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Yücel G, Arslan AK, Özgör B, Şahin MÇ, Öncül Y, Taşolar SD, Akyay A, Güngör S. Risk factors for acute symptomatic seizure in children with cerebral sinovenous thrombosis: Experience from a tertiary center. Clin Neurol Neurosurg 2024; 246:108571. [PMID: 39326278 DOI: 10.1016/j.clineuro.2024.108571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 09/20/2024] [Accepted: 09/20/2024] [Indexed: 09/28/2024]
Abstract
OBJECTIVE To investigate the risk factors for acute symptomatic seizure (ASS) in children with Cerebral Sinovenous Thrombosis (CSVT) and to evaluate the effect of ASS on outcome. METHODS Cross-sectional, single-center, hospital-based retrospective analysis of 42 children with neuroimaging-confirmed CSVT recorded between December 2009 and January 2023. ASS was defined as a seizure occurring within 7 days after CSVT. Predictors for ASS were analyzed by univariate and multivariate logistic regression. Functional outcomes were evaluated using the Pediatric Stroke Outcome Measure (PSOM). RESULTS The average age of the 42 patients included in the study sample was 105.36 ± 63.1 months. Almost one-third (28.6 %) of patients with CSVT developed ASS. In univariate analysis, factors associated with seizure risk were young age, low Glasgow Coma Scale at admission, long hospital stay, headache, change of consciousness, focal neurological findings, cerebral hemorrhage, motor deficit and high D-dimer level (p=0.018, p<0.001, p= 0.016, p= 0.001, p=0.014, p<0.001, p<0.001, p=0.019 and p=0.013, respectively). In multivariate analysis young age, focal neurological findings and D-dimer levels were potential predictors of ASS (p=0.004, p=0.003, p=0.036, respectively). Receiver operating characteristic (ROC) analysis for D-dimer diagnostic accuracy in patients with CSVT revealed D-dimer > 498 ng/mL (AUC=0.743). In both cohorts, PSOM scores at last follow-up were worse in those with acute seizures compared to those without (p<0.001). CONCLUSION Acute seizures occurred in approximately one-third of our cohort. Young age, focal neurological findings, and high D-dimer levels are potential predictors of ASS in children. Children with ASS had worse outcomes than those without.
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Affiliation(s)
- Gül Yücel
- Department of Pediatric Neurology, Faculty of Medicine, Inönü University, Malatya, Turkey.
| | - Ahmet Kadir Arslan
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Inönü University, Malatya, Turkey.
| | - Bilge Özgör
- Department of Pediatric Neurology, Faculty of Medicine, Inönü University, Malatya, Turkey.
| | - Murat Çağlar Şahin
- Department of Pediatrics, Faculty of Medicine, Inönü University, Malatya, Turkey.
| | - Yurday Öncül
- Department of Pediatric Hematology and Oncology, Faculty of Medicine, Inönü University, Malatya, Turkey.
| | - Sevgi Demiröz Taşolar
- Department of Pediatric Radiology, Faculty of Medicine, Inonu University, Malatya, Turkey
| | - Arzu Akyay
- Department of Pediatric Hematology and Oncology, Faculty of Medicine, Inönü University, Malatya, Turkey.
| | - Serdal Güngör
- Department of Pediatric Neurology, Faculty of Medicine, Inönü University, Malatya, Turkey.
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Karakas C, Herman I, Kralik SF, Webber TA, Takacs DS, Bhar S, Pehlivan D. A Comprehensive Examination of Clinical Characteristics and Determinants of Long-Term Outcomes in Pediatric Cerebral Sinus Venous Thrombosis. Pediatr Neurol 2024; 155:76-83. [PMID: 38608552 DOI: 10.1016/j.pediatrneurol.2024.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 03/17/2024] [Accepted: 03/19/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND To analyze the clinical and neuroimaging features, risk factors, treatment choices, and long-term clinical outcomes in children with cerebral sinus venous thrombosis (CSVT). METHODS This is a retrospective cohort study of children diagnosed with CSVT between 2002 and 2018 at Texas Children's Hospital. RESULTS A total of 183 children (male: 62.3%) with CSVT were included. The average presenting age was 7.7 years (S.D.: 5.6). The mean follow-up duration was 33.7 months (S.D.: 38.6). The most common presenting clinical feature was headache (36.6%). Head and neck infections other than meningitis (36.6%) were the most common risk factors. Prevalent neurological examination findings included motor deficit (21.3%) and altered mental status (AMS, 20.2%). Neuroimaging features included hemorrhagic infarction (19.6%), ischemic infarction (8.2%), and intracranial hemorrhage without infarction (5.5%). The most common site of thrombosis was the superior sagittal sinus (37.2%), with 78.2% of patients demonstrating involvement of multiple sinuses. Treatment of choice was low-molecular-weight heparin in 69.4% of patients. Factors associated with worse clinical outcomes included head and neck infections, malignancy (other than hematologic), cardiac disease, and recent surgery; seizure and dehydration on initial presentation; motor abnormalities and AMS on initial examination; ischemic infarct only; and involvement of vein of Trolard on neuroimaging. Thrombus condition on repeat imaging, receiving any anticoagulant/antithrombotic treatment, treatment duration, or follow-up duration was not associated with severity of long-term outcome. CONCLUSIONS CSVT may lead to unfavorable long-term outcomes in a remarkable portion of pediatric patients. Thus, a high index of suspicion and early and appropriate management of pediatric CSVT is imperative.
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Affiliation(s)
- Cemal Karakas
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Department of Neurology and Neurophysiology, Baylor College of Medicine, Houston, Texas; Division of Pediatric Neurology, Department of Neurology, Norton Children's Medical Group, University of Louisville, Louisville, Kentucky
| | - Isabella Herman
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Boys Town National Research Hospital, Boys Town, Nebraska
| | - Stephen F Kralik
- Department of Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Troy A Webber
- Mental Health Care Line, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Danielle S Takacs
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Department of Neurology and Neurophysiology, Baylor College of Medicine, Houston, Texas
| | - Saleh Bhar
- Division of Hematology and Oncology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Davut Pehlivan
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas.
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Karlin AR, Kumar NK, Vossough A, Abend NS, Ichord RN, Beslow LA. Pediatric Cerebral Sinovenous Thrombosis and Risk for Epilepsy. Pediatr Neurol 2023; 146:85-94. [PMID: 37453223 DOI: 10.1016/j.pediatrneurol.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/01/2023] [Accepted: 05/18/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Cerebral sinovenous thrombosis (CSVT) is a rare form of pediatric stroke with significant morbidity. We determined cumulative incidence and predictors of acute seizures, remote seizures, and epilepsy after pediatric CSVT. METHODS Retrospective analysis of 131 neonates and children with neuroimaging-confirmed CSVT enrolled between 2008 and 2020 from a single-center prospective consecutive cohort. Acute seizures occurred within 7 days of CSVT. Remote seizures occurred >7 days after CSVT. Epilepsy was defined as 2 or more remote seizures at least 24 hours apart. Survival methods determined the incidence of and risk factors for remote seizures and epilepsy. RESULTS Acute seizures occurred in 14/33 neonates (42%) and 19/98 children (19%). Among children, hemorrhage predicted acute seizures (OR 6.6, 95% CI 1.9 to 22.4, P = 0.003). Remote seizures occurred in six neonates; five developed epilepsy. Remote seizures occurred in 14 children; 10 developed epilepsy. In neonates, 1- and 3-year epilepsy-free survival were 86% (95% CI 62% to 95%) and 66% (95% CI 32% to 87%). One- and 3-year epilepsy-free survival in children were 88% (95% CI 76% to 92%) and 84% (95% CI 59% to 86%). In multivariable analysis for children, acute seizures predicted epilepsy (HR 3.8, 95% CI 1.1-13.3, P = 0.039). In both cohorts, Pediatric Stroke Outcome Measure scores at last follow-up were worse in those with epilepsy compared to those without. CONCLUSIONS Acute seizures occurred in approximately one quarter of our cohort and are an epilepsy risk factor in children with CSVT. Neonates and children with epilepsy had worse outcomes than those without.
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Affiliation(s)
- Alexis R Karlin
- Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nankee K Kumar
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arastoo Vossough
- Division of Neuroradiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicholas S Abend
- Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rebecca N Ichord
- Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lauren A Beslow
- Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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Engelhardt MI, Phan N, Zavala H, Chinnadurai S, Roby BB. Head and neck venous thrombosis secondary to pediatric otolaryngologic infection. Int J Pediatr Otorhinolaryngol 2023; 168:111513. [PMID: 37003017 DOI: 10.1016/j.ijporl.2023.111513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 02/16/2023] [Accepted: 03/11/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVES Head and neck venous thrombosis is a rare but potentially devastating complication of childhood otolaryngologic infections. This study examines the presentation and management of this condition. METHODS A retrospective chart review was performed on all pediatric patients with otolaryngologic infections complicated by cranial and cervical venous thrombosis at a tertiary children's hospital from 2007 to 2018. Patient demographics, presentation, site of infection, thrombosis location, implicated pathogen, length of hospital stay, need for surgery, and anticoagulant regimen were assessed. RESULTS This study included 33 patients (mean age, 7.5 years; age range, 0.8-17 years; 19 [58%] male). The most common infection source was otologic (n = 20), followed by ophthalmic and sinonasal pathology (n = 9), and neck infections (n = 4). The most common site of thrombosis secondary to ear pathology was the sigmoid sinus. The ophthalmic veins were the most common site of thrombosis for ophthalmic/sinonasal infections. Nine CN VI palsies, one CN VII palsy, and one CN III palsy were observed. Twenty-six subjects (79%) required surgical intervention. All those who experienced a nerve palsy required surgery. Length of hospitalization significantly differed with the stay for a neck infection complicated by thrombosis longer compared to otologic and sinonasal infections (F[2,30] = 7.08, p = 0.003). Length of hospital stay was significantly correlated with admission temperature (r = 0.506, p = 0.003) and CRP (r = 0.400, p = 0.03) but not WBC (r = 0.181, p = 0.31). Culture growth predominantly isolated a single causative organism rather than polymicrobial involvement. Forty-eight species were identified, most (n = 41/48, 85%) being Gram-positive bacteria. Alpha-hemolytic Streptococcus was the most common isolate from children with vessel thrombosis secondary to ear infections, with Streptococcus pyogenes predominant in sinonasal infections and Staphylococcus aureus the most common in neck abscesses. There was significant variability in anticoagulation management within the patient population, but no bleeding complications were documented. Most patients had no evidence of underlying thrombophilia (n = 15); for those with positive hypercoagulability screens, the most common positive marker was the presence of lupus inhibitor (n = 6). CONCLUSION Venous thrombosis resulting from adjacent otolaryngologic infection is a serious complication requiring proper recognition and management. The involved vasculature and cranial nerve findings are dependent on the anatomic location of the underlying infection. Cranial neuropathies in the presence of these infections should prompt evaluation for possible thrombosis.
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Affiliation(s)
- Margaret I Engelhardt
- University of Minnesota, Department of Otolaryngology - Head and Neck Surgery, Minneapolis, MN, USA; Children's of Minnesota, Pediatric ENT & Facial Plastic Surgery, Minneapolis, MN, USA.
| | - Noel Phan
- Icahn School of Medicine at Mount Sinai, Department of Otolaryngology - Head and Neck Surgery, New York City, NY, USA
| | - Hanan Zavala
- Children's of Minnesota, Pediatric ENT & Facial Plastic Surgery, Minneapolis, MN, USA
| | - Sivakumar Chinnadurai
- University of Minnesota, Department of Otolaryngology - Head and Neck Surgery, Minneapolis, MN, USA; Children's of Minnesota, Pediatric ENT & Facial Plastic Surgery, Minneapolis, MN, USA
| | - Brianne B Roby
- University of Minnesota, Department of Otolaryngology - Head and Neck Surgery, Minneapolis, MN, USA; Children's of Minnesota, Pediatric ENT & Facial Plastic Surgery, Minneapolis, MN, USA
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Sakr HI, Edrees B, Taher HO, Miliany TT, Gazzaz RY, AlRuwaithi AO, Alamer MF, Metawee ME. Combined Methylprednisolone Pulse Therapy plus Rituximab for Treating a Rare Juvenile Steroid-Resistant Nephrotic Syndrome with Cerebral Venous Sinus Thrombosis: A Case Report. J Cardiovasc Dev Dis 2022; 9:383. [PMID: 36354782 PMCID: PMC9692607 DOI: 10.3390/jcdd9110383] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 10/03/2024] Open
Abstract
Background: Cerebral venous sinus thrombosis (CVST) secondary to nephrotic syndrome (NS) is rarely reported. Additionally, treating steroid-sensitive nephrotic syndrome (SSNS) that changes to steroid resistance (SRNS) is difficult, with many relapses and side effects. Case presentation: A 32-month-old SSNS male child turned into SRNS and developed cerebral venous sinus thrombosis (CVST), a rare complication of NS. As a result of the administration of combined pulse methylprednisolone and IV Rituximab (RTX) therapy, the patient showed marked improvement, the results of urine analysis were remarkably improved, and the child started to respond to treatment. Conclusion: Successful treatment of a rare case of juvenile SSNS behaving as SRNS with the development of CVST could be established using combined steroid pulse therapy, Enoxaparin, and the B lymphocytes monoclonal antibodies RTX.
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Affiliation(s)
- Hader I. Sakr
- Department of Medical Physiology, Faculty of Medicine, Cairo University, Cairo 11511, Egypt
- Medicine Program, Batterjee Medical College, P.O. Box 6231, Jeddah 21442, Saudi Arabia
| | - Burhan Edrees
- Department of Pediatrics, Umm Al-Qura University, Makkah 24451, Saudi Arabia
| | - Hussein Omar Taher
- Medicine Program, Batterjee Medical College, P.O. Box 6231, Jeddah 21442, Saudi Arabia
| | - Tuleen Talal Miliany
- Medicine Program, Batterjee Medical College, P.O. Box 6231, Jeddah 21442, Saudi Arabia
| | - Raneem Yasser Gazzaz
- Medicine Program, Batterjee Medical College, P.O. Box 6231, Jeddah 21442, Saudi Arabia
| | - Asma Omar AlRuwaithi
- Medicine Program, Batterjee Medical College, P.O. Box 6231, Jeddah 21442, Saudi Arabia
| | - Mohammed Fouad Alamer
- Medicine Program, Batterjee Medical College, P.O. Box 6231, Jeddah 21442, Saudi Arabia
| | - Mostafa E. Metawee
- Department of Histology and Cytology, Faculty of Medicine, Al-Azhar University, Cairo 11511, Egypt
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Cerebral venous thrombosis in children an 18-year review of a Portuguese hospital. Neurologia 2022. [DOI: 10.1016/j.nrl.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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ÖZCAN A, CANSEVER M, YILMAZ E, ÜNAL E, KARAKÜKÇÜ M, PATIROĞLU T. The spectrum of underlying diseases in children with autoimmune hemolytic anemia. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2021. [DOI: 10.32322/jhsm.985008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Shen H, Huang X, Fan C. Clinical Characteristics and Management of Cerebral Venous Sinus Thrombosis in Patients With Antiphospholipid Syndrome: A Single-Center Retrospective Study. Clin Appl Thromb Hemost 2021; 27:1076029621999104. [PMID: 33872100 PMCID: PMC8058809 DOI: 10.1177/1076029621999104] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Antiphospholipid syndrome (APS) with cerebral venous sinus thrombosis (CVST) is a relatively rare phenomenon, and this observational study aimed to investigate the clinical characteristics of APS patients complicated with CVST. We retrospectively investigated the clinical characteristics of CVST events in APS and compared differential characteristics and associated factors between APS patients with and without CVST. Twenty-one CVST patients with APS were enrolled including 14 females (9.4%) and 7 males (5.8%). The median age and disease duration at onset of CVST was 33 years (IQR 28-48) old and 1.3 months (IQR 0.7-4), respectively. Among APS patients with CVST, 12 (57.1%) cases presented with neurologic symptoms of CVST as the initial manifestation. Onset of CVST was mainly chronic (52.4%). Headache (90.5%) was the most common neurological symptom. The common locations of CVST were transverse sinus (76.2%) and superior sagittal sinus (57.1%), with more frequently (76.2%) dual or multiple sinuses involved. All patients with CVST were treated with anticoagulant, and 5 (23.8%) patients received endovascular therapy. Sixteen (84.2%) patients had good outcomes and 3 (15.8%) patients died at last follow-up. There were no significant differences (P > 0.05) between two groups in the analysis of related APS indicators. There were no significant differences (P > 0.05) between two groups in the analysis of related APS indicators. Although APS complicated with CVST is rare and predominately chronic developed. The evaluation of CVST should be performed for APS patients with intracranial hypertension syndrome. The routine screening of antiphospholipid antibodies (aPLs) is highly recommended in unexplained CVST patients. Most CVST patients with APS will have a good prognosis after treatment, and endovascular therapy is an alternative treatment.
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Affiliation(s)
- Huixin Shen
- Department of Neurology, Xuanwu Hospital, 12517Capital Medical University, Beijing, China
| | - Xiaoqin Huang
- Department of Neurology, Xuanwu Hospital, 12517Capital Medical University, Beijing, China
| | - Chunqiu Fan
- Department of Neurology, Xuanwu Hospital, 12517Capital Medical University, Beijing, China
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He J, Yang F. Cerebral Venous Sinus Thrombosis in a Child With Idiopathic Nephrotic Syndrome: A Case Report and Review of the Literature. Cureus 2020; 12:e11248. [PMID: 33274130 PMCID: PMC7707130 DOI: 10.7759/cureus.11248] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Cerebral venous sinus thrombosis is a rare and serious complication of nephrotic syndrome. A case of a five-year-old boy with nephrotic syndrome is described here. On the fourth day of admission, the child developed an occasional cough. A percutaneous renal biopsy was conducted to characterize the frequent-relapse nephrotic syndrome that was developed. After suspension of oral anticoagulants, the patient developed mild dizziness, headache, and vomiting. The child was diagnosed with intracranial venous sinus thrombosis based on data obtained using head computed tomography and magnetic resonance imaging. He recovered after receiving heparin and warfarin anticoagulants. We summarized the case and reviewed the literature here, showing that early diagnosis and treatment have a significant impact on the prognosis of this complication.
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Sarecka-Hujar B, Kopyta I. Antiphospholipid syndrome and its role in pediatric cerebrovascular diseases: A literature review. World J Clin Cases 2020; 8:1806-1817. [PMID: 32518771 PMCID: PMC7262698 DOI: 10.12998/wjcc.v8.i10.1806] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 04/10/2020] [Accepted: 04/26/2020] [Indexed: 02/05/2023] Open
Abstract
Antiphospholipid syndrome (APS) or Hughes syndrome is an acquired thromboinflammatory disorder. Clinical criteria of APS diagnosis are large- and small-vessel thrombosis as well as obstetric problems; laboratory criteria are the presence of antiphospholipid antibodies (lupus anticoagulant, anticardiolipin antibodies and anti-β2-glycoprotein-1). The presence of at least 1 clinical and 1 laboratory criterion allows definitive diagnosis of APS. Primary APS is diagnosed in patients without features of connective tissue disease; secondary APS is diagnosed in patients with clinical signs of autoimmune disease. A high frequency of catastrophic APS as well as a high tendency to evolve from primary APS to secondary syndrome during the course of lupus and lupus-like disease is a feature of pediatric APS. The most characteristic clinical presentation of APS in the pediatric population is venous thrombosis, mainly in the lower limbs, and arterial thrombosis causing ischemic brain stroke. Currently, no diagnostic criteria for pediatric APS exist, which probably results in an underestimation of the problem. Similarly, no therapeutic procedures for APS specific for children have yet been established. In the present literature review, we discussed data concerning APS in children and its role in cerebrovascular diseases, including pediatric arterial ischemic stroke, migraine and cerebral venous thrombosis.
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Affiliation(s)
- Beata Sarecka-Hujar
- Department of Basic Biomedical Science, School of Pharmacy with the Division of Laboratory Medicine in Sosnowiec, Medical University of Silesia in Katowice, Sosnowiec 41200, Poland
| | - Ilona Kopyta
- Department of Paediatric Neurology, School of Medicine in Katowice, Medical University of Silesia in Katowice, Sosnowiec 41200, Poland
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