Neuroimaging clinics of North America
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Hemorrhagic stroke (HS) is an important cause of neurologic morbidity and mortality in children and is more common than ischemic stroke between the ages of 1 and 14 years, a notable contradistinction relative to adult stroke epidemiology. Rapid neuroimaging is of the utmost importance in making the diagnosis of HS, identifying a likely etiology, and directing acute care. Computed tomography and MR imaging with flow-sensitive MR imaging and other noninvasive vascular imaging studies play a primary role in the initial diagnostic evaluation. Catheter-directed digital subtraction angiography is critical for definitive diagnosis and treatment planning.
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Intracranial vascular malformations (IVMs) represent a significant challenge in pediatric medicine due to their diagnostic and therapeutic complexity. Despite their rarity, the severity of potential neurologic outcomes necessitates a comprehensive understanding and approach to management. ⋯ Vein of Galen malformations, pial arteriovenous fistulas, dural sinus malformations, and intracranial venous malformations will be addressed in other articles. Following a discussion of imaging and clinical considerations within the field, novel imaging techniques will be discussed.
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Vein of Galen malformations are the most common congenital neurovascular malformation and are a type of choroidal arteriovenous fistula involving the midline primitive choroidal venous circulation. The arteriovenous shunt zone of a VOGM may directly involve the embryonic precursor of the vein of Galen and/or its tributaries within the 3rd ventricle tela choroidea. Dural sinus malformations are characterized by dilated intracranial dural venous sinuses, some of which acquire multifocal arteriovenous shunts within the dural walls of these overgrown venous sinuses. Pial arteriovenous fistulae are high-flow shunts representing direct arterial to venous communication of pial blood vessels, with no definable nidus.
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Arterial ischemic stroke (AIS) in children has a high mortality and life-long disability rate in surviving patients. Diagnostic delays are longer and risk factors are different compared with AIS in the adult population. ⋯ New revascularization time windows in children require the definition of diagnostic protocols for stroke in each referral center. In this article, we discuss the neuroimaging techniques and protocols, describe the main underlying causes, and review the current treatment options for pediatric and perinatal AIS.
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Intracranial arterial aneurysms in children are rare. They differ from adult aneurysms in their etiology, natural history, and management approach. ⋯ Endovascular treatment has become the primary interventional modality in children with intracranial aneurysms. The authors discuss the management approach to pediatric intracranial aneurysms.