scholarly journals Recanalization strategies in childhood stroke: a 3-year surveillance study in Germany

2021 ◽  
Author(s):  
Martin Olivieri ◽  
Anna-Lisa Sorg ◽  
Raphael Weinberger ◽  
Karin Kurnik ◽  
Christoph Bidlingmaier ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Intervention Group ◽  
Rare Event ◽  
First Episode ◽  
Childhood Stroke ◽  
Facial Weakness ◽  
Rare Disorders ◽  
Presenting Symptoms ◽  
Nationwide Surveillance ◽  
A Minor

Abstract Objective Childhood acute ischemic stroke (CAIS) is a rare event. Diverse etiologies, risk factors, symptoms and stroke mimics hamper obtaining a fast diagnosis and implementing immediate recanalization strategies. Methods Over a period of 3 years (2015–2017), the data of 164 pediatric patients (> 28 days of life-18 years) with a first episode of AIS were submitted to a hospital-based nationwide surveillance system for rare disorders (ESPED). We report a subgroup analysis of patients who have undergone recanalization therapy and compare these data with those of the whole group. Results Twenty-eight patients (17%) with a median age of 12.2 years (range: 3.3–16.9) received recanalization therapy. Hemiparesis, facial weakness and speech disturbance were the main presenting symptoms. The time from onset of symptoms to confirmation of diagnosis was significantly shorter in the intervention group (4.1h vs. 20.4 h, p = < 0.0001). Only in one patient occurred a minor bleed. Cardiac disease as predisposing risk factor was more common in the recanalization group. Conclusion Recanalization therapies are feasible and increasingly applied in children with AIS. High awareness, timely diagnosis and a large amount of expertise may improve time to treatment and make hyperacute therapy an option for more patients improving their outcomes.

scholarly journals Recanalization strategies in childhood stroke in Germany

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Martin Olivieri ◽  
Anna-Lisa Sorg ◽  
Raphael Weinberger ◽  
Karin Kurnik ◽  
Christoph Bidlingmaier ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Intervention Group ◽  
Rare Event ◽  
First Episode ◽  
Facial Weakness ◽  
Arterial Ischemic Stroke ◽  
Rare Disorders ◽  
Presenting Symptoms ◽  
Nationwide Surveillance ◽  
A Minor

AbstractChildhood arterial ischemic stroke (CAIS) is a rare event. Diverse etiologies, risk factors, symptoms and stroke mimics hamper obtaining a fast diagnosis and implementing immediate recanalization strategies. Over a period of 3 years (2015–2017), the data of 164 pediatric patients (> 28 days of life-18 years) with a first episode of AIS were submitted to a hospital-based nationwide surveillance system for rare disorders (ESPED). We report a subgroup analysis of patients who have undergone recanalization therapy and compare these data with those of the whole group. Twenty-eight patients (17%) with a median age of 12.2 years (range 3.3–16.9) received recanalization therapy. Hemiparesis, facial weakness and speech disturbance were the main presenting symptoms. The time from onset of symptoms to confirmation of diagnosis was significantly shorter in the intervention group (4.1 h vs. 20.4 h, p ≤ 0.0001). Only in one patient occurred a minor bleed. Cardiac disease as predisposing risk factor was more common in the recanalization group. Recanalization therapies are feasible and increasingly applied in children with AIS. High awareness, timely diagnosis and a large amount of expertise may improve time to treatment and make hyperacute therapy an option for more patients.

scholarly journals 1346. Implementation of a Multidisciplinary 48 Hour Antibiotic Timeout in a Pediatric Population

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S684-S684
Author(s):  
Victoria Konold ◽  
Palak Bhagat ◽  
Jennifer Pisano ◽  
Natasha N Pettit ◽  
Anish Choksi ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Pediatric Population ◽  
Intervention Group ◽  
Post Intervention ◽  
Days Of Therapy ◽  
New Antibiotics ◽  
Core Elements ◽  
Quasi Experimental ◽  
Empirical Antibiotics ◽  
The Impact

Abstract Background To meet the core elements required for antimicrobial stewardship programs, our institution implemented a pharmacy-led antibiotic timeout (ATO) process in 2017 and a multidisciplinary ATO process in 2019. An antibiotic timeout is a discussion and review of the need for ongoing empirical antibiotics 2-4 days after initiation. This study sought to evaluate both the multidisciplinary ATO and the pharmacy-led ATO in a pediatric population, compare the impact of each intervention on antibiotic days of therapy (DOT) to a pre-intervention group without an ATO, and to then compare the impact of the pharmacy-led ATO versus multidisciplinary ATO on antibiotic days of therapy (DOT). Methods This was a retrospective, pre-post, quasi-experimental study of pediatric patients comparing antibiotic DOT prior to ATO implementation (pre-ATO), during the pharmacy-led ATO (pharm-ATO), and during the multidisciplinary ATO (multi-ATO). The pre-ATO group was a patient sample from February-September 2016, prior to the initiation of a formal ATO. The pharmacy-led ATO was implemented from February-September 2018. This was followed by a multidisciplinary ATO led by pediatric residents and nurses from February-September 2019. Both the pharm-ATO and the multi-ATO were implemented as an active non-interruptive alert added to the electronic health record patient list. This alert triggered when new antibiotics had been administered to the patient for 48 hours, at which time, the responsible clinician would discuss the antibiotic and document their decision via the alert workspace. Pediatric patients receiving IV or PO antibiotics administered for at least 48 hours were included. The primary outcome was DOT. Secondary outcomes included length of stay (LOS) and mortality. Results 1284 unique antibiotic orders (n= 572 patients) were reviewed in the pre-ATO group, 868 (n= 323 patients) in the pharm-ATO and 949 (n= 305 patients) in the multi-ATO groups. Average DOT was not significantly different pre vs post intervention for either methodology (Table 1). Mortality was similar between groups, but LOS was longer for both intervention groups (Table 1). Impact of an ATO on DOT, Mortality and LOS Conclusion An ATO had no impact on average antibiotic DOT in a pediatric population, regardless of the ATO methodology. Disclosures All Authors: No reported disclosures

Retroclival Epidural Hematomas

Neurosurgery ◽  
2010 ◽  
Vol 67 (2) ◽  
pp. 404-407 ◽  
Author(s):  
R. Shane Tubbs ◽  
Christoph J. Griessenauer ◽  
Todd Hankinson ◽  
Curtis Rozzelle ◽  
John C. Wellons ◽  
...  
Keyword(s):  
Glasgow Coma Scale ◽  
Scale Score ◽  
Glasgow Coma Scale Score ◽  
Pediatric Patients ◽  
Motor Vehicle ◽  
Coma Scale ◽  
Presenting Symptoms ◽  
Cord Injury ◽  
The Mean

Abstract BACKGROUND Retroclival epidural hematomas (REDHs) are infrequently reported. To our knowledge, only 19 case reports exist in the literature. OBJECTIVE This study was performed to better elucidate this pathology. METHODS We prospectively collected data for all pediatric patients diagnosed with REDH from July 2006 through June 2009. Data included mechanism of injury, Glasgow Coma Scale score, neurological examination, treatment modality, and outcome. Magnetic resonance imaging was used to measure REDH dimensions. RESULTS Eight children were diagnosed with REDH, and the hematomas were secondary to motor vehicle–related trauma in all cases. The mean age of patients was 12 years (range 4–17 years). The mean REDH height (craniocaudal) was 4.0 cm, and the mean thickness (dorsoventral) was 1.0 cm. At presentation, the mean Glasgow Coma Scale score was 8 (range 3–14), and there was no correlation between hematoma size and presenting symptoms. Two patients died soon after injury, and 2 additional patients had atlanto-occipital dislocation that required surgical intervention. No patient underwent surgical evacuation of the REDH. The mean follow-up was 14 months. At most recent follow-up, 4 patients are neurologically intact, 1 patient has a complete spinal cord injury, and 1 patient has mild bilateral abducens nerve palsy. CONCLUSION To our knowledge, this study of 8 pediatric patients is the largest series of patients with REDH thus far reported. Based on our study, we found that REDH is likely to be underdiagnosed, atlanto-occipital dislocation should be considered in all cases of REDH, and many patients with REDH will have minimal long-term neurological injury.

Abstract TP174: Identifying Predictors for Final Diagnosis of Ischemic Events in an Emergency Department Observation Unit

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Arooshi Kumar ◽  
Koto Ishida ◽  
Ava Liberman ◽  
Cen Zhang ◽  
Shadi Yaghi ◽  
...  
Keyword(s):  
Emergency Department ◽  
Clinical Features ◽  
Univariate Analysis ◽  
Final Diagnosis ◽  
Minor Stroke ◽  
Symptom Duration ◽  
Facial Weakness ◽  
Presenting Symptoms ◽  
History Of ◽  
Ischemic Events

Introduction: Transient neurologic events have high rates of diagnostic uncertainty. Emergency department observation units (ED-OU) allow an accelerated diagnostic work up for suspected transient ischemic attacks (TIAs). However, clinical decision support regarding which patients to admit to these units is lacking. This study aimed to identify clinical features that differentiate true ischemic events from nonischemic transient neurological attacks (NI-TNA) among patients admitted to an ED-OU for suspected TIA. Methods: A retrospective analysis was performed on consecutive patients admitted to the ED-OU at a single academic center for suspected TIA. Demographics, vascular risk factors, presenting symptoms, and details of the clinical presentation were abstracted from chart review. Final discharge diagnosis was dichotomized to either ischemic event (TIA or minor stroke, TIAMS) or NI-TNA based on the treating vascular neurologist’s final diagnosis. Standard statistical tests were used for comparison testing between the two groups. Significantly different factors with p<0.2 on univariate analysis were carried forward in a multivariable logistic regression model. Results: Of 186 consecutive patients, 101 (54%) had a final diagnosis of NI-TNA and 85 (46%) of TIAMS. The median population ABCD2 score was 4 [IQR 3-4]. On univariate analysis, older age (63 vs. 70, p<0.01), history of atrial fibrillation (AF) (12% vs. 26%, p=0.01), and facial weakness (5% vs. 14% p=0.03) were associated with TIAMS. Headache (24% vs. 12%, p=0.04) and symptom duration>60min (57% vs. 40%, p=0.02) were associated with NI-TNA. On multivariable analysis, only symptom duration>60 minutes predicted NI-TNA (OR 0.39, p=0.04) and only history of AF (OR 2.53, p=0.03) predicted TIAMS. Facial weakness was strongly predictive of TIAMS (OR 3.22, p=0.05), but not significant. Conclusion: We identified two clinical features that distinguished TIAMS from NI-TNA among patients admitted to an ED-OU for suspected TIA.These may be helpful in emergency room triage of TIAMS. Data from ED-OU can be used to identify factors associated with cerebral ischemia and improve current care pathways for patients with suspected TIA, so diagnostic evaluation is received in the most appropriate setting.

scholarly journals 148. Retrospective Evaluation of Acute Cholangitis and Clinical Implication and Management of Secondary Bacteremia

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S101-S101
Author(s):  
Ahmed Hamdi ◽  
Zachary A Yetmar ◽  
Alexander T Miller ◽  
Mark Diaz ◽  
Madiha Fida ◽  
...  
Keyword(s):  
Antibiotic Therapy ◽  
Acute Cholangitis ◽  
Source Control ◽  
First Episode ◽  
Tokyo Guidelines ◽  
Presenting Symptoms ◽  
Mortality Difference ◽  
Grade Ii ◽  
Gram Negative Organisms ◽  
Prime Target

Abstract Background Optimum duration of antimicrobial therapy for acute bacteremic cholangitis is not well established; however, 4–7 days is recommended by the 2018 Tokyo guidelines in those without Gram-positive bacteremia. Methods A retrospective study performed at Mayo Clinic - Rochester, Florida and Arizona sites was conducted, reviewing all adult patients with the first episode of acute cholangitis secondary to biliary stone obstruction, between January 1, 2012 and December 31, 2017. We reviewed the duration of prescribed antimicrobials. Results Among 331 included cases, 197(60%) were men, 66 (20%) were immuno-compromised. Presenting symptoms included fever in 202 (61.5%), abdominal pain in 289 (87%), jaundice 128(38.7%), and altered mentation in 49 (15%). Among these, 256 (77%) were classified as “definite” and 38 (11.5%) were “suspected” using the 2018 Tokyo guideline classification. Cholangitis grade was grade III in 134 (40.5%); grade II in 115 (34.7%); and grade I in 82 (24.8%). Majority of cases, 321 (97%), underwent source control—most commonly 309 (96%) achieved by endoscopic retrograde cholangiopancreatography (ERCP). Source control occurred within 24 hr of presentation in 197 (61.4%) of the cases. Bacteremia was documented in 131/277 (47%). Majority of bacteremias were due to Gram-negative organisms in 119 (91%). Mean duration of antibiotic therapy following “source control” was 9.6 days (SD 7.0). Cases with bacteremia, resulted in longer treatment duration, mean of 13 days (SD 5.6), regardless of the isolated organism. Overall 30 day mortality was 14/331 (4.2%). No mortality difference was noted in patients who underwent early (within 12 hours) vs. later source control (4.55% Vs. 4.53%), nor in those who received more or less than 6 days of antibiotic therapy after source control (4.7% Vs. 3.9%, P = 0.76). No difference in mortality was observed in those with or without bacteremia. Conclusion Our results note the use of longer courses of antimicrobials for management of bacteremic cholangitis, regardless of the organism type. This population could be a prime target for an antimicrobial stewardship intervention, to decrease the duration of prescribed antimicrobials in accordance with recent guidelines. Disclosures All authors: No reported disclosures.

scholarly journals Safety and efficacy of stereoelectroencephalography in pediatric focal epilepsy: a single-center experience

2018 ◽  
Vol 22 (4) ◽  
pp. 444-452 ◽  
Author(s):  
Hannah E. Goldstein ◽  
Brett E. Youngerman ◽  
Belinda Shao ◽  
Cigdem I. Akman ◽  
Arthur M. Mandel ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Surgical Intervention ◽  
Focal Epilepsy ◽  
Wound Care ◽  
Pediatric Population ◽  
Attractive Alternative ◽  
Safety And Efficacy ◽  
Single Center Experience ◽  
A Minor

OBJECTIVEPatients with medically refractory localization-related epilepsy (LRE) may be candidates for surgical intervention if the seizure onset zone (SOZ) can be well localized. Stereoelectroencephalography (SEEG) offers an attractive alternative to subdural grid and strip electrode implantation for seizure lateralization and localization; yet there are few series reporting the safety and efficacy of SEEG in pediatric patients.METHODSThe authors review their initial 3-year consecutive experience with SEEG in pediatric patients with LRE. SEEG coverage, SOZ localization, complications, and preliminary seizure outcomes following subsequent surgical treatments are assessed.RESULTSTwenty-five pediatric patients underwent 30 SEEG implantations, with a total of 342 electrodes placed. Ten had prior resections or ablations. Seven had no MRI abnormalities, and 8 had multiple lesions on MRI. Based on preimplantation hypotheses, 7 investigations were extratemporal (ET), 1 was only temporal-limbic (TL), and 22 were combined ET/TL investigations. Fourteen patients underwent bilateral investigations. On average, patients were monitored for 8 days postimplant (range 3–19 days). Nearly all patients were discharged home on the day following electrode explantation.There were no major complications. Minor complications included 1 electrode deflection into the subdural space, resulting in a minor asymptomatic extraaxial hemorrhage; and 1 in-house and 1 delayed electrode superficial scalp infection, both treated with local wound care and oral antibiotics.SEEG localized the hypothetical SOZ in 23 of 25 patients (92%). To date, 18 patients have undergone definitive surgical intervention. In 2 patients, SEEG localized the SOZ near eloquent cortex and subdural grids were used to further delineate the seizure focus relative to mapped motor function just prior to resection. At last follow-up (average 21 months), 8 of 15 patients with at least 6 months of follow-up (53%) were Engel class I, and an additional 6 patients (40%) were Engel class II or III. Only 1 patient was Engel class IV.CONCLUSIONSSEEG is a safe and effective technique for invasive SOZ localization in medically refractory LRE in the pediatric population. SEEG permits bilateral and multilobar investigations while avoiding large craniotomies. It is conducive to deep, 3D, and perilesional investigations, particularly in cases of prior resections. Patients who are not found to have focally localizable seizures are spared craniotomies.

Chiari malformation I and autism spectrum disorder: an underrecognized coexistence

2015 ◽  
Vol 15 (1) ◽  
pp. 96-100 ◽  
Author(s):  
Mayur Jayarao ◽  
Kristin Sohl ◽  
Tomoko Tanaka
Keyword(s):  
Autism Spectrum Disorder ◽  
Chiari Malformation ◽  
Pediatric Patients ◽  
Autism Spectrum ◽  
Spectrum Disorder ◽  
Symptom Improvement ◽  
Type I ◽  
Presenting Symptoms ◽  
Children With Asd ◽  
Cranial Mri

OBJECT Patients with symptomatic Chiari malformation Type I (CM-I) frequently present with headaches, neck pain, difficulty swallowing, and balance disturbances. In children with autism spectrum disorder (ASD), diagnosing CM-I can be a challenging task. Moreover, even if symptomatic, some patients do not undergo further evaluation or management, as their presentations are attributed to autism and its myriad symptoms. Therefore, cranial MRI findings were reviewed after evaluating and treating patients with coexisting ASD and CM-I. In this paper, the authors report on 5 children with ASD and symptomatic CM-I, including their clinical presentation, imaging studies, management, and outcomes, and discuss the likely underrecognized coexistence of these conditions. METHODS All pediatric patients with ASD and cranial MRI conducted for any reason in the period from 1999 to 2013 were considered for analysis. All cases with concomitant symptomatic CM-I were eligible for this retrospective analysis. RESULTS One hundred twenty-five pediatric patients diagnosed with ASD had undergone MRI, and 9 of them had evidence of cerebellar tonsillar herniation. Five patients were symptomatic and underwent suboccipital craniectomy, a C-1 or a C-1 and C-2 laminectomy, and duraplasty with bovine pericardium or Type I collagen allograft. There were no intraoperative complications. All patients showed symptom improvement and/or resolution of presenting symptoms, which included headache, dysphasia, speech, and irritability. CONCLUSIONS There is no identified cause of autism. Children with ASD can be difficult to assess specifically in a neurological examination. Thus, cranial MRI considered when completing a comprehensive diagnostic evaluation. While cranial MRI is not a routine part of ASD evaluation, this study demonstrates that CM-I and ASD may coexist and be underrecognized. The study reinforces the importance of a comprehensive medical evaluation designed to elucidate neurological findings in children with impaired communication abilities and suggests the judicious use of neuroimaging.

VESICO-URETHRAL FISTULA FORMATION IN PEDIATRIC PATIENTS UNDERGOING BLADDER NECK CLOSURE: A RARE EVENT

2009 ◽  
Vol 181 (4S) ◽  
pp. 404-405 ◽  
Author(s):  
James R Thomasch ◽  
Mark C. Adams ◽  
John C Pope ◽  
John C. Thomas ◽  
John W. Brock
Keyword(s):  
Bladder Neck ◽  
Pediatric Patients ◽  
Rare Event ◽  
Fistula Formation ◽  
Urethral Fistula ◽  
Bladder Neck Closure

An institutional series and literature review of pial arteriovenous fistulas in the pediatric population

2013 ◽  
Vol 12 (4) ◽  
pp. 344-350 ◽  
Author(s):  
Peter J. Madsen ◽  
Shih-Shan Lang ◽  
Jared M. Pisapia ◽  
Phillip B. Storm ◽  
Robert W. Hurst ◽  
...  
Keyword(s):  
Heart Failure ◽  
Literature Review ◽  
Cerebrovascular Disease ◽  
Pediatric Patients ◽  
Pediatric Population ◽  
Rare Form ◽  
Excellent Outcome ◽  
Arteriovenous Fistulas ◽  
Presenting Symptoms ◽  
Worse Prognosis

Object Pial arteriovenous fistulas (PAVFs) are a rare form of cerebrovascular disease that tend to be overrepresented in the pediatric population. There have been limited studies of the clinical features and outcomes in this group of patients. Here, the authors attempt to better delineate this clinical entity with institutional cases and a review of the literature. Methods A retrospective review of cases at our institution was performed to identify all pediatric patients treated for a PAVF between 2000 and 2012. Results Five patients treated for a PAVF were identified. Patients had a mean age of 1.9 years at diagnosis, and the most common presenting symptoms were seizure and macrocephaly. Patients were treated primarily with embolization, and 3 patients required both N-butyl cyanoacrylate (NBCA) glue and coiling. Four of the patients had complete obliteration of the PAVF and had a pediatric overall performance category score of either 1 (n = 3) or 2 (n = 1) at follow-up. There was 1 death due to heart failure. Analysis of the literature review suggested that a younger age or presence of intracerebral hemorrhage (ICH) or congestive heart failure (CHF) at presentation likely predicts a worse prognosis. Older patients presented more often with ICH, whereas younger patients presented significantly more often in CHF. The majority of pediatric patients reported on in the literature were treated with endovascular embolization, most commonly with NBCA glue alone. Most patients (65.4%) in the literature had an excellent outcome without neurological deficit. Conclusions Pial AVFs represent a serious yet rare form of cerebrovascular disease. Pediatric patients with ICH or CHF at presentation or those who are very young are likely to have a worse prognosis. Endovascular management of these patients has greatly changed the natural history of this disease, but the complication and mortality rates suggest the need for continued insights and advances in treatment.

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