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      Paediatric arterial ischemic stroke: acute management, recent advances and remaining issues

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          Abstract

          Stroke is a rare disease in childhood with an estimated incidence of 1-6/100.000. It has an increasingly recognised impact on child mortality along with its outcomes and effects on quality of life of patients and their families. Clinical presentation and risk factors of paediatric stroke are different to those of adults therefore it can be considered as an indipendent nosological entity. The relative rarity, the age-related peculiarities and the variety of manifested symptoms makes the diagnosis of paediatric stroke extremely difficult and often delayed. History and clinical examination should investigate underlying diseases or predisposing factors and should take into account the potential territoriality of neurological deficits and the spectrum of differential diagnosis of acute neurological accidents in childhood. Neuroimaging (in particular diffusion weighted magnetic resonance) is the keystone for diagnosis of paediatric stroke and other investigations might be considered according to the clinical condition. Despite substantial advances in paediatric stroke research and clinical care, many unanswered questions remain concerning both its acute treatment and its secondary prevention and rehabilitation so that treatment recommendations are mainly extrapolated from studies on adult population. We have tried to summarize the pathophysiological and clinical characteristics of arterial ischemic stroke in children and the most recent international guidelines and practical directions on how to recognise and manage it in paediatric emergency.

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          Management of stroke in infants and children: a scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young.

          The purpose of this statement is to review the literature on childhood stroke and to provide recommendations for optimal diagnosis and treatment. This statement is intended for physicians who are responsible for diagnosing and treating infants, children, and adolescents with cerebrovascular disease. The Writing Group members were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee. The panel included members with several different areas of expertise. Each of the panel's recommendations was weighted by applying the American Heart Association Stroke Council's Levels of Evidence grading algorithm. After being reviewed by panel members, the manuscript was reviewed by 4 expert peer reviewers and by members of the Stroke Council Leadership Committee and was approved by the American Heart Association Science Advisory and Coordinating Committee. We anticipate that this statement will need to be updated in 4 years. Evidence-based recommendations are provided for the prevention of ischemic stroke caused by sickle cell disease, moyamoya disease, cervicocephalic arterial dissection, and cardiogenic embolism. Recommendations on the evaluation and management of hemorrhagic stroke also are provided. Protocols for dosing of heparin and warfarin in children are suggested. Also included are recommendations on the evaluation and management of perinatal stroke and cerebral sinovenous thrombosis in children.
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            Predictors of cerebral arteriopathy in children with arterial ischemic stroke: results of the International Pediatric Stroke Study.

            Cerebral arteriopathies, including an idiopathic focal cerebral arteriopathy of childhood (FCA), are common in children with arterial ischemic stroke and strongly predictive of recurrence. To better understand these lesions, we measured predictors of arteriopathy within a large international series of children with arterial ischemic stroke. Between January 2003 and July 2007, 30 centers within the International Pediatric Stroke Study enrolled 667 children (age, 29 days to 19 years) with arterial ischemic stroke and abstracted clinical and radiographic data. Cerebral arteriopathy and its subtypes were defined using published definitions; FCA was defined as cerebral arterial stenosis not attributed to specific diagnoses such as moyamoya, arterial dissection, vasculitis, or postvaricella angiopathy. We used multivariate logistic regression techniques to determine predictors of arteriopathy and FCA among those subjects who received vascular imaging. Of 667 subjects, 525 had known vascular imaging results, and 53% of those (n=277) had an arteriopathy. The most common arteriopathies were FCA (n=69, 25%), moyamoya (n=61, 22%), and arterial dissection (n=56, 20%). Predictors of arteriopathy include early school age (5 to 9 years), recent upper respiratory infections, and sickle cell disease, whereas prior cardiac disease and sepsis reduced the risk of arteriopathy. The only predictor of FCA was recent upper respiratory infection. Arteriopathy is prevalent among children with arterial ischemic stroke, particularly those presenting in early school age, and those with a history of sickle cell disease. Recent upper respiratory infection predicted cerebral arteriopathy and FCA in particular, suggesting a possible role for infection in the pathogenesis of these lesions.
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              Efficacy of constraint-induced movement therapy for children with cerebral palsy with asymmetric motor impairment.

              Constraint-Induced Movement (CI) therapy has been found to be a promising treatment for substantially increasing the use of extremities affected by such neurologic injuries as stroke and traumatic brain injury in adults. The purpose of this study was to determine the applicability of this intervention to young children with cerebral palsy. A randomized, controlled clinical trial of pediatric CI therapy in which 18 children with diagnosed hemiparesis associated with cerebral palsy (7-96 months old) were randomly assigned to receive either pediatric CI therapy or conventional treatment. Pediatric CI therapy involved promoting increased use of the more-affected arm and hand by intensive training (using shaping) of the more-impaired upper extremity for 6 hours/day for 21 consecutive days coupled with bivalved casting of the child's less-affected upper extremity for that period. Children's functional upper-extremity skills were assessed in the laboratory (blinded scoring) and at home (parent ratings) just prior, after, and 3 weeks posttreatment. Treated children were followed for 6 months. Children receiving pediatric CI therapy compared with controls acquired significantly more new classes of motoric skills (9.3 vs 2.2); demonstrated significant gains in the mean amount (2.1 vs 0.1) and quality (1.7 vs 0.3) of more-affected arm use at home; and in a laboratory motor function test displayed substantial improvement including increases in unprompted use of the more-affected upper extremity (52.1% vs 2.1% of items). Benefits were maintained over 6 months, with supplemental evidence of quality-of-life changes for many children. Pediatric CI therapy produced major and sustained improvement in motoric function in the young children with hemiparesis in the study.
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                Author and article information

                Contributors
                margherita.rosa@hotmail.it
                silvidelucia@hotmail.it
                victoria.rinaldi87@gmail.com
                julie.legal@aphp.fr
                mariedesmarest@hotmail.fr
                claveropalu@hotmail.it
                silviaromanello@yahoo.it
                33 01.40.03.40.05 , luigi.titomanlio@rdb.aphp.fr
                Journal
                Ital J Pediatr
                Ital J Pediatr
                Italian Journal of Pediatrics
                BioMed Central (London )
                1824-7288
                2 December 2015
                2 December 2015
                2015
                : 41
                : 95
                Affiliations
                [ ]Department of Translational Medicine-Section of Pediatrics, Federico II University, Naples, Italy
                [ ]Department of Paediatrics, Aldo Moro University of Bari, Bari, Italy
                [ ]Department of Paediatrics, University of Perouse, Perugia, Italy
                [ ]Paediatric Migraine & Neurovascular diseases Unit, Department of Paediatrics, Robert Debré Hospital, Paris Diderot University, Sorbonne Paris Cité, Paris, France
                [ ]Paediatric Emergency Department, Robert Debré Hospital, Paris Diderot University, Sorbonne Paris Cité, Paris, France
                [ ]Pediatric Emergency Department, INSERM U-1141 AP-HP Robert Debré University Hospital, 48, Bld Sérurier, 75019 Paris, France
                Article
                174
                10.1186/s13052-015-0174-y
                4668709
                26631262
                8c9c3655-08a3-40df-826a-da7a28f4c8a1
                © Rosa et al. 2015

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 6 July 2015
                : 21 September 2015
                Categories
                Review
                Custom metadata
                © The Author(s) 2015

                Pediatrics
                paediatric stroke,arterial ischemic stroke,cerebral arteriopathy,sickle cell disease,moyamoya,antithrombotic treatment,thrombolysis

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