Successful intravenous thrombolysis in a 14-year-old boy with ischemic stroke

Clinical applications of transcranial Doppler in non-trauma critically ill children: a scoping review

BACKGROUND

Many applications of transcranial Doppler (TCD) as a diagnosis or monitoring tool have raised interest in the last decades. It is important that clinicians know when and how to perform TCD in this population, what parameter to assess and monitor and how to interpret it.

OBJECTIVE

This review aims to describe the emerging clinical applications of TCD in critically ill children excluding those suffering from trauma.

METHODS

Databases Web of Science, Cochrane and PubMed were searched in May 2020. We considered all publications since the year 2000 addressing the use of TCD as a prognostic, diagnostic or follow-up tool in children aged 0 to 15 years admitted to intensive care or emergency units, excluding neonatology and traumatic brain injury. Two independent reviewers selected 82 abstracts and full-text articles from the 2011 unique citations identified at the outset.

RESULTS

TCD provides crucial additional information at bedside about cerebrovascular hemodynamics. Many clinical applications include the diagnosis and management of various medical and surgical neurologic conditions (central nervous system infections, arterial ischemic stroke, subarachnoid hemorrhage and vasospasm, brain death, seizures, metabolic disease, hydrocephalus) as well as monitoring the impact systemic conditions on brain perfusion (hemodynamic instability, circulatory assistance).

CONCLUSION

To conclude, TCD has become an invaluable asset for non-invasive neuromonitoring in critically ill children excluding those suffering from trauma. However, the scope of TCD remains unclearly defined yet and reference values in critically ill children are still lacking.

Transcranial Doppler in pediatric emergency and intensive care unit: a case series and literature review

PURPOSE

Transcranial Doppler (TCD) has been used for more than 30 years in clinical practice. Although adult intensive care is relatively well covered, pediatric cases are still underrepresented. We intend to review a series of pediatric cases where TCD was determinant in clinical decisions and a literature review on this topic.

METHODS

We describe cases with different pathologies where TCD had an important role in clinical management of the patients. We discuss TCD utility and potential role both in the emergency department and the intensive care unit.

RESULTS

Five patients with different neurologic insults are presented. TCD was useful in the identification of intracranial hypertension in traumatic brain injury, hydrocephalus and central nervous system infection; identification of decreased cerebral perfusion pressure in hypovolemic shock and the diagnosis of impending cerebral circulatory arrest in a child with meningococcal septicemia. We discuss how TCD can be used in emergency and intensive care settings, reviewing relevant literature and our own experience.

CONCLUSIONS

Non-invasive testing using TCD can aid clinical decisions. More widespread use of this technique will allow for better care of children with neurologic insults.

Childhood Stroke and Vision: A Review of the Literature

OBJECTIVE

Here we review the current literature regarding visual outcome after perinatal and childhood stroke.

BACKGROUND

Visual deficits following stroke in adults are common and have been previously reviewed. Less is known about visual deficits following stroke in neonates and older children. Most of the literature regarding this subject has focused on preterm infants, or on other types of brain injury. This review summarizes the types of visual deficits seen in term infants following perinatal stroke and children following childhood stroke and predictors of outcome. This review suggests areas for future research.

METHODS

We performed Ovid MEDLINE searches regarding visual testing in children, vision after childhood stroke, neuroplasticity of vision, treatment of visual impairment after stroke, and driving safety concerns after stroke.

RESULTS

Visual field defects were the most commonly reported visual deficits after perinatal and childhood stroke. There is a significant lack of literature on this subject, and most is in the form of case reports and case series. Children can experience significant visual morbidity after stroke, and have the potential to show some recovery, but guidelines on assessment and treatment of this population are lacking.

CONCLUSIONS

There were limitations to this study, given the small amount of literature available. Although stroke in children can result in severe visual deficits, most children regain at least a portion of their vision. However, more research is needed regarding visual assessment of this population, long-term visual outcomes, specific predictors of recovery, and treatment options.

Successful Systemic Thrombolysis in an Adolescent With Acute Ischemic Stroke

INTRODUCTION

Current treatment guidelines for acute ischemic stroke do not recommend thrombolytic therapy in children and adolescents as data are still very scarce.

CASE REPORT

We report the case of a 15-year-old boy who suddenly developed severe left-sided weakness and speech difficulty while stooling. Upon arrival at our Emergency Department, the National Institute of Health Stroke Scale (NIHSS) score was 18. Urgent neurovascular ultrasound showed a distal occlusion of the right internal carotid artery and occlusion at the origin of the middle cerebral artery (MCA) and the anterior cerebral artery. He was treated 2 hours after symptom onset with intravenous recombinant tissue plasminogen activator without any complication. At the end of thrombolysis, a complete recanalization was shown by transcranial Doppler sonography, although a brain magnetic resonance imaging disclosed an acute right middle cerebral artery stroke. At discharge, the boy had mild weakness on his left leg and slight left facial palsy: the NIHSS score was 2. To our knowledge, this is the first intravenous thrombolytic treatment ever reported in an adolescent in Italy.

CONCLUSIONS

Despite the lack of evidence regarding the safety and the efficacy of recombinant tissue plasminogen activator in pediatric stroke, this treatment option should be considered, especially in adolescents presenting within 3 hours from symptom onset in centers with consolidated experience in adult thrombolysis.

The prospects and predicaments of intravenous rt-PA in childhood ischemic stroke

One of the biggest conundrums in acute treatment of childhood arterial ischemic stroke is administration of intravenous recombinant tissue plasminogen activator. Although the benefit of this treatment is well-established in adults, the same effectiveness in children has not been demonstrated. Diversity of underlying causes of ischemic stroke in children and delay and uncertainty in diagnosis are some of the complexities that make intravenous thrombolysis elusive in this population. Physiological, pharmacological and developmental factors may also play roles in variable effect of intravenous recombinant tissue plasminogen activator in children. Current studies are aimed to determine the safety and efficacy of intravenous thrombolysis in carefully-selected children who would benefit the most from this procedure.