Rates and Risk Factors for Arterial Ischemic Stroke Recurrence in Children

BACKGROUND AND PURPOSE: Recurrent ischemic events are common in children with arterial ischemic stroke (AIS) and put patients at risk for further neurological impairment. This study sought to identify rates and risk factors for recurrent AIS or transient ischemic attack in a cohort of children seen after index AIS and uniformly investigated and managed using contemporary clinical guidelines. METHODS: Case note and radiology review of children >28 days and <18 years of age who presented to Great Ormond Street Hospital from 2005 to 2015 with index AIS. Demographic characteristics, medical history, index AIS features, radiological findings, and neurological outcome were examined. Recurrence was identified from clinical records and coded as AIS (if there was associated new cerebral infarction) or transient ischemic attack. RESULTS: Eighty-four children (43 girls; median age at index AIS, 4.1 years) were identified. Cumulative AIS recurrence was 5% at 1 month, 10% at 3 months, 12% at 6 months, 12% at 12 months, and 15% at 60 months after index event. Factors that independently predicted AIS recurrence were referral to Great Ormond Street Hospital from outside the catchment area, a prior relevant diagnosis, bilateral arteriopathy, and AIS CASCADE category 3A or 3B (Childhood AIS Standardized Classification and Diagnostic Evaluation). Multiple infarcts and evidence of mature, as well as acute, infarcts on first brain imaging, although independently associated with AIS recurrence, were also associated with bilateral arteriopathy. Only CASCADE categories 3A and 3B (bilateral cerebral arteriopathy with or without collaterals) remained significant in multivariate analysis. AIS recurrence was not associated with poor neurological outcome. CONCLUSIONS: AIS recurrence remains a significant problem, despite the wide use of antithrombotic medications. AIS subtypes should direct clinicians and future trials to use stratified management strategies and durations of treatment. Bilateral cerebral arteriopathies are especially sinister, and consensus criteria should be developed to improve consistency of management

Presentation, course, and outcome of postneonatal presentations of vein of Galen malformation: a large, single-institution case series

AIM: To describe presentation, clinical course, and outcome in postneonatal presentations of vein of Galen malformation (VGM). METHOD: Children older than 28 days presenting with VGM (from 2006-2016) were included. Notes/scans were reviewed. Outcome was dichotomized into 'good' or 'poor' using the Recovery and Recurrence Questionnaire. Logistic regression was performed to explore relationships between clinico-radiological features and outcome. RESULTS: Thirty-one children (18 males, 13 females) were included, presenting at a median age of 9.6 months (range 1.2mo-11y 7mo), most commonly with macrocrania (n=24) and prominent facial veins (n=9). Seven had evidence of cardiac failure. VGM morphology was choroidal in 19. Hydrocephalus (n=24) and loss of white matter volume (n=15) were the most common imaging abnormalities. Twenty-nine patients underwent glue embolization (median two per child). Angiographic shunt closure was achieved in 21 out of 28 survivors. Three children died of intracranial haemorrhage (1y, 6y, and 30d after embolization). Ten patients underwent neurosurgical procedures; to treat haemorrhage in four, and hydrocephalus in the rest. Outcome was categorized as good in 20 out of 28 survivors, but this was not predictable on the basis of the variables listed above. INTERPRETATION: Postneonatally presenting VGM has distinctive clinico-radiological features, attributable to venous hypertension. Endovascular treatment is associated with good outcomes, but more specific prognostic prediction was not possible within this cohort. WHAT THIS PAPER ADDS: Clinical and radiological features in older children with vein of Galen malformation relate to venous hypertension; Outcome is good in most cases with endovascular therapy; Mortality is low but is related to intracranial haemorrhage

Cross-sectional study of a UK cohort of neonatal vein of Galen malformation

Objective: Describe the course and outcomes in a UK national cohort of neonates with vein of Galen malformation (VGM) identified before 28 days of life. // Methods: Neonates with angiographically confirmed vein of Galen malformation presenting to one of the two UK treatment centres (2006‐2016) were included; those surviving were invited to participate in neurocognitive assessment. Results in each domain were dichotomised into “good” and “poor” categories. Cross‐sectional and angiographic brain imaging studies were systematically interrogated. Logistic regression was used to explore potential outcome predictors. // Results: Of 85 children with neonatal vein of Galen malformation, 51 had survived. Thirty‐four participated in neurocognitive assessment. Outcomes were approximately evenly split between “good” and “poor” categories across all domains, namely neurological status, general cognition, neuromotor skills, adaptive behaviour, and emotional and behavioural development. Important predictors of poor cognitive outcome were initial Bicetre score </=12 and presence of brain injury, specifically white matter injury, on initial imaging; in multivariable analysis only Bicetre score </=12 remained significant. // Interpretation: Despite modern supportive and endovascular treatment, over a third of unselected newborns with vein of Galen malformation did not survive. Outcome was good in around half of survivors. The importance of white matter injury suggests that abnormalities of venous, as well as arterial, circulation are important in pathophysiology of brain injury

Making Meaning of the Impact of Pre-Exposure Prophylaxis (PrEP) on Public Health and Sexual Culture: Narratives of Three Generations of Gay and Bisexual Men.

Pre-exposure prophylaxis (PrEP) with Truvada has emerged as an increasingly common approach to HIV prevention among gay, bisexual, and other men who have sex with men. This study examined generational differences and similarities in narrative accounts of PrEP among a diverse sample of 89 gay and bisexual men in the U.S. Over 50% of men in the older (52-59 years) and younger (18-25 years) generations endorsed positive views, compared with 32% of men in the middle (34-41 years) generation. Men in the middle cohort expressed the most negative (21%) and ambivalent (47%) views of PrEP. Thematic analysis of men's narratives revealed three central stories about the perceived impact of PrEP: (1) PrEP has a positive impact on public health by preventing HIV transmission (endorsed more frequently by men in the older and younger cohorts); (2) PrEP has a positive effect on gay and bisexual men's sexual culture by decreasing anxiety and making sex more enjoyable (endorsed more frequently by men in the middle and younger cohorts); and (3) PrEP has a negative impact on public health and sexual culture by increasing condomless, multi-partner sex (endorsed more frequently by men in the middle and younger cohorts). Results are discussed in terms of the significance of generation cohort in meanings of sexual health and culture and implications for public health approaches to PrEP promotion among gay and bisexual men

Making Meaning of the Impact of Pre-Exposure Prophylaxis (PrEP) on Public Health and Sexual Culture: Narratives of Three Generations of Gay and Bisexual Men.

Pre-exposure prophylaxis (PrEP) with Truvada has emerged as an increasingly common approach to HIV prevention among gay, bisexual, and other men who have sex with men. This study examined generational differences and similarities in narrative accounts of PrEP among a diverse sample of 89 gay and bisexual men in the U.S. Over 50% of men in the older (52-59 years) and younger (18-25 years) generations endorsed positive views, compared with 32% of men in the middle (34-41 years) generation. Men in the middle cohort expressed the most negative (21%) and ambivalent (47%) views of PrEP. Thematic analysis of men's narratives revealed three central stories about the perceived impact of PrEP: (1) PrEP has a positive impact on public health by preventing HIV transmission (endorsed more frequently by men in the older and younger cohorts); (2) PrEP has a positive effect on gay and bisexual men's sexual culture by decreasing anxiety and making sex more enjoyable (endorsed more frequently by men in the middle and younger cohorts); and (3) PrEP has a negative impact on public health and sexual culture by increasing condomless, multi-partner sex (endorsed more frequently by men in the middle and younger cohorts). Results are discussed in terms of the significance of generation cohort in meanings of sexual health and culture and implications for public health approaches to PrEP promotion among gay and bisexual men