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Arterial spin labeling (ASL) magnetic resonance imaging (MRI) can assess cerebral blood flow (CBF) without using radiolabeled tracers. It is unknown whether regional increases in CBF on ASL MRI correlate with seizure location in newborns. We report 3 newborns with focal seizures localized on continuous video electroencephalogram (cEEG), anatomical brain MRI, and ASL MRI. Each patient underwent pseudocontinuous ASL with segmented 3-dimensional fast spin echo readout as part of standard care. Case 1 is a term male infant presenting with left temporal status epilepticus and recurrent cEEG seizures from an idiopathic large left intraventricular hemorrhage. ASL images demonstrated left mesial temporal lobe increased CBF. Case 2 is a late preterm male infant presenting with recurrent cEEG seizures due to focal right megalencephaly. Ictal EEG and ASL images coincided with the focal dysplasia. Case 3 is a dysmorphic term female infant with nonconvulsive partial status epilepticus identified by focal increased CBF of the left temporal lobe on ASL images. The area of increased CBF was within an area of extensive left hemisphere dysplasia. To our knowledge, this is the first report of regional increases in CBF on ASL MRI correlating with ictal cEEG in newborns.

ObjectiveResearch using neonatal electroencephalography (EEG) has been limited by a lack of a standardized classification system and interpretation terminology. In 2013, the American Clinical Neurophysiology Society (ACNS) published a guideline for standardized terminology and categorization in the description of continuous EEG in neonates. We sought to assess interrater agreement for this neonatal EEG categorization system as applied by a group of pediatric neurophysiologists.MethodsA total of 60 neonatal EEG studies were collected from three institutions. All EEG segments were from term neonates with hypoxic-ischemic encephalopathy. Three pediatric neurophysiologists independently reviewed each record using the ACNS standardized scoring system. Unweighted kappa values were calculated for interrater agreement of categorical data across multiple observers.ResultsInterrater agreement was very good for identification of seizures (κ=0.93, p&nbsp

OBJECTIVE Previous meta-analysis has demonstrated that the most important factor in seizure freedom following surgery for focal cortical dysplasia (FCD) is completeness of resection. However, intraoperative detection of epileptogenic dysplastic cortical tissue remains a challenge, potentially leading to a partial resection and the need for reoperation. The objective of this study was to determine the role of intraoperative MRI (iMRI) in the intraoperative detection and localization of FCD as well as its impact on surgical decision making, completeness of resection, and seizure control outcomes. METHODS The authors retrospectively reviewed the medical records of pediatric patients who underwent iMRI-assisted resection of FCD at the Children's National Health System between January 2014 and April 2015. Data reviewed included demographics, length of surgery, details of iMRI acquisition, postoperative seizure freedom, and complications. Postsurgical seizure outcome was assessed utilizing the Engel Epilepsy Surgery Outcome Scale. RESULTS Twelve consecutive pediatric patients (8 females and 4 males) underwent iMRI-guided resection of FCD lesions. The mean age at the time of surgery was 8.8 years ± 1.6 years (range 0.7 to 18.8 years), and the mean duration of follow up was 3.5 months ± 1.0 month. The mean age at seizure onset was 2.8 years ± 1.0 year (range birth to 9.0 years). Two patients had Type 1 FCD, 5 patients had Type 2A FCD, 2 patients had Type 2B FCD, and 3 patients had FCD of undetermined classification. iMRI findings impacted intraoperative surgical decision making in 5 (42%) of the 12 patients, who then underwent further exploration of the resection cavity. At the time of the last postoperative follow-up, 11 (92%) of the 12 patients were seizure free (Engel Class I). No patients underwent reoperation following iMRI-guided surgery. CONCLUSIONS iMRI-guided resection of FCD in pediatric patients precluded the need for repeat surgery. Furthermore, it resulted in the achievement of complete resection in all the patients, leading to a high rate of postoperative seizure freedom.

Levetiracetam (LEV) has antiepileptogenic effects in animals and is a candidate for prevention of epilepsy after traumatic brain injury. Pharmacokinetics of LEV in TBI patients was unknown. We report pharmacokinetics of TBI subjects≥6years with high PTE risk treated with LEV 55mg/kg/day orally, nasogastrically or intravenously for 30days starting ≤8h after injury in a phase II safety and pharmacokinetic study. Forty-one subjects (26 adults and 15 children) were randomized to PK studies on treatment days 3 and 30. Thirty-six out of forty-one randomized subjects underwent PK study on treatment day 3, and 24/41 subjects underwent PK study on day 30. On day 3, mean T(max) was 2.2h, C(max) was 60.2μg/ml and AUC was 403.7μg/h/ml. T(max) was longer in the elderly than in children and non-elderly adults (5.96h vs. 1.5h and 1.8h; p=0.0001). AUC was non-significantly lower in children compared with adults and the elderly (317.4μg/h/ml vs. 461.4μg/h/ml and 450.2μg/h/ml; p=0.08). C(max) trended higher in i.v.- versus tablet- or n.g.-treated subjects (78.4μg/ml vs. 59μg/ml and 48.2μg/ml; p=0.07). AUC of n.g. and i.v. administrations was 79% and 88% of AUC of oral administration. There were no significant PK differences between days 3 and 30. Treatment of TBI patients with high PTE risk with 55mg/kg/day LEV, a dose with antiepileptogenic effect in animals, results in plasma LEV levels comparable to those in animal studies.

Therapeutic hypothermia has prevented death and brain injury after asphyxiation in 5 randomized trials. Objective: Demonstrate our therapeutic hypothermia program, and compare our results with these randomized trials. Design/Methods: Whole body cooling was performed in 95 infants gestation 36 wks and < 6 hrs of age with severe acido- sis, perinatal complications, and/or CPR at birth. Infants were cooled to an esophageal temperature of 33.5 ◦ C for 72 hours, then re-warmed slowly. Results of clinical studies, adverse events, and hospital outcomes are reported. Results: 95 neonates (mean weight 3.43 ± 0.68 SD kg, gestation 39 ± 2 wks) were admitted at ages 4:31 ± 1:10 hrs. Umbilical cord pH ranged 6.43-7.36 (median 6.87). Perinatal sentinel events occurred in 51 subjects. 33/95 infants (35%) presented with clinical seizures; 74/95 infants (78%) are surviving; most are now seizure-free having had improvement of EEG during hypothermia; 19/95 (20%) had normal brain MRI, 52 (55%) had ischemic injuries. 63/74 survivors (85%) are home; 44/74 (60%) are fed orally and passed hearing screens. 30/74 (40%) require tube feedings, and/or have uncertain hearing. 11/74 (15%) were discharged to rehabilitation hospitals. 21 deaths occurred (21/95, 22%): 2 died suddenly on life support while cooling, with no response to CPR. 83% of survivors have been seen in followup; 53% have been seen at ≥9 months. Fifty percent of all followups seen have had normal neurodevelopmental exams. Conclusions: Hypothermia can be instituted safely with mortality and short term morbidity commensurate with 5 previous studies published or otherwise reported. Neurodevelopmental follow up continues.

I NVITED R EVIEW Consensus Statement on Continuous EEG in Critically Ill Adults and Children, Part I: Indications Susan T. Herman,* Nicholas S. Abend,† Thomas P. Bleck,‡ Kevin E. Chapman,§ Frank W. Drislane,* Ronald G. Emerson,k Elizabeth E. Gerard,¶ Cecil D. Hahn,# Aatif M. Husain,**†† Peter W. Kaplan,‡‡ Suzette M. LaRoche,§§ Marc R. Nuwer,kk Mark Quigg,¶¶ James J. Riviello,## Sarah E. Schmitt,*** Liberty A. Simmons,††† Tammy N. Tsuchida,‡‡‡ and Lawrence J. Hirsch§§§ Introduction: Critical Care Continuous EEG (CCEEG) is a common procedure to monitor brain function in patients with altered mental status in intensive care units. There is significant variability in patient populations undergoing CCEEG and in technical specifications for CCEEG performance. Methods: The Critical Care Continuous EEG Task Force of the American Clinical Neurophysiology Society developed expert consensus recommenda- tions on the use of CCEEG in critically ill adults and children. Recommendations: The consensus panel recommends CCEEG for diagnosis of nonconvulsive seizures, nonconvulsive status epilepticus, and other paroxysmal events, and for assessment of the efficacy of therapy for seizures and status epilepticus. The consensus panel suggests CCEEG for identification of ischemia in patients at high risk for cerebral ischemia; for assessment of level of consciousness in patients receiving intravenous sedation or pharmacologically induced coma; and for prognostication in patients after cardiac arrest. For each indication, the consensus panel describes the patient populations for which CCEEG is From the *Comprehensive Epilepsy Program, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A.; †Departments of Neurology and Pediatrics, Perelman School of Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.; ‡Departments of Neurological Sciences, Neurosurgery, Medicine, and Anesthesiology, Rush Medical College, Chicago, Illinois, U.S.A.; §Department of Pediatrics and Neurology, University of Colorado, Boulder, Colorado, U.S.A.; kDepartment of Neurology, Hospital for Special Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, U.S.A.; ¶Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A. #Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; **Department of Neurology, Duke University Medical Center, Durham, North Carolina, U.S.A.; ††Neurodiagnostic Center, Veterans Affairs Medical Center, Durham, North Carolina, U.S.A.; ‡‡Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A.; §§Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A.; kkDepartment of Neurology, David Geffen School of Medicine and Clinical Neurophysiology, Ronald Reagan UCLA Medical Center, Los Angeles, California, U.S.A.; ¶¶FE Dreifuss Comprehensive Epilepsy Program, Department of Neurology, Univer- sity of Virginia, Charlottesville, Virginia, U.S.A.; ##NYU Division of Child Neurology, Columbia University Medical Center, New York, New York, U.S. A.; ***Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.; †††School of Clinical Neurophysiology, Crozer-Chester Medical Center, Upland, Pennsylvania, U.S. A.; ‡‡‡Department of Neurology and Pediatrics, Children’s National Medical Center, George Washington University School of Medicine, Washington, District of Columbia, U.S.A.; and §§§Department of Neurology, Yale Comprehensive Epilepsy Center, Yale School of Medicine, New Haven, Connecticut, U.S.A. Address correspondence and reprint requests to Susan T. Herman, MD, Beth Israel Deaconess Medical Center, Baker 5, 330 Brookline Avenue, Boston, MA 02215, U.S.A.; e-mail: sherman2@bidmc.harvard.edu. Copyright O 2015 by the American Clinical Neurophysiology Society ISSN: 0736-0258/15/3202-0087 indicated, evidence supporting use of CCEEG, utility of video and quantitative EEG trends, suggested timing and duration of CCEEG, and suggested frequency of review and interpretation. Conclusion: CCEEG has an important role in detection of secondary injuries such as seizures and ischemia in critically ill adults and children with altered mental status. Key Words: EEG, EEG monitoring, Quantitative EEG, Seizure, Nonconvulsive seizure, Status epilepticus, Nonconvulsive status, epilepticus, Intensive care unit, Critical care, Adults, Children. (J Clin Neurophysiol 2015;32: 87–95) C ritically ill patients are at high risk for a variety of neurologic insults, including seizures, ischemia, edema, infection, and increased intracranial pressure, which can result in permanent neurologic disability if untreated. Despite these risks, there are few techniques for continuously monitoring brain function. EEG measures the brain’s electrical activity, can be recorded continuously at the bedside, has good spatial and excellent temporal resolution, and is sensitive to changes in both brain structure and function (Nuwer, 1994). Over the past decade, technical advances have improved the efficiency of continuous EEG (CEEG) recording and remote review, leading to a greater than fourfold increase in the number of CEEGs performed in intensive care units (ICUs) (Ney et al., 2013). Recent surveys, however, show variability in why and how CEEG is performed in the ICU (Abend et al., 2010; Gavvala et al., 2014; Sanchez et al., 2013a), highlighting the need for clinical guidance on this expensive and labor-intensive procedure. Critical care continuous EEG (CCEEG) refers to the simul- taneous recording of EEG and clinical behavior (video) over extended time periods (hours to weeks) in critically ill patients at risk for secondary brain injury and neurologic deterioration. Critical care continuous EEG is usually performed in an ICU setting, but this varies by hospital and some patients may be in step-down units or general medical or surgical units. Critical care continuous EEG typically includes simultaneous video recording and may include graphical displays of quantitative EEG (QEEG) trends. The goal of CCEEG is to identify changes in brain function, such as non- convulsive seizures (NCS) or ischemia, which may not be evident by neurological examination alone, to facilitate early identification and management of these abnormalities. This consensus statement applies only to critically ill adult and pediatric patients. It does not apply to long-term monitoring of awake and alert patients with epilepsy, sleep monitoring, or intraoperative monitoring. Separate recommendations have been developed by the Journal of Clinical Neurophysiology Volume 32, Number 2, April 2015

Introduction: Critical Care Continuous EEG (CCEEG) is a common procedure to monitor brain function in patients with altered mental status in intensive care units. There is significant variability in patient populations undergoing CCEEG and in technical specifications for CCEEG performance. Methods: The Critical Care Continuous EEG Task Force of the American Clinical Neurophysiology Society developed expert consensus recommendations on the use of CCEEG in critically ill adults and children. Recommendations: The consensus panel describes the qualifications and responsibilities of CCEEG personnel including neurodiagnostic technologists and interpreting physicians. The panel outlines required equipment for CCEEG, including electrodes, EEG machine and amplifier specifications, equipment for polygraphic data acquisition, EEG and video review machines, central monitoring equipment, and network, remote access, and data storage equipment. The consensus panel also describes how CCEEG should be acquired, reviewed and interpreted. The panel suggests methods for patient selection and triage; initiation of CCEEG; daily maintenance of CCEEG; electrode removal and infection control; quantitative EEG techniques; EEG and behavioral monitoring by non-physician personnel; review, interpretation, and reports; and data storage protocols. Conclusion: Recommended qualifications for CCEEG personnel and CCEEG technical specifications will facilitate standardization of this emerging technology.

Post-traumatic seizures develop in up to 20% of children following severe traumatic brain injury (TBI). Children ages 6-17 years with one or more risk factors for the development of post-traumatic epilepsy, including presence of intracranial hemorrhage, depressed skull fracture, penetrating injury or occurrence of post-traumatic seizure were recruited into this phase two study. Treatment subjects received levetiracetam 55mg/kg/day b.i.d. for 30 days, started within 8 hours post-injury. The recruitment goal was 20 treated patients. Twenty patients who presented within 8-24 hours post-TBI and otherwise met eligibility criteria were recruited for observation. Follow-up was for two years. 45 patients screened within 8 hours of head injury met eligibility criteria and 20 were recruited into the treatment arm. The most common risk factor present for pediatric inclusion following TBI was an immediate seizure. Medication compliance was 95%. No patients died; 19 of 20 treatment patients were retained; one observation patient was lost to follow-up. The most common severe adverse events in treatment subjects were headache, fatigue, drowsiness, and irritability. There was no higher incidence of infection, mood changes, or behavior problems among treatment subjects compared to observation subjects. Only 1 of 40 subjects (2.5%) developed post-traumatic epilepsy (defined as seizures > 7 days after trauma). This study demonstrates the feasibility of a pediatric post-traumatic epilepsy prevention study in an at-risk traumatic brain injury population. Levetiracetam was safe and well tolerated in this population. This study sets the stage for implementation of a prospective study to prevent post-traumatic epilepsy in an at-risk population.

Objective: To advance the understanding of KCNQ2 encephalopathy genotype–phenotype relationships and to begin to assess the potential of selective KCNQ channel openers as targeted treatments. Methods: We retrospectively studied 23 patients with KCNQ2 encephalopathy, including 11 treated with ezogabine (EZO). We analyzed the genotype–phenotype relationships in these and 70 previously described patients. Results: The mean seizure onset age was 1.8 ± 1.6 (SD) days. Of the 20 EEGs obtained within a week of birth, 11 showed burst suppression. When new seizure types appeared in infancy (15 patients), the most common were epileptic spasms (n = 8). At last follow-up, seizures persisted in 9 patients. Development was delayed in all, severely in 14. The KCNQ2 variants identified introduced amino acid missense changes or, in one instance, a single residue deletion. They were clustered in 4 protein subdomains predicted to poison tetrameric channel functions. EZO use (assessed by the treating physicians and parents) was associated with improvement in seizures and/or development in 3 of the 4 treated before 6 months of age, and 2 of the 7 treated later; no serious side effects were observed. Conclusions: KCNQ2 variants cause neonatal-onset epileptic encephalopathy of widely varying severity. Pathogenic variants in epileptic encephalopathy are clustered in “hot spots” known to be critical for channel activity. For variants causing KCNQ2 channel loss of function, EZO appeared well tolerated and potentially beneficial against refractory seizures when started early. Larger, prospective studies are needed to enable better definition of prognostic categories and more robust testing of novel interventions. Classification of evidence: This study provides Class IV evidence that EZO is effective for refractory seizures in patients with epilepsy due to KCNQ2 encephalopathy.

Objectives To evaluate the safety and tolerability of treatment with levetiracetam and determine the trough levels of levetiracetam in patients with traumatic brain injury (TBI) who are at high risk for posttraumatic epilepsy (PTE). Design Open-label, nonrandomized phase 2 study with 2 arms comparing levetiracetam treatment vs observation. Setting Two level 1 trauma centers. Patients A total of 422 participants 6 years or older with TBI who have a 20% risk for PTE were screened. Of these participants, 205 (48.6%) were eligible. A total of 126 participants were enrolled: 86 adults and 40 children. A total of 66 participants were in the treatment group (46 adults and 20 children), and a total of 60 participants were in the observation group (40 adults and 20 children). Participants presenting within 8 hours after TBI received treatment, and those presenting more than 8 to 24 hours after TBI did not. Intervention Treatment with levetiracetam (55 mg/kg/d) for 30 days starting within 8 hours after injury. Main outcome measures Number of adverse events, mood score, number of infections, trough level of levetiracetam, and PTE. Results Of the 66 participants treated with levetiracetam, 2 (3%) stopped treatment owing to toxicity (somnolence). The most common adverse events were fatigue, headache, and somnolence. Mood scores and number of infections did not differ between the treatment and observation groups. Mean trough levels of levetiracetam on days 2 to 30 ranged from 19.6 to 26.7 μg/mL. At 2 years, 13 of 86 adults (15.1%) and 1 of 40 children (2.5%) developed PTE. At 2 years, 5 of 46 treated adults (10.9%) and 8 of 40 untreated adults (20.0%) developed PTE (relative risk, 0.47; P=.18). Conclusion Treatment with 55 mg/kg/d of levetiracetam (a dose with an antiepileptogenic effect on animals) for patients with TBI at risk for PTE is safe and well tolerated, with plasma levels similar to those in animal studies. The findings support further evaluation of levetiracetam treatment for the prevention of PTE. Trial registration clinicaltrials.gov Identifier: NCT01463033.

Conventional EEG is being used more frequently in NICUs in the U.S. with the advent of therapeutic hypothermia and the growth of neurocritical care intensivists & units. Historical applications have included assessing encephalopathy, seizure evaluation and prognosis. Past reluctance or limitation of the use in the NICU are receding with the digitization of EEG recordings and increasing interest in the neonatal brain. Continuous EEG monitoring is expanding the potential for its application as a brain monitoring tool to stratify initial injury severity, monitor seizure response to treatment, and detect sentinel neurologic events in the NICU, in addition to guiding neurotherapeutic options. The progression of the EEG background after an acute insult can also increase its prognostic specificity and provide another immediate marker of NICU neurologic outcome. The future of EEG monitoring in the NICU holds many possibilities and may greatly advance the new field of neuroprotection in the NICU.

Objective To determine if early serum S100B and neuron-specific enolase (NSE)levels are associated with neuroradiographic and clinical evidence of brain injury in newborns with encephalopathy. Study design Patients who received therapeutic whole-body hypothermia were prospectively enrolled in this observational study. Serum specimens were collected at 0, 12, 24, and 72 hours of cooling. S100B and NSE levels were measured by enzyme linked immunosorbent assay. Magnetic resonance imaging was performed in surviving infants at 7-10 days of life. Standardized neurologic examination was performed by a child neurologist at 14 days of life. Multiple linear regression analyses were performed to evaluate the association between S100B and NSE levels and unfavorable outcome (death or severe magnetic resonance imaging injury/significant neurologic deficit). Cutoff values were determined by receiver operating curve analysis. Results Newborns with moderate to severe encephalopathy were enrolled (n = 75). Median pH at presentation was 6.9 (range, 6.5-7.35), and median Apgar scores of 1 at 1 minute, 3 at 5 minutes, and 5 at 10 minutes. NSE and S100B levels were higher in patients with unfavorable outcomes across all time points. These results remained statistically significant after controlling for covariables, including encephalopathy grade at presentation, Apgar score at 5 minutes of life, initial pH, and clinical seizures. Conclusion Elevated serum S100B and NSE levels measured during hypothermia were associated with neuroradiographic and clinical evidence of brain injury in encephalopathic newborns. These brain-specific proteins may be useful immediate biomarkers of cerebral injury severity. (J Pediatr 2012;161:434-40).

Hippocampal sclerosis (HS) is rarely considered as a diagnosis in children younger than 2 years. To describe imaging features in conjunction with clinical information in patients with hippocampal sclerosis who are younger than 2 years. We retrospectively reviewed MR brain imaging and clinical information in five children in whom the diagnosis of HS was made both clinically and by MRI prior to 2 years of age. Imaging features establishing the diagnosis of hippocampal sclerosis were bright T2 signal and volume loss, while the internal architecture of the hippocampal formation was preserved in almost all children. Clinically, all children had an infectious trigger. It is necessary for radiologists to consider HS in children with certain clinical features to plan an MRI protocol that is appropriate for detection of hippocampal pathology.

This article offers the preferred methods and indications for longterm, conventional electroencephalography (EEG) monitoring for selected, high-risk neonates of postmenstrual age less than 48 weeks. The authors recognize that there may be significant practical barriers to the implementation of these recommendations for many caregivers and institutions, particularly with regard to the availability of equipment, and technical and interpretive personnel. A wide range of clinical circumstances dictates the implementation of EEG monitoring, frequency of EEG review, and the subsequent treatment of seizures or EEG background abnormalities detected by neonatal EEG. Consequently, this article should be considered as an expression of idealized goals and not as a mandated standard of care.

The vagus nerve stimulator has become a standard modality for intractable pediatric epilepsy. We reviewed our experience with major adverse events, after accidental puncture of a stimulator wire by an emergency room physician seeking intravenous access to treat status epilepticus. The Children's National Medical Center database was reviewed for patients undergoing vagus nerve stimulator placement between January 1988 and June 2006. Patient characteristics, duration of therapy, and treatment-limiting adverse events were noted. Of 62 patients implanted over 8 years, 22 (35%) had adverse events which led to a change in therapy. Adverse events included prominent drooling, coughing, throat discomfort, dysphagia, wound infection, difficulty breathing, vomiting, vocal-cord weakness, lead failure, and iatrogenic (piercing of wire; surgical clipping of wire during revision). Eight patients required nonroutine surgical intervention (13%). There were two unusual case presentations. In a 13-year-old boy with status epilepticus at an outlying emergency department, the stimulator line was pierced in search of intravenous access. In a 25-year-old housepainter, neck paresthesias upon right lateral neck turning were attributed to insufficient strain relief. Treatment-limiting adverse events occurred in approximately one-third of patients. Unanticipated adverse events included misidentification of the wire for intravenous access, clipping of the wire during surgical dissection, and cervical dysesthesias associated with head-turning.

Stroke is a rare but increasingly recognized disorder in children. Current therapies for arterial ischemic stroke include thrombolytic, antithrombotic and antiplatelet agents, blood transfusion and surgery. Adult studies, pediatric case studies and expert opinion form the basis for these treatment strategies. Thrombolytic agents are increasingly used but, as in adults, the majority of arterial ischemic strokes in children are treated with antiplatelet and antithrombotic agents. Sickle-cell patients, a distinct subset of the pediatric stroke population, are treated primarily with transfusion therapy. Pediatric arterial ischemic stroke studies are needed to determine the most appropriate course of treatment. An international study is currently in progress to formally study the incidence, risk factors, treatment strategies and outcomes of stroke in children.

Cerebral sinovenous thrombosis (CSVT) is a rare but increasingly recognized disease process in children. In the pediatric population, the etiologies of CSVT are multiple and the outcomes are variable. The current therapies for CSVT include anticoagulation, thrombolysis, hydration, surgery, and supportive care. Adult studies, pediatric case studies, and expert opinion form the basis for these treatment strategies. International cooperative efforts are currently being undertaken to collect data on pediatric stroke patients, including CSVT. These multicenter collaborations are needed to increase our understanding of the incidence, risk factors, treatment modalities, and outcomes of CSVT in pediatric populations.

An 8-year-old Hispanic male resident of Maryland developed fever to 38°C, diffuse abdominal pain and dizziness in August 2005. He was previously healthy, born and raised in the United States, but had traveled to Mexico a few years prior. He was treated for sinusitis by his physician, but was hospitalized 5 days later because of persistent fever, neck stiffness, nausea, vomiting and generalized weakness. On admission, vital signs showed a temperature of 38.5°C, heart rate of 126 beats/min, respiratory rate of 28 breaths/min, blood pressure of 102/45 mm Hg and oxygen saturation 95% in room air. Physical examination was notable for stiff neck, diffuse abdominal tenderness and a focal petechial rash over his left anterior chest. Neurologic examination was normal. A complete blood count revealed a white blood cell count of 4.2/ L (87% neutrophils, 2% band forms, 9% lymphocytes and 2% monocytes), hemoglobin concentration of 11 g/dL and platelet count of 161,000/ L. Cerebrospinal fluid (CSF) analysis showed 530 leukocytes/ L (88% granulocytes, 12% lymphocytes), red blood cells 20, with glucose 61 mg/dL and protein 148 mg/ dL. A Gram-stained smear of the CSF and bacterial cultures of the CSF and blood revealed negative results. Aspartate aminotransferase was 218 units/L (normal, 26), and alanine aminotransferase was 109 units/L (normal, 44). Serum electrolyte concentrations, urinalysis, urine toxicology screen and urine culture were normal. The patient was empirically treated with vancomycin and ceftriaxone for suspected bacterial meningitis. On the second hospital day, the child’s temperature increased to 39°C, and he continued to have abdominal pain and persistent nonbilious, nonbloody emesis. Neurologic examination remained normal, and mental status was appropriate. A chest radiograph and computed tomography of the brain were normal. Contrast-enhanced abdominal computed tomography examination revealed a mildly fatty liver with no focal lesions and a moderate quantity of retained stool. Early the next morning, the patient’s cardiorespiratory monitor alarm was activated, and he was found to be unresponsive with agonal breathing and weak gag and cough reflexes. He was hypothermic (34.5°C), heart rate was 145 beats/min and oxygen saturation was not detectable by pulse oximetry. The patient was intubated. Cardiology evaluation that morning demonstrated decreased electrocardiographic voltages throughout all leads and a prolonged QTc interval. Echocardiography showed a reduced shortening fraction of 23% (normal, 28–44%) and an ejection fraction of 40% (normal, 55–70%), consistent with myocarditis. Later in the afternoon, neurologic examination was remarkable for a comatose state and complete flaccid, areflexic quadriparesis. An electroencephalogram revealed diffuse slowing, consistent with meningoencephalitis. A repeat complete blood count showed a white blood cell count of 14,280/ L (44% neutrophils, 2% band forms, 35% lymphocytes, 11% monocytes, 1% basophils and 7% reactive lymphocytes), hemoglobin 10.5 g/dL and platelet count 210,000/ L. Aspartate aminotransferase and alanine aminotransferase were improved slightly to 117 and 76 units/L, respectively. Sodium had decreased to 126 mmol/L, and chloride was 93 mmol/L as a result of inappropriate antidiuretic hormone production and cerebral salt wasting. The other electrolytes were normal. Polymerase chain reaction tests on the CSF obtained from a repeat lumbar puncture on hospital day 4 for herpes simplex virus and enteroviruses yielded negative results. T2 magnetic resonance imaging on hospital day 6, obtained because of concern for cerebral damage resulting from hypoperfusion, demonstrated mild leptomeningeal enhancement and enhancing ventral nerve roots from thoracic level spine through the cauda equina. Antimicrobial therapy was empirically broadened on hospital day 4 when the patient developed respiratory failure and demonstrated an evolving flaccid paralysis. Acyclovir (for herpes simplex virus), doxycycline (for Rocky Mountain spotted fever), rifampin, isoniazid, pyrazinamide (for tuberculosis) and fluconazole (for cryptococcal meningitis) were added. Intravenous immunoglobulin (2 g/kg; Polygam SD; Baxter, Westlake Valley, CA) was administered on the fifth hospital day, after no neurologic improvement was noted because of concern for atypical Guillain-Barre syndrome. Increased alertness was observed over the next several days, during which time ptosis was noted that improved slightly over his hospital course. On the sixth hospital day, nerve conduction studies and an electromyogram suggested an early peripheral demyelinating polyneuropathy. By the eighth hospital day, the patient was able to open his eyes slightly to pain and had minimal ability to visually track from side to side. On hospital day 9, follow-up electrocardiogram revealed low, but improved, voltages and echocardiography showed improvement of the shortening fraction to 29% and ejection fraction to 52%. For denouement, see p. 855. Accepted for publication June 16, 2006. From the *Department of Infectious Disease, Children’s National Medical Center, the †Department of Pediatrics, Uniformed Services University of the Health Sciences, and the †Department of Neurology, Children’s National Medical Center, Bethesda, MD Copyright © 2006 by Lippincott Williams & Wilkins ISSN: 0891-3668/06/2509-0853 DOI: 10.1097/01.inf.0000234058.31683.70