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Osteraas ND, Dafer RM. Advances in Management of the Stroke Etiology One-Percenters. Curr Neurol Neurosci Rep 2023; 23:301-325. [PMID: 37247169 PMCID: PMC10225785 DOI: 10.1007/s11910-023-01269-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2023] [Indexed: 05/30/2023]
Abstract
PURPOSE OF REVIEW Uncommon causes of stroke merit specific attention; when clinicians have less common etiologies of stoke in mind, the diagnosis may come more easily. This is key, as optimal management will in many cases differs significantly from "standard" care. RECENT FINDINGS Randomized controlled trials (RCT) on the best medical therapy in the treatment of cervical artery dissection (CeAD) have demonstrated low rates of ischemia with both antiplatelet and vitamin K antagonism. RCT evidence supports the use of anticoagulation with vitamin K antagonism in "high-risk" patients with antiphospholipid antibody syndrome (APLAS), and there is new evidence supporting the utilization of direct oral anticoagulation in malignancy-associated thrombosis. Migraine with aura has been more conclusively linked not only with increased risk of ischemic and hemorrhagic stroke, but also with cardiovascular mortality. Recent literature has surprisingly not provided support the utilization of L-arginine in the treatment of patients with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS); however, there is evidence at this time that support use of enzyme replacement in patients with Fabry disease. Additional triggers for reversible cerebral vasoconstriction syndrome (RCVS) have been identified, such as capsaicin. Imaging of cerebral blood vessel walls utilizing contrast-enhanced MRA is an emerging modality that may ultimately prove to be very useful in the evaluation of patients with uncommon causes of stroke. A plethora of associations between cerebrovascular disease and COVID-19 have been described. Where pertinent, authors provide additional tips and guidance. Less commonly encountered conditions with updates in diagnosis, and management along with clinical tips are reviewed.
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Affiliation(s)
| | - Rima M Dafer
- Rush University Medical Center, Chicago, IL, USA.
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison St., Suite 1118, Chicago, IL, 60612, USA.
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Zanferrari C, Fanucchi S, Sollazzo MT, Ranieri M, Volterra D, Valvassori L. Focal Cerebral Arteriopathy in a Young Adult Following SARS-CoV2 Reinfection. J Stroke Cerebrovasc Dis 2021; 30:105944. [PMID: 34271279 PMCID: PMC8196318 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105944] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/02/2021] [Accepted: 06/06/2021] [Indexed: 01/01/2023] Open
Abstract
Ten days after SARS-Cov2 reinfection with mild gastrointestinal symptoms and headache that occurred 2 months after an initial infection, a previously healthy 37-year-old woman developed fluctuating facial and upper limb paresthesia and weakness. Diffusion-weighted magnetic resonance imaging revealed ischemic lesions in the right parietal region of different stages within the same vascular territory. A cerebral angiography demonstrated an isolated focal arteriopathy with no other arterial involvement. Focal cerebral arteriopathy is exceedingly rare among adults and most commonly triggered by varicella-zoster virus reactivation. We present a case of focal cerebral arteriopathy in a patient with a recent reinfection with SARS-CoV-2.
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Affiliation(s)
- Carla Zanferrari
- Neurology and Stroke Unit, Azienda Ospedaliera di Melegnano e della Martesana, Vizzolo Predabissi, Milan, Italy.
| | - Simona Fanucchi
- Neurology and Stroke Unit, Azienda Ospedaliera di Melegnano e della Martesana, Vizzolo Predabissi, Milan, Italy
| | - Maria Teresa Sollazzo
- Neurology and Stroke Unit, Azienda Ospedaliera di Melegnano e della Martesana, Vizzolo Predabissi, Milan, Italy
| | - Michela Ranieri
- Neurology and Stroke Unit, Azienda Ospedaliera di Melegnano e della Martesana, Vizzolo Predabissi, Milan, Italy
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Oesch G, Perez FA, Wainwright MS, Shaw DWW, Amlie-Lefond C. Focal Cerebral Arteriopathy of Childhood: Clinical and Imaging Correlates. Stroke 2021; 52:2258-2265. [PMID: 34039030 DOI: 10.1161/strokeaha.120.031880] [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: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Gabriela Oesch
- Department of Pediatric Neurology, University Children's Hospital, Zurich, Switzerland (G.O.)
| | - Francisco A Perez
- Department of Radiology, Seattle Children's and University of Washington (F.A.P., D.W.W.S.)
| | - Mark S Wainwright
- Department of Neurology, Seattle Children's Hospital and University of Washington (M.S.W., C.A.-L.)
| | - Dennis W W Shaw
- Department of Radiology, Seattle Children's and University of Washington (F.A.P., D.W.W.S.)
| | - Catherine Amlie-Lefond
- Department of Neurology, Seattle Children's Hospital and University of Washington (M.S.W., C.A.-L.)
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AbdelRazek MA, Hillis JM, Guo Y, Martinez-Lage M, Gholipour T, Sloane J, Cho T, Matiello M. Unilateral Relapsing Primary Angiitis of the CNS: An Entity Suggesting Differences in the Immune Response Between the Cerebral Hemispheres. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/2/e936. [PMID: 33402525 PMCID: PMC7862090 DOI: 10.1212/nxi.0000000000000936] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/22/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To determine whether studying patients with strictly unilateral relapsing primary angiitis of the CNS (UR-PACNS) can support hemispheric differences in immune response mechanisms, we reviewed characteristics of a group of such patients. METHODS We surveiled our institution for patients with UR-PACNS, after characterizing one such case. We defined UR-PACNS as PACNS with clinical and radiographic relapses strictly recurring in 1 brain hemisphere, with or without hemiatrophy. PACNS must have been biopsy proven. Three total cases were identified at our institution. A literature search for similar reports yielded 4 additional cases. The combined 7 cases were reviewed for demographic, clinical, imaging, and pathologic trends. RESULTS The median age at time of clinical onset among the 7 cases was 26 years (range 10-49 years); 5 were male (71%). All 7 patients presented with seizures. The mean follow-up duration was 7.5 years (4-14.1 years). The annualized relapse rate ranged between 0.2 and 1. UR-PACNS involved the left cerebral hemisphere in 5 of the 7 patients. There was no consistent relationship between the patient's dominant hand and the diseased side. When performed (5 cases), conventional angiogram was nondiagnostic. CSF examination showed nucleated cells and protein levels in normal range in 3 cases and ranged from 6 to 11 cells/μL and 49 to 110 mg/dL in 4 cases, respectively. All cases were diagnosed with lesional biopsy, showing lymphocytic type of vasculitis of the small- and medium-sized vessels. Patients treated with steroids alone showed progression. Induction therapy with cyclophosphamide or rituximab followed by a steroid sparing agent resulted in the most consistent disease remission. CONCLUSIONS Combining our 3 cases with others reported in the literature allows better clinical understanding about this rare and extremely puzzling disease entity. We hypothesize that a functional difference in immune responses, caused by such discrepancies as basal levels of cytokines, asymmetric distribution of microglia, and differences in modulation of the systemic immune functions, rather than a structural antigenic difference, between the right and left brain may explain this phenomenon, but this is speculative.
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Affiliation(s)
- Mahmoud A AbdelRazek
- From the Neurology Department (M.A.A.), Mount Auburn Hospital, Harvard Medical School, Cambridge, MA; Neurology Department (J.M.H., M.M.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (Y.G.), Beijing Tongren Hospital, Capital Medical University, China; Department of Pathology (M.M.-L.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (T.G.), The George Washington University, DC; Neurology Department (J.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Neurology Department (T.C.), University of Iowa.
| | - James M Hillis
- From the Neurology Department (M.A.A.), Mount Auburn Hospital, Harvard Medical School, Cambridge, MA; Neurology Department (J.M.H., M.M.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (Y.G.), Beijing Tongren Hospital, Capital Medical University, China; Department of Pathology (M.M.-L.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (T.G.), The George Washington University, DC; Neurology Department (J.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Neurology Department (T.C.), University of Iowa
| | - Yanjun Guo
- From the Neurology Department (M.A.A.), Mount Auburn Hospital, Harvard Medical School, Cambridge, MA; Neurology Department (J.M.H., M.M.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (Y.G.), Beijing Tongren Hospital, Capital Medical University, China; Department of Pathology (M.M.-L.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (T.G.), The George Washington University, DC; Neurology Department (J.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Neurology Department (T.C.), University of Iowa
| | - Maria Martinez-Lage
- From the Neurology Department (M.A.A.), Mount Auburn Hospital, Harvard Medical School, Cambridge, MA; Neurology Department (J.M.H., M.M.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (Y.G.), Beijing Tongren Hospital, Capital Medical University, China; Department of Pathology (M.M.-L.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (T.G.), The George Washington University, DC; Neurology Department (J.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Neurology Department (T.C.), University of Iowa
| | - Taha Gholipour
- From the Neurology Department (M.A.A.), Mount Auburn Hospital, Harvard Medical School, Cambridge, MA; Neurology Department (J.M.H., M.M.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (Y.G.), Beijing Tongren Hospital, Capital Medical University, China; Department of Pathology (M.M.-L.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (T.G.), The George Washington University, DC; Neurology Department (J.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Neurology Department (T.C.), University of Iowa
| | - Jacob Sloane
- From the Neurology Department (M.A.A.), Mount Auburn Hospital, Harvard Medical School, Cambridge, MA; Neurology Department (J.M.H., M.M.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (Y.G.), Beijing Tongren Hospital, Capital Medical University, China; Department of Pathology (M.M.-L.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (T.G.), The George Washington University, DC; Neurology Department (J.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Neurology Department (T.C.), University of Iowa
| | - Tracey Cho
- From the Neurology Department (M.A.A.), Mount Auburn Hospital, Harvard Medical School, Cambridge, MA; Neurology Department (J.M.H., M.M.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (Y.G.), Beijing Tongren Hospital, Capital Medical University, China; Department of Pathology (M.M.-L.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (T.G.), The George Washington University, DC; Neurology Department (J.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Neurology Department (T.C.), University of Iowa
| | - Marcelo Matiello
- From the Neurology Department (M.A.A.), Mount Auburn Hospital, Harvard Medical School, Cambridge, MA; Neurology Department (J.M.H., M.M.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (Y.G.), Beijing Tongren Hospital, Capital Medical University, China; Department of Pathology (M.M.-L.), Massachusetts General Hospital, Harvard Medical School, Boston; Neurology Department (T.G.), The George Washington University, DC; Neurology Department (J.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Neurology Department (T.C.), University of Iowa
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Abstract
Background and Purpose- Focal cerebral arteriopathy is monophasic inflammatory stenosis of the distal internal carotid artery or the proximal segment of the middle cerebral artery. It is one of the most common causes of acute arterial ischemic stroke in young children but is a less familiar entity for adult neurologists. Methods- We retrospectively reviewed stroke service radiology records at a tertiary referral center from January 2013 to December 2014. Focal cerebral arteriopathy was defined as nonprogressive unifocal and unilateral stenosis/irregularity of the distal internal carotid artery or its proximal branches. Only patients aged 16 to 55 years with stroke were included. Results- There were 5 cases of focal cerebral arteriopathy: 2 males and 3 females. Three cases were from the cohort of 123 acute presentations of young stroke, and 2 cases were outpatient referrals. The mean age (range) was 43 (32-55) years. The majority presented with recurrent transient ischemic attacks/minor strokes within a single vascular territory over days to weeks. All cases had characteristic radiological features. Interval imaging demonstrated resolution in 1 case and improvement in 3 cases. Functional outcome was excellent with discharge modified Rankin Scale score ranging from 0 to 1. Recurrence occurred in 1 case. Conclusions- Focal cerebral arteriopathy is a rare cause of arterial ischemic stroke in young adults. Follow-up intracranial imaging is essential to differentiate from progressive arteriopathies. Evidence-based treatment warrants further investigation. Prognosis is favorable.
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Affiliation(s)
- Mary Clare McKenna
- From the Department of Neurology (M.C.M., S.C.), Cork University Hospital, Ireland
| | - Noel Fanning
- Department of Neurointerventional Radiology (N.F.), Cork University Hospital, Ireland
| | - Simon Cronin
- From the Department of Neurology (M.C.M., S.C.), Cork University Hospital, Ireland
- Department of Clinical Neuroscience, College of Medicine and Health, University College Cork, Ireland (S.C.)
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Fullerton HJ, Stence N, Hills NK, Jiang B, Amlie-Lefond C, Bernard TJ, Friedman NR, Ichord R, Mackay MT, Rafay MF, Chabrier S, Steinlin M, Elkind MSV, deVeber GA, Wintermark M. Focal Cerebral Arteriopathy of Childhood: Novel Severity Score and Natural History. Stroke 2019; 49:2590-2596. [PMID: 30355212 DOI: 10.1161/strokeaha.118.021556] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Focal cerebral arteriopathy (FCA)-a common cause of arterial ischemic stroke in previously healthy children-often progresses over days to weeks, increasing the risk of recurrent stroke. We developed a novel severity scoring system designed to quantify FCA progression and correlate with clinical outcomes. Methods- The VIPS study (Vascular Effects of Infection in Pediatric Stroke) prospectively enrolled 355 children with arterial ischemic stroke (2010-2014), including 41 with centrally confirmed FCA. Two neuroradiologists independently reviewed FCA cerebrovascular imaging, assigning a graded severity score of zero (no involvement) to 4 (occlusion) to individual arterial segments. The FCA severity score (FCASS) was the unweighted sum. In an iterative process, we modeled scores derived from different combinations of arterial segments to identify the model that optimized correlation with clinical outcome, simplicity, and reliability. Results- The optimal FCASS summed scores from 5 arterial segments: supraclinoid internal carotid artery, A1, A2, M1, and M2. The median (interquartile range) baseline FCASS was 4 (2-6). Of 33 children with follow-up imaging, the maximum FCASS (at any time point) was 7 (5-9). Twenty-four (73%) had FCA progression on follow-up with their maximum FCASS at a median of 8 (5-35.5) days poststroke; their median FCASS increase was 4 (2.5-6). FCASS did not correlate with recurrent arterial ischemic stroke. Maximum (but not baseline) FCASS correlated with 1-year pediatric stroke outcome measures ( P=0.037). Conclusions- Our novel scoring system for FCA severity correlates with neurological outcomes in the VIPS cohort and provides a tool for FCA treatment trials under development.
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Affiliation(s)
- Heather J Fullerton
- From the Department of Neurology (H.J.F., N.K.H.), University of California, San Francisco.,Department of Pediatrics (H.J.F.), University of California, San Francisco
| | - Nicholas Stence
- Department of Radiology (N.S.), University of Colorado, Denver
| | - Nancy K Hills
- From the Department of Neurology (H.J.F., N.K.H.), University of California, San Francisco.,Department of Biostatistics and Epidemiology (N.K.H.), University of California, San Francisco
| | - Bin Jiang
- Division of Neuroradiology, Department of Radiology, Stanford University, CA (B.J., M.W.)
| | | | | | - Neil R Friedman
- Center for Pediatric Neurosciences, Neurological Institute, Cleveland Clinic, OH (N.R.F.)
| | - Rebecca Ichord
- Department of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine of the University of Pennsylvania (R.I.)
| | - Mark T Mackay
- Department of Paediatrics, Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne, Victoria, Australia (M.T.M.)
| | - Mubeen F Rafay
- Department of Pediatrics and Child Health, Children's Hospital, University of Manitoba, Winnipeg, Canada (M.F.R.)
| | - Stéphane Chabrier
- INSERM, UMR1059 Sainbiose, University of Lyon, CHU Saint-Étienne, France (S.C.)
| | - Maja Steinlin
- Department of Pediatric Neurology, University Children's Hospital, University of Bern, Switzerland (M.S.)
| | - Mitchell S V Elkind
- Department of Epidemiology, Mailman School of Public Health (M.S.V.E.), Columbia University, New York, NY.,Department of Neurology, Vagelos College of Physicians and Surgeons (M.S.V.E.), Columbia University, New York, NY
| | | | - Max Wintermark
- Division of Neuroradiology, Department of Radiology, Stanford University, CA (B.J., M.W.)
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Elbers J, Armstrong D, Yau I, Benseler S. Vascular Imaging Outcomes of Childhood Primary Angiitis of the Central Nervous System. Pediatr Neurol 2016; 63:53-59. [PMID: 27469076 DOI: 10.1016/j.pediatrneurol.2016.06.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 06/09/2016] [Accepted: 06/12/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Inflammation affecting cerebral blood vessels is a common cause of stroke in children. Arterial abnormalities on vascular imaging are an important risk factor for stroke recurrence. We aimed to describe the vascular imaging outcomes in children with primary angiitis of the central nervous system after 12 months and identify factors associated with vascular progression and stroke recurrence. METHODS We retrospectively analyzed clinical and neuroimaging data from the BrainWorks Registry of children with large-vessel primary angiitis of the central nervous system. Neuroimaging was collected at baseline and at least 12-month follow-up, and vascular outcome was categorized as improved, stable, or progressed based on comparison of magnetic resonance angiography. Univariate clinical and neuroimaging predictors were associated with outcome by Fisher exact test. RESULTS Our study consisted of 27 children; 20 male; median age was 7.92 years (range, two to 15 years). Twelve patients received steroids (44%). Median follow-up time was 16 months (range, 12 to 56 months). Vascular imaging outcome was categorized as improved in 37%, stable in 22%, and progressed in 41% of patients. Discordant progression, defined as progression and improvement occurring simultaneously across multiple vessels, was observed in 26%. Stroke recurred in 15%, occurring exclusively in the group with progression on follow-up imaging (P = 0.02). CONCLUSIONS After 12 months, 40% of children with primary angiitis of the central nervous system demonstrated progression on vascular imaging, without apparent clinical or angiographic predictors. Stroke recurrence was associated with vascular progression. Discordant progression is a newly described angiographic finding. Further studies are necessary to determine if this represents a unique characteristic of inflammatory arteriopathies.
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Affiliation(s)
- Jorina Elbers
- Division of Child Neurology, Department of Neurology and Neurological Sciences, Stanford University, Stanford, California.
| | - Derek Armstrong
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ivanna Yau
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Susanne Benseler
- Division of Rheumatology, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
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Kempster PA, McLean CA, Phan TG. Ten year clinical experience with stroke and cerebral vasculitis. J Clin Neurosci 2016; 27:119-25. [DOI: 10.1016/j.jocn.2015.08.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 07/09/2015] [Accepted: 08/30/2015] [Indexed: 10/22/2022]
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Wolff V. Angiopatie cerebrali tossiche. Neurologia 2016. [DOI: 10.1016/s1634-7072(15)76143-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Poisson SN, Schardt TQ, Dingman A, Bernard TJ. Etiology and treatment of arterial ischemic stroke in children and young adults. Curr Treat Options Neurol 2014; 16:315. [PMID: 25227455 DOI: 10.1007/s11940-014-0315-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OPINION STATEMENT Stroke is the second leading cause of death worldwide (Go et al. Circulation 129:e28-292, 2014) and is a major cause of morbidity and mortality. Compared with older adults, arterial ischemic stroke (AIS) is relatively uncommon in children and young adults, comprising 5-10 % of all stroke (Biller Nat Rev Cardiol 6:395-97, 2009), but is associated with significant cost. In contrast to the declining overall incidence of stroke, some early studies suggest that the rate of stroke hospitalizations in children and young adults is rising (George et al. Ann Neurol 70:713-21, 2011; Kissela et al. Stroke 41:e224, 2010; Nguyen-Huynh et al. Stroke 43, 2012), emphasizing the importance of understanding the similarities and differences in etiology and treatment of AIS across the age spectrum. Among the most common causes of AIS in children are cardioembolism (often related to congenital heart disease), cervicocephalic arterial dissections, focal arteriopathy of childhood and several genetic and metabolic disorders, such as sickle cell disease (SCD). AIS in young adults is less well understood, but likely overlaps in etiology with both children and older adults. Young adults with AIS often have classic atherosclerotic risk factors similar to older adults, but are also more likely to have thrombophilias, cervicocephalic arterial dissections and cardioembolism, similar to children with AIS. Since little evidence exists regarding both acute treatment and secondary prevention after AIS in children and young adults, standard treatment practices are mainly extrapolated from research done in older adults. In most cases we recommend treating young adults per the guidelines published by the American Heart Association for adults with stroke (Jauch et al. Stroke 44:870-947, 2013; Kernan et al. Stroke 45:2160-2236, 2014) and children per the equivalent guidelines regarding pediatric stroke (Roach et al. Stroke 39:2644-91, 2008). It is also important in children and young adults to consider less common structural, metabolic and genetic risk factors for stroke, which may require more specific treatment. Other standard risk factors for stroke, including hypertension, hyperlipidemia and diabetes mellitus should also be addressed, but are less likely in children and young adults. Given the lack of data and possibility of rare underlying etiologies such as Antiphospholipid Antibody Syndrome or Ehlers-Danlos syndrome, we recommend including multiple specialists in the care of these patients, such as hematologists and vascular neurologists.
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Affiliation(s)
- Sharon N Poisson
- Department of Neurology, University of Colorado Denver, Leprino Building, 12401 E. 17th Ave., Mail Stop L950, Aurora, CO, 80045, USA,
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Wolff V, Armspach JP, Beaujeux R, Manisor M, Rouyer O, Lauer V, Meyer N, Marescaux C, Geny B. High Frequency of Intracranial Arterial Stenosis and Cannabis Use in Ischaemic Stroke in the Young. Cerebrovasc Dis 2014; 37:438-43. [DOI: 10.1159/000363618] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 05/15/2014] [Indexed: 11/19/2022] Open
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Abstract
PURPOSE OF REVIEW This article aims to provide a broad overview of pediatric arterial ischemic stroke, from recognition and diagnosis to the short-term and long-term management based on current available literature. RECENT FINDINGS Arterial ischemic stroke in children represents a significant disorder with a concerning high rate of adverse outcomes, including potentially preventable recurrent stroke. Although awareness of pediatric stroke is increasing, diagnosis is still commonly delayed or missed altogether, particularly in younger children. Current vascular imaging techniques have limitations in accurate diagnosis of arteriopathies that are now recognized as an important cause of childhood stroke. Significant variability exists in treatment of pediatric stroke. Management is based on published consensus guidelines; however, individual children require an individualized approach. SUMMARY As pediatric stroke specialists become increasingly available, the collaboration of such experts on individual management is crucial. Definitive evidence-based treatment for pediatric stroke awaits the development of randomized controlled trials.
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Bulder MM, Bokkers RP, Hendrikse J, Kappelle LJ, Braun KP, Klijn CJ. Arterial Spin Labeling Perfusion MRI in Children and Young Adults with Previous Ischemic Stroke and Unilateral Intracranial Arteriopathy. Cerebrovasc Dis 2014; 37:14-21. [DOI: 10.1159/000355889] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 09/23/2013] [Indexed: 11/19/2022] Open
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