RESPUESTAS CASO CLINICO

CASO CLINICO: Case 12-2008 — A Newborn Infant with Intermittent Apnea and Seizures


Dentro del tratamiento a recibir, se sabe el beneficio de la vitamina K y la aplicaría, ya que tiene TP prolongado al ingreso, habría que definir que beneficio ofrece la anticoagulaciòn en el neonato y que anticonvulsivante usar, al igual que definir si es prudente el uso de trombolisis en casos de ser necesaria, por otra parte hay que definir los estudios a realizar en el paciente, para establecer la etiologia de la coagulopatia. Por eso haría la siguiente búsqueda para evaluar el uso de anticoagulaciòn

PALABRAS CLAVE: newborn, stroke, anticoagulants

: J Child Neurol. 2008 Jan;23(1):26-31.
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Cerebral venous sinus thrombosis in children: a multicenter cohort from the United States.
Wasay M, Dai AI, Ansari M, Shaikh Z, Roach ES.
Aga Khan University, Karachi, Pakistan. mohammad.wasay@aku.edu
This study presents a large multicenter cohort of children with cerebral venous thrombosis from 5 centers in the United States and analyzes their clinical findings and risk factors. Seventy patients were included in the study (25 neonates, 35%). The age ranged from 6 days to 12 years. Thirty-eight (55%) were younger than 6 months of age, and 28 (40%) were male. Presenting features included seizures (59%), coma (30%), headache (18%), and motor weakness (21%). Common neurological findings included decreased level of consciousness (50%), papilledema (18%), cranial nerve palsy (33%), hemiparesis (29%), and hypotonia (22%). Predisposing factors were identified in 63 (90%) patients. These included infection (40%), perinatal complications (25%), hypercoagulable/hematological diseases (13%), and various other conditions (10%). Hemorrhagic infarcts occurred in 40% of the patients and hydrocephalus in 10%. Transverse sinus thrombosis was more common (73%) than sagittal sinus thrombosis (35%). Three children underwent thrombolysis, 15 patients received anticoagulation, and 49 (70%) were treated with antibiotics and hydration. Nine (13%) patients (6 of them neonates) died. Twenty-nine patients (41%) were normal, whereas 32 patients (46%) had a neurological deficit at discharge. Seizures and coma at presentation were poor prognostic indicators. In conclusion, cerebral venous thrombosis predominantly affects children younger than age 6 months. Mortality is high (25%) in neonatal cerebral venous thrombosis. Only 18 (25%) patients were treated with anticoagulation or thrombolysis
Br J Haematol. 2005 Aug;130(3):333-43.
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Perinatal stroke--risk factors and management.
Chalmers EA.
Department of Haematology, Royal Hospital for Sick Children, Yorkhill, Glasgow, UK. elizabeth.chalmers@yorkhill.scot.nhs.uk
Stroke is an uncommon but increasingly recognised cause of mortality and long-term neurological morbidity in children. A significant number of these events appear to be caused by thromboembolic disease and, as with other childhood thrombotic problems, the incidence of central nervous system events appears highest during the neonatal period. In contrast to peripheral arterial and venous thrombotic problems, it is likely that a proportion of cerebral thromboembolic events occur either in utero or perinatally and reflect different risk factors from those occurring in older infants and children. The pathophysiology of perinatal stroke is complex and in many cases is likely to be multifactorial. It is now recognised that risk factors may relate to both maternal and placental problems as well as fetal and neonatal disorders. Large prospective studies of perinatal stroke are currently lacking and efforts to define the relative contribution from each of these areas are at an early stage. The complex nature of these disorders requires collaboration between a number of different disciplines including obstetrics, fetal medicine, pathology, neonatology and neurology. Of particular interest to haematologists is the possible impact of prothrombotic abnormalities in the pathophysiology of these events and also the potential for the use of antithrombotic agents in both management and prevention.
PMID: 16042683 [PubMed - indexed for MEDLINE]
1: Semin Thromb Hemost. 2003 Aug;29(4):405-14.
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Arterial ischemic stroke in neonates, infants, and children: an overview of underlying conditions, imaging methods, and treatment modalities.
Nowak-Göttl U, Günther G, Kurnik K, Sträter R, Kirkham F.
Department of Haematology/Oncology, University of Münster Münster, Germany. leagottl@uni-muenster.de
Conditions associated with arterial ischemic stroke (AIS) in children include congenital heart malformations, sickle cell disease, and meningitis, although around half of all cases are cryptogenic. Up to 80% of children with ischemic stroke have cerebrovascular disease, and case control studies demonstrate an association of arterial ischemic stroke in children with hereditary prothrombotic risk factors and infections such as Varicella. Conventional risk factors, such as hypertension and dyslipidemia, may also play a role and most children have several potential triggers rather than a single cause. Treatment recommendations are based on small case series or have been adapted from adult stroke studies; there are no evidence-based data on efficacy in children. Low-dose aspirin appears to be relatively safe. Anticoagulation with heparins, for example, low-molecular-weight heparin or warfarin, may be indicated in children with cardioembolic stroke, arterial dissection, or persistent hypercoagulable states, and blood transfusion has a role in patients with sickle cell disease. Tissue plasminogen activator has been used in a few patients within 3 hours of the onset of symptoms. At present, the benefit of treatment has to be weighed against the risk for each patient, but randomized controlled trials for primary prevention, acute treatment, and secondary prevention of pediatric ischemic stroke are urgently needed.
Pediatr Neurol. 2007 Aug;37(2):99-107.
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Comment in:
Pediatr Neurol. 2007 Aug;37(2):152-3.
Risk factors for perinatal arterial stroke: a study of 60 mother-child pairs.
Curry CJ, Bhullar S, Holmes J, Delozier CD, Roeder ER, Hutchison HT.
Genetic Medicine Central California, Department of Pediatrics, University of California, San Francisco, California, USA. ccurry@geneticscentralcal.org
The objective of the present study was to examine demographic, historical, and prothrombotic risk factors in infants with perinatal arterial stroke and their mothers. Risk factors were evaluated in 60 mother-child pairs with perinatal arterial stroke. Prothrombotic factors analyzed included the DNA mutations factor V Leiden, prothrombin 20210, MTHFR C677T and A1298C; serum activity levels for protein C, protein S, and antithrombin III; serum levels of lipoprotein(a); and, in the mothers, antiphospholipid antibodies. Boys predominated, 36:24. There were four twin sets. Sixty percent were term and 22% were post-date. Ten were large for gestational age. Five mothers had abdominal trauma. Nine mothers (15%) had preeclampsia. Emergency caesarean section was performed in 17 cases (28%). Eight placental exams revealed seven with abnormalities. Seizures were the presenting sign in 70%, and 30% presented with early handedness or cerebral palsy. Prothrombotic risk factors were found in 28 of 51 mothers (55%) and 30 of 60 children (50%). Forty-one pairs (68%) had at least one abnormality in mother, child, or both. Long-term sequelae included cerebral palsy (40 of 51; 78%), cognitive impairment (35 of 51; 68%), seizures (23 of 51; 45%), and microcephaly (26 of 51; 51%). Perinatal arterial stroke is the result of multifactorial, synergistic fetal and maternal factors among which the prothrombotic factors, both fetal and maternal, appear significant.
PMID: 17675024 [PubMed - indexed for MEDLINE]

Br J Pharmacol. 2008 Mar;153(6):1120-7. Epub 2007 Oct 1.
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Pharmacokinetics, efficacy, and safety of LMWHs in venous thrombosis and stroke in neonates, infants and children.
Nowak-Göttl U, Bidlingmaier C, Krümpel A, Göttl L, Kenet G.
Department of Paediatric Haematology and Oncology, University of Münster, Münster, Germany. leagottl@uni-muenster.de
Since the early nineties it has been shown that low molecular weight heparin (LMWH) has significant advantages over unfractionated heparin and oral anticoagulants for both the treatment and the prevention of thrombosis, not only in adults, but also in children. The present review was based on an 'EMBASE', 'Medline' and 'PubMed' search including literature published in any language since 1980 on LMWH in neonates, infants and children. It included paediatric pharmacokinetic studies, the use of LMWH in children with venous thrombosis, LMWH administration in paediatric patients with ischaemic stroke, and its use in order to prevent symptomatic thromboembolism in children at risk. An increasing rate of off-label use of LMWH in children has been reported, showing that LMWHs offer important benefits to children with symptomatic thromboembolic events and poor venous access. Two well-conducted pharmacokinetic studies in this age group showed that neonates and younger infants require higher LMWH doses than older children to achieve the targeted anti-Xa levels, due to an increased extra vascular clearance. Recurrent symptomatic thromboses under LMWH occur in approximately 4% of children treated for venous thrombosis, and in 7% of children treated for stroke; major bleed was documented in 3% of children with therapeutic target LMWH anti-Xa levels, whereas minor bleeding was reported in approximately 23% of children receiving either therapeutic or prophylactic doses, respectively. Further randomized controlled trials are recommended to evaluate the optimum duration and application for different LMWH indications in children.
Con los anteriores articulos no hay evidencia concluyente del uso de anticoagulaciòn en neonatos, pero no excluyen su uso, sino aclaran que depende del riesgo beneficio, habrìa que realizar estudios en el paciente para detectar trombofilia, como los citados, de antitrombina III, proteina C y S, y factores de coagulaciòn