Safety of anticoagulants in children with arterial ischemic stroke

Abstract Pediatric arterial ischemic stroke (AIS) is increasingly diagnosed and carries significant risks of recurrence, morbidity, and mortality. Anticoagulant therapy (ACT) is commonly prescribed in childhood AIS. Hemorrhagic complication rates in pediatric stroke are unknown, and adult safety data are of limited applicability. We analyzed a prospectively enrolled cohort of children (aged 1 month-18 years) with acute AIS selected using standardized criteria for protocol-based ACT over14-year period. We assessed ACT-associated intracranial hemorrhage (ICH), including frequency, clinical and radiologic characteristics, predictors, and outcome. Among 215 children with AIS, 123 received ACT within 7 days after diagnosis. During anticoagulation, 14 (11%) children developed new or increased ICH, all within 26 days from diagnosis. ICH was symptomatic in 5 (4%), asymptomatic in 9 (7%), and mild (European Cooperative Acute Stroke Study grades HI1 or HI2) in all but 1 child (ECASS PH-2). Long-term neurologic outcomes after ACT-associated ICH in survivors were abnormal in 73% (8/11). Comparably, 12 of 75 (16%) children treated without anticoagulation developed new or increased ICH on follow-up imaging (P = .3507). We conclude that ACT is relatively safe in children with AIS, with a 4% risk of symptomatic ICH. Based on the safety of ACT in our study, clinical trials of ACT in childhood AIS are warranted.

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Diffusion imaging of cerebral diaschisis in neonatal arterial ischemic stroke

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2015.89 ◽

2015 ◽

Vol 42 (S1) ◽

pp. S15-S15

Author(s):

R Srivastava ◽

T Rajapakse ◽

J Roe ◽

X Wei ◽

A Kirton

Keyword(s):

Ischemic Stroke ◽

Diffusion Imaging ◽

Population Based ◽

Pediatric Stroke ◽

Arterial Ischemic Stroke ◽

Long Term Outcomes ◽

Primary Injury

Background: Neonatal arterial ischemic stroke (NAIS) is a leading cause of brain injury and cerebral palsy. Diffusion-weighted imaging (DWI) has revolutionized NAIS diagnosis and outcome prognostication. Diaschisis refers to changes in brain areas functionally connected but structurally remote from primary injury. We hypothesized that acute DWI can demonstrate cerebral diaschisis and evaluated associations with outcome. Methods: Subjects were identified from a prospective, population-based research cohort (Calgary Pediatric Stroke Program). Inclusion criteria were unilateral middle cerebral artery NAIS, DWI MRI within 10 days of birth, and >12-month follow-up (Pediatric Stroke Outcome Measure, PSOM). Diaschisis was quantified using a validated software method. Diaschisis-scores were corrected for infarct size and compared to outcomes (Mann-Whitney). Results: From 20 eligible NAIS, 2 were excluded for image quality. Of 18 remaining, 16 (89%) demonstrated diaschisis. Thalamus (88%) was most often involved. Age at imaging was not associated with diaschisis. Long-term outcomes available on 13 (81%) demonstrated no association between diaschisis score and PSOM categories. Conclusion: Cerebral diaschisis occurs in NAIS and can be quantified with DWI. Occurrence is common and should not be mistaken for additional infarction. Determining additional clinical significance will depend on larger samples with long-term outcomes.

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Could infarct location predict the long-term functional outcome in childhood arterial ischemic stroke?

Arquivos de Neuro-Psiquiatria ◽

10.1590/0004-282x20170124 ◽

2017 ◽

Vol 75 (10) ◽

pp. 692-696 ◽

Cited By ~ 2

Author(s):

Mauricio López-Espejo ◽

Marta Hernández-Chávez

Keyword(s):

Ischemic Stroke ◽

Functional Outcome ◽

Regression Models ◽

Brain Volume ◽

Arterial Ischemic Stroke ◽

Total Brain Volume ◽

Logistic Regression Models ◽

Total Brain

ABSTRACT Objective: To explore the influence of infarct location on long-term functional outcome following a first-ever arterial ischemic stroke (AIS) in non-neonate children. Method: The MRIs of 39 children with AIS (median age 5.38 years; 36% girls; mean follow-up time 5.87 years) were prospectively evaluated. Infarct location was classified as the absence or presence of subcortical involvement. Functional outcome was measured using the modified Rankin scale (mRS) for children after the follow-up assessment. We utilized multivariate logistic regression models to estimate the odds ratios (ORs) for the outcome while adjusting for age, sex, infarct size and middle cerebral artery territory involvement (significance < 0.05). Results: Both infarcts ≥ 4% of total brain volume (OR 9.92; CI 1.76 – 55.9; p 0.009) and the presence of subcortical involvement (OR 8.36; CI 1.76 – 53.6; p 0.025) independently increased the risk of marked functional impairment (mRS 3 to 5). Conclusion: Infarct extension and location can help predict the extent of disability after childhood AIS.

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Computerized Working-Memory Training for Children Following Arterial Ischemic Stroke: A Pilot Study With Long-Term Follow-Up

Applied Neuropsychology Child ◽

10.1080/21622965.2015.1055563 ◽

2016 ◽

Vol 5 (4) ◽

pp. 273-282 ◽

Cited By ~ 19

Author(s):

Megan Eve ◽

Fiadhnait O'Keeffe ◽

Simren Jhuty ◽

Vijeya Ganesan ◽

Gary Brown ◽

...

Keyword(s):

Working Memory ◽

Ischemic Stroke ◽

Pilot Study ◽

Working Memory Training ◽

Memory Training ◽

Arterial Ischemic Stroke ◽

Long Term Follow Up

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B.2 Neurologic outcome trajectory following neonatal arterial ischemic stroke (NAIS): A longitudinal observational study

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2021.271 ◽

2021 ◽

Vol 48 (s3) ◽

pp. S16-S16

Author(s):

M Slim ◽

E Pullenayegum ◽

A Aziz ◽

N Dlamini ◽

D MacGregor ◽

...

Keyword(s):

Cognitive Deficits ◽

Classification Scheme ◽

Close Monitoring ◽

Arterial Ischemic Stroke ◽

Cognitive Domains ◽

Neurologic Outcomes ◽

Longitudinal Observational Study ◽

Long Term Follow Up

Background: Studies evaluating long-term neurologic outcomes following NAIS are scanty. We aimed to study the emergence pattern of neurologic deficits following NAIS. Methods: Neonates diagnosed with AIS were prospectively enrolled and outcomes were evaluated using the validated Pediatric Stroke Outcome Measure-Severity Classification Scheme. Neurologic outcomes were classified as normal/mild, moderate or severe. Trend analysis was conducted using Cochran-Armitage test. Results: A total of 126 neonates (59% males) were followed for a median of 5.2 years (IQR:3.4-6.4 years). The proportion of children classified as normal/mild declined from 94% to 76% >5 years post-stroke (p<0.01). Moderate and severe outcomes increased from 5% to 15% and 1% to 8% (p=0.01), respectively. Sensorimotor, language and cognitive deficits emerged in 16%, 14%, and 17% of enrolled neonates, respectively. Of those who had normal/mild outcomes at baseline, 83 remained stable throughout the study. Improvement in neurologic outcomes was seen in 8 children. Thirty-five neonates had emerging deficits at one point during follow-up. Congenital heart disease predicted the emergence of deficits (odds ratio=3.3, 95% confidence interval:1.01-10.5). Conclusions: Emerging deficits following NAIS are not uncommon and can equally manifest in sensorimotor, language or cognitive domains. Thus, long-term follow-up and close monitoring of outcomes following NAIS is crucial.

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Mechanical thrombectomy in pediatric stroke: systematic review, individual patient data meta-analysis, and case series

Journal of Neurosurgery Pediatrics ◽

10.3171/2019.5.peds19126 ◽

2019 ◽

Vol 24 (5) ◽

pp. 558-571 ◽

Cited By ~ 3

Author(s):

Kartik Bhatia ◽

Hans Kortman ◽

Christopher Blair ◽

Geoffrey Parker ◽

David Brunacci ◽

...

Keyword(s):

Systematic Review ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Case Reports ◽

Meta Analysis ◽

Case Series ◽

Neurological Outcomes

OBJECTIVEThe role of mechanical thrombectomy in pediatric acute ischemic stroke is uncertain, despite extensive evidence of benefit in adults. The existing literature consists of several recent small single-arm cohort studies, as well as multiple prior small case series and case reports. Published reports of pediatric cases have increased markedly since 2015, after the publication of the positive trials in adults. The recent AHA/ASA Scientific Statement on this issue was informed predominantly by pre-2015 case reports and identified several knowledge gaps, including how young a child may undergo thrombectomy. A repeat systematic review and meta-analysis is warranted to help guide therapeutic decisions and address gaps in knowledge.METHODSUsing PRISMA-IPD guidelines, the authors performed a systematic review of the literature from 1999 to April 2019 and individual patient data meta-analysis, with 2 independent reviewers. An additional series of 3 cases in adolescent males from one of the authors’ centers was also included. The primary outcomes were the rate of good long-term (mRS score 0–2 at final follow-up) and short-term (reduction in NIHSS score by ≥ 8 points or NIHSS score 0–1 at up to 24 hours post-thrombectomy) neurological outcomes following mechanical thrombectomy for acute ischemic stroke in patients < 18 years of age. The secondary outcome was the rate of successful angiographic recanalization (mTICI score 2b/3).RESULTSThe authors’ review yielded 113 cases of mechanical thrombectomy in 110 pediatric patients. Although complete follow-up data are not available for all patients, 87 of 96 (90.6%) had good long-term neurological outcomes (mRS score 0–2), 55 of 79 (69.6%) had good short-term neurological outcomes, and 86 of 98 (87.8%) had successful angiographic recanalization (mTICI score 2b/3). Death occurred in 2 patients and symptomatic intracranial hemorrhage in 1 patient. Sixteen published thrombectomy cases were identified in children < 5 years of age.CONCLUSIONSMechanical thrombectomy may be considered for acute ischemic stroke due to large vessel occlusion (ICA terminus, M1, basilar artery) in patients aged 1–18 years (Level C evidence; Class IIb recommendation). The existing evidence base is likely affected by selection and publication bias. A prospective multinational registry is recommended as the next investigative step.

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Intracameral Bevacizumab Versus Sub-Tenon’s Mitomycin C as Adjuncts to Trabeculectomy: 3-Year Results of a Prospective Randomized Study

Journal of Clinical Medicine ◽

10.3390/jcm10102054 ◽

2021 ◽

Vol 10 (10) ◽

pp. 2054

Author(s):

Gerasimos Kopsinis ◽

Dimitrios Tsoukanas ◽

Dimitra Kopsini ◽

Theodoros Filippopoulos

Keyword(s):

Mitomycin C ◽

Primary Outcome ◽

Randomized Study ◽

Primary Outcome Measure ◽

Complication Rates ◽

Filtration Surgery ◽

Significant Difference ◽

Exfoliative Glaucoma

Conjunctival wound healing determines success after filtration surgery and the quest for better antifibrotic agents remains active. This study compares intracameral bevacizumab to sub-Tenon’s mitomycin C (MMC) in trabeculectomy. Primary open-angle or exfoliative glaucoma patients were randomized to either bevacizumab (n = 50 eyes) or MMC (n = 50 eyes). The primary outcome measure was complete success, defined as Intraocular Pressure (IOP) > 5 mmHg and ≤ 21 mmHg with a minimum 20% reduction from baseline without medications. Average IOP and glaucoma medications decreased significantly in both groups at all follow-up points compared to baseline (p < 0.001), without significant difference between groups at 3 years (IOP: bevacizumab group from 29 ± 9.4 to 15 ± 3.4 mmHg, MMC group from 28.3 ± 8.7 to 15.4 ± 3.8 mmHg, p = 0.60; Medications: bevacizumab group from 3.5 ± 0.9 to 0.5 ± 1, MMC group from 3.6 ± 0.7 to 0.6 ± 1.1, p = 0.70). Complete success, although similar between groups at 3 years (66% vs. 64%), was significantly higher for bevacizumab at months 6 and 12 (96% vs. 82%, p = 0.03; 88% vs. 72%, p = 0.04, respectively) with fewer patients requiring medications at months 6, 9 and 12 (4% vs. 18%, p = 0.03; 6% vs. 20%, p = 0.04; 8% vs. 24%, p = 0.03, respectively). Complication rates were similar between groups. In conclusion, intracameral bevacizumab appears to provide similar long-term efficacy and safety results as sub-Tenon’s MMC after trabeculectomy.

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439 Conservative Versus Surgical Management of Complicated Diverticulitis - A Retrospective Study of Long-Term Outcomes

British Journal of Surgery ◽

10.1093/bjs/znab134.280 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

E Durity ◽

G Elliott ◽

T Gana

Keyword(s):

Complicated Diverticulitis ◽

Complication Rates ◽

Long Term Outcomes ◽

Female Ratio ◽

Stoma Reversal ◽

Group A ◽

Grade 3 ◽

Group B

Abstract Introduction Management of complicated diverticulitis has shifted towards a conservative approach over time. This study evaluates the feasibility and long-term outcomes of conservative management. Method We retrospectively evaluated a consecutive series of patients managed with perforated colonic diverticulitis from 2013-2017. Results Seventy-three (73) patients were included with a male to female ratio of 1:2. Thirty-one (31) underwent Hartmann’s procedure (Group A) and 42 patients were managed with antibiotics +/- radiological drainage (Group B). Mean follow-up was 64.9 months (range 3-7 years). CT Grade 3 and 4 disease was observed in 64.5% and 40.4% of Group A and Group B patients, respectively. During follow-up, 9 (21.4%) Group B patients required Hartmann’s. Group A had longer median length of stay compared to Group B (25.1 vs 9.2 days). Post-operative complications occurred in 80.6% with 40% being Clavien-Dindo grade III or higher in group A. Stoma reversal was performed in 8 patients (25.8%). Conclusions In carefully selected cases, complicated diverticulitis including CT grade 3 and 4 disease, can be managed conservatively with acceptable recurrence rates (16.7% at 30 days, 4.8% at 90 days, 19.0% at 5 years). Surgical intervention on the other hand, carries high post-operative complication rates and low stoma reversal rates.

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Long-term outcomes of two-stage, immediate and delayed breast reconstruction with polyurethane-covered versus textured implants: protocol of a prospective, multicentre randomised controlled trial (TIPI trial)

BMJ Open ◽

10.1136/bmjopen-2020-044219 ◽

2021 ◽

Vol 11 (5) ◽

pp. e044219

Author(s):

J X Harmeling ◽

Kevin Peter Cinca ◽

Eleni-Rosalina Andrinopoulou ◽

Eveline M L Corten ◽

M A Mureau

Keyword(s):

Randomised Controlled Trial ◽

Breast Reconstruction ◽

Controlled Trial ◽

Capsular Contracture ◽

Tissue Expander ◽

Complication Rates ◽

Two Stage ◽

Randomised Controlled

IntroductionTwo-stage implant-based breast reconstruction is the most commonly performed postmastectomy reconstructive technique. During the first stage, a tissue expander creates a sufficiently large pocket for the definite breast implant placed in the second stage. Capsular contracture is a common long-term complication associated with implant-based breast reconstruction, causing functional complaints and often requiring reoperation. The exact aetiology is still unknown, but a relationship between the outer surface of the implant and the probability of developing capsular contracture has been suggested. The purpose of this study is to determine whether polyurethane-covered implants result in a different capsular contracture rate than textured implants.Methods and analysisThe Textured Implants versus Polyurethane-covered Implants (TIPI) trial is a multicentre randomised controlled trial with a 1:1 allocation rate and a follow-up of 10 years. A total of 321 breasts of female adults undergoing a two-stage breast reconstruction will be enrolled. The primary outcome is capsular contracture at 10-year follow-up which is graded with the modified Baker classification. It is analysed with survival analysis using a frailty model for clustered interval-censored data, with both an intention-to-treat and per-protocol approach. Secondary outcomes are other complication rates, surgical revision rate, patient satisfaction and quality of life and user-friendliness. Outcomes are measured 2 weeks, 6 months, 1, 2, 3, 5 and 10 years postoperatively. Interim analysis is performed when 1-year, 3-year and 5-year follow-up is completed.Ethics and disseminationThe trial has been reviewed and approved by the Medical Research Ethics Committee of the Erasmus MC, University Medical Centre Rotterdam (MEC-2018-126) and locally by each participating centre. Written informed consent will be obtained from each study participant. The results will be disseminated by publication in peer-reviewed journals.Trial registrationNTR7265.

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Association between physical exercise and stroke recurrence among first-ever ischemic stroke survivors

Scientific Reports ◽

10.1038/s41598-021-92736-5 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Lisha Hou ◽

Mier Li ◽

Ju Wang ◽

Yawen Li ◽

Qianwen Zheng ◽

...

Keyword(s):

Ischemic Stroke ◽

Exercise Duration ◽

Stroke Recurrence ◽

Stroke Survivors ◽

Face To Face ◽

Baseline Information ◽

Exercise Type ◽

The Relationship

AbstractThe relationship between exercise and stroke recurrence is controversial. This study was designed to test whether an association exists between exercise and ischemic stroke recurrence in first-ever ischemic stroke survivors. Data were collected from January 2010 to June 2016. Baseline information was obtained during face-to-face interviews, and follow-up phone interviews were conducted every 3 months. Exercise type, frequency, intensity, and duration were recorded. Discrete-time survival analysis was used to determine the relationship between exercise and stroke recurrence. 760 first-ever ischemic stroke survivors who were able to exercise were enrolled. After adjusting for covariates, patients who exercised 3.5–7 h per week and more than 7 h per week had a lower relapse risk than patients who did not exercise (3.5–7: OR 0.415; > 7: OR 0.356). Moreover, if the fluctuation of exercise duration was over 4 h, the patients had a higher risk of stroke recurrence than those with variability of less than 2 h (OR 2.153, P = 0.013). Stroke survivors who engage in long-term regular mild exercise (more than 5 sessions per week and lasting on average 40 min per session) have a lower recurrence rate. Irregular exercise increases the risk of stroke recurrence.

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