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Borhani-Haghighi A, Hooshmandi E. Cerebral venous thrombosis: a practical review. Postgrad Med J 2024; 100:68-83. [PMID: 37978050 DOI: 10.1093/postmj/qgad103] [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: 07/18/2023] [Revised: 09/27/2023] [Accepted: 09/29/2023] [Indexed: 11/19/2023]
Abstract
The evolution of the Coronavirus Disease-2019 pandemic and its vaccination raised more attention to cerebral venous thrombosis (CVT). Although CVT is less prevalent than arterial stroke, it results in larger years of life lost. CVT is more common in women and young patients. Predisposing factors are categorized as transient factors such as pregnancy, puerperium, oral contraceptive pills, trauma, and dehydration; and permanent factors such as neoplastic, vasculitic, thrombophilic, hematologic conditions, infectious causes such as severe acute respiratory syndrome coronavirus-2 infection and HIV. The most common manifestations are headache, seizures, focal neurologic deficits, altered level of consciousness, and cranial nerve palsies. The most common syndromes are stroke-like, raised-intracranial-pressure (ICP), isolated-headache, and encephalopathy, which may have overlaps. Diagnosis is mostly based on computed tomography, magnetic resonance imaging, and their respective venous sequences, supported by blood results abnormalities such as D-dimer elevation. Treatment includes the prevention of propagation of current thrombus with anticoagulation (heparin, or low molecular weight heparinoids and then warfarin, or direct oral anticoagulants), decreasing ICP (even by decompressive craniotomy), and treatment of specific underlying diseases.
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Affiliation(s)
- Afshin Borhani-Haghighi
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz 7193635899, Iran
- Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia
| | - Etrat Hooshmandi
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz 7193635899, Iran
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2
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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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Bindslev JB, Johnsen SP, Hansen K, Valentin JB, Hoei-Hansen CE, Truelsen T. The Positive Predictive Value of Pediatric Stroke Diagnoses in Administrative Data: A Retrospective Validation Study. Clin Epidemiol 2023; 15:755-764. [PMID: 37360512 PMCID: PMC10290464 DOI: 10.2147/clep.s414913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/10/2023] [Indexed: 06/28/2023] Open
Abstract
Background This retrospective cohort study aimed to examine the positive predictive value (PPV) of pediatric stroke diagnoses in the Danish National Registry of Patients (DNRP) and the impact of different stroke definitions on the PPV. Methods We included children registered with a stroke or stroke-related diagnosis in the DNRP between January 2017 through December 2020. Two assessors reviewed medical records and validated cases according to the American Heart and American Stroke Association (AHA/ASA) stroke definition. The level of interrater agreement was examined using kappa statistics. Validation by the AHA/ASA definition was compared with validation according to the definition in the International Classification of Disease 11th version (ICD-11) and the World Health Organization's definition. Results Stroke was confirmed in 120 of 309 included children, yielding an overall PPV of 0.39 (95% CI: 0.33-0.45). PPV varied across stroke subtypes from 0.83 (95% CI: 0.71-0.92) for ischemic stroke (AIS), 0.57 (95% CI: 0.37-0.76) for unspecified stroke, 0.42 (95% CI: 0.33-0.52) for intracerebral hemorrhage (ICH) to 0.31 (95% CI: 0.55-0.98) and 0.07 (95% CI: 0.01-0.22) for cerebral venous thrombosis and subarachnoid hemorrhage (SAH), respectively. Most non-confirmed ICH and SAH diagnoses were in children with traumatic intracranial hemorrhages (36 and 66% respectively). Among 70 confirmed AIS cases, 25 (36%) were identified in non-AIS code groups. PPV varied significantly across stroke definitions with the highest for the AHA/ASA definition (PPV = 0.39, 95% CI: 0.34-0.45) and the lowest for the WHO definition (PPV = 0.29, 95% CI: 0.24-0.34). Correspondingly, the incidence of pediatric AIS per 100.000 person-years changed from 1.5 for the AHA/ASA definition to 1.2 for ICD-11 and 1.0 for the WHO-definition. The overall interrater agreement was considered excellent (κ=0.85). Conclusion After validation, stroke was confirmed in only half of the children registered in the DNRP with a stroke-specific diagnosis. Non-validated administrative data should be used with caution in pediatric stroke research. Pediatric stroke incidence rates may vary markedly depending on which stroke definition is used.
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Affiliation(s)
- Julie Brix Bindslev
- Department of Neurology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Pediatrics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Soeren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Klaus Hansen
- Department of Neurology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jan Brink Valentin
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Christina Engel Hoei-Hansen
- Department of Pediatrics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Truelsen
- Department of Neurology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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4
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Bindslev JB, Hansen K, Laugesen NG, Benndorf G, Hoei-Hansen CE, Truelsen T. Acute triage of childhood stroke in Denmark. Eur Stroke J 2023; 8:483-491. [DOI: 10.1177/23969873231161381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Objective: This 2-year observational study aimed to test the feasibility of implementing a pediatric stroke triage-setup that connected frontline providers with vascular neurologists and to examine final diagnoses in children triaged for suspected stroke. Methods: Prospective, consecutive registration of children with suspected stroke triaged by a team of vascular neurologists from Jan 1st, 2020 and through Dec 2021, Eastern Denmark (census 530,000 children). Based on the provided clinical information, the children were triaged to either assessment at the Comprehensive Stroke Center (CSC) in Copenhagen or to a pediatric department. All included children were retrospectively followed-up for clinical presentations and final diagnosis. Results: A total of 163 children with 166 suspected stroke events were triaged by the vascular neurologists. Cerebrovascular disease was present in 15 (9.0%) suspected stroke events; one child had intracerebral hemorrhage, one had subarachnoid hemorrhage, two children presented with three TIA events and nine children presented with 10 ischemic stroke events. Two children with ischemic stroke were eligible for acute revascularization treatment of which both were triaged to the CSC. The sensitivity of the triage by acute revascularization indication was 1.00 (95% confidence interval (95% CI): 0.15–1.00) and specificity 0.65 (95% CI: 0.57–0.73). Non-stroke neurological emergencies were present in 34 (20.5%) children, including seizures in 18 (10.8%) and acute demyelinating disorders in 7 (4.2%). Conclusion: Implementing regional triage-setup that connected frontline providers to vascular neurologists was feasible; this system was activated for the majority of children with ischemic stroke according to an expected incidence and led to identification of children eligible for revascularization treatments.
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Affiliation(s)
- Julie Brix Bindslev
- Department of Neurology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Pediatrics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Klaus Hansen
- Department of Neurology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Goetz Benndorf
- Department of Radiology, University Hospital of Copenhagen, Rigshopitalet, Copenhagen, Denmark
- Baylor College of Medicine, Houston, TX, USA
| | - Christina Engel Hoei-Hansen
- Department of Pediatrics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Truelsen
- Department of Neurology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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5
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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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6
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Maldonado-Soto AR, Elkind MSV. Burden of adverse motor outcomes in paediatric stroke patients. Paediatr Perinat Epidemiol 2022; 36:422-424. [PMID: 35481879 DOI: 10.1111/ppe.12889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Angel R Maldonado-Soto
- Division of Vascular Neurology, Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Mailman School of Public Health, Columbia University, New York, New York, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
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Svensson K, Walås A, Bolk J, Bang P, Sundelin HK. Adverse motor outcome after paediatric ischaemic stroke: A nationwide cohort study. Paediatr Perinat Epidemiol 2022; 36:412-421. [PMID: 35172018 PMCID: PMC9304247 DOI: 10.1111/ppe.12869] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 12/19/2021] [Accepted: 01/23/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Various frequencies of adverse motor outcomes (cerebral palsy and hemiplegia) after paediatric ischaemic stroke have been reported. Few reports on the risks of adverse motor outcomes in nationwide cohorts and contributing risk factors are available. OBJECTIVES To assess risk of adverse motor outcome and potential risk factors thereof after paediatric ischaemic stroke in a nationwide cohort. METHODS This nationwide matched cohort study identified 877 children <18 years of age diagnosed with ischaemic stroke through the Swedish national health registers from 1997 to 2016. These children, exposed to ischaemic stroke, alive 1 week after stroke, were matched for age, sex and county of residence with 10 unexposed children. Using Cox regression, we estimated the risk of adverse motor outcomes in children with stroke compared to that in unexposed children. Logistic regression was applied to compare the characteristics of children with and without adverse motor outcomes after stroke. RESULTS Out of the 877 children with ischaemic stroke, 280 (31.9%) suffered adverse motor outcomes compared with 21 (0.2%) of the 8770 unexposed: adjusted hazard ratio (aHR) 167.78 (95% confidence interval (CI) 107.58, 261.66). There were no differences between risk estimates of adverse motor outcome according to age at stroke: perinatal stroke (aHR 124.11, 95% CI 30.45, 505.84) and childhood stroke (aHR 182.37, 95% CI 113.65, 292.64). An association between adverse motor outcome and childhood stroke aOR 1.56 (95% CI 1.05, 2.31) was found when analysing only children with ischaemic stroke. No associations were found between adverse motor outcome and sex, gestational age or parental age at birth. CONCLUSIONS The risk of adverse motor outcome is substantial after paediatric ischaemic stroke, especially childhood stroke, confirming results of previous smaller studies. This study found no associations between sex, gestational age or parental age and adverse motor outcome after paediatric ischaemic stroke.
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Affiliation(s)
- Katarina Svensson
- Division of Children's and Women's HealthDepartment of Biomedical and Clinical SciencesLinköping UniversityLinköpingSweden,Crown Princess Victoria's Children's and Youth HospitalUniversity HospitalLinköpingSweden
| | - Anna Walås
- Division of Children's and Women's HealthDepartment of Biomedical and Clinical SciencesLinköping UniversityLinköpingSweden,Crown Princess Victoria's Children's and Youth HospitalUniversity HospitalLinköpingSweden
| | - Jenny Bolk
- Clinical Epidemiology DivisionDepartment of Medicine SolnaKarolinska InstitutetStockholmSweden,Department of Clinical Science and Education SödersjukhusetStockholmSweden,Sachs’ Children and Youth HospitalStockholmSweden
| | - Peter Bang
- Division of Children's and Women's HealthDepartment of Biomedical and Clinical SciencesLinköping UniversityLinköpingSweden,Crown Princess Victoria's Children's and Youth HospitalUniversity HospitalLinköpingSweden
| | - Heléne E. K. Sundelin
- Division of Children's and Women's HealthDepartment of Biomedical and Clinical SciencesLinköping UniversityLinköpingSweden,Neuropaediatric UnitDepartment of Women's and Children's HealthKarolinska University HospitalKarolinska InstituteStockholmSweden
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8
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Aardoom MA, Klomberg RCW, Kemos P, Ruemmele FM, van Ommen CH(H, de Ridder L, Croft NM. The Incidence and Characteristics of Venous Thromboembolisms in Paediatric-Onset Inflammatory Bowel Disease: A Prospective International Cohort Study Based on the PIBD-SETQuality Safety Registry. J Crohns Colitis 2021; 16:695-707. [PMID: 34599822 PMCID: PMC9228884 DOI: 10.1093/ecco-jcc/jjab171] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS Guidelines regarding thromboprophylaxis for venous thromboembolisms [VTEs] in children with inflammatory bowel disease [IBD] are based on limited paediatric evidence. We aimed to prospectively assess the incidence of VTEs in paediatric-onset IBD [PIBD], characterize PIBD patients with a VTE and identify potential IBD-related risk factors. METHODS From October 2016 to September 2020, paediatric gastroenterologists prospectively replied to the international Safety Registry, monthly indicating whether they had observed a VTE case in a patient <19 years with IBD. IBD details [type, Paris classification, clinical and biochemical disease activity, treatment] and VTE details [type, location, treatment, outcome] were collected. To estimate VTE incidence, participants annually reported the number of PIBD patients, data source and catchment area of their centre. A systematic literature review and meta-analysis was performed to calculate the VTE incidence in the general paediatric population. RESULTS Participation of 129 PIBD centres resulted in coverage of 24 802 PIBD patients. Twenty cases of VTE were identified [30% Crohn's disease]. The incidence of VTEs was 3.72 (95% confidence interval [CI] 2.27-5.74) per 10 000 person-years, 14-fold higher than in the general paediatric population (0.27 [95% CI 0.18-0.38], p < 0.001). Cerebral sinus venous thrombosis was most frequently reported [50%]. All but one patient had active IBD, 45% were using steroids and 45% were hospitalized. No patient received thromboprophylaxis, whereas according to current PIBD guidelines, this was recommended in 4/20 patients. CONCLUSION There is an increased risk of VTEs in the PIBD population compared to the general paediatric population. Awareness of VTE occurrence and prevention should be extended to all PIBD patients with active disease, especially those hospitalized.
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Affiliation(s)
| | | | - Polychronis Kemos
- Paediatric Gastroenterology, Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Frank M Ruemmele
- Department of Paediatric Gastroenterology, Université Paris Descartes, Sorbonne Paris Cité, APHP, Hôpital Necker Enfants Malades, Paris, France
| | | | - C H (Heleen) van Ommen
- Department of Paediatric Haematology, Erasmus Medical Centre – Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Lissy de Ridder
- Corresponding author: Dr Lissy de Ridder, MD PhD, Erasmus Medical Center – Sophia Children’s Hospital, Department of Paediatric Gastroenterology, Room SP-2430, PO Box 2040, 3000 CA Rotterdam, the Netherlands. Tel: 0031650001782;
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9
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Oleske DM, Cheng X, Jeong A, Arndt TJ. Pediatric Acute Ischemic Stroke by Age-Group: A Systematic Review and Meta-Analysis of Published Studies and Hospitalization Records. Neuroepidemiology 2021; 55:331-341. [PMID: 34464952 DOI: 10.1159/000518281] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 07/01/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Although stroke is rare among the pediatric population, it is nevertheless associated with serious or life-threatening consequences. The etiologic factors of acute ischemic stroke (AIS) are likely to vary over the course of childhood development. The incidence rates of AIS, not previously systematically examined by pediatric age subgroup, could guide studies of its etiology. OBJECTIVE The aim of this study is to evaluate the incidence rate of AIS by age-group in the pediatric population (aged 0-17/18 years) and identify any common trends or sources of variability across different countries. METHODS Rates of pediatric AIS were collated from a systematic literature review of published studies globally (1983-2020) and hospitalization records from Europe and the USA (2015-2018). Records that were included in the analysis reported the code or description used for AIS diagnosis and age-specific data for children aged 0-17/18 years. AIS incidence rates were summarized by age-group, data source, country, and geographic region. A meta-analysis was conducted to assess the heterogeneity of AIS rates in neonates. RESULTS The pooled AIS incidence rate was 5.6 per 100,000 children across all records. When only records reporting the AIS incidence rates for children across the full age range (0-17/18 years) were analyzed, the pooled AIS incidence rate was 4.6 per 100,000 children and ranged from 7.0 per 100,000 (Germany) to 1.3 per 100,000 (Denmark). The highest pooled rates were observed in the 0-28-day age-group (24.6 per 100,000 live births), declining to the lowest rates in the 5-9-year age-group, and rising again in the 10-17/18-year age-group. AIS rates were the most heterogeneous in the 0-28-day age-group and across European countries. Significantly higher AIS rates in neonates were observed from hospital databases (35.9 per 100,000) than in the literature (19.4 per 100,000). AIS rates may be underestimated as pediatric AIS events are rare and challenging to diagnose, and limited age-specific data are available. CONCLUSIONS Incidence rates of pediatric AIS by age-groups followed a consistent overall pattern of a reverse J-shaped curve, with the highest rates in neonates, across predominantly European and North American countries. Further research is warranted to examine if this pattern is observed in other geographic regions and to identify AIS risk factors specific to different phases of childhood development.
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Affiliation(s)
| | - Xianbin Cheng
- Department of Food Science and Human Nutrition, University of Illinois, Urbana-Champaign, Illinois, USA
| | - Anna Jeong
- Neuroscience Clinical Development, AbbVie, North Chicago, Illinois, USA
| | - Thomas J Arndt
- Epidemiology, Decision Resources Group (a Clarivate business), Burlington, Massachusetts, USA
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10
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Lambicchi L, Ornaghi S, Dal Molin G, Paterlini G, Bernasconi DP, Moltrasio F, Vergani P. Different antecedents and neonatal condition in neonatal arterial ischemic stroke and hypoxic-ischemic neonatal encephalopathy. Int J Gynaecol Obstet 2021; 157:333-339. [PMID: 34101180 PMCID: PMC9290624 DOI: 10.1002/ijgo.13781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/13/2021] [Accepted: 06/07/2021] [Indexed: 11/26/2022]
Abstract
Objective To define similarities and differences between neonatal arterial ischemic stroke (NAIS) and hypoxic‐ischemic neonatal encephalopathy (HINE). Methods A retrospective case‐control study was conducted of neonates born at 35 weeks or more and weighing 1800 g or more at a tertiary care university hospital, between 2005 and 2016, with NAIS (group A), perinatal asphyxia (PA) with Stage II–III HINE (group B), and PA with or without Stage I HINE (group C). Ante‐ and intrapartum data, neonatal characteristics, and placental histopathology were compared. Results Eleven neonates were identified in group A, 10 in group B, and 227 in group C. Sentinel events occurred exclusively in groups B (80%) and C (41.4%). Umbilical cord blood gas values and Apgar score were worse in groups B and C compared to group A. No group A neonates required resuscitation at birth, whereas all group B and one‐third of group C neonates did. Seizures developed only in neonates in groups A and B. One neonatal death occurred in group A. There were no significant differences in placental histopathology. Conclusion NAIS and PA/HINE cases have different intrapartum and neonatal features. PA does not seem necessary for the occurrence of NAIS. More research is needed regarding associated placental abnormalities. Birth asphyxia does not seem necessary for neonatal arterial ischemic stroke occurrence. The two conditions have different ante‐/intrapartum and neonatal features.
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Affiliation(s)
- Laura Lambicchi
- Department of Obstetrics and Gynecology, MBBM Foundation, San Gerardo Hospital, University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Sara Ornaghi
- Department of Obstetrics and Gynecology, MBBM Foundation, San Gerardo Hospital, University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Giulia Dal Molin
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy.,Department of Obstetrics and Gynecology, Macedonio Melloni Hospital, University of Milan School of Medicine and Surgery, Milan, Italy
| | - Giuseppe Paterlini
- Neonatal Intensive Care Unit, Department of Neonatology, MBBM Foundation, San Gerardo Hospital, Monza, Italy.,Neonatal Intensive Care Unit, Department of Mother and Child Health, Fondazione Poliambulanza, Brescia, Italy
| | - Davide P Bernasconi
- Bicocca Bioinformatics Biostatistics and Bioimaging Centre - B4, University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Francesca Moltrasio
- Department of Pathology, San Gerardo Hospital, University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Patrizia Vergani
- Department of Obstetrics and Gynecology, MBBM Foundation, San Gerardo Hospital, University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
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11
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Sorg AL, Von Kries R, Klemme M, Gerstl L, Beyerlein A, Lack N, Felderhoff-Müser U, Dzietko M. Incidence and risk factors of cerebral sinovenous thrombosis in infants. Dev Med Child Neurol 2021; 63:697-704. [PMID: 33506500 DOI: 10.1111/dmcn.14816] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2020] [Indexed: 12/16/2022]
Abstract
AIM To describe the incidence of term and preterm neonatal cerebral sinovenous thrombosis (CSVT) and identify perinatal risk factors. METHOD This was a national capture-recapture calculation-corrected surveillance and nested case-control study. Infants born preterm and at term with magnetic resonance imaging-confirmed neonatal CSVT were identified by surveillance in all paediatric hospitals in Germany (2015-2017). Incidence was corrected for underreporting using a capture-recapture method in one federal state and then extrapolated nationwide. We reviewed PubMed for comparisons with previously reported incidence estimators. We used a population-based perinatal database for quality assurance to select four controls per case and applied univariate and multivariable regression for risk factor analysis. RESULTS Fifty-one newborn infants (34 males, 17 females; 14 born preterm) with neonatal CSVT were reported in the 3-year period. The incidence of term and preterm neonatal CSVT was 6.6 (95% confidence interval [CI] 4.4-8.7) per 100 000 live births. Median age at time of confirmation of the diagnosis was 9.95 days (range 0-39d). In the univariate analysis, male sex, preterm birth, hypoxia and related indicators (umbilical artery pH <7.1; 5-minute Apgar score <7; intubation/mask ventilation; perinatal asphyxia), operative vaginal delivery, emergency Caesarean section, and pathological fetal Doppler sonography were associated (p<0.05) with neonatal CSVT. Multivariable regression yielded hypoxia (odds ratio=20.3; 95% CI 8.1-50.8) as the independent risk factor. INTERPRETATION Incidence of neonatal CSVT was within the range of other population-based studies. The results suggest that hypoxia is an important perinatal risk factor for the aetiology of neonatal CSVT.
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Affiliation(s)
- Anna-Lisa Sorg
- Institute of Social Paediatrics and Adolescent Medicine, Division of Paediatric Epidemiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Rüdiger Von Kries
- Institute of Social Paediatrics and Adolescent Medicine, Division of Paediatric Epidemiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Mathias Klemme
- Department of Neonatology, University Children's Hospital and Perinatal Centre, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Lucia Gerstl
- Department of Paediatric Neurology, University Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Andreas Beyerlein
- Institute of Computational Biology, Helmholtz Zentrum München, Neuherberg, Germany
| | - Nicholas Lack
- Bavarian Quality Assurance for In-Patient Medical Care, Munich, Germany
| | | | - Mark Dzietko
- Department of Paediatrics I, Neonatology, University Duisburg-Essen, Essen, Germany
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12
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Sarecka-Hujar B, Kopyta I. The Impact of Sex on Arterial Ischemic Stroke in Young Patients: From Stroke Occurrence to Poststroke Consequences. CHILDREN-BASEL 2021; 8:children8030238. [PMID: 33803901 PMCID: PMC8003301 DOI: 10.3390/children8030238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/12/2021] [Accepted: 03/16/2021] [Indexed: 01/12/2023]
Abstract
The male sex has been suggested to predominate in paediatric patients with arterial ischemic stroke (AIS), especially in newborns. The explanation for this phenomenon remains unsatisfactory since it focuses on the analysis of the potential relationship with trauma and arterial dissection. In turn, in some populations of young adults, men suffer from AIS more frequently than women, which may be related to the protective role of oestrogen. On the other hand, certain data indicate that women dominate over men. Some of the disparities in the frequencies of particular symptoms of AIS and poststroke consequences in both children and young adults have been suggested; however, data are scarce. Unfortunately, the low number of studies on the subject does not allow certain conclusions to be drawn. For adults, more data are available for patients aged over 60 years, the results of which are more obvious. The present literature review aimed to discuss available data on the prevalence of AIS, its clinical presentations, and poststroke consequences in regard to the sex of young patients. We considered young patients to be children from birth up to the age of 19 years of life and young adults to be individuals up to the age of 55 years. The role of sex hormones in AIS and possible gender differences in genetic risk factors for AIS were also discussed briefly.
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Affiliation(s)
- Beata Sarecka-Hujar
- Department of Basic Biomedical Science, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia in Katowice, Kasztanowa Str 3, 41-200 Sosnowiec, Poland
- Correspondence: or ; Tel.: +48-32-269-98-30
| | - Ilona Kopyta
- Department of Pediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia in Katowice, Medykow Str 16, 40-752 Katowice, Poland;
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13
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Ordookhanian C, Amidon RF, Kaloostian P. Acute Alcohol Intoxication With Accompanying Neurovascular Decline in Young Adults: A Sobering Case Series. Cureus 2020; 12:e11572. [PMID: 33364097 PMCID: PMC7749838 DOI: 10.7759/cureus.11572] [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] [Indexed: 11/05/2022] Open
Abstract
With an increase in both popularity and incidence, young adults continue to consume increasing amounts of ethanol-containing beverages at alarmingly short intervals, at times, far surpassing the threshold of binge drinking. From mixed beverages to party delights, high-concentration ethanol consumption continues to wreak havoc on the health of the younger generation. In this dual case series, we discuss two unique cases of alcohol-induced neurovascular compromise following episodes of high-volume ethanol consumption and acute neurovascular decline with varying outcomes. These cases highlight the hyperacute onset of severe pathology and the dire need for immediate medical intervention. While outcomes vary from case to case, our findings are congruent with those of vast medical literature that supports the consensus that immediate intervention to restore neurovascular flow is crucial for desired outcomes. At the end of the day, we cannot control the amount of alcohol that enters the mouths of our patients, but rather, we can educate them on safer practices while highlighting the risk and life-changing consequences of such risky behavior.
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Affiliation(s)
- Christ Ordookhanian
- Emergency Medicine, University of California Riverside School of Medicine, Riverside, USA
| | - Ryan F Amidon
- Neuroscience, University of California Riverside, Riverside, USA
| | - Paul Kaloostian
- Neurological Surgery, Riverside Community Hospital, Riverside, USA.,Neurological Surgery, Paul Kaloostian MD Inc, Riverside, USA
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14
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Sarecka-Hujar B, Kopyta I. Risk Factors for Recurrent Arterial Ischemic Stroke in Children and Young Adults. Brain Sci 2020; 10:E24. [PMID: 31906461 PMCID: PMC7016965 DOI: 10.3390/brainsci10010024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 12/21/2019] [Accepted: 12/30/2019] [Indexed: 12/11/2022] Open
Abstract
Arterial ischemic stroke (AIS) experienced at a young age is undoubtedly a serious medical problem. AIS very rarely occurs at a developmental age, whereas in young adults, it occurs with a higher frequency. The etiologic mechanisms of AIS occurring in childhood and adulthood differ. However, for both age populations, neurological consequences of AIS, including post-stroke seizures, motor disability, and recurrence of the disease, are connected to many years of care, rehabilitation, and treatment. Recurrent stroke was observed to increase the risk of patients' mortality. One of the confirmed risk factors for recurrent stroke in children is the presence of vasculopathies, especially Moyamoya disease and syndrome, and focal cerebral arteriopathy of childhood (FCA). FCA causes a 5-fold increase in the risk of recurrent stroke in comparison with idiopathic AIS. In turn, young adults with recurrent stroke were found to more often suffer from hypertension, diabetes mellitus, or peripheral artery disease than young patients with first-ever stroke. Some reports also indicate relationships between specific genetic polymorphisms and AIS recurrence in both age groups. The aim of the present literature review was to discuss available data regarding the risk factors for recurrent AIS in children and young adults.
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Affiliation(s)
- Beata Sarecka-Hujar
- Department of Pharmaceutical Technology, School of Pharmacy with the Division of Laboratory Medicine in Sosnowiec, Medical University of Silesia in Katowice, 41-200 Sosnowiec, Poland
| | - Ilona Kopyta
- Department of Paediatric Neurology, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-752 Katowice, Poland;
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15
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Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke 2019; 50:e51-e96. [DOI: 10.1161/str.0000000000000183] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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16
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deVeber G, Kirkham F, Shannon K, Brandão L, Sträter R, Kenet G, Clausnizer H, Moharir M, Kausch M, Askalan R, MacGregor D, Stoll M, Torge A, Dlamini N, Ganesan V, Prengler M, Singh J, Nowak-Göttl U. Recurrent stroke: the role of thrombophilia in a large international pediatric stroke population. Haematologica 2019; 104:1676-1681. [PMID: 30679327 PMCID: PMC6669164 DOI: 10.3324/haematol.2018.211433] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/22/2019] [Indexed: 12/04/2022] Open
Abstract
Risk factors for arterial ischemic stroke in children include vasculopathy and prothrombotic risk factors but their relative importance to recurrent stroke is uncertain. Data on recurrent stroke from databases held in Canada (Toronto), Germany (Kiel-Lübeck/Münster), and the UK (London/Southampton) were pooled. Data were available from 894 patients aged 1 month to 18 years at first stroke (median age, 6 years) with a median follow-up of 35 months. Among these 894 patients, 160 (17.9%) had a recurrence between 1 day and 136 months after the first stroke (median, 3.1 months). Among 288 children with vasculopathy, recurrence was significantly more common [hazard ratio (HR) 2.5, 95% confidence interval (95% CI) 1.92-3.5] compared to the rate in children without vasculopathy. Adjusting for vasculopathy, isolated antithrombin deficiency (HR 3.9; 95% CI: 1.4-10.9), isolated elevated lipoprotein (a) (HR 2.3; 95% CI: 1.3-4.1), and the presence of more than one prothrombotic risk factor (HR 1.9; 95% CI: 1.12-3.2) were independently associated with an increased risk of recurrence. Recurrence rates calculated per 100 person-years were 10 (95% CI: 3-24) for antithrombin deficiency, 6 (95% CI: 4-9) for elevated lipoprotein (a), and 13 (95% CI: 7-20) for the presence of more than one prothrombotic risk factor. Identifying children at increased risk of a second stroke is important in order to intensify measures aimed at preventing such recurrences.
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Affiliation(s)
| | - Fenella Kirkham
- Developmental Neurosciences Programme, UCL Great Ormond Street Institute of Child Health, London, UK.,University Hospital Southampton, UK
| | | | | | - Ronald Sträter
- Department of Paediatric Haematology/Oncology, University of Münster, Münster, Germany
| | - Gili Kenet
- Pediatric Coagulation Service, National Hemophilia Centre and Institute of Thrombosis and Hemostasis Sheba Medical Center, Tel-Hashomer, Israel
| | - Hartmut Clausnizer
- Institute of Clinical Chemistry, University Hospital Kiel-Lübeck, Kiel, Germany
| | | | - Martina Kausch
- Institute of Clinical Chemistry, University Hospital Kiel-Lübeck, Kiel, Germany
| | | | | | - Monika Stoll
- Department of Genetic Epidemiology, University of Münster, Münster, Germany
| | - Antje Torge
- Institute of Clinical Chemistry, University Hospital Kiel-Lübeck, Kiel, Germany
| | | | - Vijeja Ganesan
- Developmental Neurosciences Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Mara Prengler
- Developmental Neurosciences Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Ulrike Nowak-Göttl
- Department of Paediatric Haematology/Oncology, University of Münster, Münster, Germany .,Institute of Clinical Chemistry, University Hospital Kiel-Lübeck, Kiel, Germany
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17
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Abstract
Perinatal arterial ischemic stroke is a relatively common and serious neurologic disorder that can affect the fetus, the preterm, and the term-born infant. It carries significant long-term disabilities. Herein we describe the current understanding of its etiology, pathophysiology and classification, different presentations, and optimal early management. We discuss the role of different brain imaging modalities in defining the extent of lesions and the impact this has on the prediction of outcomes. In recent years there has been progress in treatments, making early diagnosis and the understanding of likely morbidities imperative. An overview is given of the range of possible outcomes and optimal approaches to follow-up and support for the child and their family in the light of present knowledge.
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18
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Warne RR, Ramji S, Chong WK. Pediatric Stroke and Radiological Approach. Clin Neuroradiol 2019. [DOI: 10.1007/978-3-319-68536-6_35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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19
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Pediatric Stroke and Radiological Approach. Clin Neuroradiol 2019. [DOI: 10.1007/978-3-319-61423-6_35-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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20
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[Neonatal arterial ischemic stroke in term or near-term newborns: prevalence and risk factors]. Arch Pediatr 2018; 24:9S3-9S11. [PMID: 28867035 DOI: 10.1016/s0929-693x(17)30325-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The general designation ischemic perinatal stroke includes several disease states that differ in pathophysiology, timing of occurrence and presentation. While it seems logical to assume that their prevalence and their risk factors depend primarily on the considered type of stroke, most studies used inconsistent definitions or included heterogeneous populations, which limits their accuracy. Given these biases, the French Society of Neonatology and the French Centre for Paediatric Stroke wished to update the knowledge in this domain, focusing on a specific form of perinatal stroke, i.e neonatal arterial ischemic stroke (NAIS) in term or near term newborns. A comprehensive analysis of published epidemiological data was dedicated to the following issues:
Is the prevalence of NAIS well defined from epidemiological studies?
What are the best recognized risk factors and is it possible to delineate a maternal and fetal population at risk for this condition?
On July 31, 2015 a total of four hospitalized-based and five population-based studies, and six case-control studies were found. The conclusions are the following:
The prevalence of NAIS in term or near term newborns varies from 6 to 17/100,000 live births (level of evidence 2). NAIS represents a half of total ischemic perinatal strokes (i.e. including those with delayed presentation as well) and one fourth of perinatal strokes (i.e. including cerebral haemorrhage stroke as well).
Four sets of risk factors are consistent across different studies (level of evidence 3): (1) male sex, (2) obstetrical determinants (first pregnancy, caesarean section), and two peripartum complications: (3) intrapartum hypoxia and (4) materno-fetal/neonatal infection. Bacterial meningitis, cardiac disorders/procedures and invasive care such as extra-corporeal circulation carry a risk of NAIS as well.
A registry could help refining epidemiological descriptive data. It could also be used to develop etiological studies focusing on pathophysiological hypotheses derived from the identified aforementioned risk factors.
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21
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Medley TL, Miteff C, Andrews I, Ware T, Cheung M, Monagle P, Mandelstam S, Wray A, Pridmore C, Troedson C, Dale RC, Fahey M, Sinclair A, Walsh P, Stojanovski B, Mackay MT. Australian Clinical Consensus Guideline: The diagnosis and acute management of childhood stroke. Int J Stroke 2018; 14:94-106. [DOI: 10.1177/1747493018799958] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke is among the top 10 causes of death in children and survivors carry resulting disabilities for decades, at substantial cost to themselves and their families. Children are not currently able to access reperfusion therapies, due to limited evidence supporting safety and efficacy and long diagnostic delays. The Australian Clinical Consensus Guideline for the Diagnosis and Acute Management of Childhood Stroke was developed to minimize unwarranted variations in care and document best evidence on the risk factors, etiologies, and conditions mimicking stroke that differ from adults. Clinical questions were formulated to inform systematic database searches from 2007 to 2017, limited to English and pediatric studies. SIGN methodology and the National Health and Medical Research Council system were used to screen and classify the evidence. The Grades of Recommendation, Assessment, Development, and Evaluation system (GRADE) was used to grade evidence as strong or weak. The Guideline provides more than 60 evidence-based recommendations to assist prehospital and acute care clinicians in the rapid identification of childhood stroke, choice of initial investigation, to confirm diagnosis, determine etiology, selection of the most appropriate interventions to salvage brain at risk, and prevent recurrence. Recommendations include advice regarding the management of intracranial pressure and congenital heart disease. Implementation of the Guideline will require reorganization of prehospital and emergency care systems, including the development of regional stroke networks, pediatric Code Stroke, rapid magnetic resonance imaging and accreditation of primary pediatric stroke centers with the capacity to offer reperfusion therapies. The Guideline will allow auditing to benchmark timelines of care, access to acute interventions, and outcomes. It will also facilitate the development of an Australian childhood stroke registry, with data linkage to international registries, to allow for accurate data collection on stroke incidence, treatment, and outcomes.
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Affiliation(s)
- Tanya L Medley
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
| | | | - Ian Andrews
- Sydney Children's Hospital, School of Women's and Children's Health, University of New South Wales, Sydney, Australia
| | - Tyson Ware
- Royal Hobart Hospital, Hobart, Australia
| | - Michael Cheung
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Department of Cardiology Royal Children's Hospital, Melbourne, Australia
| | - Paul Monagle
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | - Simone Mandelstam
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | - Alison Wray
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | | | - Christopher Troedson
- Children's Hospital at Westmead, Discipline of Child and Adolescent Health, University of Sydney, Sydney, Australia
| | - Russell C Dale
- Children's Hospital at Westmead and University of Sydney, Sydney Australia
| | - Michael Fahey
- Department of Paediatrics Monash University, Department of Medicine Melbourne University, and Monash Children's Hospital, Melbourne, Australia
| | - Adriane Sinclair
- Lady Cilento Children's Hospital, University of Queensland, Brisbane, Australia
| | | | - Belinda Stojanovski
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | - Mark T Mackay
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Department of Neurology Royal Children's Hospital, Melbourne Australia
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22
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Hedegaard SS, Klein AC, Hvas AM. The significance of thrombophilia in paediatric thromboembolism. Scand J Clin Lab Invest 2018; 78:551-555. [PMID: 30261760 DOI: 10.1080/00365513.2018.1517418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The role of thrombophilia in paediatric thromboembolic disease remains controversial. The objective of the present study was to investigate the prevalence of thrombophilia and other risk factors among children with a thromboembolic event. We systematically examined the medical records and laboratory results of 126 children (≤15 years) referred to Aarhus University Hospital, Denmark with a recent thromboembolic event during 2005-2016. Among the 126 children with thrombosis, 99 (79%) had arterial thrombosis, 66 (52%) being in the neonatal period. Remarkably, 48 (38%) children had occurrence of acute illness or underlying disease prior to the thromboembolic event. In total, 11 (11%) children with arterial thrombosis had a hereditary or acquired thrombophilia with a non-significant odds ratio compared with the general population, while 9 of the 27 (33%) children with venous thrombosis had a hereditary or acquired thrombophilia being significantly higher than in the general population. Acute illness or underlying diseases seem to induce increased risk of thromboembolic disease in children. The present study does not support that thrombophilia is associated with arterial thrombosis. However, the results support thrombophilia testing in children with venous thromboembolism.
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Affiliation(s)
| | - Anna Christina Klein
- b Department of Clinical Biochemistry , Aarhus University Hospital , Aarhus , Denmark
| | - Anne-Mette Hvas
- b Department of Clinical Biochemistry , Aarhus University Hospital , Aarhus , Denmark.,c Institute of Clinical Medicine, Health , Aarhus University , Aarhus , Denmark
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23
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Rossor T, Arichi T, Bhate S, Hart AR, Raman Singh R. Anticoagulation in the management of neonatal cerebral sinovenous thrombosis: a systematic review and meta-analysis. Dev Med Child Neurol 2018; 60:884-891. [PMID: 29675941 DOI: 10.1111/dmcn.13760] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2018] [Indexed: 01/08/2023]
Abstract
AIM To determine whether anticoagulation therapy (ACT) in the treatment of neonatal cerebral sinovenous thrombosis (CSVT) improves outcomes, in the presence or absence of pre-existing intracerebral haemorrhage (ICH). METHOD We searched CENTRAL, MEDLINE, Embase, CINAHL, the Web of Science, and clinical trial databases. We considered data from retrospective and prospective cohort studies, case series, and randomized controlled studies evaluating outcomes of CSVT treated with anticoagulation or no anticoagulation. Studies were included if they involved infants either younger than 28 days of age or younger than 44 weeks postmenstrual age at the time of diagnosis of CSVT in which ACT was considered. RESULTS Seven non-randomized studies were included in meta-analysis. ACT had no significant effect on mortality before discharge either in the presence or absence of pre-existing ICH, nor on the incidence of extension of pre-existing ICH. ACT was associated with a reduced risk of propagation of thrombus (risk ratio 0.14, 95% confidence interval 0.03-0.72). INTERPRETATION There are no randomized trials assessing the safety and efficacy of ACT in the treatment of neonatal CSVT. The results of this meta-analysis would justify a position of equipoise and support the need for well-designed randomized controlled trials of ACT in this population. WHAT THIS PAPER ADDS No randomized studies have evaluated anticoagulation therapy (ACT) in neonatal cerebral sinovenous thrombosis. ACT may reduce thrombus propagation. No evidence of increased morbidity or mortality with ACT was demonstrated. A position of equipoise is justified, supporting the need for placebo-controlled randomized trials.
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Affiliation(s)
- Thomas Rossor
- Children's Neurosciences, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Tomoki Arichi
- Children's Neurosciences, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Perinatal Imaging & Health, King's College London, St Thomas' Hospital, London, UK.,Department of Bioengineering, Imperial College London, London, UK
| | - Sanjay Bhate
- Department of Paediatric Neurology, Great Ormond Street Hospital, London, UK
| | - Anthony R Hart
- Department of Neonatal and Paediatric Neurology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Rahul Raman Singh
- Children's Neurosciences, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
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24
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Munoz D, Hidalgo MJ, Balut F, Troncoso M, Lara S, Barrios A, Parra P. Risk Factors for Perinatal Arterial Ischemic Stroke: A Case-Control Study. CELL MEDICINE 2018; 10:2155179018785341. [PMID: 32634191 PMCID: PMC6172995 DOI: 10.1177/2155179018785341] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Arterial ischemic stroke in newborns is an important cause of neonatal morbidity and mortality. Its pathophysiology and associated risk factors are not yet clearly understood and defined. Objective The aim of this retrospective study was to investigate possible risk factors in diagnosed cases of PAIS (perinatal arterial ischemic stroke). Materials and methods Case-control study. Clinical data of patients with PAIS diagnosis were analyzed. Two healthy controls were selected for each PAIS case, matched for gestational age. Risk factors were explored using univariable and multivariable analysis. Outcome 40 patients were included in the study, 24 males and 16 females; 52.5% of cases were diagnosed within the first month of birth, and 47.5% were retrospectively diagnosed. The results showed a male predominance (66.7%). The distribution of cerebral ischemic injury was predominantly medial cerebral artery (87.5%) and occurred more commonly in the left cerebral hemisphere (62.5%). Significant risk factors in the univariate analysis (P < 0.05) were primiparity, stillbirth, neonatal sepsis, asphyxia, twin pregnancy, placenta abruption, emergency cesarean section, Apgar score ≤7 after 5 min, breech presentation, and hyperbilirubinemia. In the multivariate analysis, primiparity (OR 11.74; CI 3.28-42.02), emergency cesarean section (OR 13.79; CI 3.51-54.13), birth asphyxia (OR 40.55; CI 3.08-532.94) and Apgar score ≤7 after 5 min (OR 13.75; CI 1.03-364.03) were significantly associated factors with PAIS. Only five (16.6%) patients had an abnormal thrombophilia study. Conclusion Risk factors of primiparity, emergency cesarean section, birth asphyxia, and Apgar score ≤7 after 5 min were significantly associated with perinatal stroke. More studies with a larger number of patients and with prolonged follow up are required to establish more clearly the associated risk factors involved in this pathology.
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Affiliation(s)
- Daniela Munoz
- Department of Pediatric Neurology and Psychiatry, San Borja Arriarán
Hospital, University of Chile, Santiago, Chile
- Daniela Munoz, Department of Pediatric Neurology and
Psychiatry, San Borja Arriarán Hospital, University of Chile, Región Metropolitana, Santa
Rosa Avenue, 1234, Santiago, Chile.
| | - María José Hidalgo
- Department of Pediatric Neurology and Psychiatry, San Borja Arriarán
Hospital, University of Chile, Santiago, Chile
| | - Fernanda Balut
- Department of Pediatric Neurology and Psychiatry, San Borja Arriarán
Hospital, University of Chile, Santiago, Chile
| | - Mónica Troncoso
- Department of Pediatric Neurology and Psychiatry, San Borja Arriarán
Hospital, University of Chile, Santiago, Chile
| | - Susana Lara
- Department of Pediatric Neurology and Psychiatry, San Borja Arriarán
Hospital, University of Chile, Santiago, Chile
| | - Andrés Barrios
- Department of Pediatric Neurology and Psychiatry, San Borja Arriarán
Hospital, University of Chile, Santiago, Chile
| | - Patricia Parra
- Department of Pediatric Neurology and Psychiatry, San Borja Arriarán
Hospital, University of Chile, Santiago, Chile
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25
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Helmuth IG, Mølbak K, Uldall PV, Poulsen A. Post-varicella Arterial Ischemic Stroke in Denmark 2010 to 2016. Pediatr Neurol 2018; 80:42-50. [PMID: 29307566 DOI: 10.1016/j.pediatrneurol.2017.11.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 10/17/2017] [Accepted: 11/27/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Varicella, most often a benign disease of childhood, is associated with an increased risk of arterial ischemic stroke in children. The aim of the present study was to estimate the incidence of post-varicella arterial ischemic stroke in the Danish child population and describe clinical characteristics of children admitted with post-varicella arterial ischemic stroke. METHODS In the Danish National Patient Register, we identified inpatients 28 days to 16 years of age with a discharge diagnosis of stroke or cerebrovascular disease from 2010 to 2016. Medical files were reviewed, and children with arterial ischemic stroke and varicella infection less than 12 months before onset of symptoms were included. RESULTS We identified 15 children with arterial ischemic stroke and varicella less than 12 months before. In nine children, the diagnosis was confirmed by detection of varicella zoster virus DNA or varicella zoster virus immunoglobulin G in the cerebrospinal fluid. All children were previously healthy, the mean age was four years, and 67% were male. The median time from varicella rash to arterial ischemic stroke was 4.6 months. The most common location of arterial ischemic stroke was the basal ganglia, and affected vessels were most often in the anterior circulation. Fifty-three percent experienced neurological sequelae of varying degree. CONCLUSIONS In Denmark, where varicella vaccination is not part of the childhood vaccination program, the estimated risk of post-varicella arterial ischemic stroke was one case (including possible cases) per 26,000 children with varicella.
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Affiliation(s)
- Ida Glode Helmuth
- Department of Paediatric and Adolescent Medicine, Rigshospitalet, Copenhagen Ø, Denmark; Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen S, Denmark.
| | - Kåre Mølbak
- Division of Infectious Disease Preparedness, Statens Serum Institut, Copenhagen S, Denmark
| | - Peter Vilhelm Uldall
- Department of Paediatric and Adolescent Medicine, Rigshospitalet, Copenhagen Ø, Denmark
| | - Anja Poulsen
- Department of Paediatric and Adolescent Medicine, Rigshospitalet, Copenhagen Ø, Denmark
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26
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Giraud A, Guiraut C, Chevin M, Chabrier S, Sébire G. Role of Perinatal Inflammation in Neonatal Arterial Ischemic Stroke. Front Neurol 2017; 8:612. [PMID: 29201015 PMCID: PMC5696351 DOI: 10.3389/fneur.2017.00612] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 11/02/2017] [Indexed: 12/19/2022] Open
Abstract
Based on the review of the literature, perinatal inflammation often induced by infection is the only consistent independent risk factor of neonatal arterial ischemic stroke (NAIS). Preclinical studies show that acute inflammatory processes take place in placenta, cerebral arterial wall of NAIS-susceptible arteries and neonatal brain. A top research priority in NAIS is to further characterize the nature and spatiotemporal features of the inflammatory processes involved in multiple levels of the pathophysiology of NAIS, to adequately design randomized control trials using targeted anti-inflammatory vasculo- and neuroprotective agents.
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Affiliation(s)
- Antoine Giraud
- EA 4607 SNA EPIS, Jean Monnet University, Saint-Etienne, France.,Child Neurology Division, Department of Pediatrics, McGill University, Montréal, QC, Canada
| | - Clémence Guiraut
- Child Neurology Division, Department of Pediatrics, McGill University, Montréal, QC, Canada
| | - Mathilde Chevin
- Child Neurology Division, Department of Pediatrics, McGill University, Montréal, QC, Canada
| | - Stéphane Chabrier
- French Center for Pediatric Stroke and Pediatric Rehabilitation Unit, Department of Pediatrics, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Guillaume Sébire
- Child Neurology Division, Department of Pediatrics, McGill University, Montréal, QC, Canada
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deVeber GA, Kirton A, Booth FA, Yager JY, Wirrell EC, Wood E, Shevell M, Surmava AM, McCusker P, Massicotte MP, MacGregor D, MacDonald EA, Meaney B, Levin S, Lemieux BG, Jardine L, Humphreys P, David M, Chan AKC, Buckley DJ, Bjornson BH. Epidemiology and Outcomes of Arterial Ischemic Stroke in Children: The Canadian Pediatric Ischemic Stroke Registry. Pediatr Neurol 2017; 69:58-70. [PMID: 28254555 DOI: 10.1016/j.pediatrneurol.2017.01.016] [Citation(s) in RCA: 175] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pediatric arterial ischemic stroke remains incompletely understood. Population-based epidemiological data inform clinical trial design but are scant in this condition. We aimed to determine age-specific epidemiological characteristics of arterial ischemic stroke in neonates (birth to 28 days) and older children (29 days to 18 years). METHODS We conducted a 16-year, prospective, national population-based study, the Canadian Pediatric Ischemic Stroke Registry, across all 16 Canadian acute care children's hospitals. We prospectively enrolled children with arterial ischemic stroke from January 1992 to December 2001 and documented disease incidence, presentations, risk factors, and treatments. Study outcomes were assessed throughout 2008, including abnormal clinical outcomes (stroke-related death or neurological deficit) and recurrent arterial ischemic stroke or transient ischemic attack. RESULTS Among 1129 children enrolled with arterial ischemic stroke, stroke incidence was 1.72/100,000/year, (neonates 10.2/100,000 live births). Detailed clinical and radiological information were available for 933 children (232 neonates and 701 older children, 55% male). The predominant clinical presentations were seizures in neonates (88%), focal deficits in older children (77%), and diffuse neurological signs (54%) in both. Among neonates, 44% had no discernible risk factors. In older children, arteriopathy (49% of patients with vascular imaging), cardiac disorders (28%), and prothrombotic disorders (35% of patients tested) predominated. Antithrombotic treatment increased during the study period (P < 0.001). Stroke-specific mortality was 5%. Outcomes included neurological deficits in 60% of neonates and 70% of older children. Among neonates, deficits emerged during follow-up in 39%. Overall, an initially decreased level of consciousness, a nonspecific systemic presentation, and the presence of stroke risk factors predicted abnormal outcomes. For neonates, predictors were decreased level of consciousness, nonspecific systemic presentation, and basal ganglia infarcts. For older children, predictors were initial seizures, nonspecific systemic presentation, risk factors, and lack of antithrombotic treatment. Recurrent arterial ischemic stroke or transient ischemic attack developed in 12% of older children and was predicted by arteriopathy, presentation without seizures, and lack of antithrombotic treatment. Emerging deficit was predicted by neonatal age at stroke and by cardiac disease. CONCLUSIONS This national data set provides a population-based disease incidence rate and demonstrates the protective effect of antithrombotic treatment in older children, and frequent long-term emerging deficits in neonates and in children with cardiac disorders. Further clinical trials are required to develop effective age-appropriate treatments for children with acute arterial ischemic stroke.
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Affiliation(s)
- Gabrielle A deVeber
- Division of Neurology, Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.
| | - Adam Kirton
- Department of Pediatrics, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Frances A Booth
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jerome Y Yager
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Ellen Wood
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael Shevell
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Ann-Marie Surmava
- Division of Neurology, Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Patricia McCusker
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Daune MacGregor
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - E Athen MacDonald
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
| | - Brandon Meaney
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Simon Levin
- Department of Pediatrics, University of Western Ontario, London, Ontario, Canada
| | - Bernard G Lemieux
- Department of Pediatrics, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Lawrence Jardine
- Department of Pediatrics, University of Western Ontario, London, Ontario, Canada
| | - Peter Humphreys
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Michèle David
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Anthony K C Chan
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - David J Buckley
- Department of Pediatrics, Janeway Children's Health and Rehabilitation Centre, St. John's, Newfoundland, Canada
| | - Bruce H Bjornson
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
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28
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Pediatric arterial ischemic stroke: Epidemiology, risk factors, and management. Blood Cells Mol Dis 2017; 67:23-33. [PMID: 28336156 DOI: 10.1016/j.bcmd.2017.03.003] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 03/06/2017] [Accepted: 03/06/2017] [Indexed: 12/17/2022]
Abstract
Pediatric arterial ischemic stroke (AIS) is an uncommon but important cause of neurologic morbidity in neonates and children, with consequences including hemiparesis, intellectual disabilities, and epilepsy. The causes of pediatric AIS are unique to those typically associated with stroke in adults. Familiarity with the risk factors for AIS in children will help with efficient diagnosis, which is unfortunately frequently delayed. Here we review the epidemiology and risk factors for AIS in neonates and children. We also outline consensus-based practices in the evaluation and management of pediatric AIS. Finally we discuss the outcomes observed in this population. While much has been learned in recent decades, many uncertainties sill persist in regard to pediatric AIS. The ongoing development of specialized centers and investigators dedicated to pediatric stroke will continue to answer such questions and improve our ability to effectively care for these patients.
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29
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Béjot Y, Delpont B, Blanc C, Darmency V, Huet F, Giroud M. [Epidemiology of strokes in pediatry]. SOINS. PEDIATRIE, PUERICULTURE 2017; 38:12-13. [PMID: 28325378 DOI: 10.1016/j.spp.2017.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Incidence of perinatal arterial stroke (ischemic stroke, intracerebral hemorrhage and subarachnoid hemorrhage) occurring between 20 weeks of gestation and postnatal day 28 ranges between 20 and 65 cases per 100,000 living births. In children aged 29 days to 18 years old, the total incidence is 1.3 to 4.3 for 100,000 per year. In France, almost 450 children are hospitalized for a stroke each year, among them approximately half have an intracerebral hemorrhage.
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Affiliation(s)
- Yannick Béjot
- Registre Dijonnais des AVC, CHU Dijon Bourgogne, 14 rue Gaffarel, 21089 Dijon, France.
| | - Benoit Delpont
- Registre Dijonnais des AVC, CHU Dijon Bourgogne, 14 rue Gaffarel, 21089 Dijon, France
| | - Christelle Blanc
- Registre Dijonnais des AVC, CHU Dijon Bourgogne, 14 rue Gaffarel, 21089 Dijon, France
| | - Véronique Darmency
- UFR Sciences Santé Dijon, CHU Dijon Bourgogne, Service de Pédiatrie, 14 rue Gaffarel, 21089 Dijon, France
| | - Frédéric Huet
- UFR Sciences Santé Dijon, CHU Dijon Bourgogne, Service de Pédiatrie, 14 rue Gaffarel, 21089 Dijon, France
| | - Maurice Giroud
- Registre Dijonnais des AVC, CHU Dijon Bourgogne, 14 rue Gaffarel, 21089 Dijon, France
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30
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Saliba E, Debillon T, Auvin S, Baud O, Biran V, Chabernaud JL, Chabrier S, Cneude F, Cordier AG, Darmency-Stamboul V, Diependaele JF, Debillon T, Dinomais M, Durand C, Ego A, Favrais G, Gruel Y, Hertz-Pannier L, Husson B, Marret S, N’Guyen The Tich S, Perez T, Saliba E, Valentin JB, Vuillerot C. Accidents vasculaires cérébraux ischémiques artériels néonatals : synthèse des recommandations. Arch Pediatr 2017; 24:180-188. [DOI: 10.1016/j.arcped.2016.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 07/25/2016] [Accepted: 11/22/2016] [Indexed: 12/01/2022]
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31
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Grunt S, Mazenauer L, Buerki SE, Boltshauser E, Mori AC, Datta AN, Fluss J, Mercati D, Keller E, Maier O, Poloni C, Ramelli GP, Schmitt-Mechelke T, Steinlin M. Incidence and outcomes of symptomatic neonatal arterial ischemic stroke. Pediatrics 2015; 135:e1220-8. [PMID: 25896840 DOI: 10.1542/peds.2014-1520] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Neonatal arterial ischemic stroke (NAIS) is associated with considerable lifetime burdens such as cerebral palsy, epilepsy, and cognitive impairment. Prospective epidemiologic studies that include outcome assessments are scarce. This study aimed to provide information on the epidemiology, clinical manifestations, infarct characteristics, associated clinical variables, treatment strategies, and outcomes of NAIS in a prospective, population-based cohort of Swiss children. METHODS This prospective study evaluated the epidemiology, clinical manifestations, vascular territories, associated clinical variables, and treatment of all full-term neonates diagnosed with NAIS and born in Switzerland between 2000 and 2010. Follow-up was performed 2 years (mean 23.3 months, SD 4.3 months) after birth. RESULTS One hundred neonates (67 boys) had a diagnosis of NAIS. The NAIS incidence in Switzerland during this time was 13 (95% confidence interval [CI], 11-17) per 100,000 live births. Seizures were the most common symptom (95%). Eighty-one percent had unilateral (80% left-sided) and 19% had bilateral lesions. Risk factors included maternal risk conditions (32%), birth complications (68%), and neonatal comorbidities (54%). Antithrombotic and antiplatelet therapy use was low (17%). No serious side effects were reported. Two years after birth, 39% were diagnosed with cerebral palsy and 31% had delayed mental performance. CONCLUSIONS NAIS in Switzerland shows a similar incidence as other population-based studies. About one-third of patients developed cerebral palsy or showed delayed mental performance 2 years after birth, and children with normal mental performance may still develop deficits later in life.
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Affiliation(s)
- Sebastian Grunt
- Department of Neuropaediatrics, Development and Rehabilitation, University Children's Hospital, Inselspital, Bern, Switzerland;
| | - Lea Mazenauer
- Department of Neuropaediatrics, Development and Rehabilitation, University Children's Hospital, Inselspital, Bern, Switzerland
| | - Sarah E Buerki
- Department of Neuropaediatrics, Development and Rehabilitation, University Children's Hospital, Inselspital, Bern, Switzerland
| | - Eugen Boltshauser
- Department of Neuropaediatrics, University Children's Hospital, Zurich, Switzerland
| | | | - Alexandre N Datta
- Department of Neuropaediatrics, University Children's Hospital, Basel, Switzerland
| | - Joël Fluss
- Neuropaediatrics, Paediatric Subspecialties Service, University Children's Hospital, Geneva, Switzerland
| | | | - Elmar Keller
- Department of Neuropaediatrics, Children's Hospital, Chur, Switzerland
| | - Oliver Maier
- Department of Neuropaediatrics, Children's Hospital, St Gallen, Switzerland
| | - Claudia Poloni
- Department of Neuropaediatrics, University Children's Hospital, Lausanne, Switzerland
| | - Gian-Paolo Ramelli
- Department of Paediatrics, Children's Hospital, Bellinzona, Switzerland; and
| | | | - Maja Steinlin
- Department of Neuropaediatrics, Development and Rehabilitation, University Children's Hospital, Inselspital, Bern, Switzerland
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32
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Suppiej A, Gentilomo C, Saracco P, Sartori S, Agostini M, Bagna R, Bassi B, Giordano P, Grassi M, Guzzetta A, Lasagni D, Luciani M, Molinari AC, Palmieri A, Putti MC, Ramenghi LA, Rota LL, Sperlì D, Laverda AM, Simioni P. Paediatric arterial ischaemic stroke and cerebral sinovenous thrombosis. First report from the Italian Registry of Pediatric Thrombosis (R. I. T. I., Registro Italiano Trombosi Infantili). Thromb Haemost 2015; 113:1270-7. [PMID: 25761414 DOI: 10.1160/th14-05-0431] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 01/14/2015] [Indexed: 11/05/2022]
Abstract
Data from large case series of children with cerebral thrombotic events are pivotal to improve prevention, early recognition and treatment of these conditions. The Italian Registry of Pediatric Thrombosis (R. I. T. I.) was established in 2007 by a multidisciplinary team, aiming for a better understanding of neonatal and paediatric thrombotic events in Italy and providing a preliminary source of data for the future development of specific clinical trials and diagnostic-therapeutic protocols. We analysed data relative to the paediatric cerebral thrombotic events of the R. I. T. I. which occurred between January 2007 and June 2012. In the study period, 79 arterial ischaemic stroke (AIS) events (49 in males) and 91 cerebral sinovenous thrombosis (CSVT) events (65 in males) were enrolled in the R. I. T. I. Mean age at onset was 4.5 years in AIS, and 7.1 years in CSVT. Most common modes of presentation were hemiparesis, seizures and speech disturbances in AIS, and headache, seizures and lethargy in CSVT. Most common etiologies were underlying chronic diseases, vasculopathy and cardiopathy in AIS, and underlying chronic diseases and infection in CSVT. Time to diagnosis exceeded 24 hours in 46 % AIS and 59 % CSVT. Overall data from the Italian Registry are in substantial agreement with those from the literature, despite small differences. Among these, a longer time to diagnosis compared to other registries and case series poses the accent to the need of an earlier recognition of paediatric cerebrovascular events in Italy, in order to enable prompt and effective treatment strategies.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Paolo Simioni
- Prof. Paolo Simioni, Department of Medicine, University of Padua Medical School, Via Ospedale 105, 35100 Padua, Italy, Tel.: +39 04 9821 2667, Fax: +39 04 9821 2651, E-mail:
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33
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Abstract
Abstract
The etiology of pediatric venous thromboembolic disease (VTE) is multifactorial, and in most children, 1 or more clinical risk factors are present. In addition, inherited thrombophilic disorders contribute to the development of pediatric VTE. In this review, the role of inherited thrombophilic disorders in the development of pediatric VTE, as well as the benefits and limitations of thrombophilia testing, will be discussed.
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34
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Management and 2-year follow-up of children aged 29days to 17years hospitalized for a first stroke in France (2009–2010). Arch Pediatr 2014; 21:1305-15. [DOI: 10.1016/j.arcped.2014.08.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 06/13/2014] [Accepted: 08/20/2014] [Indexed: 11/16/2022]
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35
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Lin MP, Towfighi A. Stroke
Literature Synopses: Clinical Science. Stroke 2014. [DOI: 10.1161/strokeaha.114.004280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michelle P. Lin
- From the Department of Neurology, University of Southern California, Los Angeles; and Department of Neurology, Rancho Los Amigos National Rehabilitation Center, Downey, CA
| | - Amytis Towfighi
- From the Department of Neurology, University of Southern California, Los Angeles; and Department of Neurology, Rancho Los Amigos National Rehabilitation Center, Downey, CA
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36
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Childhood arterial ischaemic stroke incidence, presenting features, and risk factors: a prospective population-based study. Lancet Neurol 2014; 13:35-43. [DOI: 10.1016/s1474-4422(13)70290-4] [Citation(s) in RCA: 240] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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37
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Drougia AA, Zikou AK, Vartholomatos GA, Argyropoulou MI, Andronikou SK. Cerebral venous sinus thrombosis in a pre-term neonate diagnosed by MR-venography. J OBSTET GYNAECOL 2013; 33:415. [DOI: 10.3109/01443615.2013.767783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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38
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Chang CH, Kusama M, Ono S, Sugiyama Y, Orii T, Akazawa M. Assessment of statin-associated muscle toxicity in Japan: a cohort study conducted using claims database and laboratory information. BMJ Open 2013; 3:e002040. [PMID: 23585384 PMCID: PMC3641424 DOI: 10.1136/bmjopen-2012-002040] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Revised: 02/28/2013] [Accepted: 03/18/2013] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To estimate the incidence of muscle toxicity in patients receiving statin therapy by examining study populations, drug exposure status and outcome definitions. DESIGN A retrospective cohort study. SETTING 16 medical facilities in Japan providing information on laboratory tests performed in and claims received by their facilities between 1 April 2004 and 31 December 2010. PARTICIPANTS A database representing a cohort of 35 903 adult statin (atorvastatin, fluvastatin, pitavastatin, pravastatin, rosuvastatin and simvastatin) users was studied. Use of interacting drugs (fibrates, triazoles, macrolides, amiodarone and ciclosporin) by these patients was determined. MAIN OUTCOME MEASURE Statin-associated muscle toxicity (the 'event') was identified based on a diagnosis of muscle-related disorders (myopathy or rhabdomyolysis) and/or abnormal elevation of creatine kinase (CK) concentrations. Events were excluded if the patients had CK elevation-related conditions other than muscle toxicity. Incidence rates for muscle toxicity were determined per 1000 person-years, with 95% CI determined by Poisson regression. RESULTS A total of 18 036 patients accounted for 42 193 person-years of statin therapy, and 43 events were identified. The incidence of muscle toxicity in the patients treated with statins was 1.02 (95% CI 0.76 to 1.37)/1000 person-years. The estimates varied when outcome definitions were modified from 0.09/1000 person-years, which met both diagnosis and CK 10× greater than the upper limit of normal range (ULN) criteria, to 2.06/1000 person-years, which met diagnosis or CK 5× ULN criterion. The incidence of muscle toxicity was also influenced by the statin therapies selected, but no significant differences were observed. Among 2430 patients (13.5%) received interacting drugs with statins, only three muscle toxicity cases were observed (incidence: 1.69/1000 person-years). CONCLUSIONS This database study suggested that statin use is generally well tolerated and safe; however, the risk of muscle toxicity related to the use of interacting drugs requires further exploration.
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Affiliation(s)
- Chia-Hsien Chang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, National Cheng Kung University, Tainan, Taiwan
- Laboratory of Pharmaceutical Regulatory Science, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Makiko Kusama
- Laboratory of Pharmaceutical Regulatory Science, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Shunsuke Ono
- Laboratory of Pharmaceutical Regulatory Science, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Yuichi Sugiyama
- Laboratory of Pharmaceutical Regulatory Science, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
- Sugiyama Laboratory, RIKEN Innovation Center, Research Cluster for Innovation, RIKEN, Kanagawa, Japan
| | - Takao Orii
- Pharmacy Department, NTT Medical Center Tokyo, Tokyo, Japan
| | - Manabu Akazawa
- Department of Public Health and Epidemiology, Meiji Pharmaceutical University, Tokyo, Japan
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39
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Bracken J, Barnacle A, Ditchfield M. Potential pitfalls in imaging of paediatric cerebral sinovenous thrombosis. Pediatr Radiol 2013; 43:219-31. [PMID: 22948810 DOI: 10.1007/s00247-012-2402-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2011] [Revised: 01/01/2012] [Accepted: 01/15/2012] [Indexed: 11/24/2022]
Abstract
Paediatric cerebral sinovenous thrombosis (CSVT) is a rare but serious condition. The imaging signs may be subtle with a number of potential pitfalls. We present a pictorial essay of the pitfalls of diagnosis of CSVT on CT and MRI. We describe, using examples, potential pitfalls on both imaging modalities including anatomical variants of the cerebral venous system, extra-axial fluid collections and enhancement of chronic thrombus. Pitfalls particular to CT are discussed including beam-hardening artefact, image windowing and neonatal physiological intravascular hyperdensity. We review the potential variability in the appearance of thrombus on MRI, dependent largely on the stage of thrombus evolution and the pulse sequence. The signal intensity of thrombi, although described as evolving in a typical pattern on T1- and T2-weighted MRI, may be affected by variability in the degree of oxygenation of red cells in the forming thrombus, dilution and secondary propagation of thrombosis. Individual MRI sequences should not be interpreted in isolation, but as a set, and compared with CT images if available.
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Affiliation(s)
- Jennifer Bracken
- Department of Medical Imaging, Monash Children's Hospital, 246 Clayton Road, Clayton, Victoria 3168, Australia.
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40
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Lebas A, Chabrier S, Fluss J, Gordon K, Kossorotoff M, Nowak-Göttl U, de Vries LS, Tardieu M. EPNS/SFNP guideline on the anticoagulant treatment of cerebral sinovenous thrombosis in children and neonates. Eur J Paediatr Neurol 2012; 16:219-28. [PMID: 22425391 DOI: 10.1016/j.ejpn.2012.02.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 02/14/2012] [Indexed: 12/17/2022]
Abstract
Anticoagulation of cerebral sinovenous thrombosis (CSVT) is recommended in adults and has been also approved in the paediatric setting. Some controversies remain however between the existing paediatric professional consensus, notably about its use in children with intra-cranial haemorrhage and in neonates. The publication of further original studies prompted the French Society for Paediatric Neurology (SFNP) in association with a panel of EPNS experts, to update the level of evidence and the knowledge in this domain. A bibliographic analysis revealed that anticoagulants are widely used in paediatrics. Anticoagulation is well tolerated by children (Class I, level of evidence B) and also probably by neonates (Class IIa, level of evidence B). During the acute phase, anticoagulation is probably effective in reducing the risk of death and sequelae in children (Class IIa, level of evidence B). It is not yet possible to draw any conclusions regarding neonates (Class IIb). Anticoagulation is also effective in reducing the risk of recurrence (Class I, level of evidence B). This risk is dependent on several individual factors such as the age of the child, the cause of the thrombosis, the persistence or the recurrence of thrombogenic factors, and the speed of sinus recanalisation. The duration of anticoagulation needs therefore to be individually tailored (Class I, level of evidence B). These observations have led to the following recommendations: -In the absence of any contraindication, it is reasonable to initiate anticoagulation during the acute phase of CSVT in children. Prolonged treatment over 3-6 months is justified according to individual factors. -In the absence of any contraindication, anticoagulation may be considered individually during the acute phase of CSVT in neonates for a duration of 6-12 weeks.
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Affiliation(s)
- Axel Lebas
- CHU Rouen, Hôpital Charles-Nicolle, Service de Neurophysiologie, Rouen F-76031, France
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