Sunday, November 3, 2019

Cerebral sinovenous thrombosis and neuropsychological outcomes

Most children with cerebral sinovenous thrombosis (CSVT) performed poorly on a least one domain in neuropsychological testing, according to findings presented here at the annual meeting of the Child Neurology Society.

"There is a clear problem in the neuropsychological function in these kids. However, further investigation should be done using a larger sample size to better understand the impact of these abnormalities in real-life function," said Mahmoud Slim, PhD, a research fellow at the Hospital for Sick Children in Toronto, who presented the data.

The retrospective study aimed to better understand the long-term prospects for children with CSVT, an increasingly recognized cause of childhood stroke with an incidence of 0.4 to 0.7 per 100,000 children per year. Previous studies on neuropsychological outcomes have found that large percentages of the children have developmental delays and cognitive deficits in subsequent months. But, the study authors pointed out, most previous studies did not use as wide an array of instruments as the current study and had shorter follow-up times.

Researchers assessed 50 children on intellectual ability, executive function, adaptive behavior, attention, verbal learning and memory, and visual-motor integration. Not all of the children were assessed in all domains. They averaged about 2.5 years old at the time of their CSVT and were followed from about four to seven years, depending on the domain. A score that was at least one standard deviation below the mean was considered to be abnormally poor.

Eighty percent of children scored below normal in at least one domain, and 6 percent scored below normal in all domains that were tested, researchers found. Twenty percent scored normally.

To gauge how the testing results related to real-life function, researchers looked at the prevalence of individualized education plans; they found that 40 percent of the cohort had such a plan, compared with a community prevalence of just 9 percent.

Researchers did not find predictors of poor testing performance that rose to the level of significance, but that was likely limited by the study size, Dr. Slim said.

"We need larger studies to better tackle the question of predictors [of neuropsychological outcomes]," he said. "We mainly believe that close surveillance of the cognitive and behavioral functioning should be adapted by practicing clinicians and that children should be sent to the most adequate rehabilitation programs based on their specific needs."

Commenting on the study, Rebecca N. Ichord, MD, director of the pediatric stroke program at the Children's Hospital of Philadelphia, said that the high prevalence of neurocognitive impairments isn't surprising.

"Any population of children that experiences acquired brain injury can be expected to have long-term adverse neuropsychological morbidity—similar to what has been found in all other types of acquired brain injury such as arterial ischemic stroke, intracranial hemorrhage, and traumatic brain injury. The good news from these data is that the severity of the impairments appears generally to be in the mild range."

The bad news, she said, is that interventions to address these problems are limited and vary greatly according to geography and socioeconomic status.

"Good research such as this study should be helpful in understanding predictors and mechanisms," she said. "I would anticipate that interventions to address these problems will be applicable to multiple types of diseases—arterial ischemic stroke, neonatal hypoxia-ischemia, and traumatic brain injury."

The findings point to the need for strong partnerships between medical providers, families, and educators, she said.

"The solution to these problems must be recognized to be the responsibility of society at large, and not just the medical community. Economic disparities and social inequities will interfere with the educational and rehabilitation solutions that these children and their families will need," Dr. Ichord said. "Treatment for these problems necessarily extends to the community— education, social and mental health systems."

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