Vertebral artery dissection: issues in diagnosis and management.

Vertebral artery dissection is an uncommon cause of stroke in children. Accuracy of diagnosis by magnetic resonance angiography (MRA) instead of invasive transfemoral angiography (TFA) has been controversial. The need for anticoagulation and duration of such therapy is also arguable. We report 2 boys with vertebral artery dissection: one, aged 7 years, presented with hemiparesis and seizures and the other, aged 4 years, presented with ataxia. Each boy's initial MRA was not interpreted as delineating occlusive lesions to explain the posterior circulation infarcts visualized on computed tomography and magnetic resonance imaging scans. However, subsequent MRAs were suspicious for vertebral artery dissection, which was confirmed by TFA. Both children were treated with anticoagulation therapy. The first patient continued to manifest evidence of new infarcts despite treatment (initially with aspirin alone, followed by anticoagulation with heparin and warfarin), and is now maintained on a combination of high dose warfarin and aspirin. The second patient is now maintained on aspirin alone after initial anticoagulation for 6 months with heparin followed by warfarin. A high index of suspicion for vertebral artery dissection may allow diagnosis on the basis of MRA alone. Previous reports have indicated good outcomes of vertebral artery dissection in children and adults irrespective of anticoagulation treatment. Our experience suggests that anticoagulation may be beneficial in preventing further strokes caused by the dissection.

Legal issues in the treatment of children with attention deficit hyperactivity disorder.

The treatment of children with attention deficit hyperactivity disorder (ADHD) has raised a number of legal issues. Tort issues include medical malpractice and battery claims. Suits have charged physicians with negligent misdiagnosis of ADHD, and failure to obtain adequate informed consent for the use of stimulant medications, primarily by inadequate provision of information about side effects. Coercive use of medications by school systems, in the absence of parental consent, has raised issues about battery. Constitutional questions are present concerning limitations on parental rights to decline medical care for their children balanced against the State's interest in safeguarding the health and welfare of children. Children's own equal protection, due process, and privacy rights are also at issue, as well as their constitutional and statutory right to an education.

The fetal alcohol syndrome.

Within the last ten years, scientists have rediscovered the devastating effects of alcohol on fetal development. Much remains to be learned about the cause and scope of the problem. Unlike genetic disorders, FAS is totally preventable. Our best weapons in combatting this important public health problem are: Early identification and treatment of women of childbearing age with alcohol problems; Prompt diagnosis and therapy of children with FAS; and, Early and increased public awareness.

Neurologic sequelae of experimental febrile convulsions.

A study was designed to investigate the effects of experimentally produced hyperthermic seizures on the brain of the developing rat. Severty-nine newborn Sprague-Dawley white rats were divided into five groups and exposed to one of the following: Nonseizure-producing hyperthermia at 5 or 15 days (febrile controls), seizure-producing hyperthermia at 5 or 15 days, or no hyperthermia (afebrile controls). As the animals matured, seven developmental reflexes were tested and there were no differences found among the five groups in the ages at which these reflexes were acquired. At age 3 1/2 months, the ability of rats to adapt to a maze, and later to solve 12 maze problems, was studied. Although there was no significant difference in the amount of time required for any of the groups to adapt to the maze, there was a significant difference in the number of maze errors made by the different groups of rats. The mean error score for the control group was 118.5, compared with 183.0 (p less than 0.001), for rats with seizures at 5 days and 161.4 (p less than 0.001), for rats which convulsed at 15 days. It is apparent that experimental induction of a single hyperthermic seizure in the young rat interferes significantly with the animal's maze-solving ability at a later age.

Therapy of heavy drinking during pregnancy.

A survey of patients registering at the Boston City Hospital Prenatal Clinic had demonstrated that 9 percent were heavy drinkers. To reduce the health hazards to mothers and children, treatment of heavy alcohol use was integrated with prenatal care. A pediatric neurologist independently examined 322 offspring, including 42 whose mothers were heavy drinkers. Frequency of congenital anomalies, growth retardation, or functional abnormalities among these 42 was twice that of infants born to abstinent or moderate drinking mothers P less than .001). Within that group of 42, there were 15 whose mothers were able to abstain or reduce alcohol intake during the third trimester. These 15 demonstrated fewer abnormalities than those 27 whose mothers had continued heavy drinking (P less than .001). Since pregnant women can be motivated to reduce heavy drinking, treatment programs can benefit both mothers and infants.

Adverse effects on offspring of maternal alcohol abuse during pregnancy.

To evaluate the risk of offspring of heavy drinking during pregnancy, we administered a questionnaire to 633 women at the first prenatal visit. Nutritional status, smoking, drug and alcohol use were determined. Women were classified into three groups: abstinent and rare drinkers; moderate drinkers; and heavy drinkers. After delivery, detailed pediatric, neurologic and developmental examinations were administered by a physician without prior knowledge of any history. Infants born to heavy drinkers had twice the risk of abnormality of those born to abstinent or moderate drinkers (P less than 0.001). Thirty-two per cent of infants born to heavy drinkers demonstrated congenital anomalies, as compared to 9 per cent in the abstinent and 14 per cent in the moderate group (P less than 0.001). Microcephaly and multiple congenital anomalies were much more frequent in this group (P less than 0.001). Heavy drinking during pregnancy increases the risk to offspring.