Management of stroke in childhood
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《英国医生杂志》
Guidelines are welcome, but have some gaps—such as perinatal stroke
Stroke care for adults has been revolutionised in recent years, possibly in association with the publication of national clinical guidelines for stroke.1 In consequence, rehabilitative care after stroke for adults is now considered the norm. Stroke is less common in children, and clinical experience and anecdotal evidence indicate that children may receive a variable quality of care. A welcome development therefore has been the publication last year of guidelines by the UK Royal College of Physicians paediatric stroke working group.2
The guidelines deal mainly with the diagnosis, investigation, and management of acute arterial ischaemic stroke in children beyond the neonatal period, covering acute presentation, management, rehabilitation, and longer term care. They emphasise the need for early imaging and input from a paediatric neurology tertiary centre. They also appropriately emphasise that these children should be investigated for an underlying prothrombotic tendency and should undergo echocardiography.
With respect to acute care, the working group found no studies specifically examining the efficacy of acute treatments and made its recommendations based on consensus opinion. In the main, whether or not to anticoagulate a child with cardiac embolism is therefore a decision that should be based on the individual patient. Similarly no current evidence supports the use of thrombolytic agents. By contrast good evidence exists for the use of aspirin in a dose of 5 mg per kg body weight per day unless imaging suggests intracranial haemorrhage or the child has sickle cell disease.
Alongside the acute medical (and more rarely surgical) management, the guidelines recommend that at an early stage the child's disability be assessed and that acute clinicians liaise with community child health services.
It is disappointing but unsurprising that specific rehabilitative techniques and approaches that are recommended do not have an evidence base: the information that is available is largely derived from practice and experience in children with cerebral palsy.
The guidelines tackle longer term rehabilitation needs, emphasising the requirement for psychological, cognitive, and family assessments together with the likelihood that rehabilitation for many children will extend into their adult lives.
Against the background of a paucity of hard data, the working group has made various audit recommendations that relate to acute care and longer term care of children who have had a stroke.
A working group report such as this raises issues around paediatric disability that go beyond its remit. These are both general and specific. The general point to be made is that models for assessment and rehabilitation in stroke have much in common with those for most neurologically disabling conditions in childhood. These include prompt and appropriate diagnostic formulation, comprehensive assessment to include an understanding of family functioning and dynamics, appropriate health interventions at an early stage, and realistic multidisciplinary rehabilitation based on evidence based practice wherever that is possible. Hence one would wish to see paediatric stroke services integrated into and as a component of wider paediatric neurodisability services.
Specifically, what is disappointing about the deliberations of the working group is that they have not addressed the issues that relate to perinatal stroke and its usual sequel of congenital hemiplegia. Lynch et al have summarised recent knowledge of this subject.3 The diagnostic issues in this group of children are at least as complex as when stroke has its origin later in childhood, and specifically the links with intrapartum adversity are a current subject of interest and potential litigation.4 Expertise in obstetric, fetal, and neonatal medicine will need to be added to any future working group if these wider aspects of stroke in childhood are to be addressed satisfactorily.
Lewis Rosenbloom, consultant paediatric neurologist
Alder Hey Children's Hospital, Liverpool L3 0BQ (83waterloo@supanet.com)
Competing interests: None declared.
References
Royal College of Physicians, London. Intercollegiate Stroke Working Party. June 2004. National clinical guidelines for stroke. 2nd ed. www.rcplondon.ac.uk/pubs/books/stroke/stroke_guidelines_2ed.pdf (accessed 15 Apr 2005).
Royal College of Physicians, London. Paediatric Stroke Working Group. Stroke in childhood. Clinical guidelines for diagnosis, management and rehabilitation. November 2004. www.rcplondon.ac.uk/pubs/books/childstroke/childstroke_guidelines.pdf (accessed 15 Apr 2005).
Lynch, JK, Hirtz DG, DeVeber G, Nelson KB. Report of the National Institute of Neurological Disorders and Stroke workshop on perinatal and childhood stroke. Pediatrics 2002;109: 116-23.
Cowan F, Rutherford M, Groenendaaal F, Eken P, Mercuri E, Bydder GM. Origin and timing of brain lesions in term infants with neonatal encephalopathy. Lancet 2003;361: 736-42.
Stroke care for adults has been revolutionised in recent years, possibly in association with the publication of national clinical guidelines for stroke.1 In consequence, rehabilitative care after stroke for adults is now considered the norm. Stroke is less common in children, and clinical experience and anecdotal evidence indicate that children may receive a variable quality of care. A welcome development therefore has been the publication last year of guidelines by the UK Royal College of Physicians paediatric stroke working group.2
The guidelines deal mainly with the diagnosis, investigation, and management of acute arterial ischaemic stroke in children beyond the neonatal period, covering acute presentation, management, rehabilitation, and longer term care. They emphasise the need for early imaging and input from a paediatric neurology tertiary centre. They also appropriately emphasise that these children should be investigated for an underlying prothrombotic tendency and should undergo echocardiography.
With respect to acute care, the working group found no studies specifically examining the efficacy of acute treatments and made its recommendations based on consensus opinion. In the main, whether or not to anticoagulate a child with cardiac embolism is therefore a decision that should be based on the individual patient. Similarly no current evidence supports the use of thrombolytic agents. By contrast good evidence exists for the use of aspirin in a dose of 5 mg per kg body weight per day unless imaging suggests intracranial haemorrhage or the child has sickle cell disease.
Alongside the acute medical (and more rarely surgical) management, the guidelines recommend that at an early stage the child's disability be assessed and that acute clinicians liaise with community child health services.
It is disappointing but unsurprising that specific rehabilitative techniques and approaches that are recommended do not have an evidence base: the information that is available is largely derived from practice and experience in children with cerebral palsy.
The guidelines tackle longer term rehabilitation needs, emphasising the requirement for psychological, cognitive, and family assessments together with the likelihood that rehabilitation for many children will extend into their adult lives.
Against the background of a paucity of hard data, the working group has made various audit recommendations that relate to acute care and longer term care of children who have had a stroke.
A working group report such as this raises issues around paediatric disability that go beyond its remit. These are both general and specific. The general point to be made is that models for assessment and rehabilitation in stroke have much in common with those for most neurologically disabling conditions in childhood. These include prompt and appropriate diagnostic formulation, comprehensive assessment to include an understanding of family functioning and dynamics, appropriate health interventions at an early stage, and realistic multidisciplinary rehabilitation based on evidence based practice wherever that is possible. Hence one would wish to see paediatric stroke services integrated into and as a component of wider paediatric neurodisability services.
Specifically, what is disappointing about the deliberations of the working group is that they have not addressed the issues that relate to perinatal stroke and its usual sequel of congenital hemiplegia. Lynch et al have summarised recent knowledge of this subject.3 The diagnostic issues in this group of children are at least as complex as when stroke has its origin later in childhood, and specifically the links with intrapartum adversity are a current subject of interest and potential litigation.4 Expertise in obstetric, fetal, and neonatal medicine will need to be added to any future working group if these wider aspects of stroke in childhood are to be addressed satisfactorily.
Lewis Rosenbloom, consultant paediatric neurologist
Alder Hey Children's Hospital, Liverpool L3 0BQ (83waterloo@supanet.com)
Competing interests: None declared.
References
Royal College of Physicians, London. Intercollegiate Stroke Working Party. June 2004. National clinical guidelines for stroke. 2nd ed. www.rcplondon.ac.uk/pubs/books/stroke/stroke_guidelines_2ed.pdf (accessed 15 Apr 2005).
Royal College of Physicians, London. Paediatric Stroke Working Group. Stroke in childhood. Clinical guidelines for diagnosis, management and rehabilitation. November 2004. www.rcplondon.ac.uk/pubs/books/childstroke/childstroke_guidelines.pdf (accessed 15 Apr 2005).
Lynch, JK, Hirtz DG, DeVeber G, Nelson KB. Report of the National Institute of Neurological Disorders and Stroke workshop on perinatal and childhood stroke. Pediatrics 2002;109: 116-23.
Cowan F, Rutherford M, Groenendaaal F, Eken P, Mercuri E, Bydder GM. Origin and timing of brain lesions in term infants with neonatal encephalopathy. Lancet 2003;361: 736-42.