Treatment Of Stroke In Children Research Articles

Arterial Ischemic Stroke in Childhood

Arterial ischemic stroke in children is a severe disorder with significant morbidity and mortality. Urgent diagnosis is mandatory in order to save lives or minimize neurological sequelae. However, recognition of stroke in children is more difficult than in adults. Barriers such as low suspicion, diverse risk factors, difficulties performing neuroimages, and a lack of protocols for diagnosis and treatment make stroke management in children a challenge. This article aims to review the approach to arterial stroke in children. Recently, more focus has been placed in the development of comprehensive stroke centers for treatment of stroke in children. Shortening time for diagnosis allows initiating a prompt and successful hyperacute treatment. Neuroprotection must be initiated before diagnosis confirmation. As in adult patients, widening the thrombolytic treatment time window and optimizing secondary stroke prevention are main points to develop. Early decompressive hemicraniectomy in children with malignant infarct should be considered. A multidisciplinary team is necessary for the diagnosis and treatment of children with brain attack. A particular “stroke code” must be established in each institution for stroke management and evidence-based guidelines should be developed.

E-088 successful mechanical thrombectomy for basilar artery stroke in a 22-month old child

Stroke is a leading cause of morbidity and mortality. 70% of children with acute ischemic stroke will survive with disability. The use of intra-arterial thrombectomy has recently been shown to have benefit in adults with acute large vessel occlusion. There are no randomized trials to guide treatment of acute stroke in children. We present the case of a 22-month-old with basilar artery occlusion successfully treated with mechanical thrombectomy. The patient presented to the emergency department with altered mental status and gait ataxia. She “felt limp”, her breathing was shallow, and her gaze dysconjugate. Her medical history included congenital heart defects with multiple cardiac procedures. In the emergency department, she fell with attempted ambulation. Labs were normal, as was a chest x-ray, and EKG. A computerized tomography (CT) scan of the head suggested left cerebellar hemisphere attenuation. The differential included arrhythmia, stroke, or seizures. An MRI demonstrated foci of restricted diffusion in the brainstem. The MRA was notable for a lack of opacification of the mid- and distal basilar artery. Angiography and mechanical thrombectomy were recommended. The patient was in the angiography suite 16 h and 12 min after ictus. A baseline angiogram confirmed the basilar artery occlusion. A 6-French Cello balloon guide was placed into the distal V2 segment of the left vertebral artery. The Solitaire 4 × 20 mm stentriever was placed in the target vessel for five minutes and then removed under flow arrest and aspiration. Demonstrable revascularization (TICI 2b) was seen, along with severe vasospasm in the basilar and left vertebral artery. Chemical angioplasty was performed with 5mg of intra-arterial nicardipine. This resulted in significant improvement, with TICI 3 revascularization. The patient was transferred to the PICU. She was extubated on POD #1 and discharged home on POD # 10. Her NIHSS was 0 at six-months post-stroke. Disclosures C. Roark: None. L. Savastano: None. D. Wilkinson: None. R. Shastri: None. V. Vadlamudi: None. N. Chaudhary: None. A. Pandey: None. J. Gemmete: None.

Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease

Thrombosis has long been recognized as a potentially life-threatening complication in children with congenital heart disease (CHD), children with acquired heart disease, and in adults with CHD. High-risk groups include patients with shunt- dependent single ventricles (shunt thrombosis, 8%–12%; 4%

Ischemic Stroke in Children: New Aspects of Treatment

From the NIHROxford Biomedical Research Centre (I.G.) and Nuffield Department of Surgery (M.K.), University of Oxford, Oxford, United Kingdom; Department of Neurology, Saarland University, Homburg, Germany (S.W., K.F.); Department of arly treatment of stroke in children and infants is essential, but success is not supported by data. Recent studies have demonstrated a mortality rate of up to 3%-11% and persistent neurologic deficit in 68%-74% of affected children. The epidemiology of thrombembolism is vastly different in pediatric patients and adults. In children, the most common underlying conditions are sickle cell disease and heart disease. Other risk factors include head trauma, infections, anemia, leukocytosis, and prothrombotic disorders. Transient cerebral arteriopathy due to unilateral intracranial arterial wall disease is another frequent cause of childhood acute ischemic stroke (AIS), specifically in previously healthy children. Here the focus should be on a rigorous assessment of anti-inflammatory treatment. The treatment of AIS is evolving at a quick pace, and acute mechanical interventions to restore cerebral blood flow are now a reality in the management of acute stroke. We reviewed the available literature and identified 7 published reports on mechanical recanalization in acute stroke in children. Here we review the currently available evidence on acute arterial AIS and highlight recent advances and possible future advances in the use of mechanical devices to treat stroke in this vulnerable population. We identified references for this review through searches of PubMed from 1980 to 2010 with the terms ‘‘acute,’’ ‘‘stroke,’’ ‘‘stroke treatment,’’ ‘‘children,’’ ‘‘childhood,’’ ‘‘child,’’ ‘‘artery occlusion,’’ ‘‘pediatric,’’ ‘‘girl,’’ ‘‘boy,’’ ‘‘endovascular,’’ ‘‘pediatrics,’’ ‘‘mechanical recanalization,’’ and ‘‘stroke trials.’’ We also identified articles through searches of the authors’ personal files. Only articles published in English were reviewed. For ethical reasons, previous and ongoing stroke trials have conventionally excluded children. Thus, current treatment methodologies do not include a uniform treatment approach for the pharmacologic and interventional management of AIS in the pediatric population. Guidelines are scarce, do not involve mechanical recanalization, and are mainly those set forth by the American College of Chest Physicians and the Royal College of Physicians. These guidelines do not provide sufficient recommendations for the acute management of ischemic stroke, and are based mainly on consensus and expert opinion.

Cerebral Angiopathies as a Cause of Ischemic Stroke in Children

Ischemic stroke in children can present with an epileptic seizure or be initially asymptomatic. The median time to diagnosis is 24 hours. This review is based on a selective literature search, with additional consideration of published guidelines and the authors' personal experience. In Europe and the USA, the combined incidence of ischemic and hemorrhagic stroke in childhood is 2.5 to 10 per 100 000 children per year. 40% of ischemic strokes in childhood occur after an infectious illness or in association with a congenital heart defect, sickle-cell anemia, or a coagulopathy. Arterial dissection and chronic, progressive cerebral arteriopathies, particularly moyamoya disease, each account for up to 10% of childhood strokes. Magnetic resonance imaging can be used to demonstrate infarcts and to display the perfusion of ischemic areas and the surrounding brain tissue; arterial and venous occlusions can be defined more precisely. Children with arterial dissection, vasculitis, and para-infectious cerebral ischemia should be treated empirically, with medications and supportive care, according to the treatment plans developed for adults. For patients with moyamoya disease, surgical revascularization with extra-intracranial bypass techniques is recommended. The current data provide an inadequate evidence base for the treatment of stroke in children. Potential revascularization or thrombolysis must be discussed individually in each case. For the treatment of temporary, para-infectious cerebral ischemia, hemodynamic optimization is an available option. Better evidence is needed regarding the surgical treatment of moyamoya disease.

Stroke in children

To summarize 1) the definitions and epidemiological features of stroke in children; 2) the main risk factors that can lead to stroke in pediatrics and neonatology; 3) the main pathophysiological features involved in the genesis of brain injury in stroke; 4) the clinical manifestations and imaging diagnosis; and 5) the latest recommendations concerning the support measures, treatment, and prophylaxis of stroke in children. A review of the literature published in PubMed, EMBASE, and SciELO databases using the search terms stroke, pediatrics, and neonatology was performed, including relevant references from the chosen texts. Stroke in children are rare conditions, with incidence rates among two and eight per 100,000 children up to 14 years, and most cases show an underlying disease such as heart diseases, prothrombotic conditions, sickle-cell disease, and vascular malformations. There are no specific guidelines currently in place for the treatment of stroke in children, although central elements include support treatment, monitoring, and anticoagulation as secondary prevention in certain cases. Prognosis depends on the extent of brain damage and the underlying disease but recurrence rates are high in most cases. Early diagnosis of stroke in children is very important and pediatricians should be aware of the lack of specificity of the symptoms to avoid late sequelae and improve life quality.

Acidentes vasculares encefálicos em pediatria

OBJECTIVES: To summarize 1) the definitions and epidemiological features of stroke in children; 2) the main risk factors that can lead to stroke in pediatrics and neonatology; 3) the main pathophysiological features involved in the genesis of brain injury in stroke; 4) the clinical manifestations and imaging diagnosis; and 5) the latest recommendations concerning the support measures, treatment, and prophylaxis of stroke in children. SOURCES: A review of the literature published in PubMed, EMBASE, and SciELO databases using the search terms stroke, pediatrics, and neonatology was performed, including relevant references from the chosen texts. SUMMARY OF THE FINDINGS: Stroke in children are rare conditions, with incidence rates among two and eight per 100,000 children up to 14 years, and most cases show an underlying disease such as heart diseases, prothrombotic conditions, sickle-cell disease, and vascular malformations. There are no specific guidelines currently in place for the treatment of stroke in children, although central elements include support treatment, monitoring, and anticoagulation as secondary prevention in certain cases. Prognosis depends on the extent of brain damage and the underlying disease but recurrence rates are high in most cases. CONCLUSIONS: Early diagnosis of stroke in children is very important and pediatricians should be aware of the lack of specificity of the symptoms to avoid late sequelae and improve life quality.

Assessment and treatment of stroke in children

Pediatric stroke remains underrecognized by physicians and families despite efforts to increase awareness. Although the incidence is only 2 to 3 per 100,000 children, stroke is a significant cause of disability in childhood. Ischemic and hemorrhagic strokes occur with approximately equal frequency. How these children should be evaluated and treated has not been well studied, except for randomized, controlled trials performed in children with sickle cell disease. There are consensus guidelines for the evaluation and treatment of ischemic stroke in children but not for hemorrhagic stroke. Extrapolation from the adult stroke literature is problematic in some cases. Children should be evaluated urgently and thoroughly, as multiple stroke risk factors may be present. Treatment includes supportive care geared to reducing metabolic demands in the setting of cerebral ischemia or hemorrhage, as well as targeted therapy depending on the presumed cause of stroke and individual patient risk factors.

Treatment of arterial ischemic stroke in children

Stroke is a rare but increasingly recognized disorder in children. Current therapies for arterial ischemic stroke include thrombolytic, antithrombotic and antiplatelet agents, blood transfusion and surgery. Adult studies, pediatric case studies and expert opinion form the basis for these treatment strategies. Thrombolytic agents are increasingly used but, as in adults, the majority of arterial ischemic strokes in children are treated with antiplatelet and antithrombotic agents. Sickle-cell patients, a distinct subset of the pediatric stroke population, are treated primarily with transfusion therapy. Pediatric arterial ischemic stroke studies are needed to determine the most appropriate course of treatment. An international study is currently in progress to formally study the incidence, risk factors, treatment strategies and outcomes of stroke in children.

Stroke in children.

Stroke is defined as the sudden occlusion or rupture of cerebral arteries or veins resulting in focal cerebral damage and neurological deficits. Forms of stroke resulting from vascular occlusion are arterial ischemic stroke (AIS) and sinovenous thrombosis (SVT) and those resulting from vascular rupture are called hemorrhagic stroke. Stroke in children is relatively rare and frequently results in a lack of recognition and delay in diagnosis. The etiologies of stroke in children are legion and multiple risk factors coexist unlike unifactorial etiology in adults. Heart disease whether congenital or acquired, malformations, metabolic and hematological disorders and vasospastic conditions like migraine are seen more often in childhood strokes. The purpose of diagnostic evaluation includes confirmation of the presence of a cerebrovascular lesion, exclusion of other types of neurological dysfunction and identification of etiology of the stroke. The treatment of stroke in children has been primarily directed toward stabilizing systemic factors and management of the underlying causes. Various antithrombotic and non antithrombotic therapies are discussed. The use of anticoagulant therapy appears to be increasing in pediatric AIS. Mortality after stroke in children ranges from 20% to 30% depending on the location and the underlying cause. Residual neurological dysfunction is present in more than 50% of survivors.