Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage

Background

The use of antithrombotic agents, including anticoagulants, antiplatelet agents, and thrombolytics has increased over the last decade and is expected to continue to rise. Although antithrombotic-associated intracranial hemorrhage can be devastating, rapid reversal of coagulopathy may help limit hematoma expansion and improve outcomes.

Methods

The Neurocritical Care Society, in conjunction with the Society of Critical Care Medicine, organized an international, multi-institutional committee with expertise in neurocritical care, neurology, neurosurgery, stroke, hematology, hemato-pathology, emergency medicine, pharmacy, nursing, and guideline development to evaluate the literature and develop an evidence-based practice guideline. Formalized literature searches were conducted, and studies meeting the criteria established by the committee were evaluated.

Results

Utilizing the GRADE methodology, the committee developed recommendations for reversal of vitamin K antagonists, direct factor Xa antagonists, direct thrombin inhibitors, unfractionated heparin, low-molecular weight heparin, heparinoids, pentasaccharides, thrombolytics, and antiplatelet agents in the setting of intracranial hemorrhage.

Conclusions

This guideline provides timely, evidence-based reversal strategies to assist practitioners in the care of patients with antithrombotic-associated intracranial hemorrhage.

     

Closure of Patent Foramen Ovale and Cryptogenic Stroke: Unresolved Issues

Purpose of Review

This review summarises the results of randomised trials comparing closure of patent foramen ovale (PFO) with antithrombotic therapy in patients with cryptogenic stroke.

Recent Findings

Initially, three randomised trials failed to show superiority of PFO closure over antithrombotic therapy in patients with cryptogenic stroke. Three recently performed trials and the prolongation of an earlier trial provided evidence that PFO closure in patients with cryptogenic stroke and an age range of 18–60 years is superior to stroke prevention with antiplatelet therapy. PFO closure was not superior to anticoagulation. Anticoagulation, however, has a higher long-term bleeding risk. PFO closure could result in atrial fibrillation (AF) in a small number of patients. In most patients, AF was transient in duration. Optimal patient selection requires future research.

Summary

In patients with cryptogenic stroke aged <?60 years, PFO closure is superior to antiplatelet therapy in the prevention of recurrent stroke.

     

Influence of sex,menstrual cycle,and oral contraceptives on the cerebrovascular response to paced deep breathing

Purpose

Deep breathing assesses autonomic function; however, many researchers/clinicians do not account for hyperventilation, brain blood flow or blood pressure.

Methods

Men and women (with/without oral contraceptives) participated. women participated during low and high hormone phases of the menstrual cycle. Blood pressure, end-tidal carbon dioxide, middle cerebral artery velocity and cerebrovascular resistance were assessed.

Results

Deep breathing decreased end-tidal carbon dioxide and middle cerebral artery velocity while increasing cerebrovascular resistance in all participants; blood pressure decreased in men. There were no influences of menstrual cycle or oral contraceptives.

Conclusions

Men have different autonomic responses to deep breathing compared to women.

     

Spinal cavernous extradural angiolipoma manifesting as a spontaneous spinal epidural hematoma in a child

Introduction

Angiolipomas are benign tumors usually manifested as subcutaneous nodules. Rarely they may form spinal extradural masses. These spinal cavernous angiolipomas have mostly been described in adults.

Diagnosis

To our knowledge, spinal cavernous angiolipomas have been reported in nine pediatric patients.

Clinical presentation

In this paper, we present a 1-year-old child presenting with a spontaneous spinal epidural hematoma from a spinal cavernous angiolipoma and highlight the importance of conducting a histopathological analysis of spontaneous hematomas in previously healthy children.

     

Familien von anfallskranken Kindern

Background

Epilepsy has an impact on not only the affected child, but also the whole family, especially the parents.

Aim of the study

To give an overview of the psychosocial impact of a child’s epilepsy on his/her family.

Methods

This overview is based on a selection of primary studies, which were mainly identified by a PubMed search.

Results

Besides various worries, high support needs, and mental health problems on the part of the parents, the epilepsy of a child also leads to stress for their siblings and strains in the relationships within the family. Furthermore, there are several limitations both in everyday life and in the social activities of the affected families. The presence of additional behavioral or health problems in children has been found to be an important factor influencing the impact of epilepsy on families.

Conclusion

In a comprehensive treatment approach for children and adolescents with epilepsy, the disease-related burdens of the family should be taken into account and psychosocial support should be provided.

     

The effects of long-term medication on growth in children and adolescents with ADHD: an observational study of a large cohort of real-life patients

Background

Children and adolescents with ADHD treated with central stimulants (CS) often have growth deficits, but the implications of such treatment for final height and stature remain unclear.

Methods

Weight and height were assessed multiple times in 410 children and adolescents during long-term treatment with CS, which lasted between 0.9 and 16.1 years. Weight and height measures were converted to z-scores based on age- and sex-adjusted population tables.

Results

CS treatment was associated with (1) a relative reduction in body weight and a temporary halt in growth, (2) a weight and height lag after 72 months compared with relative baseline values. No relation to early start of medication (<6 years), gender, comorbid ODD/CD or emotional disorders was observed.

Conclusions

Treatment with central stimulants for ADHD impacts growth in children and adolescents, and growth should be continuously monitored in patients on chronic treatment with these medications.

     

Secondary Headaches in Children and Adolescents: What Not to Miss

Introduction

Headaches are a common occurrence in childhood and adolescence. Most children presenting with a chief complaint of headache have a self-limited infectious disorder or primary headache syndrome that should not require extensive workup.

Purpose of Review

Differentiating these conditions from other more serious causes of headache in children can sometimes be difficult. This article aims to provide information regarding “red flags” that should indicate a need for concern for disorders that require more urgent evaluation.

Recent Findings

Long-held beliefs about specific “red flags” that have been analyzed in recent years as to their validity and new criteria for the diagnosis of idiopathic intracranial hypertension have been elaborated based on study. These publications are reviewed in this article.

Summary

Knowledge of past and current literature on secondary headache in children, combined with thorough history taking and examination, should help determine when there is concern for a serious secondary cause for headache in children and adolescents and direct workup.

     

District and School Physical Education Policies: Implications for Physical Education and Recess Time

Background

The relationship between physical education (PE) policies and children’s PE and recess time is not well understood.

Purpose

The purpose of this study is to assess the association of district and school PE policies, the PE environment, and PE and recess time.

Methods

Key informants in 65 schools from 9 states completed instruments assessing district and school PE policies, the school PE environment, and time in PE and recess.

Results

Few significant associations were found between PE policies and PE or recess minutes; no policies were associated with both. A number of PE environmental variables were associated with both policies and time in PE and recess.

Conclusions

PE policies, their implementation, and PE environmental variables can have important implications for recess time. Some school PE environment measures designed to improve PE may result in PE time limitations. Deficiencies in PE and recess time are not likely to be effectively addressed through policy adoption alone.

     

Gender difference in QTc prolongation of people with mental disorders

Background

We examined gender difference in QTc interval distribution and its related factors in people with mental disorders.

Methods

We retrospectively reviewed medical charts of patients discharged from a university psychiatric unit between November 1997 and December 2000. Subjects were 328 patients (145 males and 183 females) taking psychotropics at their admission. We examined patient characteristics, medical history, diagnosis, and medication before admission.

Results

Mean QTc interval was 0.408 (SD = 0.036). QTc intervals in females were significantly longer than those in males. QTc of females without comorbidity was significantly longer than that of males.

Conclusion

The influence of gender difference on QTc prolongation in people with mental disorders merits further research.

     

Effect of Bike Lane Infrastructure Improvements on Ridership in One New Orleans Neighborhood

Background

Incorporating cycling into daily life is one way to increase physical activity.

Purpose

This study examined the impact of building new bike lanes in New Orleans to determine whether more people were cycling on the street and with the flow of traffic after bike lanes were built.

Methods

Through direct observation of one intervention and two adjacent streets, observers counted cyclists riding on the street and sidewalk, with and against traffic, before and after installation of the lanes. Data were tallied separately for adults, children, males, females, and by race for each location.

Results

There was an increase in cyclists on all three streets after the installation of the bike lanes, with the largest increase on the street with the new lane. Additionally, the proportion of riders cycling with traffic increased after the lanes were striped.

Conclusions

Bike lanes can have a positive impact in creating a healthy neighborhood.

     

Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis

Background

Chronic pain patients increasingly seek treatment through mindfulness meditation.

Purpose

This study aims to synthesize evidence on efficacy and safety of mindfulness meditation interventions for the treatment of chronic pain in adults.

Method

We conducted a systematic review on randomized controlled trials (RCTs) with meta-analyses using the Hartung-Knapp-Sidik-Jonkman method for random-effects models. Quality of evidence was assessed using the GRADE approach. Outcomes included pain, depression, quality of life, and analgesic use.

Results

Thirty-eight RCTs met inclusion criteria; seven reported on safety. We found low-quality evidence that mindfulness meditation is associated with a small decrease in pain compared with all types of controls in 30 RCTs. Statistically significant effects were also found for depression symptoms and quality of life.

Conclusions

While mindfulness meditation improves pain and depression symptoms and quality of life, additional well-designed, rigorous, and large-scale RCTs are needed to decisively provide estimates of the efficacy of mindfulness meditation for chronic pain.

     

Transsphenoidal meningoencephalocele associated with cleft lip and palate: challenges for diagnosis and surgical treatment

Purpose

The aim of this study was to highlight the challenges for early diagnosis and the difficulties observed in surgical treatment of patients with transsphenoidal meningoencephalocele associated with cleft lip and/or palate.

Method

We evaluated six male patients treated over the course of 4 years. Five patients presented encephalic herniation with nonfunctional brain tissue; one of these presented herniation of the pituitary gland and cerebral ventricles.

Results

All the patients received surgical treatment for the cleft lip and/or palate. Only one patient underwent repair of the meningoencephalocele, via nasal endoscopy. There were no postprocedural clinical or surgical complications.

Conclusion

The tendency is to avoid neurosurgery, opting for periodic follow-up with magnetic resonance imaging. In the presence of cleft palate, palatoplasty is essential to protect the meningoencephalocele.

     

Idiopathisch generalisierte Epilepsien

Background

Although the sociomedical importance of epilepsies has been extensively investigated, data regarding social long-term outcome and quality of life of people with idiopathic generalized epilepsies (IGE) are lacking.

Objectives

Predictors for the psychosocial outcome and the quality of life in patients with IGE are identified and discussed.

Materials and methods

The findings of existing studies on the social outcome in patients with various IGE syndromes are analyzed and discussed.

Results

Patients with absence epilepsy or juvenile myoclonic epilepsy (JME) are reported to have an unfavorable psychosocial outcome. While in JME a lower seizure frequency or remission of the epilepsy correlates with a favorable psychosocial outcome and a higher quality of life, remission of epilepsy is not predictive for a better social outcome among patients with absence epilepsy. Compared to other IGE syndromes, IGE with generalized, tonic–clonic seizures on awakening appears have a more favorable psychosocial outcome.

Conclusion

Several predictors for the psychosocial outcome and the quality of life have been identified and may potentially increase the clinicians’ ability and confidence to recommend different treatment options to patients with IGE.

     

Skull fracture mimicking eosinophilic granuloma

Background

Delayed swelling after skull fractures is an uncommon complication following head trauma in children. Classically, growing skull fractures typically present in patients under 3 years of age with progressive subcutaneous fluid collections, or occasionally with neurologic symptoms. We present the case of a healthy 2-year-old boy with a lytic “punched-out” frontal skull lesion. The child presented 2 months after a minor forehead injury for which no medical attention was sought.

Methods

The skull defect had no associated leptomeningeal cyst or brain herniation. Imaging and presentation were thought to be consistent with eosinophilic granuloma. Histologic findings demonstrated a healing skull fracture.

Results

Cranioplasty was performed, and the patient had an uncomplicated postoperative course.

Conclusions

In this report, we describe our experience with this atypical presentation of a healing skull fracture mimicking a typical eosinophilic granuloma.

     

Selective dorsal rhizotomy as an alternative to intrathecal baclofen pump replacement in GMFCS grades 4 and 5 children

Background

Conventionally, selective dorsal rhizotomy (SDR) has been reserved for ambulant children and implantation of intrathecal baclofen (ITB) pump for non-ambulant children with cerebral palsy. Rather than replacing the ITB pump in selected Gross Motor Function Classification System (GMFCS) grades 4 and 5 children, we elected to undertake SDR instead. We discuss the rationale and outcomes.

Objectives

To assess if children with severe spasticity treated with long-term ITB pump would benefit from SDR as alternative procedure to replacement of ITB pump.

Method

This study is a prospective review of ten children with severe spasticity. Indications for ITB pump replacement in 3/10 children were previous ITB pump infection and the remaining seven were nearing depletion of drug delivery system. Pre- and post-SDR mean modified Ashworth scores, assessment of urological function and survey of parent/carer satisfaction were undertaken.

Result

Mean Ashworth score reductions post-SDR in the lower limbs and upper limbs were 2.4 and 1.70, respectively. An improvement in urological function was also noticed in 27 % of patients. Overall, 90 % of parents/carers felt that functional outcome with SDR was improved compared with that of ITB.

Conclusion

SDR in comparison to ITB in this subgroup is cheaper, less intrusive by avoiding refills/replacement and found to be more effective than ITB in reducing spasticity and providing ease for nursing care. We therefore suggest that consideration should be given to SDR as an alternative in patients previously implanted with ITB systems complicated by infection or nearing end of battery life.

     

Pediatric Delirium: Recognition,Management, and Outcome

Purpose of Review

This review seeks to provide an update on the diagnosis, management, and outcome of pediatric delirium.

Recent Findings

Care of patients with delirium depends on correct diagnosis and treatment of its underlying cause. A variety of instruments are available to aid diagnosis. Management of delirium currently depends on atypical antipsychotics, while avoiding agents that may precipitate or exacerbate it.While most critically ill children survive delirium, many children die or have worsening function after their illness. The longer the duration of delirium, the more severe its subsequent problems including postintensive care syndrome and posttraumatic stress disorder.

Summary

Possible serious long-term consequences emphasize the importance of efforts to improve diagnosis and outcome in critically ill children suffering from delirium.

     

Acute Treatment of Stroke (Except Thrombectomy)

Purpose of Review

The management of patients with acute stroke has been revolutionized in recent years with the advent of new effective treatments. In this rapidly evolving field, we provide an update on the management of acute stroke excluding thrombectomy, looking to recent, ongoing, and future trials.

Recent Findings

Large definitive trials have provided insight into acute stroke care including broadening the therapeutic window for thrombolysis, alternatives to standard dose alteplase, the use of dual antiplatelet therapy early after minor ischemic stroke, and treating elevated blood pressure in intracerebral hemorrhage. Further ongoing and future trials are eagerly awaited in this ever-expanding area.

Summary

Although definitive trials have led to improvements in acute stroke care, there remains a need for further research to improve our understanding of pathophysiological mechanisms underlying different stroke types with the potential for treatments to be tailored to the individual.

     

Magnetic resonance imaging findings of bilateral thalamic involvement in severe paroxysmal sympathetic hyperactivity: a pediatric case series

Purpose

Paroxysmal sympathetic hyperactivity is a complication of brain injury that has mainly been described in the adult brain injury literature.

Methods

We present a case series of three pediatric patients that developed paroxysmal sympathetic hyperactivity of varying severity following hypoxic brain injury.

Results

Comparison of brain magnetic resonance imaging revealed bilateral and symmetric global ischemic changes in all three cases. However, the thalamus was not affected in the patient with the mild case of paroxysmal sympathetic hyperactivity. In contrast, bilateral and symmetric damage to the thalamus was observed in the two severe cases.

Conclusions

Our case series suggests that in hypoxic brain injury, evidence of bilateral ischemic injury to the thalamus on magnetic resonance imaging may be an important early predictor of severity and length of paroxysmal sympathetic hyperactivity. While this is an interesting observation, definite proof of our hypothesis requires further research including analysis of larger numbers of patients and comparison of MRI findings in children with hypoxic brain injury that do not develop paroxysmal sympathetic hyperactivity.

     

Physician Power to Declare Death by Neurologic Criteria Threatened

Background

Three recent lawsuits that address declaration of brain death (BD) garnered significant media attention and threaten to limit physician power to declare BD.

Methods

We discuss these cases and their consequences including: the right to refuse an apnea test, accepted medical standards for declaration of BD, and the irreversibility of BD.

Results

These cases warrant discussion because they threaten to: limit physicians’ power to determine death; incite families to seek injunctions to continue organ support after BD; and force hospitals to dispense valuable resources to dead patients in lieu of patients with reparable illnesses or injuries.

Conclusions

Physicians, philosophers, religious officials, ethicists, and lawyers must work together to address these issues and educate both the public and medical community about BD.