Stroke in childhood

A fulminant presentation of post-COVID-19 necrotizing pneumonia and ischemic stroke in an 8-year-old girl: A case report and literature review

Necrotizing pneumonia (NP) is the destruction of the interstitial part of the lung due to severe infection. One cause of this rare and fatal condition in pediatrics is Acinetobacter. Severe infections, especially pneumonia, can prone pediatric patients to ischemic stroke. This study reports an 8-year-old girl presented to the emergency department complaining of shortness of breath, fever, and fatigue. She was admitted to the intensive care unit due to respiratory distress and pericardial effusion. Swab and respiratory secretion tests for COVID-19 and Acinetobacter were positive. In her admission course, her condition deteriorated, and on the fifth day, she underwent a craniotomy due to the signs of increased intracranial pressure (ICP). The computed tomography (CT) scan showed an ischemic stroke. Despite all efforts and medical efforts, the patient's clinical condition got worse, and she died 10 days after the surgery. COVID-19 can lead to vulnerability to severe bacterial infections such as NP in pediatrics. Severe infections are a significant risk factor for ischemic stroke. The presentation might be different in intubated unconscious patients, such as detecting increased ICP signs. In severe and extensive cases of NP and ischemia, the destruction of the lungs and brain tissue might be irreversible and even lethal. Doctors and parents should consider neurologic complaints in children with infectious diseases as a serious issue since infections make children vulnerable to complications such as stroke.

Secondary Childhood glaucoma - a rare association in Seckel syndrome

A case of 12-year-old male with Seckel syndrome, presented with unilateral glaucoma leading to advanced disc damage hence, visual deterioration. Seckel syndrome being a rare inherited disorder characterized by growth delay and unique facial features, had been infrequently reported for ophthalmic anifestation especially glaucoma. Though glaucoma is a rare association in Seckel syndrome, screening at an early stage could help in preventing vision loss.

Recurrent arterial ischemic stroke with good response to mycophenolate mofetil

BACKGROUND

Arterial ischemic stroke is rare in childhood. Often, the diagnosis is made after considerable delay. A thorough workup to pinpoint the underlying etiology is necessary, as a correct diagnosis is the determining factor in treatment decision. In case of primary angiitis of the central nervous system, treatment with corticosteroids and immunosuppressive agents is indicated.

CASE STUDY

We described an eleven-year-old boy who presented at the age of six years with left hemiparesis and hemianopia. Cerebral imaging showed acute ischemia in the right posterior cerebral artery territory. Extensive workup was negative. In the following eight months, he had recurrent strokes on three separate occasions due to progressive arteriopathy involving multiple large- and medium-sized vessels. A presumed diagnosis of primary angiitis of the central nervous system was made. Pulse intravenous methylprednisolone therapy was started followed by oral prednisolone. After the fourth stroke, a six-month treatment with cyclophosphamide was given which was followed by maintenance treatment with azathioprine. Shortly after cessation of corticosteroids and cyclophosphamide the subject relapsed. Cyclophosphamide was restarted in combination with corticosteroids and subsequently replaced by mycophenolate mofetil. Under mycophenolate mofetil maintenance treatment combined with low-dose corticosteroids, the patient achieved disease control with a relapse-free period of more than four years.

CONCLUSION

A guideline for current treatment of relapsing central nervous system angiitis in childhood is missing in the literature. We describe a subject with multiple relapses despite treatment with corticosteroids and immunosuppressive agents, and stabilization of his clinical condition and of the radiological signs under mycophenolate mofetil treatment.

Migrainous infarction: a rare and often overlooked diagnosis

Migraine is a neurological entity and a well-known independent risk factor for cerebral infarction, which mostly afflicts the young female population. Researching focal neurological signs in this subset of the population with the diagnosis of a neurological ischemic event should always take into account the migraine as the etiology or as an associated factor. The etiology of central nervous system (CNS) ischemia is considerable. Migraine, although rare, also may be included in this vast etiological range, which is called migrainous infarction. In this setting, the diagnostic criteria required for this diagnosis is extensive. Herein, we present the case of a female adolescent who submitted to the emergency facility complaining of diplopia, dysarthria, and imbalance, which started concomitantly with a migrainous crisis with aura-a challenging clinical case that required extensive research to address all possible differential diagnoses.

Middle Cerebral Artery Stroke in a Neonate With a Congenital Hypercoagulable Condition Following Repair of an H-type Tracheoesophageal Fistula

We report a case of middle cerebral artery stroke with heterozygosity for 2 separate hypercoagulable conditions following repair of an H-type tracheoesophageal fistula (TEF) in an infant. Neonatal stroke is rare, occurring in 1 in 4000 births annually in the United States. Stroke after pediatric surgery occurs in approximately 0.05% of patients. Etiologies of stroke in neonates include cardiac, hematologic, vascular, traumatic, metabolic, pharmacologic, infectious, and hypoxemic insults. Thrombophilia has been described in 42% to 78% of neonates with neonatal stroke. Stroke after repair of an H-type TEF has not been reported as a postoperative complication. Manipulation of the carotid artery during this operation is presumed to have contributed to a thromboembolic event in this infant with a hypercoagulable state. Whereas preoperative workup may not be indicated due to the low prevalence of neonatal stroke, workup for a congenital hypercoaguable condition may be considered in infants with stroke as a postoperative complication. This report provides a concise review of the etiology and treatment of stroke and hypercoagulable states in neonates as well as presents the case of a previously undescribed complication of repair of an H-type TEF.

Ischemic Stroke in Confederation with Trivial Head Trauma

Minor head injuries in children are common, resulting in brain concussion, and these injuries mostly end up without complications. Usually head trauma results in hemorrhagic stroke. Here we present a case of ischemic stroke following a trivial head trauma. A 10-month-old girl presented with posttraumatic right sided hemiparesis with right sided facial palsy. MRI brain revealed an area of acute infarct in the left capsuloganglionic region. The child was initially managed conservatively, as the hematological parameters were normal, and was started on anticoagulant therapy. An improvement in the clinical condition was achieved in 12 hrs of treatment with gain in power and resolution of weakness in 10 days. The specific cause for hemiparesis in the child is not elicited; possibility of genetic and environmental factors can be attributable.

Long-Term Functional Outcome of Pediatric Stroke Survivors

PURPOSE

To examine the long-term functional, psychosocial, and medical outcome of pediatric stroke survivors.

METHOD

This was a descriptive survey performed on patients with childhood stroke who participated in an earlier study. Measures included the Vineland Adaptive Behavior Scales (VABS) and the Diener Satisfaction with Life Scale. Current information on living situation, school placement, employment, and medical outcome were obtained.

RESULTS

Twenty-nine (58%) patients participated. The mean age was 19.3 years (SD = 6.6), mean age of onset of stroke was 7.0 years (SD = 5.4), and mean follow-up time was 11.9 years (SD = 3.9). Diagnoses included hemorrhagic (31%) and ischemic (69%) stroke. All but one adult had finished high school, and the majority of participants had gone to college. 60% of patients over age 16 were employed. The average VABS levels for communication, daily living skills, socialization, and adaptive behavior fell into the moderately low range. Use of seizure medications and ADL dependence were the predictors for lower VABS levels (p <.05). Younger age, ischemic stroke, and previous dependence in mobility were risk factors for lower scores for the self-care domain, but not for lower life satisfaction. Patients who scored below adequate on VABS tended toward lower life satisfaction.

CONCLUSION

Pediatric stroke survivors had good educational and mobility outcomes, but communication, ADL, and socialization fell into the low-moderate range. The different predictors of functional and subjective quality of life outcomes suggest that functional outcomes may mediate the relations between medical factors and satisfaction with life.

Vertebral artery dissection complicated by basilar artery occlusion

Acute basilar artery occlusion (ABAO) is an infrequent but potentially fatal complication that can cause strokes in both adults and children. Traumatic vertebral artery dissection (VAD) is one of the most common causes of ABAO in young patients. We present a case of an 11-year-old boy with VAD complicated by basilar artery occlusion 2 days after a fight with classmates that caused severe neurological deficits. He did not have any direct head trauma or concomitant risk factors. Clinical symptoms included nausea, vomiting, and rapid alteration of consciousness. Magnetic resonance imaging showed total occlusion of the basilar artery, and angiography confirmed VAD from the third to the fourth segments. A history of such subtle precipitating events should be noted when diagnosing young patients with brainstem strokes. A delay in the diagnosis of ABAO is frequently due to misleading symptoms and signs and the lack of awareness of this rare condition.

Rubiano A, Moscote-Salazar LR. Fatal Massive Cerebral Infarction in a Child after Mild Brain Trauma: A Case Report and Literature Review

Traumatic brain injury is a common entity. However cerebral infarction in infants is a rare entity while the diagnosis of this pathology in the pediatric population is usually difficult. The mild head trauma is rarely accompanied by intracranial injury and even less, with cerebral infarction. We herein report the first case of cerebral infarction after a mild brain trauma in a 2-year-old Latin-American male patient, in which brain computed tomography (CT) scan was performed on the first day of the accident, showed right hemispheric cerebral ischemia compromising the fronto-parieto-occipital region. Conservative management was established. The patient died at day 5. So Brain CT scan may be beneficial to reveal any hemispheric infarction due to a probable mass effect.

Treatment of arterial ischemic stroke in children

Stroke is a rare but increasingly recognized disorder in children. Current therapies for arterial ischemic stroke include thrombolytic, antithrombotic and antiplatelet agents, blood transfusion and surgery. Adult studies, pediatric case studies and expert opinion form the basis for these treatment strategies. Thrombolytic agents are increasingly used but, as in adults, the majority of arterial ischemic strokes in children are treated with antiplatelet and antithrombotic agents. Sickle-cell patients, a distinct subset of the pediatric stroke population, are treated primarily with transfusion therapy. Pediatric arterial ischemic stroke studies are needed to determine the most appropriate course of treatment. An international study is currently in progress to formally study the incidence, risk factors, treatment strategies and outcomes of stroke in children.

Mycoplasma pneumoniae associated stroke in a 3-year-old girl

Infectious diseases precede a significant proportion of acute ischemic strokes in children. Here, we report a case of acute ischemic stroke in a 3-year-old girl with a Mycoplasma pneumonia-associated respiratory tract infection. She developed an acquired prothrombotic state of protein S deficiency and had increased fibrinogen and fibrinogen degradation product levels and increased titer of antinuclear antibodies. However, these conditions were completely alleviated at the 1-month follow-up examination. Infection with M. pneumoniae may cause a transient prothrombotic state that can potentially cause a thrombus.

Measuring Activity and Participation Outcomes for Children and Youth with Acquired Brain Injury: An Occupational Therapy Perspective

Introduction:

Intervention outcomes for children and youth with acquired brain injuries should be measured in terms of participation in activities. The aim of this study was to explore the occupational therapy outcome measures used with this group.

Method:

One cycle of an action research study, which focused specifically on occupational therapists, is reported. Ten occupational therapists working with children and youth with acquired brain injuries collated the outcome measures they used and mapped their frequently used measures onto the International Classification of Functioning, Disability and Health — Children and Youth, using established linking rules.

Findings:

Forty-two outcome measures and assessments were identified. Of these, 19 were used frequently and 15 were used as outcome measures. All activity and participation domains were represented, with learning and applying knowledge, mobility, communication and self-care (except looking after one's health) particularly well covered.

Conclusion:

Occupational therapists are using measures that reflect the domains of activity and participation, unlike those previously identified which were linked predominantly to body functions. The importance of occupational therapists working in rehabilitation teams is reiterated in that some of the domains that are not covered by occupational therapists impact on participation, for example, pain.

Unilateral Basal Ganglia Infarcts: a Red Flag for Ipsilateral Cranio-Cervical Arterial Occlusive Disease. A Report on Two Children with Moya-moya Disease

Steno-occlusive disease of the internal carotid arteries and/or the circle of Willis with development of collateral perforator vessels attempting to supply under-perfused parenchyma are the basis for moya-moya phenomenon with the classic "puff of smoke" appearance on cerebral angiogram. We describe two cases of moya-moya with unilateral macroangiopathy of the internal carotid artery and ipsilateral middle cerebral artery in two 11-year-old girls: a Down's syndrome patient, and a second idiopathic patient. The arteriopathy in our cases differs from typical or classically described moya-moya disease in that it was exclusively unilateral rather than symmetric and bilateral. The association of predominant deep grey matter (basal ganglia) strokes in children with coexisting ipsilateral parainsular infarcts, as in our cases, is potentially a red flag for ipsilateral macroangiopathy.

Thrombolytic therapy for acute stroke in a teenager

BACKGROUND

The importance of thrombolytic therapy within the first 3 hours of onset of symptoms of an acute stroke has been stressed, and in consequence, the diagnosis is most commonly made based on clinical grounds. Intracranial hemorrhage is the major life-threatening complication with the use of thrombolytic therapy. Because of the very small time window before administering thrombolytics, it is often not possible to investigate the unusual causes of a stroke that occurs most often in children.

OBJECTIVE

This study aimed to present the decision and risk of thrombolysis for an acute ischemic stroke in children.

CASE

A case of a teenager with an acute ischemic stroke who received thrombolysis and had resolution of symptoms.

CONCLUSIONS

Thrombolytic therapy is effective in acute ischemic strokes; however, in children, one must consider and exclude stroke mimickers and recognize that potentially life-threatening bleeding complicates the use of these medications.

Perfusion CT in childhood stroke--initial observations and review of the literature

INTRODUCTION

To report the preliminary results of contrast-enhanced perfusion multi-detector CT for diagnoses of perfusion disturbances in children with clinical suspicion of stroke.

PATIENTS AND METHODS

Within the last two years emergency perfusion CT was performed in ten children (age: 8-17 years, male:female=3:7) for assessment of suspected childhood stroke. These intracranial perfusion CT, intracranial CT-digital subtraction angiography (CT-DSA) and extracranial CT-angiography (CTA) studies were retrospectively reviewed and compared with MRI, follow-up CT, catheter angiography and final clinical diagnosis. The total dose length product (DLP) for the entire examination was recorded. The image quality of perfusion CT-maps, CT-DSA and CTA were evaluated with a subjective three-point scale ranging from very good to non-diagnostic image quality rating perfusion disturbance, intracranial peripheral vessel depiction, and motion- or streak artifacts.

RESULTS

In nine of ten children perfusion CT showed no false positive or false negative results. In one of ten children suffering from migraine focal hypo-perfusion was read as perfusion impairment potentially indicating early stroke, but MRI and MRA follow-up were negative. Overall, perfusion-CT with CT-DSA was rated very good in 80% of cases for the detection of perfusion disturbances and vessel anatomy.

CONCLUSIONS

In comparison to standard CT, contrast-enhanced perfusion CT improves CTs' diagnostic capability in the emergency examination of children with a strong suspicion of ischemic cerebral infarction.

Pediatric stroke: a review

Stroke is relatively rare in children, but can lead to significant morbidity and mortality. Understanding that children with strokes present differently than adults and often present with unique risk factors will optimize outcomes in children. Despite an increased incidence of pediatric stroke, there is often a delay in diagnosis, and cases may still remain under- or misdiagnosed. Clinical presentation will vary based on the child's age, and children will have risk factors for stroke that are less common than in adults. Management strategies in children are extrapolated primarily from adult studies, but with different considerations regarding short-term anticoagulation and guarded recommendations regarding thrombolytics. Although most recommendations for management are extrapolated from adult populations, they still remain useful, in conjunction with pediatric-specific considerations.

[Cerebrovascular disease in childhood: a retrospective analysis of hospital admissions in a tertiary hospital in the community of Valencia in the last ten years]

INTRODUCTION

There has been increasing interest in stroke in children in the last few years. A literature review produced little information on risk factors and other clinical questions. The aim of this study is to describe the characteristics of stroke in children, mainly in order to identify the risk factors, clinical presentation and outcomes.

PATIENTS AND METHODS

A retrospective study was conducted on patients admitted to the Hospital La Fe in Valencia between January 2000 to September 2010 with the diagnosis of ischaemic or haemorrhagic stroke.

RESULTS

A total of 76 patients were identified, of whom 44.7% had an ischaemic stroke and 55.3% had a haemorrhagic one. The average age of presentation was 6.8 years; 8.4 years for haemorrhagic strokes and 4.7 years for ischaemic strokes. Headache was the most frequent symptom of presentation. The most frequent risk factor was vascular malformations in haemorrhagic cerebral stroke, and vascular and cardiac disorders in ischaemic stroke. A study of prothrombotic factors was conducted on 34 patients, which was positive in 64.7% of them. As regards outcome, 17% of the patients died; only 3 patients had a secondary epilepsy, and 31% and 60% of the haemorrhagic and ischaemic stokes, respectively, had a hemiparesis.

CONCLUSIONS

In this study we identified the principal risk factors as well as, the age of presentation, symptomatology and outcome. We would like to emphasise that the age of presentation was earlier in ischaemic strokes than in haemorrhagic ones.

Treatment challenges in pediatric stroke patients

Aim. In this study we presented our experience of 18 years on the etiology, risk factors, prophylactic and acute treatment, the effect of treatment to recurrence rate of patients with stroke. Methods. The population included 108 patients who had been treated for stroke at Pediatric Neurology Department of Ankara University with the diagnosis of arterial ischemic stroke and sinovenous thrombosis between January 1992 and August 2010. Forty-one girls (38%) and 67 boys (62%) with mean symptom age 3.1 ± 4.04 years, (0–18 years old) were followed up with a mean period of 4.9 ± 3.78 years (0–17 years). Results. 30 patients had no risk factors, 34 patients had only one risk factor and 44 patients had multiple risk factors. Recurrence was seen in three patients. There was no any statistical correlation between the recurrence of stroke and the existence of risk factors (P = .961). Seventeen patients received prophylactic treatment; 2 of them without any risk factors, 3 had one risk factor, 12 patients, who constituted the majority of our patients, had multiple risk factors (P = .024). Conclusion. With this study we showed that the right prophylaxis for right patients reduces the rate of recurrence.

Diagnosis and management of pediatric arterial ischemic stroke

Pediatric stroke is among the top 10 causes of death in children and an important cause of chronic morbidity, with an incidence of 3.3/100,000 children/year. Risk factors associated with stroke in children include cardiac diseases, hematologic and vascular disorders, and infection. Clinical presentation varies depending on age, underlying cause, and stroke location. Antithrombotics and anticoagulants are used in the treatment of pediatric stroke; however, there are no established guidelines for the use of these agents in children. In this article we review the cause, pathophysiology, clinical presentation, diagnosis, acute management, secondary prevention, and outcome of children with stroke. The approach to patients with sickle cell disease and Moyamoya disease is also discussed. Up to date studies to determine the optimal acute treatment of childhood stroke and secondary prevention and risk factor modification are critically needed.

Ischemic stroke associated with adenoviral infection in a 4-year-old boy

We present a case of childhood arterial ischemic stroke associated with proven adenoviral upper respiratory tract infection in a previously healthy 4-year-old boy. Adenoviral meningitis and encephalitis have been reported repeatedly, thus confirming the neuroinvasive capability of these viruses. However, an association between adenoviral infection and arterial ischemic stroke has not been described thus far. HIV and varicella zoster virus are the only microorganisms that have been consistently associated with arterial ischemic stroke in the absence of acute central nervous system infection. In HIV-infected individuals ischemic stroke can be caused by vasculitis and hypercoagulability. Granulomatous arteritis of the vessel wall causes post-varicella cerebral infarction and ischemic stroke after herpes zoster ophthalmicus. We suggest that in our patient a post-varicella cerebral infarction-like mechanism of adenoviral spread to the affected artery wall occurred through the ophthalmic branch of the trigeminal nerve. Adenoviruses are neuroinvasive and inflamed conjunctiva might have permitted introduction of the virus into ophthalmic nerve tissue. In consequence, the stenotic lesion of the artery might have been induced by the presence of adenovirus and the subsequent inflammatory reaction. We recommend a prompt quest for adenoviral infection in all previously healthy children with fever and clinical presentation compatible with ischemic stroke, because timely diagnosis and treatment could improve the outcome and hasten neurological recovery.

Delays in investigation and management of acute arterial ischaemic stroke in children

The aim of this study was to investigate the timing and course of investigation and diagnosis in children with acute arterial ischaemic stroke (AIS) and factors influencing this using a retrospective case-note review. Participants comprised 50 children (26 males, 24 females; median age at presentation 3 y 4 mo, range 2 mo-16 y 10 mo). Although all had brain infarction, symptoms resolved in less than 24 hours in 21 children (transient ischaemic attack [TIA] group). Thirty-seven children saw a doctor within 6 hours of the attack; 32 did not see a paediatric neurologist until after 24 hours. Initial neuroimaging (computed tomography or magnetic resonance imaging) occurred in less than 6 hours in 13/46 children and in more than 24 hours in 18/46 children. Brain magnetic resonance imaging occurred in more than 24 hours in 43/47 children. Time to clinical diagnosis (data available on 42 children) was less than 6 hours in 14 children, 6 to 12 hours in six, 12 to 24 hours in eight, and more than 24 hours in 14 children. In multiple regression analysis, patients with stroke were more likely to have shorter time to diagnosis than those with TIA. Our results show that most children with acute AIS are seen within 6 hours but definitive imaging and specialist assessment take more than 24 hours. Time to diagnosis is significantly longer in children with TIA (p=0.001). Trials of acute treatment being designed for childhood AIS will require rapid transfer to tertiary centers and access to definitive neuroimaging, but these data suggest that this will challenge existing practice.

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

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

Clinically successful late recanalization of basilar artery occlusion in childhood: What are the odds?

BACKGROUND AND PURPOSE

Acute basilar artery occlusion is an infrequent but potentially fatal cause of stroke, both in adults and children. We present our experience with a 6-year-old child and we investigate the rationality for late treatment of acute basilar occlusion in children.

METHODS

We report the case of a 6-year-old boy with acute basilar artery occlusion presented with a full blown locked-in syndrome, admitted to the endovascular suite 44 h after the stroke onset, and we review all the reported cases of basilar artery occlusions presented with locked-in syndrome in children.

RESULTS

Six hours following admission the basilar artery was partially recanalized by intra-arterial thrombolysis combined with mechanical clot angioplasty. After 12 h, the patient was awake, oriented, his speech function was fully restored and he had only a mild right hemiparesis that recovered completely after a month.

CONCLUSIONS

To our knowledge, this is the first report of complete clinical recovery after delayed (50 h) endovascular recanalization of basilar artery in a child. Intra-arterial thrombolysis combined with cerebral angioplasty, can successfully restore the patency of the basilar artery and the neurologic deficit of children with acute basilar artery occlusion, even after a considerable delay.

Acute midbrain infarction in a child with intracranial carotid artery hypoplasia and aberrant cerebral vasculature: a case report

Strokes identified in older children typically present with sudden hemiparesis, frequent association with seizures, and occasional accompaniment of hemisensory signs or visual field defects. In this case of a left cerebral peduncle infarction, initially the patient was not found with evident right-side hemiparesis but with right-side paresthesia and mild worsening of her underlying left-side weakness, including weakness of left facial expression and left ptosis. Her right limbs became gradually weaker in the first 2 days. These bizarre clinical presentations, the mild worsening of the underlying left-side weakness, and the delayed presentation of right-side hemiparesis added to the difficulty of making a diagnosis and of the initial localization. In addition, the magnetic resonance angiography incidentally found an abnormal vessel, which was additional and serpiginous to the right posterior fossa. The right internal carotid artery was markedly smaller than the left one, and a defect was seen around the area of the presumed distal right internal carotid artery. The abnormal cerebral vasculature might be the cause of the unique clinical presentation and might be the contributing factor to the recurrence of her stroke. In conclusion, the authors report a special case of recurrent stroke on the basis of aberrant cerebral vasculature.

Clinical and Radiological Recurrence After Childhood Arterial Ischemic Stroke

Background— Data on rates and risk factors for clinical and radiological recurrence of childhood arterial ischemic stroke (AIS) might inform secondary prevention strategies.

Methods and Results— Consecutive Great Ormond Street Hospital patients with first AIS were identified retrospectively (1978–1990) and prospectively (1990–2000). Patients underwent repeat neuroimaging at the time of clinical recurrence or, if asymptomatic, at least 1 year after AIS. Cox and logistic regression analyses were used to explore the relationships between risk factors and clinical and radiological recurrence, respectively. A total of 212 patients were identified, of whom 97 had another prior diagnosis. Seventy-nine children had a clinical recurrence (29 strokes, 46 transient ischemic attacks [TIAs], 4 deaths with reinfarction 1 day to 11.5 years (median 267 days) later); after 5 years, 59% (95% confidence interval, 51% to 67%) were recurrence free. Moyamoya on angiography and low birth weight were independently associated with clinical recurrence in the whole group. Genetic thrombophilia was associated with clinical recurrence in previously healthy patients, independent of the presence of moyamoya. Sixty of 179 patients who had repeat neuroimaging had radiological reinfarction, which was clinically silent in 20. Previous TIA, bilateral infarction, prior diagnosis (specifically immunodeficiency), and leukocytosis were independently associated with reinfarction. Previous TIA and leukocytosis were also independently associated with clinically silent reinfarction.

Conclusions— Clinical and radiological recurrence are common after childhood AIS. The risk of clinical recurrence is increased in children with moyamoya and, in previously healthy patients, in those with genetic thrombophilia. Preexisting pathology, including immunodeficiency, and persistent leukocytosis are risk factors for radiological recurrence, which suggests a potential role for chronic infection.

Lessons from adult stroke trials

Before designing epidemiologic, genetic, or treatment trials in pediatric stroke, we should learn from adult trials which preceded. Adult trialists state that there is a need for improved animal models to mimic human disease. Dose-response curves with blinded outcome measures would improve preclinical data. Functional and histologic outcome measures would improve the animal model. In regard to human Phase 2 medication trials, safety, delivery, end points, and surrogate markers are necessary. The detection of biologic activity can be defined in Phase 2B trials. For Phase 3 trials, the experiment needs to be simple with global outcome measures as end points. New statistical designs such as futility analysis may improve and streamline trials in both adults and children. Clinical trials are a long process, and care needs to be incorporated at every step. Why is there a propensity of failed studies for acute ischemic stroke in adults? The reasons include (a) the animal model fails us, (b) the Phase 2 trials are ineffective in defining dose, and (c) the Phase 3 trials are poorly done. Because clinical trials, more often than not, fail to give positive (effective treatment) results, it seems reasonable to attempt to learn from others' past experiences before initiating pediatric stroke trials.

Managing stroke in children

The incidence of stroke in the pediatric population is estimated at between 2 and 3 per 100,000. Strokes are divided into ischemic or hemmorhagic categories, depending on whether the primary cause is obstruction or bleeding into the brain. Strokes may present with acute, recurrent, or evolving neurological deficits. There is a long and varied list of causes of stroke in children. The major causes of ischemic stroke are cardiac abnormalities and coagulation disorders. Cerebrovascular malformations account for the majority of hemmorhaghic strokes. The workup is guided by the initial history and imaging studies. Treatment is dependent on the specific risk factors identified, and outcome is dependent on the location and extent of the initial insult.

Evolution of cerebral arteriopathies in childhood arterial ischemic stroke

OBJECTIVE

To investigate evolution of cerebral arteriopathy in children with arterial ischemic stroke (AIS) and its influence on recurrence.

METHODS

Arteriopathy severity was graded on serial magnetic resonance angiograms from 50 children with first AIS; diagnostic categories were assigned.

RESULTS

Arteriopathy affected 72 arteries in 43 of 50 children. Five had clinical recurrence, with reinfarction in four; another had clinically silent reinfarction. Twelve children (24%; 4 with recurrence) had progressive arteriopathy. Arteriopathy improved in 24 patients (including 1 with recurrent transient ischemic attacks) and was stable in 7 patients. Magnetic resonance angiograms remained normal in seven patients; one had recurrent stroke. Diagnoses were transient cerebral arteriopathy (n = 24), chronic cerebral arteriopathy (n = 11), arterial dissection (n = 3), possible moyamoya (n = 2), primary moyamoya (n = 1), dysplastic arteriopathy (n = 1), and cerebral vasculitis (n = 1). Some of the first two categories could represent thromboembolic arterial occlusion with recanalization. The hazard of recurrence was three times higher when arterial disease had progressed (Cox regression hazard ratio, 3.2; 95% confidence intervals, 0.5-20.3; p = 0.22). After adjustment for age and number of AIS risk factors, the hazard ratio was 3.1 (95% confidence interval, 0.4-22.2; p = 0.27).

INTERPRETATION

Arteriopathy frequently progresses after childhood AIS. Further studies are needed to examine the relationship between progressive arteriopathy and recurrence.

Stroke associated with pseudoephedrine in a child with rhabdomyosarcoma

Pseudoephedrine is a nasal vasoconstrictor and is contained in many cough and cold medications. It is generally harmless when used in recommended doses. Hypertensive crisis, psychosis, hemorrhagic stroke, and intracranial hemorrhage have been reported as severe complications. We report a 4-year-old girl with nasopharyngeal rhabdomyosarcoma who developed stroke while on pseudoephedrine therapy for 3 days and had no hematological abnormalities.

Antiplatelet therapy in children

Platelets are essential for the maintenance of vascular integrity and control of bleeding at sites of injury, but they are also implicated in the progression of atherosclerotic lesions and arterial vascular thrombosis. The use of antiplatelet drugs for the primary and secondary prevention of cardiovascular and cerebrovascular thromboses in adult populations has been extensively evaluated, resulting in defined management strategies. Much less is known about the appropriate use of antiplatelet drugs (primarily aspirin) in infants and children for secondary prevention in ischemic stroke, for prevention of coronary artery thrombosis in Kawasaki disease, or for prevention of thromboembolism following surgery for congenital cardiac disease. Additional studies will be required to evaluate the relative benefits of aspirin and anticoagulants in these settings. A role for newer antiplatelet drugs in the management of pediatric arterial thrombosis is as yet unexplored.

[Pseudotumor cerebri secondary to dural sinus thrombosis: pediatric case report]

Pseudotumor cerebri is a relatively common neurologic syndrome in adolescence. In most cases, etiology is idiopathic, but it may have serious complications, such as blindness, that are related to increased intracranial pressure. The aim of this article is to emphasize the differential diagnosis of pseudotumor cerebri, with special attention to treatable etiologies. We report a case of an 12 year-old adolescent who presented with diplopia and headache 9 days after right-sided otitis media and mastoiditis. Head computerized tomography was normal, but brain magnetic resonance imaging demonstrated thrombosis of ipsilateral transverse and sigmoid sinuses, which responded promptly to early anticoagulation. The conclusion is that magnetic resonance imaging is essential for patients with a clinical diagnosis of pseudotumor cerebri in order to exclude treatable causes, such as dural sinus thrombosis.

Ischemic stroke in children treated for acute lymphoblastic leukemia: a retrospective study

The clinical and diagnostic findings and the factors influencing the neurologic and radiologic outcome of symptomatic ischemic stroke were evaluated in a group of 2,318 children with acute lymphoblastic leukemia (ALL) treated according to the AIEOP (Italian Association of Pediatric Hematology and Oncology) study protocols. In this multicentric retrospective study, a questionnaire was sent to each of the 43 AIEOP centers participating in the study. The questionnaire was designed to obtain information on the number, type, and time of occurrence of ischemic strokes, biologic and immunologic features of each case, as well as clinical data of the recruited patients. A prevalence of 0.47% was found. All ischemic strokes were sinovenous thrombosis (SVT). The most common neurologic presentations were diffuse neurologic signs and seizures. MRI with or without venography revealed SVT in 100% of cases; superficial SVT was diagnosed in the majority of cases. Antithrombotic drugs, in particular unfractioned heparin and low-molecular-weight heparin, were administered without bleeding complications. This series shows an excellent long-term neurologic outcome in children with SVT. However, a complete radiologic resolution was found in only 54% of cases; the involvement of deep cerebral venous sinuses was associated with an unfavorable imaging outcome.

TNF-α −308G/A and IL-6 −174 G/C polymorphisms in the Turkish pediatric stroke patients

INTRODUCTION

Introduction: Stroke is an important cause of mortality and morbidity in the pediatric age group. There is increasing evidence on the role of proinflammatory cytokines such as interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) in the occurrence and outcome of stroke. These proinflammatory cytokines carry functional polymorphisms (IL-6 -174 G/C and TNF-alpha -308 G/A) in their promoter regions, affecting their transcription rate and plasma cytokine levels. The aim of this study was to investigate the association of these polymorphisms with the occurrence of stroke in the Turkish pediatric stroke patients.

MATERIAL AND METHODS

Eighty six arterial stroke patients (aged between 0 and 14) and 83 healthy unrelated adult controls without personal or family history of stroke were investigated by PCR and restriction endonuclease analysis for IL-6 -174 G/C and TNF-alpha -308 G/A polymorphisms.

RESULTS

The allele distribution, allele frequencies, and combined distribution of genotypes for both polymorphisms did not differ significantly between control and patient groups.

CONCLUSIONS

The two polymorphisms did not associate with the occurrence of stroke in our study group.

The clinical outcomes of neonatal and childhood stroke: review of the literature and implications for future research

A detailed assessment of clinical outcomes after ischemic stroke in childhood is necessary to evaluate prognostic factors. Previous studies are difficult to compare because of differences in test instruments, study design, heterogeneity of cohorts and number of included cases. Depending on neurodevelopmental assessment methods, major and subtle/minor disabilities, especially in infants, may not have been detected. Most outcome studies reveal only limited information about behavioral changes and quality of life in children with ischemic stroke. Thus the assumption that children make a better recovery from stroke than adults due to the immature brain's capacity to reorganize function is not evidence-based. We systematically review the current literature with regard to the neurological and psychosocial development of affected children as well as their quality of life. Implications for future research strategies follow the review to encourage further clinical study of the neurobehavioral trajectory of childhood stroke.

Influenza A-associated stroke in a 4-year-old male

This case describes an ischemic stroke in a 4-year-old male associated with acute influenza A infection during the December 2003 nationwide influenza epidemic in the United States. To our knowledge, this is the first report of an association between influenza A and stroke in children.

Long-term follow-up after stroke in childhood

Over the last few years, the importance of paediatric stroke has become more and more evident; however, there is still little known about long-term neurological and especially neuropsychological outcome of these children. By retrospective chart review, questionnaire and clinical examination with structured interview, we analysed initial presentation, aetiology and long-term outcome of children suffering ischaemic childhood stroke between 1985 and 1999. A total of 20 children (13 boys) suffered acute arterial ischaemic events. Aetiology was detected in 14, and suspected in another five. Follow-up after 1-15 years (mean 7 years) was possible for 16 children; two had died and two were lost to follow-up. Only two were completely healthy, five suffered mild, six moderate, and three severe handicap. Eleven children presented with combined neurological and neuropsychological problems. Neurological problems were mild to moderate hemisyndrome in 11, dysphasia, epilepsy and other in six each. Mild to severe neuropsychological problems were detected in 13 children, school problems in eight, attention deficits in nine and behaviour problems in seven, increased fatigability and headache in six each. Recurrence was observed in three children, all due to progressive underlying disease. Outcome was most affected by the presence of combined cortical/subcortical and least affected by subcortical infarction. Epilepsy affected neuropsychological outcome.

CONCLUSION

although prognosis of paediatric stroke is better than for adult stroke, neurological and especially neuropsychological long-term problems significantly influence the lives of these children. Careful long-term follow-up to support these children in their school career and integration into professional life is necessary. Future studies should evaluate whether specific treatments during the acute episode could improve outcome for these children.

Misplaced peripherally inserted central catheter: an unusual cause of stroke

Stroke in pediatric patients occurs with a frequency of 3 to 8 per 100,000. The postevent evaluation attempts to identify the etiology of ischemia whether anatomic, hematologic, or embolic, with the intention of preventing future events. We present the case of a previously healthy male who developed unilateral facial and extremity weakness 2 weeks after receiving an appendectomy. Once the usual etiologies of stroke in pediatric patients were excluded, an evaluation of the peripheral venous catheter (placed for postoperative antibiotic delivery) demonstrated arterial misplacement. This article presents the first reported case of such an occurrence in the literature and exhibits the need to pursue all avenues of evaluation if the etiology of a pediatric stroke is not initially identified.

Cerebrovascular disorders in children

Cerebrovascular disorders are an important cause of mortality and chronic morbidity in children. International incidence rates for childhood stroke (ie, from 30 days to 18 years of age) have ranged from 1.3 to 13 per 100,000 children. Ischemic stroke is probably more common than hemorrhagic stroke in children. The clinical presentation of stroke in children varies according to age and location of the stroke. Over 100 risk factors for stroke in children have been reported, but in up to one third of cases no cause is identified. The management and prevention of stroke in children is not well studied and current recommendations are based on adult studies, nonrandomized trials, or expert opinion. Over half of children with stroke will develop lifelong cognitive or motor disability and up to one third will have a recurrent stroke. This review briefly describes the epidemiology, risk factors, evaluation, treatment, and outcome of stroke in children.

Cerebral infarct in children aged zero to fifteen years

Cerebral infarcts in children present peculiar characteristics either due to their diversity of causes or due to the unknown nature of the causes. The etiologies of cerebral infarct were reviewed in children from zero to 15 years old, attended at a tertiary hospital, in Ribeirão Preto (Brazil), from 1990 to 1997, adopting the modified Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria of classification; 1 - Atherosclerosis in large arteries; 2 - Cardioembolic; 3 - Occlusion of small vessels; 4 - Other etiologies; 5 - Undetermined cause. Thirty-nine children were included, 18 males and 21 females, aged 2 months to 15 years, mean age 5.67. The largest group, N=22 (56.4%), included children with ''other etiologies'', 7 of them aged under two years. The most common etiology was dehydration and septic shock leading to brain hypoperfusion and watershed infarcts. Nine (23%) children had ''Undetermined etiology'', 7 (17,9%) cardioembolic subtype and none had atherosclerosis. Laboratory improvement is needed for the large number of patients without a defined cause, and the high proportion of children with dehydration in the group with a determined cause emphasizes the need for preventive health actions among infants and children.

The paediatric overview

Stroke in children, both ischaemic and haemorrhagic, is increasingly recognised as an important paediatric illness. This review looks at the wide number of causes, highlighting the fact that often no single factor is causative on its own. There has been an increased recognition worldwide of the importance of sickle cell disease and of the importance of venous sinus thrombosis. Radiology is mandatory in diagnosis and management. Unfortunately, it is not always possible to extrapolate experience from adult stroke in terms of management of these children, and further detailed trials are necessary to understand the natural history, outcome and best forms of management.

Case of stroke in a 7-year-old male after parvovirus B19 infection

A 7-year-old male presented sudden-onset left hemiparesis, left-sided paresthesia, central paralysis of the left VII cranial nerve, and subsequent headache. Magnetic resonance scans were obtained 24 hours after admission. T(2)-weighted images disclosed hyperintensities located mainly in the posterior portion of the lenticular nucleus and in the head and body of the right caudate nucleus. A diagnosis of ischaemic stroke was made on the basis of neuroradiologic findings. Laboratory tests undertaken to establish the cause of stroke revealed parvovirus B19 infection preceding the neurologic abnormalities. In the absence of other known risk factors for stroke the possibility of parvovirus B19's being correlated with stroke onset is discussed.

Stroke in children

Childhood stroke is an infrequent occurrence. Children with sickle cell disease and congenital heart disease are particularly vulnerable. The recognition of stroke in children, unlike adults, is typically delayed by healthcare providers and family members. Large, multicentered pediatric stroke trials are absent in the literature. These studies are difficult to perform because the event is rare and the causes are numberous. Adverse outcomes such as death and reoccurrence could be reduced with defined treatment options. Pediatric stroke protocols are largely extrapolated from the adult literature. The use of treatment strategies such as thrombolytic therapy, aspirin, and anticoagulation are controversial at present.

Minor head injury as cause and co-factor in the aetiology of stroke in childhood: a report of eight cases

BACKGROUND

Traumatic stroke usually occurs after dissection of large extracranial or intracranial vessels, leading to disseminated cerebral embolism. Stretching and distorting forces in cerebral intraparenchymal end arteries can cause intimal lesions followed by an occluding thrombus.

OBJECTIVE

To investigate the importance of traumatic endothelial lesions in intraparenchymal end arteries after minor head injuries.

METHODS

The cases of eight children are reported. They were aged between two and seven years (mean 6.2 years), and they developed significant neurological deficits at 15 minutes to 72 hours (mean 16.3 hours) after minor head injuries.

RESULTS

The the patients all had hemiparesis combined with other signs, including central facial paralysis, dysphasia, dysphagia, and extrapyramidal signs. Computed tomography or magnetic resonance imaging showed cerebral infarctions affecting branches of the middle cerebral artery (n = 3), anterior cerebral artery (n = 1), posterior cerebral artery (n = 1), and basilar artery (n = 3). These lesions affected the basal ganglia, the internal capsule, and the brain stem. Neither heart disease nor dissections of large vessels were present. Two children had prothrombotic risk factors (an increase in lipoprotein (a) and a factor V Leiden mutation). The follow up period was between three months and 13 years (mean 3.9 years). Outcome was classified according to the Glasgow outcome scale as moderate disability (n = 4), severe disability (n = 2), non-disabling sequelae (n = 1), and total recovery (n = 1).

CONCLUSIONS

Minor head injuries can be cause and co-factor in the aetiology of stroke. The frequency of this may be underestimated, and detailed medical history of the days before stroke manifestation may identify more traumatic events, especially in the group of so called "idiopathic" strokes.

Functional outcome following stroke in children

The aim of this study was to describe the functional consequences of childhood stroke in terms of activity limitation and to explore the relationship between extent of brain damage, impairment, and functional sequelae. A further aim was to describe the health of the parents of these children. Seventeen children and adolescents with cerebral infarction in the territory of the middle cerebral artery were enrolled in the study. A new activity limitation measure with a 4-point Likert scale (the Paediatric Stroke Activity Limitation Measure) was designed to examine the degree of difficulty experienced by the children in daily activities. The relationship between activity limitation scores, standardized health-related quality of life assessment (Child Health Questionnaire), extent of brain damage, and results of a comprehensive neurologic examination (Pediatric Stroke Outcome Measure) were investigated. Parent health was assessed using the Short-Form 36 General Health Survey. Activity limitation was evident in the domains of education, self-care, and motor skills. There was very good interobserver agreement using the new activity limitation scale between the occupational therapist and pediatric neurologist (Cohen's kappa = 0.88). In comparison with population norms, the subjects scored below average in both physical and psychologic health. There was a clear relationship between radiologically apparent extent of brain damage, degree of impairment, and functional outcome. Parental health also rated generally lower than expected. This exploratory study suggests that both children who have had a stroke and their parents have significant and wide-ranging health needs.

Cerebrovascular event, dilated cardiomyopathy, and pheochromocytoma

Cerebral infarction in children may be the result of various disease processes, including emboli from intracardiac sources, paradoxical emboli from the venous system, sickle cell disease, cyanotic heart disease, vasculitis affecting the carotid or cerebral vascular system, vascular anomalies, and prothrombotic states. We present a previously healthy adolescent who presented with the acute onset of hemiparesis. Work-up revealed a dilated cardiomyopathy with a left ventricular mural thrombus as the etiology of his cerebrovascular event. Although dilated cardiomyopathy (DCM) may predispose to the development of a mural thrombus and subsequent embolic events, there are no previous reports in pediatric-aged patients of the development of an embolic event as the presenting manifestation of DCM. Further investigation of the etiology of the DCM led to the diagnosis of a pheochromocytoma. Congestive heart failure and DCM as the presenting sign of pheochromocytoma has likewise not been reported in a pediatric-aged patient. We review this unlikely sequence of events, the diagnostic evaluation of such patients, and treatment options.

Posterior cerebral artery occlusion associated with Mycoplasma pneumoniae infection

Cerebral infarction is a rare complication of Mycoplasma pneumoniae infection. In all cases previously reported in the literature, vascular occlusion occurred in the anterior brain circulation, either the internal carotid or the middle cerebral artery. We report a case of a child with posterior cerebral artery occlusion and resultant hemiparesis associated with M. pneumoniae infection.

Report of the National Institute of Neurological Disorders and Stroke workshop on perinatal and childhood stroke

The National Institute of Neurological Disorders and Stroke and the Office of Rare Disorders sponsored a workshop on perinatal and childhood stroke in Bethesda, Maryland, on September 18 and 19, 2000. This was an international workshop to bring together experts in the field of perinatal and childhood stroke. Topics covered included epidemiology, animal models, risk factors, outcome and prognosis, and areas of future research for perinatal and childhood stroke. Stroke in infants and children is an important cause of morbidity and mortality and an emerging area for clinical and translational research. Currently, there is no consensus on the classification, evaluation, outcome measurement, or treatment of perinatal and childhood stroke. Pediatric stroke registries are needed to generate data regarding risk factors, recurrence, and outcome. The impact of maternal and perinatal factors on risk and outcome of neonatal stroke needs to be studied. This information is essential to identifying significant areas for future treatment and prevention.