1
|
Patel ND, Wainwright MS, Moore A, Suz P, Muangman S, Vavilala MS. Establishing normal Lindegaard Ratio in healthy children 10-16 years of age. Childs Nerv Syst 2024:10.1007/s00381-024-06467-9. [PMID: 38907117 DOI: 10.1007/s00381-024-06467-9] [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: 02/09/2024] [Accepted: 05/14/2024] [Indexed: 06/23/2024]
Abstract
PURPOSE Transcranial doppler based diagnostic criteria for cerebral vasospasm are not well established in the pediatric population because there is no published normative data to support the diagnosis. Studies have relied on expert consensus, but the definitions have not been validated in children diagnosed with angiographic evidence of vasospasm. Obtaining normative data is a prerequisite to defining pediatric cerebral vasospasm and the Lindegaard Ratio (LR). In this study, we obtained normative data and calculation of the normal LR from healthy children aged 10-16 years. METHODS TCD and carotid ultrasonography was used to measure steady state velocities of both the middle cerebral artery (VMCA) and the extracranial internal cerebral artery (VEICA) in healthy children aged 10-16 years. Demographic information, hemodynamic characteristics and the calculated LR (VMCA/VEICA) was determined for each subject using descriptive statistics. RESULTS Of the 26 healthy children, 13 were male and 13 were female. VMCA ranged between 53 and 93 cm/sec. LR ranged between 1 and 2.2 for the cohort. VMCA for both males and females were within 2 standard deviations (SD) of the normal mean flow velocity. As the VMCA velocities approached 2 SD above the mean, LR did not exceed 2.2. CONCLUSION Our results help define a threshold for LR which can be used to establish radiographic criteria for cerebral vasospasm in children. Our data suggests that using VMCA criteria alone would overestimate cerebral vasospasm and raises question of whether an LR threshold other than 3 is more appropriate for the cut off between hyperemia versus vasospasm in children.
Collapse
Affiliation(s)
- Namrata D Patel
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA.
| | | | - Anne Moore
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Pilar Suz
- Department of Anesthesiology, H. Lee Moffit Cancer Center, Tampa, FL, USA
| | - Saipin Muangman
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Monica S Vavilala
- Department of Pediatrics, University of Washington, Seattle, WA, USA
- Department of Anesthesiology, University of Washington, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| |
Collapse
|
2
|
A clinically relevant model of focal embolic cerebral ischemia by thrombus and thrombolysis in rhesus monkeys. Nat Protoc 2022; 17:2054-2084. [PMID: 35760857 DOI: 10.1038/s41596-022-00707-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 03/29/2022] [Indexed: 11/08/2022]
Abstract
Over decades of research into the treatment of stroke, nearly all attempts to translate experimental treatments from discovery in cells and rodents to use in humans have failed. The prevailing belief is that it might be necessary to pretest pharmacological neuroprotection in higher-order brains, especially those of nonhuman primates (NHPs). Over the past few years, chemical thrombolysis and mechanical thrombectomy have been established as the standard of care for ischemic stroke in patients. The spotlight is now shifting towards emphasizing both focal ischemia and subsequent reperfusion in developing a clinically relevant stroke model in NHPs. This protocol describes an embolic model of middle cerebral artery occlusion in adult rhesus monkeys. An autologous clot is combined with a microcatheter or microwire through endovascular procedures, and reperfusion is achieved through local intra-artery thrombolysis with tissue plasminogen activator. These NHP models formed relatively stable infarct sizes, delivered predictable reperfusion and survival outcomes, and recapitulated key characteristics of patients with ischemic stroke as observed on MRI images and behavioral assays. Importantly, treated animals could survive 30 d after the surgery for post-stroke neurologic deficit analyses. Thus far, this model has been used in several translational studies. Here we describe in detail the teamwork necessary for developing stroke models of NHPs, including the preoperation preparations, endovascular surgery, postoperation management and histopathological analysis. The model can be established by the following procedures over a 45-d period, including preparation steps (14 d), endovascular operation (1 d) and evaluation steps (30 d).
Collapse
|
3
|
Cancer associated thrombosis in pediatric patients. Best Pract Res Clin Haematol 2022; 35:101352. [DOI: 10.1016/j.beha.2022.101352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/13/2022] [Indexed: 11/22/2022]
|
4
|
Wu D, Chen J, Zhang X, Ilagan R, Ding Y, Ji X. Selective therapeutic cooling: To maximize benefits and minimize side effects related to hypothermia. J Cereb Blood Flow Metab 2022; 42:213-215. [PMID: 34670442 PMCID: PMC8721772 DOI: 10.1177/0271678x211055959] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Selective therapeutic cooling is a promising technique for reducing final infarct volume and improving outcomes in ischemic stroke, especially as research regarding brain reperfusion continues to be explored. A recent study provided promising results on the safety and feasibility of selective therapeutic hypothermia via a closed-loop cooling catheter system for intra-carotid blood cooling in an ovine stroke model, but they failed to find efficacy of this method in this model. It is a major step forward from bench to bed side, but enhancing benefits of selective therapeutic cooling may need to take into account a more targeted induction of brain hypothermia and should mitigate potential side effects related to inducing hypothermia.
Collapse
Affiliation(s)
- Di Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Jian Chen
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Xuxiang Zhang
- Department of Ophthalmology, Capital Medical University, Beijing, China
| | - Roxanne Ilagan
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Yuchuan Ding
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China.,Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Xunming Ji
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| |
Collapse
|
5
|
Definitive Diagnostic Evaluation of the Child With Arterial Ischemic Stroke and Approaches to Secondary Stroke Prevention. Top Magn Reson Imaging 2021; 30:225-230. [PMID: 34613945 DOI: 10.1097/rmr.0000000000000272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT In children with arterial ischemic stroke (AIS), the definitive diagnosis of stroke subtype and confirmation of stroke etiology is necessary to mitigate stroke morbidity and prevent recurrent stroke. The common causes of AIS in children are sharply differentiated from the common causes of adult AIS. A comprehensive, structured diagnostic approach will identify the etiology of stroke in most children. Adequate diagnostic evaluation relies on advanced brain imaging and vascular imaging studies. A variety of medical and surgical secondary stroke prevention strategies directed at the underlying cause of stroke are available. This review aims to outline strategies for definitive diagnosis and secondary stroke prevention in children with AIS, emphasizing the critical role of neuroimaging.
Collapse
|
6
|
Sun LR, Ziai W, Brown P, Torriente AG, Cooper S, Gottesman RF, Felling RJ. Intrathecal chemotherapy-associated cerebral vasospasm in children with hematologic malignancies. Pediatr Res 2021; 89:858-862. [PMID: 32544924 DOI: 10.1038/s41390-020-1008-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/13/2020] [Accepted: 05/27/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Mechanisms of chemotherapy-associated neurotoxicity are poorly understood, and therefore, prevention strategies have not been developed. We hypothesized that a subgroup of children receiving intrathecal cytarabine develops subclinical vasospasm, which may contribute to long-term neurocognitive sequelae of cancer. METHODS We used transcranial Doppler ultrasound to serially evaluate cerebral blood flow velocities in participants ≤25 years old receiving intrathecal cytarabine for hematologic malignancies. RESULTS Four of 18 participants (22%) met the criteria for subclinical vasospasm within 4 days of intrathecal cytarabine administration. The distribution of oncologic diagnoses differed between the vasospasm and non-vasospasm groups (p = 0.02). Acute myeloid leukemia was identified as a potential risk factor for vasospasm. Children with vasospasm were more likely to have received intravenous cytarabine (75% versus 0%, p = 0.01) and less likely to have received steroids (25% versus 100%, p = 0.01). CONCLUSIONS A subpopulation of children with hematologic malignancies develops subclinical vasospasm after intrathecal cytarabine treatment. Future research is needed to determine the long-term clinical consequences of cerebral vasospasm in this population. IMPACT A subset of children with hematologic malignancies who receive intrathecal cytarabine experience subclinical cerebral vasospasm, as measured by transcranial Doppler ultrasound. Of children receiving intrathecal cytarabine, those who develop cerebral vasospasm are more likely to have diagnosis of acute myeloid leukemia, more likely to receive concurrent intravenous cytarabine, and less likely to receive steroids as part of their chemotherapy regimen, as compared with children without vasospasm. Future research is needed to determine if vasospasm during chemotherapy is associated with higher rates of neurocognitive dysfunction, and if so, to focus on prevention of these long-term sequelae of childhood cancer.
Collapse
Affiliation(s)
- Lisa R Sun
- Division of Pediatric Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Cerebrovascular Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Wendy Ziai
- Division of Neurocritical Care, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Patrick Brown
- Division of Pediatric Oncology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Stacy Cooper
- Division of Pediatric Oncology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Rebecca F Gottesman
- Division of Cerebrovascular Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ryan J Felling
- Division of Pediatric Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Division of Cerebrovascular Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| |
Collapse
|
7
|
Sun LR. Early career investigator highlight biocommentary. Pediatr Res 2021; 89:718. [PMID: 33446920 DOI: 10.1038/s41390-020-01322-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 11/24/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Lisa R Sun
- Division of Pediatric Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Cerebrovascular Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
8
|
Mendes NT, Ramos de Freitas L, Lopes RP, Silva LSAD, Meneses de Oliveira FT. Reversible cerebral vasoconstriction syndrome after intrathecal cytarabine. Hematol Transfus Cell Ther 2020; 44:422-425. [PMID: 33358684 PMCID: PMC9477767 DOI: 10.1016/j.htct.2020.10.961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/19/2020] [Accepted: 10/01/2020] [Indexed: 11/19/2022] Open
Affiliation(s)
| | | | - Rônney Pinto Lopes
- Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | | | | |
Collapse
|
9
|
Abstract
Both the onset of various malignancies as well as the treatment of cancer can lead to neurologic symptoms which can be difficult to diagnose. In this review, we highlight the varied ways in which neurologic sequelae of cancer and its treatment manifest in children. Initial neurologic presentation may be secondary to mass effect or to immune-mediated paraneoplastic syndromes. Treatment effects on the nervous system may arise from surgery, chemotherapy, radiation, or bone marrow transplantation. In addition, the rapidly expanding field of immunotherapies for cancer has generated numerous new approaches to eradicating cancer including monoclonal antibodies, checkpoint inhibitors, and chimeric antigen receptor T cells (CAR-T cells), which have neurologic side effects mediated by immune responses that are also being recognized. Here we review common consult questions to the neurologist and our general approach to these scenarios including altered mental status, headaches, seizures, and sensorimotor complaints, considering the multifactorial nature of each.
Collapse
Affiliation(s)
- Caren Armstrong
- Department of Neurology, Johns Hopkins Hospital, 200 N Wolfe St Suite 2158, Baltimore, MD, 21287, USA
| | - Lisa R Sun
- Department of Neurology, Johns Hopkins Hospital, 200 N Wolfe St Suite 2158, Baltimore, MD, 21287, USA.
| |
Collapse
|
10
|
Sun LR, Linds A, Sharma M, Rafay M, Vadivelu S, Lee S, Brandão LR, Appavu B, Estepp JH, Hukin J, Hassanein SMA, Chan A, Beslow LA. Cancer and Tumor-Associated Childhood Stroke: Results From the International Pediatric Stroke Study. Pediatr Neurol 2020; 111:59-65. [PMID: 32951663 DOI: 10.1016/j.pediatrneurol.2020.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND The prevalence of cancer among children with stroke is unknown. This study sought to evaluate cancer- and tumor-associated childhood ischemic stroke in a multinational pediatric stroke registry. METHODS Children aged 29 days to less than 19 years with arterial ischemic stroke or cerebral sinovenous thrombosis enrolled in the International Pediatric Stroke Study between January 2003 and June 2019 were included. Data including stroke treatment and recurrence were compared between subjects with and without cancer using Wilcoxon rank sum and chi-square tests. RESULTS Cancer or tumor was present in 99 of 2968 children (3.3%) with arterial ischemic stroke and 64 of 596 children (10.7%) with cerebral sinovenous thrombosis. Among children in whom cancer type was identified, 42 of 88 arterial ischemic stroke cases (48%) had brain tumors and 35 (40%) had hematologic malignancies; 45 of 58 cerebral sinovenous thrombosis cases (78%) had hematologic malignancies and eight (14%) had brain tumors. Of 54 cancer-associated arterial ischemic stroke cases with a known cause, 34 (63%) were due to arteriopathy and nine (17%) were due to cardioembolism. Of 46 cancer-associated cerebral sinovenous thrombosis cases with a known cause, 41 (89%) were related to chemotherapy-induced or other prothrombotic states. Children with cancer were less likely than children without cancer to receive antithrombotic therapy for arterial ischemic stroke (58% vs 80%, P = 0.007) and anticoagulation for cerebral sinovenous thrombosis (71% vs 87%, P = 0.046). Recurrent arterial ischemic stroke (5% vs 2%, P = 0.04) and cerebral sinovenous thrombosis (5% vs 1%, P = 0.006) were more common among children with cancer. CONCLUSIONS Cancer is an important risk factor for incident and recurrent childhood stroke. Stroke prevention strategies for children with cancer are needed.
Collapse
Affiliation(s)
- Lisa R Sun
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland; Division of Cerebrovascular Neurology, Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland.
| | - Alexandra Linds
- Division of Neurology, Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mukta Sharma
- Division of Hematology Oncology, Children's Mercy, University of Missouri Kansas City, Kansas City, Missouri
| | - Mubeen Rafay
- Section of Pediatric Neurology, Department of Pediatrics and Child Health, Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sudhakar Vadivelu
- Division of Neurosurgery, Department of Neurosurgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Neurosurgery, Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Leonardo R Brandão
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Brian Appavu
- Department of Child Health and Neurology, University of Arizona College of Medicine - Phoenix Barrow Neurologic Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Jeremie H Estepp
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee; Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Juliette Hukin
- Division of Neurology, Department of Pediatrics, Children's and Women's Health Centre, Vancouver, British Columbia, Canada; Division of Oncology, Department of Pediatrics, Children's and Women's Health Centre, Vancouver, British Columbia, Canada
| | - Sahar M A Hassanein
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Anthony Chan
- Department of Paediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Lauren A Beslow
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | |
Collapse
|
11
|
Barg AA, Kenet G. Cancer-associated thrombosis in pediatric patients. Thromb Res 2020; 191 Suppl 1:S22-S25. [PMID: 32736773 DOI: 10.1016/s0049-3848(20)30392-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/30/2019] [Accepted: 01/07/2020] [Indexed: 12/21/2022]
Abstract
Childhood malignancy and especially acute lymphoblastic leukemia are increasingly associated with thromboembolism. The etiology of pediatric cancer associated thrombosis is multifactorial and may reflect a tumor mass effect, tumor thrombi, alterations of the hemostatic system, treatment-related hazards (e.g. procoagulant changes induced by chemotherapy), presence of central venous lines and comorbidities (e.g. inherited thrombophilia). With over 80% cure rates of childhood cancer, strategies for prevention as well as for early diagnosis and optimal treatment of thromboembolism in children with malignancies are of major importance. While the use of therapeutic low molecular weight heparin prevails, prospective studies regarding guidelines for treatment or prevention are currently lacking. This review will address the epidemiology, etiology and risk factors for thrombosis, describe the presently available evidence associated with current therapy, and offer a glimpse into future treatment options.
Collapse
Affiliation(s)
- Assaf Arie Barg
- The Israeli National Hemophilia Center and Thrombosis Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Israel
| | - Gili Kenet
- The Israeli National Hemophilia Center and Thrombosis Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Israel.
| |
Collapse
|
12
|
Lin TA, Gau JP, Liu YC, Ko PS, Wang HY, Chien SH, Liu CJ, Hsiao LT, Chiou TJ, Liu JH. Cerebrovascular disease after allogeneic hematopoietic stem cell transplantation: incidence, risk, and clinical outcome. Int J Hematol 2019; 109:584-592. [PMID: 30864116 DOI: 10.1007/s12185-019-02624-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 11/30/2022]
Abstract
Cerebrovascular complications after hematopoietic stem cell transplantation (HSCT) cause serious morbidity and often contribute to mortality. The incidence, risk factors, and outcome of cerebrovascular disease (CVD) after allogeneic HSCT remain poorly defined. We retrospectively evaluated 459 adult patients who underwent allogeneic HSCT at a tertiary medical center between January 2003 and December 2015. A total of 20 patients (4.4%) developed post-transplant CVD. All cerebrovascular accidents occurred in the first two years post-transplant. The two-year incidences of post-transplant CVD, intracranial hemorrhage, and cerebrovascular infarction were 6.1%, 3.2%, and 3.2%, respectively. The incidence rate of CVD within two years after HSCT was 34.7 (95% CI 22.3 to - 53.7) per 1000 person-years, which was about tenfold higher than the general Taiwanese population. The only significant risk factor associated with post-transplant CVD is prior exposure to three or more courses of high-dose cytarabine. Post-transplant CVD is associated with dismal outcome and early mortality. The median overall survival of patients with post-transplant CVD was markedly reduced compared with those without CVD (8.0 vs. 60.6 months). Most patients with post-transplant CVD died within two months after the CVD events. Our study demonstrates that CVD remains a devastating complication after allogeneic HSCT in the modern era.
Collapse
Affiliation(s)
- Ting-An Lin
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan
| | - Jyh-Pyng Gau
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yao-Chung Liu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan. .,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Po-Shen Ko
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hao-Yuan Wang
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Sheng-Hsuan Chien
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Transfusion Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chia-Jen Liu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Liang-Tsai Hsiao
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Tzeon-Jye Chiou
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Transfusion Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jin-Hwang Liu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Hematology and Oncology, Department of Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| |
Collapse
|
13
|
Shao B, Banu MA, Carroll JJ, Meyers PM, Lavine SD, Feldstein NA, Anderson RCE. Cerebral Vasospasm after Open Fenestration of an Arachnoid Cyst in a 4-Year-Old Boy: Case Report and Review of the Literature. Pediatr Neurosurg 2019; 54:132-138. [PMID: 30650412 DOI: 10.1159/000495834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 11/23/2018] [Indexed: 11/19/2022]
Abstract
Cerebral vasospasm is associated with significant morbidity, and most commonly occurs following subarachnoid hemorrhage. Rarely, vasospasm can follow tumor resection and traumatic brain injury. We present the first reported case of a young child who developed diffuse vasospasm following open fenestration of an arachnoid cyst and was promptly treated, with full recovery of neurologic function. Although vasopasm after arachnoid cyst fenestration is rare, it can be included in the differential for a new focal neurologic deficit.
Collapse
Affiliation(s)
- Belinda Shao
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Matei A Banu
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA
| | - Jason J Carroll
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA
| | - Philip M Meyers
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA
| | - Sean D Lavine
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA
| | - Neil A Feldstein
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA.,Morgan Stanley Children's Hospital of New York-Presbyterian, New York, New York, USA
| | - Richard C E Anderson
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA, .,Morgan Stanley Children's Hospital of New York-Presbyterian, New York, New York, USA,
| |
Collapse
|
14
|
Levy-Mendelovich S, Barg AA, Kenet G. Thrombosis in pediatric patients with leukemia. Thromb Res 2018; 164 Suppl 1:S94-S97. [PMID: 29703491 DOI: 10.1016/j.thromres.2018.01.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/07/2018] [Accepted: 01/10/2018] [Indexed: 10/17/2022]
Abstract
Acute lymphoblastic leukemia (ALL) is the most common type of cancer diagnosed in children. It is reportedly the most common malignancy associated with thromboembolism in the pediatric age group. Over the last 2 decades, venous thromboembolism (VTE) has been increasingly diagnosed among pediatric ALL patients with an estimated incidence ranging from about 5% (for symptomatic cases) to about 30-70% (following sequential imaging studies in asymptomatic children). The etiology is multifactorial and may stem from alterations of the hemostatic system following various chemotherapy protocols (including use of l-Asparaginase), the presence of central venous lines (CVL), as well as comorbidities, e.g. inherited thrombophilia risk factors. Most symptomatic thrombotic events occur in the upper venous system or in the central nervous system (CNS). Prospective studies on the establishment of guidelines for treatment or prevention are lacking. The following review will address the epidemiology, etiology and risk factors for thrombosis, describe the currently available evidence, and address issues associated with diagnosis and treatment.
Collapse
Affiliation(s)
- Sarina Levy-Mendelovich
- The Israeli National Hemophilia Center and Thrombosis Unit with The Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Israel
| | - Assaf Arie Barg
- The Israeli National Hemophilia Center and Thrombosis Unit with The Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Israel
| | - Gili Kenet
- The Israeli National Hemophilia Center and Thrombosis Unit with The Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Israel.
| |
Collapse
|
15
|
Sun LR, Cooper S. Neurological Complications of the Treatment of Pediatric Neoplastic Disorders. Pediatr Neurol 2018; 85:33-42. [PMID: 30126755 DOI: 10.1016/j.pediatrneurol.2018.05.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/25/2018] [Indexed: 01/19/2023]
Abstract
Neurological complications resulting from childhood cancer treatments are common. Treatment for childhood neoplastic disorders is often multimodal and may include procedures, cranial irradiation, chemotherapy, transplant, and immunotherapy, each of which carries distinct neurological risks. Procedures, such as lumbar punctures, are commonly used in this population for diagnostic purposes as well as intrathecal medication administration. Surgery is associated with an array of potential neurological complications, with posterior fossa syndrome being a common cause of morbidity in pediatric brain tumor patients after neurosurgical resection. Cranial irradiation can cause late neurological sequelae such as stroke, cerebral vasculopathy, secondary malignancy, and cognitive dysfunction. Neurotoxic effects of chemotherapeutic agents are common and include neuropathy, coagulopathy causing stroke or cerebral sinovenous thrombosis, encephalopathy, seizures, cerebellar dysfunction, myelopathy, and neuropsychologic difficulties. Hematopoietic stem cell transplant has a high risk of neurological complications including central nervous system infection, seizures, and stroke. Immunotherapies, including chimeric antigen receptor-modified T-cells (CAR T-cells) and immune checkpoint inhibitors, are emerging as potentially effective strategies to treat some types of childhood cancer, but may carry with them substantial neurotoxicity which is just beginning to be recognized and studied. With evolving treatment protocols, childhood cancer survivorship is increasing, and the role of the neurologist in managing both the acute and chronic neurological consequences of treatment is becoming more important. Prevention, early recognition, and treatment of therapy-associated neurotoxicity are imperative to ensuring children can remain on the most effective therapeutic regimens and to improve the neurological function and quality of life of childhood cancer survivors.
Collapse
Affiliation(s)
- Lisa R Sun
- The Johns Hopkins University School of Medicine, Department of Neurology, Division of Pediatric Neurology, Baltimore, Maryland; The Johns Hopkins University School of Medicine, Department of Neurology, Division of Cerebrovascular Neurology, Baltimore, Maryland.
| | - Stacy Cooper
- The Johns Hopkins University School of Medicine, Department of Oncology, Division of Pediatric Oncology, Baltimore, Maryland
| |
Collapse
|
16
|
Domi T, Vossough A, Stence NV, Felling RJ, Leung J, Krishnan P, Watson CG, Grant PE, Kassner A. The Potential for Advanced Magnetic Resonance Neuroimaging Techniques in Pediatric Stroke Research. Pediatr Neurol 2017; 69:24-36. [PMID: 28237248 DOI: 10.1016/j.pediatrneurol.2016.12.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 12/23/2016] [Accepted: 12/24/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND This article was written to provide clinicians and researchers with an overview of a number of advanced neuroimaging techniques in an effort to promote increased utility and the design of future studies using advanced neuroimaging in childhood stroke. The current capabilities of advanced magnetic resonance imaging techniques provide the opportunity to build on our knowledge of the consequences of stroke on the developing brain. These capabilities include providing information about the physiology, metabolism, structure, and function of the brain that are not routinely evaluated in the clinical setting. METHODS During the Proceedings of the Stroke Imaging Laboratory for Children Workshop in Toronto in June 2015, a subgroup of clinicians and imaging researchers discussed how the application of advanced neuroimaging techniques could further our understanding of the mechanisms of stroke injury and repair in the pediatric population. This subgroup was established based on their interest and commitment to design collaborative, advanced neuroimaging studies in the pediatric stroke population. RESULTS In working toward this goal, we first sought to describe here the magnetic resonance imaging techniques that are currently available for use, and how they have been applied in other stroke populations (e.g., adult and perinatal stroke). CONCLUSIONS With the continued improvement in advanced neuroimaging techniques, including shorter acquisition times, there is an opportunity to apply these techniques to their full potential in the research setting and learn more about the effects of stroke in the developing brain.
Collapse
Affiliation(s)
- Trish Domi
- Department of Physiology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Arastoo Vossough
- Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicholas V Stence
- Department of Radiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Ryan J Felling
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jackie Leung
- Department of Physiology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Pradeep Krishnan
- Department of Neuroradiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christopher G Watson
- Department of Computational Neuroscience, Division of Graduate Medical Sciences, Boston University School of Medicine, Boston, Massachusetts; Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - P Ellen Grant
- Division of Newborn Medicine, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Newborn Medicine, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrea Kassner
- Department of Physiology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
17
|
Pediatric arterial ischemic stroke: Epidemiology, risk factors, and management. Blood Cells Mol Dis 2017; 67:23-33. [PMID: 28336156 DOI: 10.1016/j.bcmd.2017.03.003] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 03/06/2017] [Accepted: 03/06/2017] [Indexed: 12/17/2022]
Abstract
Pediatric arterial ischemic stroke (AIS) is an uncommon but important cause of neurologic morbidity in neonates and children, with consequences including hemiparesis, intellectual disabilities, and epilepsy. The causes of pediatric AIS are unique to those typically associated with stroke in adults. Familiarity with the risk factors for AIS in children will help with efficient diagnosis, which is unfortunately frequently delayed. Here we review the epidemiology and risk factors for AIS in neonates and children. We also outline consensus-based practices in the evaluation and management of pediatric AIS. Finally we discuss the outcomes observed in this population. While much has been learned in recent decades, many uncertainties sill persist in regard to pediatric AIS. The ongoing development of specialized centers and investigators dedicated to pediatric stroke will continue to answer such questions and improve our ability to effectively care for these patients.
Collapse
|
18
|
Aoki T, Koh K, Arakawa Y, Mori M, Oguma E, Hanada R. Reversible Cerebral Vasoconstriction Syndrome during Chemotherapy for Acute Lymphoblastic Leukemia. J Pediatr 2017; 180:284. [PMID: 27769550 DOI: 10.1016/j.jpeds.2016.09.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 09/15/2016] [Indexed: 10/20/2022]
Affiliation(s)
| | | | | | | | | | - Ryoji Hanada
- Department of Hematology/Oncology; Saitama Children's Medical Center Chiba, Japan
| |
Collapse
|