The number of paediatric patients living with a prolonged Disorder of Consciousness (DoC) is growing in high-income countries, thanks to substantial improvement in intensive care. Life expectancy is extending due to the clinical and nursing management achievements of chronic phase needs, including infections. However, long-known pharmacological therapies such as amantadine and zolpidem, as well as novel instrumental approaches using direct current stimulation and, more recently, stem cell transplantation, are applied in the absence of large paediatric clinical trials and rigorous age-balanced and dose-escalated validations. With evidence building up mainly through case reports and observational studies, there is a need for well-designed paediatric clinical trials and specific research on 0–4-year-old children. At such an early age, assessing residual and recovered abilities is most challenging due to the early developmental stage, incompletely learnt motor and cognitive skills, and unreliable communication; treatment options are also less explored in early age. In middle-income countries, the lack of rehabilitation services and professionals focusing on paediatric age hampers the overall good assistance provision. Young and fast-evolving health insurance systems prevent universal access to chronic care in some countries. In low-income countries, rescue networks are often inadequate, and there is a lack of specialised and intensive care, difficulty in providing specific pharmaceuticals, and lower compliance to intensive care hygiene standards. Despite this, paediatric cases with DoC are reported, albeit in fewer numbers than in countries with better-resourced healthcare systems. For patients with a poor prospect of recovery, withdrawal of care is inhomogeneous across countries and still heavily conditioned by treatment costs as well as ethical and cultural factors, rather than reliant on protocols for assessment and standardised treatments. In summary, there is a strong call for multicentric, international, and global health initiatives on DoC to devote resources to the paediatric age, as there is now scope for funders to invest in themes specific to DoC affecting the early years of the life course.
IntroductionEpilepsy (EP) is one of the entities that are developing in children withperinatal brain lesions (PBL). An early and accurate diagnosis of EP is important because EP has major socioeconomic consequences for both the individual patient and society.The purpose of the study:we aimed toelucidate the significance of perinatal brain damage in childhood epilepsy.Research methodologywe performed a longitudinal prospective case-control study of 1036 children with PBL withvarious degrees of severity, followedbetween the age of 1–3 months and 48±12 months. Two hundred and fifty-ninechildren from study group (25%; 95CI23,65–26,35)developed EP. The control group included 334 healthy children. EEG examination and MRI brain imaging was performed. Enzyme-linked Immunosorbent Assay (ELISA) was used to assess the concentrations of brain derived neurotrophic factor (BDNF) and ciliary neurotrophic factor (CNTF) in the serum in all children. Statistical analyses were obtained using Statistics 7.0 software (StatSoftInc) and Excel.Results: Of all cases of EP- 211 (81,47%; 95 CI 79,06–83,88) were generalised forms; 48 (18,5±2,41%; 95CI16,09–20,91)– focalforms. In 89 cases (34,4%; 95CI31,45–37,35) neonatal seizures preceded EP, in the rest 234 cases (90.3% 95 CI 88.47 to 92.13) EP started at infant age, preferentially between 3 and 6 months – 89 (34,4%; 95CI31,45–37,35). We obtained strong correlations between imaging examinations andpharmacoresistant EP (rxy=-0,72)and middle correlations (rxy=-0,53) with controlled EP. EEG changes comprised approximately 9–11 types of routes and have correlated with the type of seizures (rxy=-0,72). Some patterns (isolated slow activity, diffuse slow activity, grouped generalised peaks) werepreceding the epileptiformchanges(rxy=-0,42).The observedcorrelations between low absoluteserum levels of neurotrophic factors(NF) (at 1–3 months) and EEG changes: BDNF (rxy=-0,72) andCNTF (rxy=-0,74), suggestthe development of pharmacoresistant EP and its progress to epileptic encephalopathies with sever neurophysiological processes disturbance.ConclusionsPBL has an important role in child EP. EP is associated withstructural brain abnormalities, variable electroencephalographic changes that strongly correlate with NF deficit, suggesting a reserved prognosis and evolution towards epileptic encephalopathies. NF study allowed the understanding of the pathogeneticaspects of EP, thus forming the basis for the potential neuroprotective strategies and the need for future studies.
BackgroundPaediatric stroke is a neurological injury that can lead to significant morbidity and mortality. Stroke remains among the top 10 causes of death in children and its morecommon causes are cardiac disorders, blood disorders, vasculopathiesand metabolic disorders.AimWe aim to describe two clinical cases of different diseases, wherestroke was the first manifestation.Material and methodswepresenttwo clinical cases: (1) a2-year-old girl diagnosed with MELAS syndrome and (2) a 14-year-old girl of with systemic lupus erythematosus (SLE), both patients with clinical signs of stroke.ResultsThe 2-year-old patientwas admitted in our clinic with status epilepticus, motor deficit, shortage of speech and language, cognitive disorders. The MRI showed multiple areas of cerebral ischemia located in the left hemisphere. The laboratory tests highlightedlactic acidosis, coagulation abnormalities and central nervous system and cardiovascular system damage. The echocardiographic examination revealed cardiomyopathy. Thus the diagnosis of MELAS syndrome was made.The second patient presented the following clinical manifestations: headache, cognitive dysfunction, hemiplegia. The brain MRI showed multiple areas of ischemia.The laboratory analysis revealed anaemia, increased ofacute phase reactants, increased titers of antinuclear antibodies, increased titers of anticardiolipin IgM and IgG antibodies and elevated titer of IgM and IgG antiphospholipid antibodies. The clinical diagnosis of systemic lupus erythematosus (SLE) was established.ConclusionsThese results suggest that stroke may be the initial manifestation of other severe disease (in our case – mitochondrial disorder, MELAS syndrome and autoimmune disease, SLE). In children, multiple brain structures are involved,at the very onset the clinical symptoms are generalised, nonspecific and polymorphous. Nevertheless, in teenagers, brain nonatheroscleroticvasculopathies are more likely to be responsible for developing of stroke and the clinical syndrome correlates with focal neurological deficits.
Introduction: Status epilepticus (SE) is a life-threatening neurological emergency requiring immediate medical intervention and is associated with high mortality and morbidity. The aim of this research was evaluation of clinical and etiological profile of refractory status epilepticus (RSE) among children aged between 1 month and 18 years. Material and methods: The study was done between January 1, 2017 and December 24, 2019. All children with the age limits mentioned above, who presented convulsive SE, subsequently with development in refractory status epileptic (RSE), were included in the study. Patients were investigated and evaluated according to a standard protocol. Subsequently, the characteristics of children with RSE and those without an evolution in RSE were compared. Results: 55 children, out of whom 32 boys with SE were enrolled in the study, of which 20 children (36%) developed RSE. Central nervous system (CNS) infections were the most common causes of SE and development of RSE (51% in SE and 53% in RSE, p > 0.05). Noncompliance of antiepileptic medication served as the second cause for evolution of RSE. The overall mortality rate was 10.9%, the chances of death in RSE (20%) being higher than in SE (5.7%). The unfavorable prognosis was seven times higher in children with RSE, compared to children who developed SE. Conclusions: In the management of CNS infections, pediatricians should be aware of the high risk of developing RSE. In addition, the possibility of developing RSE should be considered and promptly managed in an intensive care unit in order to reduce the risk of mortality and morbidity of this severe neurological condition
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