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Huang SF, Xu JL, Ren CH, Sim N, Han C, Han YQ, Zhao WB, Ding YC, Ji XM, Li SJ. Remote ischemic conditioning prevents ischemic cerebrovascular events in children with moyamoya disease: a randomized controlled trial. World J Pediatr 2024:10.1007/s12519-024-00824-z. [PMID: 38951456 DOI: 10.1007/s12519-024-00824-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 05/29/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND Moyamoya disease (MMD) is a significant cause of childhood stroke and transient ischemic attacks (TIAs). This study aimed to assess the safety and efficacy of remote ischemic conditioning (RIC) in children with MMD. METHODS In a single-center pilot study, 46 MMD patients aged 4 to 14 years, with no history of reconstructive surgery, were randomly assigned to receive either RIC or sham RIC treatment twice daily for a year. The primary outcome measured was the cumulative incidence of major adverse cerebrovascular events (MACEs). Secondary outcomes included ischemic stroke, recurrent TIA, hemorrhagic stroke, revascularization rates, and clinical improvement assessed using the patient global impression of change (PGIC) scale during follow-up. RIC-related adverse events were also recorded, and cerebral hemodynamics were evaluated using transcranial Doppler. RESULTS All 46 patients completed the final follow-up (23 each in the RIC and sham RIC groups). No severe adverse events associated with RIC were observed. Kaplan-Meier analysis indicated a significant reduction in MACEs frequency after RIC treatment [log-rank test (Mantel-Cox), P = 0.021]. At 3-year follow-up, two (4.35%) patients had an ischemic stroke, four (8.70%) experienced TIAs, and two (4.35%) underwent revascularization as the qualifying MACEs. The clinical improvement rate in the RIC group was higher than the sham RIC group on the PGIC scale (65.2% vs. 26.1%, P < 0.01). No statistical difference in cerebral hemodynamics post-treatment was observed. CONCLUSIONS RIC is a safe and effective adjunct therapy for asymptomatic children with MMD. This was largely due to the reduced incidence of ischemic cerebrovascular events.
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Affiliation(s)
- Shuang-Feng Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, No 45, Changchun Street, Xicheng District, Beijing, 100053, China
| | - Jia-Li Xu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, No 45, Changchun Street, Xicheng District, Beijing, 100053, China
- Department of Rehabilitation Medicine, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing, China
| | - Chang-Hong Ren
- Beijing Institute of Brain Disorders, Capital Medical University, No.10, Xitoutiao, You'anmenwai, Fengtai District, Beijing, 100053, China
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Nathan Sim
- Department of Neurosurgery, Wayne State University, Detroit, MI, USA
| | - Cong Han
- Department of Neurosurgery, The Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Yi-Qin Han
- Department of Neurosurgery, The Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Wen-Bo Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, No 45, Changchun Street, Xicheng District, Beijing, 100053, China
| | - Yu-Chuan Ding
- Department of Neurosurgery, Wayne State University, Detroit, MI, USA
| | - Xun-Ming Ji
- Beijing Institute of Brain Disorders, Capital Medical University, No.10, Xitoutiao, You'anmenwai, Fengtai District, Beijing, 100053, China.
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China.
| | - Si-Jie Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, No 45, Changchun Street, Xicheng District, Beijing, 100053, China.
- Beijing Institute of Brain Disorders, Capital Medical University, No.10, Xitoutiao, You'anmenwai, Fengtai District, Beijing, 100053, China.
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China.
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Sun LR, Gatti JR, Ahmad SA, Burton N, Ziai W, Gottesman RF, Jordan LC. Transcranial Doppler in Childhood Moyamoya: An Underutilized Tool? Pediatr Neurol 2024; 151:111-114. [PMID: 38154237 PMCID: PMC10872573 DOI: 10.1016/j.pediatrneurol.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/21/2023] [Accepted: 12/04/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Children with moyamoya are at high risk for incident and recurrent stroke. Transcranial Doppler (TCD) ultrasound is an attractive option to screen high-risk populations for moyamoya and to provide stroke risk stratification information due to its safety and cost-effectiveness. We used TCD to evaluate cerebral blood flow velocities in children with presurgical moyamoya and to determine if velocities differ between children with stable and unstable disease. METHODS Fourteen participants aged ≤21 years with a radiographic diagnosis of moyamoya or moyamoya-like arteriopathy underwent a research TCD at a median age of 7.2 years. TCDs were performed outside of the setting of acute stroke and before surgical revascularization. Arteriopathy was classified as unstable if the participant had a stroke or transient ischemic attack within three months preceding the TCD. RESULTS Middle cerebral artery and internal carotid artery (ICA) blood flow velocities were elevated. The median M1 velocity was 138 cm/s (interquartile range [IQR] 106 to 168). Individual M1 flow velocities were a median of 5.0 S.D.s above age-based normative values. The median distal ICA velocity was 146 cm/s (IQR 124 to 163). Individual ICA flow velocities were a median of 5.9 S.D.s above normative values. Participants with unstable arteriopathy had higher M1 velocities compared with those with stable arteriopathy (170 vs 119 cm/s, P = 0.0003). We did not identify velocity differences based on comorbid conditions or age. CONCLUSIONS These preliminary data suggest that TCD is a promising tool for screening for cerebral arteriopathies in high-risk pediatric populations and assessment for unstable disease.
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Affiliation(s)
- Lisa R Sun
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland.
| | - John R Gatti
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Noah Burton
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Wendy Ziai
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rebecca F Gottesman
- National Institute of Neurological Disease and Stroke Intramural Research Program, Bethesda, Maryland
| | - Lori C Jordan
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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Gatti JR, Ahmad SA, Gardner Yelton S, DiGiusto M, Leung D, Xu R, Cohen AR, Gottesman RF, Sun LR. Relative anemia and perioperative stroke in children with moyamoya. J Stroke Cerebrovasc Dis 2024; 33:107476. [PMID: 37976795 PMCID: PMC10842685 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 10/13/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVES Surgical revascularization for moyamoya arteriopathy decreases long-term stroke risk but carries a risk of perioperative ischemic complications. We aimed to evaluate modifiable stroke risk factors in children undergoing surgical revascularization for moyamoya. MATERIALS AND METHODS In this exploratory, single-center, retrospective cohort study, medical records of pediatric patients undergoing surgical revascularization for moyamoya arteriopathy at our center between 2003 and 2021 were reviewed. Candidate modifiable risk factors were analyzed for association with perioperative stroke, defined as ischemic stroke ≤7 days after surgery. RESULTS We analyzed 53 surgeries, consisting of 39 individual patients undergoing indirect surgical revascularization of 74 hemispheres. Perioperative ischemic stroke occurred following five surgeries (9.4%). There were no instances of hemorrhagic stroke. Larger pre-to-postoperative decreases in hemoglobin (OR 3.90, p=0.017), hematocrit (OR 1.69, p=0.012) and blood urea nitrogen (OR 1.83, p=0.010) were associated with increased risk of perioperative ischemic stroke. Weight-adjusted intraoperative blood loss was not associated with risk of perioperative ischemic stroke (OR 0.94, p=0.796). Among children with sickle cell disease, all of whom underwent exchange transfusion within one week prior to surgery, none experienced perioperative stroke. CONCLUSIONS Decreases in hemoglobin, hematocrit, and blood urea nitrogen between the preoperative and postoperative periods are associated with increased risk of perioperative stroke. These novel findings suggest that dilutional anemia, possibly due to standardly administered hyperhydration, may increase the risk of perioperative stroke in some children with moyamoya. Further work optimizing both mean arterial pressure and oxygen-carrying capacity in these patients, including consideration of alternative blood transfusion thresholds, is necessary.
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Affiliation(s)
- John R Gatti
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Sarah Gardner Yelton
- Division of Pediatric Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Matthew DiGiusto
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Dennis Leung
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Alan R Cohen
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Rebecca F Gottesman
- National Institute of Neurological Disease and Stroke Intramural Research Program, Bethesda, MD, USA
| | - Lisa R Sun
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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Janas AM, Barry M, Lee S. Epidemiology, causes, and morbidities of stroke in the young. Curr Opin Pediatr 2023; 35:641-647. [PMID: 37779483 DOI: 10.1097/mop.0000000000001294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
PURPOSE OF REVIEW The purpose is to describe the latest research on epidemiology, causes, and morbidities of stroke in neonates and children. RECENT FINDINGS The global incidence of childhood stroke is approximately 2 per 100 000 person-years, which is significantly lower compared to neonates (20-40 per 100 000 live births) and adults (80-90 per 100 000 person-years). Placental abnormalities are a risk factor for perinatal stroke, although cause is usually multifactorial. In children, nonatherosclerotic arteriopathies and arteriovenous malformations are major causes of ischemic and hemorrhagic strokes, respectively. The perinatal period confers a high risk of stroke and can lead to long-term disability, including motor delay, cognitive or speech impairment, and epilepsy. Recent studies suggest that at least 50% of survivors of perinatal stroke have abnormal neurodevelopmental scores in long-term follow up. Childhood stroke is associated with significant morbidity, including epilepsy, motor impairments, and behavioral disability. Recent studies have also identified an association between pediatric stroke and behavioral disorders, such as attention deficit hyperactivity disorder and autism. SUMMARY Perinatal and childhood strokes are important causes of neurological morbidity. Given the low incidence of childhood stroke, prospective research studies on epidemiology, causes, and outcomes remain limited, highlighting the need for continued multisite collaborations.
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Affiliation(s)
- Anna M Janas
- University of Colorado School of Medicine, Department of Pediatrics, Section of Pediatric Critical Care Medicine
| | - Megan Barry
- University of Colorado School of Medicine, Department of Pediatrics, Section of Child Neurology, Aurora, Colorado
| | - Sarah Lee
- Stanford University School of Medicine, Department of Neurology, Divisions of Child Neurology and Stroke, Palo Alto, California, USA
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Hill NM, Malone LA, Sun LR. Stroke in the Developing Brain: Neurophysiologic Implications of Stroke Timing, Location, and Comorbid Factors. Pediatr Neurol 2023; 148:37-43. [PMID: 37651976 DOI: 10.1016/j.pediatrneurol.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 08/02/2023] [Accepted: 08/07/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Pediatric stroke, which is unique in that it represents a static insult to a developing brain, often leads to long-term neurological disability. Neuroplasticity in infants and children influences neurophysiologic recovery patterns after stroke; therefore outcomes depend on several factors including the timing and location of stroke and the presence of comorbid conditions. METHODS In this review, we discuss the unique implications of stroke occurring in the fetal, perinatal, and childhood/adolescent time periods. First, we highlight the impact of the developmental stage of the brain at the time of insult on the motor, sensory, cognitive, speech, and behavioral domains. Next, we consider the influence of location of stroke on the presence and severity of motor and nonmotor outcomes. Finally, we discuss the impact of associated conditions on long-term outcomes and risk for stroke recurrence. RESULTS Hemiparesis is common after stroke at any age, although the severity of impairment differs by age group. Risk of epilepsy is elevated in all age groups compared with those without stroke. Outcomes in other domains vary by age, although several studies suggest worse cognitive outcomes when stroke occurs in early childhood compared with fetal and later childhood epochs. Conditions such as congenital heart disease, sickle cell disease, and moyamoya increase the risk of stroke and leave patients differentially vulnerable to neurodevelopmental delay, stroke recurrence, silent infarcts, and cognitive impairment. CONCLUSIONS A comprehensive understanding of the interplay of various factors is essential in guiding the clinical care of patients with pediatric stroke.
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Affiliation(s)
- Nayo M Hill
- Center for Movement Studies, Kennedy Krieger Institute, Baltimore, Maryland; Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Laura A Malone
- Center for Movement Studies, Kennedy Krieger Institute, Baltimore, Maryland; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lisa R Sun
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Gatti JR, Penn R, Ahmad SA, Sun LR. Seizures in Pediatric Moyamoya: Risk Factors and Functional Outcomes. Pediatr Neurol 2023; 145:36-40. [PMID: 37271055 DOI: 10.1016/j.pediatrneurol.2023.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/23/2023] [Accepted: 04/29/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Children with moyamoya arteriopathy are at high risk for stroke and seizures. Risk factors for seizures and the impact of seizures on neurological outcomes in children with moyamoya are unknown. METHODS This is a single-center retrospective cohort study of children with moyamoya evaluated between 2003 and 2021. Functional outcome was assessed using the Pediatric Stroke Outcome Measure (PSOM). Associations between clinical variables and seizure occurrence were assessed using univariate and multivariable logistic regression. Associations between clinical variables and final PSOM score were assessed using ordinal logistic regression. RESULTS Eighty-four patients met inclusion criteria, and 34 (40%) children experienced seizure. Factors associated with seizures included moyamoya disease (vs syndrome; odds ratio [OR] 3.43, P = 0.008) and the presence of infarcts on baseline neuroimaging (OR 5.80, P = 0.002). Factors associated with decreased likelihood of experiencing seizures included older age at initial presentation (OR 0.82, P = 0.002) and asymptomatic (radiographic) presentation (OR 0.05, P = 0.006). Both older age at presentation (adjusted OR [AOR] 0.80, P = 0.004) and incidental radiographic presentation (AOR 0.06, P = 0.022) remained significant after adjusting for potential confounders. Seizures were associated with worse functional outcomes as assessed by the PSOM (regression coefficient 2.03, P < 0.001). This association remained significant after adjusting for potential confounders (adjusted regression coefficient 1.54, P = 0.025). CONCLUSIONS Younger age and symptomatic presentation are associated with increased likelihood of seizures among children with moyamoya. Seizures are associated with worse functional outcomes. Prospective studies should clarify how seizures impact outcomes and how effective seizure treatment modifies this relationship.
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Affiliation(s)
- John R Gatti
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rachel Penn
- Division of Epilepsy, Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Lisa R Sun
- Divisions of Cerebrovascular Neurology and Pediatric Neurology, Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland.
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Gatti JR, Peterson RK, Cannon A, Yedavalli V, Malone LA, Sun LR. Characterization of Neuropsychological Outcomes in a Cohort of Pediatric Patients with Moyamoya Arteriopathy. Neuropediatrics 2023; 54:134-138. [PMID: 36473489 PMCID: PMC10893819 DOI: 10.1055/a-1993-3860] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Moyamoya arteriopathy is a severe, progressive cerebral arteriopathy that places affected children at high risk for stroke. Moyamoya has been associated with a range of neuropsychological deficits in adults, but data on many cognitive domains remain limited in the pediatric population and little is known about the neuropsychological profile of children with syndromic moyamoya. METHODS This is a single-center, retrospective cohort study of children with moyamoya arteriopathy followed at our center who underwent neuropsychological testing between 2003 and 2021. Test scores were extracted from neuropsychological reports. Medical records were reviewed with attention to individual neuropsychological test results, medical comorbidities, presence of infarct(s) on neuroimaging, and history of clinical ischemic stroke. RESULTS Of the 83 children with moyamoya followed at our center between 2003 and 2021, 13 had completed neuropsychological testing across multiple cognitive domains. Compared to age-based normative data, children in this sample had lower scores in overall intelligence (p = 0.003), global executive functioning (p = 0.005), and overall adaptive functioning (p = 0.015). There was no significant difference in overall intelligence between children with (n = 6) versus without (n = 7) a history of clinical stroke (p = 0.368), though children with any radiographic infarct scored lower in this domain (p = 0.032). CONCLUSION In our cohort, children with moyamoya demonstrated impaired intelligence and executive functioning, even in the absence of clinical stroke. Neuropsychological evaluation should be considered standard of care for all children with moyamoya, even those without a history of clinical stroke.
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Affiliation(s)
- John R Gatti
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Rachel K Peterson
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland, United States
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Alicia Cannon
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland, United States
| | - Vivek Yedavalli
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Laura A Malone
- Center for Movement Studies, Kennedy Krieger Institute, Baltimore, Maryland, United States
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Lisa R Sun
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
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Sun LR, Lynch JK. Advances in the Diagnosis and Treatment of Pediatric Arterial Ischemic Stroke. Neurotherapeutics 2023; 20:633-654. [PMID: 37072548 PMCID: PMC10112833 DOI: 10.1007/s13311-023-01373-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/20/2023] Open
Abstract
Though rare, stroke in infants and children is an important cause of mortality and chronic morbidity in the pediatric population. Neuroimaging advances and implementation of pediatric stroke care protocols have led to the ability to rapidly diagnose stroke and in many cases determine the stroke etiology. Though data on efficacy of hyperacute therapies, such as intravenous thrombolysis and mechanical thrombectomy, in pediatric stroke are limited, feasibility and safety data are mounting and support careful consideration of these treatments for childhood stroke. Recent therapeutic advances allow for targeted stroke prevention efforts in high-risk conditions, such as moyamoya, sickle cell disease, cardiac disease, and genetic disorders. Despite these exciting advances, important knowledge gaps persist, including optimal dosing and type of thrombolytic agents, inclusion criteria for mechanical thrombectomy, the role of immunomodulatory therapies for focal cerebral arteriopathy, optimal long-term antithrombotic strategies, the role of patent foramen ovale closure in pediatric stroke, and optimal rehabilitation strategies after stroke of the developing brain.
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Affiliation(s)
- Lisa R Sun
- Divisions of Pediatric Neurology and Cerebrovascular Neurology, Department of Neurology, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Ste 2158, Baltimore, MD, 21287, USA.
| | - John K Lynch
- Acute Stroke Research Section, Stroke Branch (SB), National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
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