Stroke in children

Health-Related Quality of Life in Young Adults Following Pediatric Arterial Ischemic Stroke

Background and Purpose—

Pediatric arterial ischemic stroke (AIS) is a rare disease leading to long-lasting neurological sequelae. Little is known about the long-term health-related quality of life (HRQoL) of these patients. The study aims to compare HRQoL in young adults who have had pediatric AIS with a healthy control group.

Methods—

A cross-sectional study compared self-rated HRQoL, depression, fatigability, and behavior in pediatric stroke survivors to healthy controls. Patients with a confirmed diagnosis of pediatric AIS who were ≥18 years at the time of recruitment and ≥2 years after acute AIS, as well as healthy controls ≥18 years matched for age, sex, and socioeconomic status were included. Primary outcome was HRQoL measured with the Short Form Health Survey.

Results—

Thirty-three patients (median [interquartile range] aged 22 years [20–26]; 22 males, 67%) and 71 controls (median [interquartile range] aged 23 years [21–25]; 41 males, 58%) were included. Overall, HRQoL, depression, or fatigability did not differ between the patients and the control group. Patients rated themselves lower on the disinhibition scale ( P =0.049) and tended to rate themselves lower on the executive dysfunction scale ( P =0.076). Patients with a poor outcome 24 months after AIS showed a clear trend toward impairment of executive functioning ( P =0.056) and work/productivity in the stroke-specific QoL ( P =0.05).

Conclusions—

Self-rated HRQoL, depression, and fatigability in adult pediatric stroke survivors are comparable to healthy adult peers. A poor outcome 24 months after acute stroke might affect work performance and executive functioning in adulthood.

Diffusion tensor imaging of pyramidal tract reorganization after pediatric stroke

BACKGROUND

Plasticity of the developing motor tracts is a contributor to recovery of motor function after pediatric stroke. The mechanism of these plastic changes may be functional and/or structural in nature. The corticospinal tract (CST) represents the major pathway responsible for voluntary movement. Stroke-induced damage to the CST as well as to other motor tracts leads to motor deficits which may show favorable functional recovery particularly in the pediatric population.

METHODS

We report the case of a 3-year-old girl demonstrating reorganization of the pyramidal tracts after an extensive left MCA territory stroke secondary to head trauma. Reorganization is characterized using serial diffusion tensor imaging (DTI) of the pyramidal tracts which contain the CST.

RESULTS

Imaging shows decreased ipsi-lesional fractional anisotropy (FA) suggestive of Wallerian degeneration and increased contralesional FA.

CONCLUSIONS

These results point to plastic reorganization of the pyramidal tract post-stroke and the utility of DTI in recognizing these changes.

Cerebrovascular complications in pediatric intensive care unit

Cerebrovascular complications are being frequently recognized in the pediatric intensive care unit in the recent few years. The epidemiology and risk factors for pediatric stroke are different from that of the adults. The incidence of ischemic stroke is almost slightly more than that of hemorrhagic stroke. The list of diagnostic causes is increasing with the availability of newer imaging modalities and laboratory tests. The diagnostic work up depends on the age of the child and the rapidity of presentation. Magnetic resonance imaging, computerized tomography and arteriography and venography are the mainstay of diagnosis and to differentiate between ischemic and hemorrhagic events. Very sophisticated molecular diagnostic tests are required in a very few patients. There are very few pediatric studies on the management of stroke. General supportive management is as important as the specific treatment. Most of the treatment guidelines and suggestions are extrapolated from the adult studies. Few guidelines are available for the use of anticoagulants and thrombolytic agents in pediatric patients. So, our objective was to review the available literature on the childhood stroke and to provide an insight into the subject for the pediatricians and critical care providers.

Arterial ischemic stroke in childhood: risk factors and outcome in old versus new era

Risk factors of children with arterial ischemic stroke were retrospectively evaluated. The children were grouped according to values on developing diagnostic tools: 13 in the old era (1987-1994) and 18 in the new era (1995-2004). The old era battery included 5 tests: protein C, protein S, antithrombin, lupus anticoagulants, and anticardiolipin antibodies. The new era battery added 5 more tests: homocystine level, factor VIII level, mutations for factor V Leiden and prothrombin G20210A, and lipoprotein (a) level. At least 1 risk factor was found in 5 of 13 children (38.5%) in the old era and in 8 of 18 (44.4%) in the new era. The extended battery for prothrombotic disorders revealed 7 risk factors in 4 children (22.2%) in the new era, whereas the limited battery identified a single risk factor in 1 child (7.7%) in the old era. For the correct etiologic identification, prothrombotic risk factors should be extensively evaluated in patients with arterial ischemic stroke.

Isolated intracranial fibromuscular dysplasia presents as stroke in a 19-year-old female

Isolated intracranial fibromuscular dysplasia is rare and may present with cerebrovascular events. It should be considered as etiology of stroke in otherwise healthy young patients. Though diagnosis is often challenging, characteristic morphologies may be revealed on magnetic resonance and catheter angiography. Cephalocervical fibromuscular dysplasia typically involves the extracranial portion of the internal carotid artery (nearly 95%). This rare case demonstrates isolated intracranial fibromuscular dysplasia in a 19-year-old female with left caudate and genu of internal capsule stroke.

Genetic risk factors associated with thrombosis in children with congenital neurologic disorders

Thromboembolic events during the perinatal period are responsible for irreversible brain damage owing to cerebral hypoxia and neuronal necrosis. We investigated the presence of thrombophilia risk factors in children with congenital neurologic disorders. Nineteen children (9 males and 10 females), aged 1 to 14 years (median 4.5 years), who had presented with symptoms and signs of congenital neurologic disorders were studied. Thirty-five age-matched healthy children recruited from the same geographic area served as controls. Three patients of 19 (15.8%) were carrying the factor V Leiden mutation compared with 2 children among the controls (5.7%). One patient was heterozygous for the prothrombin G20210A variant (5.2%) compared with one child who was heterozygous among the controls. Three patients were homozygous (15.8%) and 11 were heterozygous (57.9%) for the C677T 5,10-methylenetetrahydrofolate reductase gene mutation compared with 4 (11.5%) and 18 (51.4%), respectively, among the controls. Three patients of 19 (15.8%) were carrying more than one mutation. We found 18 mutations in 79% (15/19) of the patients and 25 mutations in 69% (24/35) of the healthy children. Among the individuals carrying the homozygous 677TT 5,10-methylenetetrahydrofolate reductase genotype, we found 7 mutations in 32% (6/19) of the patients and 7 mutations in 20% (7/35) of the healthy children (P > .05). In one patient, lupus anticoagulant and antiphospholipid antibodies of IgG isotype were detected. Reduced activities of protein C, protein S, or antithrombin III were not observed in either the patient or the control group. Although, among our cases, we found some well-known risk factors associated with thrombosis in adults, the pathogenesis of these clinical entities remains obscure.

Ischemic cerebrovascular disease in childhood: cognitive assessment of 15 patients

The aim of this study was to evaluate and to compare the cognitive function of children with ischemic cerebrovascular disease (ICVD). Fifteen children, 7 girls and 8 boys, aged 7.9 to 16.1 years, were evaluated by Piaget's clinical method. The control group was composed by fifteen children whose ages, sex and socioeconomic conditions were similar to those of the ICVD group. The cognitive function evaluation of the ICVD group showed that most of the children (10/15) were under their age group. The SPECT was performed on 14 children with ICVD and the results showed that 8/9 children with hypoperfusion presented a poor cognitive estimation and 3/5 children with normal perfusion demonstrated an adequate performance. We conclude that ICVD in childhood may compromise cognition; therefore, it needs a follow up of acquisitions during alI the stages of development.

Transient cerebral arteriopathy in infancy associated with enteroviral infection

We report the case of an 18-month-old boy who presented aphasia and right hemiplegia of acute onset. The neurological deficit completely resolved after a few hours, but identical transient neurological deficits and seizures occurred during the following days. Imaging showed proximal stenosis of the medial cerebral artery and deep ischaemic lesions in the territory of this artery. Analysis of the cerebrospinal fluid showed pleocytosis and an active enteroviral infection with positive RNA detection. The evolution was consistent with transient cerebral arteriopathy of childhood as magnetic resonance angiography showed normalization of the arterial lesions. This is the first report of an enteroviral infection associated with this entity. We want to stress the importance of performing a cerebrospinal fluid analysis when an ischaemic stroke of unclear aetiology occurs in a child.

Trampolines, children, and strokes

Strokes in children related to sports injuries are rare, but pediatric trampoline injuries are dramatically increasing. Minor trauma to the vulnerable extracranial vertebral arteries as they travel superficially through the dorsum of the neck can begin a cascade of events that results in arterial dissection, thrombus formation, and embolization with cerebral infarction. We present the case of an 11-yr-old boy who developed left vertebral artery dissection subsequent to a trampoline injury.

Case report of fibromuscular dysplasia presenting as stroke in a 16-year-old boy

Fibromuscular dysplasia of the carotid artery is uncommon, but not rare. Although the true incidence and prevalence of the disease are not known, reported figures in adults range between 0.6% by angiography and 1.1% at autopsy. Most case reports of stroke caused by carotid fibromuscular dysplasia describe findings in adult subjects, although there are a few reports of the disease in children. In the present case, we describe a 16-year-old boy with fibromuscular dysplasia confined to one internal carotid artery and its branches, and in whom the disease declared itself by stroke. This case serves as a basis for considering diagnostic methods, treatment options, and future research in pediatric patients with cerebrovascular disease caused by fibromuscular dysplasia.

Fibromuscular dysplasia of the internal carotid artery in a child with alpha-1-antitrypsin deficiency

Fibromuscular dysplasia (FMD) is a non-inflammatory segmental arteriopathy of unknown origin. Most often the renal arteries are affected, however, also mesenteric, lumbar, vertebral, or carotid arteries may be involved. FMD has frequently been reported as a cause of stroke in adults, but very rarely in children. We report the case of an 11-year-old boy who presented with an ischaemic infarction in the anterior part of the territory of the left middle cerebral artery. Angiography demonstrated a 'string of beads' lesion suggestive of FMD causing occlusion at the origin of the middle artery. Laboratory analyses revealed the protease inhibitor (Pi) phenotype SZ (PiSZ) of alpha-1-antitrypsin deficiency as well as decreased antioxidants and signs of enhanced lipid peroxidation. Such an imbalance may be associated with diminished resistance to oxidation, possibly causing direct cellular and tissue injury. Whether alpha-1-antitrypsin deficiency and an impaired status of antioxidants, as seen in our patient, might play a role in the pathogenesis of FMD is presently unclear.

Motor speech impairment in a case of childhood basilar artery stroke: treatment directions derived from physiological and perceptual assessment

The perceptual and physiological characteristics of the speech of a nine year old child who suffered a basilar artery stroke at the age of five years were investigated using a battery of perceptual and physiological instrumental measures. Perceptual tests administered included the Frenchay Dysarthria Assessment, a perceptual analysis of a speech sample based on a reading of the Grandfather Passage and a phonetic intelligibility test. Instrumental procedures included: spirometric and kinematic analysis of speech breathing; electroglottographic evaluation of laryngeal function, nasometric assessment of velopharyngeal function and evaluation of lip and tongue function using pressure transducers. Physiological assessment indicated the most severe deficits to be in the respiratory and velopharyngeal sub-systems with significant deficits in the articulatory sub-system, all of which resulted in severely reduced intelligibility. These results were compared and contrasted with the subject's performance on the perceptual assessment battery. In a number of instances the physiological assessments were able to identify deficits in the functioning of components of the speech production apparatus either not evidenced by the perceptual assessments or where the findings of the various perceptual assessments were contradictory. The resulting comprehensive profile of the child's dysarthria demonstrated the value of using an assessment battery comprised of both physiological and perceptual methods. In particular, the need to include instrumental analysis of the functioning of the various subcomponents of the speech production apparatus in the assessment battery when defining the treatment priorities for children with acquired dysarthria is highlighted. Treatment priorities determined on the basis of both the perceptual and physiological assessments for the present CVA case are discussed.