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Figure 3. Coefficients of correlation between the parathyroid hormone serum concentration and EchoCG indicators
Note: reliability of all indicated Pearson's correlation coefficients is p <0.001.
Thus, the present research has shown that in case of CKD, the left heart chambers remodeling is observed that manifests by disturbance of early diastolic filling, myocardium hypertrophy, dilatation
References:
of the cavities and the tendency to decrease systolic LV functions correlating with a decrease in filtration functions of the kidneys and intensity of secondary hyperparathyroidism.
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DOI: http://dx.doi.org/10.20534/ESR-17-1.2-123-126
Samadov Furkatjon Nosibjanovich, Assistant of Pediatric neurology Department, Tashkent Institute of Postgraduate Medical education E-mail: furkat.samadov@gmail.com Saidazizova Shahlo Hibziddinovna, Associate professor of Pediatric neurology Department, Tashkent Institute of Postgraduate Medical education E-mail: shahlo_7@mail.ru Gulyamova Maktuba Kamalovna, Associate professor of Pediatric neurology Department, Tashkent Institute of Postgraduate Medical education E-mail: maktuba-2006@mail.ru
Post-Stroke Seizures in Children: incidence and clinical features depending on the type of stroke
Abstract: A total of 157 children with stroke were included in this study. Early post-stroke seizure were seen in 68 (43.3%) of patients. 52 of 122 (42.6%) patients with hemorrhagic stroke and 16 of 35 (45.7%) ischemic stroke patients had seizures as presenting. Most commonly witnessed seizure type was partial seizure in 50 (51.5%) of patients while 47 (48.5%) had generalized seizures. Analysis of generalized and partial seizure type between hemorrhagic and ischemic stroke patients showed no statistically significant difference (p>0.612; p>0.315).
Keywords: seizures, epilepsy, risk factors, stroke, children.
Background. Seizures are the most common pediatric neurologic disorder, with 4% to 10% of children suffering at least one seizure in the first 16 years of life [1-3]. Also, seizures one of the common presenting symptom in neonates and children with stroke. However, few data are available regarding the epidemiology of acute symptomatic seizures or the risk for later epilepsy. Estimates of seizures at presentation or in the early or acute period range from 18% to 50%, but definitions of acute symptomatic seizures or early symptomatic seizures vary [4-6].
Stroke is the most common etiology of epileptic seizures and epilepsy in children. Stroke in children are rare conditions, with incidence rates among two and eight per 100,000 children up to 14 years, and most cases show an underlying disease such as heart diseases, prothrombotic conditions, sickle-cell disease, and vascular malformations [7; 8].
Hemorrhagic stroke, subarachnoid hemorrhage, and cerebral venous sinus thrombosis (CVST) are associated with a higher risk of early seizures than is ischemic stroke [8-10].
Stroke results in a 23-to 35-fold increase in seizure incidence [3,10,11] and the risk of epilepsy increases 17-fold [12,13]. The risk of seizure after stroke is probably the same as in the general population after a first unprovoked seizure [4; 10; 14] and withholding AEDs till a second seizure occurs may not be harmful. Remote seizures and epilepsy, including medically refractory epilepsy, are common after perinatal stroke. Neonatal seizures are associated with nearly 3-fold increased remote seizure risk [2].
Although general guidelines exist for the diagnosis and the treatment of epilepsy, no specific recommendations are available concerning the management of seizures related to stroke in children. This is an underestimation as seizures occurring at stroke onset were not taken in to account and non-convulsive spells are rarely recognized as such. Risk factors, diagnosis, management and treatment will be different according to the time of onset of the seizures in relation to the stroke [13; 15].
Objective
To analyze the incidence and clinical features of post stroke related seizures in children depending on the type of stroke.
Study design and subjects
In this study, we assessed 157 patients with ischemic and hemorrhagic stroke, who had been admitted in pediatric neurology subspecialty service, Tashkent City Children's Hospital #1, Uzbekistan between February 1, 2015, and December 30, 2016. Data was collected regarding type, onset and frequency of the seizure, radiological findings regarding type, location and nature of stroke; gender and co-morbidities. Information gathered from history, examination and radiological findings, as on computed tomography (CT scan) or magnetic resonance imaging (MRI), was entered in a proforma especially designed for the study.
Statistical analysis
SPSS version 19 (IBM, USA) was used for all analyses. Descriptive statistics were applied to calculate the frequencies and percentages of categorical variables such as gender, nature of stroke and type of seizures. Mean ± standard deviation was calculated for continuous variables like age. Pearson's chi-square test and Fisher exact tests were applied accordingly to find relationship between the time of onset ofpost-stroke seizures and other variables. P-value of <0.05 was considered statistically significant.
Results
A total of 157 patients with stroke were included. There were 111 (70.7%) males and 46 (29.2%) females. For children, the median stroke onset age was 38 days (interquartile range [IQR], 27-50 days). One hundred twenty two (77.7%) had hemorrhagic
stroke (HS) and 35 (22.2%) had ischemic stroke (IS). The main findings and demographic data of the study summarized in Table 1.
Table 1. - Demographic data and main findings of the study
Age, stroke onset (Me, IQR), days 38 days (27-50)
Gender (M/F) 111/46
Type of stroke:
hemorrhagic/ischemic 122/35
perinatal/childhood 47/110
Complaints:
anxiety 106 (67.5%)
breastfeeding take-over 77(49%)
seizure as presenting 68 (43.3%)
vomiting 56 (35.5%)
Stroke etiology:
coagulopathy 96 (61.1%)
arteriovenous malformation 6 (3.8%)
unknown 49 (32.1%)
Radiological findings:
Isolated IPH 48 (30.5%)
IPH with IVH extension 77(49%)
Isolated IVH 32 (20.32%)
Abbreviations: IPH, intraparenchymal hemorrhage; IVH, intraventricular hemorrhage.
Fifty-two of 122 (42.6%) patients with hemorrhagic stroke had seizures as presenting. Most common site in affected persons was the cerebral cortex (13/20; 65%), followed by basal ganglia (5/20; 25%). Most commonly affected cortical regions were parietal and temporal accounting for approximately 40% each from cortical hemorrhages. Sixteen of35 (45.7%) ischemic stroke patients developed seizures. Most common involved arterial territory was pure middle cerebral artery (MCA) (70/97; 72%), followed by mixed middle and posterior cerebral arteries (9/97; 9%), and pure posterior cerebral artery (PCA) (6/97; 6%). Cortical involvement was noted in 75% of MCA strokes and 60% of PCA strokes.
Early post-stroke seizure were seen in 68 (43.3%) of patients. Rest of the subjects i. e. 97 (61.7%), experienced late-seizures. Most commonly witnessed seizure type was partial seizure in 50 (51.5%) of patients while 47 (48.5%) had generalized seizures. Thirty-one (31.9%) patients experienced more than two seizures. Status epilep-ticus was seen in only one subject (1.03%) who was a young male with a large intracerebral hematoma (Table 2).
Generalized seizures were seen in 36.08% patients in hemorrhagic stroke group as compared to 42.2% subjects with partial seizures. In the ischemic stroke group, 12.3% patients had generalized seizures versus 9.7% patients who had partial seizures. Most patients experienced more than one seizure; 56 (57.7%) in HS patients as compared to 18 (18.5%) in IS group. The only patient who had status epilepticus had early seizures within 24 hours of stroke onset.
Analysis of generalized and partial seizure type between hemor-rhagic and ischemic stroke patients showed no statistically significant difference (p>0.612; p>0.315).
A large proportion of patients, 112 (71.3%) had hemorrhagic infarction as evidenced by CT scan or MRI brain. Of ischemic strokes, 27 (77%) had an arterial infarct while venous infarct was found in only 3 (8.5%) of the subjects who were all young females.
Table 2. - Characteristics of post-stroke seizures (n=97)
Clinical characteristics HS (n=122) IS (n=35) x2 P
Generalized 35 12 0.257 0.612
Partial 41 9 1.009 0.315
Frequency
Single 20 3 1.331 0.249
Multiple 56 18 0.333 0.564
EEG finding*
Abnormal background 38 (39.1%)
Slowing/voltage attenuation 8 (8.24%)
Epileptiform discharges 12 (12.3%)
Normal 5 (5.1%)
Abbreviations: HS-hemorrhagic stroke; IS-ischemic stroke. * Not all children had initial EEG performed.
One hundred of the 117 (85.5%) patients achieved seizure control with one antiepileptic drug (AED), 16/117 (13.7%) required two AEDs and one (0.8%) patient required three AEDs. Valproic acid and Benzonale were most commonly prescribed AEDs followed by carbamazepine. As basic of anticonvulsants in the treatment of post-stroke seizures were used Convulex® (Gerot Lannach, Austria). The emergence of a new form ofvalproic acid — Convulex in the form of drops for oral administration has made it possible to optimize its use in infants. High efficiency of Convulex, apparently caused by blocking sodium voltage-dependent channels and impaired release of excitatory neurotransmitters (glutamates and folate) in interneuronal synaptic gap in conditions cerebral hypoxia — ischemia.
EEG was performed in 89/157 (56.6%) and 58 (65.1%) had abnormal findings. Diffuse slowing of background activity was most common finding (38/89; 42.6%), followed by focal slowing (8/89; 8.9%). Epileptifrom activity was noted in 12/89 (13.4%). Of these 12, 8 had focal activity and 3 had generalized activity.
Discussion
The relationship between seizures and stroke has been long recognized. Rate of seizure in the early period after stroke is significantly higher than adults. Typically, seizures are not the only manifestation of stroke, focal neurological deficit develops either simultaneously with onset of the stroke or immediately in postictal period.
The frequency of post stroke seizures has been reported from 5-10% in the West [4; 11; 13; 16; 17]. A slightly higher frequency i. e. 13% is reported from India [4]. A lower frequency is reported from China i. e. 3.4% [16]. We noted that 8% of our stroke patients
had post stroke seizures, which is close to earlier reports. Western literature reports a similar or higher frequency of seizures in hemorrhagic strokes as compared to ischemic strokes. Conversely, we noted a higher frequency of seizures in ischemic strokes i. e. 45.7% versus, 42.6% in hemorrhagic strokes. Reasons for this difference are not clear. Interestingly most frequent seizure type was partial. Which similar to some data showing a preponderance of partial seizures in post-stroke seizure [18; 19].
This study has a number of limitations including a relatively small number of patients with post-stroke seizures, which limits the ability to draw any causative associations among variables. Also this study lacks the EEG data, which might have helped us in identifying more seizures including non-convulsive seizures or status epilepti-cus; as well as the information regarding the antiepileptic treatment given to these subjects and their outcome. Therefore, larger-sized prospective studies are obligatory to improve the understanding of the post-stroke seizures and their impact on the person and society, translating into a better and evidence-based health care provision.
Conclusion
This study indicated that post-stroke seizures are quite a common problem in the management of children with stroke but they are usually single without recurrence. Ischemic stroke is the most common cause of post-stroke seizure, and partial seizure is the most common type. In addition, this study indicated that the initial 2 weeks after stroke carry the highest risk for stroke patients to have a seizure. Early diagnosis of stroke in children is very important and pediatricians should be aware of the lack of specificity of the symptoms to avoid late sequelae and improve life quality.
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DOI: http://dx.doi.org/10.20534/ESR-17-1.2-126-129
Khadjibaev Abdukhakim Muminovich, Republic Research Centre of Emergency Medicine Chief of Emergency Surgery Department Professor, MD, PhD Tilyakov Akbar Buriyevich, Republic Research Centre of Emergency Medicine MD, PhD, senior researcher of the traumatology department
E-mail: akbar-tilak@mail.ru Magrupov Bokhodir Asadullaevich, Republic Research Centre of Emergency Medicine Chief of pathologic anatomy department Professor, MD, PhD Urazmetova Maisa Dmitriyevna, Republic Research Centre of Emergency Medicine Chief of experimental medicine department Professor, MD, PhD Ubaydullaev Bobur Sabirovich, Republic Research Centre of Emergency Medicine Department of traumatology, MD Republican Research Centre of Emergency Medicine 2, Tashkent, Republic of Uzbekistan
The role of allofibroblasts transplantation in cartilaginous tissue regeneration process
Abstract:
Aim of investigation. Ground of embryonal allofibroblasts in the process of cartilaginous tissue regeneration. Material and methods. Investigation is based on the study the results of stimulation cartilaginous tissue regeneration process in the conditions of embryonal allofibroblasts application in 24 experimental sexually mature rabbits in which the model of symphysis pubis rupture with its following recovery have been used. Pieces of cartilaginous tissue have been fixed in 10% neutral formalin and embedded in paraffin. Histological sections were colored with hematoxylin, eosin and by Van-Gieson. Experiments duration — 7, 14, 21and 30 days.
Results. After pelvic bones symphysis pubis rupture, cartilaginous tissue is undergone alternative changes with following formation of lobulose chondromatous nodules of different sizes and sclerosis of surrounding muscular and osseous tissue. In the second series of experiment after pelvis symphysis pubis rupture and symphysis recovery with the help of cerclage, morphologic investigation results testify formation of mixed initial callus consisting of connective and chondromatous tissue elements. In the third series of experiment embryonal allofibroblasts were introduced into symphysis pubis rupture defect after its recovery by cerclage. It has been shown that within 4 weeks of experiment connective tissue having intensive basophil stain is formed in the area of symphysis pubis rupture. Connective tissue formation wit following formation of cartilaginous cells have been also noted in surrounding sift tissue structures.
Conclusion. Cartilaginous tissue formation process in the area of symphysis pubis rupture in experiment testifies stimulating influence of allogenic fibroblasts on cartilaginous tissue regeneration process in the experiment and it creates premises for applying this method in clinical practice.
Keywords: embryonal allofibroblasts; cartilaginous tissue regeneration.
