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Philipps J, Erdlenbruch B, Kuschnerow M, Jagoda S, Salihaj B, Glahn J, Schellinger PD. Hyperacute treatment of childhood stroke in Lyme neuroborreliosis: report of two cases and systematic review of the literature. Ther Adv Neurol Disord 2022; 15:17562864221102842. [PMID: 36061261 PMCID: PMC9437258 DOI: 10.1177/17562864221102842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/05/2022] [Indexed: 11/16/2022] Open
Abstract
The safety and efficacy of hyperacute reperfusion therapies in childhood stroke
due to focal cerebral arteriopathy (FCA) with an infectious and inflammatory
component is unknown. Lyme neuroborreliosis (LNB) is reported as a rare cause of
childhood stroke. Intravenous thrombolysis (IVT) and endovascular therapy (EVT)
have not been reported in LNB-associated stroke in children. We report two
children with acute stroke associated with LNB who underwent hyperacute stroke
treatment. A systematic review of the literature was performed to identify case
reports of LNB-associated childhood stroke over the last 20 years. Patient 1
received IVT within 73 min after onset of acute hemiparesis and dysarthria;
medulla oblongata infarctions were diagnosed on magnetic resonance imaging
(MRI). Patient 2 received successful EVT 6.5 hr after onset of progressive
tetraparesis, coma, and decerebrate posturing caused by basilar artery occlusion
with bilateral pontomesencephalic infarctions. Both patients exhibited a
lymphocytic cerebrospinal fluid (CSF) pleocytosis and elevated antibody index
(AI) to Borrelia burgdorferi. Antibiotic treatment, steroids,
and platelet inhibitors including tirofiban infusion in patient 2 were
administered. No side effects were observed. On follow-up, patient 1 showed good
recovery and patient 2 was asymptomatic. In the literature, 12 cases of
LNB-associated childhood stroke were reported. LNB-associated infectious and
inflammatory FCA is not a medical contraindication for reperfusion therapies in
acute childhood stroke. Steroids are discussed controversially in inflammatory
FCA due to LNB. Intensified antiplatelet regimes may be considered; secondary
prophylaxis with acetyl-salicylic acid (ASA) is recommended because of a high
risk of early stroke recurrence.
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Affiliation(s)
- Joerg Philipps
- Department of Neurology and Neurogeriatrics, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Hans-Nolte-Str. 1, D-32429 Minden, Germany
| | - Bernhard Erdlenbruch
- Department of Pediatrics, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Michael Kuschnerow
- Department of Diagnostic and Interventional Radiology, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Sunil Jagoda
- Department of Anesthesiology and Intensive Care, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Blerta Salihaj
- Department of Neurology and Neurogeriatrics, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Joerg Glahn
- Department of Neurology and Neurogeriatrics, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Peter Dieter Schellinger
- Department of Neurology and Neurogeriatrics, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
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Deskins SJ, Mamone M, Luketich S, Jennings A, Downey S, Gelman J, Brant R, John C. Acute Ischemic Stroke in an Eight-Year-Old Male With Elevated Factor VIII Activity and SARS-CoV-2 Antibodies. Cureus 2022; 14:e24982. [PMID: 35719761 PMCID: PMC9189259 DOI: 10.7759/cureus.24982] [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: 05/13/2022] [Indexed: 11/05/2022] Open
Abstract
Acute ischemic stroke (AIS) is a significant source of morbidity and mortality and is one of the top causes of death in the United States. Of these patients, most are elderly individuals, compared to a limited proportion of cases seen in pediatrics. AIS is classically associated with age-dependent atherosclerotic disease processes secondary to comorbidities such as diabetes and hypertension. When considering the pediatric population, stroke is far less common and often requires workup of other underlying etiologies that create a hypercoagulable state. Here we present a case of an eight-year-old male with a left middle cerebral artery (MCA) ischemic stroke in the setting of increased factor VIII activity and SARS-CoV-2 antibodies.
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Pediatric Hyperacute Arterial Ischemic Stroke Pathways at Canadian Tertiary Care Hospitals. Can J Neurol Sci 2021; 48:831-838. [PMID: 33568245 DOI: 10.1017/cjn.2021.27] [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] [Indexed: 01/01/2023]
Abstract
BACKGROUND Childhood acute arterial ischemic stroke (AIS) is diagnosed at a median of 23 hours post-symptom onset, delaying treatment. Pediatric stroke pathways can expedite diagnosis. Our goal was to understand the similarities and differences between Canadian pediatric stroke protocols with the aim of optimizing AIS management. METHODS We contacted neurologists at all 16 Canadian pediatric hospitals regarding AIS management. Established protocols were analyzed for similarities and differences in eight domains. RESULTS Response rate was 100%. Seven (44%) centers have an established AIS protocol and two (13%) have a protocol under development. Seven centers do not have a protocol; two redirect patients to adult neurology, five rely on a case-by-case approach for management. Analysis of the seven protocols revealed differences in: 1) IV-tPA dosage: age-dependent 0.75-0.9 mg/kg (N = 1) versus age-independent 0.9 mg/kg (N = 6), with maximum doses of 75 mg (N = 1) or 90 mg (N = 6); 2) IV-tPA lower age cut-off: 2 years (N = 5) versus 3 or 10 years (each N = 1); 3) IV-tPA exclusion criteria: PedNIHSS score <4 (N = 3), <5 (N = 1), <6 (N = 3); 4) first choice of pre-treatment neuroimaging: computed tomography (CT) (N = 3), magnetic resonance imaging (MRI) (N = 2) or either (N = 2); 5) intra-arterial tPA use (N = 3) and; 6) mechanical thrombectomy timeframe: <6 hour (N = 3), <24 hour (N = 2), unspecified (N = 2). CONCLUSIONS Although 44% of Canadian pediatric hospitals have established AIS management pathways, several differences remain among centers. Some criteria (dosage, imaging) reflect adult AIS literature. Canadian expert consensus regarding IV-tPA and endovascular treatment should be established to standardize and implement AIS protocols across Canada.
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Rambaud T, Legris N, Bejot Y, Bellesme C, Lapergue B, Jouvent E, Pico F, Smadja D, Zuber M, Crozier S, Lamy C, Spelle L, Tuppin P, Kossorotoff M, Denier C. Acute ischemic stroke in adolescents. Neurology 2019; 94:e158-e169. [PMID: 31831601 DOI: 10.1212/wnl.0000000000008783] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 06/30/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Adolescence represents a transition period between childhood and adulthood, and only limited information exists about stroke characteristics in this population. Our aim was to describe the clinical and neuroradiologic features, etiologies, initial management, and outcome of ischemic stroke in adolescents. METHODS This retrospective cohort study evaluated all consecutive patients 10 to 18 years with a first-ever ischemic stroke hospitalized between 2007 and 2017 in 10 French academic centers representing a population of ≈10 million. Extracted data from the national database served as validation. RESULTS A total of 60 patients were included (53% male, median age 15.2 years). Diagnosis at first medical contact was misevaluated in 36%, more frequently in posterior than anterior circulation strokes (55% vs 20% respectively, odds ratio 4.8, 95% confidence interval 1.41-16.40, p = 0.01). Recanalization treatment rate was high (n = 19, 32%): IV thrombolysis (17%), endovascular therapy (11.7%), or both IV and intra-arterial thrombolysis (3.3%); safety was good (only 1 asymptomatic hemorrhagic transformation). Despite thorough etiologic workup, 50% of strokes remained cryptogenic. The most common determined etiologies were cardioembolism (15%), vasculitis and autoimmune disorders (12%, occurring exclusively in female patients), and arterial dissections (10%, exclusively in male patients). Recurrent ischemic cerebrovascular events occurred in 12% (median follow-up 19 months). Recurrence rate was 50% in patients with identified vasculopathy but 0% after cryptogenic stroke. Functional outcome was favorable (Rankin Scale score 0-2 at day 90) in 80% of cases. CONCLUSIONS Ischemic strokes in adolescents harbor both pediatric and adult features, emphasizing the need for multidisciplinary collaboration in their management. Recanalization treatments appear feasible and safe.
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Affiliation(s)
- Thomas Rambaud
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Nicolas Legris
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Yannick Bejot
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Céline Bellesme
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Bertrand Lapergue
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Eric Jouvent
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Fernando Pico
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Didier Smadja
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Mathieu Zuber
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Sophie Crozier
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Catherine Lamy
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Laurent Spelle
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Philippe Tuppin
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Manoelle Kossorotoff
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Christian Denier
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France.
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Fink M, Slavova N, Grunt S, Perret E, Regényi M, Steinlin M, Bigi S. Posterior Arterial Ischemic Stroke in Childhood. Stroke 2019; 50:2329-2335. [DOI: 10.1161/strokeaha.119.025154] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Literature on the clinical manifestation and neuroradiological findings in pediatric patients with posterior circulation arterial ischemic stroke is scarce. This study aims to describe epidemiological features, clinical characteristics, and neuroimaging data on pediatric posterior circulation arterial ischemic stroke in Switzerland using the population-based Swiss Neuropediatric Stroke Registry.
Methods—
Children aged from 1 month to 16 years presenting with an isolated posterior circulation arterial ischemic stroke between 2000 and 2016 were included. Epidemiology, clinical manifestation, stroke cause, and neuroradiological features were summarized using descriptive statistics. Stroke severity was assessed using the pediatric National Institutes of Health Stroke Scale. Correlation analysis was performed using the Spearman correlation coefficient.
Results—
Forty-three children with posterior circulation arterial ischemic stroke were included (27 boys [62.8%], median age 7.9 years, interquartile range, 5 to 11.7 years). The incidence of posterior circulation arterial ischemic stroke is Switzerland was 0.183/100 000 and represented 16% of all childhood arterial ischemic strokes. Most patients presented with nonspecific neurological complaints, such as headache (58.1%) and nausea/vomiting (46.5%). The most frequent clinical manifestations were ataxia (58.1%) and motor/sensory hemisyndrome (53.5%/51.2%). Unilateral focal cerebral arteriopathy was the most common cause (11 children, 25.6%). Most infarcts were located in the cerebellum (46.5%) and thalamus (39.5%). A shorter diagnostic delay correlated with more severe stroke symptoms at presentation (rho= −0.365,
P
=0.016).
Conclusions—
Pediatric posterior circulation arterial ischemic stroke was caused by focal cerebral arteriopathy in one quarter of the patients in our cohort. The frequently reported nonspecific clinical symptoms, especially when associated with mild neurological findings, risk delaying the diagnosis of stroke. A high index of suspicion and increased awareness are required for timely diagnosis and treatment initiation.
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Affiliation(s)
- Mirjam Fink
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
| | - Nedelina Slavova
- Department of Neuroradiology, Bern University Hospital, University of Bern, Switzerland (N.S.)
| | - Sebastian Grunt
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
| | - Eveline Perret
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
| | - Maria Regényi
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
| | - Maja Steinlin
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
| | - Sandra Bigi
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
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6
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Bigi S, Dulcey A, Gralla J, Bernasconi C, Melliger A, Datta AN, Arnold M, Kaesmacher J, Fluss J, Hackenberg A, Maier O, Weber J, Poloni C, Fischer U, Steinlin M. Feasibility, safety, and outcome of recanalization treatment in childhood stroke. Ann Neurol 2018; 83:1125-1132. [DOI: 10.1002/ana.25242] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 04/18/2018] [Accepted: 04/18/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Sandra Bigi
- Department of Pediatrics, Division of Child Neurology, University Children's Hospital BernUniversity of Bern Bern
| | - Andrea Dulcey
- Department of Pediatrics, Division of Child Neurology, University Children's Hospital BernUniversity of Bern Bern
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital BernUniversity of Bern Bern
| | - Corrado Bernasconi
- Department of Neurology, Inselspital, University Hospital BernUniversity of Bern Bern
| | - Amber Melliger
- Department of Pediatrics, Division of Child Neurology, University Children's Hospital BernUniversity of Bern Bern
| | - Alexandre N. Datta
- Department of Pediatric Neurology and Developmental MedicineUniversity of Basel Children's Hospital Basel
| | - Marcel Arnold
- Department of Neurology, Inselspital, University Hospital BernUniversity of Bern Bern
| | - Johannes Kaesmacher
- Department of Neurology, Inselspital, University Hospital BernUniversity of Bern Bern
| | - Joel Fluss
- Department of Pediatrics, Division of Child Neurology, University Children's Hospital GenevaUniversity of Geneva Geneva
| | - Annette Hackenberg
- Department of Pediatrics, Division of Child Neurology, University Children's Hospital ZurichUniversity of Zurich Zurich
| | - Oliver Maier
- Department of Pediatrics, Division of Child NeurologyChildren's Hospital St Gallen
| | - Johannes Weber
- Department of RadiologyCantonal Hospital St Gallen St Gallen
| | - Claudia Poloni
- Department of Pediatrics, Division of Child Neurology, University Children's Hospital LausanneUniversity of LausanneLausanne Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, University Hospital BernUniversity of Bern Bern
| | - Maja Steinlin
- Department of Pediatrics, Division of Child Neurology, University Children's Hospital BernUniversity of Bern Bern
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7
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Kulhari A, Dorn E, Pace J, Alambyan V, Chen S, Wu OC, Rizvi M, Hammond A, Ramos-Estebanez C. Acute Ischemic Pediatric Stroke Management: An Extended Window for Mechanical Thrombectomy? Front Neurol 2017; 8:634. [PMID: 29238322 PMCID: PMC5712569 DOI: 10.3389/fneur.2017.00634] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 11/13/2017] [Indexed: 11/26/2022] Open
Abstract
Ischemic stroke is a rare condition to afflict the pediatric population. Congenital cardiomyopathy represents one of several possible etiologies in children. We report a 9-year-old boy who developed right middle cerebral artery stroke secondary to primary restrictive cardiomyopathy. In the absence of pediatric guidelines, the child met adult criteria for mechanical thrombectomy given the small core infarct and large penumbra. The literature suggests children may benefit from mechanical thrombectomy in carefully selected cases. Our patient exemplifies specific circumstances in which acute stroke therapy with thrombolysis and thrombectomy may be safe.
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Affiliation(s)
- Ashish Kulhari
- Department of Neurology, Neurological Institute, University Hospitals, Cleveland, OH, United States.,Department of Neurological Surgery, Neurological Institute, University Hospitals, Cleveland, OH, United States
| | - Elizabeth Dorn
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH, United States
| | - Jonathan Pace
- Department of Neurology, Neurological Institute, University Hospitals, Cleveland, OH, United States.,Department of Neurological Surgery, Neurological Institute, University Hospitals, Cleveland, OH, United States
| | - Vilakshan Alambyan
- Department of Neurology, Neurological Institute, University Hospitals, Cleveland, OH, United States.,Department of Neurological Surgery, Neurological Institute, University Hospitals, Cleveland, OH, United States
| | - Stephanie Chen
- Department of Physiology, Case Western Reserve University, Cleveland, OH, United States
| | - Osmond C Wu
- Department of Neurology, Neurological Institute, University Hospitals, Cleveland, OH, United States.,Department of Neurological Surgery, Neurological Institute, University Hospitals, Cleveland, OH, United States
| | - Macym Rizvi
- Department of Neurology, Neurological Institute, University Hospitals, Cleveland, OH, United States.,Department of Neurological Surgery, Neurological Institute, University Hospitals, Cleveland, OH, United States
| | - Anthony Hammond
- Department of Emergency Medicine, University Hospitals, Cleveland, OH, United States
| | - Ciro Ramos-Estebanez
- Department of Neurology, Neurological Institute, University Hospitals, Cleveland, OH, United States.,Department of Neurological Surgery, Neurological Institute, University Hospitals, Cleveland, OH, United States
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8
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Bhogal P, Pérez MA, Wendl C, Bäzner H, Ganslandt O, Henkes H. Paediatric aneurysms – Review of endovascular treatment strategies. J Clin Neurosci 2017; 45:54-59. [DOI: 10.1016/j.jocn.2017.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 08/10/2017] [Indexed: 10/18/2022]
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9
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Demaerschalk BM. Alteplase Treatment in Acute Stroke: Incorporating Food and Drug Administration Prescribing Information into Existing Acute Stroke Management Guide. Curr Atheroscler Rep 2017; 18:53. [PMID: 27363696 DOI: 10.1007/s11883-016-0602-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Despite strong evidence that intravenous tissue plasminogen activator (tPA) improves outcomes in acute ischemic stroke patients, its use in clinical practice remains modest. Complex eligibility criteria have been postulated as barriers to greater utilization. Further complicating this has been multiple guidelines and prescribing labels that have been published since first being approved for use in 1996. In this review, several warning and exclusion criteria for tPA in acute ischemic stroke are reviewed with the goal of providing readers a nuanced understanding of historical context and available evidence to make informed decision.
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Affiliation(s)
- Bart M Demaerschalk
- Mayo Clinic College of Medicine, Rochester, MN, USA. .,Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA.
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10
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Barburoglu M, Arat A. Flow Diverters in the Treatment of Pediatric Cerebrovascular Diseases. AJNR Am J Neuroradiol 2016; 38:113-118. [PMID: 27765738 DOI: 10.3174/ajnr.a4959] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 08/08/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE There is very limited data concerning utilization of flow diverters in children. Our aim is to report results for the treatment of complex intracranial aneurysms and carotid cavernous fistulas by using flow diverters in children. MATERIALS AND METHODS Retrospective review of children (17 years of age or younger) treated with flow diverters between May 2011 and July 2014 was performed. Clinical and laboratory data and angiographic findings were extracted. Seven patients (6 males, 1 female; mean age, 12.7 years; range, 3-16 years) were included. Two presented with posttraumatic fistulas. The remaining patients presented with traumatic aneurysms of the cavernous carotid artery or fusiform aneurysms of the distal vertebral artery, M1, or A2 segments. All patients were premedicated with clopidogrel (75 mg daily for patients with body weights of >45 kg, 37.5 mg daily for 1 small child with a body weight of <45 kg) and aspirin (300 mg daily for ≥45 kg, 100 mg daily for smaller children). RESULTS VerifyNow and Multiplate Analyzer values were higher than expected. No clinical complications were noted. Imaging performed at 7-52 months after the procedure (mean/median, 22.3/14 months) revealed occlusions of all aneurysms and fistulas. One patient had an asymptomatic occlusion of the parent artery; otherwise, no hemodynamically significant parent artery restenosis was observed. There were no clinically significant neurologic events during follow-up. CONCLUSIONS Although flow-diverter placement appears to be safe and effective on midterm follow-up in children, longer follow-up is critical. The current sizes of flow diverter devices and delivery systems cover the pediatric size range, obviating developing flow diverters specific to children.
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Affiliation(s)
- M Barburoglu
- From the Department of Radiology (M.B.), Istanbul University Medical School, Istanbul, Turkey
| | - A Arat
- Department of Radiology (A.A.), School of Medicine, Hacettepe University, Ankara, Turkey.
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11
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Abstract
Both adult and pediatric patients with sickle cell disease face a higher risk of stroke than the general population. Given the different underlying pathophysiology predisposing these patients to stroke, providers should be aware of differences in guidelines for stroke management. This paper reviews diagnostic considerations and recommendations during the evaluation and acute management of patients with sickle cell disease presenting with stroke, focusing on recent updates in the literature. Given the high recurrence rate of stroke in these patients, secondary prevention and curative measures will also be reviewed.
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12
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Abstract
INTRODUCTION Current treatment guidelines for acute ischemic stroke do not recommend thrombolytic therapy in children and adolescents as data are still very scarce. CASE REPORT We report the case of a 15-year-old boy who suddenly developed severe left-sided weakness and speech difficulty while stooling. Upon arrival at our Emergency Department, the National Institute of Health Stroke Scale (NIHSS) score was 18. Urgent neurovascular ultrasound showed a distal occlusion of the right internal carotid artery and occlusion at the origin of the middle cerebral artery (MCA) and the anterior cerebral artery. He was treated 2 hours after symptom onset with intravenous recombinant tissue plasminogen activator without any complication. At the end of thrombolysis, a complete recanalization was shown by transcranial Doppler sonography, although a brain magnetic resonance imaging disclosed an acute right middle cerebral artery stroke. At discharge, the boy had mild weakness on his left leg and slight left facial palsy: the NIHSS score was 2. To our knowledge, this is the first intravenous thrombolytic treatment ever reported in an adolescent in Italy. CONCLUSIONS Despite the lack of evidence regarding the safety and the efficacy of recombinant tissue plasminogen activator in pediatric stroke, this treatment option should be considered, especially in adolescents presenting within 3 hours from symptom onset in centers with consolidated experience in adult thrombolysis.
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13
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Garnés Sánchez C, Parrilla G, García Villalba B, Alarcón Martínez H, Martínez Salcedo E, Reyes Domínguez S. Oclusión basilar pediátrica tratada mediante trombectomía con stents extractores. Neurologia 2016; 31:347-50. [DOI: 10.1016/j.nrl.2014.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 05/05/2014] [Accepted: 05/13/2014] [Indexed: 10/25/2022] Open
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14
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Garnés Sánchez C, Parrilla G, García Villalba B, Alarcón Martínez H, Martínez Salcedo E, Reyes Domínguez S. A paediatric case of basilar occlusion treated with mechanical thrombectomy using stent retrievers. NEUROLOGÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.nrleng.2014.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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15
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Lena J, Eskandari R, Infinger L, Fargen KM, Spiotta A, Turk A, Turner RD, Chaudry I. Republished: Basilar artery occlusion in a child treated successfully with mechanical thrombectomy using ADAPT. J Neurointerv Surg 2016; 9:e2. [DOI: 10.1136/neurintsurg-2015-012195.rep] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2016] [Indexed: 11/04/2022]
Abstract
Acute ischemic stroke (AIS) in the pediatric population is rare. Furthermore, it is common for physicians to take significantly longer diagnosing a posterior circulation stroke in a child than in an adult. There are increasing case reports in the literature of treating AIS in children with intravenous tissue plasminogen activator, intra-arterial thrombolysis, and/or mechanical thrombectomy. We present the first case of pediatric AIS treated using a direct aspiration first pass technique (ADAPT) as a means of mechanical thrombectomy.
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16
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Lena J, Eskandari R, Infinger L, Fargen KM, Spiotta A, Turk A, Turner RD, Chaudry I. Basilar artery occlusion in a child treated successfully with mechanical thrombectomy using ADAPT. BMJ Case Rep 2016; 2016:bcr-2015-012195. [PMID: 27068722 DOI: 10.1136/bcr-2015-012195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Acute ischemic stroke (AIS) in the pediatric population is rare. Furthermore, it is common for physicians to take significantly longer diagnosing a posterior circulation stroke in a child than in an adult. There are increasing case reports in the literature of treating AIS in children with intravenous tissue plasminogen activator, intra-arterial thrombolysis, and/or mechanical thrombectomy. We present the first case of pediatric AIS treated using a direct aspiration first pass technique (ADAPT) as a means of mechanical thrombectomy.
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Affiliation(s)
- Jonathan Lena
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ramin Eskandari
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Libby Infinger
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kyle M Fargen
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alejandro Spiotta
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Aquilla Turk
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Raymond D Turner
- Department of Neurosciences, Medical University of South Carolina, Mount Pleasant, South Carolina, USA
| | - Imran Chaudry
- Department of Radiology, Medical University of South Carolina, Charleston, South Carolina, USA
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17
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Demaerschalk BM, Kleindorfer DO, Adeoye OM, Demchuk AM, Fugate JE, Grotta JC, Khalessi AA, Levy EI, Palesch YY, Prabhakaran S, Saposnik G, Saver JL, Smith EE. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke. Stroke 2016; 47:581-641. [DOI: 10.1161/str.0000000000000086] [Citation(s) in RCA: 442] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose—
To critically review and evaluate the science behind individual eligibility criteria (indication/inclusion and contraindications/exclusion criteria) for intravenous recombinant tissue-type plasminogen activator (alteplase) treatment in acute ischemic stroke. This will allow us to better inform stroke providers of quantitative and qualitative risks associated with alteplase administration under selected commonly and uncommonly encountered clinical circumstances and to identify future research priorities concerning these eligibility criteria, which could potentially expand the safe and judicious use of alteplase and improve outcomes after stroke.
Methods—
Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge and, when appropriate, formulated recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on and approved the final version of this document. The document underwent extensive American Heart Association internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.
Results—
After a review of the current literature, it was clearly evident that the levels of evidence supporting individual exclusion criteria for intravenous alteplase vary widely. Several exclusionary criteria have already undergone extensive scientific study such as the clear benefit of alteplase treatment in elderly stroke patients, those with severe stroke, those with diabetes mellitus and hyperglycemia, and those with minor early ischemic changes evident on computed tomography. Some exclusions such as recent intracranial surgery are likely based on common sense and sound judgment and are unlikely to ever be subjected to a randomized, clinical trial to evaluate safety. Most other contraindications or warnings range somewhere in between. However, the differential impact of each exclusion criterion varies not only with the evidence base behind it but also with the frequency of the exclusion within the stroke population, the probability of coexistence of multiple exclusion factors in a single patient, and the variation in practice among treating clinicians.
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18
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Elbers J, Wainwright MS, Amlie-Lefond C. The Pediatric Stroke Code: Early Management of the Child with Stroke. J Pediatr 2015; 167:19-24.e1-4. [PMID: 25937428 DOI: 10.1016/j.jpeds.2015.03.051] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 03/09/2015] [Accepted: 03/26/2015] [Indexed: 02/04/2023]
Affiliation(s)
- Jorina Elbers
- Division of Child Neurology, Stanford Children's Health, Stanford University, Stanford, CA.
| | - Mark S Wainwright
- Division of Neurology, Department of Pediatrics, Northwestern University, Chicago, IL
| | - Catherine Amlie-Lefond
- Division of Pediatric Neurology, Department of Neurology, Seattle Children's Hospital, University of Washington, Seattle, WA
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19
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San Martín García I, Rives Ferreiro M, Martínez Olorón P, Aguilera Albesa S, Herranz Aguirre M. Miocardiopatía dilatada e infarto de arteria cerebral media derecha. An Pediatr (Barc) 2015; 82:e247-9. [DOI: 10.1016/j.anpedi.2014.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 04/15/2014] [Accepted: 05/20/2014] [Indexed: 10/25/2022] Open
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20
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Marchidann A, Balucani C, Levine SR. Expansion of Intravenous Tissue Plasminogen Activator Eligibility Beyond National Institute of Neurological Disorders and Stroke and European Cooperative Acute Stroke Study III Criteria. Neurol Clin 2015; 33:381-400. [DOI: 10.1016/j.ncl.2015.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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21
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Abstract
OPINION STATEMENT Children who present with acute neurological symptoms suggestive of a stroke need immediate clinical assessment and urgent neuroimaging to confirm diagnosis. Magnetic resonance imaging (MRI) is the investigation of first choice due to limited sensitivity of computed tomography (CT) for detection of ischaemia. Acute monitoring should include monitoring of blood pressure and body temperature, and neurological observations. Surveillance in a paediatric high dependency or intensive care unit and neurosurgical consultation are mandatory in children with large infarcts at risk of developing malignant oedema or haemorrhagic transformation. Thrombolysis and/or endovascular treatment, whilst not currently approved for use in children, may be considered when stroke diagnosis is confirmed within 4.5 to 6 h, provided there are no contraindications on standard adult criteria. Standard treatment consists of aspirin, but anticoagulation therapy is frequently prescribed in stroke due to cardiac disease and extracranial dissection. Steroids and immunosuppression have a definite place in children with proven vasculitis, but their role in focal arteriopathies is less clear. Decompressive craniotomy should be considered in children with deteriorating consciousness or signs of raised intracranial pressure.
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Affiliation(s)
- Maja Steinlin
- Paediatric Neurology, University Children's Hospital and Neurocentre, Inselspital Bern, Bern, 3010, Switzerland,
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22
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Mittal SO, ThatiGanganna S, Kuhns B, Strbian D, Sundararajan S. Acute Ischemic Stroke in Pediatric Patients. Stroke 2015; 46:e32-4. [DOI: 10.1161/strokeaha.114.007681] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Shivam Om Mittal
- From the Neurological Institute, University Hospitals Case Medical Center, Cleveland, OH (S.O.M., S.T., B.K., S.S.); and Departments of Neurology and Stroke Unit, Helsinki University Central Hospital, Helsinki, Finland (D.S.)
| | - Sreenath ThatiGanganna
- From the Neurological Institute, University Hospitals Case Medical Center, Cleveland, OH (S.O.M., S.T., B.K., S.S.); and Departments of Neurology and Stroke Unit, Helsinki University Central Hospital, Helsinki, Finland (D.S.)
| | - Benjamin Kuhns
- From the Neurological Institute, University Hospitals Case Medical Center, Cleveland, OH (S.O.M., S.T., B.K., S.S.); and Departments of Neurology and Stroke Unit, Helsinki University Central Hospital, Helsinki, Finland (D.S.)
| | - Daniel Strbian
- From the Neurological Institute, University Hospitals Case Medical Center, Cleveland, OH (S.O.M., S.T., B.K., S.S.); and Departments of Neurology and Stroke Unit, Helsinki University Central Hospital, Helsinki, Finland (D.S.)
| | - Sophia Sundararajan
- From the Neurological Institute, University Hospitals Case Medical Center, Cleveland, OH (S.O.M., S.T., B.K., S.S.); and Departments of Neurology and Stroke Unit, Helsinki University Central Hospital, Helsinki, Finland (D.S.)
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23
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Stidd DA, Lopes DK. Successful mechanical thrombectomy in a 2-year-old male through a 4-French guide catheter. Neurointervention 2014; 9:94-100. [PMID: 25426305 PMCID: PMC4239415 DOI: 10.5469/neuroint.2014.9.2.94] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 08/25/2014] [Indexed: 12/02/2022] Open
Abstract
A 2-year-old boy with hypoplastic left heart syndrome that required multiple cardiovascular surgeries and a heterozygous prothrombin G20210A mutation with resulting thrombophilia maintained on warfarin presented with acute right middle cerebral artery (MCA) infarction manifesting as a left hemiplegia. An MRI revealed a complete occlusion of the right M1 segment with an area of restricted diffusion in the right basal ganglia representing only a small area of acute infarction. Patchy areas of subacute infarction were also present in the right MCA territory. He underwent endovascular mechanical thrombectomy with a stent retriever. This is an account of a successful mechanical thrombectomy performed in the youngest patient reported in the English literature to date.
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Affiliation(s)
- David A Stidd
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Demetrius K Lopes
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
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24
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Abstract
Basilar artery occlusion has poor outcome in adults; little is known regarding outcomes in children. Whether intra-arterial treatments improve adult outcomes is controversial. Safety and efficacy of intra-arterial treatments in children are unknown. We report 5 cases of basilar artery occlusion and review published cases. We estimated National Institute of Health Stroke Scale (NIHSS) and modified Rankin Score (mRS) of published cases, compared scores between non-intra-arterial treatments and intra-arterial treatments groups, and examined the correlation between NIHSS and mRS. Of our cases, 4 had good outcomes and 1 died. Of 63 published cases, 45 had no intra-arterial treatments and 18 had intra-arterial treatments. In the non-intra-arterial treatments group 24 had good outcomes. In the intra-arterial treatments group 13 had good outcomes. There was strong correlation between the NIHSS and the mRS. Children with basilar artery occlusion have better outcomes than adults. Certain children with basilar artery occlusion may be treated conservatively. A registry for childhood basilar artery occlusion is urgently needed.
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Affiliation(s)
| | - Warren D. Lo
- Department of Pediatrics, Ohio State University, Columbus, OH, USA
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25
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Rollins N, Pride GL, Plumb PA, Dowling MM. Brainstem strokes in children: an 11-year series from a tertiary pediatric center. Pediatr Neurol 2013; 49:458-64. [PMID: 24080274 DOI: 10.1016/j.pediatrneurol.2013.07.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Revised: 07/08/2013] [Accepted: 07/09/2013] [Indexed: 11/25/2022]
Abstract
METHODS Potential clinical barriers to making a timely diagnosis of pediatric brainstem stroke and pitfalls of noninvasive vascular imaging are presented. METHODS An institutional review board-approved institutional database query from 2001-2012 yielded 15 patients with brainstem strokes. Medical records were reviewed for symptoms, stroke severity using the Pediatric National Institutes of Health Stroke Scale, and outcomes using the Pediatric Stroke Outcome Measure. Magnetic resonance angiography was compared with digital subtraction angiography. RESULTS There were 10 boys and five girls; 9 months to 17 years of age (mean 7.83 years). Symptoms were headaches (eight); visual problems (eight), seizure-like activity (seven), motor deficits (six), and decreased level of consciousness in four. Time since last seen well was 12 hours to 5 days. Pediatric National Institutes of Health Stroke Scale was 1-34; <10 in eight; 3 in 1, 10-20 in two, and >20 in four. Strokes were pontine in 13/15 and involved >50% of the pons in six and <50% in seven; 2/15 had medullary strokes. Magnetic resonance angiography showed basilar artery occlusion in 8/13 patients and vertebral artery dissection in two. Digital subtraction angiography done within 9-36 hours of magnetic resonance angiography in 10/15 patients confirmed the basilar artery occlusion seen by magnetic resonance angiography and showed vertebral artery dissection in four patients. Patients were systemically anticoagulated without hemorrhagic complications. One patient died. Pediatric Stroke Outcome Measures at 2-36 months is 0-5.0/10 (mean 1.25). CONCLUSIONS Vague symptoms contributed to delays in diagnosis. Magnetic resonance angiography was equivalent to digital subtraction angiography for basilar artery occlusion but not for vertebral artery dissection. Even with basilar artery occlusion and high stroke scales, outcome was good when systemic anticoagulation was started promptly.
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Affiliation(s)
- Nancy Rollins
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas.
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Fink J, Sonnenborg L, Larsen LL, Born AP, Holtmannspötter M, Kondziella D. Basilar Artery Thrombosis in a Child Treated With Intravenous Tissue Plasminogen Activator and Endovascular Mechanical Thrombectomy. J Child Neurol 2013; 28:1521-1526. [PMID: 23034976 DOI: 10.1177/0883073812460334] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Basilar artery occlusion in children is rare. It has a high mortality and morbidity if recanalization is not achieved before extensive brainstem infarction has occurred. An 11-year-old boy presented with a clinical and radiological "top-of-the-basilar" syndrome. Intravenous tissue plasminogen activator was administered, and the patient was immediately referred to the regional stroke center. Subsequent mechanical thrombectomy using a Solitaire stent (Solitaire FR stent; ev3, Irvine, CA, USA) resulted in clot removal and recanalization of the basilar artery 4 hours after stroke onset. The patient made a full clinical recovery. To the authors' knowledge this is the first report on basilar artery occlusion in a child treated with "bridging" therapy, the combination of intravenous thrombolysis and endovascular thrombectomy. If the diagnosis can be made within the time window for intravenous thrombolysis (4.5 hours), the present case suggests that bridging therapy in pediatric basilar artery occlusion can be safe and effective.
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Affiliation(s)
- Jakob Fink
- 1Department of Radiology, Roskilde Hospital, Roskilde, Denmark
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Chabrier S, Kossorotoff M, Darteyre S. Place des antithrombotiques dans l’accident vasculaire cérébral de l’enfant. Presse Med 2013; 42:1259-66. [DOI: 10.1016/j.lpm.2013.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 06/12/2013] [Indexed: 02/06/2023] Open
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Rener-Primec Z, Švigelj V, Vesel S, Lovrič D, Škofljanec A. Safe use of alteplase in a 10 months old infant with cardio-embolic stroke. Eur J Paediatr Neurol 2013; 17:522-5. [PMID: 23603009 DOI: 10.1016/j.ejpn.2013.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2013] [Revised: 03/24/2013] [Accepted: 03/24/2013] [Indexed: 10/26/2022]
Abstract
The knowledge about safety and efficacy of thrombolysis in paediatric stroke is limited, especially for very young children. We present an infant with cardioembolic stroke treated with alteplase. He had hypoplastic left heart syndrome since birth. He underwent Norwood operation, followed by bidirectional cavopulmonary anastomosis at 3 months. On aspirin therapy he was well until heart failure developed at the age of 9 months with 2 thrombi in the right ventricle. During the course of enoxaparin therapy sudden acute left-sided haemiplegia occurred. The emergency brain CT scan was normal. Informed consent was obtained from parents after explaining the alteplase treatment protocol and possible complications. Alteplase was administered i.v. according to standard adult stroke regimen. A control CT scan obtained 24 h later was negative for intracranial haemorrhage but the hypodense area in insula, internal capsule and subcortical area of the right parietal region were indicative of ischaemic stroke. Anticoagulation therapy was continued. He recovered hand functions after 5 days and full repertoire of movements on his left side 3 weeks later. A neurological examination performed 2 months after indicated mild residual haemiparesis and a modified Rankin scale score of 1. Three months later, the patient died of progressive heart failure. An international multicentre prospective trial is ongoing to investigate the safety and appropriate dose of alteplase for paediatric ages 2-17 years. The aim of this paper is to report safe use of alteplase even in a very young child.
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Affiliation(s)
- Zvonka Rener-Primec
- University Medical Centre Ljubljana, University Children's Hospital, Department of Child, Adolescent and Developmental Neurology, Ljubljana, Slovenia.
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Steinlin M. Cerebrovascular disorders in childhood. HANDBOOK OF CLINICAL NEUROLOGY 2013; 112:1053-64. [PMID: 23622311 DOI: 10.1016/b978-0-444-52910-7.00023-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Cerebrovascular problems in childhood include diverse problems of vascular supply to the brain and occur with an overall frequency of from 5 to 8/100000 children/year. Signs and symptoms at manifestation are manifold. They depend not only on localization of the infarction but also on age at injury and specific risk factors. Acute arterial ischemic insult in neonates is oligosymptomatic (short-lasting seizures); hemiparesis is the most common symptom in children. Risk factors are multiple for both neonates and children, with more thromboembolic events in neonates and (infection-related) vasculopathies or cardiac problems in children. MRI (diffusion weighted) is the golden standard for diagnosis. In the absence of evidence for treatment in both groups, guidelines suggest use of platelet aggregation. There are some special indications for anticoagulation. Thrombolysis should be evaluated. Two-thirds of children and neonates face lifelong neurological and neuropsychological problems. Spinal artery ischemia presents with acute spinal symptoms, mostly paraplegia. Risk factors and prognosis are similar to cerebral insults. Sinus venous thromboses are significantly less common. Provoking factors in newborns are mainly neonatal problems, and in children infections, especially in the ENT region. For diagnosis the delta sign in CT is less sensitive than MR/MR venography. In the absence of any evidence, LMWH or heparinization for 3-6 months are recommended. Prognosis is better in children than in neonates. Deep vein thrombosis and/or young age worsen the outcome.
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Affiliation(s)
- Maja Steinlin
- Neuropaediatric Department, University Children's Hospital Inselspital, Bern, Switzerland.
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Goeggel Simonetti B, Ritter B, Gautschi M, Wehrli E, Boltshauser E, Schmitt-Mechelke T, Weber P, Weissert M, El-Koussy M, Steinlin M. Basilar artery stroke in childhood. Dev Med Child Neurol 2013; 55:65-70. [PMID: 23163838 DOI: 10.1111/dmcn.12015] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM Little is known about basilar artery stroke (BAS) in children. The objective of this study was to calculate the incidence of BAS in children and to analyse the clinical presentation, risk factors, radiological findings, therapeutic approaches, and outcome of BAS in childhood. METHOD A prospective, population-based study including children with arterial ischaemic stroke and a systematic review of the literature was undertaken. RESULTS Seven children with BAS were registered at the Swiss Neuropaediatric Stroke Registry between January 2000 and June 2011 (incidence 0.037 per 100,000 children per year, 95% confidence interval [CI] 0.013-0.080). A further 90 cases were identified through the literature search. The majority of patients were male (73 males, 24 females) and the median age was 9 years (interquartile range [IQR]=6-13y). The median Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score was 15 (IQR=4-27). Presenting signs and symptoms comprised impaired consciousness (n=64), quadri- or hemiparesis (n=58), bulbar dysfunction (n=46), vomiting, nausea (n=43), and headache (n=41). Prodromes occurred in 43% of cases. Aetiology was largely vasculopathic (n=38), but often unknown (n=40). Time to diagnosis varied from hours days; six patients received antithrombotic, thrombolytic, or mechanical endovascular treatment 12 hours or less after symptom onset. Outcome was good (modified Rankin Scale 0-2) in 45 patients; eight died. PedNIHSS score of up to 17 was a prognostic factor for good outcome. INTERPRETATION BAS is rare in children. Compared with adults, outcome is more favourable despite a considerable delay in diagnosis and treatment. Outcome was better in children with a PedNIHSS score of 17 or less.
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Affiliation(s)
- Barbara Goeggel Simonetti
- Division of Paediatric Neurology, Department of Paediatrics, Inselspital, University of Bern, Bern, Switzerland.
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31
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[Experts' recommendations: stroke management in the intensive care unit. Pediatric specificities (excluding neonates)]. Rev Neurol (Paris) 2012; 168:527-32. [PMID: 22579503 DOI: 10.1016/j.neurol.2010.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Revised: 10/20/2010] [Accepted: 11/22/2010] [Indexed: 11/21/2022]
Abstract
Stroke in children is not rare. Although there are no randomized trials on childhood stroke, except in sickle cell disease patients, several international guidelines have described quality criteria for stroke management in children. Age-adapted management is required, involving collaboration with a pediatric neurologist and hospitalization in a pediatric intensive care or continuous care unit. All symptomatic treatments used in adults can be recommended in children, including homeostasis assessment and maintenance or blood exchange in sickle cell disease patients. Specific treatments such as thrombolysis or mechanical thrombectomy are not recommended in children, except in the framework of clinical trials, but can be beneficial in adolescents. Multidisciplinary decision-making should be the rule in such situations. Adolescents may be managed in adult stroke units. Indications for surgery in children are adapted from adult guidelines. Appropriate management of cerebral venous thrombosis in children is similar to that in adults. The best management possible can be achieved through a multidisciplinary dialogue between the pediatric neurologist and the adult intensivist or neurologist.
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Hervieu-Bégue M, Jacquin A, Kazemi A, Nezzal N, Darmency-Stamboul V, Souchane M, Huet F, Giroud M, Osseby GV, Béjot Y. Accidents vasculaires cérébraux de l’enfant : une urgence médicale qui doit bénéficier des filières neurovasculaires régionales mises en place par le Plan National AVC. Presse Med 2012; 41:518-24. [DOI: 10.1016/j.lpm.2011.06.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Revised: 05/31/2011] [Accepted: 06/14/2011] [Indexed: 10/14/2022] Open
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Condie J, Shaibani A, Wainwright MS. Successful treatment of recurrent basilar artery occlusion with intra-arterial thrombolysis and vertebral artery coiling in a child. Neurocrit Care 2012; 16:158-62. [PMID: 21732156 DOI: 10.1007/s12028-011-9579-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Signs of brainstem ischemia in children may be subtle, and outcome following basilar artery occlusion is often poor. There currently are no guidelines in children regarding the best methods to diagnose and treat basilar artery occlusion. METHODS Case report and literature review. RESULTS We describe the presentation and management of recurrent basilar artery occlusion in a previously healthy 5-year-old boy with vertebral artery dissection. Treatment included emergent intra-arterial tPA and mechanical thrombolysis of basilar artery clot, followed by later coiling of the vertebral artery to prevent recurring episodes of basilar artery ischemia. CONCLUSION Management of brainstem stroke in children requires coordination of neurology, critical care, and interventional radiology services. Delayed intra-arterial thrombolysis and vertebral artery coiling can be successfully used to treat basilar artery occlusion and prevent the recurrence of brainstem ischemia in children.
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Affiliation(s)
- John Condie
- Department of Pediatrics, Division of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60614-3394, USA
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Lyle CA, Bernard TJ, Goldenberg NA. Childhood arterial ischemic stroke: a review of etiologies, antithrombotic treatments, prognostic factors, and priorities for future research. Semin Thromb Hemost 2011; 37:786-93. [PMID: 22187401 DOI: 10.1055/s-0031-1297169] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Childhood arterial ischemic stroke (AIS) is a rare, but serious, medical condition, which is fatal in approximately 3% and associated with both acute and long-term neurologic impairment in over 70% of cases. Common etiologies include sickle cell disease, congenital heart disease, arterial dissection, prothrombotic conditions, and preceding viral infections; however, one in four cases is considered idiopathic. To date, no randomized controlled clinical trials (RCTs) have been conducted to establish evidence for current therapeutic strategies outside of sickle cell disease, thus, treatment strategies are largely shaped by consensus-based guidelines, in which, beyond the acute period, aspirin is the mainstay of therapy and anticoagulation is reserved for select circumstances. In recent years, evidence on prognostic factors has accumulated, helping to inform the future design of prognostically stratified RCTs. In this narrative review, we discuss the current understanding of etiologies, consensus-based treatment recommendations, contemporary treatment data, and prognostic factors in childhood AIS. We also identify priorities for future research.
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Affiliation(s)
- Courtney A Lyle
- Division of Hematology/Oncology, Department of Pediatrics, University of California, San Diego, California, USA.
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35
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Bolognese M, Griebe M, Foerster A, Hennerici MG, Fatar M. Thrombolytic stroke treatment of a 12-year-old girl with intracranial fibromuscular dysplasia. Case Rep Neurol 2011; 3:210-3. [PMID: 22087100 PMCID: PMC3214672 DOI: 10.1159/000332052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Fibromuscular dysplasia, predominantly found in adult women, is a rare disease of small and middle-sized arteries of the kidney and brain. We present a case of a 12-year-old girl with acute ischemic stroke, due to fibromuscular dysplasia of the distal internal carotid artery and the proximal middle cerebral artery, which was successfully treated with t-PA.
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Affiliation(s)
- Manuel Bolognese
- Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
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36
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Mattle HP, Arnold M, Lindsberg PJ, Schonewille WJ, Schroth G. Basilar artery occlusion. Lancet Neurol 2011; 10:1002-14. [DOI: 10.1016/s1474-4422(11)70229-0] [Citation(s) in RCA: 255] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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37
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Grunwald IQ, Walter S, Fassbender K, Kühn AL, Hartmann KM, Wilson N, Sievert H, Kamran M, Hopkins LN, Wakhloo AK. Ischemic stroke in children: new aspects of treatment. J Pediatr 2011; 159:366-70. [PMID: 21592519 DOI: 10.1016/j.jpeds.2011.03.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Revised: 01/14/2011] [Accepted: 03/23/2011] [Indexed: 11/16/2022]
Affiliation(s)
- Iris Quasar Grunwald
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom.
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Lehman LL, Kleindorfer DO, Khoury JC, Alwell K, Moomaw CJ, Kissela BM, Khatri P. Potential eligibility for recombinant tissue plasminogen activator therapy in children: a population-based study. J Child Neurol 2011; 26:1121-5. [PMID: 21628693 PMCID: PMC3420804 DOI: 10.1177/0883073811408091] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Intravenous recombinant tissue plasminogen activator is an established therapy for adults with ischemic stroke. In this Greater Cincinnati/Northern Kentucky population-based study, 8% were eligible. However, no established therapy exists for children with acute ischemic stroke. Accordingly, investigators assessed rates of eligibility for recombinant tissue plasminogen activator therapy among children (<18 years of age) in the same population to aid planning of future clinical trials. The investigators identified 29 pediatric ischemic strokes during 3 separate study periods (1993-1994, 1999, and 2005) and determined potential eligibility for recombinant tissue plasminogen activator therapy based on 2007 American Heart Association guidelines for adults. Depending on how relative contraindications were considered, 1 to 3 cases (3%-10%) met eligibility criteria. On the basis of national pediatric stroke incidence rates extrapolated from our population, it is estimated that up to 178 children might be eligible for intravenous recombinant tissue plasminogen activator therapy annually in the United States. Thus, recruitment for clinical studies is likely to be challenging and requires a concerted multicenter effort.
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Affiliation(s)
- Laura L. Lehman
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Dawn O. Kleindorfer
- Department of Neurology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jane C. Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Kathleen Alwell
- Department of Neurology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Charles J. Moomaw
- Department of Neurology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Brett M. Kissela
- Department of Neurology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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39
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Bigi S, Fischer U, Wehrli E, Mattle HP, Boltshauser E, Bürki S, Jeannet PY, Fluss J, Weber P, Nedeltchev K, El-Koussy M, Steinlin M, Arnold M. Acute ischemic stroke in children versus young adults. Ann Neurol 2011; 70:245-54. [DOI: 10.1002/ana.22427] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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40
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Taneja SR, Hanna I, Holdgate A, Wenderoth J, Cordato DJ. Basilar artery occlusion in a 14-year old female successfully treated with acute intravascular intervention: case report and review of the literature. J Paediatr Child Health 2011; 47:408-14. [PMID: 21276116 DOI: 10.1111/j.1440-1754.2010.01974.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Basilar artery occlusion (BAO) is a rare cause of paediatric stroke that may result in severe neurological disability including a 'locked-in' state. Acute interventional therapy for paediatric BAO is limited to a small number of published case reports. Of 13 previously published cases that have undergone acute intravascular therapy, six made a full neurological recovery, six had residual deficits ranging from mild dysarthria and ataxia to vegetative state and one patient died. The time from symptom onset to intervention was ≥ 12 h in 77% (10/13). We reported a 14-year-old female patient presenting with altered sensorium that progressed to a 'locked-in' state due to idiopathic BAO who made a full clinical recovery after successful mechanical thrombectomy at 24 h following symptom onset. Acute neuro-interventional therapy for paediatric BAO can result in complete neurological recovery despite the presence of severe neurological deficits and a prolonged period of time from symptom onset to clinical diagnosis.
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Affiliation(s)
- Sanjeev R Taneja
- Department of Neurology, Liverpool Hospital, Liverpool, Sydney, New South Wales, Australia
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41
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Abstract
We report a healthy 14-year-old boy with an acute left middle cerebral artery stroke, treated 2 hours after the onset of symptoms with intravenous recombinant tissue plasminogen activator (r-TPA). Recanalization of the middle cerebral artery was documented with transcranial Doppler during the first 5 minutes of intravenous r-TPA perfusion, and progressive recovery of the neurological deficits occurred. Although lack of evidence regarding safety and efficacy in children precludes the recommendation of systematic use of r-TPA in pediatric stroke, we propose that this option should be considered and discussed with the parents, especially in older children presenting within 3 hours in centers with experience in adult thrombolysis.
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42
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Akinci E, Yuzbasioglu Y, Coskun F. Post Traumatic Paediatric Ischaemic Stroke: Case Presentation. HONG KONG J EMERG ME 2011. [DOI: 10.1177/102490791101800308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Stroke is a disorder, which occurs suddenly as a result of vascular disorders and presents with variable neurological signs. Occlusive vascular diseases in childhood have many causes. Connective tissue disorders such as vasculitis, metabolic disorders, migraine, cyanotic heart diseases, infections, dehydration, nephrotic syndrome, malignancies, haemoglobinopathies, Moya moya disease and trauma are some of these causes. Stroke occurring in children as a result of minor head trauma sustained during falls and sport activities are also reported in the literature. An extensive evaluation is necessary for effective treatment of these children and to show the cause of the infarction. We present a case of a two-year-old patient suffered from acute ischaemic stroke resulting from a short distance fall. (Hong Kong j.emerg.med. 2011;18:169-172)
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43
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Lanni G, Catalucci A, Conti L, Di Sibio A, Paonessa A, Gallucci M. Pediatric stroke: clinical findings and radiological approach. Stroke Res Treat 2011; 2011:172168. [PMID: 21603166 PMCID: PMC3095895 DOI: 10.4061/2011/172168] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Accepted: 02/16/2011] [Indexed: 12/13/2022] Open
Abstract
This paper focuses on radiological approach in pediatric stroke including both ischemic stroke (Arterial Ischemic Stroke and Cerebral Sinovenous Thrombosis) and hemorrhagic stroke. Etiopathology and main clinical findings are examined as well. Magnetic Resonance Imaging could be considered as the first-choice diagnostic exam, offering a complete diagnostic set of information both in the discrimination between ischemic/hemorrhagic stroke and in the identification of underlying causes. In addition, Magnetic Resonance vascular techniques supply further information about cerebral arterial and venous circulation. Computed Tomography, for its limits and radiation exposure, should be used only when Magnetic Resonance is not available and on unstable patients.
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Affiliation(s)
- Giuseppe Lanni
- Department of Neuroradiology, S.Salvatore Hospital, University of L'Aquila, Via Vetoio, Coppito, 67100 L'Aquila, Italy
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Modrau B, Sørensen L, Bartholdy NJ, von Weitzel-Mudersbach P, Andersen G, Rasmussen PV. Systemic thrombolytic therapy alone and in combination with mechanical revascularization in acute ischemic stroke in two children. Case Rep Neurol 2011; 3:91-6. [PMID: 21532986 PMCID: PMC3084039 DOI: 10.1159/000327554] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Thrombolytic therapy is not recommended for acute ischemic stroke (AIS) in patients under the age of 18 and published experience is limited. In this case report, we describe two children treated with systemic thrombolytic therapy. One child received additional mechanical revascularization and achieved a good clinical outcome. The differences in the fibrinolytic system and the different etiology of AIS in childhood may limit a simple extrapolation of the adult guidelines for systemic thrombolytic therapy. Acute multimodal imaging to clarify the etiology of AIS might help to select the most appropriate treatment modality.
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Affiliation(s)
- B Modrau
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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45
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Ng J, Ganesan V. Expert opinion on emerging drugs in childhood arterial ischemic stroke. Expert Opin Emerg Drugs 2011; 16:363-72. [DOI: 10.1517/14728214.2011.565050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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46
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Bulder M, Hellmann P, van Nieuwenhuizen O, Kappelle L, Klijn C, Braun K. Measuring Outcome after Arterial Ischemic Stroke in Childhood with Two Different Instruments. Cerebrovasc Dis 2011; 32:463-70. [DOI: 10.1159/000332087] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 08/23/2011] [Indexed: 11/19/2022] Open
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Abstract
In recent years, there has been increasing recognition of the impact of childhood stroke and interest in the role of drugs in the acute, chronic, and prophylactic management of this condition. Most treatment strategies are based on studies in adults with stroke, and the relative infrequency of stroke and the heterogeneity of etiologies in childhood compared with adults present significant challenges in study design for childhood stroke studies. The presence of thrombophilia has been associated with stroke in children, strengthening the concept that antithrombotic, antiplatelet, and even thrombolytic agents have a role in stroke treatment and prevention. There are several potential roles for drugs in the treatment of childhood stroke including hyperacute therapy, antithrombotic medication, antiplatelet medication, and disease-specific medications. Herein, we review the use and rationale of these medications in childhood arterial ischemic stroke.
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Abstract
It is now clear that a number of paediatric emergencies with a neurological presentation, including hemiparesis, visual loss, seizures and coma, commonly have a vascular basis which may not be obvious on CT scan. Although many children do well, as there is significant mortality as well as morbidity for childhood stroke, in addition to a high risk for recurrence, making a diagnosis in the acute phase important. Venography and arteriography (including the neck vessels if the intracranial vessels are normal) are usually indicated despite the problems i.e. contrast CT requires a high dose of radiation while emergency MR usually requires anaesthesia and conventional arteriography carries a small risk of stroke. Surgical decompression may be life-saving in ischaemic as well as haemorrhagic stroke. It is unusual for children with anterior circulation stroke to be triaged quickly enough (<4.5 h) for thrombolysis but this may occasionally be appropriate in posterior circulation occlusion associated with coma, where the time window is longer (<12 h). Anticoagulation carries relatively low risk and may be of benefit for children with venous sinus thrombosis (acutely and when at risk subsequently) or extracranial dissection. Aspirin to attempt to reduce the recurrence risk is appropriate in the medium term for the majority of patients with arterial ischaemic stroke. Iron and B vitamin deficiencies should be excluded or treated.
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Affiliation(s)
- Fenella Kirkham
- is a Professor in Paediatric Neurology at the Neurosciences Unit, University College London, Institute of Child Health, 30 Guilford Street, London WC1N 1EH and Southampton General Hospital, Southampton SO16 6YD, UK
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49
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Abstract
Although many underlying diseases have been reported in the setting of childhood arterial ischemic stroke, emerging research demonstrates that non-atherosclerotic intracerebral arteriopathies in otherwise healthy children are prevalent. Minor infections may play a role in arteriopathies that have no other apparent underlying cause. Although stroke in childhood differs in many aspects from adult stroke, few systematic studies specific to pediatrics are available to inform stroke management. Treatment trials of pediatric stroke are required to determine the best strategies for acute treatment and secondary stroke prevention. The high cost of pediatric stroke to children, families, and society demands further study of its risk factors, management, and outcomes. This review focuses on the recent findings in childhood arterial ischemic stroke.
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Affiliation(s)
- Christine K. Fox
- University of California, San Francisco, Box 0114, 505 Parnassus Avenue, Moffitt S798, San Francisco, CA 94143-0114 USA
| | - Heather J. Fullerton
- University of California, San Francisco, Box 0114, 505 Parnassus Avenue, Moffitt S798, San Francisco, CA 94143-0114 USA
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50
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Irazuzta J, Sullivan KJ. Hyperacute therapies for childhood stroke: a case report and review of the literature. Neurol Res Int 2010; 2010:497326. [PMID: 21152213 PMCID: PMC2989694 DOI: 10.1155/2010/497326] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Revised: 04/22/2010] [Accepted: 06/30/2010] [Indexed: 11/17/2022] Open
Abstract
Objective. The optimal management of pediatric patients with arterial ischemic stroke (AIS) is not known. Despite this, goal-oriented, time-sensitive therapies geared to rapid reestablishment of arterial blood flow are occasionally applied with beneficial effects. The inconsistent approach to AIS is in part due to a lack of knowledge and preparedness. Methods. Case report of a 12-year-old male with right middle cerebral artery (MCA) occlusion resulting in dense left hemiplegia and mutism and review of the literature. Intervention(s). Mechanical thrombectomy, intra-arterial administration of rt-PA, vasodilators, and platelet inhibitors, and systemic anticoagulation and subsequent critical care support. Results. Restoration of right MCA blood flow and complete resolution of neurologic deficits. Conclusion. We report the gratifying outcome of treatment of a case of AIS in a pediatric patient treated with hyperacute therapies geared to arterial recanalization and subsequent neurologic critical care and review the pertinent literature. Guidelines for the emergency room management of pediatric AIS from prospective, randomized trials are needed.
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Affiliation(s)
- Jose Irazuzta
- Division of Pediatric Critical Care Medicine, University of Florida Health Science Center at Jacksonville and The Wolfson Children's Hospital, 800 Prudential Drive, Jacksonville, FL 32207, USA
| | - Kevin J. Sullivan
- Division of Pediatric Critical Care Medicine, University of Florida Health Science Center at Jacksonville and The Wolfson Children's Hospital, 800 Prudential Drive, Jacksonville, FL 32207, USA
- Department of Anesthesia, Mayo Clinic Rochester, Rochester, MN 55905, USA
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