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Datyner E, Adeseye V, Porter K, Dryden I, Sarma A, Vu N, Patrick AE, Paueksakon P. Small vessel childhood primary angiitis of the central nervous system with positive anti-glial fibrillary acidic protein antibodies: a case report and review of literature. BMC Neurol 2023; 23:57. [PMID: 36737749 PMCID: PMC9895965 DOI: 10.1186/s12883-023-03093-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/25/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Small vessel childhood primary angiitis of the central nervous system (SV-cPACNS) is a rare disease characterized by inflammation within small vessels such as arterioles or capillaries. CASE PRESENTATION We report a case of SV-cPACNS in an 8-year-old boy confirmed by brain biopsy. This patient was also incidentally found to have anti-glial fibrillary acidic protein (GFAP) antibodies in the cerebrospinal fluid (CSF) but had no evidence of antibody-mediated disease on brain biopsy. A literature review highlighted the rarity of SV-cPACNS and found no prior reports of CSF GFAP-associated SV-cPACNS in the pediatric age group. CONCLUSION We present the first case of biopsy proven SV-cPACNS vasculitis associated with an incidental finding of CSF GFAP antibodies. The GFAP antibodies are likely a clinically insignificant bystander in this case and possibly in other diseases with CNS inflammation. Further research is needed to determine the clinical significance of newer CSF autoantibodies such as anti-GFAP before they are used for medical decision-making in pediatrics.
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Affiliation(s)
- E Datyner
- grid.412807.80000 0004 1936 9916Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN USA
| | - V Adeseye
- grid.412807.80000 0004 1936 9916Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN USA
| | - K Porter
- grid.152326.10000 0001 2264 7217Vanderbilt University, Nashville, TN USA
| | - I Dryden
- grid.412807.80000 0004 1936 9916Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, 1161 21St Avenue South, Nashville, TN MCN C2318B37232-2561 USA
| | - A Sarma
- grid.412807.80000 0004 1936 9916Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN USA
| | - N Vu
- grid.412807.80000 0004 1936 9916Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN USA
| | - AE Patrick
- grid.412807.80000 0004 1936 9916Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN USA
| | - P Paueksakon
- grid.412807.80000 0004 1936 9916Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, 1161 21St Avenue South, Nashville, TN MCN C2318B37232-2561 USA
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2
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Younger DS. Motor sequela of adult and pediatric stroke: Imminent losses and ultimate gains. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:305-346. [PMID: 37620077 DOI: 10.1016/b978-0-323-98817-9.00025-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Stroke is the leading cause of neurological disability in the United States and worldwide. Remarkable advances have been made over the past 20 years in acute vascular treatments to reduce infarct size and improve neurological outcome. Substantially less progress has been made in the understanding and clinical approaches to neurological recovery after stroke. This chapter reviews the epidemiology, bedside examination, localization approaches, and classification of stroke, with an emphasis on motor stroke presentations and management, and promising research approaches to enhancing motor aspects of stroke recovery.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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3
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Moore C, Pollard R, Press CA, Hiller M, Maloney J, Barry M, Kammeyer R. A 14-year-old Girl with Right-Sided Weakness and Speech Difficulty. Neurohospitalist 2022; 12:408-412. [PMID: 35419134 PMCID: PMC8995604 DOI: 10.1177/19418744211073025] [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] Open
Abstract
We herein report a case of Childhood Primary Central Nervous System (CNS) Angiitis. This case consisted of a 14-year-old girl who presented with right-sided weakness, aphasia, and a fever. A Magnetic Resonance Imaging of the brain showed multifocal areas of ischemia. Magnetic Resonance Angiography of the head and neck showed narrowing and irregularities of the left middle cerebral artery and right posterior cerebral artery. Cerebrospinal Fluid studies showed a lymphocytic pleocytosis and brain biopsy revealed leptomeningeal and perivascular inflammation. The epidemiology, presenting symptoms, work-up, pathophysiology, diagnostic criteria, and treatment of Childhood Primary CNS angiitis are discussed. This case serves as a reminder that when pediatric patients present with stroke-like symptoms inflammatory etiologies including Primary CNS Angiitis must be considered and treated appropriately in a time sensitive manner.
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Affiliation(s)
- Caitlin Moore
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Rebecca Pollard
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Craig A. Press
- Department of Pediatrics, Section of Child Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Matthew Hiller
- Department of Pediatrics, Section of Child Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - John Maloney
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Megan Barry
- Department of Pediatrics, Section of Child Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ryan Kammeyer
- Department of Pediatrics, Section of Child Neurology, University of Colorado School of Medicine, Aurora, CO, USA
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4
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de Boysson H, Pagnoux C. Vasculiti del sistema nervoso centrale. Neurologia 2021. [DOI: 10.1016/s1634-7072(21)45782-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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5
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Mossa-Basha M, Zhu C, Wu L. Vessel Wall MR Imaging in the Pediatric Head and Neck. Magn Reson Imaging Clin N Am 2021; 29:595-604. [PMID: 34717847 DOI: 10.1016/j.mric.2021.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Vessel wall MR imaging (VWI) is a technique that progressively has gained traction in clinical diagnostic applications for evaluation of intracranial and extracranial vasculopathies, with increasing use in pediatric populations. The technique has shown promise in detection, differentiation, and characterization of both inflammatory and noninflammatory vasculopathies. In this article, optimal techniques for intracranial and extracranial VWI as well as applications and value for pediatric vascular disease evaluation are discussed.
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Affiliation(s)
- Mahmud Mossa-Basha
- Department of Radiology, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA.
| | - Chengcheng Zhu
- Department of Radiology, University of Washington, 325 9th Avenue, Seattle, WA 98104, USA
| | - Lei Wu
- Department of Radiology, University of Washington, 1660 South Columbian Way, Seattle, WA 98108, USA
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6
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Keenan P, Brunner J, Quan AS, Smitka M, Hahn G, Pain CE, Häfner R, Speth F, Gerstl L, Hedrich CM. Diagnosis and Treatment of Small Vessel Childhood Primary Angiitis of the Central Nervous System (sv-cPACNS): An International Survey. Front Pediatr 2021; 9:756612. [PMID: 34712632 PMCID: PMC8546335 DOI: 10.3389/fped.2021.756612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/13/2021] [Indexed: 11/24/2022] Open
Abstract
Childhood primary angiitis of the Central Nervous System (cPACNS) is a rare autoimmune and inflammatory disease. It can result in significant neuronal damage, neurodevelopmental delay and potentially death. Childhood PACNS is divided into subcategories: angiography-positive p-cPACNS that affects medium and large vessels, and angiography-negative small vessel sv-cPACNS. Due to its rarity, variable clinical representation, and the lack of a diagnostic criteria and therapeutic plans, diagnosis and treatment of cPACNS is challenging and approaches vary. This survey collected information on diagnostic and therapeutic approaches to sv-PACNS. It was shared with international clinician networks, including the German Society for Paediatric Rheumatology, the Paediatric Rheumatology European Society, the "Network Paediatric Stroke," and members of the American College of Rheumatology/CARRA Paediatric Rheumatology list server. This project has shown consensus in numerous diagnostic and therapeutic treatment approaches, highlighting key areas which will be utilised to develop statements in the use of expert consensus meetings to standardise diagnostic and therapeutic approaches in this rare inflammatory disease.
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Affiliation(s)
- Paul Keenan
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Jürgen Brunner
- Pädiatrische Rheumatologie, Department Kinder- und Jugendheilkunde, Medizinische Universität Innsbruck, Innsbruck, Austria
| | - Angela S Quan
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Martin Smitka
- Klinik und Poliklinik fur Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Gabriele Hahn
- Institut und Poliklinik für Radiologie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Clare E Pain
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, United Kingdom
| | - Renate Häfner
- Deutsches Zentrum für Kinder- und Jugendrheumatologie, Garmisch-Partenkirchen, Germany
| | - Fabian Speth
- Zentrum für Geburtshilfe, Kinder- und Jugendmedizin, Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Lucia Gerstl
- Division of Paediatric Neurology, Developmental Medicine and Social Paediatrics, Department of Paediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Christian M Hedrich
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, United Kingdom
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7
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Abstract
Autoimmune encephalitis is a severe inflammatory disorder of the brain with diverse causes and a complex differential diagnosis. Recent advances in the past decade have led to the identification of new syndromes and biological markers of limbic encephalitis, the commonest presentation of autoimmune encephalitis. The successful use of serum and intrathecal antibodies to diagnose affected patients has resulted in few biopsy and postmortem examinations. In those available, there can be variable infiltrating inflammatory T cells with cytotoxic granules in close apposition to neurons, consistent with an inflammatory autoimmune basis, but true vasculitis is rarely seen. The exception is Hashimoto encephalopathy.
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Affiliation(s)
- David S Younger
- Department of Neurology, Division of Neuro-Epidemiology, New York University School of Medicine, New York, NY 10016, USA; School of Public Health, City University of New York, New York, NY, USA.
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8
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Abstract
Vascular injury is increasingly recognized as an important cause of mortality and morbidity in children (29 days to 18 years of age). Since vascular brain injury in children appears to be less common than in adults, the index of suspicion for vascular brain injury is usually lower. In this review article, we describe frequent and rare conditions underlying pediatric stroke including cardioembolic, viral, autoimmune, post-traumatic, and genetic etiologies. Furthermore, we provide a neuroimaging correlate for clinical mimics of pediatric stroke. This review highlights the role of multimodal noninvasive neuroimaging in the early diagnosis of pediatric stroke, providing a problem-solving approach to the differential diagnosis for the neuroradiologist, emergency room physician, and neurologist.
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9
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Amlie-Lefond C. Evaluation and Acute Management of Ischemic Stroke in Infants and Children. Continuum (Minneap Minn) 2018; 24:150-170. [PMID: 29432241 DOI: 10.1212/con.0000000000000559] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article provides an overview of stroke in neonates, infants, and children. RECENT FINDINGS Arterial ischemic stroke and cerebral venous sinus thrombosis are increasingly recognized in childhood as important causes of lifelong morbidity and mortality. Diagnosis of arterial ischemic stroke is frequently delayed, as acute neurologic deficits can be challenging to detect in the young child, and stroke is often not considered in the differential diagnosis. Neurologic sequelae following stroke are common, and strategies to minimize stroke size and optimize recovery are being developed. Recurrent arterial ischemic stroke is not uncommon, particularly in children with cerebral arteriopathy. Cerebral venous sinus thrombosis causes obstruction of venous outflow leading to venous infarcts. Complications include hemorrhagic conversion of infarcts and increased intracranial pressure. Without treatment, thrombus extension with increased symptoms is common. Robust guidelines of care that exist for adults do not exist for children, particularly for children with arterial ischemic stroke. SUMMARY The approach to stroke in infants and children can be informed by clinical experience in pediatric stroke and cerebral venous sinus thrombosis, the extensive literature on pediatric thrombosis, and extrapolation from data from adult patients.
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10
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Dlamini N, Yau I, Muthusami P, Mikulis DJ, Elbers J, Slim M, Askalan R, MacGregor D, deVeber G, Shroff M, Moharir M. Arterial Wall Imaging in Pediatric Stroke. Stroke 2018; 49:891-898. [DOI: 10.1161/strokeaha.117.019827] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/02/2018] [Accepted: 01/25/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Nomazulu Dlamini
- From the Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON (N.D., I.Y., M.S., R.A., D.M., G.d.V., M.M.); Division of Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON (P.M., M.S.); Department of Diagnostic Imaging, Toronto Western Hospital, ON (D.M.); and Division of Neurology, Lucile Packard Children’s Hospital Stanford, CA (J.E.)
| | - Ivanna Yau
- From the Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON (N.D., I.Y., M.S., R.A., D.M., G.d.V., M.M.); Division of Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON (P.M., M.S.); Department of Diagnostic Imaging, Toronto Western Hospital, ON (D.M.); and Division of Neurology, Lucile Packard Children’s Hospital Stanford, CA (J.E.)
| | - Prakash Muthusami
- From the Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON (N.D., I.Y., M.S., R.A., D.M., G.d.V., M.M.); Division of Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON (P.M., M.S.); Department of Diagnostic Imaging, Toronto Western Hospital, ON (D.M.); and Division of Neurology, Lucile Packard Children’s Hospital Stanford, CA (J.E.)
| | - David J. Mikulis
- From the Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON (N.D., I.Y., M.S., R.A., D.M., G.d.V., M.M.); Division of Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON (P.M., M.S.); Department of Diagnostic Imaging, Toronto Western Hospital, ON (D.M.); and Division of Neurology, Lucile Packard Children’s Hospital Stanford, CA (J.E.)
| | - Jorina Elbers
- From the Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON (N.D., I.Y., M.S., R.A., D.M., G.d.V., M.M.); Division of Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON (P.M., M.S.); Department of Diagnostic Imaging, Toronto Western Hospital, ON (D.M.); and Division of Neurology, Lucile Packard Children’s Hospital Stanford, CA (J.E.)
| | - Mahmoud Slim
- From the Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON (N.D., I.Y., M.S., R.A., D.M., G.d.V., M.M.); Division of Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON (P.M., M.S.); Department of Diagnostic Imaging, Toronto Western Hospital, ON (D.M.); and Division of Neurology, Lucile Packard Children’s Hospital Stanford, CA (J.E.)
| | - Rand Askalan
- From the Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON (N.D., I.Y., M.S., R.A., D.M., G.d.V., M.M.); Division of Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON (P.M., M.S.); Department of Diagnostic Imaging, Toronto Western Hospital, ON (D.M.); and Division of Neurology, Lucile Packard Children’s Hospital Stanford, CA (J.E.)
| | - Daune MacGregor
- From the Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON (N.D., I.Y., M.S., R.A., D.M., G.d.V., M.M.); Division of Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON (P.M., M.S.); Department of Diagnostic Imaging, Toronto Western Hospital, ON (D.M.); and Division of Neurology, Lucile Packard Children’s Hospital Stanford, CA (J.E.)
| | - Gabrielle deVeber
- From the Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON (N.D., I.Y., M.S., R.A., D.M., G.d.V., M.M.); Division of Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON (P.M., M.S.); Department of Diagnostic Imaging, Toronto Western Hospital, ON (D.M.); and Division of Neurology, Lucile Packard Children’s Hospital Stanford, CA (J.E.)
| | - Manohar Shroff
- From the Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON (N.D., I.Y., M.S., R.A., D.M., G.d.V., M.M.); Division of Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON (P.M., M.S.); Department of Diagnostic Imaging, Toronto Western Hospital, ON (D.M.); and Division of Neurology, Lucile Packard Children’s Hospital Stanford, CA (J.E.)
| | - Mahendranath Moharir
- From the Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON (N.D., I.Y., M.S., R.A., D.M., G.d.V., M.M.); Division of Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON (P.M., M.S.); Department of Diagnostic Imaging, Toronto Western Hospital, ON (D.M.); and Division of Neurology, Lucile Packard Children’s Hospital Stanford, CA (J.E.)
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11
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Abstract
The child presenting with possible sentinel transient ischemic event or stroke requires prompt diagnosis so that strategies to limit injury and prevent recurrent stroke can be instituted. Cerebral arteriopathy is a potent risk factor for arterial ischemic stroke in childhood. Though acute imaging study in the setting of possible stroke is often a head computed tomography, when possible magnetic resonance imaging (MRI) is recommended as the first-line study as confirmation and imaging evaluation of ischemic stroke will typically require MRI. The MRI scanning approach should include diffusion-weighted imaging (DWI) early in the sequence order, since normal DWI excludes acute infarct with rare exception. In most cases, arterial imaging with time-of-flight (TOF) magnetic resonance angiography (MRA) is warranted. Dedicated MRA may not be possible in the acute setting, but should be pursued as promptly as possible, particularly in the child with findings and history suggestive of arteriopathy, given the high risk of recurrent stroke in these children. MRA can overestimate the degree of arterial compromise due to complex/turbulent flow, and be insensitive to subtle vessel irregularity due to resolution and complex flow. In cases with high imaging suspicion for dissection despite normal MRA findings, catheter angiogram is indicated. A thoughtful, stepwise approach to arterial neuroimaging is critical to optimize diagnosis, treatment, and primary and secondary prevention of childhood stroke.
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Affiliation(s)
| | - Dennis Shaw
- Department of Radiology, Seattle Children's Hospital, Seattle, WA, USA
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12
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Johns C, Kolla S, Hart A, Sinha S, Batty R, Connolly DJA. A pictorial review of imaging in paediatric stroke. Postgrad Med J 2016; 92:545-53. [PMID: 27354547 DOI: 10.1136/postgradmedj-2015-133409] [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] [Received: 01/21/2016] [Accepted: 06/05/2016] [Indexed: 11/04/2022]
Abstract
Stroke is recognised as an important disease in adults. Paediatric stroke is less understood, yet still an important cause of morbidity and mortality, with an incidence of 5 per 100 000 children and is one of the top 10 leading causes of death in children. In adults the vast majority of strokes are ischaemic, whereas in children haemorrhage makes up half the cases. The incidence of neonatal stroke is much higher, at up to 45 per 100 000 population; however, the underlying causes are less understood. This paper acts as a guide to the different causes of stroke with the key differences on imaging discussed.
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Affiliation(s)
| | - S Kolla
- Radiology Department, Sheffield Teaching Hospitals, Sheffield, UK
| | - A Hart
- Neurology Department, Sheffield Children's Hospital, Sheffield, UK
| | - S Sinha
- Neurosurgery Department, Sheffield Children's Hospital, Sheffield, UK
| | - R Batty
- Radiology Department, Sheffield Teaching Hospitals, Sheffield, UK
| | - D J A Connolly
- Radiology Department, Sheffield Teaching Hospitals, Sheffield, UK
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13
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Dabas A, Yadav S. Primary angiitis of the central nervous system: A rare and reversible cause of childhood stroke. J Pediatr Neurosci 2016; 11:338-340. [PMID: 28217160 PMCID: PMC5314851 DOI: 10.4103/1817-1745.199473] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Childhood primary angiitis of the central nervous system (cPACNS) is a rare and a potentially fatal cause of childhood stroke. The disease poses a diagnostic dilemma for the clinicians due to overlapping and varied clinical manifestations such as headache, focal acute neurological deficits, cognitive impairment, or encephalopathy. We report a young boy who presented with low-grade fever and headache but rapidly progressed to develop acute encephalopathy and quadriparesis with multiple cranial nerve palsies, masquerading as acute disseminated encephalomyelitis. The neuroimaging was suggestive of vasculitis. He was diagnosed as cPACNS and recovered with immunosuppressive therapy.
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Affiliation(s)
- Aashima Dabas
- Department of Pediatrics, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
| | - Sangeeta Yadav
- Department of Pediatrics, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
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14
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Abstract
Stroke is as common as brain tumor in children. The etiology of childhood arterial ischemic stroke (AIS) appears to be multifactorial, resulting from the interaction between genetic predisposition and environmental triggers. The risk factors for AIS in children are markedly different from the atherosclerotic risk factors in adults. Trauma and infections have been identified as associations in previous studies and are exposures of particular interest because of their increased prevalence in the children. The aim of this review article is to provide an overview of the research studies that have addressed the role of infections and trauma in pediatric AIS.
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Affiliation(s)
- Elena Moraitis
- Rheumatology/Infectious Diseases and Immunity Unit UCL Institute of Child Health and Rheumatology Department, Great Ormond Street Hospital for Children, London, UK,
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15
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Abstract
A previously well and developmentally normal five-year-old right-handed girl, presented with acute left-sided weakness and dysarthria. Investigations confirmed an acute right lenticulostriate stroke secondary to probable childhood primary angiitis of the CNS(cPACNS), including evidence of vessel wall enhancement (Figure). Despite extensive investigations, no alternative etiology for her stroke was detected. After three weeks of steroids, the child improved and the vessel wall enhancement resolved. Moderate hemiparesis, hemidystonia, and behavioural sequelae are present at 18-month follow-up.
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16
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Benson LA, Olson H, Gorman MP. Evaluation and treatment of autoimmune neurologic disorders in the pediatric intensive care unit. Semin Pediatr Neurol 2014; 21:284-90. [PMID: 25727510 DOI: 10.1016/j.spen.2014.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Autoimmunity is being increasingly recognized as a cause of neurologic presentations both inside and outside the intensive care unit (ICU) setting. Pediatric autoimmune neurologic diseases likely to be seen in the ICU include autoimmune encephalitidies such as N-Methyl-D-aspartate (NMDA) receptor encephalitis, central nervous system vasculitis, demyelinating disorders, and neurologic involvement of systemic autoimmune disorders. In addition, there are conditions of suspected autoimmune etiology such as febrile infection-related epilepsy syndrome (FIRES) and rapid-onset obesity, hypoventilation, hypothalamic dysfunction, and autonomic dysregulation (ROHHAD) syndrome that are rare, but when they do present, it is often to the ICU. Refractory seizures, altered mental status, and disordered breathing are the most common indications for intensive care for these patients.
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Affiliation(s)
- Leslie A Benson
- Department of Neurology, Boston Children's Hospital, Boston, MA.
| | - Heather Olson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, MA
| | - Mark P Gorman
- Department of Neurology, Boston Children's Hospital, Boston, MA
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17
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Katsetos CD, Poletto E, Kasmire KE, Walleigh D, Kumar I, Pascasio JM, Legido A, Goldsmith DP. Childhood primary angiitis of the central nervous system with metachronous hemorrhagic infarcts: a postmortem study with clinicopathologic correlation. Semin Pediatr Neurol 2014; 21:184-94. [PMID: 25149960 DOI: 10.1016/j.spen.2014.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This neuropathologic case study illustrates the discovery of metachronous hemorrhagic infarcts insinuating round mass-like lesions by magnetic resonance imaging in the setting of childhood primary angiitis of the central nervous system (cPACNS) raising diagnostic awareness of this unusual presentation in a clinical and neuroimaging context. The report underscores the importance of recurrent vasculitis-induced ischemic brain damage as a pathologic correlate of relapsing cPACNS and offers a critical reappraisal of common imitators as well as a clinicopathologic approach to differential diagnosis. Attention is drawn to the caveat that although magnetic resonance imaging findings at initial presentation may not be typical for stroke, they later exhibit attributes of cerebral infarction at both the subacute and chronic stages. A pattern of cPACNS characterized predominantly by multiple petechial-like cortical hemorrhages with pathologic features of hemorrhagic infarcts is recognized. The present study lends credence to the practice of a rigorous autopsy-based approach aimed at a better understanding of the anatomic pathology and biology of cPACNS and at facilitating prospective neuroimaging and biopsy-based surgical pathology correlations, ultimately enhancing diagnostic accuracy in clinical settings. Although PACNS is, by definition, a diagnosis of exclusion, it should be considered from the outset in the differential diagnosis of ischemic stroke or hemorrhagic stroke or of unusual and relapsing intra-axial mass-like CNS lesions in children, necessitating appropriate pathologic evaluation of brain biopsy specimens.
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Affiliation(s)
- Christos D Katsetos
- Department of Pediatrics, Drexel University College of Medicine, St. Christopher׳s Hospital for Children, Philadelphia, PA; Department of Pathology and Laboratory Medicine, Drexel University College of Medicine, St. Christopher׳s Hospital for Children, Philadelphia, PA; Department of Neurology, Drexel University College of Medicine, Philadelphia, PA.
| | - Erica Poletto
- Department of Pediatrics, Drexel University College of Medicine, St. Christopher׳s Hospital for Children, Philadelphia, PA; Department of Radiology, Drexel University College of Medicine, St. Christopher׳s Hospital for Children, Philadelphia, PA
| | - Kathryn E Kasmire
- Department of Pediatrics, Drexel University College of Medicine, St. Christopher׳s Hospital for Children, Philadelphia, PA
| | - Diana Walleigh
- Department of Pediatrics, Drexel University College of Medicine, St. Christopher׳s Hospital for Children, Philadelphia, PA
| | - Indira Kumar
- Department of Pediatrics, Drexel University College of Medicine, St. Christopher׳s Hospital for Children, Philadelphia, PA
| | - Judy Mae Pascasio
- Department of Pediatrics, Drexel University College of Medicine, St. Christopher׳s Hospital for Children, Philadelphia, PA; Department of Pathology and Laboratory Medicine, Drexel University College of Medicine, St. Christopher׳s Hospital for Children, Philadelphia, PA
| | - Agustin Legido
- Department of Pediatrics, Drexel University College of Medicine, St. Christopher׳s Hospital for Children, Philadelphia, PA; Department of Neurology, Drexel University College of Medicine, Philadelphia, PA
| | - Donald P Goldsmith
- Department of Pediatrics, Drexel University College of Medicine, St. Christopher׳s Hospital for Children, Philadelphia, PA
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Eleftheriou D, Ganesan V. Controversies in childhood arterial ischemic stroke and cerebral venous sinus thrombosis. Expert Rev Cardiovasc Ther 2014; 7:853-61. [DOI: 10.1586/erc.09.41] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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19
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Mallick AA, O’Callaghan FJK. Risk factors and treatment outcomes of childhood stroke. Expert Rev Neurother 2014; 10:1331-46. [DOI: 10.1586/ern.10.106] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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20
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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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21
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Park MS, Marlin AE, Gaskill SJ. Angiography-negative primary angiitis of the central nervous system in childhood. J Neurosurg Pediatr 2014; 13:62-7. [PMID: 24160668 DOI: 10.3171/2013.9.peds13159] [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: 11/06/2022]
Abstract
Childhood primary angiitis of the CNS is a recently characterized, potentially reversible disease process. A favorable outcome requires early diagnosis and appropriate treatment. The histological findings of childhood primary angiitis of the CNS are characterized by a lymphocytic, nongranulomatous vasculitis. This disorder can lead to neurological deficits, seizures, and strokes. Laboratory and radiographic investigation are part of the evaluation, but are often nonspecific. Conventional angiography can fail to show any abnormality, and biopsy may ultimately be required for diagnosis. Although there can be significant rates of morbidity and mortality if untreated, patients who receive appropriate therapy can experience excellent outcomes, and in many cases will demonstrate near-complete or total clinical and radiographic resolution. The case of a previously healthy 13-year-old girl with new-onset generalized tonic-clonic seizures is presented, with a review of the literature.
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Affiliation(s)
- Michael S Park
- Department of Neurosurgery & Brain Repair, Division of Pediatric Neurosurgery, Morsani College of Medicine, University of South Florida, Tampa, Florida
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22
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Moharir M, Shroff M, Benseler SM. Childhood central nervous system vasculitis. Neuroimaging Clin N Am 2013; 23:293-308. [PMID: 23608691 DOI: 10.1016/j.nic.2012.12.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Inflammatory brain diseases in childhood are underrecognized and lead to devastating yet potentially reversible deficits. New-onset neurologic or psychiatric deficits in previously healthy children mandate an evaluation for an underlying inflammatory brain disease. Distinct disease entities, such as central nervous system (CNS) vasculitis, are now being increasingly reported in children. Clinical symptoms, initial laboratory test, and neuroimaging studies help to differentiate between different causes; however, more invasive tests, such as lumbar puncture, conventional angiography, and/or brain biopsy, are usually necessary before the start of treatment. This article focuses on childhood CNS vasculitis.
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Affiliation(s)
- Mahendranath Moharir
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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23
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Twilt M, Benseler SM. CNS vasculitis in children. Mult Scler Relat Disord 2013; 2:162-71. [DOI: 10.1016/j.msard.2012.11.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Revised: 10/27/2012] [Accepted: 11/19/2012] [Indexed: 01/20/2023]
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24
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Mineyko A, Kirton A, Ng D, Wei XC. Normal intracranial periarterial enhancement on pediatric brain MR imaging. Neuroradiology 2013; 55:1161-9. [DOI: 10.1007/s00234-013-1206-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 05/14/2013] [Indexed: 10/26/2022]
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25
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Kirton A, Crone M, Benseler S, Mineyko A, Armstrong D, Wade A, Sebire G, Crous-Tsanaclis AM, deVeber G. Fibromuscular dysplasia and childhood stroke. Brain 2013; 136:1846-56. [DOI: 10.1093/brain/awt111] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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26
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de Boysson H, Pagnoux C, Zuber M. Vasculiti del sistema nervoso centrale. Neurologia 2013. [DOI: 10.1016/s1634-7072(12)63926-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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O'Mahony J, Bar-Or A, Arnold DL, Sadovnick AD, Marrie RA, Banwell B. Masquerades of acquired demyelination in children: experiences of a national demyelinating disease program. J Child Neurol 2013; 28:184-97. [PMID: 22573735 DOI: 10.1177/0883073812443006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The diagnosis of acquired demyelinating syndromes of the central nervous system in children requires exclusion of other acute central nervous system disorders. In a 23-site national demyelinating disease study, standardized clinical, laboratory, and magnetic resonance imaging (MRI) data were obtained prospectively from onset, and serially at 3, 6, and 12 months and annually. Twenty of 332 (6%) participants (mean [SD] age, 10.21 [4.32] years; 12 (60%) female) were ultimately diagnosed with vascular disorders (primary or secondary central nervous system vasculitis, vasculopathy, stroke, or migraine, n = 11 children), central nervous system malignancy (n = 3), mitochondrial disease (n = 2), or central nervous system symptoms in the accompaniment of confirmed infection (n = 4). Red flags that may serve to distinguish disorders in the differential of acquired demyelination are described.
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Affiliation(s)
- Julia O'Mahony
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Toronto, Canada.
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28
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Inflammatory, vascular, and infectious myelopathies in children. HANDBOOK OF CLINICAL NEUROLOGY 2013; 112:999-1017. [PMID: 23622308 DOI: 10.1016/b978-0-444-52910-7.00020-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Acute nontraumatic myelopathies of childhood include inflammatory, infectious, and vascular etiologies. Inflammatory immune-mediated disorders of the spinal cord can be categorized as idiopathic isolated transverse myelitis, neuromyelitis optica, and multiple sclerosis. In recent years, human T-cell lymphotropic virus type 1, West Nile virus, enterovirus-71, and Lyme disease have been increasingly recognized as infectious etiologies of myelopathy, and poliomyelitis remains an important etiology in world regions where vaccination programs have not been universally available. Vascular etiologies include vasculopathies (systemic lupus erythematosus, small vessel primary angiitis of the central nervous system), arteriovenous malformations, and spinal cord infarction (fibrocartilaginous embolism, diffuse hypoxic ischemia-mediated infarction). Vascular myelopathies are less common than inflammatory and infectious myelopathies, but are more likely to lead to devastating clinical deficits. Current therapeutic strategies include acute anti-inflammatory treatment and rehabilitation. Stem cell transplantation, nerve graft implantation, and stimulation of endogenous repair mechanisms represent promising strategies for spinal cord repair.
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29
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Benseler S, Pohl D. Childhood central nervous system vasculitis. HANDBOOK OF CLINICAL NEUROLOGY 2013; 112:1065-78. [DOI: 10.1016/b978-0-444-52910-7.00024-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
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3-T Magnetic Resonance Angiography in Primary Angiitis of the Central Nervous System. J Comput Assist Tomogr 2013; 37:493-8. [DOI: 10.1097/rct.0b013e31829610e5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mechanisms of pediatric cerebral arteriopathy: an inflammatory debate. Pediatr Neurol 2013; 48:14-23. [PMID: 23290015 DOI: 10.1016/j.pediatrneurol.2012.06.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 06/27/2012] [Indexed: 11/21/2022]
Abstract
Arteriopathy is the leading cause of childhood arterial ischemic stroke, but its mechanisms are poorly understood. This review explores the possible role of inflammatory mechanisms and evidence for inflammatory pathophysiology in specific pediatric cerebral arteriopathies. Pathologically proven small-vessel central nervous system vasculitis provides a definitive inflammatory model where available treatments are likely improving outcomes. In contrast, a common large-vessel arteriopathy presents many features suggestive of inflammation, but definitive proof remains elusive. Recent advances and future research directions, including biomarker, neuroimaging, and pathologic approaches and how they might address these important clinical questions, are discussed.
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BATTHISH MICHELLE, BANWELL BRENDA, LAUGHLIN SUZANNE, HALLIDAY WILLIAM, PESCHKEN CHRISTINE, PARAS EMILE, BENSELER SUSANNE. Refractory Primary Central Nervous System Vasculitis of Childhood: Successful Treatment with Infliximab. J Rheumatol 2012; 39:2227-9. [DOI: 10.3899/jrheum.120616] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Alba MA, Espígol-Frigolé G, Prieto-González S, Tavera-Bahillo I, García-Martínez A, Butjosa M, Hernández-Rodríguez J, Cid MC. Central nervous system vasculitis: still more questions than answers. Curr Neuropharmacol 2012; 9:437-48. [PMID: 22379458 PMCID: PMC3151598 DOI: 10.2174/157015911796557920] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2010] [Revised: 11/30/2010] [Accepted: 11/30/2010] [Indexed: 12/19/2022] Open
Abstract
The central nervous system (CNS) may be involved by a variety of inflammatory diseases of blood vessels. These include primary angiitis of the central nervous system (PACNS), a rare disorder specifically targeting the CNS vasculature, and the systemic vasculitides which may affect the CNS among other organs and systems. Both situations are severe and convey a guarded prognosis. PACNS usually presents with headache and cognitive impairment. Focal symptoms are infrequent at disease onset but are common in more advanced stages. The diagnosis of PACNS is difficult because, although magnetic resonance imaging is almost invariably abnormal, findings are non specific. Angiography has limited sensitivity and specificity. Brain and leptomeningeal biopsy may provide a definitive diagnosis when disclosing blood vessel inflammation and are also useful to exclude other conditions presenting with similar findings. However, since lesions are segmental, a normal biopsy does not completely exclude PACNS. Secondary CNS involvement by systemic vasculitis occurs in less than one fifth of patients but may be devastating. A prompt recognition and aggressive treatment is crucial to avoid permanent damage and dysfunction. Glucocorticoids and cyclophosphamide are recommended for patients with PACNS and for patients with secondary CNS involvement by small-medium-sized systemic vasculitis. CNS involvement in large-vessel vasculitis is usually managed with high-dose glucocorticoids (giant-cell arteritis) or glucocorticoids and immunosuppressive agents (Takayasu's disease). However, in large vessel vasculitis, where CNS symptoms are usually due to involvement of extracranial arteries (Takayasu's disease) or proximal portions of intracranial arteries (giant-cell arteritis), revascularization procedures may also have an important role.
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Affiliation(s)
- Marco A Alba
- Vasculitis Research Unit, Department of Systemic Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d´Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Villarroel 170, 08036 Barcelona, Spain
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Cerebral haemorrhage in the presence of primary childhood central nervous system vasculitis--a review. Childs Nerv Syst 2012; 28:1141-8. [PMID: 22684518 DOI: 10.1007/s00381-012-1827-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 05/24/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE The aim of the study was to evaluate frequency and clinical relevance of haemorrhagic events associated with primary angiitis of the central nervous system in childhood (cPACNS), a rare but increasingly recognized disease with varying clinical presentations. METHOD A systematic literature review from 1990 onwards was conducted to identify reported cases of cPACNS. RESULTS A total of 110 paediatric patients met the inclusion criteria. The median age was 9.5 years. Seven children (7/110, 6.4 %) demonstrated cerebral haemorrhage. Death occurred only in children with cerebral haemorrhage (4/110, 3.6 %); both a sudden and prolonged course of disease was observed. CONCLUSION PACNS is a rare disease and the occurrence of haemorrhage with this condition is even rarer; however, the risk of an unfavourable outcome under these circumstances seems to be increased. PACNS adds to the list of differential diagnoses of intracerebral haemorrhage in the paediatric population.
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Cellucci T, Tyrrell PN, Pullenayegum E, Benseler SM. von Willebrand factor antigen--a possible biomarker of disease activity in childhood central nervous system vasculitis? Rheumatology (Oxford) 2012; 51:1838-45. [PMID: 22740622 DOI: 10.1093/rheumatology/kes156] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE The main objective was to develop a trajectory for von Willebrand factor (vWF) antigen in childhood primary CNS vasculitis (cPACNS) after treatment and compare this with disease activity and other inflammatory markers. METHODS A single-centre cohort study of consecutive children diagnosed with cPACNS was performed. Demographic, clinical, laboratory, imaging and histological data were collected at diagnosis and during standardized clinic visits. Outcome measures included disease activity measured by physician global assessment and serial measures of vWF antigen. Analysis included descriptive statistics and parametric methods. RESULTS The study cohort consisted of 39 children diagnosed with cPACNS: 25 with angiography-negative cPACNS and 14 with angiography-positive disease. Twenty-one patients were female, median age at diagnosis was 9.8 years, and median follow-up was 18 months. All patients presented with neurological deficits. Disease activity and neurological outcome improved significantly during follow-up. vWF antigen levels were increased at diagnosis in 65% of children with cPACNS and were decreased significantly after treatment. In contrast, levels of CRP and ESR fluctuated over time. Higher vWF antigen levels at diagnosis were associated with lower measures of disease activity at 12 months. CONCLUSION In our study, all children with cPACNS improved over time. Changes in CRP and ESR, other laboratory tests, and MRI did not consistently reflect altered disease activity. However, vWF antigen may help clinicians to identify changes in disease activity during follow-up and predict treatment response. Controlled studies are necessary to evaluate the sensitivity and specificity of vWF antigen as a biomarker of disease activity.
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Affiliation(s)
- Tania Cellucci
- Division of Rheumatology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
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36
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Tsai SL, Lewis EC, Sell E, Whiting S. Central nervous system vasculitis with positive antithyroid antibodies in an adolescent boy. Pediatr Neurol 2011; 45:189-92. [PMID: 21824569 DOI: 10.1016/j.pediatrneurol.2011.04.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Accepted: 04/18/2011] [Indexed: 11/18/2022]
Abstract
Hashimoto's encephalopathy is diagnosed when patients exhibit features of corticosteroid-responsive encephalopathy and positive antithyroid antibodies. The relationship between antithyroid antibodies and encephalopathy is subject to considerable debate. We describe corticosteroid-responsive encephalopathy in a 14-year-old boy with positive antimicrosomal antibodies. His history included subtle neurocognitive decline. He presented with seizures. He underwent a brain biopsy before initiating treatment after his third episode. That biopsy was consistent with central nervous system vasculitis. This report is unique because, to our knowledge, it describes the first pretreatment brain biopsy of a pediatric patient who fits the criteria for Hashimoto's encephalopathy.
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Affiliation(s)
- Sarah L Tsai
- Division of Endocrinology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.
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38
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Elbers J, Halliday W, Hawkins C, Hutchinson C, Benseler SM. Brain biopsy in children with primary small-vessel central nervous system vasculitis. Ann Neurol 2010; 68:602-10. [DOI: 10.1002/ana.22075] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Small vessel childhood primary angiitis of the CNS: first steps toward a standardised treatment regimen. Lancet Neurol 2010; 9:1042-4. [PMID: 20889381 DOI: 10.1016/s1474-4422(10)70244-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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40
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Grauer O, Wolff D, Bertz H, Greinix H, Kühl JS, Lawitschka A, Lee SJ, Pavletic SZ, Holler E, Kleiter I. Neurological manifestations of chronic graft-versus-host disease after allogeneic haematopoietic stem cell transplantation: report from the Consensus Conference on Clinical Practice in chronic graft-versus-host disease. Brain 2010; 133:2852-65. [PMID: 20846944 DOI: 10.1093/brain/awq245] [Citation(s) in RCA: 155] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
A major obstacle of allogeneic haematopoietic stem cell transplantation is graft-versus-host disease, an immune-mediated disorder that affects multiple tissues and organs with varying severity. Neurological complications of acute and chronic graft-versus-host disease are rare but can produce severe clinical problems with significant morbidity and mortality. In this article, we review neurological manifestations of chronic graft-versus-host disease that comprise immune-mediated neuropathies, myasthenia gravis and myositis in the peripheral nervous system and various cerebrovascular complications, demyelination and immune-mediated encephalitis in the central nervous system. The National Institutes of Health consensus on criteria for clinical trials in chronic graft-versus-host disease recommended that the diagnosis of chronic graft-versus-host disease of the nervous system can be made only when other organs are affected by graft-versus-host disease and frequent neurological differential diagnoses such as drug-induced toxicities or opportunistic infections are excluded. The Consensus Conference on Clinical Practice in chronic graft-versus-host disease, held in autumn 2009 in Regensburg, aimed to summarize the literature and to provide guidelines for the diagnostic approach in children and adults with neurological manifestations of chronic graft-versus-host disease. Moreover, we present therapeutic recommendations and their level of evidence for the management of these complications. Overlapping symptoms and comorbidities after allogeneic haematopoietic stem cell transplantation and the limited knowledge about the underlying biological mechanisms of chronic graft-versus-host disease affecting the nervous system emphasize the need for further experimental and clinical investigations.
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Affiliation(s)
- Oliver Grauer
- Department of Neurology, University Medical Centre Regensburg, Universitätsstraße 84, Regensburg, Germany
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Eleftheriou D, Cox T, Saunders D, Klein NJ, Brogan PA, Ganesan V. Investigation of childhood central nervous system vasculitis: magnetic resonance angiography versus catheter cerebral angiography. Dev Med Child Neurol 2010; 52:863-7. [PMID: 20132140 DOI: 10.1111/j.1469-8749.2009.03591.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM We compared the clinical utility of magnetic resonance angiography (MRA) to catheter cerebral angiography (CA) in the investigation of children with suspected central nervous system (CNS) vasculitis. METHOD Single-centre retrospective review of children with a suspected diagnosis of CNS vasculitis studied with both MRA and CA. MRA and CA-detected abnormalities (location, multiplicity, and morphology) were compared; sensitivity and specificity were calculated on a per lesion and per patient basis for MRA, with CA as the reference standard. RESULTS Findings in fourteen patients (median age at presentation of 5 y 10 mo [range 1 y 5 mo-14 y 5 mo]; eight males, six females) relating to sixteen paired studies of MRA and CA were reviewed. CA-detected lesions were commonly bilateral (13/16 studies, p<0.05), and likely to be proximally distributed (15/16 studies, p<0.05).The sensitivity and specificity of MRA for CA lesion detection was 63% (95% confidence interval [CI] 48-78) and 89% (95% CI 81-93), respectively with moderate agreement between the two modalities (kappa=0.51, 95% CI 0.37-0.66). The majority of the false negative observations involved the posterior circulation (9/14). The overall sensitivity for MRA diagnosis of vasculitis per patient was 94% (95% CI 67-99). INTERPRETATION MRA failed to identify all lesions detected on CA, particularly those in the posterior circulation. MRA is a reasonable initial modality in the investigation of suspected CNS vasculitis but in cases of abnormal parenchymal MRI and normal MRA, CA should be considered.
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Affiliation(s)
- Despina Eleftheriou
- Department of Paediatric Rheumatology, Institute of Child Health, London, UK.
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The "other" vasculitis syndromes and kidney involvement. Pediatr Nephrol 2010; 25:1633-9. [PMID: 19898878 PMCID: PMC2908464 DOI: 10.1007/s00467-009-1327-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2009] [Revised: 09/03/2009] [Accepted: 09/03/2009] [Indexed: 11/16/2022]
Abstract
There are a number of vasculitides that are not confined to a specific vessel size, do not have characteristic features, and/or are not secondary to another disease. Most of these vasculitides are rare in childhood. Behçet disease is representative of this group as it involves vessels of any size on both the arterial and venous side. In addition to renal vascular involvement, Behçet disease may involve the kidney through glomerulonephritis, secondary amyloidosis and, rarely, tubulointerstital involvement. Vasculitis secondary to infections, malignancy, and drugs are not common among children. However, vasculitis may be associated with a number of rheumatic diseases in childhood and the auto-inflammatory syndromes (periodic fever syndromes). Auto-inflammatory syndromes are diseases characterized by periodic attacks of clinical and laboratory inflammation. Studies carried out during the past decade have provided valuable information on the mechanism of inflammation and innate immunity in general. This group of vasculitides is associated with secondary amyloidosis of the kidney if not treated. Hypocomplementemic urticarial vasculitis is an interesting vasculitic disease with frequent kidney involvement. Here, we introduce the reader to the wide scope of these diseases; although rare, such diseases represent a challenge to the nephrologist.
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Ng WF, Chiu SC, Lam DSY, Wong YC, Tam S, Kwong NS, Loo KT, Yuen KY. A 7-year-old boy dying of acute encephalopathy. Brain Pathol 2010; 20:261-4. [PMID: 20438486 DOI: 10.1111/j.1750-3639.2009.00346.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
A 7 year old Chinese boy died of a rapidly progressive encephalopathy after influenza infection. MRI showed bilateral and symmetrical lesions including the thalamus and brainstem tegmentum. The pathology of necrosis and vasculopathy were in keeping with acute necrotizing encephalopathy (ANE). ANE was first described in Japan and carries a high mortality and morbidity. A vasculopathy with breakdown of the blood-brain-barrier was incriminated but the pathogenesis remained obscure and autopsy studies have been limited. A review of the literature showed only nine postmortem reports in the acute stage. Symmetrical brain necrosis always involved the thalamus followed by the tegmentum of the pons and other regions. Exudative vasculopathy was commonly observed and often accompanied by endothelial cell necrosis. In the present case there was inflammatory fibrinoid vasculitis which has not been previously described.
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Imaging in childhood arterial ischaemic stroke. Neuroradiology 2010; 52:577-89. [PMID: 20445969 DOI: 10.1007/s00234-010-0704-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Accepted: 04/07/2010] [Indexed: 10/19/2022]
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Abstract
Systemic vasculitis is a group of disorders with multiorgan involvement. These disorders have diverse clinical manifestations associated with significant morbidity and mortality. The most common vasculitides in children--Henoch-Schönlein purpura and Kawasaki disease--are self-limiting conditions. The lifelong and chronic vasculitides (eg, giant cell arteritis, Wegener's granulomatosis, microscopic polyangiitis, Churg-Strauss syndrome, polyarteritis nodosa, and Takayasu arteritis) are rarely seen in children. Therefore, the outcome in general is more favorable in children. This article offers an overview of the epidemiologic, etiologic, pathophysiologic, and clinical features of vasculitis in children, with emphasis on common conditions.
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Stepensky P, Waldman E, Simanovsky N, Fried I, Revel-Vilk S, Resnick IB, Weintraub M. Isolated CNS vasculitis: unusual presentation of relapsed Ewing sarcoma. Pediatr Blood Cancer 2010; 54:326-8. [PMID: 19890904 DOI: 10.1002/pbc.22299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We describe a 12-year-old boy male who presented with an expressive dysphasia after completion of treatment for unifocal Ewing sarcoma. CNS vasculitis was diagnosed by MRI/MRA and cerebral angiography. Extensive rheumatologic work-up failed to identify an underlying primary process. Restaging studies showed no evidence of tumor. Complete neurologic recovery was achieved on prednisone. Four months later the patient developed overt, extensive metastases, confirmed by biopsy to represent recurrent Ewing sarcoma. Despite intensive therapy the patient succumbed 6 months later. This case demonstrates the unique finding of isolated CNS vasculitis as a presenting sign of Ewing sarcoma.
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Affiliation(s)
- Polina Stepensky
- Departments of Pediatric Hematology-Oncology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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Sen ES, Leone V, Abinun M, Forsyth R, Ramesh V, Friswell M, O'Callaghan F, Ramanan AV. Treatment of primary angiitis of the central nervous system in childhood with mycophenolate mofetil. Rheumatology (Oxford) 2010; 49:806-11. [PMID: 20100791 DOI: 10.1093/rheumatology/kep453] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the use of mycophenolate mofetil (MMF) in the treatment of refractory primary angiitis of the CNS in childhood (cPACNS). METHODS A retrospective chart review was performed in patients with cPACNS who were treated with MMF following failure of a combination of corticosteroids and another immunosuppressant. RESULTS Three patients from two centres were included in this study. The age of onset of disease was 5, 6 and 9 years. All the patients improved when treated with MMF, such that the dose of corticosteroids could be weaned or stopped. CONCLUSIONS MMF should be considered for maintenance treatment in the management of patients with cPACNS refractory to the combination of corticosteroids and first-line immunosuppressive agents.
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Affiliation(s)
- Ethan S Sen
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
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Abstract
PURPOSE OF REVIEW To examine recent advances in the pathophysiology and therapy of pediatric vasculitis. RECENT FINDINGS The past 2 years have been marked by significant progress in extending novel techniques to the investigation of the two most common pediatric vasculitis syndromes, Henoch-Schonlein purpura and Kawasaki disease. Study of other vasculitides, such as Wegener granulomatosis, Churg-Strauss syndrome, and microscopic polyangiitis, is impeded by the small number of pediatric patients. Nonetheless, national and international registries are beginning to provide the foundation for generation of testable hypotheses regarding pathogenesis and optimal treatment. Thus, recent data from the study of children suggest that disorders in the control of inflammation, such as those that underlie familial Mediterranean fever and other autoinflammatory diseases, may predispose to vasculitis. Improved knowledge of mechanisms of disease, in turn, should pave the way for more targeted, effective, and tolerable therapies for children with systemic vasculitis. SUMMARY International collaboration to study rare disorders such as pediatric vasculitis are demonstrating disorders of inflammatory regulation that predispose to these diseases and may point toward new treatment approaches.
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