[show abstract][hide abstract] ABSTRACT: IMPORTANCE Hematoma expansion is the only modifiable predictor of outcome in adult intracerebral hemorrhage; however, the frequency and clinical significance of hematoma expansion after childhood intracerebral hemorrhage are unknown. OBJECTIVE To assess the frequency and extent of hematoma expansion in children with nontraumatic intracerebral hemorrhage. DESIGN, SETTING, AND PARTICIPANTS Prospective observational cohort study at 3 tertiary care pediatric hospitals. Children (≥37 weeks' gestation to 18 years) with nontraumatic intracerebral hemorrhage were enrolled in a study from 2007 to 2012 focused on predictors of outcome. For this planned substudy of hematoma expansion, neonates 28 days or younger and participants with isolated intraventricular hemorrhage were excluded. Children with 2 head computed tomography (CT) scans within 48 hours were evaluated for hematoma expansion and were compared with children with only 1 head CT scan. Consent for the primary cohort was obtained from 73 of 87 eligible participants (84%); 41 of 73 children enrolled in the primary cohort met all inclusion/exclusion criteria for this substudy, in whom 22 had 2 head CT scans obtained within 48 hours that could be evaluated for hematoma expansion. Within our substudy cohort, 21 of 41 (51%) were male, 25 of 41 (61%) were white, 16 of 41 (39%) were black, and median age was 7.7 years (interquartile range, 2.0-13.4 years). MAIN OUTCOME AND MEASURE Primary outcome was prevalence of hematoma expansion. RESULTS Of 73 children, 41 (56%) met inclusion criteria, and 22 (30%) had 2 head CT scans to evaluate expansion. Among these 22 children, median time from symptom onset to first CT was 2 hours (interquartile range, 1.3-6.5 hours). Median baseline hemorrhage volume was 19.5 mL, 1.6% of brain volume. Hematoma expansion occurred in 7 of 22 (32%). Median expansion was 4 mL (interquartile range, 1-11 mL). Three children had significant (>33%) expansion; 2 required urgent hematoma evacuation. Expansion was not associated with poorer outcome. Compared with children with only 1 head CT scan within 48 hours, children with 2 head CT scans had larger baseline hemorrhage volumes (P = .05) and were more likely to receive treatment for elevated intracranial pressure (P < .001). CONCLUSIONS AND RELEVANCE Hematoma expansion occurs in children with intracerebral hemorrhage and may require urgent treatment. Repeat CT should be considered in children with either large hemorrhage or increased intracranial pressure.
[show abstract][hide abstract] ABSTRACT: The intracerebral hemorrhage (ICH) score is the most commonly used clinical grading scale for outcome prediction after adult ICH. We created a similar scale in children to inform clinical care and assist in clinical research.
Children, full-term newborns to 18 years, with spontaneous ICH were prospectively enrolled from 2007 to 2012 at 3 centers. The pediatric ICH score was created by identifying factors associated with poor outcome. The score's ability to detect moderate disability or worse and severe disability or death was examined with sensitivity, specificity, and area under the receiver operating characteristic curve.
The pediatric ICH score components include ICH volume >2% to 3.99% of total brain volume (TBV): 1 point; ICH volume ≥4% TBV: 2 points; acute hydrocephalus: 1 point; herniation: 1 point; and infratentorial location: 1 point. The score ranges from 0 to 5. At 3-month follow-up of 60 children, 10 were severely disabled or dead, 30 had moderate disability, and 20 had good recovery. A pediatric ICH score ≥1 predicted moderate disability or worse with a sensitivity of 75% (95% confidence interval [CI], 59% to 87%) and a specificity of 70% (95% CI, 46% to 88%). A pediatric ICH score ≥2 predicted severe disability or death with a sensitivity and specificity of 90% (95% CI, 55% to 99%) and 68% (95% CI, 53% to 80%), respectively. The area under the receiver operating characteristic curve for classifying outcome as severe disability or death was 0.88 (95% CI, 0.78-0.97).
The pediatric ICH score is a simple clinical grading scale that may ultimately be used for risk stratification, clinical care, and research.
[show abstract][hide abstract] ABSTRACT: Background: Children with myocarditis have multiple risk factors for thrombotic events, yet the role of antithrombotic therapy is unclear in this population. We hypothesised that thrombotic events in critically ill children with myocarditis are common and that children with myocarditis are at higher risk for thrombotic events than children with non-inflammatory dilated cardiomyopathy. Methods: This is a retrospective chart review of all children presenting to a single centre cardiac intensive care unit with myocarditis from 1995 to 2008. A comparison group of children with dilated cardiomyopathy was also examined. Antithrombotic regimens were recorded. The primary outcome of thrombotic events included intracardiac clots and any thromboembolic events. Results: Out of 45 cases with myocarditis, 40% were biopsy-proven, 24% viral polymerase chain reaction-supported, and 36% diagnosed based on high clinical suspicion. There were two (4.4%) thrombotic events in the myocarditis group and three (6.7%) in the dilated cardiomyopathy group (p = 1.0). Neither the use of any antiplatelet or anticoagulation therapy, use of intravenous immune globulin, presence of any arrhythmia, nor need for mechanical circulatory support were predictive of thrombotic events in the myocarditis, dilated cardiomyopathy, or combined groups. Conclusions: Thrombotic events in critically ill children with myocarditis and dilated cardiomyopathy occurred in 6% of the combined cohort. There was no difference in thrombotic events between inflammatory and non-inflammatory cardiomyopathy groups, suggesting that the decision to use antithrombotic prophylaxis should be based on factors other than the underlying aetiology of a child's acute decompensated heart failure.
Cardiology in the Young 09/2013; · 0.95 Impact Factor
[show abstract][hide abstract] ABSTRACT: Few data regarding causes and outcomes of haemorrhagic stroke (HS) in term neonates are available. We characterised risk factors, mechanism and short-term outcomes in term and late preterm neonates with acute HS.
Single-centre tertiary care stroke registry.
Term and late preterm neonates (≥34 weeks gestation), born 2004-2010, with acute HS ≤28 days of life were identified, and clinical information was abstracted. Short-term outcomes were assessed via standardised neurological exam and rated using the Paediatric Stroke Outcome Measure (PSOM).
Among 42 neonates, median gestational age was 39.7 weeks (IQR 38-40.7 weeks). Diagnosis occurred at a median of 1 day (IQR 0-7 days) after delivery. Twenty-seven (64%) had intraparenchymal and intraventricular haemorrhage. Mechanism was haemorrhagic transformation of venous or arterial infarction in 22 (53%). Major risk factors included congenital heart disease (CHD), fetal distress and haemostatic abnormalities. Common presentations included seizure, apnoea, and poor feeding or vomiting. Acute hydrocephalus was common. Mortality was 12%. Follow-up occurred in 36/37 survivors at a median of 1 year (IQR 0.5-2.0 years). Among 17/36 survivors evaluated in stroke clinic, 47% demonstrated neurologic deficits. Deficits were mild (PSOM 0.5-1.5) in 9/36 (25%), and moderate-to-severe (PSOM ≥2.0) in 8/36 (22%).
In our cohort with acute HS, most presented with seizures, apnoea and/or poor feeding. Fetal distress and CHD were common. Nearly two-thirds had intraparenchymal with intraventricular haemorrhage. Over half were due to haemorrhagic transformation of infarction. Short-term neurologic deficits were present in 47% of survivors.
Archives of Disease in Childhood - Fetal and Neonatal Edition 08/2013; · 3.45 Impact Factor
[show abstract][hide abstract] ABSTRACT: We evaluated the validity and interrater reliability of encephalographer interpretation of color density spectral array EEG for seizure identification was evaluated in critically ill children and explored predictors of accurate seizure identification.
Conventional EEG tracings from 21 consecutive critically ill children were scored for electrographic seizures. Four 2-hour long segments from each subject were converted to 8-channel color density spectral array displays, yielding 84 images. Eight encephalographers received color density spectral array training and circled elements thought to represent seizures. Images were reviewed in random order (Group A) or with information regarding seizure presence in the initial 30 minutes and with subject images in order (Group B). Sensitivity, specificity, and interrater reliability were calculated. Factors associated with color density spectral array seizure identification were assessed.
Seizure prevalence was 43% on conventional EEG. Specificity was significantly higher for Group A than Group B (92.3% vs. 78.2%, P < 0.00). Sensitivity was not significantly different between Groups A and B (64.8% vs. 75%, P = 0.22). Interrater reliability was moderate in both groups. Ten percent of images were falsely classified as containing a seizure. Seizure duration ≥2 minutes predicted identification (P < 0.001).
Color density spectral array may be a useful screening tool for seizure identification by encephalographers, but it does not identify all seizures and false positives occur.
Journal of clinical neurophysiology: official publication of the American Electroencephalographic Society 08/2013; 30(4):371-375. · 1.47 Impact Factor
[show abstract][hide abstract] ABSTRACT: Object Cerebral arteriovenous malformations (AVMs) have a higher postresection recurrence rate in children than in adults. The authors' previous study demonstrated that a diffuse AVM (low compactness score) predicts postresection recurrence. The aims of this study were to evaluate the intra- and interrater reliability of the AVM compactness score. Methods Angiograms of 24 patients assigned a preoperative compactness score (scale of 1-3; 1 = most diffuse, 3 = most compact) in the authors' previous study were rerated by the same pediatric neuroradiologist 9 months later. A pediatric neurosurgeon, pediatric neuroradiology fellow, and interventional radiologist blinded to each other's ratings, the original ratings, and AVM recurrence also rated each AVM's compactness. Intrarater and interrater reliability were calculated using the κ statistic. Results Of the 24 AVMs, scores by the original neuroradiologist were 1 in 6 patients, 2 in 16 patients, and 3 in 2 patients. Intrarater reliability was 1.0. The κ statistic among the 4 raters was 0.69 (95% CI 0.44-0.89), which indicates substantial reliability. The interrater reliability between the neuroradiologist and neuroradiology fellow was moderate (κ = 0.59 [95%CI 0.20-0.89]) and was substantial between the neuroradiologist and neurosurgeon (κ = 0.74 [95% CI 0.41-1.0]). The neuroradiologist and interventional radiologist had perfect agreement (κ = 1.0). Conclusions Intrarater and interrater reliability of the AVM compactness score were excellent and substantial, respectively. These results demonstrate that the AVM compactness score is reproducible. However, the neuroradiologist and interventional radiologist had perfect agreement, which indicates that the compactness score is applied most accurately by those with extensive angiography experience.
Journal of Neurosurgery Pediatrics 03/2013; · 1.63 Impact Factor
[show abstract][hide abstract] ABSTRACT: OBJECTIVE:
To determine whether severe recurrent headache is a risk factor for neurovascular events in children who received radiation for brain tumors.
This is a retrospective cohort study of children with brain tumors who received cranial irradiation at a large tertiary care center, aged 0-21 years at diagnosis, with initial treatment between January 1, 1993 and December 31, 2002, and 2 or more follow-up visits. Patients were considered to have severe recurrent headache if this appeared as a complaint on 2 or more visits. Headaches attributed to tumor progression, shunt malfunction, or infection, or appearing at the end of life, were excluded. Medical records were reviewed for events of stroke or TIA.
Of 265 subjects followed for a median of 6.0 years (interquartile range 1.7-9.2 years), stroke or TIA occurred in 7/37 (19%) with severe headaches compared to 6/228 (3%) without these symptoms (hazard ratio 5.3, 95% confidence interval 1.8-15.9, p = 0.003). Adjusting for multiple variables did not remove the significance of this risk. Median time to first neurovascular event for the entire cohort was 4.9 years (interquartile range 1.7-5.5 years).
Severe recurrent headache appears to be a risk factor or predictor for subsequent cerebral ischemia in pediatric brain tumor survivors treated with radiation. This finding has clinical implications for both monitoring survivors and targeting a specific population for primary stroke prevention.
[show abstract][hide abstract] ABSTRACT: OBJECTIVE: To determine whether severe recurrent headache is a risk factor for neurovascular events in children who received radiation for brain tumors. METHODS: This is a retrospective cohort study of children with brain tumors who received cranial irradiation at a large tertiary care center, aged 0-21 years at diagnosis, with initial treatment between January 1, 1993 and December 31, 2002, and 2 or more follow-up visits. Patients were considered to have severe recurrent headache if this appeared as a complaint on 2 or more visits. Headaches attributed to tumor progression, shunt malfunction, or infection, or appearing at the end of life, were excluded. Medical records were reviewed for events of stroke or TIA. RESULTS: Of 265 subjects followed for a median of 6.0 years (interquartile range 1.7-9.2 years), stroke or TIA occurred in 7/37 (19%) with severe headaches compared to 6/228 (3%) without these symptoms (hazard ratio 5.3, 95% confidence interval 1.8-15.9, p = 0.003). Adjusting for multiple variables did not remove the significance of this risk. Median time to first neurovascular event for the entire cohort was 4.9 years (interquartile range 1.7-5.5 years). CONCLUSIONS: Severe recurrent headache appears to be a risk factor or predictor for subsequent cerebral ischemia in pediatric brain tumor survivors treated with radiation. This finding has clinical implications for both monitoring survivors and targeting a specific population for primary stroke prevention.
[show abstract][hide abstract] ABSTRACT: IMPORTANCE Seizures are believed to be common presenting symptoms in neonates and children with spontaneous intracerebral hemorrhage (ICH). However, few data are available on the epidemiology of acute symptomatic seizures or the risk for later epilepsy. OBJECTIVE To define the incidence of and explore risk factors for seizures and epilepsy in children with spontaneous ICH. Our a priori hypotheses were that younger age at presentation, cortical involvement of ICH, acute symptomatic seizures after presentation, ICH due to vascular malformation, and elevated intracranial pressure requiring urgent intervention would predict remote symptomatic seizures and epilepsy. DESIGN Prospective cohort study conducted between March 1, 2007, and January 1, 2012. SETTING Three tertiary care pediatric hospitals. PARTICIPANTS Seventy-three pediatric subjects with spontaneous ICH including 20 perinatal (≥37 weeks' gestation to 28 days) and 53 childhood subjects (>28 days to <18 years at presentation). MAIN OUTCOME MEASURES Acute symptomatic seizures (clinically evident and electrographic-only seizures within 7 days), remote symptomatic seizures, and epilepsy. RESULTS Acute symptomatic seizures occurred in 35 subjects (48%). Acute symptomatic seizures as a presenting symptom of ICH occurred in 12 perinatal (60%) and 19 childhood (36%) subjects (P = .07). Acute symptomatic seizures after presentation occurred in 7 children. Electrographic-only seizures were present in 9 of 32 subjects (28%) with continuous electroencephalogram monitoring. One-year and 2-year remote symptomatic seizure-free survival rates were 82% (95% CI, 68-90) and 67% (95% CI, 46-82), respectively. One-year and 2-year epilepsy-free survival rates were 96% (95% CI, 83-99) and 87% (95% CI, 65-95), respectively. Elevated intracranial pressure requiring acute intervention was a risk factor for seizures after presentation (P = .01; Fisher exact test), remote symptomatic seizures, and epilepsy (P = .03, and P = .04, respectively; log-rank test). CONCLUSIONS AND RELEVANCE Presenting seizures are common in perinatal and childhood ICH. Continuous electroencephalography may detect electrographic seizures in some subjects. Single remote symptomatic seizures occur in many, and development of epilepsy is estimated to occur in 13% of patients at 2 years. Elevated intracranial pressure requiring acute intervention is a risk factor for acute seizures after presentation, remote symptomatic seizures, and epilepsy.
[show abstract][hide abstract] ABSTRACT: IMPORTANCE Hematoma expansion is the only modifiable predictor of outcome in adult intracerebral hemorrhage; however, the frequency and clinical significance of hematoma expansion after childhood intracerebral hemorrhage are unknown. OBJECTIVE To assess the frequency and extent of hematoma expansion in children with nontraumatic intracerebral hemorrhage. DESIGN, SETTING, AND PARTICIPANTS Prospective observational cohort study at 3 tertiary care pediatric hospitals. Children (37 weeks' gestation to 18 years) with nontraumatic intracerebral hemorrhage were enrolled in a study from 2007 to 2012 focused on predictors of outcome. For this planned substudy of hematoma expansion, neonates 28 days or younger and participants with isolated intraventricular hemorrhage were excluded. Children with 2 head computed tomography (CT) scans within 48 hours were evaluated for hematoma expansion and were compared with children with only 1 head CT scan. Consent for the primary cohort was obtained from 73 of 87 eligible participants (84%); 41 of 73 children enrolled in the primary cohort met all inclusion/exclusion criteria for this substudy, in whom 22 had 2 head CT scans obtained within 48 hours that could be evaluated for hematoma expansion. Within our substudy cohort, 21 of 41 (51%) were male, 25 of 41 (61%) were white, 16 of 41 (39%) were black, and median age was 7.7 years (interquartile range, 2.0-13.4 years).
[show abstract][hide abstract] ABSTRACT: The true postoperative incidence of arteriovenous malformation (AVM) recurrence in the pediatric population remains largely unreported. Some literature suggests that delayed imaging studies should be obtained at 6 months to 1 year after negative findings on a postoperative angiogram. The aim of this study was to describe the timing of AVM recurrences after resection and the neuroimaging modalities on which the recurrences were detected.
This study was performed in a retrospective cohort of all pediatric patients treated surgically for AVM resection by a single neurosurgeon between 2005 and 2010. Patients were followed after resection with MR angiography (MRA) or conventional angiography, when possible, at various time points. A visual scale for compactness of the initial AVM nidus was used, and the score was correlated with probability of recurrence after surgery.
A total of 28 patients (13 female, 15 male) underwent an AVM resection. In 18 patients (64.3%) an intraoperative angiogram was obtained. In 4 cases the intraoperative angiogram revealed residual AVM, and repeat resections were performed immediately. Recurrent AVMs were found in 4 children (14.3%) at 50, 51, 56, and 60 weeks after the initial resection. Recurrence risk was 0.08 per person-year. No patient with normal results on an angiogram obtained at 1 year developed a recurrence on either a 5-year angiogram or one obtained at 18 years of age. All patients with recurrence had a compactness score of 1 (diffuse AVM); a lower compactness score was associated with recurrence (p = 0.0003).
All recurrences in this cohort occurred less than 15 months from the initial resection. The authors recommend intraoperative angiography to help ensure complete resection at the time of the surgery. Follow-up vascular imaging is crucial for detecting recurrent AVMs, and conventional angiography is preferred because MRA can miss smaller AVMs. One-year follow-up imaging detected these recurrences, and no one who had negative results on an angiogram obtained at 1 year had a late recurrence. However, not all of the patients have been followed for 5 years or until 18 years of age, so longer follow-up is required for these patients. A lower compactness score predicted recurrent AVM in this cohort.
Journal of Neurosurgery Pediatrics 05/2012; 9(5):497-504. · 1.63 Impact Factor
[show abstract][hide abstract] ABSTRACT: Background and Purpose: Larger infarct volume as a percent of supratentorial brain volume (SBV) predicts poor outcome and hemorrhagic transformation in childhood arterial ischemic stroke (AIS). In perinatal AIS, higher scores on a modified pediatric version of the Alberta Stroke Program Early CT Score using acute MRI (modASPECTS) predict later seizure occurrence. The objectives were to establish the relationship of modASPECTS to infarct volume in perinatal and childhood AIS and to establish the interrater reliability of the score. Methods: We performed a cross sectional study of 31 neonates and 40 children identified from a tertiary care center stroke registry with supratentorial AIS and acute MRI with diffusion weighted imaging (DWI) and T2 axial sequences. Infarct volume was expressed as a percent of SBV using computer-assisted manual segmentation tracings. ModASPECTS was performed on DWI by three independent raters. The modASPECTS were compared among raters and to infarct volume as a percent of SBV. Results: ModASPECTS correlated well with infarct volume. Spearman rank correlation coefficients (ρ) for the perinatal and childhood groups were 0.76, p < 0.001 and 0.69, p < 0.001, respectively. Excluding one perinatal and two childhood subjects with multifocal punctate ischemia without large or medium sized vessel stroke, ρ for the perinatal and childhood groups were 0.87, p < 0.001 and 0.80, p < 0.001, respectively. The intraclass correlation coefficients for the three raters for the neonates and children were 0.93 [95% confidence interval (CI) 0.89-0.97, p < 0.001] and 0.94 (95% CI 0.91-0.97, p < 0.001), respectively. Conclusion: The modified pediatric ASPECTS on acute MRI can be used to estimate infarct volume as a percent of SBV with a high degree of validity and interrater reliability.
[show abstract][hide abstract] ABSTRACT: The Pediatric National Institutes of Health Stroke Scale (PedNIHSS), an adaptation of the adult National Institutes of Health Stroke Scale, is a quantitative measure of stroke severity shown to be reliable when scored prospectively. The ability to calculate the PedNIHSS score retrospectively would be invaluable in the conduct of observational pediatric stroke studies. The study objective was to assess the concurrent validity and reliability of estimating the PedNIHSS score retrospectively from medical records.
Neurological examinations from medical records of 75 children enrolled in a prospective PedNIHSS validation study were photocopied. Four neurologists of varying training levels blinded to the prospective PedNIHSS scores reviewed the records and retrospectively assigned PedNIHSS scores. Retrospective scores were compared among raters and to the prospective scores.
Total retrospective PedNIHSS scores correlated highly with total prospective scores (R(2)=0.76). Interrater reliability for the total scores was "excellent" (intraclass correlation coefficient, 0.95; 95% CI, 0.94-0.97). Interrater reliability for individual test items was "substantial" or "excellent" for 14 of 15 items.
The PedNIHSS score can be scored retrospectively from medical records with a high degree of concurrent validity and reliability. This tool can be used to improve the quality of retrospective pediatric stroke studies.
[show abstract][hide abstract] ABSTRACT: Previous studies of pediatric intracerebral hemorrhage have investigated isolated intraparenchymal hemorrhage. The authors investigated whether detailed assessment of intraventricular hemorrhage enhanced outcome prediction after intracerebral hemorrhage. They prospectively enrolled 46 children, full-term to 17 years, median age 2.7 years, with spontaneous intraparenchymal hemorrhage and/or intraventricular hemorrhage. Outcome was assessed with the King's Outcome Scale for Childhood Head Injury. Twenty-six (57%) had intraparenchymal hemorrhage, 10 (22%) had pure intraventricular hemorrhage, and 10 (22%) had both. There were 2 deaths, both with intraparenchymal hemorrhage and intraventricular hemorrhage volume ≥4% of total brain volume. Presence of intraventricular hemorrhage was not associated with poor outcome, but hydrocephalus showed a trend (P = .09) toward poor outcome. In receiver operating characteristic curve analysis, combined intraparenchymal hemorrhage and intraventricular hemorrhage volume also showed a trend toward better outcome prediction than intraparenchymal hemorrhage volume alone. Although not an independent outcome predictor, future studies should assess intraventricular hemorrhage qualitatively and quantitatively.
Journal of child neurology 11/2011; 27(4):526-31. · 1.59 Impact Factor
[show abstract][hide abstract] ABSTRACT: Brain tumors are rare in infants who are younger than six months of age. These tumors can be challenging to treat surgically. We analyzed a modern series of patients treated by a multidisciplinary team at a tertiary care center and performed a literature review of this unique population.
Retrospective clinical data were collected for patients surgically treated for intracranial mass lesions at The Children's Hospital of Philadelphia from 1998 to 2007. Dermoid cysts and other skull-based lesions were excluded from the analysis.
Sixteen patients younger than six months of age underwent surgery for primary intracranial mass lesions. The median age of the patients at surgery was 5.2 months (range, 1.4-6 months of age). Children most often presented with a bulging fontanelle, hydrocephalus, or macrocephaly (seven patients). Vomiting was seen in five patients, cranial nerve palsies in one patient, and seizures in three patients. All patients had tumor resections and postoperatively were monitored in the intensive care unit. The final pathology consisted of atypical teratoid/rhabdoid tumor (three patients), primitive neuroectodermal tumor/medulloblastoma (three patients), choroid plexus papilloma (two patients), astrocytoma (two patients), ganglioglioma (two patients), desmoplastic infantile ganglioglioma (two patients), glioblastoma multiforme (one patient), and choroid plexus carcinoma (one patient). Two intraoperative deaths occurred. Of the surviving 14, a gross total resection was achieved in four. Adjuvant therapy was determined by a multidisciplinary team composed of neuro-oncology, neurosurgery, and radiation oncology. Seven patients were treated with chemotherapy, and one patient had proton beam therapy. Five-year overall survival was 45%. The eight surviving patients had neurological sequelae, and developmental outcome was variable.
Brain tumors are uncommon in children younger than six months of age. Patients present with a variety of tumor pathologies. Children who survive have neurological sequelae. More studies are necessary to understand the impact that different treatment options, tumor pathology, and tumor location have on neurological outcome.
World Neurosurgery 11/2011; 78(1-2):137-44. · 1.77 Impact Factor
[show abstract][hide abstract] ABSTRACT: To define the incidence of seizures as a presenting symptom of acute arterial ischemic stroke (AIS) in children and to determine whether younger age, infarct location, or AIS etiology were risk factors for seizure at AIS presentation.
Children aged 2 months to 18 years presenting with AIS between January 2005 and December 2008 were identified from a single center prospective pediatric stroke registry. Clinical data were abstracted, and a neuroradiologist reviewed imaging studies.
Among the 60 children who met our inclusion criteria, 13 experienced seizure at stroke presentation (22%). Median age was significantly younger in children who presented with seizures than in those who did not (1.1 years vs 10 years; P = .0009). Seizures were accompanied by hemiparesis in all patients. Three of 4 children with clinically overt seizures at presentation also had nonconvulsive seizures on continuous electroencephalography monitoring.
Twenty-two percent of children with acute AIS present with seizures. Seizures were always accompanied by focal neurologic deficits. Younger age was a risk factor for seizures at presentation. Seizure at presentation was not associated with infarct location or etiology. Nonconvulsive seizures may occur during the acute period.
The Journal of pediatrics 03/2011; 159(3):479-83. · 4.02 Impact Factor
[show abstract][hide abstract] ABSTRACT: Stroke is an important cause of death and disability among children. Clinical trials for childhood stroke require a valid and reliable acute clinical stroke scale. We evaluated interrater reliability (IRR) of a pediatric adaptation of the National Institutes of Health Stroke Scale.
The pediatric adaptation of the National Institutes of Health Stroke Scale was developed by pediatric and adult stroke experts by modifying each item of the adult National Institutes of Health Stroke Scale for children, retaining all examination items and scoring ranges of the National Institutes of Health Stroke Scale. Children 2 to 18 years of age with acute arterial ischemic stroke were enrolled in a prospective cohort study from 15 North American sites from January 2007 to October 2009. Examiners were child neurologists certified in the adult National Institutes of Health Stroke Scale. Each subject was examined daily for 7 days or until discharge. A subset of patients at 3 sites was scored simultaneously and independently by 2 study neurologists.
IRR testing was performed in 25 of 113 a median of 3 days (interquartile range, 2 to 4 days) after symptom onset. Patient demographics, total initial pediatric adaptation of the National Institutes of Health Stroke Scale scores, risk factors, and infarct characteristics in the IRR subset were similar to the non-IRR subset. The 2 raters' total scores were identical in 60% and within 1 point in 84%. IRR was excellent as measured by concordance correlation coefficient of 0.97 (95% CI, 0.94 to 0.99); intraclass correlation coefficient of 0.99 (95% CI, 0.97 to 0.99); precision measured by Pearson ρ of 0.97; and accuracy measured by the bias correction factor of 1.0.
There was excellent IRR of the pediatric adaptation of the National Institutes of Health Stroke Scale in a multicenter prospective cohort performed by trained child neurologists.
[show abstract][hide abstract] ABSTRACT: The objective of this study was to describe the occurrence of hemorrhagic transformation (HT) among children with arterial ischemic stroke within 30 days after symptom onset and to describe clinical factors associated with HT.
Sixty-three children aged 1 month to 18 years with arterial ischemic stroke between January 2005 and November 2008 were identified from a single-center prospective pediatric stroke registry. All neuroimaging studies within 30 days of stroke were reviewed by a study neuroradiologist. Hemorrhage was classified according to the European Cooperative Acute Stroke Study-1 definitions. Association of HT with clinical factors, systemic anticoagulation, stroke volume, and outcome was analyzed.
HT occurred in 19 of 63 children (30%; 95% CI, 19% to 43%), only 2 (3%) of whom were symptomatic. Hemorrhage classification was hemorrhagic infarction (HI)1 in 14, HI2 in 2, parenchymal hematoma (PH)1 in 2, and PH2 in 1. HT was less common in children with vasculopathy (relative risk, 0.27; 95% CI, 0.07 to 1.06; P=0.04) than in those with other stroke mechanisms. HT was not significantly associated with anticoagulation versus antiplatelet therapy (relative risk, 0.6; 95% CI, 0.2 to 1.5; P=0.26) but was associated with larger infarct volumes (P=0.0084). In multivariable analysis, worse Pediatric Stroke Outcome Measure scores were associated with infarct volume ≥5% of total supratentorial brain volume (OR, 4.0; 95% CI, 1.1 to 15; P=0.04), and a trend existed toward association of worse Pediatric Stroke Outcome Measure scores with HT (OR, 4.0; 95% CI, 0.9 to 18; P=0.07).
HT occurred in 30% of children with arterial ischemic stroke within 30 days. Most hemorrhages were petechial and asymptomatic. Infarct volume was associated with HT and worse outcome.
[show abstract][hide abstract] ABSTRACT: Population-based estimates of the annual incidence of childhood stroke range from 2 to 13 per 100,000 person-years. More than half of children who have had a stroke have long-term neurological sequelae. The goal of this article is to review recent literature on both hemorrhagic and ischemic stroke in children with a focus on cerebral arteriopathy and vascular malformations as stroke risk factors. Additionally, we review diagnostic studies for childhood stroke, outcome data, and regional and geographic practice differences.
PubMed was searched using the terms child, childhood, pediatric, stroke, ischemic, intracerebral hemorrhage, vasculopathy, and vascular malformation. Reference lists of these articles were reviewed for additional key publications. Preference was given to articles published since the year 2000; however, seminal articles in the field were also reviewed.
Pediatric stroke is a heterogeneous disorder and a major cause of morbidity in the pediatric population. Five-year recurrence risk is estimated to be 5-19%. Children with cerebrovascular abnormalities are at the highest risk of recurrence (66% at 5 years for ischemic stroke in one study). Furthermore, cerebral arteriopathy including arterial dissection may account for up to 80% of childhood stroke in otherwise healthy children.
In many cases, evaluation and treatment of pediatric stroke is not evidence-based, and regional and geographic variations in practice patterns exist. Ultimately multicenter cohort studies and dedicated pediatric clinical trials are essential to establish comprehensive evidence-based guidelines for pediatric stroke care.
Child s Nervous System 10/2010; 26(10):1263-73. · 1.24 Impact Factor
[show abstract][hide abstract] ABSTRACT: Vein of Galen aneurysmal malformations (VGAM) are rare but clinically significant intracranial arteriovenous shunt lesions that most often present in neonates and infants.
Retrospective clinical data were collected for patients evaluated with a diagnosis of VGAM from 1994 to 2007.
Thirteen patients with VGAM were evaluated from 1994 to 2007. Seven patients presented emergently with medically intractable cardiac failure, and six were treated in the first 2 weeks of life. Five children treated after this period (1.5-31 months of age) manifested enlarging head circumference, abnormal development, or subarachnoid hemorrhage. Eleven patients were managed endovascularly. Four disease or procedure-related complications occurred. Two complications were associated with poor outcome, both of which occurred in patients treated at less than 2 weeks of age. Two other patients experienced transient neurological deficits with no evidence of permanent sequelae. Outcome in the six patients treated emergently in the first 2 weeks of life included two patients who developed normally, one with mild to moderate neurological deficits, one with severe neurological deficits, and two deaths. Outcome in the five older patients (treated between 1.5 and 31 months) was considerably better than in the group treated early and included three with normal outcome and two with mild neurological deficits.
Contemporary endovascular techniques remain the preferred treatment for VGAM in all age groups. Early diagnosis and multimodality treatment are essential for the best management and treatment of the complex constellation of clinical problems often arising from this disorder.
Child s Nervous System 07/2010; 26(7):879-87. · 1.24 Impact Factor