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PreparedbythePaediatricStrokeWorkingGroupNovember2004StrokeinchildhoodClinicalguidelinesfordiagnosis,managementandrehabilitationClinicalEffectiveness&EvaluationUnitROYALCOLLEGEOFPHYSICIANSTheClinicalEffectivenessandEvaluationUnitTheClinicalEffectivenessandEvaluationUnit(CEEU)oftheRoyalCollegeofPhysicianshasexpertiseinthedevelomentofevidence-basedguidelinesandtheorganisingandreportingofmulticentrecomparativeperformancedata.
Theworkprogrammeiscollaborativeandmultiprofessional,involvingtherelevantspecialistsocietiesandpatientgroups,theNationalInstituteforClinicalExcellence(NICE)andtheHealthcareCommission.
TheCEEUisself-financingwithfundingfromnationalhealthservicebodies,theRoyalCollegeofPhysicians,charitiesandotherorganisations.
AcknowledgementThedevelopmentoftheseguidelineswassupportedbyfundingfromavarietyofsourcesincluding:TheStrokeAssociation,DifferentStrokes,BoehringerIngelheim,MerckSharp&Dohme,andSanofi-Synthelabo&Bristol-MyersSquibb.
TheRoyalCollegeofPhysiciansisalsopleasedtoacknowledgeagrantfromTheHaymillsCharitableTrusttowardsthecostofdesigningandprintingtheguidelines.
FrontcoverDesignbyMerritonSharp,London.
Thecoverphotograph,ofayoungboywhosufferedastrokeat15monthsbutwhohasmadeanalmostcompleterecovery,isusedbykindpermissionofDerekandJaneWalkerandDifferentStrokes.
DifferentStrokes,9CanonHarnettCourt,WolvertonMill,MiltonKeynesMK125NF.
Tel:08451307172;E-mail:info@differentstrokes.
co.
uk;Website:www.
differentstrokes.
co.
uk.
WebsiteaddressesEveryefforthasbeenmadetoensurethatthewebsiteaddressesinthisdocumentarevalidatthetimeofgoingtopress.
However,readersshouldbeawarethattheymaybesubjecttochangeovertime.
RoyalCollegeofPhysiciansofLondon11StAndrewsPlace,LondonNW14LERegisteredCharityNo210508Copyright2004RoyalCollegeofPhysiciansofLondonISBN1860162363TextdesignbythePublicationsUnitoftheRoyalCollegeofPhysiciansTypesetbyDan-SetGraphics,Telford,ShropshirePrintedinGreatBritainbyTheLavenhamPressLtd,SuffolkiiiThePaediatricStrokeWorkingGroupVijeyaGanesan(Chair)SeniorLecturerinPaediatricNeurology,InstituteofChildHealth,UniversityCollegeLondonKlingChongConsultantNeuroradiologist,GreatOrmondStreetHospitalforChildrenNHSTrustJaneEvansConsultantPaediatricHaematologist,UniversityCollegeLondonHospitalAnneGordonResearchOccupationalTherapist,InstituteofChildHealth,UniversityCollegeLondonDianneGumleyConsultantClinicalPsychologist,GreatOrmondStreetHospitalforChildrenNHSTrustPennyIrwinStrokeProgrammeCo-ordinator,RoyalCollegeofPhysicians,LondonFenellaKirkhamReaderinPaediatricNeurology,InstituteofChildHealth,UniversityCollegeLondonJanetLeesConsultantSpeechandLanguageTherapistandHonoraryLecturer,DepartmentofHumanCommunicationSciences,UniversityofSheffield,andHonoraryResearchFellow,NeurosciencesUnit,InstituteofChildHealth,UniversityCollegeLondonDonalO'KellyDifferentStrokesTerryPountneySeniorPhysiotherapist,ChaileyHeritageSchool,EastSussexEoinRedahanTheStrokeAssociationSusanRideoutClinicalSpecialistPaediatricNeurology,PhysiotherapyDepartment,BirminghamChildren'sHospitalDominicThompsonConsultantNeurosurgeon,GreatOrmondStreetHospitalforChildrenNHSTrustBethWardClinicalNurseSpecialist,GreatOrmondStreetHospitalforChildrenSueWayneTheStrokeAssociationAndrewWilliamsConsultantCommunityPaediatrician,NorthamptonGeneralHospitalKeithWoodDifferentStrokesSicklecellsubgroupKofiAnieConsultantClinicalPsychologist,BrentSickleCell&ThalassaemiaCentreLolaOniNurseDirector/Lecturer,BrentSickleCell&ThalassaemiaCentreThePaediatricStrokeWorkingGroupiiiForewordviiThechildandfamilyperspectiveixINTRODUCTION1Introduction31.
1Background31.
2Scopeoftheguidelines41.
3Purposeoftheguidelines41.
4Methodology41.
5Contextanduse62Terminologyandtheoreticalframework72.
1TheInternationalClassificationofFunctioning,DisabilityandHealth73Serviceorganisation134Childrenandtheirfamilies174.
1Consent174.
2Familiesandcarers175Acutediagnosisofarterialischaemicstrokeinchildren215.
1Definition215.
2Presentationanddiagnosis215.
3Investigations236Acutecare256.
1Generalcaremeasures256.
2Specificmedicaltreatments266.
3Secondarypreventionofarterialischaemicstrokeinchildhood276.
4Earlydisabilityassessmentandmanagement29vChapter8ContentsStrokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitation7Approachestorehabilitation317.
1Sensorimotorrehabilitation327.
1.
1Underlyingapproachtosensorimotortherapy327.
1.
2Deliveryofsensorimotortherapy337.
1.
3Useofassessmentmeasures337.
2Motorimpairment347.
2.
1Musclestrengthening347.
2.
2Managementofspasticity347.
2.
3Anklefootorthoses357.
3Sensoryimpairment367.
3.
1Somatosensoryimpairment367.
3.
2Hearingandvisionimpairment367.
3.
3Pain367.
4Languageandcommunication377.
5Cognitiveaffects387.
6Moodandbehaviour407.
7Activitiesofdailyliving418Longer-termandcommunitycare438.
1Returntoschool438.
2Transitionbetweenpaediatricandadultservices459Primaryprevention47APPENDICESAppendix1:Peerreviewers51Appendix2:Proposedauditcriteria53Appendix3:AnexampleoftheICF55Appendix4:Usefuladdresses57EVIDENCETABLES61REFERENCES77viStroke,inbothadultsandchildren,usedtobesomethingthathappenedbutwhichmedicinecoulddo,orchosetodo,littleabout.
Overthelastdecadetherehasbeenarevolutioninstrokecareforadults,withtheadventofspecialiststrokeunitsandevolvingtreatments.
PublicationofthefirsteditionoftheNationalclinicalguidelinesforstrokein2000andtheNationalSentinelAuditofStrokestimulatedlocalunitstoconsiderthequalityofthecaretheyweredeliveringandputimprovementsinplace.
Rehabilitativecareafterstrokeforadultsisnowconsideredthenorm,andthecollaborationbetweenphysicians,nurses,therapistsandpatientsintheseprojectshasledtotruemultidisciplinaryworking–muchtothebenefitofpatients.
Similarimprovements,however,havenotbeseeninthetreatmentofchildhoodstrokewhich,althoughlesscommonthanadultstroke,isstillaseriousproblemandonewhichanecdotalevidencesuggestsispronetoanevenmorevariablequalityofcare.
Thus,whenthenationalguidelineswerebeingrevisedbytheIntercollegiateStrokeWorkingParty,asubgroupwasformedtoconsiderthepaediatricaspectsofstrokecare.
Duringdevelopmentitbecameclearthatlittleevidenceexistedformanyareas.
Thegapswerefilledusingtheexpertiseofthegroupandtheviewsofpatients,parentsandcarers,butitisclearthatthereisaneedformoreformalresearch.
ThisguidelineisaimedathealthcarestaffinallpartsoftheNHSandrelatedservices,butmuchofitmayalsobeofvaluetopatients,parentsandfamilies.
Itishopedthatitwillhelpchildhoodstrokeservicestoemulatetheimprovementthathasoccurred,andiscontinuingtooccur,inthecareofadults,bringingaconsistencyandaknowledgeofbestpracticetoanareamarkeduntilnowbydislocatedcareanduncertainstandards.
Tothecasualreaderwonderingifthisisimportant–Iwouldurgeyoutobeginbyglancingattheitalicisedquotesfromparticipantsinthechildandcarerworkshopwhicharescatteredthroughthedocument.
Theyplainlyshowhowmuchmoreshouldandcanbedonetoensuregoodacutemanagement,rehabilitationandsecondaryprevention,andtohelptheseyoungpeopleandtheirparentsandfamiliesadjusttoandcopewiththeeffectsoftheirstroke.
Childrenhavealifetimeaheadofthem–anybenefitsfromimprovedcarewillalsolastalifetime.
November2004ProfessorMikePearsonDirector,ClinicalEffectivenessandEvaluationUnit,RoyalCollegeofPhysiciansviiChapter8ForewordAspartoftheguidelinedevelopmentprocessaworkshopwasheldforchildrenaffectedbystrokeandtheirfamilies.
Itgaveasenseoftheissueschildrenandfamiliesfelttobeimportant.
Weparticularlyfocusedontheseissuesindevelopingtheguidelines,andtheyareoutlinedhere.
Thechildispartofafamilyand,therefore,anychildhoodillnesswillhaveeffectsonboththeimmediateandextendedfamily.
Thediagnosisofstrokeisanunexpectedoneinachild,whichcompoundstheshockexperiencedbyfamiliesatthetimeofdiagnosis.
Thelackofinformationforfamiliesofchildrenaffectedbystrokewasastrongthemeintheworkshop.
Informationonwhathashappenedandwhattoexpectcouldempowerfamiliestoensurethattheimmediateandlong-termneedsoftheirchildcanbemet.
Informationforparents,carersandchildrenshouldbedesignedtomeettheirspecificneeds.
Thesameinformationpackisunlikelytobeappropriateinallcasesbuttheinformationleafletprovidedwiththisdocumentmayformausefulstartingpoint.
Itisimportantthatthequestionsaskedbyparents,carers,andchildrenareanswered.
Thecommunicationofinformationtochildrenisoftenparticularlyneglected.
Parentsandcarersofchildrenaffectedbystrokewelcomesupportfromthosewhohavehadsimilarexperiences–theyappreciatesomeonetotalktoaboutwhathashappenedandtohelpthemlookatthefuture.
Childrenalsowelcomemeetingswiththoseintheirownagegroupaffectedbystroke.
Bothparentsandchildrenexplainedthatthediagnosisofstrokeistraumaticandthattheyneedhelpinadjusting.
Itisimportantforfamiliestoseethatlifegoeson.
Attheendofthisdocumentthereisalistofusefulorganisations,includingsupportgroups,whichmaybeabletoprovideinformationandsupport.
Familiescommentedonsignificantgapsincommunicationbetweenthevariousprofessionalteamsinvolvedinthecareofachildaffectedbystroke,and,asdiscussedabove,betweenprofessionalsandthefamily.
Thisisanareawhichisextensivelyaddressedintheguidelines.
Therearesignificantproblemsinaccessingtherapyfollowingchildhoodstrokeinsomeareas.
Itisimportantthatthereisacoherentplanforrehabilitationwhichtakesintoaccountallofthechild'sneedsandwhichcanbemetwithinlocalresources.
Gapsinserviceprovisionshouldbehighlightedandbroughttotheattentionofserviceplanners.
ixChapter8ThechildandfamilyperspectiveIntroduction4EarlydisabilityassessmentandmanagementChapter81Introduction1.
1BackgroundChildhoodstrokeisaneglectedarea,withbothprofessionalsandthegeneralpubliclackingawarenessoftheproblemanditspotentialconsequences.
StrokeaffectsseveralhundredchildrenintheUKeachyearandisoneofthetoptencausesofchildhooddeath(Fullertonetal2002).
Manychildrenwhohaveastrokehaveanothermedicalcondition(suchasacardiacdisorderorsicklecelldisease)and,therefore,arealreadyvulnerabletoadverseneurodevelopmentaleffects(Lanthieretal2000,Ganesanetal2003).
TheprevalenceofsicklecelldiseasevarieswidelywithintheUnitedKingdom.
However,itisnoteworthythatatleast10%ofthesechildrenandyoungpeoplewillhaveastrokeduringchildhood.
Theburdenofchildhoodstrokeonthehealthservicesis,numerically,smallerthanstrokeintheelderly.
However,thelong-lastingphysical,emotionalandsocialeffectsofstrokeonanindividualnearthebeginningoftheirlifeaffectnotonlytheindividualthemselves,butalsotheirfamilyandsocietyasawhole.
Manyprofessionalagenciescanbeinvolvedinhelpingtheaffectedchildfulfiltheirpotentialandinprovidingsupportandadvicetothefamily.
Theseagenciesmaychangeinthecourseofthechild'slifeanditisimportantthattheyareallawareoftheconsequencesofchildhoodstroke,andthattheireffortsareco-ordinated.
Thechild'scognitive,socialandemotionalneedsareinconstantevolutionandthefunctionalimpactofchildhoodstrokemay,asaconsequence,varyovertime.
Wehavetakenachild-centredapproachtoformulatingtheseguidelines,workinginpartnershipwithchildren,familiesandsupportgroups,specificallyseekingtheviewsofchildrenandfamilies,andcentringtheguidelinesonissuesraisedbythem.
Throughoutthisdocumentuseoftheterm'parents'isintendedtoencompassthechild'sparentsandanyothercarers.
Thelargenumberofconsensusstatementsandgoodpracticepointsintheseguidelinesemphasisethatresearchinthefieldofchildhoodstrokeisurgentlyneededtoprovidedefinitiveanswerstomanyoftheissuesraised.
Thereisanacknowledgedneedformulticentrecollaborationinsuchresearchtoenablethedesignofstudieswithsufficientpowertoproducedefinitiveresults.
Thenetworksnecessaryforthisarebeginningtobeestablishedandmayleadtoworkwhichcouldprovideafirmerevidencebaseforthecareofchildrenaffectedbystroke.
Participantinpaediatricstrokeworkshop:Iamnotastroke,Ihavehadone.
3Strokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitation1.
2ScopeoftheguidelinesTheseguidelineswillprimarilyaddressthediagnosis,investigationandmanagementofacutearterialischaemicstrokeinchildrenbeyondtheneonatalperiod(agedonemonthto18yearsattimeofpresentation),includingacutepresentationandmanagement,rehabilitationandlonger-termcare.
Manyoftheissuescoveredhere,inparticularthoserelatingtorehabilitation,willalsoberelevanttochildrenwithothercausesofstroke(forexamplecerebralvenousinfarction,neonatalstrokeorintracranialhaemorrhage).
1.
3PurposeoftheguidelinesTheseguidelinesareaimedatprofessionalsworkinginprimarycare,secondarylevelacuteandcommunitypaediatrics,tertiarylevelpaediatricneurologyandneurodisability,education,andsocialservices.
Theaimoftheguidelinesistoprovideevidence-basedrecommendationsforclinicians.
1.
4MethodologyTheseguidelineswereformulatedinaccordancewiththeprinciplesspecifiedbytheAppraisalofGuidelinesResearchandEvaluation(AGREE)collaboration(www.
agreecollaboration.
org)FollowingthepublicationoftheNationalClinicalGuidelinesforStrokein2000(IntercollegiateWorkingPartyforStroke2000)–referredtohereafter,alongwiththesecondedition(IntercollegiateStrokeWorkingParty2004),asthe'adultguidelines'–severalpartiesapproachedtheRoyalCollegeofPhysiciansinquiringaboutguidelinesforchildhoodstroke.
TheBritishPaediatricNeurologyAssociationinstigatedaworkingpartytoformulateguidelines.
ThisworkwasdoneincollaborationwiththeClinicalEffectivenessandEvaluationUnitoftheRoyalCollegeofPhysicians.
Potentialmemberswereidentifiedthroughtheirrecognisedrecordofclinicalandresearchactivityinthefieldofpaediatricstrokeandalsothroughtheirprofessionalorganisations.
Representationwassoughtacrossabroadrangeofdisciplinesandtwopatientorganisations(theStrokeAssociationandDifferentStrokes).
Themembersoftheworkingpartyarelistedatthefrontofthisbook.
Conflictsofinterestweredeclaredandmonitored(andfullstatementsheldonfile).
Theworkingpartybeganbyconstructingalistofheadingsusingtheexistingadultstrokeguidelines(IntercollegiateWorkingPartyforStroke2000)asareference.
Wealsoconsideredspecificadditionalissuesrelevanttochildren(forexample,returntoschool).
Foreacharea,thegroupdecidedonalistofspecificquestionsthatwouldbeconsidered.
Searchesweredoneusingkeywordsrelevanttothesequestionsofavailablecomputeriseddatabasesfrom1966onwards:Medline,AMED,CINAHLandEmbase.
Inaddition,theCochraneCollaborationdatabasewassearchedandothernationalguidelinesandpublicationswerereviewed.
Membersoftheworkingpartybroughttheirownexpertiseandknowledgeoftheliterature,aswellasinformationfromtheirorganisationsandprofessionalbodies.
41IntroductionTopicsweredividedandallocatedtoindividualmembersforevaluationaccordingtotheirexpertise.
Theseindividualshadresponsibilityforappraisingtheevidenceanddraftingtherecommendations.
TheScottishIntercollegiateGuidelinesNetwork(SIGN50)guidelinesappraisalchecklistswereusedtoassessthequalityofpublishedarticles(www.
sign.
ac.
uk/guidelines).
Guidelineswerewrittenonthebasisoftheavailableevidencewithgradingofthestrengthoftherecommendationandexplanatorystatementswherenecessary.
Allrecommendationswerethenpresentedtotheworkingpartyasawholefordiscussionandagreement.
Selectionofarticlesforinclusionwasbasedonthefollowingprinciples.
Whereevidencespecificallyrelatingtochildhoodstrokewasavailable,thisalonewasused.
However,suchliteratureisextremelylimitedand,therefore,researchfromotherpaediatricneurologicalconditionswasevaluatedwheretheseconditionswerefelttoberelevanttotheissuesbeingconsidered.
Ifarecommendationwasbasedonextrapolationfromresearchinadifferentpopulationtothatcoveredbytheguideline,thegradeofrecommendationwasreducedbyonelevel.
Whereevidencefrommeta-analysesorrandomisedcontrolledtrials(RCTs)wasavailable,thiswasused.
WheretherewaslimitedornoevidencefromRCTs,thenevidencefromobservationalgroupstudiesorsmall-groupstudieswasused.
Ingeneral,evidencefromsingle-casestudieswasnotused,primarilybecauseitisdifficulttodrawgeneralconclusionsfromthem.
Wheretherewasnoevidencebasetosupportguidelinesinareaswhichwerehighlyrelevanttoclinicalpractice,consensusstatementsfromthisworkingparty,otherworkingpartiesandprofessionalbodieswereused.
ManyrecommendationsareinlinewiththoseinthedevelopingNationalServiceFrameworkforChildren(www.
dh.
gov.
uk/PolicyAndGuidance/HealthAndSocialCareTopics/ChildrenServices/fs/en).
ThestrengthofevidenceandrecommendationsweregradedusingtheschemeproposedbySIGN50andsummarisedintables1.
1and1.
2,overleaf.
The'Evidence'sectionsfollowingguidelinesgiveanindicationofthenatureandextentofthesupportingevidence,togetherwithkeyreferences.
Lastly,foreachtopic,thereisanevidencetableorgroupofevidencetablesgivingfurtherdetailsofthemainstudies.
Childrenaffectedbystrokeandtheirparentswereinvitedtoattendastructuredworkshopinordertoidentifyareastheythoughtshouldbeaddressedwithintheguidelines.
Thefindingswereusedtoidentifykeythemes,whichweresubsequentlyincorporatedintotheissuesaddressedbytheguidelines.
Alltheguidelineshavebeenpeerreviewedbyexternalreviewers,agroupwhichincludedarangeofstakeholders(seeAppendix1).
5Strokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitation1.
5ContextanduseTheseguidelinesareintendedtoinformclinicaldecisionsratherthantoberigidlyapplied.
6Table1.
1Guidelinestrength:levelsofevidenceLevelofevidenceTypeofevidence1++Highqualitymeta-analyses,systematicreviewsofRCTs,orRCTswithaverylowriskofbias1+Well-conductedmeta-analyses,systematicreviewsofRCTs,orRCTswithalowriskofbiasI–Meta-analyses,systematicreviewsofRCTs,orRCTswithahighriskofbias2++Highqualitysystematicreviewsofcasecontrolorcohortstudies;highqualitycasecontrolorcohortstudieswithaverylowriskofconfounding,biasorchanceandahighprobabilitythattherelationshipiscausal2+Well-conductedcasecontrolorcohortstudieswithalowriskofconfounding,biasorchanceandamoderateprobabilitythattherelationshipiscausal2–Casecontrolorcohortstudieswithahighriskofconfounding,biasorchanceandasignificantriskthattherelationshipisnotcausal3Non-analyticstudies,egcasereports,caseseries4ExpertopinionTable1.
2Guidelinestrength:gradesofrecommendationGradeofrecommendationEvidenceAAtleastonemeta-analysis,systematicrevieworRCTratedas1++,anddirectlyapplicabletothetargetpopulation;or,asystematicreviewofRCTsorabodyofevidenceconsistingprincipallyofstudiesratedas1+,directlyapplicabletothetargetpopulationanddemonstratingoverallconsistencyofresultsBAbodyofevidenceincludingstudiesratedas2++,directlyapplicabletothetargetpopulation,anddemonstratingoverallconsistencyofresults;or,extrapolatedevidencefromstudiesratedas1++or1+CAbodyofevidenceincludingstudiesratedas2+,directlyapplicabletothetargetpopulationanddemonstratingoverallconsistencyofresults;orextrapolatedevidencefromstudiesratedas2++DEvidencelevel3or4;or,extrapolatedevidencefromstudiesratedas2+Atickafteraguidelinerepresentsa'goodpracticepoint'–therecommendedbestpracticebasedontheclinicalexperienceoftheguidelinedevelopmentgroup√4EarlydisabilityassessmentandmanagementChapter82TerminologyandtheoreticalframeworkAfactorinterferingwithdeliveryofgoodstrokecareforchildrenisthelackofawidelyacceptedframeworkofcareanduniversalvocabularyandterminology.
Healthprofessionalshavewidelyvaryingexperiencesofchildhoodstroke,buttheproblemisexacerbatedbythevariationinexpertiseandpreferencesforinterventionintheabsenceofanacceptedframework.
TherevisedWorldHealthOrganization(WHO)classification(InternationalClassificationofFunctioning,DisabilityandHealth(ICF))isintendedtoincludeallaspectsofthehealthofanindividualthroughoutlife.
ThisisdesignedtoreplacetheformerICIDH(InternationalClassificationofImpairments,DisabilitiesandHandicap),whichwaswidelyacceptedandusedindescribinghealth.
2.
1TheInternationalClassificationofFunctioning,DisabilityandHealthICFclassifieshealthandhealth-relatedstates.
Theunitofclassificationis'categories'withinhealthandhealth-relateddomains.
Itisimportanttonote,therefore,thatintheICFpersonsarenottheunitsofclassification;thatis,ICFdoesnotclassifypeople,butdescribesthesituationofeachpersonwithinanarrayofhealthorhealth-relateddomains.
Moreover,thedescriptionisalwayswithinthecontextofenvironmentalandpersonalfactors.
Thisinteractioncanbeviewedasaprocessoraresultdependingontheuser.
ForanexampleofhowtheICFmightbeusedinpractice,seeAppendix3.
OverviewofICFcomponentsInthecontextofhealth:ibodyfunctionsarethephysiologicalfunctionsofbodysystems(includingpsychologicalfunctions)ibodystructuresareanatomicalpartsofthebodysuchasorgans,limbsandtheircomponentsiimpairmentsareproblemsinbodyfunctionorstructuresuchasasignificantdeviationorlossiactivityistheexecutionofataskoractionbyanindividualiparticipationisinvolvementinalifesituationiactivitylimitationsaredifficultiesanindividualmayhaveinexecutingactivitiesiparticipationrestrictionsareproblemsanindividualmayexperienceininvolvementinlifesituations7Strokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitationienvironmentalfactorsmakeupthephysical,socialandattitudinalenvironmentinwhichpeopleliveandconducttheirlives.
Anoverviewoftheseconceptsisgiven[inthetablebelow].
Asthetableindicates:iICFhastwoparts,eachwithtwocomponents:Part1.
FunctioningandDisability(a)BodyFunctionsandStructures(b)ActivitiesandParticipationPart2.
ContextualFactors(a)EnvironmentalFactors(b)PersonalFactorsiEachcomponentcanbeexpressedinbothpositiveandnegativeterms.
.
.
AnoverviewofICFPart1:FunctioningandDisabilityPart2:ContextualFactorsComponentsBodyFunctionsActivitiesandEnvironmentalPersonalandStructuresParticipationFactorsFactorsDomainsBodyfunctionsLifeAreasExternalinfluencesInternalinfluencesBodysructures(tasks,actions)onfunctioningandonfunctioningdisabilityanddisabilityConstructsChangeinbodyCapacityfunctionsExecutingtasks(physiological)inastandardFacilitatingorenvironmenthinderingimpactImpactofoffeaturesoftheattributesofthePerformancephysical,socialpersonChangeinbodyExecutingtasksinandattitudinalstructuresthecurrentworld(anatomical)environmentPositiveFunctionalandActivitiesAspectstructuralintegrityParticipationFacilitatorsnotapplicableFunctioningNegativeImpairmentActivitylimitationAspectParticipationrestrictionBarriers/hindrancesnotapplicableDisabilitySource:WorldHealthOrganization(2001)ICF:InternationalClassificationofFunctioningDisabilityandHealth.
WHO:Geneva.
Availableat:www3.
who.
int/icf/icftemplate.
cfm82TerminologyandtheoreticalframeworkGuidelines1Eachteamshoulduseaconsistentframeworkandterminologyinprovidingcaretothechildaffectedbystroke2ItisrecommendedthattheWorldHealthOrganization'sInternationalClassificationofFunctioning(ICF)terminologyisusedEvidence1&2Workingpartyconsensus√√9Theguidelines4EarlydisabilityassessmentandmanagementChapter83ServiceorganisationChildrenaffectedbystrokemakeuseofalllevelsofhealth,educationandsocialservicesintheUnitedKingdom.
Fromamedicalperspectivethepatientjourneycanbeconsideredintermsofacutemedicalcare,andbothacuteandlonger-termrehabilitation.
Rehabilitationshouldbeintegratedwiththechild'seducational,socialandemotionalneeds.
Incontrasttoadultstroke,wherethemodelistodevelopspecialiststrokeservices,therelativerarityofchildhoodstrokemeansthatexistingprimary,secondaryandtertiarysystemsofchildhealthwill–appropriately–beinvolved.
TheseservicesandtheirpotentialrolesareoutlinedinTable3.
1,overleaf.
Servicesfortherehabilitationandlonger-termneedsofchildrenwithanyacquiredbraininjury,includingstroke,arerelativelyunderdevelopedintheUnitedKingdom;infact,theircarechallengesservicesandprocessesinbothhealthandeducation,whicharetypicallybuiltaroundtheneedsofchildrenwithmuchmorestable,slowlychangingrequirements(egthosewithcerebralpalsy).
Althoughthedevelopmentofmoreaccuratelytargetedservicesisbeingproposed,thefollowingsectionwilldescribethepotentialroles,andinvolvementinthemanagementofchildrenaffectedbystroke,ofservicesastheyarecurrentlystructured.
Thewidevariationinthenatureandpotentialseverityofthelong-termeffectsofstrokemeansthatitisdifficulttoproposeasingleapproachwhichwouldbesuitableforallchildren,andtheapplicabilityofeachrecommendationtothespecificchildandfamilyshouldbeconsidered.
Itisourviewthatallchildrenaffectedbyacutestrokeshouldbereferredtoaconsultantpaediatricneurologist.
However,itmaynotalwaysbeappropriateforthechildtobetransferredtoanacutepaediatricneurologyunit.
Ifthisisthecase,thechild'smanagementshouldbediscussedwiththetertiarylevelpaediatricneurologyservice.
Atpresentmany,butnotall,tertiarypaediatricneurologyunitshavemultidisciplinaryteamswithexpertiseintheevaluationofchildrenwithacquiredneurologicalproblems.
Howeverinothertertiarycentres,andmanysecondarycentres,formalacute-basedteamsdonotexistandareconvenedonanadhocbasis.
Wherespecialistexpertiseisnotavailablelocallyprofessionalsareencouragedtoliaisewith,andobtainadvicefrom,colleaguesinspecialistcentres.
Theneedsofthechildmustremaincentraltotheconsiderationofwhichprofessionalstoinvolve.
Thelackofstructuredpaediatricrehabilitationservicescouldbeattributedtoi)alackofresearchregardinglong-termoutcomesofacquiredbraininjuryinchildhood,ii)amisplacedoptimismregardingtheplasticityofthechild'sbrainandthepotentialforrecovery,iii)alackofappreciationofthedevelopmentalcontext,andthefactthateffectsnotapparentimmediatelymayemergewithtime,iv)alackofrecognitionofthe'invisible'consequencesofbraininjury(forexample,cognitiveoremotionaleffects).
Thesefactorsallneedtobetakenintoaccountwhenconsideringtheservicesavailabletochildrenaffectedbystroke.
The13Strokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitation14Table3.
1CompositionofcurrentpaediatricservicesintheUnitedKingdomandpotentialrolesinthecareofchildrenaffectedbystrokeServiceProfessionalsRolesTertiarycareservicesSpecialistchildren's–Paediatricneurologist–Establishdiagnosishospital–Nursingstaff–Acutemedical(orsurgical)treatment–Alliedhealthprofessionals–Earlydisabilityassessmentandtreatment(occupationaltherapist,duringinpatientperiodphysiotherapist,speechand–Liaisonwithsecondaryacuteandcommunitylanguagetherapist)services(includingprovisionofadviceand–Clinicalpsychologistsupporttosecondaryservicesafterdischarge)–Socialworker–OthertertiarylevelpaediatricspecialistsSpecialistchildren's–Paediatricianwith–Assessmentofimpairmentanddisabilityrehabilitationunitneurodisabilityorrehabilitation–Rehabilitationtraining–Planfortransitiontocommunityservices–Nursingstaff–Liaisonwithsecondaryacuteandcommunity–Alliedhealthprofessionalsservices(includingprovisionofadviceand–Educationalpsychologistsupporttosecondaryservicesafter–Teacherdischarge)–ChildandadolescentmentalhealthprofessionalsSecondarycareservicesAcutepaediatrics–Consultantpaediatrician–Establishdiagnosis–Nursingstaff–Acutemedicaltreatment–Alliedhealthprofessionals–Earlydisabilityassessmentandtreatment–Socialworkerduringinpatientperiod–Teacher–Maytakeonlonger-termrehabilitationdependingonavailabilityoflocalservices–LiaisonwithtertiaryhospitalandcommunityservicesCommunitychildhealthChilddevelopmentservice–Assessmentofimpairmentsanddisabilitiesusuallyincludes(Standardsfor–Setupanddeliverlong-termpackageofcarechilddevelopmentservices–Liaisonwitheducationalandsocialservices,(RCPCH1999)):secondaryandtertiaryhospitalpaediatric–Consultantpaediatricianservices–Communitynurse–Alliedhealthprofessionals–Clinicalpsychologist–Socialworker–Portageworker–Teacher–Childpsychiatrist–EducationalpsychologistPrimarycareservicesGeneralpractice–Generalpractitioner–Ongoingdevelopmentalsurveillance–Healthvisitor–Managementofgeneralmedicalissues–Communitynurse–Liaisonwithsecondaryandtertiarycareservicesasrequired3Serviceorganisationproposednationalworkinggrouptodevelopapaediatricrehabilitationpolicywouldbehighlyrelevanttochildrenaffectedbystroke.
Atpresentthereareonly50specialistpaediatricrehabilitationbedsintheUK.
Thismeansthattherehabilitationofthemajorityofchildrenaffectedbystrokewilltakeplaceeitherinthecommunityorongeneralpaediatricwards.
Multidisciplinaryassessmentandco-ordination,andtheprovisionoflong-termcare,areusuallyundertakenbycommunitychildhealthservices,mostoftenbythechilddevelopmentservice.
Itisalsoatthislevelthatongoingliaisonbetweenhealth,socialandeducationservicesshouldoccur.
Inmanyareastherewillbeaspecificteam,usuallybasedinachilddevelopmentcentre,responsibleforchildrenagedfiveandunderwithdisabilities(Standardsforchilddevelopmentservices(RCPCH1999)).
Thecommunitychildhealthservice,alongsideprofessionalsintheeducationservices,willalsobeinvolvedinthemanagementofschoolagechildren.
Itisimportantthatservicesarenotduplicatedandthatallthoseinvolvedareclearonwhoistakingthelead.
Primarycareservicesareusuallyinvolvedingeneralhealthissues,andthechild'sgeneralpractitionershouldberoutinelyandregularlyinformedbytertiaryandsecondaryservicesofachild'shealthandtheservicestheyareusing.
Thehealthvisitormayplayanimportantco-ordinatingrolewithinthemultidisciplinaryteam.
Effectivemulti-andinter-agencyworkingisessentialtoensurecomprehensivecareintherehabilitationofchildrenwithacquiredbraininjury.
Thisisalsoemphasisedinseveraldocuments,forexampleTogetherfromthestart(DfES2002),andtheStandardsforchilddevelopmentservices(RCPCH1999).
Developmentsininformationsharingresources,suchastheforthcomingIntegratedChildren'sSystem(DfES)shouldfacilitatemulti-andinteragencyworking.
Theaimofteam-workingistoprovideasmooth,coordinatedandintegratedserviceforchildrenandtheirfamilies.
A'team'isdefinedasagroupofpeopleworkingtowardsasinglegoalorsetofgoals,butitisimportantthatthisisaninteractiveeffort.
Theaimofthemultidisciplinaryteamistoprovideaholisticperspectiveofthechildandfamilyinplanningorprovidinginterventions,andtostopanyduplicationofquestions,assessmentsorservices.
Themodelofhavingakeyworkerforthechildandfamilyiscontroversialandhasnotbeenresearchedinthisgroupofchildren.
However,documentsrelatingtothemanagementofchildrenwithdisability(forexampleTogetherfromthestart(DfES2002)andStandardsforchilddevelopmentservices(RCPCH1999))aswellastherecentgreenpaper,Everychildmatters(DH2003b),advocatesuchamodel.
Giventhecomplexandevolvingnatureofthepotentialconsequencesofchildhoodstrokeandthemultitudeofagencieswhichcouldbeinvolved,wefeelthatakeyworkerislikelytoincreasethelikelihoodofdeliveringaco-ordinatedcarepackage.
Akeyworkerisdefinedasapersonwho'worksinpartnershipwiththefamily,withthefunctionofco-ordinatingserviceprovisionandservingasapointofreferenceforthefamily'(Togetherfromthestart,DfES2002).
Afurthercriticalaspectofthisroleisthatthekeyworkertakesresponsibilityforensuringdeliveryofthepackageofcare.
Anyprofessionalcouldtakeontheroleofkeyworker,butitislikelytobemostappropriatethatthisisamemberofthesecondarylevelteam.
Additionalfactorswhichshouldinfluencethechoiceofthekeyworkerarethepreferenceofthechildandfamilyandthekeyworker'scompetencies.
Thefamilyshouldbegivenclearinformationabouttheidentityandroleoftheirkeyworker.
15Strokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitationGuidelines1Allchildrenwithacutestrokeshouldbereferredto,orhavetheirmanagementdiscussedwith,aconsultantpaediatricneurologist2Wherespecialistexpertiseisnotavailablelocally,professionalsfromalldisciplinesareencouragedtoliaisewith,andobtainadvicefrom,colleaguesinspecialistcentresregardingtheacuteassessmentandmanagementofthechildaffectedbystroke3Careshouldbeprovidedinanenvironmentthatisappropriateforthechild'sageanddevelopmentallevel(D)4Themedical,social,emotionalandeducationalneedsofthechildaffectedbystrokeshouldbeconsideredearlyandsystematicallyassessedinaco-ordinatedmannerwhenplanningtheirsubsequentcare(D)5Allmembersofthehealthcareteamshouldworktogetherwiththechildandfamily,usinganagreedtherapeuticapproach(D)6Thelonger-termmanagementofthechildaffectedbystrokeshouldbeco-ordinatedbyaconsultantpaediatrician7Amultidisciplinaryteamwithexpertiseinthecareofchildrenwithneurologicalconditionsshouldbeinvolvedinthemanagementofthechildaffectedbystroke.
Whilstthismayinitiallybeattertiarylevel,itisessentialthattherelevantsecondarylevelchilddevelopmentserviceisinvolvedfromanearlystage8Akeyworkershouldbeappointedtoco-ordinatethepackageofcare,ensureitsdeliveryandtoactasacentralpointofcontactforthefamily(D).
ThekeyworkerandtheirroleshouldbeexplainedtothefamilyEvidence1Consensusofworkingparty2Consensusofworkingparty3Recommendation18ofLearningfromBristol:thereportofthepublicinquiryintochildren'sheartsurgeryattheBristolRoyalinfirmary1984–1995(www.
bristol-inquiry.
org.
uk);Children'sNationalServiceFramework(www.
dh.
gov.
uk)(4)4Togetherfromthestart(DfES2002)(4);Standardsforchilddevelopmentservices(RCPCH1999)(4)5Standardsforchilddevelopmentservices(RCPCH1999)(4)6Consensusofworkingparty7Consensusofworkingparty8Togetherfromthestart(DfES2002)(4);Standardsforchilddevelopmentservices(RCPCH1999)(4)√√√√164EarlydisabilityassessmentandmanagementChapter84Childrenandtheirfamilies4.
1ConsentChildren,whatevertheirage,havearighttobeconsultedandinformedaboutanyproposedtreatment.
TheUNConventiononChildren'sRightsrecognisestherightofchildrentomakeinformeddecisions.
Information(eitherverbalorwritten)needstobeaccessibletochildren.
Theirdignity,self-respect,andrightstoself-determinationandnon-interferenceshouldbepreserved(www.
unicef.
org/crc/crc.
htm).
TheChildrenAct1989andEuropeanAssociationforChildreninHospitalcharter(www.
each-for-sick-children.
org/charter.
htm)requirethatchildrenandparentsparticipateindecision-making.
Children'sfeelingsandwishesshouldbesoughtandtakenintoaccount,andanyreasonsfornotfollowingthemshouldbeexplained.
Religiouspersuasion,racialorigin,cultureandlanguageshouldalsobeconsidered.
Childrenshouldbeprotectedfromunnecessarytreatmentandinterference.
TheGillickJudgement(GillickvWestNorfolkHealthAuthority1985)requiresthatconsentbegivenbyachildiftheyhave'sufficientunderstandingandintelligencetoenableunderstandingfullywhatisproposed,evenifundertheageofconsent'.
4.
2FamiliesandcarersThechildandfamilyperspective'Iwantedtoknow…ifIcouldusemyhandnormally,howlongitwouldtaketoheal'(participantinpaediatricstrokeworkshop).
Parentsofaffectedchildrenhadexperienced'notbeingtoldwhatisgoingon'and'beingkeptinthedark'.
Parentsandcarersalsoreportedfeelingsofhelplessness,distressandguiltfromwitnessingtheirchildren'spainandfearandbeingunabletohelpthem:'Ifelthelpless,Icouldn'tdoanythingforher','Irushed…tothehospital,allIcouldhearwasmyniecescreaming…Icried,sayingtomyselfshe'sonly15yearsold','Seeingyourchildsufferingandfeelingguilty'.
Parentsfoundithardwhentheyfeltthattheirknowledgeoftheirchildwasignored:'Thestaffathospitalwhodidnotlistentomother','Nothavingyourmothering/fatheringinstinctslistenedto'.
Parentssuggestedthatitwouldbehelpfulifdoctorscouldtalktothemusingmoreaccessiblelanguagewhenexplainingwhatiswrongwiththeirchild:'Gettingdoctorstoexplainthechild'sconditioninlaymanterms,not"doctorspeak"'.
Parentsalsoreportedsignificantemotionalproblemsfollowingtheirchild'sstrokeand17Strokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitationsuggestedthatmeetingotherparentswouldbeverybeneficial:'Wehaveattimesbothseriouslycontemplatedsuicide','Parentsbenefitfrommeetingotherparents'.
Themajorityofparentsfeltthattheyhavetoconstantlyfightpublicservicessotheirchildcanreceivethecareandtreatmentthattheyshouldbegetting:'Havingtoconstantlyfightforthejusticeofyourchild','Havingtofight/askforhelpwhenyouaresovulnerable'.
Allquotesarefromparticipantsinthepaediatricstrokeworkshop.
CommunicationwiththechildandtheirfamilyTherecognitionthatthechildispartofafamilyiscentraltopaediatriccare.
Anychildhoodillnesshasanimpactonthewholefamily,includingparents,siblingsandgrandparents.
Childhoodstrokehasbeenshowntohaveanadverseimpactonparents'emotionalandphysicalhealth(Gordonetal2002).
Strokeisacompletelyunexpectedillnessinachildandparentsandchildrenfeelemotionallydevastatedbythediagnosis.
Thisiscompoundedbythelackofawarenessofchildhoodstrokeamongstprofessionals,whichmeansthatitisoftenlefttothechildandfamilytopursuetreatment,rehabilitationandappropriateeducationalsupport.
Allprofessionalsshouldbeawareofthestressassociatedwithadiagnosisofstrokeonthechildandfamilyfromtheoutset.
Theimportanceofemotionalsupportandsensitiveandcomprehensivecommunicationatthetimeofdiagnosisofadisorderwithpotentiallong-termdevelopmentalconsequencesisemphasisedinTogetherfromthestart(DfES2002)andtheStandardsforchilddevelopmentservices(RCPCH1999).
TheStrokeAssociationandDifferentStrokes(seeAppendix4forcontactdetails)provideinformationandsupportforchildrenaffectedbystrokeandtheirfamilies.
Children,familymembersorcarersneedbothfactualandpracticalinformationatvariousstages,presentedinaformatappropriatetotheirneeds(Rushforth1999;Helpsetal2003).
Itshouldberecognisedthatparentshaveparticularknowledgeoftheirchildand,therefore,theirconcernsshouldbeaddressedinplanningthechild'scareandeducationalplacement.
Guidelines1Families/carersshouldbegivenfactualinformationabouttheirchild'sconditionassoonaspossibleafterdiagnosis(D).
Thisshouldbesimpleandconsistent,avoidingtechnicaltermsandjargon2Writteninformationshouldbeprovidedtothechildandfamilyregardingthechild'shealthandthestatutoryandvoluntaryservicesavailable(D)3Childrenshouldbegiveninformationabouttheirconditionatanappropriatelevel(D)4Thechildandfamilyshouldbeinvolvedinmakingdecisionsaboutthechild'scare,includingrehabilitationandeducation(D)5Themultidisciplinaryhealthteamatsecondarylevelshouldprovideco-ordinatedcareandliaisecloselywitheducationandsocialservicesthroughthekeyworker(D)184ChildrenandtheirfamiliesEvidence1Paediatricstrokeworkshop(4);Togetherfromthestart(DfES2002)(4);Standardsforchilddevelopmentservices(RCPCH1999)(4)2Togetherfromthestart(DfES2002)(4);Paediatricstrokeworkshop(4)3Rushforth2002(4)4ReportofBristolenquiry(www.
bristol-inquiry.
org.
uk)(4);Togetherfromthestart(DfES2002)(4);Standardsforchilddevelopmentservices(RCPCH1999)(4);Children'sNationalServiceFramework(DH2003a)(www.
dh.
gov.
uk)(4)5Consensusofworkingparty(4);Mukherjeeetal1999(4)194EarlydisabilityassessmentandmanagementChapter85Acutediagnosisofarterialischaemicstrokeinchildren5.
1DefinitionTheWorldHealthOrganizationdefinesstrokeas'aclinicalsyndrometypifiedbyrapidlydevelopingsignsoffocalorglobaldisturbanceofcerebralfunctions,lastingmorethan24hoursorleadingtodeath,withnoapparentcausesotherthanofvascularorigin'(WorldHealthOrganization1978).
Thisdefinitionisaclinicaloneandsuchapresentationhasmanypotentialunderlyingcausesinchildhood.
Brainimagingismandatoryforaccuratediagnosis,subsequentreferraland,inparticular,toexcludeconditionsrequiringurgentneurosurgicalintervention.
Arterialischaemicstroke,whichisthemainfocusoftheseguidelines,canbedefinedas'aclinicalstrokesyndromeduetocerebralinfarctioninanarterialdistribution'.
Transientischaemicattacks(TIAs)(wheretheneurologicaldeficitresolveswithin24hours)mayalsooccurinchildren.
Althoughclinicalsymptomsmaybetransient,asignificantproportionofchildrenwiththispresentationhavecerebralinfarction.
Termssuchas'acuteinfantilehemiplegia'areclinicaldescriptions,whichdonotidentifytheunderlyingaetiology;theyshould,therefore,beavoided.
Thefollowingsectionswilldeal,firstly,withguidelinesforestablishingadiagnosisinachildpresentingwithanacuteclinicalstrokesyndrome(section5.
2),andthendiscussthefurtherinvestigationofchildrenwithadiagnosisofarterialischaemicstrokeinordertoestablishunderlyingaetiology(section5.
3).
Itmaybepragmatictocombinetheinitial(diagnostic)andsubsequentinvestigations,especiallyinthecaseofimaging,andbothsectionsshould,therefore,beconsideredtogether.
5.
2PresentationanddiagnosisAtthetimeofstrokechildrenandfamiliesreportedfeelingssuchas'frightened','annoyed','angry','confused','devastated'.
Parentsreportedfeelingconcernedandfrightenedattheamountoftimetheyhadtowaitfordiagnosis,treatmentandinformationabouttheirchild'scondition:'Sittingforhoursintheemergencydepartment,with———,beforeitwasfinallyacknowledgedshehadhadastroke'(parentparticipantinpaediatricstrokeworkshop).
21Strokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitationRecognitionofclinicalstrokemaybedifficult,particularlyininfantsandyoungchildren,andespeciallyasneurologicalsignsmayberelativelysubtle.
Ifthereisdoubt,thechildshouldbeexaminedbyaseniorpaediatrician.
Themostcommonclinicalpresentationofclinicalstrokeinchildhoodiswithacutehemiparesis.
Focalsignsmaybeabsentinneonatesoryounginfants,inwhomseizuresmaybetheonlymanifestationofclinicalstroke.
Clinicalsymptomsandsignsofarterialischaemicstrokemaybeparticularlysubtleinchildrenwithsicklecelldisease,andmaybedifficulttodistinguishfrompainfulcrisisortheeffectsoftreatment,forexampletreatmentwithopiates.
Adviceshouldbesoughtfromatertiarycentreifthereisconcernabouttheacquisitionandinterpretationofimagingstudiesinachildwithclinicalstroke.
Guidelines1Allchildrenwithaclinicalpresentationofstrokeshouldbeunderthecareofaconsultantpaediatrician2Cross-sectionalbrainimagingismandatoryinchildrenpresentingwithclinicalstroke(C)3Brainmagneticresonanceimaging(MRI)isrecommendedfortheinvestigationofchildrenpresentingwithclinicalstroke(C)4BrainMRIshouldbeundertakenassoonaspossibleafterpresentation.
IfbrainMRIwillnotbeavailablewithin48hours,computedtomography(CT)isanacceptableinitialalternative5Brainimagingshouldbeundertakenurgentlyinchildrenwithclinicalstrokewhohaveadepressedlevelofconsciousnessatpresentationorwhoseclinicalstatusisdeteriorating6Anynewneurologicalsymptomsorsignsinchildrenwithsicklecelldiseaseshouldbeevaluatedaspotentiallybeingduetostroke7AllchildrenwithclinicalstrokeshouldhaveregularassessmentofconsciouslevelandvitalsignsEvidence(Tables1and2)1Consensusofworkingparty2Ganesanetal2003(2+)3Bryanetal1991(2+);Kucinskietal2002(2+);Barberetal1999(2–);Lansbergetal2000(2–)4Consensusofworkingparty5Consensusofworkingparty6Consensusofworkingparty7Consensusofworkingparty√√√√√225Acutediagnosisofarterialischaemicstrokeinchildren5.
3InvestigationsThissectionaimstoprovidesomeguidanceaboutinvestigationsintheevaluationofachildwitharterialischaemicstroke;itisnot,however,intendedtobecomprehensive.
Therearemanypotentialriskfactorsforarterialischaemicstrokeinchildrenandthediagnosticprocessshouldbedirectedtowardsidentifyingasmanyoftheseaspossible.
Theproportionofpatientsinwhomnoriskfactorsareidentifiedhasdecreasedasunderstandingofaetiologyandinvestigationmethodshaveimproved.
Thereislittleinformationonthediagnosticsensitivityofindividualinvestigations.
Althoughtheinvestigationsdiscussedbelowshouldbeundertakeninallcases,otherinvestigationsmaybeindicatedinindividualpatients,andshouldbeconsideredonacase-by-casebasis.
ForamorecompletediscussionofthistopicseeKirkham1999.
Aclerkingchecklistisprovidedtohighlightimportantaspectsoftheclinicalhistoryandexamination.
Transfertoatertiarycentremaybenecessaryiffacilitiesfordefinitiveimagingorotherinvestigations(egechocardiography)arenotavailablelocally.
Asmentionedinrelationtobrainimaging,adviceshouldbesoughtfromatertiarycentreifthereisconcernabouttheacquisitionandinterpretationofpaediatricechocardiography.
Non-invasivecerebrovascularimagingwithtechniquessuchasMRangiography(Hussonetal2003),CTangiography,ultrasoundwithDopplertechniquesoracombinationofsuchmodalitiescanbeappliedinthefirstinstance,andmaybeadequate.
TheexistingresearchonpaediatricarterialischaemicstrokeonlyincludesstudieslimitedtovisualisationofthearterialvasculaturebetweenthedistalcommoncarotidarteryandthecircleofWillis.
Thevalueofimagingtheaorticarchanditsproximalmainbranchesisunknown.
Itisacknowledgedthat,insomecases,non-invasiveangiographictechniquesalonewillnotprovidesufficientinformationtoenabletheplanningofsubsequentmanagement,andinthesecasescathetercerebralangiographymayalsoberequired.
DuetothelackofspecificresearchevidencewehavenotmademoredetailedrecommendationsregardingimagingsequencesbutahelpfuldiscussionofthesecanbefoundinthereviewarticlebyHunter(Hunter2002).
Ifthereareunusualfeaturestotheidentifiedinfarct,suchastheanatomicallocation,thepresenceofexcessivebrainswellingandthenthepossibilityofvenousinfarctionorhaemorrhageshouldbeconsidered.
Morespecificvenousimaginginvestigationsmaythenbeappliedbytheradiologistasnecessary.
Inthefirstinstance,non-invasiveoptionssuchasMRvenographyorCTvenographyarepreferredovercatheterangiography.
Theyieldofinvestigatingchildrenwitharterialischaemicstrokeforthrombophiliaisvariableandwilldependonfactorssuchasethnicity.
ProteinCdeficiencyandelevatedlipoprotein(a)havebeenshowntobeassociatedwithanincreasedriskofrecurrence(Strateretal2002).
Althoughtheappropriatepreventativetreatmentinaffectedpatientsisunknown,identificationofaprothrombotictendencymayhaveotherimplicationsforthechild'smoregeneralhealth,forexampleriskofvenousthrombosis.
Additionalspecificinvestigationstobeincludedwhenscreeningforthrombophiliashouldbediscussedwiththelocalhaematologyservice,withconsiderationofthelocalprevalenceofspecificthrombophilia.
23Strokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitationTheimportanceofmoreconventionalchildhoodstrokeriskfactorsinchildrenwithsicklecelldiseasehasnotbeenevaluated.
Theclinicalexperienceoftheworkingpartyisthatthesemayplayaroleinsomepatientsandthereforewewouldnotexcludechildrenwithsicklecelldiseasefromtherecommendationsbelow.
Guidelines1Imagingofthecervicalandproximalintracranialarterialvasculatureshouldbeperformedinallchildrenwitharterialischaemicstroke(C)2Imagingofthecervicalvasculaturetoexcludearterialdissectionshouldbeundertakenwithin48hoursofpresentationwitharterialischaemicstroke3Transthoraciccardiacechocardiographyshouldbeundertakenwithin48hoursafterpresentationinallchildrenwitharterialischaemicstroke4Allchildrenwitharterialischaemicstrokeshouldbeinvestigatedforanunderlyingprothrombotictendency.
ThisshouldincludeevaluationforproteinCproteinSdeficiency,activatedproteinCresistance,increasedlipoprotein(a),increasedplasmahomocysteine,factorVLeiden,prothrombinG20210AandMTHFRTT677mutationsandantiphospholipidantibodies(C)Evidence(Tables3and4)Thepaperscitedhereprovideinformationaboutriskfactorsassociatedwithchildhoodarterialischaemicstroke,butdonotallprovidedirectinformationaboutsensitivityorspecificityofspecificdiagnostictestsinthecontextofchildhoodarterialischaemicstroke.
1Levyetal1994(2+);Ganesanetal2002(2+);Hussonetal2003(2+);Ganesanetal1999(3)2Consensusofworkingparty3Consensusofworkingparty4NowakGottletal1999(2+);deVeberetal1998b(2+);Strateretal2002(2+);SubcommitteeforPerinatalandPediatricThrombosisoftheScientificandStandardizationCommitteeoftheInternationalSocietyofThrombosisandHaemostasis(4)√√244EarlydisabilityassessmentandmanagementChapter86AcutecareThissectionrelatestoallaspectsofacutecare.
Medicalcare,earlyevaluationofdisabilityandrehabilitationareequallyimportantaspects.
Theseguidelinesassumethat,asisusualintheUnitedKingdom,theearlycareofachildwhohashadastrokewillbeundertakeninaspecialistpaediatricneurologyorgeneralpaediatricward.
Theacutemedicalmanagementofarterialischaemicstrokecanbedividedintogeneralcaremeasuresandmeasuresaimedatlimitingtheextentofischaemicdamageorpreventingearlyrecurrence.
Thelatterdependonthelikelycauseofstrokeineachcase.
Aswiththeadultguidelines,treatmentofsecondarycomplicationsorofassociateddiseasesisnotconsideredhere.
Earlymultidisciplinaryevaluationisvitaltopreventcomplicationsandplanrehabilitation.
Ifthechildisinanacutepaediatricneurologyward,heorsheislikelytohaveaccesstoamultidisciplinaryteamwithexpertiseinpaediatricneurology.
However,onageneralpaediatricwarditmaybenecessaryforanymemberoftheteamtoseekadvicefromcolleaguesinatertiarycentre.
Thereisnospecificresearchrelatingtotheevaluationandmanagementofchildrenaffectedbystroke,butprinciplesrelatingtotheevaluationandcareofchildrenwithotheracuteneurologicalconditionsand,whereavailable,publishedguidelineshavebeenappliedinformulatingtheserecommendations.
6.
1GeneralcaremeasuresTherearenostudieswhichhavespecificallyexaminedtheeffectofdisruptionsinhomeostasisonstrokeoutcomeinchildrenbutwehavehighlightedthepointsbelowbasedonprincipleswhichwouldbeappliedtothecareofanyacutelyillchild,aswellasfromtheevidencebaseinadultsaffectedbystroke.
Guidelines1Temperatureshouldbemaintainedwithinnormallimits(D)2Oxygensaturationshouldbemaintainedwithinnormallimits(D)25Strokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitationEvidence1ExtrapolationfromNationalclinicalguidelinesforstroke:secondedition(IntercollegiateStrokeWorkingParty2004)(4)2Consensusofworkingparty;Nationalclinicalguidelinesforstroke:secondedition(IntercollegiateStrokeWorkingParty2004)(4)6.
2SpecificmedicaltreatmentsTherearenostudiesspecificallyexaminingtheefficacyofacutetreatmentsforarterialischaemicstrokeinchildren.
Thefollowingrecommendationsarebasedontheconsensusopinionoftheworkingparty.
Theuseofanticoagulationinchildrenwithcardiacembolismiscontroversialasitinvolvesbalancingtheriskofprecipitatinghaemorrhagictransformationoftheinfarctwiththepotentialtopreventfurtherembolicevents.
Thedecisionmaybeinfluencedbythecardiacpathology,timeelapsedafterthestrokeandbyneurologicalandimagingfindings.
Intheabsenceofanyevidence,wewereunabletomakeageneralrecommendation,butfeltthatindividualpatientmanagementshouldinvolveseniorcliniciansinpaediatriccardiologyandneurology.
Theefficacyandoptimaldoseofaspirininthetreatmentofchildrenwithacutearterialischaemicstrokeisunknown.
Thelowestdoserecommendedfortreatmentofotherpaediatricconditions,suchasKawasakidisease,inthepaediatricformularyMedicinesforchildren(RoyalCollegeofPaediatricsandChildHealth2003)is5mg/kg/day.
Thiswouldapproximatetothedose(300mg)recommendedforacutetreatmentofischaemicstrokeinadults(Nationalclinicalguidelinesforstroke:secondedition,IntercollegiateStrokeWorkingParty2004)andthereforehasbeenrecommendedbelow.
Thelowesteffectivedoseforlong-termprophylaxismaybelower,asdiscussedinthefollowingsection.
Althoughchildrenwithsicklecelldiseasehavebeenexcludedfromthefirstguideline,aspirinoranticoagulationmayneedtobeconsideredifotherriskfactors,forexamplearterialdissection,areidentifiedinindividualpatients.
Thereiscurrentlynoevidencetosupportuseofthrombolyticagentssuchastissueplasminogenactivator(tPA)intheacutetreatmentofarterialischaemicstrokeinchildren.
Guidelines1Aspirin(5mg/kg/day)shouldbegivenoncethereisradiologicalconfirmationofarterialischaemicstroke,exceptinpatientswithevidenceofintracranialhaemorrhageonimagingandthosewithsicklecelldisease2Inchildrenwithsicklecelldiseaseandarterialischaemicstroke:iurgentexchangetransfusionshouldbeundertakentoreduceHbSto200cm/susingappropriatelytrainedpersonnelandtranscranialDopplerultrasound(B)2Childrenwithsicklecelldiseasewhohaveinternalcarotidartery/middlecerebralarteryvelocity>200cm/sshouldbeofferedlong-termbloodtransfusion(B)Evidence1Adamsetal1998(2++)2Adamsetal1998(2++)47Appendices51Chapter8Appendix1PeerreviewersChildandadolescentpsychiatristProfessorRobertGoodmanKing'sCollegeHospital,LondonChildneurologistDrGabrielledeVeberTheHospitalforSickChildren,Toronto,CanadaClinicalpsychologistsDrPeterFuggleBritishPsychologicalSociety,LeicesterMsAnnetteLawsonBirminghamChildren'sHospitalMsDianneMelvinGreatOrmondStreetHospitalforChildren,LondonDrArletaStazaSmithQueen'sMedicalCentre,NottinghamCommunitypaediatriciansDrMoiraDickMarySheridanCentreforChildHealth,LondonDrTomHutchisonBathandNESomersetPrimaryCareTrustEducationconsultantMsBethWicksNottinghamNeuroradiologistsProfessorPaulGriffithsUniversityofSheffieldDrNeilStoodleyFrenchayHospital,BristolOccupationaltherapistsMsJaneGalvinRoyalChildren'sHospital,MelbourneDrElizabethWhiteCollegeofOccupationalTherapists,LondonPaediatrician(neurologyandneurodisability)DrDianeSmythStMary'sHospital,LondonPaediatricneurologistsDrRichardAppletonAlderHeyChildren'sHospital,LiverpoolDrTonyMcShaneJohnRadcliffeInfirmary,OxfordDrKeithPohlGuy'sHospital,LondonDrWilliamWhitehouseQueen'sMedicalCentre,NottinghamStrokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitation52PaediatricneurologynursespecialistMsShonaMackieSouthamptonGeneralHospitalPatientorganisationsMrsMargaretGooseStrokeAssociation,LondonMrKeithWoodDifferentStrokes,MiltonKeynesPhysiotherapistsMsShelleyCoxSouthamptonGeneralHospitalMsLornaStybelskaCumberlandInfirmary,CarlisleSpeechandlanguagetherapistsMsLucyCuthbertsonSouthamptonGeneralHospitalMsNicolaJolleffWolfsonCentre,LondonMsValerieMoffattChaileyHeritageSchool,EastSussexProfessorBruceMurdochUniversityofQueensland,Brisbane53Chapter8Appendix2ProposedauditcriteriaThesecriteriahavebeenproposedbytheworkingpartyforclinicalaudit.
Theyaredividedintotwosections–onedealingwithacutecareandanotherwithlonger-termissues.
Werecognisetheimportanceofpatient(childandfamily)andpublicinvolvementintheauditprocess(seewww.
chi.
nhs.
uk/eng/audit/index.
shtml).
Duetolackofresourcesithasnotprovedpossibletoincludethisperspectiveintheproposedcriteriabutthiswillbeaddressedinfutureeditions.
Acutecare1Duringacutemanagement:iwasthechildreferredtoaconsultantpaediatricneurologistiifnot,wasthemanagementofthechilddiscussedwithaconsultantpaediatricneurologist2Howmanyhoursaftertheonsetofacutesymptomsdidthechildundergobrainimaging(includesallchildrenpresentingwithclinicalstroke)3Inchildrenwitharterialischaemicstrokewhatotherimagingstudieswerecarriedoutandwhenwerethesedone:iMRIbrainiMRAcircleofWillisiimagingofcervicalvessels(anymodality)icardiacechocardiogram4Whenwasthefirstdocumentedassessment(statehoursafteradmission)by:ianurseiaphysiotherapistianoccupationaltherapistiaspeechandlanguagetherapistiapsychologistStrokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitation545Wasamemberofthecommunitychildhealthteamcontactedpriortotransfertothecommunity(statenumberofdaysbeforetransferandwhichprofessionalwascontacted)6Duringtheinitialadmission,wasthefamilyprovidedwithwritteninformationregarding:ichildhoodstrokeistatutoryandvoluntaryagenciesLonger-termcare7IsthechildunderthecareofaconsultantpaediatricianIfso,havetheybeenseeninthelast12months8Isthechildontreatmentforsecondarypreventionofstroke9Whenwasthefirstdocumentedcontact(stateweeksaftertransferhome)by:iakeyworkerianurseiaphysiotherapistianoccupationaltherapistiaspeechandlanguagetherapistiapsychologist10Wasameetingheldbetweenprofessionalsinhealthandeducationservicesandthechild'sparentspriortothechild'sreturntoschool55Chapter8Appendix3AnexampleoftheICFThecomponentsoftheInternationalClassificationofFunctioning,DisabilityandHealth(ICF)mightbeusedtodescribethehealthofanine-year-oldboyaffectedbyarighthemisphereischaemicstrokeinthefollowingway.
BodyfunctionsandstructuresImpairmentsincludei)clinicalfindingsofleftsidedhyperreflexia,hypotoniaandpersistentposturingoftheleftfootandankle,ii)imagingfindingsofrightmiddlecerebralarteryterritoryinfarction.
Functionalandstructuralintegrityincludestheabilitytoswallow,speakandstandindependentlyandtheabsenceofneurologicalsignsintherightside.
ActivitiesandparticipationActivitylimitationsincludedifficultiestransferringfromchairtostandingandnegotiatingobstacleswhenwalking.
Short-termmemorydifficultiesfoundonformaltestingleadingtodifficultiesinmaintainingattentioninschool,thusaffectingschoolgrades.
Activitiesabletobeperformedindependentlymayincludeself-feedingwiththerighthand,writing,managingbuttonsone-handed,andconversingwithfriends.
Participationrestrictionmayincludeinabilitytorejointheschoolfootballteam(amajorsourceofsocialcontactwithfriendsatweekends)duetorunningdifficulties.
Parentsmayreportdifficultybeingsentonerrandsindependentlyduetopoormemory.
Participationthatremainsunaffectedmayincludeplayingcomputergameswithsiblings,readingwithparents,andgoingforwalkswithfriendsintheneighbourhood.
ContextualfactorsEnvironmental:Thechildmustclimbtwoflightsofstairstoreachhisclasseverymorningatschool.
Hehasdifficultywalkingquickly,especiallywhencarryingaschoolbag.
Thisiscompoundedbythedistancebetweenclassesandthenumberofchildrencrowdingthecorridor.
ThefootballcoachishesitanttoallowthechildtorejointhefootballteamincaseStrokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitationitplaceshimatriskofinjury.
Theboy'sfriendswelcomehimbacktoschool,buthenotalwaysabletokeepupwithplaygroundactivitiesandsoissometimeslefttoplayalone.
Personal:Theboydoesnotwanttobesingledoutsodoesnotagreetoleavingclassearlierthanhispeersinordertogettothenextclassontime.
Hissenseofhumourenableshimtomakefriendseasily,andthushewidenshissocialnetworktoincludeotherchildrenformorevarietyofsocialcontactatschool.
5657Chapter8Appendix4UsefuladdressesAcquireHelpschildren,youngpeopleandadultswhohaveanacquiredbraininjuryandfacedifficultiesinlearningasaresult.
ManorFarmHouse,Wendlebury,Bicester,OxfordshireOX252PW.
Tel:01869324339.
Fax:01869234683.
Email:info@acquire.
org.
ukWebsite:www.
acquire.
org.
ukAfasicRepresentschildrenandyoungadultswithcommunicationimpairments,worksfortheirinclusioninsocietyandsupportstheirparentsandcarers.
2ndFloor,50–52GreatSuttonStreet,LondonEC1V0DJ.
Helpline:08453555577.
Fax:02072512834.
Email:info@afasic.
org.
ukWebsite:www.
afasic.
org.
ukChest,Heart&StrokeScotlandProvidesadviceandsupportforpeopleinScotlandaffectedbychest,heartandstrokeconditions.
65NorthCastleSt,EdinburghEH23LT.
Adviceline:08450776000.
Fax:01312206313.
Email:adviceline@chss.
org.
ukWebsite:www.
chss.
org.
ukChildren'sBrainInjuryTrustAimstoimprovethequalityoflifeforallchildrenwhohaveanacquiredbraininjury(ABI)andtoenablethemtoachievetheirfullpotential.
ChildBrainInjuryTrust,TheRadcliffeInfirmary,WoodstockRoad,OxfordOX26HE.
Helpline:08456014939.
Tel:01865552467.
Email:helpline@cbituk.
orgWebsite:www.
cbituk.
orgChildren'sHemiplegiaandStrokeAssociationOfferssupportandinformationforfamiliesofchildrenwhohavehemiplegia,hemiparesisand/orstroke.
BasedintheUSA.
CHASAFoundation,Suite305,PMB149,4101WestGreenOaks,ArlingtonTX76016,USA.
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uk/lifeevent/famchild/index.
aspDifferentStrokesForyoungerpeoplewhohavehadastroke,mainlyyoungadults.
Includesinformationonaccesstoleisureactivities,counsellingservices,benefitsandrightsinformation,andinformationpacks.
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ukStrokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitation58DisabilityAllianceProvidesinformationandadvicetodisabledpeopleandtheirfamiliesaboutentitlementtosocialsecuritybenefitsandservices.
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sicklecellsociety.
orgTablesofevidenceTable1AcutediagnosisandpresentationSourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentGanesanetal,Observationalstudyof356Descriptionofriskfactors–Nearly20%ofchildrenwithUncontrolledstudy;possible2003childrenwithstrokeandencountered;incidentaldatastrokehadadiagnosisotherreferral/selectionbias;descriptionofriskfactorsondiagnosesinpatientswiththanAIS.
Another10%hadopportunisticsampleencounteredin212withclinicalstrokesubsequentlynormalimagingradiologicallyconfirmedAISfoundnottohaveAISpresentingtotertiaryreferralcentreAIS=ArterialischaemicstrokeTable2CTvsMRIintheneuroimagingdiagnosisofacuteischaemicstrokeSourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentBryanetal,Observationalstudy;n=31CTandMRIperformedwithin–MRappearstobemoreStudydesignfavoursMRIover199124hoursandat7–10dayssensitivethanCTintheCT.
JustificationbyauthorsinimagingofacutestrokesubsequentcommentaryKucinskietal,Observationalstudy;n=25QuantificationofdiffusionDiffusion(MRI)changesbyProvidestechnicalevidencetoObjectivesupportforprevious2002changesonMRIagainstdensity21%.
Density(CT)changesexplainthelowersensitivityofsubjectiveobservationalstudieschangesonCTinacutestrokeby4%CTcomparedwithMRIforthatshowMRIbeingdetectionofearlyischaemicadvantageousoverCT(seechangesinimagingstudiesbelow)BarberPAetal,Observationalstudy;n=17Identificationofmajor–DWIismoresensitivethanSubjectiveobservationalstudy1999ischaemiaandassociationCTintheidentificationofshowingMRIbeingadvantageouswithoutcomeacuteischaemiaandcanoverCTvisualisemajorischaemiamoreeasilythanCTLansbergMGObservationalstudy;AccuracyofearlyMRIvsCT–MRIwasmoreaccurateforSubjectiveobservationalstudyetal,2000n=19andcorrelationwithfinalidentifyingacuteinfarctionandshowingMRIbeingadvantageousinfarctvolumemoresensitive.
LesionvolumeoverCTonacuteMRI,butnotonacuteCT,correlatedstronglywithfinalinfarctvolumeCT=Computerisedtomography;DWI=Diffusionweightedimaging;MRA=Magneticresonanceangiography;MRI=Magneticresonanceimaging;Obs=ObservationalstudyTablesofevidence61Strokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitation62Table3InvestigationSourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentGanesanetal,ObservationalstudyofDescriptionofriskfactorsRadiologicallyconfirmedAIS1.
79%hadcerebralarterialUncontrolledstudy,notall2003356childrenwithstrokeandencountered;incidentaldataabnormalitiespatientshadallinvestigations;descriptionofriskfactorsondiagnosesinpatientswith2.
Significantassociationpossiblereferral/selectionbiasencounteredin212withclinicalstrokesubsequentlybetweentraumaandpreviousradiologicallyconfirmedAISfoundnottohaveAISchickenpoxandAISinpresentingtotertiaryreferralpreviouslyhealthypatientscentre3.
Anaemia(40%),riskofhyperhomocysteinaemia(21%)common4.
Echocardiographyabnormalin7%ofpatientsonlyNowak-GottlMulticentrecasecontrolsstudyComparisonoftheratesofPrevalenceratesLp(a)>30mg/dLOR7.
2,Increasedprevalenceofalletal,1999of148childrenwithAISandFVL,PT20210,t-MTHFRFVLOR6,mutationsandespeciallyof296controlsmutationsandproteinProteinCdeficiencyOR9.
5,combineddefects.
EstablishesCdeficiencyandincreasedPT20210OR4.
7,association,notcausation.
TheLp(a)levelsinchildrenwithMTHFRTTOR2.
64,prevalenceislikelytobedifferentAISandcontrolsForcombinedriskfactorsinotherethnicgroupssotheOR35.
75generalisabilityisquestionableDeVeberetal,TertiarycentreCanadianEvaluatedforproteinC,S,AT,Incidenceofthrombophilia92patients(73arterial);35hadLimitedvalueasmixedpopulation1998bpopulation;includesarterialPlasminogendeficiencies,FVL,atleast1abnormality,25/73butsuggestshighincidenceofandvenous,neonatesandolderlupusanticoagulantandwitharterialischaemicstroke.
abnormalitiesinarterialsubgroupanticardiolipinantibodies23hadanticardiolipinantibodies,6hadlupusanticoagulant,10hadATdeficiency,10hadproteinSdeficiency,7hadplasminogendeficiency,6hadproteinCdeficiency,6hadAPCresistance,0hadFVL.
NosignificantdifferencebetweenneonatesandolderchildrencontinuedTablesofevidence63Table3InvestigationcontinuedSourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentStrateretal,Multi-centrestudy,Germany;AllinvestigatedforStrokerecurrence301followedup.
20hadGoodstudybutlimitedbyhighly2002324whitechildrenagedthrombophilia(proteinC,Srecurrenceatmedianofselectedpatientsgroup–7monthsto18yearsattimeandATdeficiencies,fVandfII5months;fatalin3.
applicabletootherpopulationsoffirststroke.
Allradiologicallymutations,APCresistance,IndependentassociationswithThoroughnessofinvestigationsconfirmed.
Excludedsicklecell.
antiphospholipidantibodiesandrecurrence:proteinCotherthanforprothrombotic123hadanotherdiagnosishighLp(a).
Otherinvestigationsdeficiency(OR10.
7),Lp(a)statesnotclearvariable>300mg/LOR2.
8,vascularstrokeOR3.
9AIS=Arterialischaemicstroke;FVL=factorVLeiden;Lp(a)=lipoprotein(a);t-MTHFR=Thermolabilemethylenetetrahydrofolatereductasemutation;OR=oddsratio;PT=prothrombinTable4AngiographicimagingfollowingAISSourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentGanesanetal,Observationalstudy;n=212.
––SpectrumofcerebrovascularProvidesguidanceforimaging2003Paediatricstroke,withcerebraldiseaseidentifiableasriskrecommendationsangiographyin185casesfactorsinpaediatricstrokeLevyetal,1994Observationalstudy;n=19ComparingMRAagainstCAin–MRAperformslesswellforEarlypaper.
Providessometheinvestigationofdissection.
vertebraldissectionguidanceforimagingCAusedasgoldstandardrecommendationsGanesanetal,Observationalstudy;n=22Radiologicalfindingsof–ManypatternsofangiographicProvidessomeguidancefor2002posteriorcirculationstrokeinabnormalityimagingrecommendationschildrenHasanetal,2002ReviewpaperStudiesofvertebraldissection–IndicatespoorresultsforMRASummaryoftheimagingissues.
inchildrenProvidessomeguidanceforimagingrecommendationsGanesanetal,RetrospectivereviewofAngiography–IndicateshighprevalenceofProvidessomeguidancefor1999angiographicresultsinpaediatricabnormalitiesandaddedvalueimagingrecommendationsstroke;n=46ofcatheterangiographyinselectedcasescontinuedStrokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitation64Table4AngiographicimagingfollowingAIScontinuedSourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentHussonetal,Diagnosticobservational;MRAvscontrastangiographyNo.
oflesionsMRAfoundallmajorlesions.
Reasonablestudy,ratherlimited2003n=24childrenwithischaemicNonormalcasesmissed.
MRAsamplestrokeissensitiveenoughtogiveinitialevaluationofarterialbraindiseaseinchildren(non-invasively)MRA=MagneticresonanceimagingTable5AcutetreatmentSourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentStametal,2003Cochranereview.
2studieswithEffectivenessandsafetyofDeath,deathordependency,AnticoagulationassociatedwithNon-significantreductioninn=79;onewithstandardanticoagulationinpatientswithbleedingandthromboticrelativeriskofdeath0.
33deathordependency;basedonheparin(n=20)andtheothercerebralvenoussinuscomplications(0.
08,1.
21)andofdeath/smallnumbersfrom2studieswithLMWheparinthrombosisdependency0.
46(0.
16,1.
31).
OneGIhaemorrhageintreatedgroupand2PEincontrolsGI=Gastrointestinal;LMW=Lowmolecularweight;PE=PulmonaryembolismTable6RevascularisationsurgeryformoyamoyaSourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentGolbyetal,1999QualitativeDirectEC-IC(concurrentTIA/strokerecurrence;RadiolAllimproved/stabilised;nonewHeterogeneoustreatment;n=12(21hemispheres);EDASin6)(MRI);cerebralbloodflow;clinicalstrokesorischaemicmeanfollow-up35months;paediatricmoyamoya(XenonCT)lesionsonMRI;improvedadvocatedirectprocedurebloodflowOldsetal,Casecontrol(retrospective);Surgery15(direct5,Clinical(subjective);radiologyNosurgerypooroutcome.
Weakstudybutsomeattemptat1987n=23indirect10);nosurgery8(weak)Surgerystabilisedorimprovedcontrol.
ReasonsfornosurgeryConclusion:surgerybetterthannosurgery,directbetterthanindirectcontinuedTablesofevidence65Table6RevascularisationsurgeryformoyamoyacontinuedSourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentGeorgeetal,Qualitative;n=15Direct14;indirect1Clinical(subjective)Furtherstroke2;furtherTIA5Qualitativedata,uncontrolled,1993(decreasedseverity3);noimplicationdirectsurgery:furtherevents7;death1-lowmorbidity-improvesnaturalhistoryIshikawaetal,Qualitative;paediatricIndirect16hemispheres;directClinical(subjective);Post-opischaemicdeficits;Usefulretrospectivestudy;1997n=34(64hemispheres);+indirect(combined)i)ischaemicevents,indirect56%,combined10%.
favouringdirectsurgery.
(studysubgroup23patients48hemispheresii)ADLLong-termfollow-upADLnoComparablegroups>5yearsfollow-up)significantdifferencebetweensurggroupsMatsushimaRetrospectivecohortpaediatricComparisonofdirectvsCollateralvesselformation;CollateralformationbetterandOneofveryfewpaperstoetal,1992indirect(7vs13hemispheres)clinicalsymptomsclinicalimprovementbetterinaddresstheissueof'bestdirectgrouptechnique';smallnumbersFryeretal,2003Columbia,NYcohortofEncephaloduroarteriosynangiosisRecurrentclinicalevent1/6hadafurthereventSmallnumbers,nocontrolgrouppatientswithSCDandipsilateraltotheEDAS2weeksmoyamoya;n=6.
Follow-uplatermean33months(28–43months)ADL=Activitiesofdailyliving;EC-IC=Extra-intracranial;EDAS=Encephaloarteriodurosynangiosis;MRI=Magneticresonanceimaging;SCD=Sicklecelldisease;TIA=TransientischaemicattackTable7Secondarypreventionofstrokeinsicklecelldisease(bloodtransfusion)SourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentPowarsetal,Cohort+3referral.
33SS,None(naturalhistorystudyRecurrent'episode'inpatients10/15(67%)ofpatientswithPartretrospective.
Endpoint19782SC.
Firststrokeagedwithwhichallotherswithinfarctinfarctshadrecurrenceinincludesstrokes+TIAS+20monthsto36years.
compared)childhoodseizures;norepeatimaging.
25infarct,1haemorrhagePortnoy&ColumbiaCohortNoneRecurrence20%–Herion,1972continuedStrokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitation66Table7Secondarypreventionofstrokeinsicklecelldisease(bloodtransfusion)continuedSourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentBalkaranetal,Jamaicancohort;n=13NoneRecurrence6(47%)recurrentevent–1992Wilimasetal,Memphiscohort;n=12;TransfusionHbS8–10g/dl,HbS30%).
RecurrentTIAin13:6HbS>30%Scothornetal,Multicentrecohort.
1ststrokeAlltransfusedforatleastRecurrentstroke:acute31/137(23%)hadatleastClinicaldefinition.
Vascularimaging20021.
4–14years.
AllSSn=137.
5yearsatleast6weeklyneurologicalsyndrome–1recurrentstroke.
Meantimenotreported.
RetrospectiveHbSStrokedefinedclinicallyandsymptomsandsigns>24hourstorecurrence=4years.
attimeofstrokenotavailableforwithimagingRecurrence2.
2/100patientallbutatvaryingtimesafter1styears.
After2yearsrecurrencestrokecontinuedonlyinthosewithnoantecedenteventDobsonetal,Singlecentrecohort.
SSwithTransfusiontoHbS24h±imaging.
TIA.
RecurrencecommonerimagingTIA(n=11)orwerehadstroke4monthsafternon-compliant(n=5)withstoppingbloodtxand/orchelationSumozaetal,Valencia,VenezualacohortHydroxyurea40mg/kg/dayinRecurrentstrokeorTIANonehadrecurrenteventCohort;smallnumbers;no2002n=5;1TIA,4stroke.
4,30mg/kg/dayin1over42–112monthsvascularimaging;parietalinfarctsRxhydroxyurea;2after2ndorwhitematterabnormality.
strokes;3-1ststroke(noTx)VenousinfarctsTablesofevidence67Strokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitation68Table9Secondarypreventionofstrokeinsicklecelldisease(bonemarrowtransplantation)SourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentVermylen1998BelgianBMTxHLA-identicalstemcellTxSurvival,disease-freesurvival93%survival,82%diseasefree–(bonemarrow,48;cordblood,2)Bernaudin1999FrenchBMTxBonemarrowtransplantfromSurvival,absenceofSCD,91%survival,85%diseasefree,–HLA-identicalsiblingsrecurrentstroke1/16(6%)recurrentstrokeWaltersetal,USABMTxcohortn=50StemcelltransplantcPxClinicalstroke,progressionof94%survival;84%diseasefree;ShortFU;1diedcerebralhaem2000(48SS);followup57.
9monthsphenytoin,controlofsilentinfarctiononMRInonewclinicalstrokes;MRIand2GVHD;9/43(20%)had(38–95)hypertension,Mg2+suppsifstableorimprovedinallseizuressoonafterBMTxlow,Hb9-11,plt>50,000BMTx=Bonemarrowtransplantation;GVHD=Graftvshostdisease;Px=Prophylactic;QALY=Qualityadjustedlifeyears;FU=Follow-upTable10EarlydisabilityassessmentSourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentMorganetal,ChildrenwithTBIpresentingIncidencecharacteristicsandDysphagia61patients(5.
3%)hadGoodstudy,populationbased2003to2majorhospitalsinBrisbane;predictivefactorsfordysphagiadysphagia,68%severeTBI,butretrospectiven=1145childrenagedafterpaediatrictraumaticbrain15%moderateTBIand1%mild0–16yearsinjuryTBIiemoresevereinjuryassociatedwithhigerincidenceofdysphagia.
NeedforanddurationofSALTtreatmentgreaterindysphagicgroup.
PatientswithdysphagialikelytohavelowerGCSandlongerneedforventilationGCS=Glasgowcomascore;SALT=Speechandlanguagetherapy;TBI=TraumaticbraininjuryTablesofevidence69Table11TherapyinterventionsSourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentvanderWeelMatchedcontrols;7–11years;3conditionsofforearmComputerisedmeasuresofInaffectedarm20%increaseGood.
Implicationsforassessmentetal,19919hemiplegia;12normalpronation/supination–passive,rangeofmovementinrangeonactivemovementandtherapyactivenotaskandactivewithwithtasktaskLawetal,1991RCT,2x2factorialdesign.
Upperlimb(UL)inhibitivePeabodyScales(handfunction);NosignificantdifferenceWelldesigned.
Potential72childrenaged18months–casting±intensiveorregularQUEST(qualityofULbetweengroupsinhandconfoundingfactorsand8yearswithspasticcerebralneurodevelopmentaltherapymovement);Goniometerfunction.
Castingsignificantinfluenceofexternalfactorspalsy(quadriplegicor(NDT),orjustregularNDT(rangeofmovement)improvementinwristextensionconsideredinanalysis.
Widehemiplegic)for6monthperiodrange.
AlsoqualityofULvariationhoweverbetweenmovementimprovedwithsubjectscastingbutdecreasedpost-treatment.
ParentcomplianceimportantpredictorvariableLawetal,1997RCTrandomizedcrossover.
4monthintervention(seePeabodyFineMotorScales;Nodifferencehandfunction,Welldesigned.
Effectoftherapy50childrenwithcerebralpalsybelow),2monthwashout,QUEST;CanadianOccupationalqualityofULmovementorvsnotherapyinputnot(classificationquad,diplegia,4monthsotherintervention.
PerformanceMeasure(COPM)parents'perceptionofchild'saddressed.
Asstatedbyauthors,hemi),age18months–4years,InterventioneitherregularforparentalperceptionofhandfunctionineithergroupanyimprovementinfunctionvaryinghandfunctionfromOT=1xweekto1xmonthorchild'sabilityinhandactivitiescouldbedueeithertomoderatetosevereimpairmentintensiveNDT=1xweek+developmentalprogressand/orhomeprogramme+ULcasttherapy=4hours/day.
Assessmentatbaseline,4months,6monthsand10monthsHur1995ReviewofresearchstudiesonVarioustypesoftherapyVarietyPoorlycontrolled,smallsampleNoevidenceofsuperiorityoftherapeuticinterventionsinterventionsNDT,Vojta,sizedstudiesthereforenoanytreatmentapproachvestibularstimulationevidenceWright&Cohortstudy;8childrenwithFunctionalelectricalstimulation3sub-testsofJebsenHandImprovementincomponentsNocontrolgroup.
SmallGranat2000cerebralpalsy,recruitedfrom(FES)fordaily30minuteAssessment;rangeofwristofhandfunctionassessedandnumbers.
Resultssuggestiveofhospital.
Baselineassessmentsessionmovement;strength('moment')activewristextensionduringassociation.
Wouldbenefitfrom(3weeks),treatmentwithFESusingcomputer-basedtooltreatmentblockandinlargersamplesize.
Onlysome(6weeks)andfollow-upfollow-upperiod.
Nochangeincomponentsofhandfunction(6weeks)wristextension'moment'assessed(strength)duringtreatmentblockcontinuedStrokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitation70Table11TherapyinterventionscontinuedSourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentBoydRetal,Systematicreview;managementTherapies,splinting,casing,CategorisedaccordingtoPaucityofRCTs.
BestevidenceGoodsummaryofliterature2001ofupperlimbdysfunctioninmedicalandsurgicalICIDH-2(WHO)foroccupationaltherapyandcerebralpalsyinterventionscasting,butsmalltreatmenteffectsKetelaaretal,RCT;n=55children2–7yearsFunctionalvsNDTPEDI;GMFMPEDIshowedimprovementinGood2001withcerebralpalsyfunctionaltherapygroup.
NodifferenceinGMFMBoweretal,RCT:56childrenin2x2design.
IntensivetreatmentvsgoalGMFM;GMPMNosignificantdifferencesGood2001Age3–12.
GMCS111&belowsettingbetweengroupsButler&ReviewpaperNDTvsothertypesofVariedNosignificantdifferencesfoundGoodDarrah2001interventionbetweentypesoftreatmentVolmanetal,12childrenwithhemiplegiaComparisonofreachingKinematicsofmovementandThefunctionalconditionGood20028–14yearsmovementswithaffectedandmovementtimedemonstratedincreasednon-affectedarmin3conditionsvelocityandimprovementsinsmoothnessandcontrolWillisetal,200225subjects,finalnumber17;Cross-overtrial;constraint-PDMSSignificantimprovementsGood,althoughvalidityofPDMS1–8yearsinducedtherapywithplasterbetweencontrolandnotclearlyestablishedcastfor1monthtreatmentconditionsPierceetal,Singlecasestudy;1childConstraint-inducedtherapy;JebsonTaylortestofhandImprovedperformancetimesSmallsamplewithappropriate2002cottonsling6hoursperdayfunction,FingertipforceandonJTTHF;noconsistentmeasurementsfor14daysverticalgrip(custommade)changesinprecisionofmovementCOPM=CanadianOccupationalPerformanceMeasure;FES=Functionalelectricalstimulation;GMCS=GrossMotorFunctionClassificationSystem;GMFM=GrossMotorFunctionMeasure;GMPM=GrossMotorPerformanceMeasure;JTTHF=JebsonTaylorTestofHandFunction;NDT=Neuro-developmentaltherapy;PDMS=PeabodyDevelopmentalMotorScales;PEDI=PaediatricEvaluationofDisabilityInventory;RCT=RandomisedcontrolledtrialTablesofevidence71Table12StrengthtrainingSourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentDamiano&Abel,23+9CPMeasurementofstrengthandDynamometer;GMFMMusclestiffnessrelatedtoGood1998functionweakness;improvedmusclestrengthcorrelatedwithimprovedGMFMscoresRoss&EngsbergRetrospectiveanalysisofdataStrengthandspasticitytestatDynamometerNorelationshipbetweenGood2002kneeandankle;60childrenspasticityandstrengthwithdiplegia,meanage12yearsShortlandetal,5adults&5childrenwithCPUltrasoundimagingofDecreasedmusclefibreShorteningrelatedtodecreasedGoodquality:smallstudyonone2002gastrocnemiusmusclediameterinchildrenwithCPmusclefibrediameterandmuscleeffectonaponeurosisindicatingmuscleweaknessCP=Cerebralpalsy;GMFM=GrossMotorFunctionMeasureTable13OrthoticsSourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentRomkes&CCT;12subjects&10controls;HingedAFO;DAFOGaitanalysisHingedAFOproducedagaitGood,smallsampleBrunner2002hemiplegiacycleclosertonormal.
ImproveheeltoegaitandincreasedstridelengthcomparedtoDAFOOunpuuetal,31children(19withhemiplegia);UseofposteriorleafspringGaitanalysismeasuringankleIncreaseddorsiflexioninGood1996crossoverdesign,2conditionsAFOcomparedtobarefootandfootmovement&positionterminalandswingphases.
NocomparedwalkingincreaseinwalkingvelocityBrunneretal,14children;crossoverdesignSpringtype;AFOvsrigid;GaitanalysisSpringtypeachievedalmostGood19983conditionsAFOvsbarefootnormalrockingoffoot,decreasedequinusandhipadduction.
RigidAFOre-establishedheeltoegait.
BothbetterthanbarefootDesloovereetal,–PosteriorleafspringvsGaitanalysisIncreasedstridelength,Moderate1999hingedAFOsimprovedkneeflexiondecreasedhyperextensionAFO=Ankle–footorthosis;DAFO=DynamicanklefootorthosisStrokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitation72Table14BotulinumtoxinSourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentAde-Hall&CochraneReviewofBtxAinBotulinumtoxinAGaitanalysis;GMFM;3DgaitNostrongevidencefororGood;smallnumberswithshortMoore2002treatmentoflowerlimbanalysisagainstfollow-ups;needtoaddressspasticityNo.
oftrials=3long-termeffectsanddosagelevelsFriedmanetal,32children,17quadriplegiaBotulinumtoxinAtorangeofROMandMASImprovedelbowextensionatPoor.
Mixedsample;largeage2000and14hemiplegia;upperlimbmuscles1and3monthsnotat6months;range;weakoutcomemeasures1–18yearswristextensionimprovedat1monthonly;caregiverreportedimprovementReddihoughRCTcross-over;n=49.
BotulinumtoxinandphysioGMFM,MAS,jointrangeandMinimalchangeswithGoodqualitystudynotspecifictoetal,2002MixtureoftypesofCPmainlyvsphysioaloneVulpeAssessmentBatteryatsignificancein1or2strokeorhemiplegiathoseatmoresevereend3and6monthscomponents,limitedbenefittofunctionaloutcomeat3and6months.
TrendtoimprovedfinemotorskillsonBtxABakeretal,2002RCTdoubleblindBotulinumtoxinatdosesofGoniometry,activeand20u/kgmosteffectivedose.
Goodquality.
20u/kgmost10,20,30u/kgandplacebotopassiveROM,GMFMat4,8Dynamiccomponentofeffectivedoseingastrocnemius.
gastrocnemiusand16weeksshorteningimprovedatLonger-termstudyneeded16weeksBtxA=BotulinumtoxinA;GMFM=GrossMotorFunctionMeasure;MAS=ModifiedAshworthScale;RCT=Randomisedcontrolledtrial;ROM=RangeofmotionTablesofevidence73Table15PsychologySourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentGanesanetal,128withischaemicstroke;Parentalquestionnaire;Whetherimpairments13(14%)noresidualGood2000105included,23notavailable90children3months–15yearsinterferedwithdailylifeimpairments;37(40%)outcome(movedaway,died)attimeofstroke(mediangood;53(60%)outcomepoor.
5years);22neuropsychologicalYoungerageattimeofstrokeassessment;MRIscansonlysignificantpredictorofadverseoutcome.
42%speechandlanguagedifficulty;59%helpinschool,SENHoganetal,ReviewIntelligenceafterstroke–IQscorestowardlowerendofGood2000includinghemisphericsideofaveragerangebutsignificantlyinjury,ageatinjury,locusandbelowpoplationmean.
extentoflesion,genderandLateralisationofintellectuallongitudinaleffectsfunctionnotevidentbefore5yearsbeginstoemergeafterthisandappearstoberestrictedtopreservationofverbalIQafterRHinjury.
EmphasiseneedforrepeatedIQassessmentstodeterminelong-termoutcomeDeSchryverLong-termfollow-upcohortFollow-up7yearsafterstroke.
Structuredinterview;RavensRPMslightbutstatistically–etal,2000study37children1/3rdspecialeducation;>1/3rdnoimpairmentatmeanfollow-upof7yearscontinuedStrokeinchildhood:clinicalguidelinesfordiagnosis,managementandrehabilitation74Table15PsychologycontinuedSourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentBallantyneetal,Cohortstudy;17subjects,–IQscores,includingVIQ,PIQLHgroup:VIQ,PIQ–19948LHdamage(meanage9years,compromiseduniformly.
4.
1–16.
5),9RHdamage(meanRHgroup:PIQmostaffected,age11.
2yrs,4.
11–20.
10).
VIQlessaffected.
LH,RHPIQ17controlsmatchedforage,equallyeffected.
ComparedsexandSESwithcontrolsIQlowerthanexpectedDelsingetal,Consecutiveseries,cohortMedical/developmentalhistory–4childrendied,27(87%)–2001study.
31childrenwithIAS,andscreening.
Neurologicalchildrensurvived.
Ofthese:19male,12female.
examination.
Parent9(29%)noresidualimpairment,Ageofonset2months–questionnaire9(29%)mildmotorand14.
3years(meanage4.
3years).
cognitiveimpairment,9(29%)6childrenolderthan5.
11.
severeresidualimpairment,Timeoffollow-up1.
6–5.
9years1/3rdofchildrenattendeda(m=3.
5)schoolforspecialeducationorattendedacentreforseverementaldisability,58%recoveredorshowedmildresidualimpairment.
Largecorticalasopposedtosub-corticallocationofinfarctionisasignificantriskfactorforpooroutcome.
YoungagewasnotsignificantlyrelatedtopooroutcomeKraletal,2001GeneralreviewofReviewoftheliteratureonIntellectualfunctioning,languageLesionsonright–visualspatial–neuropsychologicalaspectsofneuropsychologicalfindingsandverbalabilities,visual-motordeficitsandconstructionalpaediatricSCDfromPsych-litandMedlineandvisual-spatialprocessing,apraxia.
Lesionsontheleft–database(1960–2001).
memoryandacademicrelativelygreaterdecrementinLiteraturereviewedaccordingachievementlanguage.
DeficitsinattentiontopresentationofsymptomsandexecutivefunctionarewithdatapertainingtoovertassociatedwithanteriorfocalCVA,andinvestigationsoflesions.
Growingevidenceofmoresubtleimpairment(silentimpairmentinsustainedinfarcts)attentionandconcentration,executivefunctionandvisual-motorspeedandcoordinationcontinuedTablesofevidence75Table15PsychologycontinuedSourceDesignandsubjectsInterventionOutcomemeasuresResultsQualityandcommentBonietal,200152childrenAge6–17yearswithEvaluationoflearningandAbbreviatedWISC;DiagnosticChildrenwhoscoredlower–EVAsicklecelldiseasebehaviourproblems;non-verbalAnalysisofNonverbalAccuracyFSIQhadhighermeasuresonemotionaldecodingabilities;(DANVA);SocialSkillsRatingtheDANVAsubtests.
ratingsofsocialemotionalSystem;Children'sDepressionWhenIQscoreswerecontrolledfunctioningInventory(CDI);MRIscansstatistically,resultssuggestthatchildrenwithSCDwhosufferfromdocumentedCNSpathologymayencounterdifficultydecodingorinterpretingcertainsocialsituationsthatareparticularlycomplexorambiguousMaxetal,2002Childrenaged5–19;29Psychiatricstatus,cognitive,CurrentpsychiatricdisorderNosignificantdifference–stroke;29congenitalclubfoot,academic,adaptiveandfamilynotpresentbeforestrokeorbetweengroupsonfamilyorscoliosis(ascontrols)functioning.
Familypsychiatricorthopaedicdisorder(controls)functionandfamilypsychiatrichistory.
Neuroimagingandhistory.
17/29(59%)ofchildrenneurologicalstatuswithstrokehadpostconditionPD,4/29(14%)oforthopaediccontrols.
12(41%)ofstrokesubjectshadaresolvedpost-medicalconditionPD8(28%)oforthopaedicsubjectshadresolvedpost-medicalconditionPD.
Attentiondeficit/hyperactivitydisordermostcommon(46%poststroke,17%postorthopaedic).
Anxietydisorders–31%poststroke,7%postorthopaedic.
Mooddisorders21%poststroke,7%postorthopaedic.
Psychiatricco-morbiditycommoninstrokesubjects.
Post-strokePDchildrenhigherneurologicalseverity,andseizureactivityCNS=Centralnervoussystem;CVA=Cerebrovascularaccident;IQ=Intelligencequotient;LH=Lefthemisphere;MRI=Magneticresonanceimaging;PD=Psychiatricdisorder;RH=Righthemisphere;SCD=Sicklecelldisease4EarlydisabilityassessmentandmanagementChapter8ReferencesAdamsRJ,McKieVC,HsuL,FilesBetal(1998)PreventionofafirststrokebytransfusionsinchildrenwithsicklecellanemiaandabnormalresultsontranscranialDopplerultrasonography.
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