Anatomical Venous Variants in Children with Cerebral Sinovenous Thrombosis

Background and Purpose - Literature is sparse on the frequency and significance of anatomical venous variants (AVVs) in pediatric cerebral sinovenous thrombosis (CSVT). Methods - We retrospectively reviewed children with CSVT and controls undergoing computed tomography/magnetic resonance venography from January 2008 to 2014. Clinical features examined included raised intracranial pressure, risk factors, and treatment. Radiological features examined included CSVT location, presence and type of AVVs, hemorrhagic venous infarction, and venous collateralization. Clinical outcome was measured by the pediatric stroke outcome measure and radiological outcome by thrombus recanalization. Results - Fifty-one children with CSVT were identified. Twenty-two (43%) had AVVs at presentation. Nineteen (86%) had hypoplasia/absence of major dural sinus, 5 (23%) had persistent fetal structures, 3 (14%) had duplications/fenestrations, and 1 (5%) had disconnected superficial and deep venous systems. Controls had a slightly higher but nonsignificant prevalence 26 (51%) of AVVs. No significant clinical and radiological differences were observed between children with CSVT and AVVs compared with those with typical venous anatomy. Conclusions - AVVs are seen in many children with and without CSVT and do not seem to alter the presentation or clinical course. The influence of these variations on the brain\u27s ability to tolerate venous congestion because of thrombosis merits further study

The State of Inpatient Child Neurology: A Survey of North American Academic Programs

BACKGROUND AND OBJECTIVES: Inpatient child neurology programs provide essential services for children. We sought to understand the current structure and challenges of inpatient pediatric neurologic care delivery in academic programs in North America. METHODS: We identified a single child neurologist from 39 of the first 40 programs on the 2019-2020 US News and World Report ranking and 3 large Canadian programs to be invited to participate in an inpatient focused survey. In October 2020, these 42 child neurologists were invited to complete an anonymous on-line survey including 37 questions about the structure, workload, and challenges of their inpatient program. Data was analyzed descriptively. RESULTS: We received responses from 30/42 (71%) invited child neurologists from unique programs. The majority (25/30, 83%) were Child Neurology Program Directors, Inpatient Directors, and/or Division Chiefs. Two-thirds (20/30, 67%) reported a total of 2-4 inpatient services. Two-thirds (20/30, 67%) reported a primary neurology admitting service. Nearly two-thirds (19/30, 63%) reported a separate ICU service, and about one-third (11/30, 37%) reported a separate stroke/vascular service. Half of respondents (15/30, 50%) reported some attendings whose primary clinical effort is in the inpatient setting. Over half (17/30, 57%) reported having trainees interested in inpatient-focused careers. About half (16/30, 53%) reported a full-time equivalent metric for inpatient time, and under half (13/30, 43%) reported use of critical-care billing. Most respondents (26/30, 87%) endorsed that inpatient attendings frequently complete documentation/sign notes outside of normal daytime hours. During night call, attendings commonly spend 30 minutes-2 hours on patient care-related phone calls between 5pm-10pm (24/30, 80%) and receive 1-3 patient care-related phone calls after 10pm (21/30, 70%). Faculty burnout was the biggest inpatient-specific challenge before the COVID-19 pandemic (25/30, 83%), and concern about faculty well-being during the COVID-19 pandemic was reported in nearly all respondents (28/30, 93%). DISCUSSION: Academic child neurology programs in North America implement varied models for inpatient care delivery and face common challenges. The information presented in this study serves to stimulate discussion, help optimize operations, and encourage novel approaches to accomplish work and advance careers in academic inpatient child neurology

Association Between Prolonged Seizures and Malignant Middle Cerebral Artery Infarction in Children With Acute Ischemic Stroke.

BACKGROUND Malignant middle cerebral artery infarct syndrome is a potentially fatal complication of stroke that is poorly understood in children. We studied the frequency, associated characteristics, and outcomes of this condition in children. METHODS Children, aged two months to 18 years with acute middle cerebral artery infarct diagnosed at our center between January 2005 and December 2012 were studied. Associations with malignant middle cerebral artery infarct syndrome were sought, including age, seizures, neurological deficit severity (Pediatric National Institute of Health Stroke Severity Score), stroke etiology, fever, blood pressure, blood glucose, infarct location, infarct volume (modified pediatric Alberta Stroke Program Early Computed Tomography Score), and arterial occlusion. Death and neurological outcomes were determined. RESULTS Among 66 children with middle cerebral artery stroke, 12 (18%) developed malignant middle cerebral artery infarct syndrome, fatal in three. Prolonged seizures during the first 24 hours (odds ratio, 25.51; 95% confidence interval, 3.10 to 334.81; P = 0.005) and a higher Pediatric National Institute of Health Stroke Severity Score (odds ratio, 1.22; 95% confidence interval, 1.08 to 1.45; P = 0.006) were independently associated with malignant middle cerebral artery infarct syndrome. All children aged greater than two years with a Pediatric National Institute of Health Stroke Severity Score ≥8 and initial seizures ≥5 minutes duration developed malignant middle cerebral artery infarct syndrome (100%). CONCLUSIONS Malignant middle cerebral artery infarct syndrome affects nearly one in five children with acute middle cerebral artery stroke. Children with higher Pediatric National Institute of Health Stroke Severity Scores and prolonged initial seizures are at greatly increased risk for malignant middle cerebral artery infarct syndrome. Children with middle cerebral artery infarcts warrant intensive neuroprotective management and close monitoring to enable early referral for hemicraniectomy surgery