Cerebral infarction and neurodevelopmental outcome in childhood tuberculous meningitis.
Springer Priscilla,Swanevelder Sonja,van Toorn Ronald,van Rensburg Anita Janse,Schoeman Johan
European journal of paediatric neurology : EJPN : official journal of the European Paediatric Neurology Society
INTRODUCTION:Cerebral infarction is an important cause of neurological sequelae in childhood tuberculous meningitis (TBM). AIM:To investigate neurodevelopmental outcome and development of motor sequelae in TBM-related cerebral infarction. METHODS:A group of 64 children with TBM and computerized tomographic (CT) evidence of infarction were compared with regard to motor sequelae and neurodevelopmental outcome, with 54 children with TBM but no radiological evidence of infarction. The association between infarct number, size, location and outcome was investigated in the infarct group. Selected covariates were entered into a multivariate model to better understand the independent contribution of each factor on neurodevelopmental outcome. RESULTS:An association was found between the presence, number and size of hemispheric infarcts and motor handicap on follow-up. Location of single basal ganglia infarcts, however, did not correlate with motor outcome. The Griffiths general developmental quotient (GQ) was significantly lower in children with bilateral (p<0001) and unilateral multiple infarcts (p=0.0239) compared to those without infarcts. The GQ of children with unilateral single infarcts was not significantly lower than those without infarction (p=0.2282). CONCLUSION:Infarct characteristics should be taken into account when neurodevelopmental outcome is prognosticated in TBM. Young age, unilateral multiple or bilateral infarction on CT at 1 month, advanced stage of TBM and the interaction term stage x Glasgow coma score are the best predictors of neurodevelopmental outcome at 6 months.
10.1016/j.ejpn.2008.07.004
[Recurrent idiopathic cerebral infarction in a 5-year-old boy, with emphasis on the importance of platelet aggregation analysis for appropriate selection of anti-platelet drugs].
Sugiyama Nobuyoshi,Matsuda Shin-ichi,Shimizu Mie,Obara Saori,Ikegami Mariko,Yokoyama Jyun-ichi,Miyashita Yoshihiro,Takizawa Shyunya,Takagi Shigeharu
No to hattatsu = Brain and development
We present a 5-year-old boy with recurrent idiopathic cerebral infarction in which analysis of platelet hyperaggregability was useful in choosing appropriate anti-platelet drugs. The patient presented with gait disturbance at the age of 5 years and 1 month. Brain MRI demonstrated multiple infarctions in the right thalamus and left cerebellum. There were no apparent underlying diseases including hematological, cardiac and vascular abnormalities. He was diagnosed as idiopathic cerebral infarction. First, we administered ticlopidine and he remained stable with persistent mild intention tremor in the left upper extremity for 4 months. Then he developed the second stroke at the age of 5 years and 5 months, and multiple infarctions in the right celebellum and cerebellar vermis were demonstrated. On platelet aggregation analysis, adenosine diphosphate (ADP)-induced aggregation was inhibited, probably due to ticlopidine administration. Collagen- and epinephrine-induced platelet aggregation showed hyperaggregation, so we started to administer cilostazol, which inhibits only epinephrine-induced hyperaggregation. We also added aspirin, which inhibits collagen-induced hyperaggregation. The combination of anti-platelet drugs inhibited epinephrine-, collagen- and ADP-induced hyperaggregation in this patient. He has been stable on the triple combination of anti-platelet drugs without further episodes of cerebral infarction or transient ischemic attack for 4 years to date. Appropriate selection of anti-platelet therapy was achieved by the simple and repeatable platelet aggregation analyses, which must be considered even in pediatric patients with cerebral infarction.
Acute silent cerebral infarction in children with sickle cell anemia.
Dowling Michael M,Quinn Charles T,Rogers Zora R,Buchanan George R
Pediatric blood & cancer
Silent cerebral infarctions (SCI) occur in up to 35% of children with sickle cell anemia (HbSS) but are rarely recognized during the initial 10-14 days when diffusion weighted magnetic resonance imaging (MRI) can differentiate acute infarctions from remote events. We report acute SCI in seven children with HbSS who had areas of restricted diffusion on MRI without persistent focal neurologic deficits. Four had acute SCI identified following acute anemic events. Our observations suggest that SCI are detectible in the acute phase, present with subtle neurologic symptoms, result in permanent neurologic injury, and may be caused by acute anemic events.
10.1002/pbc.22242
Post-traumatic cerebral infarction: a rare complication in a pediatric patient after mild head injury.
Yılmaz Serkan,Pekdemir Murat,Sarısoy Hasan Tahsin,Yaka Elif
Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery : TJTES
Because the cases of post-traumatic cerebral infarction in children are uncommon, little research has been done on this subject. The case of a 14-month-old child who had cerebral infarction after mild head injury is discussed. He fell from a height of approximately 70 cm 12 hours before. He did not use his left arm after the injury. His parents took him to the public hospital, where he was investigated in terms of mechanical complication and was observed for six hours, but no computed tomography (CT) scan was performed at that time. The patient was then presented to our department by his parents. He was not able to walk and was sitting. His neurological examination revealed right hemihypoesthesia, hemiparesis and mild left facial paresis. CT showed a hypodense region in the right basal ganglia location. The right lateral ventricle seemed mildly compressed due to edematous changes. The magnetic resonance imaging revealed hyperintense signal changes that affected the right lentiform nucleus and the head of the caudate nucleus. The aim of the case is to remind emergency physicians that post-traumatic ischemic stroke is uncommon but may be the cause of disability in pediatric patients, and a systematic physical examination must be performed in all ages even if the patients appear quite well.
Acute cerebral infarction and extra pontine myelinolysis in children with new onset type 1 diabetes mellitus.
Petzold Stefanie,Kapellen Thomas,Siekmeyer Manuela,Hirsch Wolfgang,Bartelt Heike,Siekmeyer Werner,Kiess Wieland
Pediatric diabetes
Neurological complications of diabetic ketoacidosis (DKA) are still associated with significant mortality and morbidity. We report on two children who suffered from acute cerebral infarction (CI) and extra pontine myelinolysis (EPM) at onset of type 1 diabetes. Initially, clinical management had not been performed according to generally accepted guidelines. Putative risk factors that may have predisposed for the development of acute cerebrovascular complications are discussed. Not only cerebral edema (CE) but also other severe neurological complications such as CI should be suspected when neurological deterioration occurs during DKA. We conclude that not only an exceeded rehydration therapy but also a rapidly reduced serum osmolality due to an unbalanced rapid blood sugar decrease and serum sodium increase may have lead to the neurological disease. We propose that a reserved and well-defined rehydration strategy in the first 6 (-12) h of therapy is crucial for recovery and can reduce neurological complications of patients with DKA.
10.1111/j.1399-5448.2010.00732.x
Association Between Prolonged Seizures and Malignant Middle Cerebral Artery Infarction in Children With Acute Ischemic Stroke.
Andrade Andrea,Bigi Sandra,Laughlin Suzanne,Parthasarathy Sujatha,Sinclair Adriane,Dirks Peter,Pontigon Ann Marie,Moharir Mahendranath,Askalan Rand,MacGregor Daune,deVeber Gabrielle
Pediatric neurology
BACKGROUND:Malignant middle cerebral artery infarct syndrome is a potentially fatal complication of stroke that is poorly understood in children. We studied the frequency, associated characteristics, and outcomes of this condition in children. METHODS:Children, aged two months to 18 years with acute middle cerebral artery infarct diagnosed at our center between January 2005 and December 2012 were studied. Associations with malignant middle cerebral artery infarct syndrome were sought, including age, seizures, neurological deficit severity (Pediatric National Institute of Health Stroke Severity Score), stroke etiology, fever, blood pressure, blood glucose, infarct location, infarct volume (modified pediatric Alberta Stroke Program Early Computed Tomography Score), and arterial occlusion. Death and neurological outcomes were determined. RESULTS:Among 66 children with middle cerebral artery stroke, 12 (18%) developed malignant middle cerebral artery infarct syndrome, fatal in three. Prolonged seizures during the first 24 hours (odds ratio, 25.51; 95% confidence interval, 3.10 to 334.81; P = 0.005) and a higher Pediatric National Institute of Health Stroke Severity Score (odds ratio, 1.22; 95% confidence interval, 1.08 to 1.45; P = 0.006) were independently associated with malignant middle cerebral artery infarct syndrome. All children aged greater than two years with a Pediatric National Institute of Health Stroke Severity Score ≥8 and initial seizures ≥5 minutes duration developed malignant middle cerebral artery infarct syndrome (100%). CONCLUSIONS:Malignant middle cerebral artery infarct syndrome affects nearly one in five children with acute middle cerebral artery stroke. Children with higher Pediatric National Institute of Health Stroke Severity Scores and prolonged initial seizures are at greatly increased risk for malignant middle cerebral artery infarct syndrome. Children with middle cerebral artery infarcts warrant intensive neuroprotective management and close monitoring to enable early referral for hemicraniectomy surgery.
10.1016/j.pediatrneurol.2016.08.015
Extensive and Progressive Cerebral Infarction after Infection.
Choi Yu Hyeon,Jeong Hyung Joo,Lee Bongjin,An Hong Yul,Lee Eui Jun,Park June Dong
Korean journal of critical care medicine
Acute cerebral infarctions are rare in children, however they can occur as a complication of a (MP) infection due to direct invasion, vasculitis, or a hypercoagulable state. We report on the case of a 5-year-old boy who had an extensive stroke in multiple cerebrovascular territories 10 days after the diagnosis of MP infection. Based on the suspicion that the cerebral infarction was associated with a macrolide-resistant MP infection, the patient was treated with levofloxacin, methyl-prednisolone, intravenous immunoglobulin, and enoxaparin. Despite this medical management, cerebral vascular narrowing progressed and a decompressive craniectomy became necessary for the patient's survival. According to laboratory tests, brain magnetic resonance imaging, and clinical manifestations, the cerebral infarction in this case appeared to be due to the combined effects of hypercoagulability and cytokine-induced vascular inflammation.
10.4266/kjccm.2016.00283
Spectrum of cerebral arteriopathies in children with arterial ischemic stroke.
Rafay Mubeen F,Shapiro Kevin A,Surmava Ann-Marie,deVeber Gabrielle A,Kirton Adam,Fullerton Heather J,Amlie-Lefond Catherine,Weschke Bernhard,Dlamini Nomazulu,Carpenter Jessica L,Mackay Mark T,Rivkin Michael,Linds Alexandra,Bernard Timothy J,
Neurology
OBJECTIVE:To determine that children with arterial ischemic stroke (AIS) due to an identifiable arteriopathy are distinct from those without arteriopathy and that each arteriopathy subtype has unique and recognizable clinical features. METHODS:We report a large, observational, multicenter cohort of children with AIS, age 1 month to 18 years, enrolled in the International Pediatric Stroke Study from 2003 to 2014. Clinical and demographic differences were compared by use of the Fisher exact test, with linear step-up permutation min- adjustment for multiple comparisons. Exploratory analyses were conducted to evaluate differences between cases of AIS with and without arteriopathy and between arteriopathy subtypes. RESULTS:Of 2,127 children with AIS, 725 (34%) had arteriopathy (median age 7.45 years). Arteriopathy subtypes included dissection (27%), moyamoya (24.5%), focal cerebral arteriopathy-inflammatory subtype (FCA-i; 15%), diffuse cerebral vasculitis (15%), and nonspecific arteriopathy (18.5%). Children with arteriopathic AIS were more likely to present between 6 and 9 years of age (odds ratio [OR] 1.93, = 0.029) with headache (OR 1.55, = 0.023), multiple infarctions (OR 2.05, < 0.001), sickle cell anemia (OR 2.9, = 0.007), and head/neck trauma (OR 1.93, = 0.018). Antithrombotic use and stroke recurrence were higher in children with arteriopathy. Among arteriopathy subtypes, dissection was associated with male sex, older age, headache, and anticoagulant use; FCA-i was associated with hemiparesis and single infarcts; moyamoya was associated with seizures and recurrent strokes; and vasculitis was associated with bilateral infarctions. CONCLUSION:Specific clinical profiles are associated with cerebral arteriopathies in children with AIS. These observations may be helpful indicators in guiding early diagnosis and defining subgroups who may benefit most from future therapeutic trials.
10.1212/WNL.0000000000009557
Atrial standstill presenting as cerebral infarction in a 7-year-old girl.
Ahnfeldt Agnethe May,de Knegt Victoria Elizabeth,Reimers Jesper Irving,Børresen Malene Landbo
SAGE open medical case reports
Atrial standstill is a rare arrhythmia defined by the absence of mechanical and electrical activity in the atria. Few cases of atrial standstill have been described in children, none of which have presented with cerebral infarction confirmed by imaging. We report a unique case of a 7-year-old girl presenting with expressive aphasia, central facial palsy and irregular pulse with cerebral infarction secondary to atrial standstill. This case illustrates that cardiogenic cerebral embolism in children can be caused by rare conditions like atrial standstill and should be considered in paediatric patients undergoing evaluation for stroke. There are no established treatment guidelines for atrial standstill. We recommend that treatment be directed towards any potential underlying cause. All patients with atrial standstill should receive long-term oral anticoagulation treatment and a permanent cardiac pacemaker implant to reduce the risk of further strokes or other cardiac events.
10.1177/2050313X19827735
Silent cerebral infarcts in patients with sickle cell disease: a systematic review and meta-analysis.
Houwing Maite E,Grohssteiner Rowena L,Dremmen Marjolein H G,Atiq Ferdows,Bramer Wichor M,de Pagter Anne P J,Zwaan C Michel,White Tonya J H,Vernooij Meike W,Cnossen Marjon H
BMC medicine
BACKGROUND AND PURPOSE:Silent cerebral infarcts (SCIs) are the most common neurological complication in children and adults with sickle cell disease (SCD). In this systematic review, we provide an overview of studies that have detected SCIs in patients with SCD by cerebral magnetic resonance imaging (MRI). We focus on the frequency of SCIs, the risk factors involved in their development and their clinical consequences. METHODS:The databases of Embase, MEDLINE ALL via Ovid, Web of Science Core Collection, Cochrane Central Register of Trials via Wiley and Google Scholar were searched from inception to June 1, 2019. RESULTS:The search yielded 651 results of which 69 studies met the eligibility criteria. The prevalence of SCIs in patients with SCD ranges from 5.6 to 80.6% with most studies reported in the 20 to 50% range. The pooled prevalence of SCIs in HbSS and HbSβ SCD patients is 29.5%. SCIs occur more often in patients with the HbSS and HbSβ genotype in comparison with other SCD genotypes, as SCIs are found in 9.2% of HbSC and HbSβ patients. Control subjects showed a mean pooled prevalence of SCIs of 9.8%. Data from included studies showed a statistically significant association between increasing mean age of the study population and mean SCI prevalence. Thirty-three studies examined the risk factors for SCIs. The majority of the risk factors show no clear association with prevalence, since more or less equal numbers of studies give evidence for and against the causal association. CONCLUSIONS:This systematic review and meta-analysis shows SCIs are common in patients with SCD. No clear risk factors for their development were identified. Larger, prospective and controlled clinical, neuropsychological and neuroimaging studies are needed to understand how SCD and SCIs affect cognition.
10.1186/s12916-020-01864-8
[Mycoplasma pneumonia associated with cerebral infarction in 3 children].
Wang Wei,Shen Kun-ling
Zhonghua er ke za zhi = Chinese journal of pediatrics
OBJECTIVE:To study the clinical features and diagnostic methods of mycoplasma pneumonia complicated with cerebral infarction. METHOD:Data of 3 children with mycoplasma pneumonia who developed cerebral infarction, including clinical manifestations and imaging were collected, analyzed and the literature was reviewed. RESULT:All the cases were pre-school or school-aged children, who developed the respiratory infection initially, the neurological symptoms were acute hemiparesis, with or without convulsion. The IgM antibody to Mycoplasma pneumoniae (Mp) was positive. Pulmonary imaging showed unilateral consolidation with atelectasis and pleural exudate. Neuroimaging showed occlusion of middle cerebral artery and infarction of its territory. After giving azithromycin, anti-coagulative and thrombolytic treatments, the neurological deficits recovered to some extent. CONCLUSION:Mycoplasma pneumonia were diagnosed based on respiratory symptoms and pulmonary imaging, the accompanied cerebral infarction was confirmed by neurological and neuroimaging findings.
[Cerebral infarction suspected due to dissection of intracranial carotid artery in 2 children].
Hori Emiko,Fukuda Osamu,Eiraku Naoto,Takahashi Chiaki,Hamada Hideo,Hayashi Nakamasa,Endo Shunro
No shinkei geka. Neurological surgery
Intracranial cerebral artery dissection in children is very rare. We report 2 children who were diagnosed as having cerebral infarction which was suspected to be due to dissection of intracranial cerebral artery. Case 1: An 11-year-old girl presented with conscious disturbance and hemiparesis after seizure. Computed tomography (CT) showed cerebral infarction in the right frontal lobe. Her symptoms did not change, but angiography demonstrated reversible change. She received conservative therapy. Case 2: A 10-year-old boy complained of headache, and presented nausea and monoparesis of the left upper extremity. CT showed cerebral infarction in the right frontal lobe. He received superficial temporal artery-middle cerebral artery anastomosis because his symptoms fluctuated. In both cases, cerebral angiography showed string sign from the supraclinoid portion of the internal carotid artery to the middle and the anterior cerebral artery. Follow-up angiography showed improvement of stenosis. In pediatric cases of cerebral artery dissection, improvement with conservative therapy is frequently reported. It is necessary to follow-up such patients closely using magnetic resonance angiography or conventional angiography to determine whether or not surgery is indicated.
[Forensic clinical analysis on 25 cases of traumatic cerebral infarction].
Zhang Wu,Hu Yong-Liang
Fa yi xue za zhi
OBJECTIVE:To investigate characteristics of forensic clinical identification on traumatic cerebral infarction(TCI). METHODS:Twenty-five cases of TCI were analyzed retrospectively, including the general situation, location of infarction and clinical feature. RESULTS:TCI occurred primarily in children and elderly. All the cases had definite cerebral trauma which was located mainly in the regions of basal ganglia-internal capsule, frontal, temporal and parietal cerebral cortex. CONCLUSION:The consequence of TCI has direct correlation with location of cerebral infarction. More attention should be paid to this issue in forensic practice.
Cerebral infarction after mild head trauma in children.
Yang Feng-Hua,Wang Hua,Zhang Jun-Mei,Liang Hong-Yuan
Indian pediatrics
We conducted this retrospective, case record review to determine the risk factors and clinical features associated with cerebral infarction after mild head trauma in children. The median age of the cohort was 2.18 years (range, 6 mo-8 y). Most (26/29) of the patients developed the neurological symptoms and signs within 72 hours after trauma, 51.7% within 30 minutes. The first symptoms included hemiparesis (20), facial paresis (7), and convulsion (7). 86.21% of the lesions lay in basal ganglia region. Pre-existing basal ganglia calcification was identified in 13 as a risk factor.
Symptomatic cerebral infarction in a child with severe diabetic ketoacidosis.
Güven Ayla,Hancili Suna,Karatoprak Elif Y,Tasel Bülent
Journal of pediatric endocrinology & metabolism : JPEM
BACKGROUND:Diabetic ketoacidosis (DKA) is a common initial presentation of pediatric type 1 diabetes mellitus. Intracerebral complications of DKA pose significant mortality and morbidity rates. OBJECTIVE:Our aim is to emphasize the importance of early identification, investigation, and treatment for patients who present with DKA and stroke. CASE REPORT:Here, we report a case of a 4-year-old female patient who presented with ischemic-hemorrhagic stroke as a complication of DKA. CONCLUSION:Cerebrovascular complications of DKA in children are a rare condition; however, higher risks take place in their youngest age. Clinicians should be aware of these complications so as to develop appropriate approach for its management.
10.1515/jpem-2014-0037
[Cerebral infarction related to varicella zoster virus vasculopathy].
Namitome Satoshi,Shindo Seigo,Wada Kuniyasu,Terasaki Tadashi,Nakajima Makoto,Ando Yukio
Rinsho shinkeigaku = Clinical neurology
A 14-year-old girl developed transient disturbance of consciousness, dysarthria, and clumsiness of the right upper limb 4 months after herpes zoster ophthalmicus. Brain MRI showed acute cerebral infarction in the left middle cerebral artery (MCA) territory. CT angiography demonstrated mild stenosis in the top of the left internal carotid artery and the proximal side of the MCA. Cerebrospinal fluid (CSF) examination showed slightly mononuclear pleocytosis (6/μl). Titer of the anti-varicella zoster virus (VZV) IgG antibodies in CSF was increased, and gadolinium-enhanced brain MRI (T-weighted imaging) revealed enhancement of the vessel walls at the stenotic lesions. Based on the diagnosis of VZV vasculopathy, methylprednisolone and valacicrovir were administered, followed by acyclovir, in addition to antithrombotic therapy using aspirin and warfarin. After these treatment, her right upper clumsiness was resolved and gadolinium-enhancement of the vessel walls was disappeared on MRI. VZV vasculopathy may cause ischemic stroke in young patients, especially in children. A careful history-taking about herpes is necessary to detect the disease as a potential cause in young stroke patients.
10.5692/clinicalneurol.cn-001117
[Thrombolysis in arterial cerebral infarction in children].
Waje-Andreassen Ulrike,Thomassen Lars,Aarli Anen,Kråkenes Jostein,Norgård Gunnar,Russell David
Tidsskrift for den Norske laegeforening : tidsskrift for praktisk medicin, ny raekke
BACKGROUND:After the neonatal period, the incidence of arterial cerebral infarction is 1-2/100 000 children/year. Thrombolysis in cerebral stroke is recommended for adults, but is still controversial for children. The aim of this paper was to provide an overview of documentation on treatment with thrombolysis after arterial cerebral infarction in children. MATERIAL AND METHODS:The article is based on literature identified through a non-systematic search in PubMed and own clinical experience in treating young adults with cerebral infarction. RESULTS:In the western world cardiac disease, cardiac interventions and infections are the most important causes of cerebral infarction in children. Children with arterial cerebral infarction should initially be treated as adults, i.e. rapid admission to hospital and immediate imaging, preferably magnetic resonance imaging with diffusion and intracranial angiography. There are no randomized controlled trials of efficacy and safety of thrombolysis in cerebral infarction in children. Thrombolysis is normally not recommended for children because of the lack of scientific evidence. Nevertheless, thrombolysis is used in children with cerebral infarction and case reports are available. INTERPRETATION:The prospect of severe disability should lead to consideration of thrombolysis if age below 18 years is the only contraindication. Treatment of children with thrombolysis should be recorded in an international registry.
10.4045/tidsskr.09.0098
Cerebral Infarction following Acute Subdural Hematoma in Infants and Young Children: Predictors and Significance of FLAIR Vessel Hyperintensity.
Momose Hiroaki,Sorimachi Takatoshi,Aoki Rie,Atsumi Hideki,Matsumae Mitsunori
Neurologia medico-chirurgica
A phenomenon of cerebral infarction following acute subdural hematoma (ASDH) in infants and young children, termed cerebral infarction following ASDH (CIASDH), has been well recognized, though both its mechanisms and risk factors have been poorly understood. The purpose of the present study was to investigate the predictors for CIASDH in a population of ASDH, and to evaluate the imaging studies to presume the mechanisms of CIASDH. We retrospectively examined consecutive children 6 years of age or younger, who were diagnosed with ASDH and were admitted to our hospital between 2000 and 2014. In 57 consecutive children with ASDH, 12 (21.1%) developed CIASDH. The multivariate analysis revealed five predictors for CIASDH: presence of seizure, consciousness disturbance at admission, absence of skull fracture, hematoma thickness ≥ 5 mm on computed tomography (CT), and midline shift ≥ 3 mm on CT (p < 0.05). In three of six patients (50%) undergoing magnetic resonance (MR) imaging/fluid-attenuated inversion recovery (FLAIR) within 5 days of admission, serpentine hyperintensities in the subarachnoid space (FLAIR vessel hyperintensities) were demonstrated. MR angiography showed neither occlusion nor stenosis of the cerebral arteries. Single photon emission CT performed at admission in one patient showed a cerebral blood flow reduction in the ASDH side. All the children with CIASDH showed unfavorable outcomes at discharge. Children showing multiple predictors at admission should be carefully observed for development of CIASDH. Evaluation of the imaging studies suggested that a blood flow disturbance in the level of peripheral arteries to microcirculation was one candidate for possible mechanisms to induce the CIASDH.
10.2176/nmc.oa.2014-0334
Cerebral infarction and femoral venous thrombosis detected in a patient with diabetic ketoacidosis and heterozygous factor V Leiden G1691A and PAI-1 4G/5G mutations.
Yaroglu Kazanci Selcen,Yesilbas Osman,Ersoy Melike,Kihtir Hasan Serdar,Yildirim Hamdi Murat,Sevketoglu Esra
Journal of pediatric endocrinology & metabolism : JPEM
Cerebral infarction is one of the serious neurological complications of diabetic ketoacidosis (DKA). Especially in patients who are genetically prone to thrombosis, cerebral infarction may develop due to inflammation, dehydration, and hyperviscocity secondary to DKA. A 6-year-old child with DKA is diagnosed with cerebral infarction after respiratory insufficiency, convulsion, and altered level of consciousness. Femoral and external iliac venous thrombosis also developed in a few hours after central femoral catheter had been inserted. Heterozygous type of factor V Leiden and PAI-14G/5G mutation were detected. In patients with DKA, cerebral infarction may be suspected other than cerebral edema when altered level of consciousness, convulsion, and respiratory insufficiency develop and once cerebral infarction occurs the patients should also be evaluated for factor V Leiden and PAI-14G/5G mutation analysis in addition to the other prothrombotic risk factors.
10.1515/jpem-2015-0056
Vasculitis, cerebral infarction and persistent Bartonella henselae infection in a child.
Balakrishnan Nandhakumar,Ericson Marna,Maggi Ricardo,Breitschwerdt Edward B
Parasites & vectors
BACKGROUND:The genus Bartonella is comprised of a rapidly increasing number of pathogenic species that induce a seemingly diverse spectrum of neurological symptoms. During the 12 year period that followed the initial onset of neurological and gastrointestinal symptoms, an 11 year-old girl experienced a spectrum of neurological complaints including frequent headaches, visual and auditory hallucinations, anxiety, vision loss involving the lower left quadrant of both eyes, episodic bouts of generalized paralysis, facial palsy, chronic insomnia, seizures, dizziness, cognitive dysfunction, and memory loss. PCR assays targeting Bartonella spp. were used to test formalin-fixed, paraffin embedded brain tissue, patient blood specimens and Bartonella alpha Proteobacteria growth medium (BAPGM) enrichment blood cultures. PCR positive amplicons were sequenced directly and compared to GenBank sequences. Bartonella spp. serology was performed by indirect fluorescent antibody testing and confocal laser scanning microscopy was used to visualize B. henselae organisms in resected brain. RESULTS:Bartonella henselae DNA was independently PCR amplified and sequenced from the girl's right parietal lobe, surgically resected in 2000 and from a blood specimen collected in 2012. Although causation cannot be established by a case report, prior diagnostic testing resulted in findings that were either inconclusive or within normal reference ranges and no etiological diagnosis had been obtained to explain the patient's initial or progressive neurological symptoms. CONCLUSIONS:As intravascular, intra-erythrocytic and endotheliotropic bacteria, it is possible that B. henselae initially induced a vasculitis, resulting in secondary cerebral infarction, tissue necrosis and surgical resection. Bartonella bacteremia, potentially spanning a 12-year time frame, in conjunction with the therapeutic administration of immunosuppressive drugs may have resulted in a progression and potentiation of the neurological disease that was partially reversible following antibiotic administration.
10.1186/s13071-016-1547-9
[Brain plasticity and early rehabilitative care for children after neonatal arterial cerebral infarction].
Dinomais M,Marret S,Vuillerot C
Archives de pediatrie : organe officiel de la Societe francaise de pediatrie
Currently, in the literature of the evidence based medicine, little data are available to confirm the benefit and the specific procedures of an early intervention for a neonatal arterial ischemic stroke. However, data about the effect of an early physical rehabilitation program on the cerebral plasticity, and preliminary results of clinical studies in children with cerebral palsy strongly suggest the benefit of an early rehabilitation with a multidisciplinary approach. The type of the rehabilitation and its frequency must be determined because a wide variability in the practices exists. A comprehensive care, of the children and his family is necessary to limit the orthopaedics but also the social consequences of a neonatal stroke.
10.1016/S0929-693X(17)30333-0
Panton-Valentine leukocidin-positive novel sequence type 5959 community-acquired methicillin-resistant Staphylococcus aureus meningitis complicated by cerebral infarction in a 1-month-old infant.
Oshima Nozomu,Hamada Hiromichi,Hirose Shoko,Shimoyama Kyohei,Fujimori Makoto,Honda Takafumi,Yasukawa Kumi,Ishiwada Naruhiko,Ohkusu Misako,Takanashi Jun-Ichi
Journal of infection and chemotherapy : official journal of the Japan Society of Chemotherapy
Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has become a pathogen of major importance in pediatric patients. CA-MRSA can cause skin and soft tissue infection in children and young active adults with no predisposing factors, and life-threatening infections such as meningitis or necrotizing pneumonia have been reported. We report here a case of CA-MRSA meningitis complicated by acute left middle cerebral artery (MCA) infarction and necrotizing pneumonia in a previously healthy 1-month-old Vietnamese boy. He was firstly treated with vancomycin, but changed to linezolid because of persistent fever and low vancomycin trough level. He recovered successfully with residual right-sided hemiparesis. The mode of transmission of CA-MRSA and the mechanism of cerebral infarction (thrombotic or embolic) were unknown. The isolate was genotyped as staphylococcal cassette chromosome (SCC) mec type V with a novel sequence type (ST) 5959 harboring the Panton-Valentine leukocidin (PVL) gene. ST 5959 is a double locus variant of ST 59, which is a major PVL-positive CA-MRSA strain isolated in invasive disease in Asian countries. This case report may serve as a warning about the dissemination of PVL-positive CA-MRSA in and around Japan, with the possibility of causing serious life-threatening disease. The potential of linezolid for the treatment of MRSA meningitis as one of the alternative MRSA therapeutic drugs is also discussed.
10.1016/j.jiac.2020.09.011
A case report of an infant after episodes of paroxysmal supraventricular tachycardia with left ventricular thrombosis and cerebral infarction.
Li Dan,Guo Jinghui,Li Xiao-Hui,Liao Yanmei,Zhang Ming-Ming,Shi Lin,Lin Yao,Liu Yang
Annals of palliative medicine
Left ventricular thrombosis and cerebral infarction caused by recurrent episodes of paroxysmal supraventricular tachycardia (PSVT) are uncommon in infants. We present the case of a 23-month-old girl whose echocardiography revealed a left ventricular thrombus, which resolved after sinus rhythm was restored. The girl had experienced repeated systemic convulsions and high muscular tension of the left limb accompanied by movement disorder. Soon afterward, cranial magnetic resonance imaging (MRI) revealed scattered lacunar cerebral infarctions in the right lateral ventricle. The symptoms, signs, and laboratory examination satisfied the diagnosis of left ventricular thrombosis and cerebral infarction caused by recurrent episodes of PSVT. The girl was given antiarrhythmic drugs, including propranolol, esmolol, and amiodarone, intracranial pressure decreasing treatment (mannitol), heart and brain cell nutritional therapy, anticoagulant therapy, and her condition gradually improved. This case report highlights the importance of pediatric PSVT patients' clinical management and that more emphasis should be placed on early recognition and prevention of severe complications. Pediatricians should be trained early recognition of the nonspecific clinical manifestations of PSVT, make effectively and quickly diagnosis by electrocardiogram, evaluation of cardiac function and thrombosis by echocardiography, and termination PSVT as rapidly as possible. Thromboprophylaxis therapy might be considered for recurrent episodes of PSVT.
10.21037/apm-20-1797
Kawasaki Disease Complicated by Late-Onset Fatal Cerebral Infarction: A Case Report and Literature Review.
Frontiers in pediatrics
Cerebral infarction is a rare neurological complication of Kawasaki disease (KD) and occurs in the acute or subacute stage. There have been no reported cases of late-onset fatal cerebral infarction presenting over 1 year after the onset of KD. A 5-month-old male patient with KD received timely intravenous immunoglobulin therapy; however, extensive coronary artery aneurysms (CAA) and coronary artery thrombosis (CAT) developed 1 month later. Anticoagulation and thrombolytic agents were suggested, but the child's parents refused. Fifteen months after KD onset, an attack of syncope left him with left hemiplegia; brain computerized tomography (CT) scans revealed cerebral infarction of the right basal ganglion without hemorrhage. Magnetic resonance angiography (MRA) revealed severe stenosis of the right middle cerebral artery, and a series of tests were performed to exclude other causes of cerebral infarction. Considering the cerebral infarction and CAT, combination therapy with urokinase and low-molecular-weight heparin (LMWH) was initiated within 24 h of syncope onset, together with oral aspirin and clopidogrel. Five days later, his clinical symptoms partially regressed and he was discharged. Unfortunately, 5 days after discharge, his clinical condition suddenly deteriorated. Repeat brain CT showed hemorrhagic stroke involving the entire left cerebral area, in addition to the previous cerebral infarction in the right basal ganglion, with obvious secondary cerebral swelling and edema, which might have been caused by previous thrombolysis. Severe cerebral hernias developed quickly. Regrettably, the patient's parents abandoned treatment because of economic factors and unfavorable prognosis, and he died soon after. Cerebral infarction and cerebral artery stenosis can develop late, even 1 year after the onset of KD. Pediatricians should be aware of the possibility of cerebrovascular involvement in addition to cardiac complications during long-term follow-up of KD patients. Prompt anticoagulation therapy and regular neuroimaging evaluation are essential for the management of patients with KD with giant CAA and/or CAT.
10.3389/fped.2021.598867
Retinal vein occlusion with cerebral infarction in a preterm neonate: a case report.
Zhu Xiuyu,Cai Xiaojing,Zhou Xiaohong,Li Yian,Yang Chenhao
BMC pediatrics
BACKGROUND:Retinal vein occlusion (RVO) is a common disease that causes blindness in elderly patients, and cerebral infarction is also a severe disorder impairing the health of individuals. Both diseases are not common in neonates and are related to thrombosis. To date, only one case of simultaneous occurrence of RVO with intracranial haemorrhage in a full-term neonate has been reported. CASE PRESENTATION:A preterm neonate was diagnosed with cerebral infarction and RVO. Retinal haemorrhage and macular oedema were detected in the left eye after the onset of ipsilateral stroke. Although the retinal conditions in this case resolved spontaneously without ocular treatment, the long-term effect on visual function is still unknown. CONCLUSIONS:Given that ocular fundus examinations are rarely performed in paediatric stroke patients, a screening fundus examination in these newborns with stroke might be worth considering.
10.1186/s12887-021-02989-2
Central retinal artery occlusion and cerebral infarction associated with Mycoplasma pneumonia infection in children.
Bao Yunguang,Li Xiaobing,Wang Kaixuan,Zhao Chan,Ji Xiumei,Jiang Mizu
BMC pediatrics
BACKGROUND:Central retinal artery occlusion (CRAO) is an arterial ischemic stroke, rarely occurred in children accompanied with asymptomatic cerebral infarction and almost never involved in severe pneumonia related to Mycoplasma pneumonia infection. CASE PRESENTATION:An 8-year-old boy with severe pneumonia related to Mycoplasma pneumonia infection that developed loss of vision in the left eye on the 14 day. No light perception and no pupillary reaction to light were found in the left eye. The fundus examination revealed a cherry red spot with severe retinal edema at the macular and peripapillary area, and the optic disc was pale in the left eye but normal in the right eye, suggesting CRAO in the left eye. No obvious neurological symptoms and signs were observed on presentation. Magnetic resonance imaging of the brain showed an abnormal signal of the left lentiform nucleus, caudate nucleus and within the temporal lobe, suggesting an acute cerebral infarction. The analysis of cerebrospinal fluid showed an increasing leukocyte count, but no any pathogenic microorganisms were found. His respiratory symptoms disappeared promptly after therapy, and the patient was discharged after 11 days later, but there was no light in the left eye 2 months after discharge. CONCLUSION:M. pneumoniae infection could be developed the risk for cerebral ischemic stroke, including CRAO in children with severe pneumonia. CRAO is a devastating ophthalmologic event leading to a severe impairment of vision. Patients treated within about 6 h of vision loss had a better visual outcome after the onset of vision loss.
10.1186/s12887-016-0750-3
Increased levels of anti-phosphatidylcholine and anti-phosphatidylethanolamine antibodies in pediatric patients with cerebral infarction.
Korematsu Seigo,Yamada Hiroshi,Miyahara Hiroaki,Ihara Kenji
Brain & development
Cerebral infarction in children is rare and often occurs secondary to moyamoya disease, hereditary coagulopathies, vasculitis, antiphospholipid antibody syndrome, heart disease, mitochondrial disease. However, in some cases, the causes of cerebral infarction is unknown. In this study, we detected increased levels of serum anti-phosphatidylcholine and anti-phosphatidylethanolamine IgG antibodies in three pediatric patients with cerebral infarction whose primary disorders are unknown by routine examination. For the five disease control patients of cerebral infarction due to other primary disorders, there was no such increase in these antibodies levels. Phosphatidylcholine and phosphatidylethanolamine are major components of the phospholipids of vascular endothelial cells, while cardiolipin is a minor component. Anti-phosphatidylcholine and anti-phosphatidylethanolamine antibodies, as well as anti-cardiolipin antibody, might also be risk factors with cerebral infarction.
10.1016/j.braindev.2017.01.010
Refractory Mycoplasma pneumoniae pneumonia with concomitant acute cerebral infarction in a child: A case report and literature review.
Jin Xingnan,Zou Yingxue,Zhai Jia,Liu Jie,Huang Bing
Medicine
RATIONALE:Mycoplasma pneumoniae pneumonia, a common cause of community-acquired pneumonia in children, is rarely complicated with acute cerebral infarction. PATIENT CONCERNS:We present a 7-year-old boy with severe M pneumoniae pneumonia who developed impaired consciousness, aphasia, and reduced limb muscle power 7 days postadmission. DIAGNOSES:Mycoplasma pneumoniae pneumonia with concomitant acute cerebral infarction. INTERVENTIONS:The patient recovered with aggressive antibiotic therapy, antiinflammation therapy with methylprednisolone, and gamma immunoglobulin and anticoagulation therapy with aspirin and low molecular weight heparin along with rehabilitation training. OUTCOMES:At 8 days postadmission, his consciousness was improved and at the 6-month follow-up visit, his muscle power of bilateral upper and lower limbs was normal except still poor right handgrip power. LESSONS:Stroke or cerebral infarction should be considered and promptly managed in rare cases of M pneumoniae pneumonia with neurologic manifestations.
10.1097/MD.0000000000010103
[Clinical and imaging features of cerebral infarction in children].
Zhao Qi-Yu,Zheng Yang,Wang Xiao-Ming
Zhongguo dang dai er ke za zhi = Chinese journal of contemporary pediatrics
OBJECTIVE:To summarize and analyze the etiology, clinical manifestations and imaging features of children with cerebral infarction. METHODS:A retrospective analysis was performed for the clinical data of 54 children with cerebral infarction, including etiology, clinical manifestations, distribution of infarcts, type of infarcts and clinical outcome. RESULTS:Of the 54 children, 93% had a clear cause, among whom 46% had the coexistence of multiple factors, and the top three causes were infection (54%), vascular disease (40%) and trauma (26%). Major clinical manifestations included limb paralysis (85%), pyrexia (20%), disturbance of consciousness (19%) and convulsion (17%). As for the location of infarcts, 80% of the infarcts were located in the cerebral cortex and 52% in the basal ganglia. Major types of infarcts were small-area infarcts (74%) and multifocal infarcts (56%). Viral encephalitis was the most common cause of cerebral infarction caused by infection, with the cerebral cortex as the most common location of infarcts (21/23, 91%) and multiple infarcts as the most common type of infarcts (13/23, 57%). Among the 12 children with cerebral infarction caused by nonspecific endarteritis, 10 (83%) had infarcts located in the basal ganglia and only one child had multiple infarcts. Among the five children with cerebral infarction caused by moyamoya disease, four children (80%) had infarcts located in the cerebral cortex, and large-area infarction (4/5, 80%) and multifocal infarction (4/5, 80%) were the major types of infarcts. Among the children with traumatic cerebral infarcts, 92% had infarcts located in the basal ganglia, and small-area infarcts (92%) and single infarcts (85%) were the major types of infarcts. Among the 46 children with limb paralysis, 34 (74%) had infarcts located in the basal ganglia; 50% of the children with disturbance of consciousness had infarcts located in the basal ganglia. Subcortical infarcts were observed in all six children with epilepsy. Seventy-five percent of the infarcts located in the cerebral cortex and 87% of the infarcts located in the basal ganglia had a good prognosis. Among the two children with cerebral infarcts located in the brainstem, one had the sequela of hemiplegia and the other had the sequela of cognitive impairment. Eighty-eight percent of the children with cerebral infarction caused by infection and 82% of the children with traumatic cerebral infarction tended to have a good prognosis, and 83% of the children with cerebral infarction caused by nonspecific endarteritis had good prognosis. Recurrence was observed in all three children with cerebral infarction caused by vascular malformations. Of the five children with cerebral infarction caused by moyamoya disease, one child died and four children survived with the sequela of localized brain atrophy, among whom one child also had the sequela of epilepsy. CONCLUSIONS:Infection, vascular disease and trauma are the most common causes of cerebral infarction in children, and limb paralysis is the most common clinical manifestation. Cerebral cortex is the most common infarct site, and small-area infarcts and multifocal infarcts are the most common types of infarcts, which tend to have a better prognosis.
Risk Factors for Cerebral Infarction in Duchenne Muscular Dystrophy: Review With our 2 Cases.
Nozaki Fumihito,Kusunoki Takashi,Kumada Tomohiro,Shibata Minoru,Fujii Tatsuya
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
BACKGROUND:Although the incidence of cerebral infarction is higher in Duchenne muscular dystrophy (.75 per 100) than in the general population (7.5-11.4 per 100 000), only 18 cases have been reported, and prevention and management guidelines for infarction in this disorder remain lacking. PATIENTS AND METHODS:We encountered 2 cases of Duchenne muscular dystrophy with cerebral infarction. To clarify risk factors for such infarction in Duchenne muscular dystrophy, we reviewed 20 cases, including our 2 patients. RESULTS:Age at onset of infarction ranged from 4 to 31 years (n = 19). Most patients were 16-21 years old (14 of 19; 73.7%). Eighteen patients (90%) had dilated cardiomyopathy (DCM), showing a higher frequency than in the age-matched general Duchenne muscular dystrophy population. Left ventricular ejection fraction (LVEF) ranged from 10.2% to 42% (median, 20%; n = 9). Detectable cardiac thrombus and atrial fibrillation were rare (2 of 17; 11.8%, and 1 of 17; 5.9%, respectively). CONCLUSIONS:Presence of DCM with low LVEF seems to be the strongest risk factor for cerebral infarction in Duchenne muscular dystrophy.
10.1016/j.jstrokecerebrovasdis.2019.06.023
Infantile cerebral infarction caused by severe diabetic ketoacidosis in new-onset type 1 diabetes mellitus.
Suzuki Junichi,Fuchigami Tatsuo,Kawamura Kengo,Aoki Masako,Urakami Tatsuhiko,Morioka Ichiro
Journal of pediatric endocrinology & metabolism : JPEM
Background Diabetic ketoacidosis (DKA) is a common complication of type 1 diabetes mellitus (T1DM). Infants and children with new-onset T1DM may present with DKA, and the risk of cerebral edema is high in infantile DKA. What is new? Neurological deterioration during an episode of DKA is usually attributed to cerebral edema and cerebrovascular accidents. However, cerebral infarction is a very rare complication in infantile DKA. Case presentation We describe a rare case of infantile cerebral infarction caused by severe DKA in a patient with new-onset T1DM. Conclusions Cerebral infarction is an important intracranial complication in infantile DKA. Careful observation and treatment for DKA during the first 24 h of therapy are necessary in infants with new-onset T1DM because the risk of cerebral infarction is highest during this timeframe.
10.1515/jpem-2019-0233
Methylprednisolone pulse therapy as an adjuvant treatment of Streptococcus pneumoniae meningitis complicated by cerebral infarction-a case report and review of the literature.
Chan Oi-Wa,Lin Jainn-Jim,Hsia Shao-Hsuan,Lin Chia-Ying,Lin Kung-Lin
Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery
PURPOSE:The role of methylprednisolone pulse therapy as adjuvant treatment of Streptococcus pneumoniae meningitis complicated by cerebral infarction has rarely been reported. METHODS:We reported a case report and also performed a systematic literature review. RESULTS:A 1-year 2-month-old boy who presented with high fever, status epilepticus, and septic shock was diagnosed with cerebral infarction caused by Streptococcus pneumoniae meningitis on magnetic resonance imaging (MRI). He was treated with methylprednisolone pulse therapy and his clinical condition gradually improved thereafter. At the follow-up visit 1 year after discharge, he was able to sit without support, but he had moderate delays in speech and developmental milestones and epilepsy sequelae. CONCLUSION:In severe cases, the use of high-dose methylprednisolone should be considered to modulate the inflammatory response in patients with severe cerebral infarction caused by Streptococcus pneumoniae meningitis.
10.1007/s00381-019-04485-6
A case of pediatric moyamoya disease with severe cerebral vasospasm and delayed cerebral infarction following an intraventricular hemorrhage.
Inoue Kohei,Shimokawa Shoko,Yoshioka Fumitaka,Ogata Atsushi,Masuoka Jun,Abe Tatsuya
Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery
Reports on patients with moyamoya disease presenting cerebral ischemic complications after the onset of intraventricular hemorrhage (IVH) and/or intracerebral hemorrhage (ICH) are limited. Herein, we report a case of a 7-year-old girl with moyamoya disease with severe cerebral vasospasm and delayed cerebral infarction following an IVH. Although the case is rare, the potential for vasospasm-induced cerebral infarction should be carefully considered and thus, intensive treatment should be immediately initiated.
10.1007/s00381-020-04769-2
Refractory cerebral infarction in a child with an ACTA2 mutation.
Kanamori Keita,Sakaguchi Yuri,Tsuda Kyoji,Ihara Satoshi,Miyama Sahoko
Brain & development
INTRODUCTIONS:A specific mutation in the ACTA2 gene is known to cause multisystemic smooth muscle dysfunction syndrome, which is associated with cerebrovascular diseases and various organ disorders. Cerebral infarctions resulting from severe vasculopathy can be refractory; however, there are no previous reports describing the detailed clinical course of recurrent cerebral infarctions due to an ACTA2 mutation. Herein, we report a patient with an ACTA2 mutation who experienced multiple refractory cerebral infarctions in early childhood. PATIENT DESCRIPTION:The patient was aged 1 year and 5 months at her first episode of cerebral infarction. Arteriopathy due to an ACTA2 mutation was diagnosed based on the characteristic cerebrovascular findings and abnormal physical findings, such as bilateral dilated pupils. Bilateral encephaloduroarteriosynangiosis and encephalogaleosynangiosis were performed after the first episode. Because the cerebral infarctions recurred postoperatively, administration of cilostazol followed by bosentan was started. However, despite these treatments she experienced seven cerebral infarctions by age 2 years and 6 months. INTERPRETATION:Cerebral infarctions in patients with a specific ACTA2 mutation can occur even in early childhood, recur frequently, and cause severe motor and cognitive impairment. Physicians should be highly aware of this disease and be ready to provide the medical and surgical interventions necessary to minimize the disabling sequelae.
10.1016/j.braindev.2020.12.001
Risk Factors for Cerebral Infarction Early After Revascularization in Children Younger than 5 Years with Moyamoya Disease.
World neurosurgery
OBJECTIVE:Cerebral revascularization is necessary for pediatric patients younger than 5 years with moyamoya disease (MMD). However, they have a high risk of developing cerebral infarction early after surgery. This study aimed to analyze the risk factors for developing cerebral infarction among these patients. METHODS:The charts of 21 consecutive patients with MMD (39 surgeries) younger than 5 years who had undergone revascularization at our hospital were retrospectively analyzed. Because cerebral infarction occurring within 1 month after surgery was the primary end point, other clinical information was evaluated, including each surgical procedure. Multivariate analysis of the risk factors for postoperative cerebral infarction was performed. RESULTS:Cerebral infarction occurred after 7 of 39 surgeries (17.9%). Of the 39 surgeries, 23 (59%) included direct and indirect combined revascularization. The incidence of cerebral infarction did not differ significantly between the combined (21.7%) and indirect (12.5%) groups (P = 0.46). Logistic regression showed no association between the revascularization procedure and the occurrence of cerebral infarction after surgery (P = 0.3). However, younger age at surgery was correlated with a higher risk of developing cerebral infarction in the early postoperative period (P = 0.05). CONCLUSIONS:No differences were found in the risk of developing cerebral infarction early after surgery as a result of surgical procedures. However, younger patients had higher postoperative risk. Further multicenter research should examine this issue for young pediatric patients with moyamoya at high risk of developing cerebral infarction.
10.1016/j.wneu.2021.12.115