10 yeras experience in paediatric spontaneus intracerebral haemorrhage
TRANSCRIPT
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Original article S W I S S M E D W K LY 2 0 0 8 ; 1 3 8 ( 5 - 6 ) : 5 9 6 9 w w w . s m w . c h
Peer reviewed article
59
A 10-year experience in paediatricspontaneous cerebral haemorrhage:
which children with headache need morethan a clinical examination?
Sandrine de Ribaupierrea, Bndict Rillieta,b, Jacques Cottingc, Luca Reglia
a Service of Neurosurgery, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanneb Service of Neurosurgery, Hpital Universitaire de Genve (HUG), Genvec Paediatric intensive care unit, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne
Introduction: When a child is seen in a clinicwith a headache, stroke is certainly not the rst onthe list of differential diagnoses. In western coun-tries, stroke is typically associated with adults andthe elderly. Although rare, haemorrhagic strokesare not exceptional in the paediatric population,as their incidence is around 1/100 000/year.Prompt diagnosis is essential, since delayed treat-ment may lead to disastrous prognosis in thesechildren.
Materials and methods: This is a retrospectivereview of paediatric cases with spontaneous cere-bral haemorrhage that presented in two universityhospitals in the last ten years. The experience ofthese primary and tertiary referral centres com-prises 22 consecutive cases that are analysed ac-cording to aetiology, presenting symptoms, treat-ment and outcome.
Results: 77% of the children diagnosed withhaemorrhagic stroke presented with headaches.41% of them had a sudden onset, while 9% devel-oped headaches over a period of hours to weeks.
While 9% presented only with headaches, themajority had either subtle (diplopia, balanceproblems) or obvious (focal decits, unilateral
weakness and decreased level of consciousness)concomitant neurological signs. 55% had an arte-riovenous malformation (AVM), 18% had ananeurysm and 14% had a cavernous malforma-tion. In 14% the aetiology could not be deter-
mined. The majority of haemorrhages (82%)were supratentorial, while 18% bled into the pos-terior fossa. All children underwent an emergencycerebral CT scan followed by specic investiga-tions. The treatment was dependent on the aeti-ology as well as the mass effect of the haematoma.In 23% an emergent evacuation of thehaematoma was performed. Two children (9%)died, and 75% had a favourable clinical outcome.
Conclusion: Headaches in children are a com-
mon problem, and a small minority may reveal anintracranial haemorrhage with poor prognosis ifnot treated promptly. Although characterisationof headaches is more difcult in a paediatricpopulation, sudden, unusual or intense headachesshould lead to imaging work-up.Any neurologicalnding, even one as subtle as hemianopsia or dys-metria, should alarm the physician and should befollowed by emergency imaging investigation. Ifthe cerebral CT reveals a haemorrhage, the childshould be referred immediately to a neurosurgicalreferral centre without further investigation. The
outcome is grim for children presenting in comawith xed, dilated pupils. The long-term resultoverall for children after spontaneous intracranialhaemorrhage is not dismal and depends criticallyon specialised management.
Key words: hemorrhagic stroke; pediatric; AVM;cavernoma; aneurysm; headache
Summary
Headaches regularly or occasionally occur in1525% of the paediatric population [24]. Whenthey occur, paediatricians or general practitionersare the rst to be consulted. Their clinical appre-ciation of the headache plays a major role in de-
tecting a serious pathology such as intracerebralhaemorrhage, sinus thrombosis, tumour ormeningitis, as opposed to tension headache, mi-graine, or prodromal symptoms of u or viral dis-eases.
Introduction
59
No financial
support declared
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Even though spontaneous cerebral haemor-rhages are rare in children, they must be consid-ered, and excluded rapidly in the differential diag-noses of headaches, as immediate treatmentmight be required in order to avoid devastatingdecits. Unlike benign headaches, serious in-tracranial pathologies are often accompanied bysymptoms, such as vomiting or focal neurological
signs.Haemorrhagic strokes will, in a majority of
cases, reveal themselves with an altered level ofconsciousness, but might also be less symptomatic
with headaches, vomiting, seizures or focal neuro-logical decits [5, 6]. The average incidence ofhaemorrhagic stroke in the paediatric population
is reported to be between 0.741.1/100000/year[68]. Their incidence is slightly lower than thatof ischaemic strokes; they represent between 27and 52% of paediatric strokes [6, 911].
The purpose of this study is to analyse thesigns and symptoms of a consecutive paediatricseries presenting with spontaneous cerebralhaemorrhages in two primary and tertiary referral
centres. The work-up and the treatment of thesechildren are reviewed. Main aetiologies are pre-sented as well as recommendations for follow-up.Differences in the management of haemorrhagicstroke between the paediatric and adult popula-tions will also be highlighted.
60A 10-year experience in paediatric spontaneous cerebral haemorrhage
Materials and methods
We retrospectively reviewed the charts of paediatricpatients (
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Table1
Age
Aetiology
Grade
Localisation
Headaches
Firsts
ymptoms
Signs/symptomsonarrivalatuniversityhospital
NV
Seizures
GCS
(years)
1
0,2
Aneurysm
FischerIV
Lanteriorcereb
ralartery
?
Fewco
nvulsions,syncope
Cardiacarrestduringtransport,opistotonos,
Yes
3
dilatedreactivepupils
2
1
Aneurysm
FischerIV
Anteriorcommunicatingartery
Sudden
Criesh
oldinghishead,vomit
Reactivepup
ils
Yes
Yes
3
3
6
AVM
SpetzlerIII
RParasplenium
and
Sudden
While
atschool,H
Athen
Symetricmo
uvements
910
intraventricular
decreasedlevelofconsciousness
4
6.5
AVM
Cerebellumand
mesencephalon
?
Equilibrium
Ataxia
15
5
6.5
?
RFrontal
Yes
HA,leftsideparesis,memory
Lsideparesis
14
difculties,coordination
6
8
AVM
SpetzlerIV
LThalamic
No
Rightsideparesis
Rsideparesis
15
7
8
AVM
SpetzlerI
LFrontal
Sudden
Leftey
epainwithHA,pallor,
GCS3then
improvestoGCS11,vomit,desorientation
?
3to11
lossof
consciousness,hypotonia
8
9.5
AVM
SpetzlerIII
LThalamic
?
Rsideparesis
Rsideparesis
15
9
9.5
Cavernoma
RCerebellum
Yes
Cerebellarsigns
Cerebellarsyndrome
15
10
10
AVM
SpetzlerIII
RFrontal
Sudden
ComplainsofHAthenlossof
Rxeddilatedpupil
3
consciousness
11
11
AVM
Cerebellum
Sudden
HAthendecreaselevelof
Bilateralxeddilatedpupils
7
consciousness(10min)
12
11
?
Suprasellar
Progressive
IncreaseinHA,v
isualeldloss,
Progressiveworsening,hypertension,bradycardia
Yes
12
fewweeks
thenvomiting
13
12
AVM
SpetzlerIII
Ltrigoneandin
traventricular
Sudden
HAwithNV
HA
Yes
15
14
12
?
RFronto-tempo
ralandPallidum
Sudden
Complainsofheadachethenloss
Bilateralxeddilatedpupils
Yes
3
ofconsciousness
15
12
Cavernoma
RFronto-tempo
ral
Progressive
HAthenvomitinginthemorning
RthenLxeddilatedpupils,L
Babinski
Yes
9
fewhours
16
12
Aneurysm
RCarotidbifurcation
Yes
While
watchingTV,H
A,v
isual
Diplopia,desorientation
Yes
14
difcultiesthenvomiting
17
12.5
AVM
SpetzlerII
RSylvian,externalcapsule
Sudden
HAwh
ileskiingthenrapidonset
Lsideparesis
15
leftsideparesis
18
14
AVM
SpetzlerIV
LThalamic
?
Shortlossofconsciousness,
Rsideparesis,aphasia
14
disorientationthenaphasia
19
15
AVM
ROccipital
Sudden
HA,vo
mit,t
hendecreasedlevel
Rreactivedilatedpupil
Yes
13
ofconsciousness
20
15.5
?
LTemporo-Parietal
Yes
While
skiing,HAthenvomiting
Reactivepup
ils
Yes
7
21
15.5
Aneurysm
FischerV
LCarotidbifurcation
Yes
HAduringgym,t
henvomiting
HA
Yes
15
22
17.5
Cavernoma
LCerebellum
Progressive
Progre
ssiveHA,N
V,equilibrium
Nystagmus,cerebellarsyndrome
Yes
15
3days
23
18
AVM
SpetzlerI
RParieto-Occip
ital
Yes
Hemia
nopsia2dayspriorthenHA
Hemianopsia,GCSimprovedto15
Yes
15
(wasat8inp
eripherichospital)
Table
1
L:
left
,R:ri
ght,
AVM:art
eri
o-v
enou
sma
lform
ation
,HA:
hea
da
che
,NV:nau
seaan
dv
om
iting
,GCS:
Glasgo
w
Coma
Sca
le
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mild neurological signs that were difcult to de-tect on general neurological examination (hemi-anopsia, moderate balance disorders), four (18%)had moderate neurological symptoms, includingcerebellar signs, diplopia or disorientation, and 15(68%) had severe symptoms ranging from clearmotor decit to altered state of consciousness.
Three patients presented with onset of epileptic
seizures (14%) (table 1).Nine (41%) of the children had a normal
Glasgow coma score (GCS), three (14%) had aGCS of 14, four (18%) had a GCS between 8 and13, and six (27%) had a GCS less than 8 (table 1).
62A 10-year experience in paediatric spontaneous cerebral haemorrhage
Aetiology of haemorrhage
Twelve (55%) of the children had an arterio-venous malformation (AVM) that bled (g. 14).Arteriovenous malformations are classied ac-cording to Spetzler-Martin grade by their func-tional localisation, size and drainage type (table 2).
Two AVMs were classied as grade I, one grade II,four grade III, and three were grade IV. Two casescould not be classied due to incomplete work-up.
Three patients (14%) had a cavernous an-gioma (g. 5), and four children (18%) had a rup-tured aneurysm (g. 6). In three patients (14%),the aetiology of the haemorrhage could not bedetermined. In two of them, an AVM destroyed bythe haemorrhage was suspected.
Spetzler Grading System
Size of AVM 6 cm 3
Eloquent area yes 1
no 0
Deep veinous drainage yes 1
no 0
Add the points to obtain the Grade. The higher the grade,the higher the risk of microsurgical resection [1]
Table 2
Spetzler Grading
System of arterio-
venous malforma-
tion.
Figure 1
Cerebral CT-scan demonstrating a frontal haemorrhage with intraventricular rupture
caused by an AVM.
Figure 2
Sagittal FLAIR image showing an occipital haemorrhage
after an AVM bleeding.
Figure 3
Right sylvian AVM.
Left: Conventional
angiogram revealing
a right sylvian AVM
fed by numerous
small lateral
branches.
Right: Angio-MRI of
the AVM.The haemor-rhage is visualised,
and partially masks
the nidus of the AVM.
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There were 18 supratentorial haemorrhages(82%), which could be subdivided into seven sub-cortical (considered supercial) and six deep (inthe basal ganglia or thalamus). There was one iso-lated intraventricular haemorrhage. Four patients
with ruptured aneurysms had subarachnoidbleeding, 2 of which also had an associated intra-cerebral clot.
There were 4 posterior fossa haemorrhages(18%): 3 involved only the cerebellum, while the
fourth involved the cerebellum and the mesen-cephalon.
In the supercial supratentorial haemor-rhages there were 4 AVMs, 1 cavernous malfor-mation and 1 haemorrhage of unknown aetiology.In the deep haemorrhages, there were 5 AVMsand 1 haemorrhage of unknown aetiology. Theintraventricular haemorrhage came from an AVMand the subarachnoid haemorrhages from rup-tured aneurysms.
The aetiologies in the posterior fossa were2 cavernous malformations and 2 AVMs.
InvestigationsAll children underwent an emergency cere-
bral CT scan with and without contrast at admis-sion except those that had a CT scan at an outsidehospital.
Life-threatening mass effect indicated needfor emergency surgical evacuation of the clot ordrainage of acute hydrocephalus without furtherinvestigations in 8 (36%) of the children. Addi-tional investigations were ordered dependant onthe aspect and localisation of the haemorrhage.
When haemorrhage suggested aneurysm rup-ture, multislice CT-angiography was per-formed urgently. Intraarterial angiography
was not necessary for aneurysm diagnosis. When an arteriovenous malformation was
suspected, intraarterial cerebral angiography
63S W I S S M E D W K L Y 2 0 0 8 ; 1 3 8 ( 5 - 6 ) : 5 9 6 9 w w w . s m w . c h
Figure 4
Large capsule-
thalamic AVM.
ab:T2-weighted MRI
demonstrating a left
capsule-thalamic
AVM with a large
draining vein going
into the Galen vein.
cd: Conventional an-
giography showing
the thalamic AVMwith deep venous
drainage.
Figure 5
Cavernous malformation associated to a developmental anomaly.
Left:T2-weighted MRI demonstrating a right cerebellar haemorrhage from a cavernous
angioma (different signal intensities revealing different states of haemorrhage).
Right: Associated developmental anomaly of the venous drainage, often present
with the cavernoma seen on a sagittalT1-weighted MRI with gadolinium.
Localization
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was always necessary. Since, unlike adults,most of the children required general anaes-thesia for this investigation, endovasculartreatment of the AVM was planned during thesame procedure whenever feasible. All AVMs
were managed by a multidisciplinary team in-volving the neurosurgeon, the interventionalneuroradiologist, and the radiation specialist.
When a cavernous angioma was suspected,or when the aetiology remained unknown de-spite angiography, MRI was the examinationof choice.
TreatmentManagement of cerebral vascular malforma-
tions necessitates a multidisciplinary approachinvolving a vascular neurosurgeon, an interven-tional neuroradiologist, a radiation specialist, as
well as a paediatric neurointensivist, and a paedi-atric neurologist. Multimodal treatment options
are frequent and have to be planned from the startwhenever possible. The presence of life-threaten-ing mass effect necessitates immediate surgicaltreatment. An arteriovenous malformation maybe treated by microsurgery, by the endovascularapproach and with radiosurgery. A cavernous an-gioma typically needs microsurgical resection,
whereas an aneurysm may be treated surgicallyand by endovascular approaches.
Of the nine children with a mass effect, ve(23%) required emergency evacuation of theirhaematoma as a life saving treatment. In four ofthose patients, the cause of the haemorrhage(AVM) was treated at the same time (table 3). Onepatient with a cavernoma underwent primary ur-
gent evacuation of the clot and then elective sur-gery for resection of the cavernous angioma.
Two patients (9%) had hydrocephalus withincreased intracranial pressure requiring emer-gency external ventricular drainage; they had cur-ative surgery a few days later after stabilisation ofintracranial pressure. Both of them had an AVM.One patient (5%) had only an ICP monitor in-
serted.Five other patients (23%) were treated surgi-
cally, semi-electively, within the week followingthe haemorrhage; two patients had an aneurysm,two had cavernomas, and the last one had an
AVM. Two other patients (9%) who had an AVMunderwent elective surgery at 1 month and at4 months.
Two patients (9%) were embolised during thediagnostic angiography, one as the sole treatment,the other in a multimodality treatment plan fol-lowed by elective surgery. There was an attempt
at embolisation in another patient with an AVM,but it was technically impossible to achieve, andhe had subsequent surgical cure.
Three patients (14%) had elective radio-surgery as only treatment of their AVM, and twoothers in addition to their initial treatment (inone case surgery, in the other embolisation).
One child (5%) beneted from multimodaltreatment with endovascular embolisation fol-lowed rst by microsurgery and then by radio-surgery.
In one patient (5%) the causative lesion wasnot identied and no treatment was performed asthe haematoma had no mass effect.
64A 10-year experience in paediatric spontaneous cerebral haemorrhage
Figure 6
Subarachnoid blood
due to an anterior
communicating ar-
tery aneurysm.
a Cerebral CT-scan
without contrast
showing a sub-
arachnoid haemor-
rhage, predomi-
nantly in the basal
cistern, as wellas in the Sylvian
fissure.
b The cause of the
haemorrage was
an anterior com-
municating artery
aneurysm which is
here reconstructed
in 3D from the
angio-CT.
c A sagittal recon-
struction of the
angio-CT showing
the aneurysm
d The same anterior
communicating
aneurysm this time
with an angio-MRIseen from an ante-
rior point of view.
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Follow-up and prognosis:The mean follow-up time of the 20 children
who survived was 35 months (median 16 months)(table 3).
Two children died (9%); both were intubatedbefore admission (GCS
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and had to go into an institution. However, sincethis was the patient who had a second haemor-rhage, the causality of the symptoms between the
radionecrosis and the second bleed is difcult toassess.
From a radiological point of view, outcomeanalysis is easier to perform according to the aeti-ology:
In the 4 (18%) patients treated for ananeurysm, follow-up consisted of multislice CT-angiography that conrmed complete occlusionin 3 patients (75%). In one patient (25%), a smallresidual dilatation (
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these 3 characteristics: sudden, unusual, worst. Ifheadache is associated with other neurologicalsigns and symptoms, urgent investigation is alsomandatory unless the clinical presentation is usualfor the child and has already been investigated inthe past.
The average incidence of haemorrhagicstroke in the literature varies between 0.74
1.1/100 000/year [68]. In our series, according toour recruitment population, it seems to be slightlylower with 0.66/100 000/year.
Since this is a small series, we found no statis-tical difference in outcome resulting from eitherthe distance to the nearest hospital or whether thechild was treated rst in a peripheral hospital orin the university hospital.
The aetiologies of spontaneous intracerebralhaemorrhages vary among the different publishedseries. However, AVM is the leading cause in chil-dren, unlike in adults, and accounts for 1456%
[6, 7, 9, 1619], followed by cavernous angiomas(327% [7, 9, 16]) and intracranial aneurysms (629% [6, 9, 16, 18]). An additional aetiology forspontaneous intracranial haemorrhage in childrenis the vein of Galen malformation, no cases werefound in our series. It can reveal itself at birth,usually with cardiac failure, but in some rare casesit can lead, if undiagnosed, to haemorrhages inolder children. The localisation of the haemor-rhage depends upon the underlying lesion. Al-though AVMs are more common in the posteriorfossa in children than in adults, they remain morefrequent in the supratentorial space even inchildren [13, 20]. Aneurysmal ruptures are morefrequent in the anterior circulation than in theposterior circulation [21], and according toProust [22], they tend to be located on the inter-nal carotid artery bifurcation (36%), middle cere-bral artery (36%), anterior communicating artery(18%) or within the vertebrobasilar system (9%).Supratentorial localisation is also more commonfor cavernomas [23, 24].
Improved management thanks to specialisedneurovascular teams and technological develop-ments has decreased morbidity and mortality of
intracerebral haemorrhage in the last 50 years.However, the mortality of haemorrhagic strokesin children remains high, ranging between 6 and38% [10, 11, 1618, 25]. Mortality varies depend-ing on the primary lesion; it reaches 4042% for
AVMs and increases to 4275% for posteriorfossa AVMs [20, 26, 27]. In our series, mortality
was in the lower range: 8% for AVMs, and 9% intotal).
This series conrms that morbidity and mor-tality depend mainly on the location of the haem-orrhage. While any clot leading to a signicant
mass effect can threaten survival, a posterior fossableed has a comparatively higher risk, as it may di-rectly compress the brainstem. The following arepoor prognostic factors in the literature: coma-tose state (GCS
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Cavernous angiomas are typically microsurgi-cal lesions and should be resected in totoif possi-ble [23, 36]. Cavernous angiomas are often asso-ciated with developmental venous drainageanomalies that increase the risk of surgical resec-tion and favor recurrence of a cavernous angioma.Radiosurgery did not show favourable outcomesand is not indicated [23, 24]. In our series only
1 out of 3 children operated upon for a cavernousangioma were completely cured.
Follow-up imaging is particularly importantin the paediatric population as recurrences can beobserved even after complete cure of an intracra-nial vascular malformation. In children and youngadults re-growth after complete obliteration of
AVMs have been described. AVMs seem to have adifferent pattern of angiogenesis in children thanin adults, with a higher potential for new abnor-mal vessels to form [37]. Similarly, cavernous an-giomas can recur after complete resection, espe-
cially if they are associated with a developmentalanomaly of the venous drainage [38]. Intracranialaneurysms can grow and re-bleed, if they are in-completely excluded. The higher recurrence rateof coiled aneurysms than for clipped ones, is ofimportance when treating children [39]. In theabsence of sufcient data in aneurysm treatmentin children, we favour surgical clipping due to itsbetter durability. The review of this paediatric se-ries allows us to emphasise some differences inthe management of spontaneous intracranialhaemorrhages between the paediatric and adult
population at our institutions. To start let us recallthat in the paediatric population AVMs are themost frequent cause of spontaneous haemor-rhage. Emergent work-up is mandatory and CT-scan with multislice CT-angiography is the pre-ferred imaging study [40]. In most situations itallows to diagnose the aetiology in the emergencysetting and safer life-saving surgery when needed.
MRI and MRAngiography have their role in thefollow-up as well as in the diagnosis of unclearaetiology. However, in an emergency setting, theyhave little place. Diagnostic angiography necessi-tates general anaesthesia in the paediatric popula-tion. For this reason we prefer to combine andplan the diagnostic angiography and the thera-peutic endovascular treatment in one session.
This mandates excellent collaboration betweenthe neurosurgeon, the interventional radiologistand the paediatric neurointensivist. Finally, thefollow-up of the paediatric population after treat-
ment of an intracranial vascular malformationneeds to be more aggressive, with repeated imag-ing studies, as the risk of recurrence and de novoformation of vascular malformations is higherthan in adults. Our preferred imaging for follow-up is MRI, followed by multislice CT-angiogra-phy [41]. Intraarterial angiography is only re-commended for detailed treatment planning.
Although there are no evidence-based recom-mendations in the literature, we recommend im-aging at least once at the beginning of adulthood.
68A 10-year experience in paediatric spontaneous cerebral haemorrhage
Conclusion
Headaches are frequent also in the paediatricpopulation and are of benign origin in the vastmajority. However, emergency neurological
work-up is mandatory if the headache is sudden,unusual or intense. Emergency admission ismandatory if those headaches are associated withneurological signs or symptoms. Urgent admis-sion should be considered for every headache
characterised asrstandworst.Work-up includes an emergency CT-scan
without and with contrast. If this shows a haemor-rhage, then a multislice CT-angiography shouldbe added. The choice of the additional investiga-tions depends on the suspected diagnosis; for ex-ample an intraarterial angiography would be usedfor arteriovenous malformations and an MRI forcavernous angiomas.
Intracranial vascular malformations that bledshould be treated when ever possible because thenatural history carries a high cumulative risk of
re-bleeding, particularly in the paediatric popula-tion due to the long life expectancy.The follow-up is important in the paediatric
population and should include imaging studies,because there is a risk of recurrence even aftercomplete occlusion of the malformation.
The long-term result for children after spon-taneous intracranial haemorrhage is not dismaland emphasises the importance of emergencytransfer to a referral centre. The outcome is grimfor children presenting in coma with xed dilatedpupils.
In conclusion, the most important factor isnot to delay diagnosis and emergency transfer.
Whereas an emergency CT scan may be per-formed in a general hospital setting, we stronglybelieve that the rest of the management has to beconducted in a specialised referral centre, wherethe child can benet from the expertise of aspecialised neurovascular team including neuro-surgeons, interventional neuroradiologists andpaediatric neurointensivists.
Correspondence:
Luca RegliService of NeurosurgeryCentre Hospitalier Universitaire Vaudois(CHUV)CH1011 Lausanne
E-Mail : [email protected]
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References
1 Spetzler RF, Zabramski JM. Grading and staged resection ofcerebral arteriovenous malformations. Clin Neurosurg. 1990;36:31837.
2 Bandell-Hoekstra IE, et al. Prevalence and characteristics ofheadache in Dutch schoolchildren. Eur J Pain. 2001;5(2):14553.
3 Burton LJ, et al. Headache etiology in a pediatric emergency
department. Pediatr Emerg Care. 1997;13(1):14.4 Deda G, Caksen H, Ocal A. Headache etiology in children: a
retrospective study of 125 cases. Pediatr Int. 2000;42(6):66873.
5 Calder K, et al. Emergency department presentation of pedi-atric stroke. Pediatr Emerg Care. 2003;19(5):3208.
6 Eeg-Olofsson O, Ringheim Y. Stroke in children. Clinicalcharacterisics and prognosis. Acta Paediatr Scand. 1983;72(3):3915.
7 Jordan LC, Hillis AE. Hemorrhagic stroke in children. PediatrNeurol. 2007;36(2):7380.
8 Celli P, et al. Cerebral arteriovenous malformations in chil-dren. Clinical features and outcome of treatment in childrenand in adults. Surg Neurol. 1984;22(1):439.
9 Giroud M, et al. Stroke in children under 16 years of age. Clin-ical and etiological difference with adults. Acta Neurol Scand.
1997;96(6):4016.10 Hurvitz E, et al. Long-term functional outcome of pediatric
stroke survivors. Top Stroke Rehabil. 2004;11(2):519.11 Simma B, et al. Risk factors for pediatric stroke: consequences
for therapy and quality of life. Pediatr Neurol. 2007;37(2):1216.
12 Levy EI, et al. Radiosurgery for childhood intracranial arteri-ovenous malformations. Neurosurgery. 2000;47(4):83441;discussion 8412.
13 Smyth MD, et al. Stereotactic radiosurgery for pediatric in-tracranial arteriovenous malformations: the University of Cal-ifornia at San Francisco experience. J Neurosurg. 2002;97(1):4855.
14 Leon-Diaz A, Gonzalez-Rabelino G, Alonso-Cervino M.Analysis of the aetiologies of headaches in a paediatric emer-gency service. Rev Neurol. 2004;39(3):21721.
15 Guidetti V, Galli F. Recent development in paediatricheadache. Curr Opin Neurol. 2001;14(3):33540.16 Al-Jarallah A, et al. Nontraumatic brain hemorrhage in chil-
dren: etiology and presentation. J Child Neurol. 2000;15(5):2849.
17 Lin CL, et al. Spontaneous intracerebral hemorrhage in chil-dren. Kaohsiung J Med Sci. 1999;15(3):14651.
18 Blom I, et al. Prognosis of haemorrhagic stroke in childhood: along-term follow-up study. Dev Med Child Neurol. 2003;45(4):2339.
19 Takeshita M, et al. Hemorrhagic stroke in infancy, childhood,and adolescence. Surg Neurol. 1986;26(5):496500.
20 Humphreys RP, et al. Choices in the 1990s for the manage-ment of pediatric cerebral arteriovenous malformations. Pedi-atr Neurosurg. 1996;25(6):27785.
21 Sanai N, et al. Pediatric intracranial aneurysms: durability of
treatment following microsurgical and endovascular manage-ment. J Neurosurg. 2006;104(2 Suppl):829.22 Proust F, et al. Pediatric cerebral aneurysms. J Neurosurg.
2001;94(5):7339.
23 Di Rocco C, Iannelli A, Tamburrini G. Cavernous angiomas ofthe brain stem in children. Pediatr Neurosurg. 1997;27(2):929.
24 Mottolese C, et al. Central nervous system cavernomas in thepediatric age group. Neurosurg Rev. 2001;24(2-3):5571; dis-cussion 723.
25 Lanthier S, et al. Stroke in children: The coexistence of multi-
ple risk factors predicts poor outcome. Neurology. 2000;54:3718.
26 Meyer PG, et al. Emergency management of deeply comatosechildren with acute rupture of cerebral arteriovenous malfor-mations. Can J Anaesth. 2000;47(8):75866.
27 Puzzilli F, et al. Spontaneous cerebellar haemorrhages in child-hood. Childs Nerv Syst. 1997;13(11-12):6013; discussion 604.
28 Meyer-Heim AD, Bolthauser E. Spontaneous intracranialhaemorrhage in children: aetiology, presentation and outcome.Brain Dev. 2003;25:41621.
29 Haacke C, et al. Long-term outcome after stroke. Evaluatinghealth-related quality of life using utility measurements.Stroke. 2006;37:1938.
30 Sturm JW, et al. Quality of life after stroke: The north eastMelbourne stroke incidence study. Stroke. 2004;35(10):23405.
31 Cioni G, et al. Reorganisation of the sensorimotor cortex afterearly focal brain lesion: a functional MRI study in monozygotictwins. Neuroreport. 2001;12(7):133540.
32 Boatman D. et al. Language recovery after left hemispherec-tomy in children with late-onset seizures. Ann Neurol. 1999;46(4):57986.
33 Hertz-Pannier L, et al. Late plasticity for language in a childsnon-dominant hemisphere: a pre- and post-surgery fMRIstudy. Brain. 2002;125(Pt 2):36172.
34 Huang J, et al. Intracranial aneurysms in the pediatric popula-tion: case series and literature review. Surg Neurol. 2005;63(5):42432; discussion 4323.
35 Pollo C, et al. Ruptured cerebral aneurysm in the early stage oflife a congenital origin? Neuropediatrics. 2004;35(4):2303.
36 Bruneau M, et al. Early surgery for brainstem cavernomas.Acta Neurochir (Wien) 2006;148(4):40514.
37 Kader A, et al. Recurrent cerebral arteriovenous malformationsafter negative postoperative angiograms. J Neurosurg. 1996;85(1):148.
38 Wurm G, et al. Recurrent cryptic vascular malformation asso-ciated with a developmental venous anomaly. Br J Neurosurg.2003;17(2):18895.
39 Campi A, et al. Retreatment of Ruptured Cerebral Aneurysmsin Patients Randomized by Coiling or Clipping in the Interna-tional Subarachnoid Aneurysm Trial (ISAT). Stroke. 2007;38:153844.
40 Wintermark M, et al. Multislice computerized tomographyangiography in the evaluation of intracranial aneurysms: acomparison with intraarterial digital subtraction angiography.
J Neurosurg. 2003;98(4):82836.41 Dehdashti AR, et al. Comparison of multislice computerized
tomography angiography and digital subtraction angiography
in the postoperative evaluation of patients with clippedaneurysms. J Neurosurg. 2006;104(3):395403.
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