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Pais-Cunha I, Almeida AI, Curval AR, Fonseca J, Melo C, Sampaio M, Sousa R. Cerebral Venous Thrombosis in Pediatric Age: Risk Factors and Prognosis. Neuropediatrics 2024; 55:183-190. [PMID: 38057147 DOI: 10.1055/a-2223-6395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
INTRODUCTION Cerebral venous thrombosis (CVT) is a rare but potentially fatal disease in pediatric age with an important morbimortality. In adults several factors have been associated with worse outcomes, however there are still few studies in children. This study aims to identify risk factors associated with clinical manifestations and long-term sequelae in pediatric CVT. METHODS Retrospective analysis of pediatric inpatients admitted to a tertiary-care hospital due to CVT between 2008 and 2020. RESULTS Fifty-four children were included, 56% male, median age of 6.5 years (9 months-17.3 years). Permanent risk factors were identified in 13 patients (malignancy, 8; hematologic condition, 5) and transient risk factors in 47, including head and neck infections (57%) and head trauma (15%). Multiple venous sinuses involvement was present in 65% and the deep venous system was affected in four patients. Seventeen percent had intracranial hemorrhage and 9% cerebral infarction. Sixty-four percent of patients with multiple venous sinuses involvement presented with severe clinical manifestations: impaired consciousness, intracranial hypertension, acute symptomatic seizures or focal deficits. Regarding long-term prognosis, six patients had major sequelae: epilepsy (n = 3), sensory motor deficits (n = 2), and cognitive impairment (n = 3). Permanent risk factors were associated with severe clinical manifestations (p = 0.043). Cerebral infarction and intracranial hemorrhage were associated with major sequelae (p = 0.006 and p = 0.03, respectively, adjusted for age and sex). CONCLUSION Permanent risk factors, involvement of multiple venous sinuses, intracranial hemorrhage, and cerebral infarction, were related to worse prognosis. Detection and early management of risk factors may limit CVT extension and reduce its morbimortality.
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Affiliation(s)
- Inês Pais-Cunha
- Serviço de Pediatria, Unidade Autónoma Gestão da Mulher e da Criança, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Ana I Almeida
- Serviço de Neurorradiologia, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Ana R Curval
- Serviço de Pediatria, Unidade Autónoma Gestão da Mulher e da Criança, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Jacinta Fonseca
- Unidade de Neuropediatria, Unidade Autónoma Gestão da Mulher e da Criança, Centro Hospitalar Universitário de São João, Porto, Portugal
- Departamento de Ginecologia-Obstetrícia e Pediatria, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Cláudia Melo
- Unidade de Neuropediatria, Unidade Autónoma Gestão da Mulher e da Criança, Centro Hospitalar Universitário de São João, Porto, Portugal
- Departamento de Ginecologia-Obstetrícia e Pediatria, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Mafalda Sampaio
- Unidade de Neuropediatria, Unidade Autónoma Gestão da Mulher e da Criança, Centro Hospitalar Universitário de São João, Porto, Portugal
- Departamento de Ginecologia-Obstetrícia e Pediatria, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Raquel Sousa
- Unidade de Neuropediatria, Unidade Autónoma Gestão da Mulher e da Criança, Centro Hospitalar Universitário de São João, Porto, Portugal
- Departamento de Ginecologia-Obstetrícia e Pediatria, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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Karakas C, Herman I, Kralik SF, Webber TA, Takacs DS, Bhar S, Pehlivan D. A Comprehensive Examination of Clinical Characteristics and Determinants of Long-Term Outcomes in Pediatric Cerebral Sinus Venous Thrombosis. Pediatr Neurol 2024; 155:76-83. [PMID: 38608552 DOI: 10.1016/j.pediatrneurol.2024.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 03/17/2024] [Accepted: 03/19/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND To analyze the clinical and neuroimaging features, risk factors, treatment choices, and long-term clinical outcomes in children with cerebral sinus venous thrombosis (CSVT). METHODS This is a retrospective cohort study of children diagnosed with CSVT between 2002 and 2018 at Texas Children's Hospital. RESULTS A total of 183 children (male: 62.3%) with CSVT were included. The average presenting age was 7.7 years (S.D.: 5.6). The mean follow-up duration was 33.7 months (S.D.: 38.6). The most common presenting clinical feature was headache (36.6%). Head and neck infections other than meningitis (36.6%) were the most common risk factors. Prevalent neurological examination findings included motor deficit (21.3%) and altered mental status (AMS, 20.2%). Neuroimaging features included hemorrhagic infarction (19.6%), ischemic infarction (8.2%), and intracranial hemorrhage without infarction (5.5%). The most common site of thrombosis was the superior sagittal sinus (37.2%), with 78.2% of patients demonstrating involvement of multiple sinuses. Treatment of choice was low-molecular-weight heparin in 69.4% of patients. Factors associated with worse clinical outcomes included head and neck infections, malignancy (other than hematologic), cardiac disease, and recent surgery; seizure and dehydration on initial presentation; motor abnormalities and AMS on initial examination; ischemic infarct only; and involvement of vein of Trolard on neuroimaging. Thrombus condition on repeat imaging, receiving any anticoagulant/antithrombotic treatment, treatment duration, or follow-up duration was not associated with severity of long-term outcome. CONCLUSIONS CSVT may lead to unfavorable long-term outcomes in a remarkable portion of pediatric patients. Thus, a high index of suspicion and early and appropriate management of pediatric CSVT is imperative.
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Affiliation(s)
- Cemal Karakas
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Department of Neurology and Neurophysiology, Baylor College of Medicine, Houston, Texas; Division of Pediatric Neurology, Department of Neurology, Norton Children's Medical Group, University of Louisville, Louisville, Kentucky
| | - Isabella Herman
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Boys Town National Research Hospital, Boys Town, Nebraska
| | - Stephen F Kralik
- Department of Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Troy A Webber
- Mental Health Care Line, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Danielle S Takacs
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Department of Neurology and Neurophysiology, Baylor College of Medicine, Houston, Texas
| | - Saleh Bhar
- Division of Hematology and Oncology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Davut Pehlivan
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas.
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Weimar C, Beyer-Westendorf J, Bohmann FO, Hahn G, Halimeh S, Holzhauer S, Kalka C, Knoflach M, Koennecke HC, Masuhr F, Mono ML, Nowak-Göttl U, Scherret E, Schlamann M, Linnemann B. New recommendations on cerebral venous and dural sinus thrombosis from the German consensus-based (S2k) guideline. Neurol Res Pract 2024; 6:23. [PMID: 38637841 PMCID: PMC11027218 DOI: 10.1186/s42466-024-00320-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/20/2024] [Indexed: 04/20/2024] Open
Abstract
Over the last years, new evidence has accumulated on multiple aspects of diagnosis and management of cerebral venous and dural sinus thrombosis (CVT) including identification of new risk factors, studies on interventional treatment as well as treatment with direct oral anticoagulants. Based on the GRADE questions of the European Stroke Organization guideline on this topic, the new German guideline on CVT is a consensus between expert representatives of Austria, Germany and Switzerland. New recommendations include:• CVT occurring in the first weeks after SARS-CoV-2 vaccination with vector vaccines may be associated with severe thrombocytopenia, indicating the presence of a prothrombotic immunogenic cause (Vaccine-induced immune thrombotic thrombocytopenia; VITT).• D-dimer testing to rule out CVT cannot be recommended and should therefore not be routinely performed.• Thrombophilia screening is not generally recommended in patients with CVT. It should be considered in young patients, in spontaneous CVT, in recurrent thrombosis and/or in case of a positive family history of venous thromboembolism, and if a change in therapy results from a positive finding.• Patients with CVT should preferably be treated with low molecular weight heparine (LMWH) instead of unfractionated heparine in the acute phase.• On an individual basis, endovascular recanalization in a neurointerventional center may be considered for patients who deteriorate under adequate anticoagulation.• Despite the overall low level of evidence, surgical decompression should be performed in patients with CVT, parenchymal lesions (congestive edema and/or hemorrhage) and impending incarceration to prevent death.• Following the acute phase, oral anticoagulation with direct oral anticoagulants instead of vitamin K antagonists should be given for 3 to 12 months to enhance recanalization and prevent recurrent CVT as well as extracerebral venous thrombosis.• Women with previous CVT in connection with the use of combined hormonal contraceptives or pregnancy shall refrain from continuing or restarting contraception with oestrogen-progestagen combinations due to an increased risk of recurrence if anticoagulation is no longer used.• Women with previous CVT and without contraindications should receive LMWH prophylaxis during pregnancy and for at least 6 weeks post partum.Although the level of evidence supporting these recommendations is mostly low, evidence from deep venous thrombosis as well as current clinical experience can justify the new recommendations.This article is an abridged translation of the German guideline, which is available online.
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Affiliation(s)
- C Weimar
- BDH Klinik Elzach und Institut für Medizinische Informatik, Biometrie und Epidemiologie, Universitätsklinikum Essen, Essen, Germany.
| | - J Beyer-Westendorf
- Department of Medicine I; Division "Thrombosis & Hemostasis ", Dresden University Hospital "Carl Gustav Caris; Technical University Dresden, Dresden, Germany
| | - F O Bohmann
- Department of Neurology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
| | - G Hahn
- Department of Pediatric Radiology, University Children`s Hospital Basel UKBB, Basel, Switzerland
| | - S Halimeh
- Universitätsklinikum Essen, gerinnungszentrum rhein-ruhr, Duisburg, Germany
| | - S Holzhauer
- Klinik für Pädiatrie mit Schwerpunkt Onkologie und Hämatologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - C Kalka
- Vascular Institute Central Switzerland, Aarau, Switzerland and University of Cologne, Cologne, Germany
| | - M Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - H-C Koennecke
- Klinik für Neurologie, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - F Masuhr
- Abteilung für Neurologie, Bundeswehrkrankenhaus Berlin, Berlin, Germany
| | - M-L Mono
- Abteilung für Neurologie, Stadtspital Triemli, Zürich, Switzerland
| | - U Nowak-Göttl
- Gerinnungszentrum UKSH (Campus Kiel und Lübeck), Institut für Klinische Chemie, Kiel, Germany
| | - E Scherret
- Klinik für Neurologie der Charité - , Universitätsmedizin Berlin, Berlin, Germany
| | - M Schlamann
- Sektion Neuroradiologie, Institut für Diagnostische und Interventionelle Radiologie, Klinikum der Universität zu Köln, Cologne, Germany
| | - B Linnemann
- Klinik für Kardiologie III - Angiologie, Universitätsmedizin Mainz, Mainz, Germany
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Benedetti GM, Wainwright MS. Commentary: Characteristics and Outcomes of Children with Cerebral Sinus Venous Thrombosis. Neurocrit Care 2023; 39:306-308. [PMID: 37438551 DOI: 10.1007/s12028-023-01787-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 04/18/2023] [Indexed: 07/14/2023]
Affiliation(s)
- Giulia M Benedetti
- Division of Pediatric Neurology, Department of Pediatrics, University of Michigan and C.S. Mott Children's Hospital, 1540 E Hospital Drive, Ann Arbor, MI, 48105, USA.
| | - Mark S Wainwright
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, WA, USA
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Proaño JS, Martinez PA, Sendi P, Totapally BR. Characteristics and Outcomes of Children with Cerebral Sinus Venous Thrombosis. Neurocrit Care 2023; 39:331-338. [PMID: 37438549 DOI: 10.1007/s12028-023-01765-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/19/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Cerebral sinus venous thrombosis (CSVT) is an uncommon condition in children with potentially serious outcomes. Large epidemiological studies in children with CSVT are few. The objective of this study is to evaluate the epidemiology and in-hospital outcomes of hospitalized children with CSVT in the United States. METHODS We performed a retrospective cross-sectional analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database for the combined years 2016 and 2019. The database was queried using the diagnoses for intracranial and intraspinal phlebitis and thrombophlebitis, nonpyogenic thrombosis of the intracranial venous system, and cerebral infarction due to cerebral venous thrombosis. Sample weighting was employed to produce national estimates. RESULTS Of 12,165,621 discharges, 3202 had CSVT (in-hospital prevalence 26.3 per 100,000 discharges). Male patients accounted for 57% of CSVT discharges. The median age was 8 years (interquartile range 1-16), with a U-shaped distribution with peaks in patients younger than 4 years and patients aged between 18 and 20 years. A total of 19.3% of children with CSVT had either hemorrhagic or ischemic stroke. Patients with stroke were more likely to require mechanical ventilation (odds ratio [OR] 2.7; 95% confidence interval [CI] 2.1-3.3; p < 0.001) and have higher mortality (OR 2.3; 95% CI 1.6-3.4; p < 0.001). Mechanical ventilation was necessary for 25.2% of patients with CSVT, of whom the majority were neonates and young children. The need for mechanical ventilation was associated with increased mortality (OR 16.6; 95% CI 9.9-27.9; p < 0.001). The overall mortality rate for CSVT was 4.1%, and 16.5% of patients with CSVT were discharged with home health care or to a skilled nursing facility. CONCLUSIONS CSVT, which has a U-shaped age distribution, is an uncommon condition in children. Stroke is common in children with CSVT, and it is associated with an increased need for mechanical ventilation and increased mortality. The need for mechanical ventilation is more common in infants, and it is associated with increased mortality across all age groups.
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Affiliation(s)
- Juan Sebastian Proaño
- Marshall University Joan C Edwards School of Medicine, 1600 Medical Center Drive, Huntington, WV, 25705, USA.
| | - Paul A Martinez
- Department of Pediatric Critical Care, Nicklaus Children's Hospital, Miami, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, USA
| | - Prithvi Sendi
- Department of Pediatric Critical Care, Nicklaus Children's Hospital, Miami, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, USA
| | - Balagangadhar R Totapally
- Department of Pediatric Critical Care, Nicklaus Children's Hospital, Miami, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, USA
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Otufowora A, Lee C, Mohideen A, DeSena G, Pringle C, Guyer F, Sharma P, Baines T, Carr S. Cerebral venous sinus thrombosis and skull base osteomyelitis as manifestations of cat-scratch disease in a pediatric patient: A case report and literature review. Clin Case Rep 2023; 11:e7561. [PMID: 37361655 PMCID: PMC10288016 DOI: 10.1002/ccr3.7561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/18/2023] [Accepted: 06/02/2023] [Indexed: 06/28/2023] Open
Abstract
Cat-scratch disease (CSD) is caused by Bartonella henselae and usually presents with regional lymphadenopathy. Skull base osteomyelitis and cerebral venous sinus thrombosis are rarely reported, particularly in immunocompetent children. CSD should be considered in the differential diagnosis of any patient with persistent headaches in the setting of cat exposure.
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Affiliation(s)
- Ayodeji Otufowora
- Department of PediatricsCollege of Medicine, University of FloridaGainesvilleFloridaUSA
| | - Christine Lee
- Department of PediatricsCollege of Medicine, University of FloridaGainesvilleFloridaUSA
| | - Aneeb Mohideen
- Department of PediatricsCollege of Medicine, University of FloridaGainesvilleFloridaUSA
| | - Grace DeSena
- Department of PediatricsCollege of Medicine, University of FloridaGainesvilleFloridaUSA
| | - Charlene Pringle
- Department of PediatricsCollege of Medicine, University of FloridaGainesvilleFloridaUSA
| | - Freddie Guyer
- Department of PediatricsCollege of Medicine, University of FloridaGainesvilleFloridaUSA
| | - Priya Sharma
- Department of RadiologyCollege of Medicine, University of FloridaGainesvilleFloridaUSA
| | - Torrey Baines
- Department of PediatricsCollege of Medicine, University of FloridaGainesvilleFloridaUSA
| | - Silvana Carr
- Department of PediatricsCollege of Medicine, University of FloridaGainesvilleFloridaUSA
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Karlin AR, Kumar NK, Vossough A, Abend NS, Ichord RN, Beslow LA. Pediatric Cerebral Sinovenous Thrombosis and Risk for Epilepsy. Pediatr Neurol 2023; 146:85-94. [PMID: 37453223 DOI: 10.1016/j.pediatrneurol.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/01/2023] [Accepted: 05/18/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Cerebral sinovenous thrombosis (CSVT) is a rare form of pediatric stroke with significant morbidity. We determined cumulative incidence and predictors of acute seizures, remote seizures, and epilepsy after pediatric CSVT. METHODS Retrospective analysis of 131 neonates and children with neuroimaging-confirmed CSVT enrolled between 2008 and 2020 from a single-center prospective consecutive cohort. Acute seizures occurred within 7 days of CSVT. Remote seizures occurred >7 days after CSVT. Epilepsy was defined as 2 or more remote seizures at least 24 hours apart. Survival methods determined the incidence of and risk factors for remote seizures and epilepsy. RESULTS Acute seizures occurred in 14/33 neonates (42%) and 19/98 children (19%). Among children, hemorrhage predicted acute seizures (OR 6.6, 95% CI 1.9 to 22.4, P = 0.003). Remote seizures occurred in six neonates; five developed epilepsy. Remote seizures occurred in 14 children; 10 developed epilepsy. In neonates, 1- and 3-year epilepsy-free survival were 86% (95% CI 62% to 95%) and 66% (95% CI 32% to 87%). One- and 3-year epilepsy-free survival in children were 88% (95% CI 76% to 92%) and 84% (95% CI 59% to 86%). In multivariable analysis for children, acute seizures predicted epilepsy (HR 3.8, 95% CI 1.1-13.3, P = 0.039). In both cohorts, Pediatric Stroke Outcome Measure scores at last follow-up were worse in those with epilepsy compared to those without. CONCLUSIONS Acute seizures occurred in approximately one quarter of our cohort and are an epilepsy risk factor in children with CSVT. Neonates and children with epilepsy had worse outcomes than those without.
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Affiliation(s)
- Alexis R Karlin
- Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nankee K Kumar
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arastoo Vossough
- Division of Neuroradiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicholas S Abend
- Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rebecca N Ichord
- Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lauren A Beslow
- Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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Wang Q, Cui Y, Liang P, Wang C, Zhou K, Ma F, Duan H. Case report: cerebral venous sinus thrombosis and pulmonary embolism as the initial presentation in a child with asymptomatic primary nephrotic syndrome. Front Pediatr 2023; 11:1169116. [PMID: 37215608 PMCID: PMC10196485 DOI: 10.3389/fped.2023.1169116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 04/12/2023] [Indexed: 05/24/2023] Open
Abstract
Background Cerebral venous sinus thrombosis (CVST) is rare, but potentially life-threatening. The clinical course definitely become more unpredictable and fatal in patients complicated by pulmonary embolism (PE). Nephrotic syndrome (NS) is an uncommon etiology of CVST. Concurrence of CVST and PE at the initial onset of NS is extremely unusual and rarely reported. Considering that edema might be absent in NS individuals, thromboembolic events probably become unrecognized, thereby causing a missed or delayed diagnosis and poor outcome. Herein, we described an extraordinary case of an adolescent boy presenting with both CVST and PE initially just within 5 days of disease onset, who was ultimately diagnosed with asymptomatic NS, aiming to emphasize a high index of suspicion of these diseases in patients with conditions of hypercoagulability. Case presentation A 13-year-old male child presented acutely with dizziness, fever and dyspnea, with signs of shock but undetected edema. Initial laboratory investigations revealed hypoalbuminemia, typical images of pneumonia, and normal radiographic findings on non-enhanced computed tomography of head. Despite evidence of hypoalbuminemia and neurological symptoms, the child was still misdiagnosed as pneumonia. His dyspnea and period of headache deteriorated even if hemodynamic stability and undetected fever after initial therapy. The delayed urinalysis and 24-h urine examination both showed massive proteinuria. A computed tomography angiography of chest along with cranial magnetic resonance imaging/magnetic resonance venography were subsequently performed, consistent with the imaging features of PE and CVST, respectively. The diagnosis of asymptomatic primary NS complicated by PE and CVST was ultimately confirmed. The patient received corticosteroids and antithrombotic therapy with satisfactory results. Conclusion A persistent clinical suspicion of CVST should be borne in mind in patients with a sudden, new or worsening headache, specifically among those with prothrombotic conditions. NS should always be considered in the differential diagnosis of risk factors for CVST, even in absence of edema. Since CVST and PE can be present simultaneously at extraordinary early-onset of NS, early radiological diagnosis is clinically substantial to proper management and satisfactory long-term outcomes.
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Affiliation(s)
- Qinhui Wang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children’s Health, West China Second University Hospital, Sichuan University, Chengdu, China
- West China Medical School of Sichuan University, Chengdu, China
| | - Yaru Cui
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children’s Health, West China Second University Hospital, Sichuan University, Chengdu, China
- West China Medical School of Sichuan University, Chengdu, China
| | - Ping Liang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Chuan Wang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children’s Health, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Development and Diseases of Women and Children of Sichuan Province, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Kaiyu Zhou
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children’s Health, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Development and Diseases of Women and Children of Sichuan Province, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Fan Ma
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children’s Health, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Development and Diseases of Women and Children of Sichuan Province, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Hongyu Duan
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children’s Health, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Development and Diseases of Women and Children of Sichuan Province, West China Second University Hospital, Sichuan University, Chengdu, China
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Pelizza MF, Martinato M, Rosati A, Nosadini M, Saracco P, Giordano P, Luciani M, Ilardi L, Lasagni D, Molinari AC, Bagna R, Palmieri A, Ramenghi LA, Grassi M, Magarotto M, Magnetti F, Francavilla A, Indolfi G, Suppiej A, Gentilomo C, Restelli R, Tufano A, Tormene D, Pin JN, Tona C, Meneghesso D, Rota L, Conti M, Russo G, Lorenzoni G, Gregori D, Sartori S, Simioni P. The new Italian registry of infantile thrombosis (RITI): A reflection on its journey, challenges and pitfalls. Front Pediatr 2023; 11:1094246. [PMID: 37152311 PMCID: PMC10159054 DOI: 10.3389/fped.2023.1094246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 03/06/2023] [Indexed: 05/09/2023] Open
Abstract
Introduction Thrombotic events in neonates and children represent a rare although severe occurrence in view of the associated risk of mortality and sequelae. Quality evidence is limited in this field, and registry studies provide an essential base for research. The aim of this paper is to present the new Italian Registry of Infantile Thrombosis (RITI), set it into the scene of international thrombosis and stroke registries, and provide some insight on the challenges associated with registry management. Methods We present the detailed structure and content of the new RITI registry, a brief overview of its main data, and a reflection on its features, pitfalls and the main challenges related to its management. Results The RITI, initially started in 2007 and officially re-launched in 2017 after structural modifications, is a non-interventional retrospective and prospective registry study collecting data on neonatal and pediatric patients (0-18 years) who experienced a systemic or cerebral thrombotic event in Italy. The RITI is managed by a multidisciplinary team with expertise in pediatric thrombosis, and participation is open to all Italian physicians, on a voluntary basis. The overall aim of the registry is to acquire new evidence to better characterize the population of children with thrombotic events and improve their management and outcome. 48 Italian pediatric and intensive care units are actively involved in the RITI, including 85 medical doctors from 16 Italian regions. A total of 1,001 neonates and children affected by cerebral or systemic thrombosis have been enrolled. Discussion The RITI is one of the largest available European registries of neonatal and pediatric thrombosis. National registries like the RITI represent a model for the study of rare conditions based on multidisciplinary and multicenter collaboration, aimed at overcoming the limitations due to small populations of patients, and creating a network of experts for patient referral and continuous education. Moreover, registry studies have a pivotal role in the research on pediatric thrombosis, due to the limited feasibility of high-quality studies. In our experience, the main critical stages, pitfalls and challenges in registry management include adequate registry designing, diffusion, data completeness and quality control.
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Affiliation(s)
- Maria Federica Pelizza
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
- Master in Pediatrics and Pediatric Subspecialties, University of Padova, Padova, Italy
| | - Matteo Martinato
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
- Department of Statistics, Computer Science, Applications “G. Parenti”, University of Firenze, Firenze, Italy
| | - Anna Rosati
- Neuroscience Center of Excellence, Children's Hospital Anna Meyer, University of Firenze, Firenze, Italy
| | - Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Paola Saracco
- Paediatric Haematology Unit, Department of Paediatrics, University Hospital “Città Della Salute e Della Scienza”, Torino, Italy
| | - Paola Giordano
- Department of Biomedical Science and Human Oncology, Aldo Moro University of Bari-Giovanni XXIII Hospital, Bari, Italy
| | - Matteo Luciani
- Department of Paediatric Hemato-Oncology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, Roma, Italy
| | - Laura Ilardi
- Neonatal Intensive Care Unit, Niguarda Ca’ Granda Hospital, Milano, Italy
| | - Donatella Lasagni
- Paediatric Unit, Children's Hospital Anna Meyer, University of Firenze, Firenze, Italy
| | - Angelo Claudio Molinari
- Regional Reference Center for Hemorrhagic Diseases, IRCCS Giannina Gaslini Children's Hospital, Genova, Italy
| | - Rossana Bagna
- Neonatal Intensive Care Unit, University Hospital “Città Della Salute e Della Scienza”, Torino, Italy
| | - Antonella Palmieri
- Department of Paediatric Emergency, IRCCS Giannina Gaslini Children's Hospital, Genova, Italy
| | - Luca Antonio Ramenghi
- Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Children's Hospital, Genova, Italy
| | - Massimo Grassi
- Department of Biomedical Science and Human Oncology, Aldo Moro University of Bari-Giovanni XXIII Hospital, Bari, Italy
| | - Mariella Magarotto
- Neonatal Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Federica Magnetti
- Neonatal Intensive Care Unit, University Hospital “Città Della Salute e Della Scienza”, Torino, Italy
| | - Andrea Francavilla
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Giuseppe Indolfi
- NEUROFARBA Department, Children's Hospital Anna Meyer, University of Firenze, Firenze, Italy
| | - Agnese Suppiej
- Section of Pediatrics, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | | | - Roberta Restelli
- Neonatal Intensive Care Unit, Niguarda Ca’ Granda Hospital, Milano, Italy
| | - Antonella Tufano
- Regional Reference Centre for Coagulation Disorders, Department of Clinical Medicine and Surgery, Federico II University Hospital, Napoli, Italy
| | - Daniela Tormene
- General Internal Medicine and Thrombotic and Haemorrhagic Unit, University Hospital of Padova, Padova, Italy
| | - Jacopo Norberto Pin
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Clarissa Tona
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Davide Meneghesso
- Paediatric Nephrology, Dialysis and Transplant Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Lidia Rota
- Cardiovascular Prevention Centre, Humanitas Research Hospital, Milano, Italy
| | - Marta Conti
- Child Neurology Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
| | - Giovanna Russo
- Unit of Pediatric Onco-Haematology, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Giulia Lorenzoni
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
- Master in Pediatrics and Pediatric Subspecialties, University of Padova, Padova, Italy
| | - Paolo Simioni
- General Internal Medicine and Thrombotic and Haemorrhagic Unit, University Hospital of Padova, Padova, Italy
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10
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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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11
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Narcy L, Durand S, Grimaud M, Leboucq N, Grevent D, Cambonie G, Couloigner V, Rivier F, Meyer P, Kossorotoff M. Cerebral sinovenous thrombosis associated with head/neck infection in children: Clues for improved management. Dev Med Child Neurol 2023; 65:215-222. [PMID: 35765978 DOI: 10.1111/dmcn.15331] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/11/2022] [Accepted: 06/02/2022] [Indexed: 01/06/2023]
Abstract
AIM To compare paediatric patients with cerebral sinovenous thrombosis (CSVT) with and without head/neck infection to improve management of the condition. METHOD We conducted a bicentric retrospective study of consecutive children (neonates excluded) with radiologically confirmed CSVT, comparing children with a concurrent head/neck infection and children with other causes. RESULTS A total of 84 consecutive patients (46 males and 38 females) with a median age of 4 years 6 months (range 3 months-17 years 5 months) were included. Associated head/neck infection was identified in 65.4% of cases and represented the main identified CSVT aetiology. Children in the head/neck infection group displayed a milder clinical presentation and less extensive CSVT. Median time to complete recanalization was significantly shorter in this group (89 days [interquartile range 35-101] vs 112.5 days [interquartile range 83-177], p = 0.005). These findings were even more pronounced in the subgroup of patients with otogenic infection and no neurological sign. INTERPRETATION As CSVT in the setting of an otogenic infection and no neurological sign seems to represent a milder condition with a shorter course, these results suggest adapting current recommendations: consider earlier control imaging in paediatric otogenic CSVT, and shorter anticoagulant treatment if recanalization is obtained. WHAT THIS PAPER ADDS Children with cerebral sinovenous thrombosis related to head/neck infections have a milder clinical presentation. They also have a shorter recanalization time, especially if there is otogenic infection without neurological symptoms.
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Affiliation(s)
- Lucie Narcy
- Paediatric Neurology Department, APHP, University Hospital Necker-Enfants Malades, Paris, France.,Sorbonne Université, Paris, France
| | - Sabine Durand
- Paediatric and Neonatal Intensive Care Unit, CHU Arnaud de Villeneuve, Montpellier, France
| | - Marion Grimaud
- Paediatric Intensive Care Unit, APHP, University Hospital Necker-Enfants Malades, Paris, France
| | - Nicolas Leboucq
- Paediatric Imaging Department, CHU Arnaud de Villeneuve, Montpellier, France
| | - David Grevent
- Paediatric Imaging Department, APHP, University Hospital Necker-Enfants Malades, Paris, France
| | - Gilles Cambonie
- Paediatric and Neonatal Intensive Care Unit, CHU Arnaud de Villeneuve, Montpellier, France
| | - Vincent Couloigner
- Paediatric Otorhinolaryngology Department, APHP, University Hospital Necker-Enfants Malades, Paris, France
| | - François Rivier
- Paediatric Neurology Department, Phymedexp, Montpellier University, Inserm, CNRS, University Hospital Montpellier, Montpellier, France
| | - Pierre Meyer
- Paediatric Neurology Department, Phymedexp, Montpellier University, Inserm, CNRS, University Hospital Montpellier, Montpellier, France
| | - Manoelle Kossorotoff
- Paediatric Neurology Department, APHP, University Hospital Necker-Enfants Malades, Paris, France.,French Centre for Paediatric Stroke, APHP, University Hospital Necker-Enfants Malades, Paris, France
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12
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Grigore I, Miron I, Gavrilovici C, Lupu VV, Antal DC, Schreiner TG, Prazaru C, Lupu A, Dragan F, Grigore E. SARS-CoV-2 Possible Etiology of Cerebral Venous Thrombosis in a Teenager: Case Report and Review of Literature. Viruses 2023; 15:v15020405. [PMID: 36851619 PMCID: PMC9965073 DOI: 10.3390/v15020405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/25/2023] [Accepted: 01/31/2023] [Indexed: 02/04/2023] Open
Abstract
Cerebral venous thrombosis in pediatric patient has a varied etiology. The authors present the case of a teenager who, since the debut of SARS-CoV-2 infection, has accused intermittent right side hemicrania, which has become persistent in association with nausea and vomiting since the 5th day of quarantine. She was hospitalized in the 9th day since the debut. Neuroimaging revealed extended venous cerebral thrombosis affecting the right sigmoid sinus, the transverse sinus bilaterally, the confluence of the transverse sinuses and the right internal jugular vein. The evolution was favorable under anticoagulant and symptomatic treatment. Laboratory tests excluded other etiological causes for the cerebral venous thrombosis, thus the authors consider that cerebral thrombosis is a possible complication of SARS-CoV-2 infection in teenagers.
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Affiliation(s)
- Ioana Grigore
- “St. Mary” Children Emergency Hospital, 700309 Iasi, Romania
| | - Ingrith Miron
- Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Cristina Gavrilovici
- Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Vasile Valeriu Lupu
- Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Correspondence: (V.V.L.); (A.L.)
| | - Dorin Cristian Antal
- Neurology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | | | - Catalin Prazaru
- “St. Mary” Children Emergency Hospital, 700309 Iasi, Romania
| | - Ancuta Lupu
- Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Correspondence: (V.V.L.); (A.L.)
| | - Felicia Dragan
- Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania
| | - Ecaterina Grigore
- Faculty of General Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
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13
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Cerebral Sinovenous Thrombosis in Infants and Children: A Practical Approach to Management. Semin Pediatr Neurol 2022; 44:100993. [PMID: 36456034 DOI: 10.1016/j.spen.2022.100993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/27/2022] [Accepted: 08/29/2022] [Indexed: 11/23/2022]
Abstract
Cerebral sinovenous thrombosis (CSVT) is a rare, yet potentially devastating disorder, associated with acute complications and long-term neurologic sequelae. Consensus-based international pediatric CSVT treatment guidelines emphasize early clinical-radiologic recognition and prompt consideration for anticoagulation therapy. However, lack of clinical trials has precluded evidence-based patient selection, anticoagulant choice, optimal monitoring parameters and treatment duration. Consequently, uncertainties and controversies persist regarding anticoagulation practices in pediatric CSVT. This review focuses on commonly encountered issues that continue to pose questions and raise debates regarding anticoagulation therapy among pediatric neurologists and hematologists.
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14
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An Integrated Approach on the Diagnosis of Cerebral Veins and Dural Sinuses Thrombosis. Life (Basel) 2022; 12:life12050717. [PMID: 35629384 PMCID: PMC9145675 DOI: 10.3390/life12050717] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/09/2022] [Accepted: 05/09/2022] [Indexed: 01/05/2023] Open
Abstract
(1) Objective: This review paper aims to discuss multiple aspects of cerebral venous thrombosis (CVT), including epidemiology, etiology, pathophysiology, and clinical presentation. Different neuroimaging methods for diagnosis of CVT, such as computer tomography CT/CT Venography (CTV), and Magnetic Resonance Imaging (MRI)/MR Venography (MRV) will be presented. (2) Methods: A literature analysis using PubMed and the MEDLINE sub-engine was done using the terms: cerebral venous thrombosis, thrombophilia, and imaging. Different studies concerning risk factors, clinical picture, and imaging signs of patients with CVT were examined. (3) Results: At least one risk factor can be identified in 85% of CVT cases. Searching for a thrombophilic state should be realized for patients with CVT who present a high pretest probability of severe thrombophilia. Two pathophysiological mechanisms contribute to their highly variable clinical presentation: augmentation of venular and capillary pressure, and diminution of cerebrospinal fluid absorption. The clinical spectrum of CVT is frequently non-specific and presents a high level of clinical suspicion. Four major syndromes have been described: isolated intracranial hypertension, seizures, focal neurological abnormalities, and encephalopathy. Cavernous sinus thrombosis is the single CVT that presents a characteristic clinical syndrome. Non-enhanced CT (NECT) of the Head is the most frequently performed imaging study in the emergency department. Features of CVT on NECT can be divided into direct signs (demonstration of dense venous clot within a cerebral vein or a cerebral venous sinus), and more frequently indirect signs (such as cerebral edema, or cerebral venous infarct). CVT diagnosis is confirmed with CTV, directly detecting the venous clot as a filling defect, or MRI/MRV, which also realizes a better description of parenchymal abnormalities. (4) Conclusions: CVT is a relatively rare disorder in the general population and is frequently misdiagnosed upon initial examination. The knowledge of wide clinical aspects and imaging signs will be essential in providing a timely diagnosis.
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15
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Karakas C, Hajiyev Y, Skrehot HC, Kralik SF, Lambert EM, Pehlivan D. Clinical Profile and Long-Term Outcomes in Pediatric Cavernous Sinus Thrombosis. Pediatr Neurol 2022; 130:28-40. [PMID: 35306302 DOI: 10.1016/j.pediatrneurol.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 12/23/2021] [Accepted: 02/25/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pediatric cavernous sinus thrombosis (CST) is a rare condition with limited data regarding its clinical characteristics and long-term outcomes. The objective of this study was to describe the clinical and radiologic features, diagnostic evaluation, management, and long-term prognosis and to identify clinical variables associated with long-term outcomes in pediatric CST. METHODS A retrospective chart review of patients younger than 18 years diagnosed with a CST between 2004 and 2018 at a single center was conducted. RESULTS We identified 16 (M:F = 10:6) children with CST with a mean age of 7.6 years (10 days to 15 years) and average follow-up duration of 29 months (3 weeks to 144 months). The most common symptom and examination finding at presentation was eyelid swelling (n = 8). Six patients had bilateral CST. The most common etiologies were sinusitis (n = 5) and orbital cellulitis (n = 5). Treatments included antibiotics (n = 14), anticoagulation (n = 11), and surgery (n = 5). Only one patient died due to intracranial complications. Twelve patients had a normal examination at follow-up. None of the clinical variables including age (P = 0.14), gender (P = 0.09), use of antibiotics (P = 1.00) or anticoagulation (P = 1.00), surgery (P = 0.28), parenchymal abnormalities (P = 0.30), additional cerebral venous thrombosis (P = 0.28), and early versus late commencing of anticoagulation (P = 1.00) were significant when comparing patients with full/partial resolution versus those with no resolution of thrombosis on follow-up neuroimaging. CONCLUSIONS Our study is one of the largest cohorts with the longest follow-up data for the pediatric CST. Most of our patients had favorable outcomes at follow-up. We found no statistical difference between clinical variables when comparing patients with full/partial resolution versus those with no resolution of thrombosis on follow-up neuroimaging.
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Affiliation(s)
- Cemal Karakas
- Division of Pediatric Neurology, Department of Neurology, University of Louisville, Norton Children's Medical Group, Louisville, Kentucky
| | - Yusif Hajiyev
- Department of Pediatric Otolaryngology, Baylor College of Medicine, Houston, Texas
| | - Henry C Skrehot
- Department of Neurology, Baylor College of Medicine, Houston, Texas
| | - Stephen F Kralik
- Department of Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Elton M Lambert
- Department of Pediatric Otolaryngology, Baylor College of Medicine, Houston, Texas
| | - Davut Pehlivan
- Department of Pediatrics, Section of Pediatric Neurology and Developmental Neuroscience, Baylor College of Medicine, Houston, Texas.
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16
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Sánchez van Kammen M, Male C, Connor P, Monagle P, Coutinho JM, Lensing AWA. Anticoagulant Treatment for Pediatric Infection-Related Cerebral Venous Thrombosis. Pediatr Neurol 2022; 128:20-24. [PMID: 35032886 DOI: 10.1016/j.pediatrneurol.2021.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND We aimed to describe the clinical presentation, risk of bleeding and recurrent thrombosis, and perioperative anticoagulant management of children with cerebral venous thrombosis (CVT) and an associated head or neck infection. METHODS In this subgroup analysis of the EINSTEIN-Jr study, we included children with CVT and an associated head or neck infection who received therapeutic anticoagulants with either low-molecular-weight heparin (with or without subsequent vitamin K antagonists) or rivaroxaban for a period of 3 months. Analyses are descriptive. RESULTS Of 74 included children, 59 (80%) had otomastoiditis, 21 (28%) a central nervous system infection, 18 (24%) sinusitis, and 9 (12%) another upper respiratory tract infection; 29 (39%) had infection of multiple regions of the head or neck. All 74 children received antibiotics and therapeutic anticoagulants; 41 (55%) underwent surgery, of whom 34 were diagnosed with CVT preoperatively. Anticoagulation was started before surgery in 12 children and interrupted 0-1 days prior to surgery. Anticoagulation was (re)started in all 34 children at a median of 1 day (interquartile range: 0-1) postoperatively, in therapeutic doses in 94%. Overall, one child (1%, 95% confidence interval: 0-7) had recurrent thrombosis, and one (1%, 95% confidence interval: 0-7) had major bleeding; neither was associated with surgery. At 3 months, no children had died, 3 (4%) had persistent focal neurologic deficits, and 2 (3%) had impaired vision. CONCLUSIONS Children with CVT and an associated head or neck infection administered therapeutic anticoagulants generally had low risks of bleeding and thrombotic complications, including those who had surgical interventions with delay or interruption of anticoagulation.
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Affiliation(s)
| | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - Philip Connor
- Department of Paediatric Haematology/Oncology, Noah's Ark Children's Hospital for Wales, Cardiff, United Kingdom
| | - Paul Monagle
- Kids Cancer Centre, Sydney Children's Hospital Randwick, NSW, Department of Clinical Haematology, Royal Children's Hospital, Haematology Research Murdoch Children's Research Institute, Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Amsterdam, The Netherlands.
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17
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Kalyva N, Mousafeiris VK, Giannakopoulos A. Sigmoid Sinus Thrombosis As Complication of Otitis Media in a 3-Year-Old Boy: Case Report and Review of the Literature. Cureus 2022; 14:e22262. [PMID: 35340493 PMCID: PMC8931448 DOI: 10.7759/cureus.22262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 11/11/2022] Open
Abstract
Sigmoid sinus thrombosis is a relatively rare, but severe complication of acute otitis media and mastoiditis among other conditions. We report a case of a 3-year-old boy with a history of recurrent acute otitis media which was initially partially treated with antibiotics for 1 month before his admission to our department for high fever and headache. Although initially, no signs of central nervous system (CNS) involvement were present, clinical suspicion for CNS pathology led our whole work-up to conclude the diagnosis of sigmoid sinus thrombosis. The patient was subsequently treated with intravenous antibiotics, anticoagulation therapy and also underwent myringotomy, bilateral tympanostomy tube placement, and mastoidectomy. Cerebral sinus thrombosis is a life-threatening condition that usually complicates the neglected acute otitis media or mastoiditis. Optimal treatment includes antibiotic therapy, hydration, and pain management, with the debatable role of anticoagulation therapy and mastoidectomy.
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18
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Vaslow DF. Chronic subdural hemorrhage predisposes to development of cerebral venous thrombosis and associated retinal hemorrhages and subdural rebleeds in infants. Neuroradiol J 2022; 35:53-66. [PMID: 34167377 PMCID: PMC8826291 DOI: 10.1177/19714009211026904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
For infants presenting with subdural hemorrhage, retinal hemorrhage, and neurological decline the "consensus" opinion is that this constellation represents child abuse and that cerebral venous sinus thrombosis and cortical vein thrombosis is a false mimic. This article contends that this conclusion is false for a subset of infants with no evidence of spinal, external head, or body injury and is the result of a poor radiologic evidence base and misinterpreted data. Underdiagnosis of thrombosis is the result of rapid clot dissolution and radiologic under recognition. A pre-existing/chronic subdural hemorrhage predisposes to development of venous sinus thrombosis/cortical vein thrombosis, triggered by minor trauma or an acute life-threatening event such as dysphagic choking, variably leading to retinal and subdural hemorrhages and neurologic decline. These conclusions are based on analysis of the neuroradiologic imaging findings in 11 infants, all featuring undiagnosed cortical vein or venous sinus thrombosis. Subtle neuroradiologic signs of and the mechanisms of thrombosis are discussed. Subarachnoid hemorrhage from leaking thrombosed cortical veins may be confused with acute subdural hemorrhage and probably contributes to the development of retinal hemorrhage ala Terson's syndrome. Chronic subdural hemorrhage rebleeding from minor trauma likely occurs more readily than bleeding from traumatic bridging vein rupture. Radiologists must meet the challenge of stringent evaluation of neuro imaging studies; any infant with a pre-existing subdural hemorrhage presenting with neurologic decline must be assumed to have venous sinus or cortical vein thrombosis until proven otherwise.
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Affiliation(s)
- Dale F Vaslow
- Department of Radiology, Harry S.
Truman Veterans Administration Hospital, Columbia, MO, USA,Dale F Vaslow, 2504 Lenox Place, Columbia,
MO 65203, USA.
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19
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Jankovic M, Petrovic B, Novakovic I, Brankovic S, Radosavljevic N, Nikolic D. The Genetic Basis of Strokes in Pediatric Populations and Insight into New Therapeutic Options. Int J Mol Sci 2022; 23:ijms23031601. [PMID: 35163523 PMCID: PMC8835808 DOI: 10.3390/ijms23031601] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/27/2022] [Accepted: 01/28/2022] [Indexed: 02/04/2023] Open
Abstract
Strokes within pediatric populations are considered to be the 10th leading cause of death in the United States of America, with over half of such events occurring in children younger than one year of life. The multifactorial etiopathology that has an influence on stroke development and occurrence signify the importance of the timely recognition of both modifiable and non-modifiable factors for adequate diagnostic and treatment approaches. The early recognition of a stroke and stroke risk in children has the potential to advance the application of neuroprotective, thrombolytic, and antithrombotic interventions and rehabilitation strategies to the earliest possible timepoints after the onset of a stroke, improving the outcomes and quality of life for affected children and their families. The recent development of molecular genetic methods has greatly facilitated the analysis and diagnosis of single-gene disorders. In this review, the most significant single gene disorders associated with pediatric stroke are presented, along with specific therapeutic options whenever they exist. Besides monogenic disorders that may present with stroke as a first symptom, genetic polymorphisms may contribute to the risk of pediatric and perinatal stroke. The most frequently studied genetic risk factors are several common polymorphisms in genes associated with thrombophilia; these genes code for proteins that are part of the coagulation cascade, fibrolysis, homocystein metabolism, lipid metabolism, or platelets. Single polymorphism frequencies may not be sufficient to completely explain the stroke causality and an analysis of several genotype combinations is a more promising approach. The recent steps forward in our understanding of the disorders underlying strokes has given us a next generation of therapeutics and therapeutic targets by which to improve stroke survival, protect or rebuild neuronal connections in the brain, and enhance neural function. Advances in DNA sequencing and the development of new tools to correct human gene mutations have brought genetic analysis and gene therapy into the focus of investigations for new therapeutic options for stroke patients.
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Affiliation(s)
- Milena Jankovic
- Neurology Clinic, Clinical Center of Serbia, 11000 Belgrade, Serbia;
| | - Bojana Petrovic
- Clinic of Gynecology and Obstetrics, Clinical Center of Serbia, 11000 Belgrade, Serbia;
| | - Ivana Novakovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Slavko Brankovic
- Faculty of Sciences and Mathematics, University of Priština in Kosovska Mitrovica, 38220 Kosovska Mitrovica, Serbia;
| | - Natasa Radosavljevic
- Department of Physical Medicine and Rehabilitation, King Abdulaziz Specialist Hospital, Taif 26521, Saudi Arabia;
| | - Dejan Nikolic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
- Physical Medicine and Rehabilitation Department, University Children’s Hospital, 11000 Belgrade, Serbia
- Correspondence:
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Devianne J, Legris N, Crassard I, Bellesme C, Bejot Y, Guidoux C, Pico F, Germanaud D, Obadia M, Rodriguez D, Tuppin P, Kossorotoff M, Denier C. Epidemiology, Clinical Features, and Outcome in a Cohort of Adolescents With Cerebral Venous Thrombosis. Neurology 2021; 97:e1920-e1932. [PMID: 34544816 DOI: 10.1212/wnl.0000000000012828] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 09/02/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVES We aimed to analyze the epidemiologic, clinical, and paraclinical features of adolescents with cerebral venous thrombosis (CVT) and its therapeutic management and outcome. METHODS This multicenter retrospective cohort included patients 10 to 18 years of age hospitalized for a first episode of CVT in 2 French regions between 1999 and 2019. The number of cases was compared to the number recorded by the French health insurance system. The CVT registry of the Lariboisière hospital allowed comparisons with adults. RESULTS One hundred two patients were included (52.9% female; median age 15.1 years). Estimated incidence was 0.37 to 0.38 per 100,000 adolescents per year; 45.5% of patients presented with focal deficits or seizures or in a coma. Male patients were younger than female patients (14.2 vs 15.6 years; p < 0.01) and more often admitted to intensive care (52.1% vs 24.1%; p = 0.0,035). The lateral sinus was the most common CVT location (72.3%), and 29.4% of adolescents had associated venous infarction or hematoma. Most patients (94.1%) received anticoagulation. Treatment also included an endovascular procedure (2.9%), decompressive craniectomy (4.9%), and CSF shunt (6.9%). The most frequently identified CVT-associated condition was local infection in male (18.6%) and systemic disease in female (14.8%; p < 0.001) patients. The proportion of CVTs in adolescents without an identified associated condition or risk factor was low (1.9% vs 11.4% in adults; p < 0.002). Adverse outcome at 1 year was more frequent than in adults (33.3% vs 11.8%; p = 0.0,001). DISCUSSION CVT in adolescents is rare and complex with specific epidemiology, including differences in clinical presentation and associated conditions between sexes, and more severe outcomes than in adults. Careful specialized management and follow-up are therefore recommended.
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Affiliation(s)
- Julia Devianne
- From the Stroke Units and Departments of Neurology of Hôpital Bicêtre (J.D., N.L., C.D.), Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), and Paris Saclay University; Hôpital Lariboisière (I.C.), AP-HP, Paris; Pediatric Neurology and Stroke Unit (C.B.), AP-HP, Hôpital Bicêtre; University Région Bourgogne (Y.B.), Hôpital de Dijon; Hôpital Bichat (C.G.), AP-HP, Paris; Hôpital André Mignot (F.P.), Versailles; Hôpital Armand Trousseau (D.R.), AP-HP; Hôpital Fondation Rothschild (M.O.); Hôpital Robert Debré (D.G.), AP-HP; French National Health Insurance (CNAM) (P.T.); and Pediatric Neurology Unit and French Center for Pediatric Stroke (M.K.), AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Nicolas Legris
- From the Stroke Units and Departments of Neurology of Hôpital Bicêtre (J.D., N.L., C.D.), Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), and Paris Saclay University; Hôpital Lariboisière (I.C.), AP-HP, Paris; Pediatric Neurology and Stroke Unit (C.B.), AP-HP, Hôpital Bicêtre; University Région Bourgogne (Y.B.), Hôpital de Dijon; Hôpital Bichat (C.G.), AP-HP, Paris; Hôpital André Mignot (F.P.), Versailles; Hôpital Armand Trousseau (D.R.), AP-HP; Hôpital Fondation Rothschild (M.O.); Hôpital Robert Debré (D.G.), AP-HP; French National Health Insurance (CNAM) (P.T.); and Pediatric Neurology Unit and French Center for Pediatric Stroke (M.K.), AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Isabelle Crassard
- From the Stroke Units and Departments of Neurology of Hôpital Bicêtre (J.D., N.L., C.D.), Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), and Paris Saclay University; Hôpital Lariboisière (I.C.), AP-HP, Paris; Pediatric Neurology and Stroke Unit (C.B.), AP-HP, Hôpital Bicêtre; University Région Bourgogne (Y.B.), Hôpital de Dijon; Hôpital Bichat (C.G.), AP-HP, Paris; Hôpital André Mignot (F.P.), Versailles; Hôpital Armand Trousseau (D.R.), AP-HP; Hôpital Fondation Rothschild (M.O.); Hôpital Robert Debré (D.G.), AP-HP; French National Health Insurance (CNAM) (P.T.); and Pediatric Neurology Unit and French Center for Pediatric Stroke (M.K.), AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Celine Bellesme
- From the Stroke Units and Departments of Neurology of Hôpital Bicêtre (J.D., N.L., C.D.), Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), and Paris Saclay University; Hôpital Lariboisière (I.C.), AP-HP, Paris; Pediatric Neurology and Stroke Unit (C.B.), AP-HP, Hôpital Bicêtre; University Région Bourgogne (Y.B.), Hôpital de Dijon; Hôpital Bichat (C.G.), AP-HP, Paris; Hôpital André Mignot (F.P.), Versailles; Hôpital Armand Trousseau (D.R.), AP-HP; Hôpital Fondation Rothschild (M.O.); Hôpital Robert Debré (D.G.), AP-HP; French National Health Insurance (CNAM) (P.T.); and Pediatric Neurology Unit and French Center for Pediatric Stroke (M.K.), AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Yannick Bejot
- From the Stroke Units and Departments of Neurology of Hôpital Bicêtre (J.D., N.L., C.D.), Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), and Paris Saclay University; Hôpital Lariboisière (I.C.), AP-HP, Paris; Pediatric Neurology and Stroke Unit (C.B.), AP-HP, Hôpital Bicêtre; University Région Bourgogne (Y.B.), Hôpital de Dijon; Hôpital Bichat (C.G.), AP-HP, Paris; Hôpital André Mignot (F.P.), Versailles; Hôpital Armand Trousseau (D.R.), AP-HP; Hôpital Fondation Rothschild (M.O.); Hôpital Robert Debré (D.G.), AP-HP; French National Health Insurance (CNAM) (P.T.); and Pediatric Neurology Unit and French Center for Pediatric Stroke (M.K.), AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Celine Guidoux
- From the Stroke Units and Departments of Neurology of Hôpital Bicêtre (J.D., N.L., C.D.), Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), and Paris Saclay University; Hôpital Lariboisière (I.C.), AP-HP, Paris; Pediatric Neurology and Stroke Unit (C.B.), AP-HP, Hôpital Bicêtre; University Région Bourgogne (Y.B.), Hôpital de Dijon; Hôpital Bichat (C.G.), AP-HP, Paris; Hôpital André Mignot (F.P.), Versailles; Hôpital Armand Trousseau (D.R.), AP-HP; Hôpital Fondation Rothschild (M.O.); Hôpital Robert Debré (D.G.), AP-HP; French National Health Insurance (CNAM) (P.T.); and Pediatric Neurology Unit and French Center for Pediatric Stroke (M.K.), AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Fernando Pico
- From the Stroke Units and Departments of Neurology of Hôpital Bicêtre (J.D., N.L., C.D.), Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), and Paris Saclay University; Hôpital Lariboisière (I.C.), AP-HP, Paris; Pediatric Neurology and Stroke Unit (C.B.), AP-HP, Hôpital Bicêtre; University Région Bourgogne (Y.B.), Hôpital de Dijon; Hôpital Bichat (C.G.), AP-HP, Paris; Hôpital André Mignot (F.P.), Versailles; Hôpital Armand Trousseau (D.R.), AP-HP; Hôpital Fondation Rothschild (M.O.); Hôpital Robert Debré (D.G.), AP-HP; French National Health Insurance (CNAM) (P.T.); and Pediatric Neurology Unit and French Center for Pediatric Stroke (M.K.), AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - David Germanaud
- From the Stroke Units and Departments of Neurology of Hôpital Bicêtre (J.D., N.L., C.D.), Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), and Paris Saclay University; Hôpital Lariboisière (I.C.), AP-HP, Paris; Pediatric Neurology and Stroke Unit (C.B.), AP-HP, Hôpital Bicêtre; University Région Bourgogne (Y.B.), Hôpital de Dijon; Hôpital Bichat (C.G.), AP-HP, Paris; Hôpital André Mignot (F.P.), Versailles; Hôpital Armand Trousseau (D.R.), AP-HP; Hôpital Fondation Rothschild (M.O.); Hôpital Robert Debré (D.G.), AP-HP; French National Health Insurance (CNAM) (P.T.); and Pediatric Neurology Unit and French Center for Pediatric Stroke (M.K.), AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Michael Obadia
- From the Stroke Units and Departments of Neurology of Hôpital Bicêtre (J.D., N.L., C.D.), Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), and Paris Saclay University; Hôpital Lariboisière (I.C.), AP-HP, Paris; Pediatric Neurology and Stroke Unit (C.B.), AP-HP, Hôpital Bicêtre; University Région Bourgogne (Y.B.), Hôpital de Dijon; Hôpital Bichat (C.G.), AP-HP, Paris; Hôpital André Mignot (F.P.), Versailles; Hôpital Armand Trousseau (D.R.), AP-HP; Hôpital Fondation Rothschild (M.O.); Hôpital Robert Debré (D.G.), AP-HP; French National Health Insurance (CNAM) (P.T.); and Pediatric Neurology Unit and French Center for Pediatric Stroke (M.K.), AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Diana Rodriguez
- From the Stroke Units and Departments of Neurology of Hôpital Bicêtre (J.D., N.L., C.D.), Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), and Paris Saclay University; Hôpital Lariboisière (I.C.), AP-HP, Paris; Pediatric Neurology and Stroke Unit (C.B.), AP-HP, Hôpital Bicêtre; University Région Bourgogne (Y.B.), Hôpital de Dijon; Hôpital Bichat (C.G.), AP-HP, Paris; Hôpital André Mignot (F.P.), Versailles; Hôpital Armand Trousseau (D.R.), AP-HP; Hôpital Fondation Rothschild (M.O.); Hôpital Robert Debré (D.G.), AP-HP; French National Health Insurance (CNAM) (P.T.); and Pediatric Neurology Unit and French Center for Pediatric Stroke (M.K.), AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Philippe Tuppin
- From the Stroke Units and Departments of Neurology of Hôpital Bicêtre (J.D., N.L., C.D.), Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), and Paris Saclay University; Hôpital Lariboisière (I.C.), AP-HP, Paris; Pediatric Neurology and Stroke Unit (C.B.), AP-HP, Hôpital Bicêtre; University Région Bourgogne (Y.B.), Hôpital de Dijon; Hôpital Bichat (C.G.), AP-HP, Paris; Hôpital André Mignot (F.P.), Versailles; Hôpital Armand Trousseau (D.R.), AP-HP; Hôpital Fondation Rothschild (M.O.); Hôpital Robert Debré (D.G.), AP-HP; French National Health Insurance (CNAM) (P.T.); and Pediatric Neurology Unit and French Center for Pediatric Stroke (M.K.), AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Manoelle Kossorotoff
- From the Stroke Units and Departments of Neurology of Hôpital Bicêtre (J.D., N.L., C.D.), Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), and Paris Saclay University; Hôpital Lariboisière (I.C.), AP-HP, Paris; Pediatric Neurology and Stroke Unit (C.B.), AP-HP, Hôpital Bicêtre; University Région Bourgogne (Y.B.), Hôpital de Dijon; Hôpital Bichat (C.G.), AP-HP, Paris; Hôpital André Mignot (F.P.), Versailles; Hôpital Armand Trousseau (D.R.), AP-HP; Hôpital Fondation Rothschild (M.O.); Hôpital Robert Debré (D.G.), AP-HP; French National Health Insurance (CNAM) (P.T.); and Pediatric Neurology Unit and French Center for Pediatric Stroke (M.K.), AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Christian Denier
- From the Stroke Units and Departments of Neurology of Hôpital Bicêtre (J.D., N.L., C.D.), Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), and Paris Saclay University; Hôpital Lariboisière (I.C.), AP-HP, Paris; Pediatric Neurology and Stroke Unit (C.B.), AP-HP, Hôpital Bicêtre; University Région Bourgogne (Y.B.), Hôpital de Dijon; Hôpital Bichat (C.G.), AP-HP, Paris; Hôpital André Mignot (F.P.), Versailles; Hôpital Armand Trousseau (D.R.), AP-HP; Hôpital Fondation Rothschild (M.O.); Hôpital Robert Debré (D.G.), AP-HP; French National Health Insurance (CNAM) (P.T.); and Pediatric Neurology Unit and French Center for Pediatric Stroke (M.K.), AP-HP, Hôpital Necker-Enfants malades, Paris, France.
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Nakae K, Ueno K, Moriyama M, Baba Y, Kawano Y. Low-molecular-weight heparin for asymptomatic cerebral sinovenous thrombosis in a neonate. Pediatr Int 2021; 63:1388-1390. [PMID: 34351664 DOI: 10.1111/ped.14627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 01/10/2021] [Accepted: 01/26/2021] [Indexed: 01/20/2023]
Affiliation(s)
- Koji Nakae
- Department of Pediatrics, Kagoshima University Hospital, Kagoshima, Japan
| | - Kentaro Ueno
- Department of Pediatrics, Kagoshima University Hospital, Kagoshima, Japan
| | - Mizuki Moriyama
- Department of Pediatrics, Kagoshima University Hospital, Kagoshima, Japan
| | - Yusei Baba
- Department of Pediatrics, Kagoshima University Hospital, Kagoshima, Japan
| | - Yoshifumi Kawano
- Department of Pediatrics, Kagoshima University Hospital, Kagoshima, Japan
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22
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Rodrigues SG, Vieira D, Bernardo F, Coelho J, Ribeiro JA, Palavra F, Robalo C, Levy A, Quintas S. Pediatric cerebral sinus venous thrombosis: clinical characterization of a Portuguese cohort. Acta Neurol Belg 2021; 122:1211-1218. [PMID: 34606070 DOI: 10.1007/s13760-021-01807-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/15/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Pediatric cerebral sinus venous thrombosis (CSVT) is a rare entity. Risk factors differ from the adults, and treatment is not consensual. With this work, we aimed to characterize a pediatric cohort from two Portuguese tertiary centers. METHODS All patients under 18 years old with confirmed CSVT admitted between 2006 and 2019 were retrospectively included. Demographics, clinical presentation, workup, and follow-up were evaluated. RESULTS Fifty-three patients were included, 29 were male (54.7%). Median age was 5 years (IQR 11.08, range 0-17 years old). Headache, seizures and impairment of consciousness were the most frequent manifestations. A risk factor was identified in 90.6% (n = 48), mostly infections (43.8%; n = 21). CNS complications were comprised of hemorrhage, venous infarction, hydrocephalus and edema. Treatment included anticoagulation in 36 patients (67.9%), and there were no recurrences on follow-up. Prognosis was favorable, with most patients presenting no or only slight disability comparing to same age and sex children, on the follow-up. DISCUSSION In this cohort, impairment of consciousness was the most frequent clinical presentation and infections were the most frequent risk factors. The outcome was mainly favorable, with most patients presenting none or mild disability and without recurrences on follow-up. Studies are needed to define the criteria for anticoagulation and its recommended duration in children.
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Gadgil N, Aldave G, Whitehead WE, Dmytriw AA, Chen K, Orbach D, Maier I, Behme D, Fargen KM, Elijovich L, Dornbos D, Spiotta A, Kan P. Endovascular Intervention for Refractory Pediatric Cerebral Venous Sinus Thrombosis. Pediatr Neurol 2021; 121:45-50. [PMID: 34147818 DOI: 10.1016/j.pediatrneurol.2021.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/18/2021] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Cerebral venous sinus thrombosis (CVST) is a rare but potentially morbid disease in the pediatric population, and the optimal treatment is not fully understood. Endovascular intervention for this condition has been rarely reported. METHODS The Stroke Thrombectomy and Aneurysm Registry was queried for patients aged less than or equal to 18 years undergoing endovascular treatment for CVST in the past 10 years. Clinical charts and radiographic data were retrospectively reviewed. Modified Rankin Score (mRS) at 90 days postprocedure was determined as the primary outcome. RESULTS A total of seven patients across five pediatric centers ranging from 7 to 16 years of age were identified with a mean follow-up of 28 months. All had underlying conditions predisposing to CVST. Endovascular intervention was undertaken due to neurological deterioration despite systemic anticoagulation; venous infarct was evident preoperatively in six of seven patients. Mechanical venous thrombectomy was attempted in all individuals, and intrasinus thrombolytic therapy was also performed in three cases. Six patients had favorable outcome with mRS 0 or 1 at 90 days postprocedure; one remained neurologically devastated. CONCLUSIONS Endovascular treatment by an experienced interventionalist may be safe and effective in severe cases of CVST in children failing frontline therapy. Children with radiographic or clinical progression despite anticoagulation may be considered for endovascular intervention in a timely manner.
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Affiliation(s)
- Nisha Gadgil
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine/ Texas Children's Hospital, Houston, Texas
| | - Guillermo Aldave
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine/ Texas Children's Hospital, Houston, Texas
| | - William E Whitehead
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine/ Texas Children's Hospital, Houston, Texas
| | - Adam A Dmytriw
- Department of Neurointerventional Radiology, Boston Children's Hospital/ Harvard Medical School, Boston, Massachusetts
| | - Karen Chen
- Department of Neurointerventional Radiology, Boston Children's Hospital/ Harvard Medical School, Boston, Massachusetts
| | - Darren Orbach
- Department of Neurointerventional Radiology, Boston Children's Hospital/ Harvard Medical School, Boston, Massachusetts
| | - Ilko Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Daniel Behme
- Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Kyle M Fargen
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Caroline
| | - Lucas Elijovich
- Department of Neurology and Neurosurgery, Semmes-Murphey Clinic and University of Tennessee Health Science Center, Memphis, Tennessee
| | - David Dornbos
- Department of Neurological Surgery, Semmes-Murphey Clinic and University of Tennessee Health Science Center, Memphis, Tennessee
| | - Alejandro Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas.
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Ku JC, Hanak B, Muthusami P, Narvacan K, Girgis H, terBrugge K, Krings T, Rutka JT, Dirks P. Improving long-term outcomes in pediatric torcular dural sinus malformations with embolization and anticoagulation: a retrospective review of The Hospital for Sick Children experience. J Neurosurg Pediatr 2021; 28:469-475. [PMID: 34330098 DOI: 10.3171/2021.3.peds20921] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 03/10/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Torcular dural sinus malformations (tDSMs) are rare pediatric cerebrovascular malformations characterized by giant venous lakes localized to the midline confluence of sinuses. Historical clinical outcomes of patients with these lesions were poor, though better prognoses have been reported in the more recent literature. Long-term outcomes in children with tDSMs are uncertain and require further characterization. The goal of this study was to review a cohort of tDSM patients with an emphasis on long-term outcomes and to describe the treatment strategy. METHODS This study is a single-center retrospective review of a prospectively maintained data bank including patients referred to and cared for at The Hospital for Sick Children for tDSM from January 1996 to March 2019. Each patient's clinical, radiological, and demographic information, as well as their mother's demographic information, was collected for review. RESULTS Ten patients with tDSM, with a mean follow-up of 58 months, were included in the study. Diagnoses were made antenatally in 8 patients, and among those cases, 4 families opted for either elective termination (n = 1) or no further care following delivery (n = 3). Of the 6 patients treated, 5 had a favorable long-term neurological outcome, and follow-up imaging demonstrated a decrease or stability in the size of the tDSM over time. Staged embolization was performed in 3 patients, and anticoagulation was utilized in 5 treated patients. CONCLUSIONS The authors add to a growing body of literature indicating that clinical outcomes in tDSM may not be as poor as initially perceived. Greater awareness of the lesion's natural history and pathophysiology, advancing endovascular techniques, and individualized anticoagulation regimens may lead to continued improvement in outcomes.
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Affiliation(s)
- Jerry C Ku
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto.,2Division of Neurosurgery, The Hospital for Sick Children, Toronto
| | - Brian Hanak
- 3Department of Neurosurgery, Loma Linda University Health, Loma Linda, California
| | - Prakash Muthusami
- 4Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto
| | - Karl Narvacan
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto.,2Division of Neurosurgery, The Hospital for Sick Children, Toronto
| | - Hidy Girgis
- 5Division of Neurosurgery, Department of Surgery, University of Ottawa, Ottawa
| | - Karel terBrugge
- 4Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto.,6Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada; and
| | - Timo Krings
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto.,4Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto.,6Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada; and
| | - James T Rutka
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto.,2Division of Neurosurgery, The Hospital for Sick Children, Toronto
| | - Peter Dirks
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto.,2Division of Neurosurgery, The Hospital for Sick Children, Toronto
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25
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Anderst J, Carpenter S, Frazier T, Appavu B, Noetzel M, Beslow LA, Sharma M. Subdural hemorrhage in a cohort with cerebral sinovenous thrombosis: Application to abusive head trauma. CHILD ABUSE & NEGLECT 2021; 117:105119. [PMID: 34023741 DOI: 10.1016/j.chiabu.2021.105119] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/23/2021] [Accepted: 05/11/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Cerebral sinovenous thrombosis (CSVT) is a postulated cause of subdural hemorrhage (SDH) that is hypothesized to mimic abusive head trauma (AHT). Minimal data exists directly investigating this relationship. OBJECTIVES To evaluate the frequency of SDH in children with CSVT, identify factors associated with CSVT and SDH, and to assess if any association supports the hypothesis that CSVT causes SDH. PARTICIPANTS AND SETTING The International Pediatric Stroke Study (IPSS) prospectively collects data on subjects birth to 19 years of age with intracranial thrombosis. METHODS IPSS subjects with CSVT and SDH were compared to those with CSVT and no SDH. For subjects with CSVT and SDH, neuroimaging reports further characterized the findings. In any case with no known risk factors for SDH, neuroimaging studies were reviewed by a pediatric neuroradiologist. RESULTS Of 216 subjects with CSVT, 20 (9.3%) had SDH. Those with SDH (median age 0.3 years) were younger than those without SDH (median age 4.2 years), p < 0.001. Subjects with CSVT and SDH more frequently had anoxia (OR = 10.8; 95% CI: 1.4, 81.1), head/neck injury (OR = 4.0; 95% CI: 1.3, 12.6), or abnormal consciousness (OR = 3.0; 95% CI: 1.2, 7.6). Of 20 subjects with CSVT and SDH, 19 had known risk factors for SDH. The remaining subject had a chronic SDH identified concomitantly to a newly symptomatic CSVT with accompanying venous infarctions. CONCLUSIONS SDH in the setting of CSVT is typically identified in children with independent risk factors for SDH. This study does not support the hypothesis that CSVT causes SDH.
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Affiliation(s)
- James Anderst
- Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States.
| | - Shannon Carpenter
- Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
| | - Terra Frazier
- Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
| | - Brian Appavu
- Department of Pediatrics, University of Arizona College of Medicine, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Michael Noetzel
- Department of Neurology, St. Louis Children's Hospital, Washington University, St. Louis, MO, United States
| | - Lauren A Beslow
- Departments of Neurology and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Mukta Sharma
- Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
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Bhattacharya D, Angurana SK, Sundaram V, Singh P. Cerebral Sinovenous Thrombosis due to Hypernatremic Dehydration in a Neonate. Neurol India 2021; 69:164-166. [PMID: 33642292 DOI: 10.4103/0028-3886.310090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Cerebral sinus venous thrombosis is an uncommon complication of hypernatremic dehydration in neonates. Non-improvement in neurological status even after correction of hypernatremia should lead to suspicion of intracranial complications due to hypernatremia or its overtreatment. Slow correction of hypernatremia, calculated fluid administration, and anticoagulation improve outcome in neonates with CSVT.
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Affiliation(s)
- Deepanjan Bhattacharya
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Suresh Kumar Angurana
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Venkataseshan Sundaram
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Paramjeet Singh
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Hasbani GE, Taher AT, Sunji N, Sciascia S, Uthman I. Antiphospholipid antibodies and cerebrovascular thrombosis in the pediatric population: Few answers to many questions. Lupus 2021; 30:1365-1377. [PMID: 34082580 DOI: 10.1177/09612033211021488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Most of the knowledge in pediatric antiphospholipid syndrome (APS) is derived from studies performed on the adult population. As in adults, antiphospholipid antibodies (aPL) can contribute to thrombosis, especially cerebrovascular thrombosis, in neonates and children. Since aPL have the potential to cross the placental barrier, and since the pediatric population is prone to infections, re-testing for their positivity is essential to specify their role in cerebrovascular thrombosis.In this review, we aimed at assessing the prevalence of aPL, criteria or non-criteria, in neonatal and childhood ischemic stroke and sinovenous thrombosis trying to find an association between aPL and cerebrovascular thrombosis in the neonatal and pediatric population. Also, we looked into the effect of aPL and anticoagulants/antiplatelets on the long term neurological outcomes of affected neonates or children. The questions regarding the prevalence of aPL among pediatric patients with cerebrovascular thrombosis, the relationship between the titers of aPL and incidence and recurrence of cerebrovascular events, the predictability of the long term neurological outcomes, and the most optimal anticoagulation plan are still to be answered. However, it is crucial for clinicians to screen neonates and children with cerebrovascular thrombosis for aPL and confirm their presence if positive.
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Affiliation(s)
- Georges El Hasbani
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nadine Sunji
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Savino Sciascia
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy.,Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy.,Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Imad Uthman
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Safety and efficacy of rivaroxaban in pediatric cerebral venous thrombosis (EINSTEIN-Jr CVT). Blood Adv 2021; 4:6250-6258. [PMID: 33351120 DOI: 10.1182/bloodadvances.2020003244] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/20/2020] [Indexed: 11/20/2022] Open
Abstract
Anticoagulant treatment of pediatric cerebral venous thrombosis has not been evaluated in randomized trials. We evaluated the safety and efficacy of rivaroxaban and standard anticoagulants in the predefined subgroup of children with cerebral venous thrombosis (CVT) who participated in the EINSTEIN-Jr trial. Children with CVT were randomized (2:1), after initial heparinization, to treatment with rivaroxaban or standard anticoagulants (continued on heparin or switched to vitamin K antagonist). The main treatment period was 3 months. The primary efficacy outcome, symptomatic recurrent venous thromboembolism (VTE), and principal safety outcome, major or clinically relevant nonmajor bleeding,were centrally evaluated by blinded investigators. Sinus recanalization on repeat brain imaging was a secondary outcome. Statistical analyses were exploratory. In total, 114 children with confirmed CVT were randomized. All children completed the follow-up. None of the 73 rivaroxaban recipients and 1 (2.4%; CVT) of the 41 standard anticoagulant recipients had symptomatic, recurrent VTE after 3 months (absolute difference, 2.4%; 95% confidence interval [CI], -2.6% to 13.5%). Clinically relevant bleeding occurred in 5 (6.8%; all nonmajor and noncerebral) rivaroxaban recipients and in 1 (2.5%; major [subdural] bleeding) standard anticoagulant recipient (absolute difference, 4.4%; 95% CI, -6.7% to 13.4%). Complete or partial sinus recanalization occurred in 18 (25%) and 39 (53%) rivaroxaban recipients and in 6 (15%) and 24 (59%) standard anticoagulant recipients, respectively. In summary, in this substudy of a randomized trial with a limited sample size, children with CVT treated with rivaroxaban or standard anticoagulation had a low risk of recurrent VTE and clinically relevant bleeding. This trial was registered at clinicaltrials.gov as #NCT02234843.
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Abstract
Neurovascular disorders are an important cause of brain injury in the paediatric population, leading to substantial mortality and morbidity. These include ischaemic, haemorrhagic strokes, and cerebral venous sinus thromboses. Despite remarkable improvements in our understanding and management of strokes in general, and in the quality of immediate care and rehabilitation, the outcomes in childhood strokes lag far behind adult strokes. This is a multifaceted problem. There remain several challenges including delays in recognition due to vague clinical presentations, a failure to consider strokes in many cases, delays in obtaining imaging and inadequate imaging when performed, as well as limited evidence and availability for hyper acute intervention in children. Stroke in children is also a vastly different entity to adult strokes, with a unique set of risk factors and often with an underlying cause to be found. This review is by no means exhaustive, but instead aims to provide an overview of the epidemiology, sub-classification and aetiology of paediatric neurovascular disorders, mainly ischaemic, haemorrhagic strokes and cerebral venous sinus thrombosis. We also focus on the risk factors for each of these, the clinical presentation, recommended diagnostic protocol, pertinent imaging findings, as well as the current treatment and follow-up practices.
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Affiliation(s)
- Richa Sinha
- Department of Neuroradiology, Royal Preston Hospital, Preston, UK
| | - Saipriya Ramji
- Department of Neuroradiology, Charing Cross Hospital, London, UK
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30
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Diagnosis and management of cerebral venous sinus thrombosis in children: a single-center retrospective analysis. Childs Nerv Syst 2021; 37:153-160. [PMID: 33156360 DOI: 10.1007/s00381-020-04958-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/29/2020] [Indexed: 01/14/2023]
Abstract
PURPOSE Cerebral venous thrombosis (CVT) is a rare disease in children, characterized by partial or total occlusion of blood flow in the cerebral venous system. The aim of this study is to describe clinical presentation, neuroimaging features, therapeutic management, and outcome of children with CVT. METHODS We retrospectively analyzed the data, including clinical manifestations, laboratory data, neurological findings, and treatment of children with radiologically confirmed CVT, admitted between January 2010 and March 2020 to our hospital. Cases of CVT complicating brain surgery were excluded. RESULTS We enrolled 24 children with CVT. Infection was the main etiology (58.3%), followed by trauma in 16.7% of cases. In the remaining 25% of cases, the cause was identified only in one patient presenting a thrombophilic factor. The most frequent site of thrombosis was the superficial venous system (86.8%), with multiple localizations disclosed in 79% of patients. All children received anticoagulant therapy with low molecular weight heparin (LMWH). One patient died for systemic complications of an underlying disease. No patient developed hemorrhagic events during the therapy, lasting from 35 to 360 days (mean 86 days). In all but one surviving patients (22 out of 24), recanalization of the sinus was observed at AngioMRI performed during follow-up. No neurological complications of CVT were recorded (mean follow-up: 1.5 year). CONCLUSIONS CVT may present with subtle and unspecific clinical manifestations in children. High level of suspicion should be kept in trauma and sinusitis. Anticoagulation treatment is safe and effective and should be promptly started to improve outcome.
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Slim M, Aziz AS, Westmacott R, Dlamini N, Deveber G, MacGregor D, Yau I, Andres K, Moharir M. Long-term cognitive outcomes after cerebral sinovenous thrombosis in childhood. Dev Med Child Neurol 2020; 62:1437-1443. [PMID: 32909303 DOI: 10.1111/dmcn.14664] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2020] [Indexed: 10/23/2022]
Abstract
AIM To assess long-term cognitive function in children after cerebral sinovenous thrombosis (CSVT). METHOD Children with CSVT, who had neuropsychological testing for intellectual ability, executive function, attention, language, or behavior, were included in a prospective observational study. Outcomes were compared with normative means using one-sample t-tests. Predictors of abnormal function were examined using logistic regression. RESULTS Fifty children with CSVT were included (median age at diagnosis 2y 10mo, interquartile range 7d-6y 10mo; 35 males, 15 females). The median follow-up time was 4 years 2 months (interquartile range 2y 8mo-6y 4mo). Compared with normative means, children with CSVT had lower mean (± standard deviation) full-scale IQ, working memory, and processing speed scores (93.3±16, p=0.01; 93.6±16, p=0.04; 93.7±15.3, p=0.02 respectively). They also had lower scores in executive function, attention, and language domains. Refractory seizure at presentation was associated with a trend in behavioral problems (odds ratio [OR] 6.3, 95% confidence interval [CI] 0.9-46, p=0.07). Females were less likely to experience processing speed difficulties (OR 0.22, 95% CI 0.04-1.3, p=0.09). Incomplete recanalization was associated with a greater risk of abnormal verbal comprehension (OR 5.3, 95% CI 0.93-30.5, p=0.059). INTERPRETATION Children with CSVT as a group performed below age expectations on standardized neuropsychological tests, although there was variability across individuals and cognitive domains. Larger studies are needed to evaluate predictors of cognitive deficits in children with CSVT.
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Affiliation(s)
- Mahmoud Slim
- Division of Neurology, Children's Stroke Program, The Hospital for Sick Children, Toronto, Canada
| | | | - Robyn Westmacott
- Department of Psychology, The Hospital for Sick Children, Toronto, Canada
| | - Nomazulu Dlamini
- Division of Neurology, Children's Stroke Program, The Hospital for Sick Children, Toronto, Canada
| | - Gabrielle Deveber
- Division of Neurology, Children's Stroke Program, The Hospital for Sick Children, Toronto, Canada
| | - Daune MacGregor
- Division of Neurology, Children's Stroke Program, The Hospital for Sick Children, Toronto, Canada
| | - Ivanna Yau
- Division of Neurology, Children's Stroke Program, The Hospital for Sick Children, Toronto, Canada
| | - Kathleen Andres
- Division of Neurology, Children's Stroke Program, The Hospital for Sick Children, Toronto, Canada
| | - Mahendranath Moharir
- Division of Neurology, Children's Stroke Program, The Hospital for Sick Children, Toronto, Canada
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Forest C, Gallo P, Fumarola A, Burnelli R, Suppiej A. Jak2 mutation expands the thrombophilic panel in children. J Thromb Haemost 2020; 18:2636-2639. [PMID: 32654426 DOI: 10.1111/jth.14999] [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: 06/28/2020] [Accepted: 07/02/2020] [Indexed: 08/31/2023]
Abstract
Cerebral sinus venous thrombosis (CSVT) is an important cause of vascular accidents in children. The diagnosis of the underlying disease allows appropriate and timely management of the risk factors and guide therapy, but the etiology remains unknown in 20% to 25% of the cases. We present the first case of a child presenting with CSVT caused by the Janus Kinase 2 (JAK2) V617F mutation, occurring without the hematological abnormalities diagnostic for myeloproliferative neoplasms. We therefore suggest including the molecular study of the JAK2 gene in the coagulation panel of all children affected by CSVT of unknown cause.
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Affiliation(s)
- Cristina Forest
- Department of Medical Sciences, Pediatric Section, University of Ferrara, Ferrara, Italy
| | - Paola Gallo
- Department of Medical Sciences, Pediatric Section, Sant'Anna Hospital, Ferrara, Italy
| | - Adriana Fumarola
- Department of Medical Sciences, Pediatric Section, Sant'Anna Hospital, Ferrara, Italy
| | - Roberta Burnelli
- Pediatric Onco-Hematology Unit, Sant'Anna Hospital, Ferrara, Italy
| | - Agnese Suppiej
- Department of Medical Sciences, Pediatric Section, University of Ferrara, Ferrara, Italy
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33
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Trapani S, Stivala M, Lasagni D, Rosati A, Indolfi G. Otogenic Lateral Sinovenous Thrombosis in Children: A Case Series from a Single Centre and Narrative Review. J Stroke Cerebrovasc Dis 2020; 29:105184. [PMID: 32912560 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/08/2020] [Accepted: 07/19/2020] [Indexed: 10/23/2022] Open
Abstract
AIM We aimed to describe otogenic lateral sinovenous thrombosis (OLST), a rare, potentially life-threatening complication of otomastoiditis. METHODS Children diagnosed with OLST in a tertiary-care Hospital from 2014 to 2019 was retrospectively selected. Clinical and radiological features, timing of diagnosis, treatment and outcome are reported. RESULTS Seven children (5 males) were studied. Fever and neurological symptoms (headache, lethargy, diplopia, dizziness and papilledema) were always present. Otalgia and/or otorrhea were found in 6 children; none had signs of mastoiditis. Diagnosis was reached after 7 days (median) from clinical onset. Brain CT-scan was performed in 5 children being diagnostic for 3. Venography-MRI detected OLST and mastoiditis in all cases without parenchymal lesions. Treatment was based on intravenous rehydration, antibiotic and low-molecular weight heparin; acetazolamide was added in 3 children. Mastoidectomy and ventriculoperitoneal-shunting were selectively performed. Patients were discharged after 26 days (median). Follow-up neuroimaging showed sinus recanalization after a median time of 6 months. CONCLUSION A multidisciplinary approach is needed to optimize diagnostic-therapeutic protocols of pediatric OLST.
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Affiliation(s)
- Sandra Trapani
- Department of Health Sciences, Paediatric Unit, Meyer Children's University Hospital, Viale Pieraccini 24, Florence 50139, Italy.
| | - Micol Stivala
- Paediatric Unit, Meyer Children's Hospital, Viale Pieraccini 24, Florence 50139, Italy.
| | - Donatella Lasagni
- Paediatric Unit, Meyer Children's Hospital, Viale Pieraccini 24, Florence 50139, Italy.
| | - Anna Rosati
- Child Neurology Unit, Meyer Children's Hospital, Viale Pieraccini, 24 Florence 50139, Italy.
| | - Giuseppe Indolfi
- Professor NEUROFARBA Department, Meyer Children's Hospital, Viale Pieraccini 24, Florence 50139, Italy.
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Farias-Moeller R, Siddiqui S, Orr M, Mondok L. Too Much of a Good Thing? Cerebral Sinovenous Thrombosis Due to Excessive Milk Intake Associated Anemia. J Child Neurol 2020; 35:585-590. [PMID: 32429785 DOI: 10.1177/0883073820923807] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION In young children, excessive cow's milk intake causes iron-deficiency anemia, which is associated with hypercoagulable states. We present a case series of 4 toddlers with excessive milk intake iron-deficiency anemia and cerebral sinovenous thrombosis. METHODS Retrospective chart review of 4 patients was performed for patients with cerebral sinovenous thrombosis and iron-deficiency anemia secondary to excessive milk intake. Iron-deficiency anemia was defined as hemoglobin <11 mg/dL, mean corpuscular volume <70 fL, and serum ferritin <12 μg/L. Excessive milk intake was defined as consumption of >24 oz daily. Clinical, laboratory, and radiographic features were reviewed. RESULTS Age ranged from 12 to 24 months. Average hemoglobin, hematocrit, mean corpuscular volume, and ferritin levels were 6.1 g/dL, 22.7 g/dL, 52.7 fL, and 3.2 ng/mL, respectively. Daily milk consumption ranged from 40 to 60 oz. All patients presented with focal neurologic deficits, including seizures in 3. The location of cerebral sinovenous thrombosis varied, and 3 patients had venous infarcts, one of them hemorrhagic. All patients had a limited diet and were described as "picky eaters" by their parents, and only 1 had transitioned of a bottle. All patients were treated with anticoagulation, iron supplementation, and extensive dietary counseling to reduce cow's milk intake. CONCLUSION Iron-deficiency anemia due to excessive milk intake is an important and preventable etiology of pediatric cerebral sinovenous thrombosis. Focused anticipatory guidance is necessary for at-risk groups to prevent this neurologic emergency.
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Affiliation(s)
- Raquel Farias-Moeller
- Division of Child Neurology, Department of Neurology, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, WI, USA.,Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, WI, USA
| | - Sara Siddiqui
- Division of Child Neurology, Department of Neurology, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, WI, USA
| | - Megan Orr
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lileth Mondok
- Division of Child Neurology, Department of Neurology, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, WI, USA
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Goldenberg NA, Ignjatovic V. Foreword: Current Topics in Pediatric Translational Research. J Pediatr 2020; 221S:S1-S2. [PMID: 32482228 DOI: 10.1016/j.jpeds.2019.12.008] [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: 11/07/2019] [Revised: 11/26/2019] [Accepted: 12/05/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Neil A Goldenberg
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute, Johns Hopkins All Children's Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL.
| | - Vera Ignjatovic
- Hematology Research, Murdoch Children's Research Institute; Department of Pediatrics, The University of Melbourne, Parkville, Australia
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Mineyko A, Kirton A, Billinghurst L, Tatishvili NN, Wintermark M, deVeber G, Fox C. Seizures and Outcome One Year After Neonatal and Childhood Cerebral Sinovenous Thrombosis. Pediatr Neurol 2020; 105:21-26. [PMID: 31882182 PMCID: PMC7071986 DOI: 10.1016/j.pediatrneurol.2019.08.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/16/2019] [Accepted: 08/20/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pediatric cerebral sinovenous thrombosis is a treatable cause of brain injury, acute symptomatic seizures, and remote epilepsy. Our objective was to prospectively study epilepsy and outcomes in neonates and children one year after cerebral sinovenous thrombosis diagnosis. METHODS Patients with cerebral sinovenous thrombosis were enrolled prospectively from 21 international sites through the Seizures in Pediatric Stroke Study. Clinical data, including acute symptomatic seizures and cerebral sinovenous thrombosis risk factors, were collected at diagnosis. A neuroradiologist who was unaware of the diagnosis reviewed acute imaging. At one year, outcomes including seizure recurrence, epilepsy diagnosis, antiepileptic drug use, and modified Engel score were collected. Outcomes were assessed using the modified Rankin score and the King's Outcome Scale for Childhood Head Injury. RESULTS Twenty-four participants with cerebral sinovenous thrombosis were enrolled (67% male, 21% neonates). Headache was the most common presenting symptom in non-neonates (47%, nine of 19). Nine (37.5%) presented with acute symptomatic seizures. Six (25%; 95% confidence interval, 10% to 47%) developed epilepsy by one-year follow-up. No clinical predictors associated with epilepsy were identified. King's Outcome Scale for Childhood Head Injury and modified Rankin scores at one year were favorable in 71%. Half of the patients who developed epilepsy (three of six) did not have infarcts, hemorrhage, or seizures identified during the acute hospitalization. CONCLUSION Our study provides a prospective estimate that epilepsy occurs in approximately one-quarter of patients by one year after diagnosis of cerebral sinovenous thrombosis. Later epilepsy can develop in the absence of acute seizures or parenchymal injury associated with the acute presentation.
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Affiliation(s)
- Aleksandra Mineyko
- Section of Neurology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Section of Neurology, Department Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Adam Kirton
- Section of Neurology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Section of Neurology, Department Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lori Billinghurst
- Division of Neurology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nana Nino Tatishvili
- Department of Neurosciences, D. Tvildiani Medical University, M. Iashvili Central Children Hospital, Tbilis, Georgia
| | - Max Wintermark
- Neuroimaging and Neurointervention Division, Department of Radiology, Stanford University Hospital, Stanford, California
| | - Gabrielle deVeber
- Neurology Division, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Christine Fox
- Department of Neurology, University of California San Francisco, San Francisco, California; Department of Pediatrics, University of California San Francisco, San Francisco, California
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Abstract
Perinatal stroke is a heterogeneous syndrome resulting from brain injury of vascular origin that occurs between 20 weeks of gestation and 28 days of postnatal life. The incidence of perinatal stroke is estimated to be between 1:1600 and 1:3000 live births (approximately 2500 children per year in the United States), though its actual incidence is difficult to estimate because it is likely underdiagnosed. Perinatal arterial ischemic stroke (PAIS) accounts for approximately 70% of cases of perinatal stroke. Cerebral sinovenous thrombosis, while less common, also accounts for a large proportion of the morbidity and mortality seen with perinatal stroke. Hemorrhagic stroke leads to disruption of neurologic function due to intracerebral hemorrhage that is nontraumatic in origin. While most cases of PAIS fall into one of these three categories, other patterns of injury should also be considered perinatal stroke. In some cases, the etiology of PAIS is not known but is idiopathic. This chapter will review the classification, risk factors, pathogenesis, clinical presentation, management, and long-term sequelae of perinatal stroke.
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Affiliation(s)
- Emmett E Whitaker
- Department of Anesthesiology, University of Vermont Larner College of Medicine, Burlington, VT, United States; Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, United States.
| | - Marilyn J Cipolla
- Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, United States; Department of Obstetrics, Gynecology & Reproductive Sciences, University of Vermont Larner College of Medicine, Burlington, VT, United States; Department of Pharmacology, University of Vermont Larner College of Medicine, Burlington, VT, United States
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38
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Felling RJ, Hassanein SMA, Armstrong J, Aversa L, Billinghurst L, Goldenberg NA, Lee JE, Maxwell EC, Noetzel MJ, Lo W. Treatment and outcome of childhood cerebral sinovenous thrombosis. Neurol Clin Pract 2019; 10:232-244. [PMID: 32642325 DOI: 10.1212/cpj.0000000000000720] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/26/2019] [Indexed: 11/15/2022]
Abstract
Objective To test our hypothesis that anticoagulation is associated with better neurologic outcomes in childhood cerebral sinovenous thrombosis (CSVT), we analyzed treatment and outcomes in a population of 410 children from the International Pediatric Stroke Study (IPSS). Methods We included patients enrolled in the IPSS registry with a diagnosis of CSVT at age >28 days with radiologic confirmation, in isolation or with concomitant arterial ischemic stroke. The primary outcome was the neurologic status at discharge. We defined unfavorable outcome as severe neurologic impairment or death at discharge. The Pediatric Stroke Outcome Measure was used for long-term outcome in those with follow-up. Predictors of anticoagulation use and outcome were analyzed by logistic regression. Results Most children (95%) had identifiable risk factors, and 82% received anticoagulation. Shift analysis demonstrated better outcomes at discharge in children who were anticoagulated, and this persisted with longer-term outcomes. In multivariable analysis, anticoagulation was significantly associated with favorable outcomes (adjusted odds ratio [aOR] unfavorable 0.32, p = 0.007) whereas infarct was associated with unfavorable outcome (aOR unfavorable 6.71, p < 0.001). The trauma/intracranial surgery was associated with a lower odds of anticoagulation use (aOR 0.14, p < 0.001). Conclusions Within the IPSS registry, children with risk factors of trauma or intracranial surgery were less likely to receive anticoagulation for CSVT. Anticoagulation was associated with a lower odds of severe neurologic impairment or death at hospital discharge, but this finding is limited and needs further confirmation in randomized, controlled, prospective studies.
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Affiliation(s)
- Ryan J Felling
- Division of Child Neurology (RJF), Department of Neurology and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics (SMAH), Faculty of Medicine, Ain Shams University, Egypt; Section of Child Neurology and Hemophilia and Thrombosis Center (JA, ECM), Department of Pediatrics, University of Colorado, Boulder; Department of Hematology (LA), Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina; Department of Neurology (LB), Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Divisions of Hematology (NAG), Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute (NAG), Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Neurology (JEL, WL), the Ohio State University and Nationwide Children's Hospital; College of Nursing (JEL), the Ohio State University, Columbus; Department of Neurology and Pediatrics (MJN), Washington University School of Medicine, St. Louis, MO; and Department of Pediatrics (WL), the Ohio State University and Nationwide Children's Hospital
| | - Sahar M A Hassanein
- Division of Child Neurology (RJF), Department of Neurology and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics (SMAH), Faculty of Medicine, Ain Shams University, Egypt; Section of Child Neurology and Hemophilia and Thrombosis Center (JA, ECM), Department of Pediatrics, University of Colorado, Boulder; Department of Hematology (LA), Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina; Department of Neurology (LB), Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Divisions of Hematology (NAG), Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute (NAG), Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Neurology (JEL, WL), the Ohio State University and Nationwide Children's Hospital; College of Nursing (JEL), the Ohio State University, Columbus; Department of Neurology and Pediatrics (MJN), Washington University School of Medicine, St. Louis, MO; and Department of Pediatrics (WL), the Ohio State University and Nationwide Children's Hospital
| | - Jennifer Armstrong
- Division of Child Neurology (RJF), Department of Neurology and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics (SMAH), Faculty of Medicine, Ain Shams University, Egypt; Section of Child Neurology and Hemophilia and Thrombosis Center (JA, ECM), Department of Pediatrics, University of Colorado, Boulder; Department of Hematology (LA), Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina; Department of Neurology (LB), Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Divisions of Hematology (NAG), Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute (NAG), Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Neurology (JEL, WL), the Ohio State University and Nationwide Children's Hospital; College of Nursing (JEL), the Ohio State University, Columbus; Department of Neurology and Pediatrics (MJN), Washington University School of Medicine, St. Louis, MO; and Department of Pediatrics (WL), the Ohio State University and Nationwide Children's Hospital
| | - Luis Aversa
- Division of Child Neurology (RJF), Department of Neurology and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics (SMAH), Faculty of Medicine, Ain Shams University, Egypt; Section of Child Neurology and Hemophilia and Thrombosis Center (JA, ECM), Department of Pediatrics, University of Colorado, Boulder; Department of Hematology (LA), Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina; Department of Neurology (LB), Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Divisions of Hematology (NAG), Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute (NAG), Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Neurology (JEL, WL), the Ohio State University and Nationwide Children's Hospital; College of Nursing (JEL), the Ohio State University, Columbus; Department of Neurology and Pediatrics (MJN), Washington University School of Medicine, St. Louis, MO; and Department of Pediatrics (WL), the Ohio State University and Nationwide Children's Hospital
| | - Lori Billinghurst
- Division of Child Neurology (RJF), Department of Neurology and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics (SMAH), Faculty of Medicine, Ain Shams University, Egypt; Section of Child Neurology and Hemophilia and Thrombosis Center (JA, ECM), Department of Pediatrics, University of Colorado, Boulder; Department of Hematology (LA), Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina; Department of Neurology (LB), Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Divisions of Hematology (NAG), Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute (NAG), Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Neurology (JEL, WL), the Ohio State University and Nationwide Children's Hospital; College of Nursing (JEL), the Ohio State University, Columbus; Department of Neurology and Pediatrics (MJN), Washington University School of Medicine, St. Louis, MO; and Department of Pediatrics (WL), the Ohio State University and Nationwide Children's Hospital
| | - Neil A Goldenberg
- Division of Child Neurology (RJF), Department of Neurology and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics (SMAH), Faculty of Medicine, Ain Shams University, Egypt; Section of Child Neurology and Hemophilia and Thrombosis Center (JA, ECM), Department of Pediatrics, University of Colorado, Boulder; Department of Hematology (LA), Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina; Department of Neurology (LB), Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Divisions of Hematology (NAG), Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute (NAG), Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Neurology (JEL, WL), the Ohio State University and Nationwide Children's Hospital; College of Nursing (JEL), the Ohio State University, Columbus; Department of Neurology and Pediatrics (MJN), Washington University School of Medicine, St. Louis, MO; and Department of Pediatrics (WL), the Ohio State University and Nationwide Children's Hospital
| | - Jo Ellen Lee
- Division of Child Neurology (RJF), Department of Neurology and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics (SMAH), Faculty of Medicine, Ain Shams University, Egypt; Section of Child Neurology and Hemophilia and Thrombosis Center (JA, ECM), Department of Pediatrics, University of Colorado, Boulder; Department of Hematology (LA), Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina; Department of Neurology (LB), Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Divisions of Hematology (NAG), Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute (NAG), Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Neurology (JEL, WL), the Ohio State University and Nationwide Children's Hospital; College of Nursing (JEL), the Ohio State University, Columbus; Department of Neurology and Pediatrics (MJN), Washington University School of Medicine, St. Louis, MO; and Department of Pediatrics (WL), the Ohio State University and Nationwide Children's Hospital
| | - Emily C Maxwell
- Division of Child Neurology (RJF), Department of Neurology and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics (SMAH), Faculty of Medicine, Ain Shams University, Egypt; Section of Child Neurology and Hemophilia and Thrombosis Center (JA, ECM), Department of Pediatrics, University of Colorado, Boulder; Department of Hematology (LA), Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina; Department of Neurology (LB), Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Divisions of Hematology (NAG), Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute (NAG), Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Neurology (JEL, WL), the Ohio State University and Nationwide Children's Hospital; College of Nursing (JEL), the Ohio State University, Columbus; Department of Neurology and Pediatrics (MJN), Washington University School of Medicine, St. Louis, MO; and Department of Pediatrics (WL), the Ohio State University and Nationwide Children's Hospital
| | - Michael J Noetzel
- Division of Child Neurology (RJF), Department of Neurology and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics (SMAH), Faculty of Medicine, Ain Shams University, Egypt; Section of Child Neurology and Hemophilia and Thrombosis Center (JA, ECM), Department of Pediatrics, University of Colorado, Boulder; Department of Hematology (LA), Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina; Department of Neurology (LB), Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Divisions of Hematology (NAG), Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute (NAG), Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Neurology (JEL, WL), the Ohio State University and Nationwide Children's Hospital; College of Nursing (JEL), the Ohio State University, Columbus; Department of Neurology and Pediatrics (MJN), Washington University School of Medicine, St. Louis, MO; and Department of Pediatrics (WL), the Ohio State University and Nationwide Children's Hospital
| | - Warren Lo
- Division of Child Neurology (RJF), Department of Neurology and Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics (SMAH), Faculty of Medicine, Ain Shams University, Egypt; Section of Child Neurology and Hemophilia and Thrombosis Center (JA, ECM), Department of Pediatrics, University of Colorado, Boulder; Department of Hematology (LA), Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina; Department of Neurology (LB), Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Divisions of Hematology (NAG), Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; All Children's Research Institute (NAG), Johns Hopkins All Children's Hospital, St. Petersburg, FL; Department of Neurology (JEL, WL), the Ohio State University and Nationwide Children's Hospital; College of Nursing (JEL), the Ohio State University, Columbus; Department of Neurology and Pediatrics (MJN), Washington University School of Medicine, St. Louis, MO; and Department of Pediatrics (WL), the Ohio State University and Nationwide Children's Hospital
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Hutchinson ML, Beslow LA. Hemorrhagic Transformation of Arterial Ischemic and Venous Stroke in Children. Pediatr Neurol 2019; 95:26-33. [PMID: 30904397 DOI: 10.1016/j.pediatrneurol.2019.01.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/30/2019] [Accepted: 01/31/2019] [Indexed: 11/28/2022]
Abstract
Hemorrhagic transformation can complicate both arterial ischemic stroke and cerebral sinus venous thrombosis. Risk factors for hemorrhagic transformation after adult arterial ischemic stroke include larger infarct volume, cardioembolic stroke, and anticoagulation in the acute period. Large hemorrhagic transformation in adults is associated with poor outcome. Therefore hemorrhagic transformation is used as a safety end point for most arterial ischemic stroke acute treatment and secondary prevention trials. Up to 30% of children with arterial ischemic stroke have hemorrhagic transformation, most of which are petechial. As in adults, large infarct size is the greatest predictor of hemorrhagic transformation, but in children, acute anticoagulation is not a clear predictor of hemorrhage. As use of acute endovascular interventions for arterial ischemic stroke has expanded in adults, these therapies have also been used in some teenagers and even younger children. More information, including safety data with end points like hemorrhagic transformation, is needed in the pediatric population. In adults with cerebral sinus venous thrombosis, including those with hemorrhagic transformation, acute anticoagulation is associated with better outcomes and is the standard of care. Some hemorrhagic transformation may be evident at baseline in over half of children and neonates with cerebral sinus venous thrombosis. Anticoagulation-associated hemorrhage in pediatric cerebral sinus venous thrombosis occurs in about 10% of children but is not clearly related to outcome, whereas lack of anticoagulation may be associated with clot propagation and worse outcomes. This review provides background on hemorrhagic transformation of ischemic stroke in adults and summarizes literature regarding hemorrhagic transformation of pediatric arterial ischemic stroke and cerebral sinus venous thrombosis, with a focus on implications for acute treatment and outcome.
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Affiliation(s)
- Melissa L Hutchinson
- Division of Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lauren A Beslow
- Division of Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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Sanchez Espino LF. 50 Years Ago in The Journal of Pediatrics: Thrombosis of the Superior Longitudinal Sinus during Infancy: Report of 2 Cases. J Pediatr 2019; 207:79. [PMID: 30922505 DOI: 10.1016/j.jpeds.2018.09.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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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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Kouzmitcheva E, Andrade A, Muthusami P, Shroff M, MacGregor DL, deVeber G, Dlamini N, Moharir M. Anatomical Venous Variants in Children With Cerebral Sinovenous Thrombosis. Stroke 2019; 50:178-180. [PMID: 30580715 DOI: 10.1161/strokeaha.118.023482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Literature is sparse on the frequency and significance of anatomical venous variants (AVVs) in pediatric cerebral sinovenous thrombosis (CSVT). Methods- We retrospectively reviewed children with CSVT and controls undergoing computed tomography/magnetic resonance venography from January 2008 to 2014. Clinical features examined included raised intracranial pressure, risk factors, and treatment. Radiological features examined included CSVT location, presence and type of AVVs, hemorrhagic venous infarction, and venous collateralization. Clinical outcome was measured by the pediatric stroke outcome measure and radiological outcome by thrombus recanalization. Results- Fifty-one children with CSVT were identified. Twenty-two (43%) had AVVs at presentation. Nineteen (86%) had hypoplasia/absence of major dural sinus, 5 (23%) had persistent fetal structures, 3 (14%) had duplications/fenestrations, and 1 (5%) had disconnected superficial and deep venous systems. Controls had a slightly higher but nonsignificant prevalence 26 (51%) of AVVs. No significant clinical and radiological differences were observed between children with CSVT and AVVs compared with those with typical venous anatomy. Conclusions- AVVs are seen in many children with and without CSVT and do not seem to alter the presentation or clinical course. The influence of these variations on the brain's ability to tolerate venous congestion because of thrombosis merits further study.
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Affiliation(s)
- Elizabeth Kouzmitcheva
- From the Division of Neurology (E.K., D.L.M., G.d., N.D., M.M.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andrea Andrade
- Division of Neurology, Schulich School of Medicine and Dentistry, London, Ontario, Canada (A.A.)
| | - Prakash Muthusami
- Department of Diagnostic Imaging (P.M., M.S.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Manohar Shroff
- Department of Diagnostic Imaging (P.M., M.S.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Daune L MacGregor
- From the Division of Neurology (E.K., D.L.M., G.d., N.D., M.M.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gabrielle deVeber
- From the Division of Neurology (E.K., D.L.M., G.d., N.D., M.M.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nomazulu Dlamini
- From the Division of Neurology (E.K., D.L.M., G.d., N.D., M.M.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mahendranath Moharir
- From the Division of Neurology (E.K., D.L.M., G.d., N.D., M.M.), The Hospital for Sick Children, Toronto, Ontario, Canada
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Salloum S, Belzer K. Cerebral sinovenous thrombosis as a complication of otitis media. Clin Case Rep 2019; 7:186-188. [PMID: 30656038 PMCID: PMC6333077 DOI: 10.1002/ccr3.1948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 11/13/2018] [Indexed: 12/05/2022] Open
Abstract
Otogenic cerebral sinovenous thrombosis (CSVT) is a rare complication of otitis media and associated with significant morbidity and mortality. Classic clinical signs of mastoiditis (pain, swelling, and erythema posterior to the pinna) are not always present at presentation. Treatment of otogenic CSVT consists of conservative surgery, antibiotics, and anticoagulation.
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Affiliation(s)
- Shafee Salloum
- Department of Pediatric Hospital MedicineDayton Children's HospitalDaytonOhio
| | - Kira Belzer
- Pediatric resident PGY‐2Dayton Children's HospitalDaytonOhio
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44
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Amlie-Lefond C. Evaluation and Acute Management of Ischemic Stroke in Infants and Children. Continuum (Minneap Minn) 2018; 24:150-170. [PMID: 29432241 DOI: 10.1212/con.0000000000000559] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article provides an overview of stroke in neonates, infants, and children. RECENT FINDINGS Arterial ischemic stroke and cerebral venous sinus thrombosis are increasingly recognized in childhood as important causes of lifelong morbidity and mortality. Diagnosis of arterial ischemic stroke is frequently delayed, as acute neurologic deficits can be challenging to detect in the young child, and stroke is often not considered in the differential diagnosis. Neurologic sequelae following stroke are common, and strategies to minimize stroke size and optimize recovery are being developed. Recurrent arterial ischemic stroke is not uncommon, particularly in children with cerebral arteriopathy. Cerebral venous sinus thrombosis causes obstruction of venous outflow leading to venous infarcts. Complications include hemorrhagic conversion of infarcts and increased intracranial pressure. Without treatment, thrombus extension with increased symptoms is common. Robust guidelines of care that exist for adults do not exist for children, particularly for children with arterial ischemic stroke. SUMMARY The approach to stroke in infants and children can be informed by clinical experience in pediatric stroke and cerebral venous sinus thrombosis, the extensive literature on pediatric thrombosis, and extrapolation from data from adult patients.
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Fiume A, Deveber G, Jang SH, Fuller C, Viner S, Friefeld S. Development and validation of the Pediatric Stroke Quality of Life Measure. Dev Med Child Neurol 2018; 60:587-595. [PMID: 29451699 DOI: 10.1111/dmcn.13684] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2017] [Indexed: 11/26/2022]
Abstract
AIM To develop and validate a disease-specific parent proxy and child quality of life (QoL) measure for patients aged 2 to 18 years surviving cerebral sinovenous thrombosis (CSVT) and arterial ischaemic stroke (AIS). METHOD Utilizing qualitative and quantitative methods, we developed a 75-item Pediatric Stroke Quality of Life Measure (PSQLM) questionnaire. We mailed the PSQLM and a standardized generic QoL measure, Pediatric Quality of Life Inventory (PedsQL), to 353 families. Stroke type, age at stroke, and neurological outcome on the Pediatric Stroke Outcome Measure were documented. We calculated the internal consistency, validity, and reliability of the PSQLM. RESULTS The response rate was 29%, yielding a sample of 101 patients (mean age 9y 9mo [SD 4.30]; 69 AIS [68.3%], 32 CSVT [31.7%]). The internal consistency of the PSQLM was high (Cronbach's α=0.94-0.97). Construct validity for the PSQLM was moderately strong (r=0.3-0.4; p<0.003) and, as expected, correlation with the PedsQL was moderate, suggesting the PSQLM operationalizes QoL distinct from the PedsQL. Test-retest reliability at 2 weeks was very good (intraclass correlation coefficient [ICC] 0.85-0.95; 95% confidence interval 0.83-0.97) and good agreement was established between parent and child report (ICC 0.63-0.76). INTERPRETATION The PSQLM demonstrates sound psychometric properties. Further research will seek to increase its clinical utility by reducing length and establishing responsiveness for descriptive and longitudinal evaluative assessment. WHAT THIS PAPER ADDS A pediatric stroke-specific quality of life (QoL) measurement tool for assessments based on perceptions of importance and satisfaction. Moderate-to-high reliability and validity established for a new clinical scale evaluating QoL among children with stroke. Perceived QoL measured using the Pediatric Stroke Quality of Life Measure appears lower in children with neurological impairment.
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Affiliation(s)
- Andrea Fiume
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada.,Clinician Investigator Program, McMaster University, Hamilton, ON, Canada
| | - Gabrielle Deveber
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Neurology, Hospital for Sick Children, Toronto, ON, Canada
| | - Shu-Hyun Jang
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada
| | - Colleen Fuller
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada
| | - Shani Viner
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada
| | - Sharon Friefeld
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada
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Mather M, Musgrave K, Dawe N. Is anticoagulation beneficial in acute mastoiditis complicated by sigmoid sinus thrombosis? Laryngoscope 2018. [PMID: 29521448 DOI: 10.1002/lary.27151] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Michael Mather
- Department of Otolaryngology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom.,Institute of Cellular Medicine, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Kate Musgrave
- Institute of Cellular Medicine, Newcastle University, Newcastle-upon-Tyne, United Kingdom.,Department of Haematology, Royal Victoria Infirmary, Newcastle-upon-Tyne, United Kingdom
| | - Nicholas Dawe
- Department of Otolaryngology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
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Sibson KR, Biss TT, Furness CL, Grainger JD, Hough RE, Macartney C, Payne JH, Chalmers EA. BSH Guideline: management of thrombotic and haemostatic issues in paediatric malignancy. Br J Haematol 2018; 180:511-525. [DOI: 10.1111/bjh.15112] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 10/28/2017] [Accepted: 11/07/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Keith R. Sibson
- Department of Haematology; Great Ormond Street Hospital; London UK
| | - Tina T. Biss
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust; Newcastle Upon Tyne UK
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López-Espejo M, Hernández-Chávez M. Could infarct location predict the long-term functional outcome in childhood arterial ischemic stroke? ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:692-696. [PMID: 29166459 DOI: 10.1590/0004-282x20170124] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 07/17/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To explore the influence of infarct location on long-term functional outcome following a first-ever arterial ischemic stroke (AIS) in non-neonate children. METHOD The MRIs of 39 children with AIS (median age 5.38 years; 36% girls; mean follow-up time 5.87 years) were prospectively evaluated. Infarct location was classified as the absence or presence of subcortical involvement. Functional outcome was measured using the modified Rankin scale (mRS) for children after the follow-up assessment. We utilized multivariate logistic regression models to estimate the odds ratios (ORs) for the outcome while adjusting for age, sex, infarct size and middle cerebral artery territory involvement (significance < 0.05). RESULTS Both infarcts ≥ 4% of total brain volume (OR 9.92; CI 1.76 - 55.9; p 0.009) and the presence of subcortical involvement (OR 8.36; CI 1.76 - 53.6; p 0.025) independently increased the risk of marked functional impairment (mRS 3 to 5). CONCLUSION Infarct extension and location can help predict the extent of disability after childhood AIS.
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Affiliation(s)
- Mauricio López-Espejo
- Pontifícia Universidad Católica de Chile, Escuela de Medicina, Unidad de Neurología, División de Pediatria, Chile
| | - Marta Hernández-Chávez
- Pontifícia Universidad Católica de Chile, Escuela de Medicina, Unidad de Neurología, División de Pediatria, Chile
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Pediatric cerebral sinovenous thrombosis following cranial surgery. Childs Nerv Syst 2017; 33:491-497. [PMID: 28091816 DOI: 10.1007/s00381-016-3329-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 12/19/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Pediatric cerebral sinovenous thrombosis (CSVT) is an important, though less common subtype of pediatric stroke. It has been linked to several risk factors, including cranial procedures, with few studies highlighting this relationship. The aim of this study was to characterize the diagnosis and treatment of CSVT after cranial surgery. METHODS An institutional pediatric stroke research database was used to identify all CSVT cases diagnosed within 30 days of cranial surgery from November 2004 to December 2014. Thirteen subjects were retrospectively analyzed for clinical presentation, surgical details, radiographic characteristics, laboratory study results, treatment, and outcome. Diagnostic testing and treatment adhered to a consensus-based institutional stroke protocol. RESULTS Cranial vault reconstruction, subdural empyema evacuation, and tumor resection were each observed in three subjects. Eleven (85%) subjects had sinus exposure during surgery, and eight (73%) developed thrombus in a sinus within or adjacent to the operative field. Two (15%) had documented iatrogenic sinus injury. On post-operative testing, ten (77%) subjects had prothrombotic abnormalities. Seven (54%) were treated with anti-coagulation therapy (ACT) starting on a median of post-operative day (POD) 3 (IQR 1-3) for a median of 2.9 months (IQR 2.4-5.4). Median time to imaging evidence of partial or complete recanalization was 2.4 months (IQR 0.7-5.1). No symptomatic hemorrhagic complications were encountered. CONCLUSIONS Pediatric CSVT may be encountered after cranial surgery, and decisions related to anti-coagulation are challenging. The risk of CSVT should be considered in pre-surgical planning and post-operative evaluation of cases with known risk factors. In our study, judicious use of ACT was safe in the post-operative period.
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Abstract
Cerebral sinovenous thrombosis (CSVT) is a rare but serious cerebrovascular disorder affecting children from the newborn period through childhood and adolescence. The incidence is estimated at 0.6/100,000/year, with 30-50% occurring in newborns. Causes are diverse and are highly age dependent. Acute systemic illness is the dominant risk factor among newborns. In childhood CSVT, acute infections of the head and neck such as mastoiditis are most common, followed by chronic underlying diseases such as nephrotic syndrome, cancer, and inflammatory bowel disease. Signs and symptoms are also age related. Seizures and altered mental status are the commonest manifestations in newborns. Headache, vomiting, and lethargy, sometimes with 6th nerve palsy, are the most common symptoms in children and adolescents. Recent multicenter cohort studies from North America and Europe have provided updated information on risk factors, clinical presentations, treatment practices, and outcomes. While systemic anticoagulation is the most common specific treatment used, there are wide variations and many uncertainties even among experts concerning best practice. The treatment dilemma is especially pronounced for neonatal CSVT. This is due in part to the higher prevalence of intracranial hemorrhage among newborns on the one hand, and the clear evidence that newborns suffer greater long-term neurologic morbidity on the other hand. With the advent of widespread availability and acceptance of acute endovascular therapy for arterial ischemic stroke, there is renewed interest in this therapy for children with CSVT. Limited published evidence exists regarding the benefits and risks of these invasive therapies. Therefore, the authors of current guidelines advise reserving this therapy for children with progressive and severe disease who have failed optimal medical management. As research focused on childhood cerebrovascular disease continues to grow rapidly, the future prospects for improving knowledge about this disorder should be good.
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Affiliation(s)
- Rebecca Ichord
- Department of Neurology and Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, United States
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