A Billinghurst potpourri

Billinghurst LL, Beslow LA, Abend NS, Uohara M, Jastrzab L, Licht DJ, Ichord RN. Incidence and predictors of epilepsy after pediatric arterial ischemic stroke. Neurology. 2017 Jan 13. pii: 10.1212/WNL.0000000000003603. doi:10.1212/WNL.0000000000003603. [Epub ahead of print]

Abstract

OBJECTIVE:

To determine the cumulative incidence and clinical predictors of remote symptomatic seizures and epilepsy after pediatric arterial ischemic stroke (AIS).

METHODS:

We performed a retrospective analysis of 218 participants with neonatal AIS (NAIS), presumed perinatal AIS (PPAIS), and childhood AIS (CAIS) from a single-center prospective consecutive cohort enrolled from 2006 to 2014. Medical records were reviewed for timing, semiology, and treatment of acute symptomatic seizures, remote symptomatic seizures (RSS), and epilepsy. Cumulative incidence of RSS and epilepsy were assessed using survival analysis.

RESULTS:

Acute symptomatic seizures occurred in 94% of NAIS (n = 70/74) and 17% of CAIS (n = 18/105). Younger children were more likely to present with seizures at stroke ictus, and acute symptomatic seizures were predictive of later RSS and epilepsy in CAIS. Median follow-up for the entire cohort was 34 months, interquartile range 44.9 months (16.3-61.2). Estimated cumulative incidence of RSS at 2 years was 19% in NAIS, 24% in PPAIS, and 7% in CAIS. Estimated cumulative incidence of epilepsy at 2 years was 11% in NAIS, 19% in PPAIS, and 7% in CAIS. The median time to these outcomes was <2 years in all stroke subtypes. Among participants developing epilepsy (n = 34), seizures were often well-controlled at last follow-up with median Engel class of ≤2 (<1 seizure/month).

CONCLUSIONS:

RSS and epilepsy are important neurologic sequelae of pediatric AIS. Children with perinatal stroke and CAIS with acute symptomatic seizures are at increased risk of these outcomes. These cohorts need further study to identify biomarkers and potential therapeutic targets for epileptogenesis.

Courtesy of:   https://www.mdlinx.com/neurology/medical-news-article/2017/01/17/pediatric-arterial-ischemic-stroke-epilepsy/7011141/?category=latest&page_id=1

Petrov D, Uohara MY, Ichord R, Ali Z, Jastrzab L, Lang SS, Billinghurst L. Pediatric cerebral sinovenous thrombosis following cranial surgery. Childs Nerv Syst. 2017 Jan 14. doi: 10.1007/s00381-016-3329-2. [Epub ahead of print]

Abstract

PURPOSE:

Pediatric cerebral sinovenous thrombosis (CSVT) is an important, though less common subtype of pediatric stroke. It has been linked to several risk factors, including cranial procedures, with few studies highlighting this relationship. The aim of this study was to characterize the diagnosis and treatment of CSVT after cranial surgery.

METHODS:

An institutional pediatric stroke research database was used to identify all CSVT cases diagnosed within 30 days of cranial surgery from November 2004 to December 2014. Thirteen subjects were retrospectively analyzed for clinical presentation, surgical details, radiographic characteristics, laboratory study results, treatment, and outcome. Diagnostic testing and treatment adhered to a consensus-based institutional stroke protocol.

RESULTS:

Cranial vault reconstruction, subdural empyema evacuation, and tumor resection were each observed in three subjects. Eleven (85%) subjects had sinus exposure during surgery, and eight (73%) developed thrombus in a sinus within or adjacent to the operative field. Two (15%) had documented iatrogenic sinus injury. On post-operative testing, ten (77%) subjects had prothrombotic abnormalities. Seven (54%) were treated with anti-coagulation therapy (ACT) starting on a median of post-operative day (POD) 3 (IQR 1-3) for a median of 2.9 months (IQR 2.4-5.4). Median time to imaging evidence of partial or complete recanalization was 2.4 months (IQR 0.7-5.1). No symptomatic hemorrhagic complications were encountered.

CONCLUSIONS:

Pediatric CSVT may be encountered after cranial surgery, and decisions related to anti-coagulation are challenging. The risk of CSVT should be considered in pre-surgical planning and post-operative evaluation of cases with known risk factors. In our study, judicious use of ACT was safe in the post-operative period. 

Binenbaum G, Reid JE, Rogers DL, Jensen A, Billinghurst LL, Forbes BJ. Patterns of retinal hemorrhage associated with pediatric cerebral sinovenous thrombosis. J AAPOS. 2017 Jan 10. pii: S1091-8531(17)30011-3. doi:10.1016/j.jaapos.2016.10.004. [Epub ahead of print]

Abstract

BACKGROUND:

Cerebral sinovenous thrombosis (CSVT) has been proposed as an alternative cause of retinal hemorrhage (RH) in children being evaluated for abusive head trauma. This study investigated the prevalence and characteristics of RH in children with CSVT.

METHODS:

The medical records of children >6 weeks of age with newly diagnosed CSVT and fundus examination by an ophthalmologist were examined retrospectively. Primary outcomes were presence and patterns of RH.

RESULTS:

A total of 29 children (median age, 9 years; range, 7 weeks to 17 years) were studied. Of these, 5 (17%) had RH, in 4 of whom RH were peripapillary, superficial, intraretinal, and adjacent to a swollen optic disk. In the fifth child, who had meningitis, sepsis, and multiple cerebral infarcts, there were a moderate number of posterior pole intraretinal hemorrhages. Eighteen children (62%) had optic disk swelling. In 13 children, cerebrospinal fluid opening pressure was recorded (range, 27-59 cm H20). CSVT risk factors included meningitis, mastoiditis, and hypercoagulability.

CONCLUSIONS:

RH in pediatric CSVT was uncommon. When RHs were present, the appearance matched RH patterns known to be caused by medical conditions, such as raised intracranial pressure and sepsis, that were also present in these children. These findings suggest that the RHs are due to these other causes and not directly to CSVT itself. In children with CSVT, if RHs are multilayered, extend beyond the peripapillary region into the rest of the posterior pole or retinal periphery, or occur in the absence of optic disk swelling, another etiology for the RH should be sought.

Bosenbark DD, Krivitzky L, Ichord R, Jastrzab L, Billinghurst L. Attention and executive functioning profiles in children following perinatal arterial ischemic stroke. Child Neuropsychol. 2016 Sep 7:1-18. [Epub ahead of print]

Abstract

Perinatal arterial ischemic stroke (PAIS) is a form of childhood stroke; the majority of those affected experience neurologic sequelae, including motor, language and neurocognitive impairments. This study examines the attention and executive functioning (EF) profiles of children following PAIS, as well as the impact of age and sex. In this single-center cross-sectional study, 40 children aged 3 to 16 years (median age 7.2 years; 58% male) who have suffered a PAIS underwent a comprehensive neuropsychological battery to assess attention and EF. Parents completed behavioral questionnaires regarding real-world functioning. Composite scores were calculated for seven attention and EF domains (Attention, Working Memory, Verbal Retrieval, Inhibitory Control, Flexibility/Shifting, Planning/Organization, and Processing Speed). The results for all measured domains of attention and EF are significantly lower in the participants compared to the normative samples (p < .001), with the exception of Working Memory. However, increasing difficulty with Working Memory is associated with developing age. Older age at time of testing is also associated with a higher incidence of clinically-elevated attention deficit hyperactivity disorder (ADHD) symptoms. Sex is not associated with performance measures or parental report of functioning. The participants demonstrate mild-to-moderate attention and EF impairment compared to the normative population. Clinicians, families, and educators should be informed about the neurocognitive sequelae of PAIS and the need for close developmental surveillance in this population to identify vulnerable children and initiate appropriate therapeutic interventions in a timely fashion.