleyman Demirel University, Faculty of Medicine, Isparta
| | - Nejat Akar
- Department of Pediatric Molecular Genetics Ankara University, Faculty of Medicine, Ankara Turkey
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Goldenberg NA, Bernard TJ, Fullerton HJ, Gordon A, deVeber G. Antithrombotic treatments, outcomes, and prognostic factors in acute childhood-onset arterial ischaemic stroke: a multicentre, observational, cohort study. Lancet Neurol 2009; 8:1120-7. [PMID: 19801204 DOI: 10.1016/s1474-4422(09)70241-8] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Govaert P, Ramenghi L, Taal R, de Vries L, Deveber G. Diagnosis of perinatal stroke I: definitions, differential diagnosis and registration. Acta Paediatr 2009; 98:1556-67. [PMID: 19663912 DOI: 10.1111/j.1651-2227.2009.01461.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Perinatal stroke can be divided into three subtypes: ischaemic stroke, either arterial or sinovenous and haemorrhagic stroke. For the sake of universal registration and to perform intervention studies, we propose a detailed diagnostic registration system for perinatal stroke taking 10 variables into account. These variables are discussed here and in the accompanying article. MATERIAL AND RESULTS Differentiation is needed from focal brain changes as a result of disorders other than stroke, whereby accurate timing is possible only when early neonatal imaging is available. Detailed templates are presented for arterial and venous vascular classification. AIS is further subdivided into single territory and complex infarction and some stratification is proposed in the complicated stroke group. This registration system has been applied to a retrospective cohort of 134 newborns with stroke (single-centre observation from 1999 to 2007) and the results are compared with published data. By applying this registration system, intervention studies for one homogeneous stroke type (e.g. complete middle cerebral artery stroke) may be facilitated. CONCLUSION Ten variables may be sufficient to register a perinatal stroke. These include gestational age, birthweight, gender, delivery mode, time of detection, presentation, type of stroke, vessel affected or type of cavity, imaging method at detection and clinical context.
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Affiliation(s)
- P Govaert
- Department of Neonatology, Sophia Children's Hospital Erasmus MC Rotterdam, Rotterdam, The Netherlands.
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Braun KPJ, Bulder MMM, Chabrier S, Kirkham FJ, Uiterwaal CSP, Tardieu M, Sébire G. The course and outcome of unilateral intracranial arteriopathy in 79 children with ischaemic stroke. Brain 2008; 132:544-57. [PMID: 19039009 PMCID: PMC2640213 DOI: 10.1093/brain/awn313] [Citation(s) in RCA: 166] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Arteriopathies are the commonest cause of arterial ischaemic stroke (AIS) in children. Repeated vascular imaging in children with AIS demonstrated the existence of a ‘transient cerebral arteriopathy’ (TCA), characterized by lenticulostriate infarction due to non-progressive unilateral arterial disease affecting the supraclinoid internal carotid artery and its proximal branches. To further characterize the course of childhood arteriopathies, and to differentiate TCA from progressive arterial disease, we studied the long-term evolution of unilateral anterior circulation arteriopathy, and explored predictors of stroke outcome and recurrence. From three consecutive cohorts in London, Paris and Utrecht, we reviewed radiological studies and clinical charts of 79 previously healthy children with anterior circulation AIS and unilateral intracranial arteriopathy of the internal carotid bifurcation, who underwent repeated vascular imaging. The long-term evolution of arteriopathy was classified as progressive or TCA. Clinical and imaging characteristics were compared between both groups. Logistic regression modelling was used to determine possible predictors of the course of arteriopathy, functional outcome and recurrence. After a median follow-up of 1.4 years, 5 of 79 children (6%) had progressive arteriopathy, with increasing unilateral disease or bilateral involvement. In the others (94%), the course of arteriopathy was classified as TCA. In 23% of TCA patients, follow-up vascular imaging showed complete normalization, the remaining 77% had residual arterial abnormalities, with improvement in 45% and stabilization in 32%. Stroke was preceded by chickenpox in 44% of TCA patients, and in none of the patients with progressive arteriopathies. Most infarcts were localized in the basal ganglia. In 14 (19%) of TCA patients, transient worsening of the arterial lesion was demonstrated before the arteriopathy stabilized or improved. Thirteen TCA patients (18%) had a recurrent stroke or TIA. Thirty TCA patients (41%) had a good neurological outcome, compared with none of the five patients with progressive arteriopathy. Arterial occlusion, moyamoya vessels and ACA involvement were more frequent in progressive arteriopathies. Cortical infarct localization was significantly associated with poor neurological outcome (OR 6.14, 95% CI 1.29–29.22, P = 0.02), while there was a trend for occlusive arterial disease to predict poor outcome (OR 3.00, 95% CI 0.98–9.23, P = 0.06). Progressive arteriopathy was associated with recurrence (OR 18.77, 95%CI 1.94–181.97, P = 0.01). The majority of childhood unilateral intracranial anterior circulation arteriopathies (94%) have a course that is consistent with TCA, in which transient worsening is common. Although the arterial inflammation probably causing TCA is ‘transient’, most children are left with permanent arterial abnormalities and residual neurological deficits.
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Affiliation(s)
- K P J Braun
- Department of Child Neurology, Rudolf Magnus Institute of Neuroscience, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.
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Arterial ischemic stroke in children--recent advances. Indian J Pediatr 2008; 75:1149-57. [PMID: 19132317 DOI: 10.1007/s12098-008-0239-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2008] [Accepted: 10/16/2008] [Indexed: 10/21/2022]
Abstract
Childhood stroke syndromes are an important cause of mortality and morbidity. This paper focuses on the recent advances in arterial ischaemic stroke beyond the neonatal period. Vascular risk factors are identified in the majority of children and guide both acute and longer term treatments, as well as determining prognosis. Contrary to popular belief many children have residual impairments encompassing a wide range of domains. National and international collaborations are facilitating an increase in the understanding of childhood stroke and have the eventual aim of conducting trials of potential therapeutic interventions.
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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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Ischemic stroke and anoxic-ischemic encephalopathy. HANDBOOK OF CLINICAL NEUROLOGY 2008. [PMID: 18631823 DOI: 10.1016/s0072-9752(07)01710-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register]
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Venkatesan C, Wainwright MS. Pediatric endocarditis and stroke: a single-center retrospective review of seven cases. Pediatr Neurol 2008; 38:243-7. [PMID: 18358401 PMCID: PMC2409276 DOI: 10.1016/j.pediatrneurol.2007.12.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Revised: 10/05/2007] [Accepted: 12/12/2007] [Indexed: 11/17/2022]
Abstract
The acute management of strokes in children with infective endocarditis is limited by the paucity of published data on their clinical course and outcomes. Our retrospective study at an urban tertiary-care academic center characterized the clinical course of seven pediatric patients with endocarditis and subsequent cerebral infarcts. Among 115 patients with endocarditis, a stroke occurred in seven. Four patients manifested congenital heart disease. In six patients, the stroke occurred in the distribution of the middle cerebral artery, with no preference for the left or right hemisphere. The most common presenting sign was focal weakness. Three patients manifested mycotic aneurysms, all of which were successfully repaired. Two patients received aspirin therapy, with no adverse effects. All patients survived, but neurologic recovery was variable. The two youngest patients (aged 3 and 14 weeks) demonstrated the longest periods of hospitalization, with the most severe neurologic impairment. These findings suggest that children may have better outcomes than adults after a stroke secondary to bacterial endocarditis. Routine surveillance for mycotic aneurysms in patients with new neurologic deficits, and the use of aspirin, should be considered in the medical management.
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Affiliation(s)
- Charu Venkatesan
- Division of Neurology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60614, USA.
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Inherited and acquired risk factors for arterial ischemic stroke in childhood. J Thromb Thrombolysis 2008; 27:239-48. [DOI: 10.1007/s11239-008-0202-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2007] [Accepted: 01/28/2008] [Indexed: 10/22/2022]
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Jain SV, Morton LD. Ischemic stroke and excellent recovery after administration of intravenous tissue plasminogen activator. Pediatr Neurol 2008; 38:126-9. [PMID: 18206794 DOI: 10.1016/j.pediatrneurol.2007.10.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2007] [Revised: 08/16/2007] [Accepted: 10/15/2007] [Indexed: 10/22/2022]
Abstract
Intravenous tissue plasminogen activator has become a mainstream treatment for ischemic hyperacute stroke in the adult population. Its safety and efficacy remain undetermined in the pediatric population. We present a teenager who was hospitalized with left-sided paralysis, and with decreased sensations on the left side. Head computed tomography indicated hyperdensity in the middle cerebral artery region, which confirmed the diagnosis of acute ischemic stroke. Her score on the National Institutes of Health stroke scale was 11. She received intravenous tissue plasminogen activator without any complications. At a follow-up visit 5 months after the stroke, the patient manifested mild apraxia in her left hand and mild expressive amusia. This case underscores the need for emergency head imaging in the pediatric population to establish a diagnosis. The excellent recovery in our patient indicates the need to establish thrombolytic treatment as an option for acute stroke in pediatric populations. It also suggests that tissue plasminogen activator can be used safely and effectively, even in pediatric populations. However, further studies are needed to establish the adequate dosage and adverse-effect profile in pediatric populations.
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Affiliation(s)
- Sejal V Jain
- Department of Neurology, Virginia Commonwealth University Medical Center, Richmond, Virginia 23298, USA
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Gentilomo C, Franzoi M, Laverda AM, Suppiej A, Battistella PA, Simioni P. Cerebral sinovenous thrombosis in children: Thrombophilia and clinical outcome. Thromb Res 2008; 121:589-91. [PMID: 17675220 DOI: 10.1016/j.thromres.2007.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2006] [Revised: 06/05/2007] [Accepted: 06/06/2007] [Indexed: 10/23/2022]
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Lo W, Zamel K, Ponnappa K, Allen A, Chisolm D, Tang M, Kerlin B, Yeates KO. The Cost of Pediatric Stroke Care and Rehabilitation. Stroke 2008; 39:161-5. [DOI: 10.1161/strokeaha.107.497420] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Warren Lo
- From the Departments of Pediatrics and Psychology, The Ohio State University and Children’s Hospital, Columbus, Ohio
| | - Khaled Zamel
- From the Departments of Pediatrics and Psychology, The Ohio State University and Children’s Hospital, Columbus, Ohio
| | - Kavita Ponnappa
- From the Departments of Pediatrics and Psychology, The Ohio State University and Children’s Hospital, Columbus, Ohio
| | - Antoni Allen
- From the Departments of Pediatrics and Psychology, The Ohio State University and Children’s Hospital, Columbus, Ohio
| | - Deena Chisolm
- From the Departments of Pediatrics and Psychology, The Ohio State University and Children’s Hospital, Columbus, Ohio
| | - Monica Tang
- From the Departments of Pediatrics and Psychology, The Ohio State University and Children’s Hospital, Columbus, Ohio
| | - Bryce Kerlin
- From the Departments of Pediatrics and Psychology, The Ohio State University and Children’s Hospital, Columbus, Ohio
| | - Keith O. Yeates
- From the Departments of Pediatrics and Psychology, The Ohio State University and Children’s Hospital, Columbus, Ohio
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Abstract
Stroke in children is relatively rare. Advances in the clinical recognition and radiographic diagnosis of ischemic stroke have increased the frequency of the diagnosis in infants and children and have raised the need for immediate therapy. A vast amount of data has recently become available through basic research and neuroimaging techniques shedding new light on the chain of events that occur in ischemic stroke in animal models and in the adult population. Whether this new information can also be applied to the pediatric population remains to be seen, but it is likely that the active management of children with acute ischemic stroke in the near future will include brain protection, brain reperfusion, and prevention measures.
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Affiliation(s)
- Tali Jonas Kimchi
- Division of Neuroradiology, Department of Medical Imaging, Sheba Medical Center, Ramat-Gan, Israel.
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Yamalik N. Quality systems in dentistry Part 1. The increasing pressure for quality and implementation of quality assurance and improvement (QA/I) models in health care. Int Dent J 2007; 57:338-46. [DOI: 10.1111/j.1875-595x.2007.tb00143.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Simma B, Martin G, Müller T, Huemer M. Risk factors for pediatric stroke: consequences for therapy and quality of life. Pediatr Neurol 2007; 37:121-6. [PMID: 17675027 DOI: 10.1016/j.pediatrneurol.2007.04.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Revised: 02/28/2007] [Accepted: 04/05/2007] [Indexed: 10/23/2022]
Abstract
A retrospective population-based study was conducted to calculate incidence of pediatric stroke, detect risk factors, determine long term outcome and to optimize therapy. Patients (age: >1 month and <19 years) with stroke in Vorarlberg, Austria, from 1984-2005 were investigated. Outcome was evaluated in terms of neurological deficits, neuropsychological measures, and quality of life. Consequences on therapy were established according to current guidelines. Twenty-two children, median age 6 years (range, 0.9-14) years, 16 ischemic and 6 hemorrhagic stroke, correspond to an incidence of 1.96 and 0.74/100.000 child-years, respectively. No child died; one had a recurrent stroke. Twenty children (12 boys) were included after a median time of 3.7 years (range, 0.4-18). Risk factors were vasculopathy (17/20; 85%), lipometabolic disorders (17/20; 85%), and prothrombotic abnormality (10/20; 50%). Three children had no risk factor; four children had a reduced quality of life. The study led to therapeutic consequences in 13 of 20 children (65%): aspirin (5/20; 25%), folic acid in (3/20; 15%), and rehabilitative therapy (9/20; 45%). Most children with pediatric stroke have more than one risk factor, mainly vasculopathies or elevation of lipoprotein(a). Overall outcome is determined solely by neurological deficits and is positively influenced by good quality of life.
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Affiliation(s)
- Burkhard Simma
- Department of Pediatrics, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria.
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