1,721,041 research outputs found
Stroke in childhood
No full textPresentation with stroke is rare in children, with an incidence of 2.6 and 3.1/100 0000 white and black children, respectively.1 Half are haemorrhagic, requiring immediate transfer to a neurosurgical unit in case decompression is required. Traditionally, ischaemic strokes have been considered to be idiopathic and to have a good prognosis, with a low recurrence risk and good recovery of motor function and school performance. They have not been investigated extensively, on the basis that management would not alter. However, there is a significant mortality,1 as well as considerable morbidity and a risk of recurrence, none of which has been adequately defined epidemiologically. In addition, there is now evidence that the neurological outcome could be improved, at least in some subgroups, by appropriate emergency management and, particularly, that recurrence might be preventable. This article proposes essential investigations and management for “good practice” in the current state of knowledge, although further research is clearly required before evidence based guidelines can be produced
Acute neurology
No full textThe importance of thorough clinical examination of the child who presents with acute neurological problems is emphasized. A number of new diagnostic techniques are available, most of which are relatively non-invasive. The recent investigative advances may play a part in exposing the pathology underlying stroke, trauma or coma and in guiding management, which needs to be carefully tailored to the individual child's condition
Stroke in childhood
No full textAlthough considerable advances have been made in understanding the underlying basis for stroke in childhood, there are very few population based studies. For idiopathic ischaemic stroke, the relative importance of cerebrovascular disease, subtle cardiac anomalies and abnormalities of anticoagulation will remain controversial in the forseeable future but it is now possible to investigate the paediatric patient non-invasively and appropriate assessment off the risk factors for recurrence will aid management decisions on the use of prophylactic aspirin and warfarin. There is a case for referring urgently strokes seen within 4 h since removal of haemorrhage may be life-saving and thrombolysis can be considered for embolic stroke in centres with appropriate neurological, neurosurgical and radiological support.</p
Recognition and prevention of neurological complications in pediatric cardiac surgery
No full textBecause of advances in surgical and cardiopulmonary bypass techniques it is now possible to definitively repair the vast majority of congenital heart disease in infancy or childhood. Although the majority of survivors do not have obvious cerebral sequelae, there is increasing disquiet about the high incidence of acute neurological events in the immediated postoperative period as well as evidence that at long-term follow-up there are subtle cognitive and motor deficits in many. Some children are more at risk of neurodevelopmental problems, either because of their cardiac (e.g., extensive aortopulmonary collaterals) or cerebrovascular (e.g., the propensity to large vessel dissection) anatomy or because of genetic predisposition (e.g., to prothrombotic disorders). The incidence may vary with the surgery (e.g., the Fontan operation) and the cardiopulmonary bypass technique necessary to achieve an adequate technical repair (e.g., low or no flow at deep hypothermia). Recognition of the population at risk will lead to prevention of serious sequelae. Data collected in adults may be misleading, and many pediatric units have developed their own practice, but recent studies in animal models of child surgery and in children have produced some evidence to guide management to ensure the optimal cerebral as well as cardiac outcome. Pump flow should be maintained at least 30 ml/kg/min where possible, with inotropic support to maintain blood pressure if necessary. If pump flow must be lowered or circulatory arrest is essential, thorough cerebral cooling to deep hypothermic temperatures is mandatory; a pH-stat strategy may make this easier, but an α-stat strategy may be better in those operations that can be performed at moderate hypothermia. There is no evidence that the available pulsatile pumps offer an advantage. Tissue oxygenation may reach critical levels and a high hematocrit and oxygen tension may reduce the risk of significant hypoxia. There is a risk of embolization in children, which can be reduced with membrane oxygenators and careful monitoring; the role of arterial filtration remains controversial. The only protective agent that can currently be recommended is methylprednisolone to protect the spinal cord (e.g., in operations on the aortic arch). Further studies are needed in this important area.</p
Characteristics of children with underlying cardiac defects who developed Arterial Ischaemic Stroke (IS)
No full textBackground: Cardiac disease is a common underlying condition in children with arterial ischemic stroke (AIS). Embolism, dissection and moyamoya are recognised mechanisms and iron deficiency has been associated. However, few recent data
exist relating the nature of the underlying cardiac defects, or associations withrecent investigational or surgical proceduresObjective: To investigate characteristics of children with underlying cardiac defects who developed AIS.Method: Review of cardiac cases from Great Ormond Street first AIS cohort presenting 1978-2000.Results: Of 212 with AIS, 33 (16%) children had underlying cardiac disease, with more boys (23; 70%). Median age at presentation was 4.7 (range 0.6-16.3) years. 17
(52%) developed stroke following cardiac surgery, 1 following catheterisation and15 (49%) spontaneously. 6 had another diagnosis (skin haemangioma, linear sebaceous naevus, Down syndrome, Williams syndrome, acute lympoblastic leukaemia
and immunodeficiency). The majority had right sided cerebral infarction (49%) followed
by left side (30%) and bilateral (21%). Anterior (n=30) was commoner than posterior circulation involvement (n=3). Cerebral infarction was purely subcortical in 8, purely cortical in 7, and involved both cortical and subcortical tissue in 18
children. 20 (60%) had arterial imaging which showed occlusion in 7, stenosis in 4, dissection in 2, moyamoya in 2 and normal vessels in 5. 6 (16%) died following stroke, 6 (16%) had recurrent stroke, and 4 (11%) had further transient ischaemic
attacks. Seven (21%) had iron deficiency.Conclusion: Children with underlying cardiac defects comprised 1/6th of our AIS cohort; half had strokes spontaneously. Apparently primary cerebrovascular disease
is as common as occlusion, presumably secondary to embolism. Iron deficiency was a risk factor in 1/5th but this and the other underlying diagnoses in addition to cardiac defects might increase the risk of developing AIS. This needs further investigation so that preventative strategies can be designed
Mechanisms of ischaemic stroke after chickenpox
No full textIschaemic stroke is a recognised complication of chickenpox. Seven cases of ischaemic stroke in children after recent varicella infection are discussed in detail to emphasise that there are several mechanisms by which this may arise.</p
Successful management of severe intracranial hypertension by surgical decompression
No full textBecause of the rather disappointing results in the treatment of acute head‐injury in adults, surgical decompression has been little used in the management of severe intracranial hypertension. The authors report the successful use of the technique for a child with encephalitis in whom cerebral perfusion was compromised. Traitement efficace de l'hypertension intracranienne majeure par décompression chirurgicale En raison des résultats décevants dans le traitement des traumatismes céphaliques aigus chez l'adulte, la décompression chirurgicale a été peu utilisée dans le traitement de l'hypertension intracranienne majeure. Les auteurs rapportent l'utilisation efficace de la technique chez un enfant porteur d'encéphalite don't l'irrigation cérébrale était compromise. Erfolgreiche Behandlung eines schweren intrakraniellen Hochdrucks durch chirurgische Dekompression Wegen der relativ enttäuschenden Ergebnisse bei der Behandlung akuter Kopfverletzungen bei Erwachsenen ist die chirurgische Dekompression bei schwerem intrakraniellem Hochdruck selten durchgeführt worden. Die Autoren berichten über die erfolgreiche Anwendung dieser Methode bei einem Kind mit Enzephalitis, bei dem die cerebrale Perfusion gefährdet war. Tratamiento con éxito de la hipertensión endocraneana severa por descompresión quirúrgica Debido a los resultados más bien decepcionantes obtenidos en la lesión craneal aguda en adultos, la descompresión quirúrgica se ha usado poco en el tratamiento de la hipertensiön intracraneal aguda grave. Los autorea aportan !a utilizatión con éxito de la técnica en un niño con encefalitis en que la perfusión cerebral estaba comprometida.</p
Case summary: Kate
No full textAfter an uneventful birth and normal early milestones, Kate presented with infantile spasms at the age of seven months. Seizures terminated within two days of initiation of ACTH but her subsequent development was delayed. At two-and-a-half years of age she developed complex partial seizures that responded to carbamazepine monotherapy. The dosage was increased when she developed generalized tonic-clonic seizures and she is currently maintained on a maximal dose of a controlled release formulation. The EEG strongly supports the clinical diagnosis of complex partial seizures and an MRI shows a classical neuronal migration defect with gross band heterotopia throughout both cerebral hemispheres. She attends a school for children with moderate learning difficulties.</p
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