1
|
van Ommen CH, Luijnenburg SE. Anticoagulation of pediatric patients with venous thromboembolism in 2023. Thromb Res 2024; 235:186-193. [PMID: 38378308 DOI: 10.1016/j.thromres.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 12/24/2023] [Accepted: 12/24/2023] [Indexed: 02/22/2024]
Abstract
Venous thromboembolism (VTE) is a rare and heterozygous disease in children. Management of VTE in children is complicated by age-related differences in epidemiology, recurrent VTE and bleeding risk, hemostatic proteins and pharmacokinetics of anticoagulants. Recently, the choice of anticoagulation has expanded to oral factor IIa and Xa inhibitors, which have been authorized for children for treatment of acute VTE and extended secondary prevention. These drugs have several properties that make them extremely suitable for use in children, including oral administration, antithrombin independence, less interactions with food and drugs and no need for monitoring. Unfortunately, the phase 3 studies had many exclusion criteria, and only a few term neonates and infants were included in these studies. Additional real-world data is needed to make evidence-based recommendations in these age and patient groups, as well.
Collapse
Affiliation(s)
- C Heleen van Ommen
- Department of Pediatric Hematology, Sophia Children's Hospital, Erasmus MC, Rotterdam, the Netherlands.
| | - Saskia E Luijnenburg
- Department of Pediatric Hematology, Sophia Children's Hospital, Erasmus MC, Rotterdam, the Netherlands
| |
Collapse
|
2
|
Pin JN, Leonardi L, Nosadini M, Pelizza MF, Capato L, Piretti L, Cavicchiolo ME, Simioni P, Baraldi E, Perilongo G, Luciani M, Sartori S. Deep Medullary Vein Thrombosis in Newborns: A Systematic Literature Review. Neonatology 2023; 120:539-547. [PMID: 37379822 DOI: 10.1159/000530647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 03/31/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Deep medullary vein (DMV) thrombosis is a rare cause of brain damage in both preterm and full-term neonates. In this study, we aimed to collect data on clinical and radiological presentation, treatment, and outcome of neonatal DMV thrombosis. METHODS Systematic literature review on neonatal DMV thrombosis was carried out in PubMed, ClinicalTrial.gov, Scopus, and Web of Science up to December 2022. RESULTS Seventy-five published cases of DMV thrombosis were identified and analysed (preterm newborns were 46%). Neonatal distress, respiratory resuscitation, or need for inotropes were present in 34/75 (45%) of patients. Signs and symptoms at presentation included seizures (38/75, 48%), apnoea (27/75, 36%), lethargy or irritability (26/75, 35%). At magnetic resonance imaging (MRI), fan-shaped linear T2 hypointense lesions were documented in all cases. All had ischaemic injuries, most often involving the frontal (62/74, 84%) and parietal lobes (56/74, 76%). Signs of haemorrhagic infarction were present in 53/54 (98%). Antithrombotic treatment was not mentioned in any of the studies included. Although mortality was low (2/75, 2.6%), a large proportion of patients developed neurological sequelae (intellectual disability in 19/51 [37%] and epilepsy in 9/51 [18%] cases). CONCLUSIONS DMV thrombosis is rarely identified in the literature, even if it is possibly under-recognized or under-reported. Presentation in neonatal age is with seizures and non-specific systemic signs/symptoms that often cause diagnostic delay, despite the pathognomonic MRI picture. The high rate of morbidity, which determines significant social and health costs, requires further in-depth studies aimed at earlier diagnosis and evidence-based prevention and therapeutic strategies.
Collapse
Affiliation(s)
- Jacopo Norberto Pin
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Letizia Leonardi
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
- Neuroimmunology Group, Paediatric Research Institute "Città della Speranza,", Padua, Italy
| | - Maria Federica Pelizza
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Luca Capato
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Luca Piretti
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Maria Elena Cavicchiolo
- Neonatal Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Paolo Simioni
- General Internal Medicine and Thrombotic and Hemorrhagic Unit, University Hospital of Padua, Padua, Italy
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Giorgio Perilongo
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Matteo Luciani
- Department of Paediatric Hematology Oncology, Bambino Gesù Children Hospital IRCSS, Roma, Italy
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
- Neuroimmunology Group, Paediatric Research Institute "Città della Speranza,", Padua, Italy
- Department of Neuroscience, University Hospital of Padua, Padua, Italy
| |
Collapse
|
3
|
An Integrated Approach on the Diagnosis of Cerebral Veins and Dural Sinuses Thrombosis. Life (Basel) 2022; 12:life12050717. [PMID: 35629384 PMCID: PMC9145675 DOI: 10.3390/life12050717] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/09/2022] [Accepted: 05/09/2022] [Indexed: 01/05/2023] Open
Abstract
(1) Objective: This review paper aims to discuss multiple aspects of cerebral venous thrombosis (CVT), including epidemiology, etiology, pathophysiology, and clinical presentation. Different neuroimaging methods for diagnosis of CVT, such as computer tomography CT/CT Venography (CTV), and Magnetic Resonance Imaging (MRI)/MR Venography (MRV) will be presented. (2) Methods: A literature analysis using PubMed and the MEDLINE sub-engine was done using the terms: cerebral venous thrombosis, thrombophilia, and imaging. Different studies concerning risk factors, clinical picture, and imaging signs of patients with CVT were examined. (3) Results: At least one risk factor can be identified in 85% of CVT cases. Searching for a thrombophilic state should be realized for patients with CVT who present a high pretest probability of severe thrombophilia. Two pathophysiological mechanisms contribute to their highly variable clinical presentation: augmentation of venular and capillary pressure, and diminution of cerebrospinal fluid absorption. The clinical spectrum of CVT is frequently non-specific and presents a high level of clinical suspicion. Four major syndromes have been described: isolated intracranial hypertension, seizures, focal neurological abnormalities, and encephalopathy. Cavernous sinus thrombosis is the single CVT that presents a characteristic clinical syndrome. Non-enhanced CT (NECT) of the Head is the most frequently performed imaging study in the emergency department. Features of CVT on NECT can be divided into direct signs (demonstration of dense venous clot within a cerebral vein or a cerebral venous sinus), and more frequently indirect signs (such as cerebral edema, or cerebral venous infarct). CVT diagnosis is confirmed with CTV, directly detecting the venous clot as a filling defect, or MRI/MRV, which also realizes a better description of parenchymal abnormalities. (4) Conclusions: CVT is a relatively rare disorder in the general population and is frequently misdiagnosed upon initial examination. The knowledge of wide clinical aspects and imaging signs will be essential in providing a timely diagnosis.
Collapse
|
4
|
Abstract
There are many neuro-imaging studies on the presence of brain lesions in the preterm infant, using cranial ultrasound (cUS) and/or term equivalent age MRI (TEA-MRI). These studies however tend to focus on germinal matrix-intraventricular hemorrhage (GMH-IVH) and white matter injury. Data about perinatal arterial ischemic stroke (PAIS) or cerebral sinovenous thrombosis (CSVT) in the preterm infant are very limited. In fact, several large cohort studies on neuro-imaging in preterm infants do not even mention neonatal stroke.1-4 Most studies about PAIS exclude preterm infants.5 The aim of this review was to provide an update on neonatal stroke in the preterm infant, with a focus on neuro-imaging findings.
Collapse
|
5
|
Rodrigues SG, Vieira D, Bernardo F, Coelho J, Ribeiro JA, Palavra F, Robalo C, Levy A, Quintas S. Pediatric cerebral sinus venous thrombosis: clinical characterization of a Portuguese cohort. Acta Neurol Belg 2021; 122:1211-1218. [PMID: 34606070 DOI: 10.1007/s13760-021-01807-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/15/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Pediatric cerebral sinus venous thrombosis (CSVT) is a rare entity. Risk factors differ from the adults, and treatment is not consensual. With this work, we aimed to characterize a pediatric cohort from two Portuguese tertiary centers. METHODS All patients under 18 years old with confirmed CSVT admitted between 2006 and 2019 were retrospectively included. Demographics, clinical presentation, workup, and follow-up were evaluated. RESULTS Fifty-three patients were included, 29 were male (54.7%). Median age was 5 years (IQR 11.08, range 0-17 years old). Headache, seizures and impairment of consciousness were the most frequent manifestations. A risk factor was identified in 90.6% (n = 48), mostly infections (43.8%; n = 21). CNS complications were comprised of hemorrhage, venous infarction, hydrocephalus and edema. Treatment included anticoagulation in 36 patients (67.9%), and there were no recurrences on follow-up. Prognosis was favorable, with most patients presenting no or only slight disability comparing to same age and sex children, on the follow-up. DISCUSSION In this cohort, impairment of consciousness was the most frequent clinical presentation and infections were the most frequent risk factors. The outcome was mainly favorable, with most patients presenting none or mild disability and without recurrences on follow-up. Studies are needed to define the criteria for anticoagulation and its recommended duration in children.
Collapse
|
6
|
Clinical Profile and Long-Term Outcome in Neonatal Cerebral Sinus Venous Thrombosis. Pediatr Neurol 2021; 121:20-25. [PMID: 34126318 DOI: 10.1016/j.pediatrneurol.2021.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/20/2021] [Accepted: 05/01/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Neonatal cerebral sinus venous thrombosis (CSVT) causes high morbidity and mortality. Factors associated with either favorable or unfavorable long-term outcomes have not been clearly established. This study aimed to determine the factors involved in long-term neurological outcomes in patients with neonatal CSVT. METHODS This was a retrospective cohort study of patients with neonatal CSVT at a single institution. Clinical factors associated with long-term neurological outcomes were examined. RESULTS A total of 67 patients met study inclusion criteria for radiologically confirmed neonatal CSVT. The mean patient follow-up duration was four years (range one week to 16 years, median six years). We observed a favorable neurological outcome defined by a pediatric stroke outcome measures (PSOM) score of 0 to 0.5 in 26 (53%) of osurviving patients at follow-up. An unfavorable neurological outcome as defined by PSOM score >0.5 was observed in 23 survivors (47%). Death was reported in 18 (27%) patients, of which 10 patients died due to direct complications of CSVT. Congential heart disease and genetic disease were associated with significantly increased odds for all-cause death. Cardiorespiratory failure and altered mental status during the initial neurological examination were significantly associated with increased odds of death due to CSVT. Among surviving patients, higher PSOM scores were associated with premature birth (i.e., gestational age < 37 weeks), traumatic birth, site of thrombosis in the straight sinus, site of thrombosis in the internal cerebral veins, and hemorrhagic infarct. In contrast, lower PSOM scores were associated with a normal neurological examination at presentation, thrombosis in only superficial sinuses, and hemorrhage without infarct. There was no statistically significant association between the type and duration of CSVT treatment. CONCLUSIONS The major factors influencing outcome of neonates following CSVT included comorbid medical conditions, abnormal neurological examination at presentation, location of venous thrombosis, and type of cerebral injury. These results can help guide further studies in neonatal CSVT aiming to decrease morbidity and mortality with the goal of improving long-term neurological outcomes.
Collapse
|
7
|
|
8
|
Sorg AL, Von Kries R, Klemme M, Gerstl L, Beyerlein A, Lack N, Felderhoff-Müser U, Dzietko M. Incidence and risk factors of cerebral sinovenous thrombosis in infants. Dev Med Child Neurol 2021; 63:697-704. [PMID: 33506500 DOI: 10.1111/dmcn.14816] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2020] [Indexed: 12/16/2022]
Abstract
AIM To describe the incidence of term and preterm neonatal cerebral sinovenous thrombosis (CSVT) and identify perinatal risk factors. METHOD This was a national capture-recapture calculation-corrected surveillance and nested case-control study. Infants born preterm and at term with magnetic resonance imaging-confirmed neonatal CSVT were identified by surveillance in all paediatric hospitals in Germany (2015-2017). Incidence was corrected for underreporting using a capture-recapture method in one federal state and then extrapolated nationwide. We reviewed PubMed for comparisons with previously reported incidence estimators. We used a population-based perinatal database for quality assurance to select four controls per case and applied univariate and multivariable regression for risk factor analysis. RESULTS Fifty-one newborn infants (34 males, 17 females; 14 born preterm) with neonatal CSVT were reported in the 3-year period. The incidence of term and preterm neonatal CSVT was 6.6 (95% confidence interval [CI] 4.4-8.7) per 100 000 live births. Median age at time of confirmation of the diagnosis was 9.95 days (range 0-39d). In the univariate analysis, male sex, preterm birth, hypoxia and related indicators (umbilical artery pH <7.1; 5-minute Apgar score <7; intubation/mask ventilation; perinatal asphyxia), operative vaginal delivery, emergency Caesarean section, and pathological fetal Doppler sonography were associated (p<0.05) with neonatal CSVT. Multivariable regression yielded hypoxia (odds ratio=20.3; 95% CI 8.1-50.8) as the independent risk factor. INTERPRETATION Incidence of neonatal CSVT was within the range of other population-based studies. The results suggest that hypoxia is an important perinatal risk factor for the aetiology of neonatal CSVT.
Collapse
Affiliation(s)
- Anna-Lisa Sorg
- Institute of Social Paediatrics and Adolescent Medicine, Division of Paediatric Epidemiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Rüdiger Von Kries
- Institute of Social Paediatrics and Adolescent Medicine, Division of Paediatric Epidemiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Mathias Klemme
- Department of Neonatology, University Children's Hospital and Perinatal Centre, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Lucia Gerstl
- Department of Paediatric Neurology, University Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Andreas Beyerlein
- Institute of Computational Biology, Helmholtz Zentrum München, Neuherberg, Germany
| | - Nicholas Lack
- Bavarian Quality Assurance for In-Patient Medical Care, Munich, Germany
| | | | - Mark Dzietko
- Department of Paediatrics I, Neonatology, University Duisburg-Essen, Essen, Germany
| |
Collapse
|
9
|
Sorg AL, Klemme M, von Kries R, Felderhoff-Müser U, Flemmer AW, Gerstl L, Dzietko M. Clinical Diversity of Cerebral Sinovenous Thrombosis and Arterial Ischaemic Stroke in the Neonate: A Surveillance Study. Neonatology 2021; 118:530-536. [PMID: 33784682 DOI: 10.1159/000512526] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 10/23/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Incidence, risk factors, clinical presentation, onset of symptoms, and age at diagnosis differ between neonatal arterial ischaemic stroke (AIS) and cerebral sinovenous thrombosis (CSVT). A more accurate and earlier discrimination of these two entities can be of eminent importance. METHODS Active surveillance for AIS and CSVT was performed in 345 German paediatric hospitals. Only MRI confirmed cases were included in our analysis. Patients with AIS were compared to CSVT cases with regard to age at diagnosis, pattern of clinical symptoms, and case characteristics. RESULTS Data on 144 AIS and 51 CSVT neonatal cases were collected from 2015 to 2017. The frequency of reported AIS cases was 2.8 [95% CI 2.1; 3.9] times higher compared to reported CSVT cases. CSVT patients were more likely to be born premature (CSVT 14/48, 29.2%; AIS 19/140, 13.2%; p = 0.02) and to have signs of perinatal acidosis (30.2% CSVT vs. 13.5% AIS; p = 0.01). Generalized seizures and lethargy were more likely to occur in infants with CSVT (p < 0.0001). Age at onset of symptoms and at time of diagnosis were shifted to older ages in CSVT (p < 0.0001). DISCUSSION/CONCLUSION In the neonatal period, AIS is about three times more common than CSVT. A higher proportion of critically ill infants in CSVT and a later onset of symptoms may indicate that perinatal and postnatal complications are more important for CSVT than for AIS.
Collapse
Affiliation(s)
- Anna-Lisa Sorg
- Division of Pediatric Epidemiology, Institute of Social Pediatrics and Adolescent Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Mathias Klemme
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Rüdiger von Kries
- Division of Pediatric Epidemiology, Institute of Social Pediatrics and Adolescent Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | | | - Andreas W Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Lucia Gerstl
- Department of Pediatric Neurology, University Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Mark Dzietko
- Department of Pediatrics I, Neonatology, University Duisburg-Essen, Essen, Germany
| |
Collapse
|
10
|
Geraldo AF, Messina SS, Tortora D, Parodi A, Malova M, Morana G, Gandolfo C, D'Amico A, Herkert E, Govaert P, Ramenghi LA, Rossi A, Severino M. Neonatal Developmental Venous Anomalies: Clinicoradiologic Characterization and Follow-Up. AJNR Am J Neuroradiol 2020; 41:2370-2376. [PMID: 33093132 DOI: 10.3174/ajnr.a6829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/06/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Although developmental venous anomalies have been frequently studied in adults and occasionally in children, data regarding these entities are scarce in neonates. We aimed to characterize clinical and neuroimaging features of neonatal developmental venous anomalies and to evaluate any association between MR imaging abnormalities in their drainage territory and corresponding angioarchitectural features. MATERIALS AND METHODS We reviewed parenchymal abnormalities and angioarchitectural features of 41 neonates with developmental venous anomalies (20 males; mean corrected age, 39.9 weeks) selected through a radiology report text search from 2135 neonates who underwent brain MR imaging between 2008 and 2019. Fetal and longitudinal MR images were also reviewed. Neurologic outcomes were collected. Statistics were performed using χ2, Fisher exact, Mann-Whitney U, or t tests corrected for multiple comparisons. RESULTS Developmental venous anomalies were detected in 1.9% of neonatal scans. These were complicated by parenchymal/ventricular abnormalities in 15/41 cases (36.6%), improving at last follow-up in 8/10 (80%), with normal neurologic outcome in 9/14 (64.2%). Multiple collectors (P = .008) and larger collector caliber (P < .001) were significantly more frequent in complicated developmental venous anomalies. At a patient level, multiplicity (P = .002) was significantly associated with the presence of ≥1 complicated developmental venous anomaly. Retrospective fetal detection was possible in 3/11 subjects (27.2%). CONCLUSIONS One-third of neonatal developmental venous anomalies may be complicated by parenchymal abnormalities, especially with multiple and larger collectors. Neuroimaging and neurologic outcomes were favorable in most cases, suggesting a benign, self-limited nature of these vascular anomalies. A congenital origin could be confirmed in one-quarter of cases with available fetal MR imaging.
Collapse
Affiliation(s)
- A F Geraldo
- From the Neuroradiology Unit (A.F.G.), Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal.,Neuroradiology Unit (A.F.G., D.T., G.M., A.R., M.S.)
| | - S S Messina
- Radiology Unit (S.S.M.), Casa di Cura Regina Pacis, Palermo, Italy
| | - D Tortora
- Neuroradiology Unit (A.F.G., D.T., G.M., A.R., M.S.)
| | - A Parodi
- Neonatal Intensive Care Unit (A.P., M.M., L.A.R.)
| | - M Malova
- Neonatal Intensive Care Unit (A.P., M.M., L.A.R.)
| | - G Morana
- Neuroradiology Unit (A.F.G., D.T., G.M., A.R., M.S.)
| | - C Gandolfo
- Interventional Unit (C.G.), IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - A D'Amico
- Dipartimento di Scienze Biomediche Avanzate (A.D.), Universita' Federico II, Napoli, Italy
| | - E Herkert
- Division of Neonatology (E.H., P.G.), Department of Paediatrics, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - P Govaert
- Division of Neonatology (E.H., P.G.), Department of Paediatrics, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - L A Ramenghi
- Neonatal Intensive Care Unit (A.P., M.M., L.A.R.)
| | - A Rossi
- Neuroradiology Unit (A.F.G., D.T., G.M., A.R., M.S.)
| | - M Severino
- Neuroradiology Unit (A.F.G., D.T., G.M., A.R., M.S.)
| |
Collapse
|
11
|
Poisson KE, Thomas CW, Leach JL. A 2-week-old Infant Presenting with Seizures. Neoreviews 2020; 21:e631-e635. [PMID: 32873659 DOI: 10.1542/neo.21-9-e631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Kelsey E Poisson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Divisions of Neurology, and
| | - Cameron W Thomas
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Divisions of Neurology, and
| | - James L Leach
- Radiology and Medical Imaging, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| |
Collapse
|
12
|
Chen D, Sun J, Li Q, Bai W, Mao J. An Important Finding of White Matter Injury in Late Preterm Infant: Deep Medullary Vein Involvement. Front Pediatr 2020; 8:597567. [PMID: 33392116 PMCID: PMC7773939 DOI: 10.3389/fped.2020.597567] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 11/25/2020] [Indexed: 11/30/2022] Open
Abstract
Objective: To investigate high risk factors and magnetic resonance imaging (MRI) features in late preterm infants with severe white matter injury (WMI) associated with abnormal deep medullary veins (DMVs). Materials and Methods: Preterm infants with severe WMI, who were hospitalized in Shengjing Hospital from 1st January 2009 to 31st December 2018, were enrolled in this retrospective study. High risk factors and MRI characteristics of infants with abnormal DMVs were analyzed and compared with those of infants without DMV abnormalities. Results: A total of 2032 late preterm infants were examined by MRI; 71 cases (3.5%) had severe WMI and 15 of these (21.1%) had abnormal DMVs. The incidence of maternal diabetes was higher in infants with abnormal DMVs and neonatal convulsions were more likely (P < 0.05). The incidence of grade IV injury (P < 0.05), white matter periventricular cysts and thalamic injury (P < 0.01), cerebral venous sinus thrombus (P < 0.01) and germinal matrix/intraventricular hemorrhage (P < 0.05) were higher in infants with abnormal DMVs than in infants with normal DMVs. Conclusions: Congestion/thrombosis of DMVs may be an important cause of severe WMI in late preterm infants, especially in periventricular leukomalacia-like WMI. WMI with abnormal DMVs is more likely to lead to thalamic injury.
Collapse
Affiliation(s)
- Dan Chen
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jing Sun
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Qiuyu Li
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Wenjuan Bai
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jian Mao
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| |
Collapse
|
13
|
Abstract
Perinatal stroke is a heterogeneous syndrome resulting from brain injury of vascular origin that occurs between 20 weeks of gestation and 28 days of postnatal life. The incidence of perinatal stroke is estimated to be between 1:1600 and 1:3000 live births (approximately 2500 children per year in the United States), though its actual incidence is difficult to estimate because it is likely underdiagnosed. Perinatal arterial ischemic stroke (PAIS) accounts for approximately 70% of cases of perinatal stroke. Cerebral sinovenous thrombosis, while less common, also accounts for a large proportion of the morbidity and mortality seen with perinatal stroke. Hemorrhagic stroke leads to disruption of neurologic function due to intracerebral hemorrhage that is nontraumatic in origin. While most cases of PAIS fall into one of these three categories, other patterns of injury should also be considered perinatal stroke. In some cases, the etiology of PAIS is not known but is idiopathic. This chapter will review the classification, risk factors, pathogenesis, clinical presentation, management, and long-term sequelae of perinatal stroke.
Collapse
Affiliation(s)
- Emmett E Whitaker
- Department of Anesthesiology, University of Vermont Larner College of Medicine, Burlington, VT, United States; Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, United States.
| | - Marilyn J Cipolla
- Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, United States; Department of Obstetrics, Gynecology & Reproductive Sciences, University of Vermont Larner College of Medicine, Burlington, VT, United States; Department of Pharmacology, University of Vermont Larner College of Medicine, Burlington, VT, United States
| |
Collapse
|
14
|
Abstract
Perinatal strokes are a diverse but specific group of focal cerebrovascular injuries that occur early in brain development and affect an estimated 5 million people worldwide. The objective of this review is to describe the epidemiology, clinical presentations, pathophysiology, outcomes, and management for the 6 subtypes of perinatal stroke. Some perinatal strokes are symptomatic in the first days of life, typically with seizures, including neonatal arterial ischemic stroke, neonatal hemorrhagic stroke, and cerebral sinovenous thrombosis. The remaining subtypes present in the first year of life or later, usually with motor asymmetry and include arterial presumed perinatal ischemic stroke, presumed perinatal hemorrhagic stroke, and in utero periventricular venous infarction. The consequences of these injuries include cerebral palsy, epilepsy, and cognitive and behavioral challenges, in addition to the psychosocial impact on families. While there have been significant advances in understanding mechanisms of both injury and recovery, there is still a great deal to learn regarding causation and the optimization of outcomes.
Collapse
Affiliation(s)
- Mary Dunbar
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; Calgary Pediatric Stroke Program, University of Calgary, Calgary, AB, Canada
| | - Adam Kirton
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada; Department of Clinical Neuroscience, University of Calgary, Calgary, AB, Canada; Department of Radiology, Faculty of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, Calgary, AB, Canada; Hotchkiss Brain Institute, Calgary, AB, Canada; Calgary Pediatric Stroke Program, University of Calgary, Calgary, AB, Canada.
| |
Collapse
|
15
|
Garrido-Barbero M, Arnaez J, Loureiro B, Arca G, Agut T, Garcia-Alix A. The Role of Factor V Leiden, Prothrombin G20210A, and MTHFR C677T Mutations in Neonatal Cerebral Sinovenous Thrombosis. Clin Appl Thromb Hemost 2019; 25:1076029619834352. [PMID: 31025572 PMCID: PMC6714919 DOI: 10.1177/1076029619834352] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Little is known about the pathogenesis of cerebral sinovenous thrombosis (CSVT) in the
neonate. Although thrombophilia has been described as increasing the risk of CSVT in
adults, it remains controversial in pediatric patients, and prospective case–control
studies regarding neonatal CSVT are lacking. From 2008 to 2017, all 26 consecutive newborn
infants ≥35 weeks of gestation diagnosed with neonatal CSVT, and their mothers, were
tested for factor V Leiden (FV) G1691A, FII G20210A, and methylenetetrahydrofolate
reductase C677T (MTHFR C677T) mutations. Eighty-five mother–infant pairs were recruited as
controls. All infants except 1 with CSVT were suspected due to clinical symptoms, mainly
seizures (22/25). Magnetic resonance imaging was performed in 24/26 infants. Heterozygous
FV G1691A, FII G20210A, and homozygous MTHFR C677T mutations were present in 1/26, 3/26,
and 3/20 infants with CSVT, respectively. FII (odds ratio: 10.96; 95% confidence interval
[CI]: 1.09-110.35) and male sex (3.93; 95% CI: 1.43-10.76) were associated with CSVT. When
FII G20210A analysis was adjusted for sex, the OR for FII G20210A was 6.70 (95% CI:
0.65-69.22). No differences were found for FV G1691A or homozygous MTHFR mutations between
neonates with CSVT and their mothers, compared to controls.
Collapse
Affiliation(s)
| | - Juan Arnaez
- Unidad Neonatal, Hospital Universitario de Burgos, Burgos, Spain
- Fundación NeNe, Spain
- Juan Arnaez, Neonatologia, Hospital Universitario de
Burgos, Islas Baleares, 3, 09006 Burgos, Spain.
| | - Begoña Loureiro
- Unidad Neonatal, Hospital Universitario Cruces, Vizcaya, Spain
| | - Gemma Arca
- Unidad Neonatal, Hospital Universitario Clinic Maternitat, Barcelona,
Spain
| | - Thais Agut
- Fundación NeNe, Spain
- Unidad Neonatal, Institut de Recerca Pediatrica Sant Joan de Dèu, Hospital
Sant Joan de Dèu, Barcelona, Spain
| | - Alfredo Garcia-Alix
- Fundación NeNe, Spain
- Unidad Neonatal, Institut de Recerca Pediatrica Sant Joan de Dèu, Hospital
Sant Joan de Dèu, Barcelona, Spain
- Universitat de Barcelona, Barcelona, Spain
| |
Collapse
|
16
|
Fluss J, Dinomais M, Chabrier S. Perinatal stroke syndromes: Similarities and diversities in aetiology, outcome and management. Eur J Paediatr Neurol 2019; 23:368-383. [PMID: 30879961 DOI: 10.1016/j.ejpn.2019.02.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 02/04/2019] [Accepted: 02/24/2019] [Indexed: 01/09/2023]
Abstract
With a birth-prevalence of 37-67/100,000 (mostly term-born), perinatal stroke encompasses distinct disease-states with diverse causality, mechanism, time of onset, mode of presentation and outcome. Neonatal primary haemorrhagic stroke and ischemic events (also divided into neonatal arterial ischemic stroke and neonatal cerebral sinus venous thrombosis) that manifest soon after birth are distinguished from presumed perinatal - ischemic or haemorrhagic - stroke. Signs of the latter become apparent only beyond the neonatal period, most often with motor asymmetry or milestones delay, and occasionally with seizures. Acute or remote MRI defines the type of stroke and is useful for prognosis. Acute care relies on homeostatic maintenance. Seizures are often self-limited and anticonvulsant agents might be discontinued before discharge. Prolonged anticoagulation for a few weeks is an option in some cases of sinovenous thrombosis. Although the risk of severe impairment is low, many children develop mild to moderate multimodal developmental issues that require a multidisciplinary approach.
Collapse
Affiliation(s)
- Joel Fluss
- Pediatric Neurology Unit, Geneva Children's Hospital, 6 rue Willy-Donzé, 1211 Genève 4, Switzerland
| | - Mickaël Dinomais
- CHU Angers, Département de Médecine Physique et de Réadaptation, CHU Angers-Capucins, F-49933, Angers, France; Université d'Angers, Laboratoire Angevin de Recherche en Ingénierie des Systèmes (LARIS) EA7315, F-49000, Angers, France
| | - Stéphane Chabrier
- CHU Saint-Étienne, French Centre for Paediatric Stroke, Paediatric Physical and Rehabilitation Medicine Department, INSERM, CIC 1408, F-42055, Saint-Étienne, France; INSERM, U1059 Sainbiose, Univ Saint-Étienne, Univ Lyon, F-42023, Saint-Étienne, France.
| |
Collapse
|
17
|
Benninger KL, Maitre NL, Ruess L, Rusin JA. MR Imaging Scoring System for White Matter Injury after Deep Medullary Vein Thrombosis and Infarction in Neonates. AJNR Am J Neuroradiol 2019; 40:347-352. [PMID: 30655251 DOI: 10.3174/ajnr.a5940] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 12/01/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND PURPOSE Advanced imaging techniques have allowed earlier and more accurate detection of cerebral deep medullary vein thrombosis and infarction. Our objective was to develop an MR imaging scoring system to evaluate the severity of white matter injury in neonates with deep medullary vein thrombosis and infarction. MATERIALS AND METHODS This was a retrospective study of infants born ≥32 weeks' gestation (2000-2016) diagnosed with deep medullary vein thrombosis and infarction on neuroimaging in the first 30 days of life. A 102-point deep medullary vein white matter injury global severity score was developed. MR images were scored by 2 pediatric radiologists. Subject clinical data and regional and global severity scores were recorded. RESULTS Fifty-one patients (mean gestational age, 37.3 ± 2.2 weeks; mean birth weight, 3182 ± 720 g) were included with a mean age at diagnosis via MR imaging of postnatal day 10.1 ± 6.1. Global severity scores ranged from 1 to 53, with a median score of 11 (interquartile range, 5-25). Lesions were more common in the frontal and parietal regions and less common in the occipital and temporal regions. Fifty-five percent of the group had neonatal seizures. No difference in perinatal risk factors (gestational age, birthweight, 5-minute Apgar score, chorioamnionitis, delivery room resuscitation, ventilator, or inotrope requirement) was observed among severity score quartiles. CONCLUSIONS An MR imaging scoring system provides a comprehensive and objective classification of WM injury after deep medullary vein thrombosis and infarction in late preterm and term neonates. The global severity score is independent of gestational age and other antenatal risk factors, consistent with presentation in previously healthy-appearing neonates.
Collapse
Affiliation(s)
- K L Benninger
- From the Departments of Pediatrics and Center for Perinatal Research (K.L.B., N.L.M.) .,Wexner Medical Center (K.L.B., N.L.M., L.R., J.A.R.), Ohio State University, Columbus, Ohio
| | - N L Maitre
- From the Departments of Pediatrics and Center for Perinatal Research (K.L.B., N.L.M.).,Wexner Medical Center (K.L.B., N.L.M., L.R., J.A.R.), Ohio State University, Columbus, Ohio
| | - L Ruess
- Radiology (L.R., J.A.R.), Nationwide Children's Hospital, Columbus, Ohio.,Wexner Medical Center (K.L.B., N.L.M., L.R., J.A.R.), Ohio State University, Columbus, Ohio
| | - J A Rusin
- Radiology (L.R., J.A.R.), Nationwide Children's Hospital, Columbus, Ohio.,Wexner Medical Center (K.L.B., N.L.M., L.R., J.A.R.), Ohio State University, Columbus, Ohio
| |
Collapse
|
18
|
Abstract
Cerebral sinovenous thrombosis (CSVT) is a focal or diffuse disruption of cerebral blood flow secondary to occlusion of cerebral veins and/or sinuses. The challenge of CSVT during the neonatal age has led to a great interest in this condition among neonatologists, child neurologists, and pediatric neuroradiologists. The highly variable clinical spectra, etiologies, and prognosis require fine medical skills and a high level of suspicion. Nevertheless, the diagnosis is often delayed or missed altogether. Differences in brain vulnerability at different stages of maturation may explain the spectrum of associated brain lesions, which varies with gestational age. Treatment is controversial and reported clinical outcomes vary widely. The controversial treatment of CSVT with anticoagulant therapy is based only on case series and expert consensus, there is lack of safety data.
Collapse
Affiliation(s)
- Luca A Ramenghi
- Neonatal Intensive Care Unit, Giannina Gaslini Children's Hospital, Genova, Italy.
| | - Valentina Cardiello
- Neonatal Intensive Care Unit, Giannina Gaslini Children's Hospital, Genova, Italy
| | - Andrea Rossi
- Neonatal Intensive Care Unit, Giannina Gaslini Children's Hospital, Genova, Italy
| |
Collapse
|
19
|
Tan AP, Svrckova P, Cowan F, Chong WK, Mankad K. Intracranial hemorrhage in neonates: A review of etiologies, patterns and predicted clinical outcomes. Eur J Paediatr Neurol 2018; 22:690-717. [PMID: 29731328 DOI: 10.1016/j.ejpn.2018.04.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 03/31/2018] [Accepted: 04/18/2018] [Indexed: 12/29/2022]
Abstract
Intracranial hemorrhage (ICH) in neonates often results in devastating neurodevelopmental outcomes as the neonatal period is a critical window for brain development. The neurodevelopmental outcomes in neonates with ICH are determined by the maturity of the brain, the location and extent of the hemorrhage, the specific underlying etiology and the presence of other concomitant disorders. Neonatal ICH may result from various inherited and acquired disorders. We classify the etiologies of neonatal ICH into eight main categories: (1) Hemorrhagic stroke including large focal hematoma, (2) Prematurity-related hemorrhage, (3) Bleeding diathesis, (4) Genetic causes, (5) Infection, (6) Trauma-related hemorrhage, (7) Tumor-related hemorrhage and (8) Vascular malformations. Illustrative cases showing various imaging patterns that can be helpful to predict clinical outcomes will be highlighted. Potential mimics of ICH in the neonatal period are also reviewed.
Collapse
Affiliation(s)
- Ai Peng Tan
- Department of Diagnostic Imaging, National University Health System, 1E Kent Ridge Rd 119228, Singapore.
| | - Patricia Svrckova
- Department of Radiology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond St, London WC1N 3JH, UK.
| | - Frances Cowan
- Dept. of Neonatology, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College, London, SW10 9NH, UK.
| | - Wui Khean Chong
- Department of Radiology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond St, London WC1N 3JH, UK.
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond St, London WC1N 3JH, UK.
| |
Collapse
|
20
|
Dmytriw AA, Song JSA, Yu E, Poon CS. Cerebral venous thrombosis: state of the art diagnosis and management. Neuroradiology 2018; 60:669-685. [PMID: 29752489 DOI: 10.1007/s00234-018-2032-2] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 05/03/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE This review article aims to discuss the pathophysiology, clinical presentation, and neuroimaging of cerebral venous thrombosis (CVT). Different approaches for diagnosis of CVT, including CT/CTV, MRI/MRV, and US will be discussed and the reader will become acquainted with imaging findings as well as limitations of each modality. Lastly, this exhibit will review the standard of care for CVT treatment and emerging endovascular options. METHODS A literature search using PubMed and the MEDLINE subengine was completed using the terms "cerebral venous thrombosis," "stroke," and "imaging." Studies reporting on the workup, imaging characteristics, clinical history, and management of patients with CVT were included. RESULTS The presentation of CVT is often non-specific and requires a high index of clinical suspicion. Signs of CVT on NECT can be divided into indirect signs (edema, parenchymal hemorrhage, subarachnoid hemorrhage, and rarely subdural hematomas) and less commonly direct signs (visualization of dense thrombus within a vein or within the cerebral venous sinuses). Confirmation is performed with CTV, directly demonstrating the thrombus as a filling defect, or MRI/MRV, which also provides superior characterization of parenchymal abnormalities. General pitfalls and anatomic variants will also be discussed. Lastly, endovascular management options including thrombolysis and mechanical thrombectomy are discussed. CONCLUSIONS CVT is a relatively uncommon phenomenon and frequently overlooked at initial presentation. Familiarity with imaging features and diagnostic work-up of CVT will help in providing timely diagnosis and therapy which can significantly improve outcome and diminish the risk of acute and long-term complications, optimizing patient care.
Collapse
Affiliation(s)
- Adam A Dmytriw
- Department of Medical Imaging, University of Toronto, 263 McCaul St, 4th Floor, Toronto, ON, M5T 1W7, Canada.
| | - Jin Soo A Song
- Department of Medical Imaging, University of Toronto, 263 McCaul St, 4th Floor, Toronto, ON, M5T 1W7, Canada
| | - Eugene Yu
- Department of Medical Imaging, University of Toronto, 263 McCaul St, 4th Floor, Toronto, ON, M5T 1W7, Canada
| | - Colin S Poon
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
21
|
Clinical and neuroimaging characteristics of cerebral sinovenous thrombosis in neonates undergoing cardiac surgery. J Thorac Cardiovasc Surg 2017; 155:1150-1158. [PMID: 29221746 DOI: 10.1016/j.jtcvs.2017.10.083] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 09/28/2017] [Accepted: 10/11/2017] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Neonates with congenital heart disease may have an increased risk of cerebral sinovenous thrombosis, but incidence rates are lacking. This study describes the clinical and neuroimaging characteristics of cerebral sinovenous thrombosis in neonates undergoing cardiac surgery. METHODS Forty neonates (78% male) requiring neonatal univentricular or biventricular cardiac repair using cardiopulmonary bypass were included. All underwent preoperative (median postnatal day 7) and postoperative (median postoperative day 7) magnetic resonance imaging of the brain, including venography, to detect cerebral sinovenous thrombosis. Clinical characteristics were compared between cerebral sinovenous thrombosis positive and cerebral sinovenous thrombosis negative neonates. RESULTS Postoperatively, cerebral sinovenous thrombosis was diagnosed in 11 neonates (28%), with the transverse sinus affected in all, and involvement of multiple sinuses in 10 (91%). Preoperatively, signs of thrombosis were seen in 3 cases (8%). Focal infarction of the basal ganglia was significantly more common in cerebral sinovenous thrombosis positive than cerebral sinovenous thrombosis negative neonates (P = .025). Cerebral sinovenous thrombosis positive neonates spent more time in the intensive care unit preoperatively (P = .001), had lower weight (P = .024) and lower postmenstrual age (P = .030) at surgery, and had prolonged use of a central venous catheter (P = .023) and a catheter placed in the internal jugular vein more often (P = .039). Surgical and postoperative factors were not different between new postoperative cerebral sinovenous thrombosis positive and cerebral sinovenous thrombosis negative neonates. CONCLUSIONS Cerebral sinovenous thrombosis might be more common than previously understood in neonates undergoing cardiac surgery. In our study, cerebral sinovenous thrombosis was associated with a higher risk of additional intra-parenchymal brain injury.
Collapse
|
22
|
Merlini L, Hanquinet S, Fluss J. Thalamic Hemorrhagic Stroke in the Term Newborn: A Specific Neonatal Syndrome With Non-uniform Outcome. J Child Neurol 2017; 32:746-753. [PMID: 28429607 DOI: 10.1177/0883073817703503] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Neonatal thalamic hemorrhagic stroke is related to cerebral sinus venous thrombosis and associated with neurological sequelae. Predicting factors are however lacking. METHODS Clinical and radiological findings at onset and on follow-up of 5 neonates with thalamic hemorrhage stroke are described. RESULTS All neonates presented with abrupt lethargy, ophistotonos, irritability and/or seizures. The thalamic hemorrhagic stroke was most often unilateral (4/5), involving the posterior/entire thalamus in 3 cases and the anterior thalamus in 2. Cerebral venous thrombosis was identified in a single patient. At follow-up, children with unilateral anterior thalamic hemorrhagic stroke demonstrated thalamic atrophy without neurological symptoms, whereas children whose thalamus lesion was extensive exhibit a porencephalic cavity and presented with late-onset epilepsy. DISCUSSION Although deep cerebral venous thrombosis is probably the cause of neonatal thalamic hemorrhagic stroke, its radiological evidence is challenging. Outcome seems dependent of the size and location of thalamic hemorrhagic stroke. Epilepsy is a frequent morbidity after thalamic hemorrhagic stroke.
Collapse
Affiliation(s)
- Laura Merlini
- 1 Pediatric Radiology, University Hospital of Geneva, Geneva, Switzerland
| | - Sylviane Hanquinet
- 1 Pediatric Radiology, University Hospital of Geneva, Geneva, Switzerland
| | - Joel Fluss
- 2 Pediatric Neurology, University Hospital of Geneva, Geneva, Switzerland
| |
Collapse
|
23
|
Benninger KL, Ruess L, Slaughter LA, Maitre NL, Rusin JA. Neonatal Vein of Labbé Infarction Size is Associated With Long-Term Language Outcomes. Pediatr Neurol 2017; 72:70-75.e1. [PMID: 28495146 PMCID: PMC5480620 DOI: 10.1016/j.pediatrneurol.2017.03.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/16/2017] [Accepted: 03/26/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The vein of Labbé is a superficial cortical vein, which drains the lateral surface of the temporal lobe. Thrombosis of the vein of Labbé can occur in the neonatal period. The developmental outcomes of infants who had vein of Labbé thrombosis are unknown as few studies of outcomes exist. METHODS We completed a retrospective review of infants born ≥34 weeks of gestation, diagnosed with vein of Labbé thrombosis, and/or infarction on neuroimaging during the first 30 days of life. Size of each temporal lobe infarction was estimated based on the number of temporal lobe segments involved. Primary outcomes were the presence of major neurodevelopmental impairments in childhood and Bayley scores at two years. RESULTS Our cohort of 19 infants had a median gestational age of 38 weeks (interquartile range 36 to 39) and mean birth weight 2892 ± 920 grams. The most common presenting symptoms of vein of Labbé thrombosis and infarction of surrounding tissue were seizures, apnea, lethargy, and either hypertonia or hypotonia. At the latest clinical follow-up appointment documented in the electronic medical record (mean 4.4 ± 3.08 years), 44% had major neurodevelopmental impairment. Patients with large vein of Labbé infarctions had significantly worse average Bayley scores than those with small to moderate lesions, and differences in language composite were statistically significant (72.7 vs 107.8, P = 0.017). CONCLUSIONS Neonates with large vein of Labbé infarctions are more likely to have poor language outcomes. This finding suggests a need for targeted surveillance to ensure early identification of deficits and referral for intervention.
Collapse
Affiliation(s)
- Kristen L. Benninger
- Center for Perinatal Research, The Research Institute at Nationwide
Children’s Hospital,The Ohio State University, Wexner Medical Center, Columbus, OH
| | - Lynne Ruess
- Department of Radiology, Nationwide Children’s
Hospital,The Ohio State University, Wexner Medical Center, Columbus, OH
| | - Laurel A. Slaughter
- Division of Neurology, Department of Pediatrics, Nationwide
Children’s Hospital,The Ohio State University, Wexner Medical Center, Columbus, OH
| | - Nathalie L. Maitre
- Center for Perinatal Research, The Research Institute at Nationwide
Children’s Hospital,The Ohio State University, Wexner Medical Center, Columbus, OH
| | - Jerome A. Rusin
- Department of Radiology, Nationwide Children’s
Hospital,The Ohio State University, Wexner Medical Center, Columbus, OH
| |
Collapse
|
24
|
Abstract
PURPOSE To provide consensus-based, suggested imaging protocols to facilitate the accurate and timely diagnosis of a neonate with symptoms concerning for stroke. METHODS The Writing Group, an international collaboration of pediatric neurologists and neuroradiologists with expertise in perinatal and childhood stroke, participated in a series of pediatric stroke neuroimaging symposia. These discussions, in conjunction with extensive literature review, led to a consensus for imaging protocols to guide practitioners in the diagnosis of neonatal stroke subtypes as defined by the National Institute of Neurological Disorders and Stroke Common Data Elements. The epidemiology, clinical presentation, and associated risk factors for arterial ischemic stroke, cerebral sinovenous thrombosis, and hemorrhagic stroke are reviewed, with a focused discussion regarding the role of neuroimaging for each subtype. RESULTS In a neonate with suspected stroke, magnetic resonance imaging is the preferred modality, given the lack of X-irradiation, superior anatomic resolution, and sensitivity for acute ischemia. Core recommended sequences include diffusion-weighted imaging and apparent diffusion coefficient mapping to diagnose acute ischemia, gradient-recalled echo or susceptibility-weighted imaging to detect intracranial blood and its breakdown products, and T1- and T2-weighted imaging to assess for myelination, extra-axial blood, and edema. Magnetic resonance angiography of the brain may be useful to detect vascular abnormalities, with venography if venous sinus thrombosis is suspected. The application of more novel sequences, as well as the utility of follow up-imaging, is also discussed.
Collapse
|
25
|
Rajagopal R, Cheah FC, Monagle P. Thromboembolism and anticoagulation management in the preterm infant. Semin Fetal Neonatal Med 2016; 21:50-6. [PMID: 26553525 DOI: 10.1016/j.siny.2015.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The incidence of preterm thromboembolism has been increasing due to advances in diagnostic imaging which allow better detection of thrombi in sick preterm infants. At the same time, improvement in neonatal intensive care unit supportive care has increased the number of surviving and living preterm infants with thromboembolic risk factors. Disruption in the fine balance of hemostasis with potential risk factors, specifically septicemia and indwelling catheters, increase the occurrence of thromboembolic events. Treatment strategies in preterm infants are challenging due to limited data.
Collapse
Affiliation(s)
- Revathi Rajagopal
- Pediatric Hemato-Oncology, Department of Pediatrics, University of Malaya, Kuala Lumpur, Malaysia
| | - Fook-Choe Cheah
- Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Paul Monagle
- Department of Clinical Hematology, Department of Pediatrics, Royal Children's Hospital, University of Melbourne, Parkville, Victoria, Australia.
| |
Collapse
|
26
|
Kim SH, Lee NM, Chae SA. A Rare Case of Cerebral Sinovenous Thrombosis Associated with MTHFRA1298C and C677T Mutations. NEONATAL MEDICINE 2016. [DOI: 10.5385/nm.2016.23.3.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Seh Hyun Kim
- Department of Pediatrics, Chung-Ang University College of Medicine, Seoul, Korea
| | - Na Mi Lee
- Department of Pediatrics, Chung-Ang University College of Medicine, Seoul, Korea
| | - Soo Ahn Chae
- Department of Pediatrics, Chung-Ang University College of Medicine, Seoul, Korea
| |
Collapse
|
27
|
Machado V, Pimentel S, Pinto F, Nona J. Perinatal ischemic stroke: a five-year retrospective study in a level-III maternity. EINSTEIN-SAO PAULO 2015; 13:65-71. [PMID: 25993071 PMCID: PMC4946814 DOI: 10.1590/s1679-45082015ao3056] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 01/07/2015] [Indexed: 12/04/2022] Open
Abstract
Objective To study the incidence, clinical presentation, risk factors, imaging diagnosis, and clinical outcome of perinatal stroke. Methods Data was retrospectively collected from full-term newborns admitted to the neonatal unit of a level III maternity in Lisbon with cerebral stroke, from January 2007 to December 2011. Results There were 11 cases of stroke: nine were arterial ischemic stroke and two were cerebral venous sinus thrombosis. We estimated an incidence of arterial ischemic stroke of 1.6/5,000 births and of cerebral venous sinus thrombosis of 7.2/100,000 births. There were two cases of recurrent stroke. Eight patients presented with symptoms while the remaining three were asymptomatic and incidentally diagnosed. The most frequently registered symptoms (8/11) were seizures; in that, generalized clonic (3/8) and focal clonic (5/8). Strokes were more commonly left-sided (9/11), and the most affected artery was the left middle cerebral artery (8/11). Transfontanelle ultrasound was positive in most of the patients (10/11), and stroke was confirmed by cerebral magnetic resonance in all patients. Electroencephalographic recordings were carried out in five patients and were abnormal in three (focal abnormalities n=2, burst-suppression pattern n=1). Eight patients had previously identified risk factors for neonatal stroke which included obstetric and neonatal causes. Ten patients were followed up at outpatients setting; four patients developed motor deficits and one presented with epilepsy. Conclusions Although a modest and heterogeneous sample, this study emphasizes the need for a high level of suspicion when it comes to neonatal stroke, primarily in the presence of risk factors. The prevalence of neurological sequelae in our series supports the need of long-term follow-up and early intervention strategies.
Collapse
Affiliation(s)
| | | | | | - José Nona
- Maternidade Dr. Alfredo da Costa, Lisboa, Portugal
| |
Collapse
|
28
|
Abstract
Neonates have the highest risk for pathologic thrombosis among pediatric patients. A combination of genetic and acquired risk factors significantly contributes to this risk, with the most important risk factor being the use of central venous catheters. Proper imaging is critical for confirming the diagnosis. Despite a significant number of these events being life- and limb-threatening, there is limited evidence on what the appropriate management strategy should be. Evaluation and treatment of any neonate with a clinically significant thrombosis should occur at a tertiary referral center that has proper support.
Collapse
Affiliation(s)
- Matthew A Saxonhouse
- Division of Neonatology, Levine Children's Hospital at Carolinas Medical Center, 1000 Blythe Boulevard, 7th Floor, Charlotte, NC 28203, USA.
| |
Collapse
|
29
|
Yurttutan S, Oncel MY, Yurttutan N, Degirmencioglu H, Uras N, Dilmen U. A novel association between cerebral sinovenous thrombosis and nonketotic hyperglycinemia in a neonate. KOREAN JOURNAL OF PEDIATRICS 2015. [PMID: 26213552 PMCID: PMC4510357 DOI: 10.3345/kjp.2015.58.6.230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Lethargy in newborns usually indicates central nervous system dysfunction, and many conditions such as cerebrovascular events, infections, and metabolic diseases should be considered in the differential diagnosis. Nonketotic hyperglycinemia is an autosomal recessive error of glycine metabolism, characterized by myoclonic jerks, hypotonia, hiccups, apnea, and progressive lethargy that may progress to encephalopathy or even death. Cerebral sinovenous thrombosis is a rare condition with various clinical presentations such as seizures, cerebral edema, lethargy, and encephalopathy. Here, we report the case of a newborn infant who presented with progressive lethargy. An initial diagnosis of cerebral venous sinus thrombosis was followed by confirmation of the presence of nonketotic hyperglycinemia.
Collapse
Affiliation(s)
- Sadık Yurttutan
- Neonatal Intensive Care Unit, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | - Mehmet Yekta Oncel
- Neonatal Intensive Care Unit, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | | | - Halil Degirmencioglu
- Neonatal Intensive Care Unit, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | - Nurdan Uras
- Neonatal Intensive Care Unit, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | - Ugur Dilmen
- Department of Pediatrics, Yıldırım Beyazıt University Hospital, Ankara, Turkey
| |
Collapse
|
30
|
Dang LT, Shavit JA, Singh RK, Joshi SM, Leber SM, Barks JDE, Shellhaas RA. Subdural hemorrhages associated with antithrombotic therapy in infants with cerebral atrophy. Pediatrics 2014; 134:e889-93. [PMID: 25113301 DOI: 10.1542/peds.2013-3029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Low-molecular-weight heparins, such as enoxaparin, are often used to treat thrombosis in infants. We present 4 infants with diffuse brain injury who developed cerebral venous sinus thrombosis or deep vein thrombosis and were treated with enoxaparin. These infants subsequently developed subdural hemorrhages, and enoxaparin was stopped. In 3 cases, the subdural hemorrhages were found on routine surveillance brain MRI, and in 1 case imaging was urgently obtained because of focal seizures. Two patients needed urgent neurosurgical intervention, and all subdural hemorrhages improved or resolved on follow-up imaging. Each infant developed severe neurologic deficits, probably from the coexisting diffuse brain injury rather than from the subdural hemorrhages themselves. The risk of intracranial hemorrhage from enoxaparin may be accentuated in patients with diffuse brain injury, and careful consideration should be given before treatment in this population.
Collapse
Affiliation(s)
| | | | | | | | | | - John D E Barks
- Neonatology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | | |
Collapse
|
31
|
Bektaş Ö, Teber S, Akar N, Uysal LZ, Arsan S, Atasay B, Deda G. Cerebral Sinovenous Thrombosis in Children and Neonates. Clin Appl Thromb Hemost 2014; 21:777-82. [DOI: 10.1177/1076029614523491] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Our aim is to present the etiology and risk factors for cerebral sinovenous thrombosis (CSVT) and the radiological findings, anticoagulant therapy used, and treatment outcome of patients with CSVT. This study included 12 patients who were treated for CSVT at the Ankara University, School of Medicine, Department of Pediatric Neurology. This study included 5 girls (41.7%) and 7 boys (58.3%) with a mean age of symptom onset of 5.2 ± 6.29 years (range: 0-18 years), who were followed at our institution for a mean of 1.8 ± 1.73 years (range: 0-6.5 years). Among the patients, 3 had no risk factors, 2 had 1 risk factor, and 7 had multiple risk factors. Anticoagulant therapy was administered to 4 patients, of which 1 had neurological sequelae; neurological sequelae or exitus occurred in 4 of the 8 patients who did not receive anticoagulant therapy. The present findings showed that appropriate prophylaxis in appropriately selected patients reduced the rate of recurrence of CSVT.
Collapse
Affiliation(s)
- Ömer Bektaş
- Department of Pediatric Neurology, Ankara University Medical School, Ankara, Turkey
| | - Serap Teber
- Department of Pediatric Neurology, Ankara University Medical School, Ankara, Turkey
| | - Nejat Akar
- Department of Pediatric Molecular Genetics, TOBB ETU Hospital, Ankara, Turkey
| | - Leyla Zümrüt Uysal
- Department of Pediatric Hematology, Ankara University Medical School, Ankara, Turkey
| | - Saadet Arsan
- Department of Neonatology, Ankara University Medical School, Ankara, Turkey
| | - Begüm Atasay
- Department of Neonatology, Ankara University Medical School, Ankara, Turkey
| | - Gülhis Deda
- Department of Pediatric Neurology, Ankara University Medical School, Ankara, Turkey
| |
Collapse
|
32
|
Oulmaati A, Babakhoya A, Chaouki S, Hida M, Bouharrou A. Apport de l’échographie transfontanellaire dans le diagnostic précoce des thromboses veineuses cérébrales néonatales : à propos de trois cas. Arch Pediatr 2014; 21:214-8. [DOI: 10.1016/j.arcped.2013.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 07/09/2013] [Accepted: 11/26/2013] [Indexed: 11/29/2022]
|
33
|
Raets MMA, Sol JJ, Govaert P, Lequin MH, Reiss IKM, Kroon AA, Appel IM, Dudink J. Serial Cranial US for Detection of Cerebral Sinovenous Thrombosis in Preterm Infants. Radiology 2013. [DOI: 10.1148/radiology.13130401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
34
|
Raets MMA, Sol JJ, Govaert P, Lequin MH, Reiss IKM, Kroon AA, Appel IM, Dudink J. Serial cranial US for detection of cerebral sinovenous thrombosis in preterm infants. Radiology 2013; 269:879-86. [PMID: 23985276 DOI: 10.1148/radiol.13130401] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To report the incidence of cerebral sinovenous thrombosis (CSVT) in a prospective cohort of preterm infants with a gestational age of less than 29 weeks. MATERIALS AND METHODS The local medical ethics review board approved this study, and written parental consent was obtained. Preterm infants with a gestational age of less than 29 weeks who were admitted to the neonatal intensive care unit were prospectively studied with cranial ultrasonography (US). The scanning protocol included visualization with color Doppler imaging of the superior sagittal sinus and transverse sinuses through the anterior (8.5-MHz probe) and mastoid (13-MHz probe) fontanelles. When feasible, magnetic resonance imaging was performed to confirm cranial US-diagnosed CSVT. The differences between preterm infants with and those without CSVT were analyzed by using Mann-Whitney tests for continuous variables and Fisher exact tests for categorical data. RESULTS Cranial US was used to document CSVT in 11 of 249 preterm infants with a gestational age of less than 29 weeks. Transverse sinuses were most frequently affected (in all 11 patients with CSVT). All infants with CSVT were asymptomatic. Postnatal age at diagnosis ranged from 5 to 34 days. The mean gestational age was significantly lower in infants with CSVT (25.9 weeks vs 26.8 weeks, P = .038). Of the risk factors studied, only duration of mechanical ventilation was associated with CSVT; it was significantly longer in the CSVT group. CONCLUSION Systematic serial cranial US of infants with a gestational age of less than 29 weeks showed a remarkably high incidence of CSVT of 4.4%. Cranial US including color Doppler imaging with scans obtained through the mastoid fontanelle can depict CSVT at an early stage. Treatment of this possibly important condition needs attention.
Collapse
Affiliation(s)
- Marlou M A Raets
- From the Departments of Neonatology (M.M.A.R., J.J.S., P.G., I.K.M.R., A.A.K., J.D.), Pediatric Radiology (M.H.L., J.D.), and Hematology (I.M.A.), Erasmus MC-Sophia Children's Hospital Rotterdam, Dr Molewaterplein 60, 3015 GJ Rotterdam, the Netherlands; and Department of Pediatrics, Koningin Paola Children's Hospital, Antwerp, Belgium (P.G.)
| | | | | | | | | | | | | | | |
Collapse
|
35
|
Cizmeci MN, Kanburoglu MK, Akelma AZ, Donmez A, Sonmez FM, Polat A, Kosehan D, Tatli MM. Cerebral sinovenous thrombosis associated with MTHFR A1298C mutation in the newborn: a case report. J Thromb Thrombolysis 2013; 35:279-81. [PMID: 22797907 DOI: 10.1007/s11239-012-0776-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although cerebral sinovenous thrombosis (CSVT) is a rare condition in the neonatal period, high rates of morbidity and mortality necessitate the establishment of an early diagnosis. Methylenetetrahydrofolate reductase (MTHFR) plays a central role in the folate cycle and mutations of MTHFR are associated with vascular disease. While the C677T common missense mutation is the most well-defined MTHFR polymorphism, another common missense mutation, A1298C also exists. There has been no reported case of CSVT associated with MTHFR A1298C mutation in the neonatal period. Herein, we report a neonate with CSVT who was found to have MTHFR A1298C homozygosity.
Collapse
Affiliation(s)
- Mehmet Nevzat Cizmeci
- Division of Neonatology, Department of Pediatrics, Fatih University Medical School, Alparslan Turkes Caddesi No:57, Emek, Ankara, Turkey.
| | | | | | | | | | | | | | | |
Collapse
|
36
|
Sannia A, Natalizia AR, Parodi A, Malova M, Fumagalli M, Rossi A, Ramenghi LA. Different gestational ages and changing vulnerability of the premature brain. J Matern Fetal Neonatal Med 2013; 28 Suppl 1:2268-72. [PMID: 23968292 DOI: 10.3109/14767058.2013.796166] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In recent decades, there has been a general increase in survival rates of preterm and low birth weight infants, but this overall decrease in perinatal mortality has not been accompanied by a decrease in long-term physical and mental disability. In order to reduce the long-term sequelae of prematurity and to establish preventive measures, it is important to identify risk factors since the main determinant of specific vulnerability to different types of lesions is gestational age. The regional tissue vulnerability at a given gestational age is probably determined by the local metabolic requirements together with specific cell characteristics and their level of maturation. In this article, we discuss the most common neonatal cerebral lesions (cerebellar haemorrhage, germinal matrix intraventricular haemorrhage, periventricular leukomalacia, arterial ischaemic stroke, cerebral vein sinus thrombosis and hypoxic-ischaemic encephalopathy) related to the gestational age-dependent vulnerability of the premature brain.
Collapse
Affiliation(s)
- Andrea Sannia
- a Neonatal Intensive Care Unit , Istituto Giannina Gaslini , Genova , Italy
| | - Anna R Natalizia
- a Neonatal Intensive Care Unit , Istituto Giannina Gaslini , Genova , Italy
| | - Alessandro Parodi
- a Neonatal Intensive Care Unit , Istituto Giannina Gaslini , Genova , Italy
| | - Mariya Malova
- a Neonatal Intensive Care Unit , Istituto Giannina Gaslini , Genova , Italy
| | - Monica Fumagalli
- b NICU, Department of Clinical Sciences and Community Health , Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano , Milan , Italy , and
| | - Andrea Rossi
- c Pediatric Neuroradiology Unit , Istituto Giannina Gaslini , Genova , Italy
| | - Luca A Ramenghi
- a Neonatal Intensive Care Unit , Istituto Giannina Gaslini , Genova , Italy
| |
Collapse
|
37
|
Chander A, Nagel K, Wiernikowski J, Paes B, Chan AK. Evaluation of the use of low-molecular-weight heparin in neonates: a retrospective, single-center study. Clin Appl Thromb Hemost 2013; 19:488-93. [PMID: 23478571 DOI: 10.1177/1076029613480557] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Controversies exist over the currently recommended guidelines for the use of low-molecular-weight heparin (LMWH) in neonates. We retrospectively studied 30 neonates treated with LMWH and found a poor therapeutic response to recommended doses as measured by anti-Xa levels. Sixty percent of the study participants required their doses to be increased because of subtherapeutic anti-Xa levels during the initial course of their treatment. The mean starting enoxaparin dose was 1.53 ± 0.38 mg/kg. The mean enoxaparin dose, once therapeutic anti-Xa levels had been achieved, was 1.86 ± 0.50 mg/kg. Preterm and term infants required doses of 2.06 ± 0.61 mg/kg and 1.67 ± 0.26 mg/kg, respectively, to achieve therapeutic anti-Xa levels. In summary, our results suggest that higher initial doses are required to achieve therapeutic anticoagulation in neonates.
Collapse
Affiliation(s)
- Ankush Chander
- 1Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | | |
Collapse
|
38
|
Monagle P, Chan AKC, Goldenberg NA, Ichord RN, Journeycake JM, Nowak-Göttl U, Vesely SK. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e737S-e801S. [PMID: 22315277 DOI: 10.1378/chest.11-2308] [Citation(s) in RCA: 950] [Impact Index Per Article: 79.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Neonates and children differ from adults in physiology, pharmacologic responses to drugs, epidemiology, and long-term consequences of thrombosis. This guideline addresses optimal strategies for the management of thrombosis in neonates and children. METHODS The methods of this guideline follow those described in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. RESULTS We suggest that where possible, pediatric hematologists with experience in thromboembolism manage pediatric patients with thromboembolism (Grade 2C). When this is not possible, we suggest a combination of a neonatologist/pediatrician and adult hematologist supported by consultation with an experienced pediatric hematologist (Grade 2C). We suggest that therapeutic unfractionated heparin in children is titrated to achieve a target anti-Xa range of 0.35 to 0.7 units/mL or an activated partial thromboplastin time range that correlates to this anti-Xa range or to a protamine titration range of 0.2 to 0.4 units/mL (Grade 2C). For neonates and children receiving either daily or bid therapeutic low-molecular-weight heparin, we suggest that the drug be monitored to a target range of 0.5 to 1.0 units/mL in a sample taken 4 to 6 h after subcutaneous injection or, alternatively, 0.5 to 0.8 units/mL in a sample taken 2 to 6 h after subcutaneous injection (Grade 2C). CONCLUSIONS The evidence supporting most recommendations for antithrombotic therapy in neonates and children remains weak. Studies addressing appropriate drug target ranges and monitoring requirements are urgently required in addition to site- and clinical situation-specific thrombosis management strategies.
Collapse
Affiliation(s)
- Paul Monagle
- Haematology Department, The Royal Children's Hospital, Department of Paediatrics, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Anthony K C Chan
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Neil A Goldenberg
- Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplantation and Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, Aurora, CO
| | - Rebecca N Ichord
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Janna M Journeycake
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
| | - Ulrike Nowak-Göttl
- Thrombosis and Hemostasis Unit, Institute of Clinical Chemistry, University Hospital Kiel, Kiel, Germany
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK.
| |
Collapse
|
39
|
Abstract
Neonates have one of the highest risks for thromboembolism among pediatric patients. This risk is attributable to a combination of multiple genetic and acquired risk factors. Despite a significant number of these events being either life threatening or limb threatening, there is limited evidence on appropriate management strategy. Most of what is recommended is based on uncontrolled studies, case series, or expert opinion. This review begins with a discussion of the neonatal hemostatic system, focusing on the common sites and imaging modalities for the detection of neonatal thrombosis. Perinatal and postnatal risk factors are presented and management options discussed.
Collapse
Affiliation(s)
- Matthew A Saxonhouse
- Pediatrix Medical Group, Jeff Gordon Children's Hospital, 920 Church Street North, CMC-NE, Concord, NC 28025, USA.
| |
Collapse
|
40
|
Squier W. The "Shaken Baby" syndrome: pathology and mechanisms. Acta Neuropathol 2011; 122:519-42. [PMID: 21947257 DOI: 10.1007/s00401-011-0875-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 09/09/2011] [Accepted: 09/11/2011] [Indexed: 01/01/2023]
Abstract
The "Shaken Baby" syndrome (SBS) is the subject of intense controversy; the diagnosis has in the past depended on the triad of subdural haemorrhage (SDH), retinal haemorrhage and encephalopathy. While there is no doubt that infants do suffer abusive injury at the hands of their carers and that impact can cause catastrophic intracranial damage, research has repeatedly undermined the hypothesis that shaking per se can cause this triad. The term non-accidental head injury has therefore been widely adopted. This review will focus on the pathology and mechanisms of the three physiologically associated findings which constitute the "triad" and are seen in infants suffering from a wide range of non-traumatic as well as traumatic conditions. "Sub" dural bleeding in fact originates within the deep layers of the dura. The potential sources of SDH include: the bridging veins, small vessels within the dura itself, a granulating haemorrhagic membrane and ruptured intracranial aneurysm. Most neuropathologists do not routinely examine eyes, but the significance of this second arm of the triad in the diagnosis of Shaken Baby syndrome is such that it merits consideration in the context of this review. While retinal haemorrhage can be seen clinically, dural and subarachnoid optic nerve sheath haemorrhage is usually seen exclusively by the pathologist and only rarely described by the neuroradiologist. The term encephalopathy is used loosely in the context of SBS. It may encompass anything from vomiting, irritability, feeding difficulties or floppiness to seizures, apnoea and fulminant brain swelling. The spectrum of brain pathology associated with retinal and subdural bleeding from a variety of causes is described. The most important cerebral pathology is swelling and hypoxic-ischaemic injury. Mechanical shearing injury is rare and contusions, the hallmark of adult traumatic brain damage, are vanishingly rare in infants under 1 year of age. Clefts and haemorrhages in the immediate subcortical white matter have been assumed to be due to trauma but factors specific to this age group offer other explanations. Finally, examples of the most common causes of the triad encountered in clinical diagnostic and forensic practice are briefly annotated.
Collapse
Affiliation(s)
- Waney Squier
- Department of Neuropathology, West Wing, John Radcliffe Hospital, Oxford, UK.
| |
Collapse
|
41
|
Cerebral Venous Thrombosis: A Potential Mimic of Primary Traumatic Brain Injury in Infants. AJR Am J Roentgenol 2011; 197:W503-7. [DOI: 10.2214/ajr.10.5977] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
42
|
Bowers KJ, deVeber GA, Ferriero DM, Roach ES, Vexler ZS, Maria BL. Cerebrovascular disease in children: recent advances in diagnosis and management. J Child Neurol 2011; 26:1074-100. [PMID: 21778188 PMCID: PMC5289387 DOI: 10.1177/0883073811413585] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cerebrovascular disease in children manifests in many forms, all of which have devastating and long-lasting effects. Recent advances in diagnostic imaging have revealed that this condition is much more common in the pediatric population than previously believed, affecting as many as 1 in 1500 neonates and 1 in 3000 children. The underlying mechanisms that cause stroke—ischemic stroke, sinovenous thrombosis, and hemorrhagic stroke—are only beginning to be understood; however, progress has been made toward better understanding the mechanisms of disease, particularly in the fields of genetics, inflammation, and thrombus formation. Furthermore, new imaging techniques, and better understanding of how to use imaging in managing stroke, have enabled practitioners to more quickly and accurately identify cerebrovascular disease type in children, which is key to mitigation of negative outcomes. The 2010 Neurobiology of Disease in Children symposium, held in conjunction with the 39th annual meeting of the Child Neurology Society, aimed to (1) describe clinical issues surrounding childhood stroke, including diagnosis and acute care; (2) discuss recent advances in the understanding of the pathogenesis of childhood stroke; (3) review current management of and therapies for childhood stroke, including controversial therapies; and (4) establish research directions for investigators. This article summarizes the speakers’ presentations and includes an edited transcript of question-and-answer sessions.
Collapse
Affiliation(s)
- Karen J. Bowers
- Department of Pediatrics, Medical College of Georgia, Augusta, Georgia
| | | | - Donna M. Ferriero
- Department of Pediatrics, Medical College of Georgia, Augusta, Georgia
| | - E. Steve Roach
- Department of Pediatrics, Medical College of Georgia, Augusta, Georgia
| | - Zinaida S. Vexler
- Department of Pediatrics, Medical College of Georgia, Augusta, Georgia
| | - Bernard L. Maria
- Department of Pediatrics, Medical College of Georgia, Augusta, Georgia
| |
Collapse
|
43
|
Moharir MD, Shroff M, Pontigon AM, Askalan R, Yau I, MacGregor D, deVeber GA. A prospective outcome study of neonatal cerebral sinovenous thrombosis. J Child Neurol 2011; 26:1137-44. [PMID: 21628696 PMCID: PMC3695693 DOI: 10.1177/0883073811408094] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Neonatal cerebral sinovenous thrombosis is a frequent contributor to neonatal mortality and morbidity. Treatment is controversial, and reported clinical outcomes vary widely. Newborns with radiologically confirmed neonatal cerebral sinovenous thrombosis from 1992 to 2009 were prospectively followed in our Children's Stroke Clinic for standardized outcomes, including the Pediatric Stroke Outcome Measure. Outcomes were available in 90 of 104 (87%) neonates. Early outcomes included cerebral sinovenous thrombosis-associated death (5) and thrombus propagation (15 [6 associated with new venous infarcts]). Lack of anticoagulation predicted propagation (RR = 13; P = .0007). Complete thrombus recanalization occurred in 90% by 3 months. Late outcomes (median, 2.5 years) were epilepsy (15) and neurological disability (50), which included moderate-severe language (43), sensorimotor (38), and cognitive/behavioral (24) deficits. Overall, 61% had poor outcome (death/any deficit). Concurrent neurological comorbidity at diagnosis (odds ratio = 2.8; P = .029) predicted poor outcome. Clinical trials are urgently needed to establish more effective treatment strategies.
Collapse
Affiliation(s)
| | - Manohar Shroff
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ann-Marie Pontigon
- Department of Population Health Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rand Askalan
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ivanna Yau
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Daune MacGregor
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gabrielle A. deVeber
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Population Health Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| |
Collapse
|
44
|
Kersbergen KJ, Groenendaal F, Benders MJNL, de Vries LS. Neonatal cerebral sinovenous thrombosis: neuroimaging and long-term follow-up. J Child Neurol 2011; 26:1111-20. [PMID: 21693652 PMCID: PMC3674555 DOI: 10.1177/0883073811408090] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Neonates are known to have a higher risk of cerebral sinovenous thrombosis than children of other age groups. The exact incidence in neonates remains unknown and is likely to be underestimated, as clinical presentation is nonspecific and diagnosis can only be made when dedicated neuroimaging techniques, including computed tomographic venography or magnetic resonance venography, are performed. Associated intracranial lesions are common and some, such as a unilateral thalamic hemorrhage, should suggest cerebral sinovenous thrombosis as the underlying etiology. Neurodevelopmental outcome is poor in approximately 50% of these infants and is adversely affected by associated parenchymal lesions. Anticoagulation therapy will limit propagation of the clot and possibly the development or enhancement of parenchymal lesions. Multicenter randomized clinical trials are urgently needed to address many of these important issues.
Collapse
Affiliation(s)
- Karina J Kersbergen
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, the Netherlands
| | | | | | | |
Collapse
|