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Yücel G, Arslan AK, Özgör B, Güngör S. Risk factors for epilepsy following arterial ischemic stroke childhood: A retrospective cohort study. Epilepsy Behav 2024; 157:109873. [PMID: 38936215 DOI: 10.1016/j.yebeh.2024.109873] [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: 02/21/2024] [Revised: 05/28/2024] [Accepted: 05/30/2024] [Indexed: 06/29/2024]
Abstract
AIM PSE is reported more frequently in childhood than in adults. In this study, we aimed to investigate potential risk factors for the development of post-stroke epilepsy (PSE) in children with arterial ischemic stroke (AIS). MATERIAL METHODS The current retrospective cohort study included the medical records of 50 pediatric participants (aged 29 days to 18 years) diagnosed with AIS at a university hospital between January 2006 and December 2023. All information of the patients who were followed for at least two years for the development of PSE after AIS was entered into the hospital database and recorded in a pre-designed questionnaire. Acute symptomatic seizures were defined as seizures occurring within 7 days after stroke. Two or more late seizures occurring after the acute period (>7 days) were classified as PSE. The incidence of PSE and potential risk factors were investigated. RESULTS After AIS, more than half of the patients (58 %) developed acute seizures and almost one-third (38 %) developed PSE. Risk factors associated with the development of PSE, very early seizures (within the first six hours), high stroke severity, cortical lesions, neurological deficits and low serum vitamin D levels were detected (p = 0.05, p = 0.036, p = 0.011, p < 0.001, p < 0.001, respectively). CONCLUSION Seizures within the first six hours, high stroke severity, and neurological deficits are important risk factors for the development of PSE in children. Knowing the potential risk factors of PSE may be helpful for clinicians to identify high-risk patients. It can also contribute to treatment decision-making and post-discharge follow-up planning.
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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
| | - Serdal Güngör
- Department of Pediatric Neurology, Faculty of Medicine, Inönü University, Malatya, Turkey
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Lopez-Espejo M, Skorin I, Mesa T, Hernandez-Chavez MI. Three-year incidence and acute setting predictors of epilepsy after neonatal and childhood arterial ischaemic stroke: a disease-based cohort study. Eur J Pediatr 2024; 183:1415-1423. [PMID: 38170290 DOI: 10.1007/s00431-023-05384-4] [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: 07/27/2023] [Revised: 11/27/2023] [Accepted: 12/10/2023] [Indexed: 01/05/2024]
Abstract
To assess the association between clinical and MRI characteristics of arterial ischaemic stroke (AIS) and the 3-year risk of post-stroke epilepsy (PSE) in paediatric patients. Retrospective cohort study. Database from a single tertiary referral centre for paediatric stroke in Chile. Two hundred seven neonates and children (1 day to 18 years) with a first-ever supratentorial AIS diagnosed between January 2003 and December 2019 were evaluated. Diagnosis of PSE and explanatory variables were consecutively recorded from hospital inpatient and annual outpatient records in a predesigned database. Competing risk analysis (competing events: death and loss to follow-up) of multiple Cox proportional hazards regression was performed to estimate adjusted subhazard ratios (SHRs) of PSE. Confidence intervals (95% CI) were calculated using bootstrap resampling (1000 replications). Interaction terms were added to investigate moderating effects. The 3-year incidence rate of PSE was 166.5 per 1000 person-years (neonatal: 150.1; childhood: 173.9). The 3-year cumulative incidence was 33%. Patients with acute symptomatic non-status seizures (SHR = 3.13; 95% CI = 1.43-6.82), status epilepticus (SHR = 5.16; 95% CI = 1.90-13.96), abnormal discharge neurological status (SHR = 2.52; 95% CI = 1.12-5.63), cortical lesions (SHR = 2.93; 95% CI = 1.48-5.81), and multifocal infarcts with stroke size < 5% of supratentorial brain volume (SHR = 3.49; 95% CI = 1.44-8.46) had a higher risk of PSE. CONCLUSION This study identified specific and reliable acute clinical and imaging predictors of PSE in paediatric patients, helping clinicians identify high-risk patients with potential implications for treatment decisions. WHAT IS KNOWN • Numerous risk factors have been proposed for post-stroke epilepsy, but there is a lack of studies evaluating these variables while accounting for confounding factors and competing risks over time. WHAT IS NEW • After adjustment for competing events, acute symptomatic seizures, both non-status and status epilepticus, abnormal mental status or motor neurological examination at hospital discharge, cortical involvement, and multifocal ischaemic lesions in small strokes are all independent predictors of post-stroke epilepsy. • Knowing the predictors of post-stroke epilepsy is essential for clinicians to make well-informed and effective decisions about treatment.
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Affiliation(s)
- Mauricio Lopez-Espejo
- Section of Neurology, Division of Paediatrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Ilona Skorin
- Section of Neurology, Division of Paediatrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Tomas Mesa
- Section of Neurology, Division of Paediatrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Marta I Hernandez-Chavez
- Section of Neurology, Division of Paediatrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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Caffarelli M, Karukonda V, Aghaeeaval M, McQuillen PS, Numis AL, Mackay MT, Press CA, Wintermark M, Fox CK, Amorim E. A quantitative EEG index for the recognition of arterial ischemic stroke in children. Clin Neurophysiol 2023; 156:113-124. [PMID: 37918222 DOI: 10.1016/j.clinph.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 09/22/2023] [Accepted: 10/02/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE To describe and assess performance of the Correlate Of Injury to the Nervous system (COIN) index, a quantitative electroencephalography (EEG) metric designed to identify areas of cerebral dysfunction concerning for stroke. METHODS Case-control study comparing continuous EEG data from children with acute ischemic stroke to children without stroke, with or without encephalopathy. COIN is calculated continuously and compares EEG power between cerebral hemispheres. Stroke relative infarct volume (RIV) was calculated from quantitative neuroimaging analysis. Significance was determined using a two-sample t-test. Sensitivity, specificity, and accuracy were measured using logistic regression. RESULTS Average COIN values were -34.7 in the stroke cohort compared to -9.5 in controls without encephalopathy (p = 0.003) and -10.5 in controls with encephalopathy (p = 0.006). The optimal COIN cutoff to discriminate stroke from controls was -15 in non-encephalopathic and -18 in encephalopathic controls with >92% accuracy in strokes with RIV > 5%. A COIN cutoff of -20 allowed discrimination between strokes with <5% and >5% RIV (p = 0.027). CONCLUSIONS We demonstrate that COIN can identify children with acute ischemic stroke. SIGNIFICANCE COIN may be a valuable tool for stroke identification in children. Additional studies are needed to determine utility as a monitoring technique for children at risk for stroke.
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Affiliation(s)
- Mauro Caffarelli
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA.
| | - Vishnu Karukonda
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Mahsa Aghaeeaval
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Patrick S McQuillen
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA; Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Adam L Numis
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Mark T Mackay
- Royal Children's Hospital, Melbourne, Victoria, Australia; The Murdoch Children's Research Institute Melbourne, Victoria, Australia; The Department of Paediatrics, University of Melbourne, Victoria, Australia
| | - Craig A Press
- Departments of Pediatrics and Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Max Wintermark
- Department of Neuroradiology, University of Texas MD Anderson Center, Houston, TX, USA
| | - Christine K Fox
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Edilberto Amorim
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
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Benedetti GM, Guerriero RM, Press CA. Review of Noninvasive Neuromonitoring Modalities in Children II: EEG, qEEG. Neurocrit Care 2023; 39:618-638. [PMID: 36949358 PMCID: PMC10033183 DOI: 10.1007/s12028-023-01686-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 01/30/2023] [Indexed: 03/24/2023]
Abstract
Critically ill children with acute neurologic dysfunction are at risk for a variety of complications that can be detected by noninvasive bedside neuromonitoring. Continuous electroencephalography (cEEG) is the most widely available and utilized form of neuromonitoring in the pediatric intensive care unit. In this article, we review the role of cEEG and the emerging role of quantitative EEG (qEEG) in this patient population. cEEG has long been established as the gold standard for detecting seizures in critically ill children and assessing treatment response, and its role in background assessment and neuroprognostication after brain injury is also discussed. We explore the emerging utility of both cEEG and qEEG as biomarkers of degree of cerebral dysfunction after specific injuries and their ability to detect both neurologic deterioration and improvement.
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Affiliation(s)
- Giulia M Benedetti
- Division of Pediatric Neurology, Department of Neurology, Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, WA, USA.
- Division of Pediatric Neurology, Department of Pediatrics, C.S. Mott Children's Hospital and the University of Michigan, 1540 E Hospital Drive, Ann Arbor, MI, 48109-4279, USA.
| | - Rejéan M Guerriero
- Division of Pediatric and Developmental Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Craig A Press
- Departments of Neurology and Pediatric, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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5
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Chung MG, Pabst L. Acute management of childhood stroke. Curr Opin Pediatr 2023; 35:648-655. [PMID: 37800414 DOI: 10.1097/mop.0000000000001295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
PURPOSE OF REVIEW The purpose of this paper is to review recent updates in the acute management of childhood arterial ischemic stroke, including reperfusion therapies and neuroprotective measures. RECENT FINDINGS With the emergence of pediatric stroke centers in recent years, processes facilitating rapid diagnosis and treatment have resulted in improved implementation of early targeted neuroprotective measures as well as the increased use of reperfusion therapies in childhood arterial ischemic stroke. Retrospective data has demonstrated that alteplase is safe in carefully selected children with arterial ischemic stroke in the first 4.5 h from symptom onset, though data regarding its efficacy in children are still lacking. There is also increasing data that suggests that thrombectomy in children with large vessel occlusion improves functional outcomes. Recent adult studies, including the use of Tenecteplase as an alteplase alternative and expansion of late thrombectomy to include patients with large ischemic cores, also are reviewed along with limitations to application of the adult data to pediatric care. SUMMARY There have been significant advances in the hyperacute care of children with ischemic stroke and early diagnosis and targeted management are of the upmost importance in improving long-term outcomes.
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Affiliation(s)
- Melissa G Chung
- Nationwide Children's Hospital, Department of Pediatrics, Divisions of Critical Care Medicine and Pediatric Neurology
| | - Lisa Pabst
- Department of Pediatrics, Division of Neurology, University of Utah, Salt Lake City, Utah, USA
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Felling RJ, Jordan LC, Mrakotsky C, deVeber G, Peterson RK, Mineyko A, Feldman SJ, Shapiro K, Lo W, Beslow LA. Roadmap for the Assessment and Management of Outcomes in Pediatric Stroke. Pediatr Neurol 2023; 141:93-100. [PMID: 36805967 DOI: 10.1016/j.pediatrneurol.2023.01.008] [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: 11/20/2022] [Revised: 01/04/2023] [Accepted: 01/16/2023] [Indexed: 01/22/2023]
Abstract
Neurological morbidity is common after pediatric stroke, with moderate to severe deficits that can significantly impact education and social function. Care and recovery occur in phases distinguished by the time interval after stroke onset. These phases include the hyperacute and acute periods in which the focus is on cerebral reperfusion and prevention of neurological deterioration, followed by the subacute and chronic phases in which the focus is on secondary stroke prevention and mitigation of disability through rehabilitation, adaptation, and reintegration into the community. In this article, a multidisciplinary group of pediatric stroke experts review the stages of recovery after pediatric stroke with an emphasis on critical assessment time points. Our goal is to encourage increased standardization of outcome assessment to facilitate future clinical trials comparing various treatment and intervention options and advance optimized care for children with stroke.
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Affiliation(s)
- Ryan J Felling
- Departments of Neurology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christine Mrakotsky
- Departments of Psychiatry & Neurology, Center for Neuropsychology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gabrielle deVeber
- Child Health Evaluative Sciences Program, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Rachel K Peterson
- Neuropsychology Department, Kennedy Krieger Institute, Baltimore, Maryland; Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Aleksandra Mineyko
- Section of Neurology, Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Samantha J Feldman
- Neurosciences and Mental Health Research Program, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Kevin Shapiro
- Cortica Healthcare, Westlake Village, California; Division of Neurology, Children's Hospital Lost Angeles, Los Angeles, California
| | - Warren Lo
- Departments of Pediatrics and Neurology, The Ohio State University Nationwide Children's Hospital, Columbus, Ohio
| | - Lauren A Beslow
- Division of Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Fox C. Pediatric Ischemic Stroke. Continuum (Minneap Minn) 2023; 29:566-583. [PMID: 37039410 DOI: 10.1212/con.0000000000001239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Pediatric cerebrovascular disease is one of the leading causes of death and disability in children. Survivors of childhood stroke and their families are often left to cope with long-lasting sequelae, such as barriers to school reentry and long-term challenges in attaining independence as adults. Because childhood stroke is rare and providers may not be familiar with the disorder, this article reviews the risk factors, acute management, and sequelae of ischemic stroke in children. LATEST DEVELOPMENTS High-quality evidence has resulted in an organized approach to emergent treatment of ischemic stroke in adults, but most front-line providers are less prepared for emergent stroke management in children. The level of evidence for reperfusion therapies in children remains low but is growing. Thrombolysis and thrombectomy are sometimes considered for hyperacute treatment of stroke in children. Readiness for pediatric stroke at regional centers should include an organized approach to pediatric stroke triage and management based on extrapolation from adult stroke trials, expert consensus, and emerging pediatric studies. ESSENTIAL POINTS This review provides up-to-date information about ischemic stroke risk factors and management in children. Preparation for rapid stroke diagnosis and management in children may improve outcomes.
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8
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Harrar DB, Sun LR, Segal JB, Lee S, Sansevere AJ. Neuromonitoring in Children with Cerebrovascular Disorders. Neurocrit Care 2023; 38:486-503. [PMID: 36828980 DOI: 10.1007/s12028-023-01689-2] [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: 04/29/2022] [Accepted: 01/31/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Cerebrovascular disorders are an important cause of morbidity and mortality in children. The acute care of a child with an ischemic or hemorrhagic stroke or cerebral sinus venous thrombosis focuses on stabilizing the patient, determining the cause of the insult, and preventing secondary injury. Here, we review the use of both invasive and noninvasive neuromonitoring modalities in the care of pediatric patients with arterial ischemic stroke, nontraumatic intracranial hemorrhage, and cerebral sinus venous thrombosis. METHODS Narrative review of the literature on neuromonitoring in children with cerebrovascular disorders. RESULTS Neuroimaging, near-infrared spectroscopy, transcranial Doppler ultrasonography, continuous and quantitative electroencephalography, invasive intracranial pressure monitoring, and multimodal neuromonitoring may augment the acute care of children with cerebrovascular disorders. Neuromonitoring can play an essential role in the early identification of evolving injury in the aftermath of arterial ischemic stroke, intracranial hemorrhage, or sinus venous thrombosis, including recurrent infarction or infarct expansion, new or recurrent hemorrhage, vasospasm and delayed cerebral ischemia, status epilepticus, and intracranial hypertension, among others, and this, is turn, can facilitate real-time adjustments to treatment plans. CONCLUSIONS Our understanding of pediatric cerebrovascular disorders has increased dramatically over the past several years, in part due to advances in the neuromonitoring modalities that allow us to better understand these conditions. We are now poised, as a field, to take advantage of advances in neuromonitoring capabilities to determine how best to manage and treat acute cerebrovascular disorders in children.
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Affiliation(s)
- Dana B Harrar
- Division of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA.
| | - Lisa R Sun
- Divisions of Pediatric Neurology and Vascular Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J Bradley Segal
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Arnold J Sansevere
- Division of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
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Malone LA, Levy TJ, Peterson RK, Felling RJ, Beslow LA. Neurological and Functional Outcomes after Pediatric Stroke. Semin Pediatr Neurol 2022; 44:100991. [PMID: 36456032 DOI: 10.1016/j.spen.2022.100991] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/15/2022] [Accepted: 08/22/2022] [Indexed: 12/01/2022]
Abstract
Pediatric stroke results in life-long morbidity for many patients, but the outcomes can vary depending on factors such as age of injury, or mechanism, size, and location of stroke. In this review, we summarize the current understanding of outcomes in different neurological domains (eg, motor, cognitive, language) for children with stroke of different mechanisms (ie, arterial ischemic stroke, cerebral sinus venous thrombosis, and hemorrhagic stroke), but with a focus on World Health Organization International Classification for Functioning, Disability, and Health (ICF-CY) framework for measuring health and disability for children and youth. We describe outcomes for the population as a whole and certain factors that may further refine prognostication.
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Affiliation(s)
- Laura A Malone
- Kennedy Krieger Institute, Baltimore, MD; Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD; Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD.
| | - Todd J Levy
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Rachel K Peterson
- Kennedy Krieger Institute, Baltimore, MD; Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD
| | - Ryan J Felling
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Lauren A Beslow
- The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Seizure Burden, EEG, and Outcome in Neonates With Acute Intracranial Infections: A Prospective Multicenter Cohort Study. Pediatr Neurol 2022; 137:54-61. [PMID: 36270133 DOI: 10.1016/j.pediatrneurol.2022.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/11/2022] [Accepted: 09/09/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Limited data exist regarding seizure burden, electroencephalogram (EEG) background, and associated outcomes in neonates with acute intracranial infections. METHODS This secondary analysis was from a prospective, multicenter study of neonates enrolled in the Neonatal Seizure Registry with seizures due to intracranial infection. Sites used continuous EEG monitoring per American Clinical Neurophysiology Society guidelines. High seizure burden was defined a priori as seven or more EEG-confirmed seizures. EEG background was categorized using standardized terminology. Primary outcome was neurodevelopment at 24-months corrected age using Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA-FS). Secondary outcomes were postneonatal epilepsy and motor disability. RESULTS Twenty-seven of 303 neonates (8.9%) had seizures due to intracranial infection, including 16 (59.3%) bacterial, 5 (18.5%) viral, and 6 (22.2%) unknown. Twenty-three neonates (85%) had at least one subclinical seizure. Among 23 children with 24-month follow-up, the WIDEA-FS score was, on average, 23 points lower in children with high compared with low seizure burden (95% confidence interval, [-48.4, 2.1]; P = 0.07). After adjusting for gestational age, infection etiology, and presence of an additional potential acute seizure etiology, the effect size remained unchanged (β = -23.8, P = 0.09). EEG background was not significantly associated with WIDEA-FS score. All children with postneonatal epilepsy (n = 4) and motor disability (n = 5) had high seizure burden, although associations were not significant. CONCLUSION High seizure burden may be associated with worse neurodevelopment in neonates with intracranial infection and seizures. EEG monitoring can provide useful management and prognostic information in this population.
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Hashish M, Bassiouny MR. Neonatal seizures: stepping outside the comfort zone. Clin Exp Pediatr 2022; 65:521-528. [PMID: 35381172 PMCID: PMC9650361 DOI: 10.3345/cep.2022.00115] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/22/2022] [Indexed: 11/27/2022] Open
Abstract
Seizures are the most common neurological disorders in newborns. Managing neonatal seizures is challenging, especially for neurologists who are not neonatal specialists. Acute brain injury during ischemic insult is a key component of seizure occurrence, while genetic and metabolic disorders play less prevalent but more severe roles. The diagnosis of neonatal seizure is ambiguous, as the subjective differentiation between seizure and nonepileptic events is difficult; therefore, electrographic recording is the gold standard for diagnosis. The detection of electrographic seizures by neonatologists is currently facilitated by amplitude-integrated electroencephalography availability in many neonatal intensive care units. Although it is less sensitive than conventional electroencephalography, it is better to record all risky neonates to filter the abnormal events as early as possible to enable the initiation of dedicated therapy at proper dose and time and facilitate the initial response to antiepileptic drugs. This, in turn, helps maintain the balance between unnecessary drug use and their neurotoxic effects. Moreover, the early treatment of electrographic seizures plays a vital role in the suppression of subsequent abnormal brain electricity (status epilepticus) and shortening the hospital stay. An explicit understanding of seizure etiology and pathophysiology should direct attention to the proper prescription of short- and long-term antiepileptic medications to solve the challenging issue of whether neonatal seizures progress to postneonatal epilepsy and long-term cognitive deficits. This review addresses recent updates in different aspects of neonatal seizures, particularly electrographic discharge, including their definition, etiology, classification, diagnosis, management, and neurodevelopmental outcomes.
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Affiliation(s)
- Menna Hashish
- Neonatal Intensive Care Unit, Mansoura University Children's Hospital, Mansoura, Egypt
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12
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Acute Hospital Management of Pediatric Stroke. Semin Pediatr Neurol 2022; 43:100990. [PMID: 36344020 DOI: 10.1016/j.spen.2022.100990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 08/13/2022] [Accepted: 08/14/2022] [Indexed: 11/24/2022]
Abstract
The field of pediatric stroke has historically been hampered by limited evidence and small patient cohorts. However the landscape of childhood stroke is rapidly changing due in part to increasing awareness of the importance of pediatric stroke and the emergence of dedicated pediatric stroke centers, care pathways, and alert systems. Acute pediatric stroke management hinges on timely diagnosis confirmed by neuroimaging, appropriate consideration of recanalization therapies, implementation of neuroprotective measures, and attention to secondary prevention. Because pediatric stroke is highly heterogenous in etiology, management strategies must be individualized. Determining a child's underlying stroke etiology is essential to appropriately tailoring hyperacute stroke management and determining best approach to secondary prevention. Herein, we review the methods of recognition, diagnosis, management, current knowledge gaps and promising research for pediatric stroke.
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Markovic I, Milenkovic Z, Jocic-Jakubi B, Futaisi AA, Kakaria KA, Walli Y. Stroke in sickle cell disease in association with bilateral absence of the internal carotid arteries. Case report. BMC Neurol 2022; 22:182. [PMID: 35581570 PMCID: PMC9112539 DOI: 10.1186/s12883-022-02702-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 05/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background Congenital absence of the internal carotid artery (ICA) is a highly infrequent congenital incidence and occurs in less than 0.01% of the population; bilateral absence is exceedingly rare, diagnosed below 10% of the unilateral absence of the ICA. Sickle cell disease (SCD) is a serious disorder and carries a high risk of stroke. Case presentation We present a five-year-old child with SCD who experienced an ischemic stroke episode with epileptic seizures. Neuroimaging revealed the agenesis of both ICAs. The frequency, embryology, and collateral pathway of the vascular anomaly as the clinical presentation, of this rare hematologic disease, are discussed. Conclusions Sickle cell disease (SCD) carries a high risk of stroke. Congenital absence of ICA occurs in less than 0.01% of the population; bilateral absence is diagnosed below 10% of the unilateral absence of the ICA.
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Affiliation(s)
- Ivana Markovic
- IvanaMarkovic, Sultan Qaboos University Hospital, Radiology Department, Muscat, Oman
| | - Zoran Milenkovic
- General Hospital "Sava Surgery", Kej 29 Decembar 2, Niš, 18000, Serbia.
| | | | - Amna Al Futaisi
- Hospital, Child Health, Sultan Qaboos University Hospital, College of Medicine and Health Sciences, Muscat, Oman
| | - Kakaria Anupam Kakaria
- Department of Radiology and Molecular Imaging, Sultan Qaboos University Hospital, Muscat, Oman
| | - Yasser Walli
- Child Health Department, Sultan Qaboos University Hospital, Muscat, Oman
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Sundelin H, Söderling J, Bang P, Bolk J. Risk of Autism After Pediatric Ischemic Stroke: A Nationwide Cohort Study. Neurology 2022; 98:e1953-e1963. [PMID: 35314504 PMCID: PMC9141625 DOI: 10.1212/wnl.0000000000200253] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 02/04/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Ischemic stroke increases the risk of neurodevelopmental disorders; however, the risk of autism is not thoroughly explored. Our aim was to evaluate risk of autism and risk factors for autism in children with pediatric ischemic stroke and in their first-degree relatives. METHODS In this cohort study, individuals with ischemic stroke from 1969 to 2016, <18 years of age, alive 1 week after stroke, and without prior autism were identified in Swedish national registers. Ten matched controls per index individual and all first-degree relatives of index individuals and controls were identified. Conditional Cox regression was used to calculate the risk of autism. Unconditional logistic regression was performed to analyze sex, gestational age, age at stroke diagnoses, comorbid adverse motor outcome, comorbid epilepsy, and a sibling with autism as risk factors for autism in children with ischemic stroke. RESULTS Of the 1,322 index individuals, 46 (3.5%) were diagnosed with autism compared to 161 (1.2%) controls (adjusted hazard ratio [aHR] 3.02, 95% CI 2.15-4.25). There was no significant difference in risk of autism according to age at stroke: perinatal (aHR 2.69, 95% CI 1.44-5.03) and childhood stroke (aHR 3.18, 95% CI 2.12-4.78). The increased risk remained after exclusion of children born preterm or small for gestational age (aHR 3.78, 95% CI 2.55-5.60) and when children with stroke diagnosed from 1997 to 2014 were analyzed (aHR 2.91, 95% CI = 1.95-4.35). Compared to controls, the risk of autism was increased in individuals with ischemic stroke and comorbid epilepsy (aHR 7.05, 95% CI 3.74-13.30), as well as adverse motor outcome (aHR 4.28, 95% CI 2.44-7.51). When individuals with adverse motor outcome and epilepsy were censored, the risk of autism was still increased (aHR 2.37, 95% CI 1.45-3.85). Sex, gestational age, and having a sibling with autism were not associated with autism in individuals with pediatric ischemic stroke. DISCUSSION An increased risk of autism was seen after pediatric ischemic stroke, particularly in individuals with comorbid epilepsy, and could not be explained by being born preterm or small for gestational age. The risk was increased also in individuals free from epilepsy and adverse motor outcome, implying that all children with ischemic stroke should be readily screened for autism if the disorder is suspected.
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Affiliation(s)
- Heléne Sundelin
- From the Department of Women's and Children's Health (H.S.), Neuropediatric Unit, Karolinska University Hospital; Department of Medicine Solna (J.S., J.B.), Clinical Epidemiology Division, Karolinska Institutet, Stockholm; Department of Biomedical and Clinical Sciences (H.S., P.B.), Division of Children's and Women's Health, Linköping University; Department of Clinical Science and Education Södersjukhuset (J.B.); and Sachs' Children and Youth Hospital (J.B.), Stockholm, Sweden
| | - Jonas Söderling
- From the Department of Women's and Children's Health (H.S.), Neuropediatric Unit, Karolinska University Hospital; Department of Medicine Solna (J.S., J.B.), Clinical Epidemiology Division, Karolinska Institutet, Stockholm; Department of Biomedical and Clinical Sciences (H.S., P.B.), Division of Children's and Women's Health, Linköping University; Department of Clinical Science and Education Södersjukhuset (J.B.); and Sachs' Children and Youth Hospital (J.B.), Stockholm, Sweden
| | - Peter Bang
- From the Department of Women's and Children's Health (H.S.), Neuropediatric Unit, Karolinska University Hospital; Department of Medicine Solna (J.S., J.B.), Clinical Epidemiology Division, Karolinska Institutet, Stockholm; Department of Biomedical and Clinical Sciences (H.S., P.B.), Division of Children's and Women's Health, Linköping University; Department of Clinical Science and Education Södersjukhuset (J.B.); and Sachs' Children and Youth Hospital (J.B.), Stockholm, Sweden
| | - Jenny Bolk
- From the Department of Women's and Children's Health (H.S.), Neuropediatric Unit, Karolinska University Hospital; Department of Medicine Solna (J.S., J.B.), Clinical Epidemiology Division, Karolinska Institutet, Stockholm; Department of Biomedical and Clinical Sciences (H.S., P.B.), Division of Children's and Women's Health, Linköping University; Department of Clinical Science and Education Södersjukhuset (J.B.); and Sachs' Children and Youth Hospital (J.B.), Stockholm, Sweden
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15
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Sundelin HEK, Tomson T, Zelano J, Söderling J, Bang P, Ludvigsson JF. Pediatric Ischemic Stroke and Epilepsy: A Nationwide Cohort Study. Stroke 2021; 52:3532-3540. [PMID: 34470493 DOI: 10.1161/strokeaha.121.034796] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background and Purpose The risk of epilepsy after stroke has not been thoroughly explored in pediatric ischemic stroke. We examined the risk of epilepsy in children with ischemic stroke as well as in their first-degree relatives. Methods In Swedish National Registers, we identified 1220 children <18 years with pediatric ischemic stroke diagnosed 1969 to 2016, alive 7 days after stroke and with no prior epilepsy. We used 12 155 age- and sex-matched individuals as comparators. All first-degree relatives to index individuals and comparators were also identified. The risk of epilepsy was estimated in children with ischemic stroke and in their first-degree relatives using Cox proportional hazard regression model. Results Through this nationwide population-based study, 219 (18.0%) children with ischemic stroke and 91 (0.7%) comparators were diagnosed with epilepsy during follow-up corresponding to a 27.8-fold increased risk of future epilepsy (95% CI, 21.5–36.0). The risk of epilepsy was still elevated after 20 years (hazard ratio [HR], 7.9 [95% CI, 3.3–19.0]), although the highest HR was seen in the first 6 months (HR, 119.4 [95% CI, 48.0–297.4]). The overall incidence rate of epilepsy was 27.0 per 100 000 person-years (95% CI, 21.1–32.8) after ischemic stroke diagnosed ≤day 28 after birth (perinatal) and 11.6 per 100 000 person-years (95% CI, 9.6–13.5) after ischemic stroke diagnosed ≥day 29 after birth (childhood). Siblings and parents, but not offspring, to children with ischemic stroke were at increased risk of epilepsy (siblings: HR, 1.64 [95% CI, 1.08–2.48] and parents: HR, 1.41 [95% CI, 1.01–1.98]). Conclusions The risk of epilepsy after ischemic stroke in children is increased, especially after perinatal ischemic stroke. The risk of epilepsy was highest during the first 6 months but remained elevated even 20 years after stroke which should be taken into account in future planning for children affected by stroke.
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Affiliation(s)
- Heléne E K Sundelin
- Division of Children's and Women's Health, Department of Biomedical and Clinical Sciences, Linköping University, Sweden (H.E.K.S., P.B.).,Neuropediatric Unit, Department of Women's and Children's Health, Karolinska University Hospital (H.E.K.S.), Karolinska Institutet, Stockholm, Sweden
| | - Torbjörn Tomson
- Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Johan Zelano
- Sahlgrenska University Hospital, Institute of Neuroscience and Physiology, Gothenburg University, Sweden (J.Z.)
| | - Jonas Söderling
- Clinical Epidemiology Division, Department of Medicine (Solna) (J.S.), Karolinska Institutet, Stockholm, Sweden
| | - Peter Bang
- Division of Children's and Women's Health, Department of Biomedical and Clinical Sciences, Linköping University, Sweden (H.E.K.S., P.B.)
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics (J.F.L.), Karolinska Institutet, Stockholm, Sweden.,Department of Pediatrics, Örebro University Hospital, Sweden (J.F.L.).,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, United Kingdom (J.F.L.).,Department of Medicine, Columbia University, NY (J.F.L.)
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16
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Sporns PB, Fullerton HJ, Lee S, Kirton A, Wildgruber M. Current treatment for childhood arterial ischaemic stroke. THE LANCET CHILD & ADOLESCENT HEALTH 2021; 5:825-836. [PMID: 34331864 DOI: 10.1016/s2352-4642(21)00167-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/18/2021] [Accepted: 05/24/2021] [Indexed: 12/23/2022]
Abstract
Paediatric arterial ischaemic stroke is an important cause of neurological morbidity in children, with consequences including motor disorders, intellectual impairment, and epilepsy. The causes of paediatric arterial ischaemic stroke are unique compared with those associated with stroke in adulthood. The past decade has seen substantial advances in paediatric stroke research and clinical care, but many unanswered questions and controversies remain. Shortage of prospective evidence for the use of recanalisation therapies in patients with paediatric stroke has resulted in little standardisation of disease management. Substantial time delays in diagnosis and treatment continue to challenge best possible care. In this Review, we highlight on some of the most pressing and productive aspects of research in the treatment of arterial ischaemic stroke in children, including epidemiology and cause, rehabilitation, secondary stroke prevention, and treatment updates focusing on advances in hyperacute therapies such as intravenous thrombolysis, mechanical thrombectomy, and critical care. Finally, we provide a future perspective for improving outcomes and quality of life for affected children and their families.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heather J Fullerton
- Departments of Neurology and Pediatrics, Weill Institute of Neurosciences, University of California at San Francisco, San Francisco, CA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Adam Kirton
- Department of Pediatrics and Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Moritz Wildgruber
- Department of Radiology, University Hospital Munich, LMU Munich, Munich, Germany.
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17
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Vojcek E, Jermendy A, Laszlo AM, Graf R, Rudas G, Berenyi M, Seri I. The role of brain territorial involvement and infection/inflammation in the long-term outcome of neonates with arterial ischemic stroke: A population-based cohort study. Early Hum Dev 2021; 158:105393. [PMID: 34034089 DOI: 10.1016/j.earlhumdev.2021.105393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 05/08/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Neonatal arterial ischemic stroke (NAIS) carries the risk of significant long-term neurodevelopmental burden on survivors. AIMS To assess the long-term neurodevelopmental outcome of term neonates diagnosed with NAIS and investigate the associations among brain territorial involvement on MRI, clinical risk factors and neurodevelopmental outcomes. STUDY DESIGN Population-based cohort study. SUBJECTS Seventy-nine term neonates with NAIS confirmed by MRI born between 2007 and 2017. OUTCOME MEASURES Long-term neurodevelopmental outcome assessed using the Bayley Scales of Infant Development-II, the Brunet-Lézine test and the Binet Intelligence scales-V. RESULTS Follow-up was available in 70 (89%) of the subjects enrolled, at a median age of 60 months [IQR: 35-84]. Normal neurodevelopmental outcome was found in 43% of the patients. In a multivariable model, infants with main MCA stroke had an increased risk for overall adverse outcome (OR: 9.1, 95% CI: 1.7-48.0) and a particularly high risk for cerebral palsy (OR: 55.9, 95% CI: 7.8-399.2). The involvement of the corticospinal tract without extensive stroke also increased the risk for cerebral palsy/fine motor impairment (OR: 13.5, 95% CI: 2.4-76.3). Multiple strokes were associated with epilepsy (OR: 9.5, 95% CI: 1.0-88.9) and behavioral problems (OR: 4.4, 95% CI: 1.1-17.5) and inflammation/infection was associated with cerebral palsy (OR: 9.8, 95% CI: 1.4-66.9), cognitive impairment (OR: 9.2, 95% CI: 1.8-47.8) and epilepsy (OR: 10.3, 95% CI: 1.6-67.9). CONCLUSIONS Main MCA stroke, involvement of the corticospinal tract, multiple strokes and inflammation/infection were independent predictors of adverse outcome, suggesting that the interplay of stroke territorial involvement and clinical risk factors influence the outcome of NAIS.
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Affiliation(s)
- Eszter Vojcek
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary; Department of Pediatrics, Saint John Hospital and North-Buda Unified Hospitals, Budapest, Hungary.
| | - Agnes Jermendy
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Anna M Laszlo
- Institute of Mathematics and Base Sciences, Szent István University, Budapest, Hungary
| | - Rozsa Graf
- Department of Rehabilitation, Szent János Hospital and North Buda United Hospitals, Budapest, Hungary
| | - Gabor Rudas
- Department of Neuroradiology, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Marianne Berenyi
- Department of Developmental Neurology, Saint Margaret Hospital, Budapest, Hungary
| | - Istvan Seri
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary; Department of Pediatrics, Children's Hospital Los Angeles, University of Southern California, Los Angeles, United States
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18
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Lauzier DC, Galardi MM, Guilliams KP, Goyal MS, Amlie-Lefond C, Hallam DK, Kansagra AP. Pediatric Thrombectomy: Design and Workflow Lessons From Two Experienced Centers. Stroke 2021; 52:1511-1519. [PMID: 33691502 DOI: 10.1161/strokeaha.120.032268] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Endovascular thrombectomy has played a major role in advancing adult stroke care and may serve a similar role in pediatric stroke care. However, there is a need to develop better evidence and infrastructure for pediatric stroke care. In this work, we review 2 experienced pediatric endovascular thrombectomy programs and examine key design features in both care environments, including a formalized protocol and workflow, integration with an adult endovascular thrombectomy workflow, simplification and automation of workflow steps, pediatric adaptations of stroke imaging, advocacy of pediatric stroke care, and collaboration between providers, among others. These essential features transcend any single hospital environment and may provide an important foundation for other pediatric centers that aim to enhance the care of children with stroke.
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Affiliation(s)
- David C Lauzier
- Mallinckrodt Institute of Radiology (D.C.L., M.S.G., A.P.K.), Washington University School of Medicine, St Louis, MO
| | - Maria M Galardi
- Department of Neurology (M.M.G., K.P.G., M.S.G., A.P.K.), Washington University School of Medicine, St Louis, MO
| | - Kristin P Guilliams
- Department of Neurology (M.M.G., K.P.G., M.S.G., A.P.K.), Washington University School of Medicine, St Louis, MO.,Department of Pediatrics (K.P.G.), Washington University School of Medicine, St Louis, MO
| | - Manu S Goyal
- Mallinckrodt Institute of Radiology (D.C.L., M.S.G., A.P.K.), Washington University School of Medicine, St Louis, MO.,Department of Neurology (M.M.G., K.P.G., M.S.G., A.P.K.), Washington University School of Medicine, St Louis, MO.,Department of Neuroscience (M.S.G.), Washington University School of Medicine, St Louis, MO
| | | | - Danial K Hallam
- Department of Radiology (D.K.H.), University of Washington, Seattle.,Department of Neurological Surgery (D.K.H.), University of Washington, Seattle
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology (D.C.L., M.S.G., A.P.K.), Washington University School of Medicine, St Louis, MO.,Department of Neurology (M.M.G., K.P.G., M.S.G., A.P.K.), Washington University School of Medicine, St Louis, MO.,Department of Neurological Surgery (A.P.K.), Washington University School of Medicine, St Louis, MO
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19
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Pisani F, Fusco C, Nagarajan L, Spagnoli C. Acute symptomatic neonatal seizures, brain injury, and long-term outcome: The role of neuroprotective strategies. Expert Rev Neurother 2020; 21:189-203. [PMID: 33176104 DOI: 10.1080/14737175.2021.1848547] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Neonatal seizures are frequent but underdiagnosed manifestations of acute brain dysfunction and an important contributor to unfavorable outcomes. Etiology and severity of brain injury are the single strongest outcome determinants. AREAS COVERED The authors will discuss the prognostic role of acute symptomatic seizures versus brain injury and the main neuroprotective and neurorestorative strategies for full-term and preterm infants. EXPERT OPINION Prolonged acute symptomatic seizures likely contribute to long-term outcomes by independently adding further brain injury to initial insults. Correct timing and dosing of therapeutic interventions, depending on etiology and gestational ages, need careful evaluation. Although promising strategies are under study, the only standard of care is whole-body therapeutic hypothermia in full-term newborns with hypoxic-ischemic encephalopathy.
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Affiliation(s)
- Francesco Pisani
- Child Neuropsychiatric Unit, Medicine and Surgery Department, University of Parma , Parma, Italy
| | - Carlo Fusco
- Child Neurology Unit, Department of Paediatrics, Azienda USL-IRCCS Di Reggio Emilia , Reggio Emilia, Italy
| | - Lakshmi Nagarajan
- Department of Neurology, Perth Children's Hospital, University of Western Australia , Perth, Australia
| | - Carlotta Spagnoli
- Child Neurology Unit, Department of Paediatrics, Azienda USL-IRCCS Di Reggio Emilia , Reggio Emilia, Italy
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20
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Polat İ, Yiş U, Ayanoğlu M, Okur D, Edem P, Paketçi C, Bayram E, Hız Kurul S. Risk Factors of Post-Stroke Epilepsy in Children; Experience from a Tertiary Center and a Brief Review of the Literature. J Stroke Cerebrovasc Dis 2020; 30:105438. [PMID: 33197802 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105438] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 10/02/2020] [Accepted: 10/29/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Acute seizures and post-stroke epilepsy have been reported more frequently in patients with pediatric stroke than adults. Acute seizures in the first days of a stroke may deteriorate stroke and ischemia-related neurodegeneration and contribute to the development of post-stroke epilepsy. In this study, we aimed to investigate risk factors for the development of post-stroke epilepsy in children with arterial ischemic stroke. MATERIALS AND METHODS We recruited 86 children with arterial ischemic stroke. We analyzed variables, including age at admission, gender, complaints at presentation, focal or diffuse neurologic signs, neurologic examination findings, laboratory investigations that were conducted at admission with stroke (complete blood cell count, biochemical-infectious-metabolic-immunological investigations, vitamin B12 levels, vitamin D levels), neuroimaging results, etiologies, time of the first seizure, time of remote seizures, and development of neurologic deficit retrospectively. Seizures during the first six hours after stroke onset were defined as 'very early seizures'. 'Early seizures' were referred to seizures during the first 48 h. Patients who experienced two or more seizures that occurred after the acute phase of seizures were classified as 'epileptic.' A binary logistic regression analysis was used to estimate risk factors. RESULTS An acute seizure was detected in 59% and post-stroke epilepsy developed in 41% of our cohort. Binary logistic regression analysis demonstrated that 'very early seizures' increased epilepsy risk six-fold. Epilepsy was 16 times higher in patients with 'early seizures'. Low vitamin D levels were defined as a risk factor for post-stroke epilepsy. CONCLUSION Seizures in the very early period (within the first six hours) are the most significant risk factors for the development of post-stroke epilepsy Further studies regarding seizure prevention and neuroprotective therapies are needed because post-stroke epilepsy will affect long term prognosis in patients with pediatric stroke.
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Affiliation(s)
- İpek Polat
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Uluç Yiş
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Müge Ayanoğlu
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Derya Okur
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Pınar Edem
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Cem Paketçi
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Erhan Bayram
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
| | - Semra Hız Kurul
- Department of Pediatric Neurology, Dokuz Eylul University, Faculty of Medicine, İzmir, Narlıdere, Turkey.
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21
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Pisani F, Fusco C, Spagnoli C. Linking acute symptomatic neonatal seizures, brain injury and outcome in preterm infants. Epilepsy Behav 2020; 112:107406. [PMID: 32889509 DOI: 10.1016/j.yebeh.2020.107406] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/06/2020] [Accepted: 08/09/2020] [Indexed: 11/29/2022]
Abstract
Neonatal seizures (NS) are the most frequent sign of neurological dysfunction in newborn infants. With increased survival of preterm neonates, the current clinical focus has shifted from preventing death to improving long-term neurological outcome. In the context of acute symptomatic NS, the main negative prognostic factors include etiology, and severity of brain injury, but also prolonged seizures and especially status epilepticus. However, the reasons for the detrimental contribution of seizures to outcome are still unclear, and evidence has been collected both in favor of seizures being an epiphenomenon of brain injury and of independently contributing to further damage. In this narrative focused review, we will discuss both hypotheses, with special emphasis on data relating to preterm infants. We will also identify present controversies and possible future lines of research.
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Affiliation(s)
- Francesco Pisani
- Child Neuropsychiatric Unit, Medicine & Surgery Department, Neuroscience Section, University of Parma, Italy.
| | - Carlo Fusco
- Department of Pediatrics, Child Neurology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy.
| | - Carlotta Spagnoli
- Department of Pediatrics, Child Neurology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy.
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22
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Slim M, Fox CK, Friefeld S, Dlamini N, Westmacott R, Moharir M, MacGregor D, deVeber G. Validation of the pediatric stroke outcome measure for classifying overall neurological deficit. Pediatr Res 2020; 88:234-242. [PMID: 32179868 DOI: 10.1038/s41390-020-0842-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 02/06/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND The pediatric stroke outcome measure (PSOM) is a standardized, disease-specific outcome measure. We aimed to validate the overall classification of neurological deficit severity using PSOM. METHODS We identified 367 neonates/children with arterial ischemic stroke (AIS) (Derivation Cohort). We analyzed the PSOM subscales (scored as 0 [no deficit], 0.5 [minimal/mild deficit; normal function], 1 [moderate deficit; slowing function], or 2 [severe deficit; missing function]) to derive severity levels using latent class analysis (LCA). We validated a severity classification scheme (PSOM-SCS) in: (a) children who had Pediatric Evaluation of Disability Inventory (PEDI; n = 63) and/or the Pediatric Quality-of-Life Inventory (PedsQL; n = 97) scored; and (b) an external cohort (AIS; n = 102) with concurrently scored modified Rankin Scale (mRS), King's Outcome Scale for Childhood Head-Injury (KOSCHI) and PSOM. RESULTS Within the Derivation Cohort, LCA identified three severity levels: "normal/mild," "moderate," and "severe" (83.7%, 13.3%, and 3%, respectively). We developed severity classification based on PSOM subscale scores: "normal/mild"-normal function in all domains or slowing in one domain, "moderate"-slowing in ≥2 domains or missing function in one domain, and "severe"-missing function in ≥2 domains or slowing in ≥1 plus missing in one domain. PEDI and PedsQL both differed significantly across the severity groups. PSOM-SCS displayed high concordance with mRS (agreement coefficient [AC2] = 0.88) and KOSCHI (AC2 = 0.79). CONCLUSION The PSOM-SCS constitutes a valid tool for classifying overall neurological severity emphasizing function and encompassing the full range of severity in pediatric stroke. IMPACT Arithmetic summing of the PSOM subscales scores to assess severity classification is inadequate.The prior severity classification using PSOM overestimates poor outcomes.Three distinct severity profiles using PSOM subscales are identified.The PSOM-SCS is in moderate to excellent agreement with other disability measures.PSOM-SCS offers a valid tool for classifying the overall neurological deficit severity.
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Affiliation(s)
- Mahmoud Slim
- Department of Pediatrics, Division of Neurology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Christine K Fox
- Departments of Neurology and Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Sharon Friefeld
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada
| | - Nomazulu Dlamini
- Department of Pediatrics, Division of Neurology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Robyn Westmacott
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mahendranath Moharir
- Department of Pediatrics, Division of Neurology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Daune MacGregor
- Department of Pediatrics, Division of Neurology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Gabrielle deVeber
- Department of Pediatrics, Division of Neurology, The Hospital for Sick Children, Toronto, ON, Canada.
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23
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Mineyko A, Kirton A, Billinghurst L, Tatishvili NN, Wintermark M, deVeber G, Fox C. Seizures and Outcome One Year After Neonatal and Childhood Cerebral Sinovenous Thrombosis. Pediatr Neurol 2020; 105:21-26. [PMID: 31882182 PMCID: PMC7071986 DOI: 10.1016/j.pediatrneurol.2019.08.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/16/2019] [Accepted: 08/20/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pediatric cerebral sinovenous thrombosis is a treatable cause of brain injury, acute symptomatic seizures, and remote epilepsy. Our objective was to prospectively study epilepsy and outcomes in neonates and children one year after cerebral sinovenous thrombosis diagnosis. METHODS Patients with cerebral sinovenous thrombosis were enrolled prospectively from 21 international sites through the Seizures in Pediatric Stroke Study. Clinical data, including acute symptomatic seizures and cerebral sinovenous thrombosis risk factors, were collected at diagnosis. A neuroradiologist who was unaware of the diagnosis reviewed acute imaging. At one year, outcomes including seizure recurrence, epilepsy diagnosis, antiepileptic drug use, and modified Engel score were collected. Outcomes were assessed using the modified Rankin score and the King's Outcome Scale for Childhood Head Injury. RESULTS Twenty-four participants with cerebral sinovenous thrombosis were enrolled (67% male, 21% neonates). Headache was the most common presenting symptom in non-neonates (47%, nine of 19). Nine (37.5%) presented with acute symptomatic seizures. Six (25%; 95% confidence interval, 10% to 47%) developed epilepsy by one-year follow-up. No clinical predictors associated with epilepsy were identified. King's Outcome Scale for Childhood Head Injury and modified Rankin scores at one year were favorable in 71%. Half of the patients who developed epilepsy (three of six) did not have infarcts, hemorrhage, or seizures identified during the acute hospitalization. CONCLUSION Our study provides a prospective estimate that epilepsy occurs in approximately one-quarter of patients by one year after diagnosis of cerebral sinovenous thrombosis. Later epilepsy can develop in the absence of acute seizures or parenchymal injury associated with the acute presentation.
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Affiliation(s)
- Aleksandra Mineyko
- Section of Neurology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Section of Neurology, Department Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Adam Kirton
- Section of Neurology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Section of Neurology, Department Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lori Billinghurst
- Division of Neurology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nana Nino Tatishvili
- Department of Neurosciences, D. Tvildiani Medical University, M. Iashvili Central Children Hospital, Tbilis, Georgia
| | - Max Wintermark
- Neuroimaging and Neurointervention Division, Department of Radiology, Stanford University Hospital, Stanford, California
| | - Gabrielle deVeber
- Neurology Division, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Christine Fox
- Department of Neurology, University of California San Francisco, San Francisco, California; Department of Pediatrics, University of California San Francisco, San Francisco, California
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Liu X, Feng Z, Du L, Huang Y, Ge J, Deng Y, Mei Z. The Potential Role of MicroRNA-124 in Cerebral Ischemia Injury. Int J Mol Sci 2019; 21:ijms21010120. [PMID: 31878035 PMCID: PMC6981583 DOI: 10.3390/ijms21010120] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 01/01/2023] Open
Abstract
Cerebral ischemia injury, the leading cause of morbidity and mortality worldwide, initiates sequential molecular and cellular pathologies that underlie ischemic encephalopathy (IE), such as ischemic stroke, Alzheimer disease (AD), Parkinson's disease (PD), epilepsy, etc. Targeted therapeutic treatments are urgently needed to tackle the pathological processes implicated in these neurological diseases. Recently, accumulating studies demonstrate that microRNA-124 (miR-124), the most abundant miRNA in brain tissue, is aberrant in peripheral blood and brain vascular endothelial cells following cerebral ischemia. Importantly, miR-124 regulates a variety of pathophysiological processes that are involved in the pathogenesis of age-related IE. However, the role of miR-124 has not been systematically illustrated. Paradoxically, miR-124 exerts beneficial effects in the age-related IE via regulating autophagy, neuroinflammation, oxidative stress, neuronal excitability, neurodifferentiation, Aβ deposition, and hyperphosphorylation of tau protein, while it may play a dual role via regulating apoptosis and exerts detrimental effects on synaptic plasticity and axonal growth. In the present review, we thus focus on the paradoxical roles of miR-124 in age-related IE, as well as the underlying mechanisms. A great understanding of the effects of miR-124 on the hypoxic-ischemic brain will open new avenues for therapeutic approaches to protect against cerebral ischemia injury.
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Affiliation(s)
- Xiaolu Liu
- Third-Grade Pharmacological Laboratory on Chinese Medicine Approved by State Administration of Traditional Chinese Medicine, Medical College of China Three Gorges University, Yichang 443002, China; (X.L.); (Z.F.); (L.D.); (Y.H.)
| | - Zhitao Feng
- Third-Grade Pharmacological Laboratory on Chinese Medicine Approved by State Administration of Traditional Chinese Medicine, Medical College of China Three Gorges University, Yichang 443002, China; (X.L.); (Z.F.); (L.D.); (Y.H.)
| | - Lipeng Du
- Third-Grade Pharmacological Laboratory on Chinese Medicine Approved by State Administration of Traditional Chinese Medicine, Medical College of China Three Gorges University, Yichang 443002, China; (X.L.); (Z.F.); (L.D.); (Y.H.)
| | - Yaguang Huang
- Third-Grade Pharmacological Laboratory on Chinese Medicine Approved by State Administration of Traditional Chinese Medicine, Medical College of China Three Gorges University, Yichang 443002, China; (X.L.); (Z.F.); (L.D.); (Y.H.)
| | - Jinwen Ge
- The Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, Hunan University of Chinese Medicine, Changsha 410208, China (Y.D.)
| | - Yihui Deng
- The Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, Hunan University of Chinese Medicine, Changsha 410208, China (Y.D.)
| | - Zhigang Mei
- Third-Grade Pharmacological Laboratory on Chinese Medicine Approved by State Administration of Traditional Chinese Medicine, Medical College of China Three Gorges University, Yichang 443002, China; (X.L.); (Z.F.); (L.D.); (Y.H.)
- The Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, Hunan University of Chinese Medicine, Changsha 410208, China (Y.D.)
- Correspondence:
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Amlie-Lefond C, Wainwright MS. Organizing for Acute Arterial Ischemic Stroke in Children. Stroke 2019; 50:3662-3668. [DOI: 10.1161/strokeaha.119.025497] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
| | - Mark S. Wainwright
- Division of Neurology, Seattle Children’s Hospital, University of Washington
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Zhao X, Li X, Ma Y, Zhu Y. The design of a homocysteine fluorescent probe based on Rhodamine B and its responsiveness in the serum of cerebral infarction patients. Exp Ther Med 2019; 18:2675-2680. [PMID: 31555369 DOI: 10.3892/etm.2019.7833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 05/16/2019] [Indexed: 11/06/2022] Open
Abstract
High levels of homocysteine (Hcy) is closely associated with the onset of cerebral infarction. The present study aimed to synthesize a novel Hcy probe based on Rhodamine B, named S1-4, a new compound that has not been previously reported. This probe exhibited good linear range under physiological fluid viscosity and pH; it has good selectivity for Hcy, and is able to avoid interference from other amino acids and metal ions. This probe can effectively measure the level of Hcy in the blood sera of healthy people and in patients with transient cerebral ischemia and cerebral infarction. However, satisfactory specificity and sensitivity to Hcy was not achieved according to receiver operating characteristic curve analysis. Overall, results from the present study suggested that following further optimization, this probe may be potentially applied in the diagnosis of cerebral infarction.
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Affiliation(s)
- Xiubao Zhao
- Department of Intensive Care Unit, Tianjin First Central Hospital, Tianjin 300192, P.R. China
| | - Xu Li
- Department of Clinical Laboratory, Tianjin Huanhu Hospital, Tianjin 300350, P.R. China
| | - Ying Ma
- Tianjin Key Laboratory on Technologies Enabling Development of Clinical Therapeutics and Diagnostics (Theranostics), School of Pharmacy, Tianjin Medical University, Tianjin 300070, P.R. China
| | - Yu Zhu
- Department of Clinical Laboratory, Tianjin Huanhu Hospital, Tianjin 300350, P.R. China
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Rattani A, Lim J, Mistry AM, Prablek MA, Roth SG, Jordan LC, Shannon CN, Naftel RP. Incidence of Epilepsy and Associated Risk Factors in Perinatal Ischemic Stroke Survivors. Pediatr Neurol 2019; 90:44-55. [PMID: 30409458 DOI: 10.1016/j.pediatrneurol.2018.08.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 08/23/2018] [Accepted: 08/28/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Epilepsy is a serious and often lifelong consequence of perinatal arterial ischemic stroke (PAIS). Variable incidences and risk factors for long-term epilepsy in PAIS have been reported. To determine the incidence of epilepsy in PAIS survivors and report factors associated with the risk of developing epilepsy, a meta-analysis and systematic review of prior publications was performed. METHODS We examined studies on perinatal or neonatal patients (≤28 days of life) with arterial ischemic strokes in which the development of epilepsy was reported. EMBASE and MEDLINE/PubMed databases were systematically searched in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. RESULTS A meta-analysis of 10 studies revealed a summary incidence of epilepsy in PAIS patients of 27.2% (95% confidence interval 16.6% to 41.4%) over a mean study duration of 10.4 years (range 1.5 to 17). More recent studies generally reported a lower epilepsy incidence. A systematic review identified seven possible risk factors for epilepsy in PAIS patients: hippocampal volume reduction, infarct on prenatal ultrasound, a modified Alberta Stroke Program Early Computed Tomography score ≥9, family history of seizures, cerebral palsy, and initial presentation with cognitive impairment or seizures. CONCLUSIONS About a third of children with PAIS will develop epilepsy. While seven possible risk factors have been reported, further research is warranted to confirm the strength of their association with the development of epilepsy.
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Affiliation(s)
- Abbas Rattani
- Loyola University Chicago Stritch School of Medicine, Maywood, Illinois; Surgical Outcomes Center for Kids, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Jaims Lim
- Surgical Outcomes Center for Kids, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Neurosurgery, University at Buffalo, Buffalo, New York
| | - Akshitkumar M Mistry
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marc A Prablek
- Surgical Outcomes Center for Kids, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Steven G Roth
- Surgical Outcomes Center for Kids, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chevis N Shannon
- Surgical Outcomes Center for Kids, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert P Naftel
- Surgical Outcomes Center for Kids, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Scavarda D, Cavalcante T, Trébuchon A, Lépine A, Villeneuve N, Girard N, McGonigal A, Milh M, Bartolomei F. Tailored suprainsular partial hemispherotomy: a new functional disconnection technique for stroke-induced refractory epilepsy. J Neurosurg Pediatr 2018; 22:601-609. [PMID: 30141751 DOI: 10.3171/2018.5.peds17709] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 05/22/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVEHemispherotomy is currently the most frequently performed surgical option for refractory epilepsy associated with large perinatal or childhood ischemic events. Such an approach may lead to good seizure control, but it has inherent functional consequences linked to the disconnection of functional cortices. The authors report on 6 consecutive patients who presented with severe epilepsy associated with hemiplegia due to stroke and who benefitted from a new, stereoelectroencephalography-guided partial disconnection technique.METHODSThe authors developed a new disconnection technique termed "tailored suprainsular partial hemispherotomy" (TSIPH). Disconnection always included premotor and motor cortex with variable anterior and posterior extent.RESULTSAt a mean follow-up of 28 months, there were no deaths and no patient had hydrocephalus. Motor degradation was observed in all patients in the 2 weeks after surgery, but all patients completely recovered. The 6 patients were seizure free (Engel class IA) at the last follow-up. No neuropsychological aggravation was observed.CONCLUSIONSTSIPH appears to be a conservative alternative to classic hemispherotomy, leading to favorable outcome in this series.
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Affiliation(s)
| | | | - Agnès Trébuchon
- 2Institut de Neurosciences des Systèmes, Aix Marseille Université; and
- 3Neurophysiologie Clinique
| | - Anne Lépine
- 4Neurologie Pédiatrique, and
- 5Hôpital Henri Gastaut, Marseille, France
| | | | | | - Aileen McGonigal
- 2Institut de Neurosciences des Systèmes, Aix Marseille Université; and
- 3Neurophysiologie Clinique
| | | | - Fabrice Bartolomei
- 2Institut de Neurosciences des Systèmes, Aix Marseille Université; and
- 3Neurophysiologie Clinique
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Fox CK, Jordan LC, Beslow LA, Armstrong J, Mackay MT, deVeber G. Children with post-stroke epilepsy have poorer outcomes one year after stroke. Int J Stroke 2018; 13:820-823. [PMID: 29956597 DOI: 10.1177/1747493018784434] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Epilepsy is a common complication of pediatric stroke. Aim In this study, we aim to measure the association between epilepsy and neurologic outcome after childhood arterial ischemic stroke. Methods Prospective cohort study of children (29 days-19 years) enrolled after an acute arterial ischemic stroke at 21 international pediatric stroke centers and followed to identify epilepsy. One year post-stroke, outcomes were scored using the examination-based Pediatric Stroke Outcome Measure (range = 0-10); higher values reflect greater disability. Ordinal logistic regression was used to measure the association of Pediatric Stroke Outcome Measure scores (categorized as 0-1, 1.5-3, 3.5-6, 6.5-10) with epilepsy. Results Investigators enrolled 86 children (median age = 6.1 years, interquartile range (IQR) = 1.4-12.2 years) with acute stroke. At 1 year, 18/80 (23%) remained on an anticonvulsant including 8/80 (10%) with epilepsy. Among the 70 with Pediatric Stroke Outcome Measure scored, the median was 0.5 (IQR = 0-1.5) for children without epilepsy ( n = 63), and 6 (IQR = 0.5-10) for children with epilepsy ( n = 7). In univariable analyses, poorer 1-year outcome was associated with middle cerebral artery stroke, cortical infarcts, hemorrhagic transformation, hospital disposition not to home, and epilepsy. In multivariable analysis, middle cerebral artery stroke (odds ratio (OR) = 4.9, 95% confidence intervals (CI) = 1.1-21.3) and epilepsy (OR = 24.1, CI = 1.5-380) remained associated with poorer outcome. Conclusions Children who developed epilepsy during the first year post-stroke had poorer neurologic outcomes than those without epilepsy.
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Affiliation(s)
- Christine K Fox
- 1 Neurology and Pediatrics Departments, University of California, San Francisco, San Francisco, CA, USA
| | - Lori C Jordan
- 2 Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lauren A Beslow
- 3 Division of Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Mark T Mackay
- 5 Department of Neurology, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Gabrielle deVeber
- 6 Neurology Division, Department of Pediatrics, Hospital for Sick Children, University of Toronto, ON, Canada
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Glass HC, Grinspan ZM, Shellhaas RA. Outcomes after acute symptomatic seizures in neonates. Semin Fetal Neonatal Med 2018; 23:218-222. [PMID: 29454756 DOI: 10.1016/j.siny.2018.02.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute symptomatic seizures are a common sign of neurological dysfunction and brain injury in neonates and occur in approximately one to three per 1000 live births. Seizures in neonates are usually a sign of underlying brain injury and, as such, are commonly associated with adverse outcomes. Neurological morbidities in survivors often co-occur; epilepsy, cerebral palsy, and intellectual disability often occur together in the most severely affected children. Risk factors for adverse outcome include prematurity, low Apgar scores, low pH on the first day of life, seizure onset <24 or >72 h after birth, abnormal neonatal neurological examination, abnormal neonatal electroencephalographic background, status epilepticus, and presence and pattern of brain injury (particularly deep gray or brainstem injury). Despite this list of potential indicators, accurate prediction of outcome in a given child remains challenging. There is great need for long-term, multicenter studies to examine risk factors for, and pathogenesis of, adverse outcomes following acute symptomatic seizures in neonates.
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Affiliation(s)
- Hannah C Glass
- Department of Neurology, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco, CA, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.
| | - Zachary M Grinspan
- Department of Healthcare Policy, Department of Research and Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Renée A Shellhaas
- Department of Pediatrics, Department of Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
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Outcomes following electrographic seizures and electrographic status epilepticus in the pediatric and neonatal ICUs. Curr Opin Neurol 2018; 30:156-164. [PMID: 28118303 DOI: 10.1097/wco.0000000000000425] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Increasing recognition of electrographic seizures and electrographic status epilepticus in critically ill neonates and children has highlighted the importance of identifying their potential contributions to neurological outcomes to guide optimal management. RECENT FINDINGS Recent studies in children and neonates have found an independent association between increasing seizure burden and worse short-term and long-term outcomes, even after adjusting for other important contributors to outcome such as seizure cause and illness severity. The risk of worse neurological outcome has been shown to increase above a seizure burden threshold of 12-13 min/h, which is considerably lower than the conventional definition of status epilepticus of 30 min/h. Randomized controlled trials in neonates have demonstrated that electroencephalography-targeted therapy can successfully reduce seizure burden, but due to their small size these trials have not been able to demonstrate that more aggressive electroencephalography-targeted treatment of both subclinical and clinical seizures results in improved outcome. SUMMARY Despite mounting evidence for an independent association between increasing seizure burden and worse outcome, further study is needed to determine whether early seizure identification and aggressive antiseizure treatment can improve neurodevelopmental outcomes.
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López-Espejo M, Hernández-Chávez M. Prevalence and Predictors of Long-Term Functional Impairment, Epilepsy, Mortality, and Stroke Recurrence after Childhood Stroke: A Prospective Study of a Chilean Cohort. J Stroke Cerebrovasc Dis 2017; 26:1646-1652. [PMID: 28476510 DOI: 10.1016/j.jstrokecerebrovasdis.2017.03.043] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 03/31/2017] [Accepted: 03/31/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND To evaluate the prevalence and predictors of long-term impairment, epilepsy, mortality, and recurrences after the first stroke in a cohort of Chilean children. METHODS A prospective study involving 98 children who suffered a first stroke and underwent follow-up for at least 3 years in a single center. Functional outcome was measured using the modified Rankin Scale for children. We utilized multivariate logistic regression models to estimate the odds ratios (ORs) for outcomes while adjusting for age, sex, and underlying conditions (significance <.05). RESULTS Stroke recurrences were present in 18 children and were strongly associated with arteriopathies (OR 8.11; CI 1.5-43). Of 26 children who died during the follow-up period, a significant proportion had a cardiopathy (OR 6.57; CI 1.3-32) or a chronic head and neck disease (OR 41.3; CI 3.5-490). Among 72 survivors (median age 1.49 years; 38 girls; mean follow-up time 4.85 years), 28 presented marked impairment; these children were younger (P = .019) and had more commonly arteriopathies (OR 9.33; CI 1.7-51) and epilepsy (OR 10.5; CI 3.1-36) as compared to survivors without disabilities. Cumulative epilepsy prevalence was 55.6%; children with epilepsy were younger (P = .037) and had more commonly acute symptomatic seizures (OR 12.16; CI 2.93-50.4) as compared to survivors without epilepsy. CONCLUSIONS The prevalence of long-term adverse outcomes after childhood stroke is high and does not differ from other geographical and racial groups. Younger age, acute seizures, and arteriopathies but not sex and other underlying conditions predict adverse outcome following childhood stroke.
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Affiliation(s)
- Mauricio López-Espejo
- Unit of Pediatric Neurology, Division of Pediatrics, School of Medicine, Pontifical University Catholic of Chile, Santiago, Chile.
| | - Marta Hernández-Chávez
- Unit of Pediatric Neurology, Division of Pediatrics, School of Medicine, Pontifical University Catholic of Chile, Santiago, Chile.
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Rivkin MJ. Epilepsy as the 'echo' of acute stroke in children. Dev Med Child Neurol 2017; 59:6. [PMID: 27519161 DOI: 10.1111/dmcn.13231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Michael J Rivkin
- Department of Neurology, Stroke and Cerebrovascular Center, Boston Children's Hospital, Boston, MA, USA
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