Pediatricians, Neurologist (brain, nervous system)
13 years of experience
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Accepting new patients
3401 Civic Center Blvd
University City, Philadelphia, PA 19104
215-590-1000
Locations and availability (5)

Education ?

Medical School Score Rankings
UMDNJ (1997)
  • Currently 3 of 4 apples
Top 50%

Awards & Distinctions ?

Awards  
"Top Doctors" in Neurology, Main Line Today (2011)

Affiliations ?

Dr. Licht is affiliated with 4 hospitals.

Hospital Affilations

Score

Rankings

  • Taylor Hospital - Crozer Chester
    175 E Chester Pike, Ridley Park, PA 19078
    • Currently 2 of 4 crosses
  • Crozer-Chester Medical Center
    1 Medical Center Blvd, Chester, PA 19013
    • Currently 2 of 4 crosses
  • Children's Hospital of Philadelphia
    324 S 34th St, Philadelphia, PA 19104
    • Currently 2 of 4 crosses
  • Delaware County Memorial Hospital
    501 N Lansdowne Ave, Drexel Hill, PA 19026
    • Currently 2 of 4 crosses
  • Publications & Research

    Dr. Licht has contributed to 43 publications.
    Title Seizures As a Presenting Symptom of Acute Arterial Ischemic Stroke in Childhood.
    Date November 2011
    Journal The Journal of Pediatrics
    Excerpt

    To define the incidence of seizures as a presenting symptom of acute arterial ischemic stroke (AIS) in children and to determine whether younger age, infarct location, or AIS etiology were risk factors for seizure at AIS presentation.

    Title Csf Opening Pressure in Children with Optic Nerve Head Edema.
    Date July 2011
    Journal Neurology
    Excerpt

    We previously reported that an abnormal CSF opening pressure (OP) in children was greater than 28 cm H(2)O. Since elevated intracranial pressure can cause optic nerve head edema (ONHE), we would expect that most patients with ONHE would have an OP greater than 28 cm H(2)O. This study describes the range of OP for children with ONHE and compared them to age-matched controls without ONHE.

    Title Hemorrhagic Transformation of Childhood Arterial Ischemic Stroke.
    Date May 2011
    Journal Stroke; a Journal of Cerebral Circulation
    Excerpt

    The objective of this study was to describe the occurrence of hemorrhagic transformation (HT) among children with arterial ischemic stroke within 30 days after symptom onset and to describe clinical factors associated with HT.

    Title Cerebral Cortical Folding Analysis with Multivariate Modeling and Testing: Studies on Gender Differences and Neonatal Development.
    Date December 2010
    Journal Neuroimage
    Excerpt

    This paper presents a novel statistical framework for human cortical folding pattern analysis that relies on a rich multivariate descriptor of folding patterns in a region of interest (ROI). The ROI-based approach avoids problems faced by spatial normalization-based approaches stemming from the deficiency of homologous features between typical human cerebral cortices. Unlike typical ROI-based methods that summarize folding by a single number, the proposed descriptor unifies multiple characteristics of surface geometry in a high-dimensional space (hundreds/thousands of dimensions). In this way, the proposed framework couples the reliability of ROI-based analysis with the richness of the novel cortical folding pattern descriptor. This paper presents new mathematical insights into the relationship of cortical complexity with intra-cranial volume (ICV). It shows that conventional complexity descriptors implicitly handle ICV differences in different ways, thereby lending different meanings to "complexity". The paper proposes a new application of a nonparametric permutation-based approach for rigorous statistical hypothesis testing with multivariate cortical descriptors. The paper presents two cross-sectional studies applying the proposed framework to study folding differences between genders and in neonates with complex congenital heart disease. Both studies lead to novel interesting results.

    Title Optical Measurement of Cerebral Hemodynamics and Oxygen Metabolism in Neonates with Congenital Heart Defects.
    Date October 2010
    Journal Journal of Biomedical Optics
    Excerpt

    We employ a hybrid diffuse correlation spectroscopy (DCS) and near-infrared spectroscopy (NIRS) monitor for neonates with congenital heart disease (n=33). The NIRS-DCS device measured changes during hypercapnia of oxyhemoglobin, deoxyhemoglobin, and total hemoglobin concentrations; cerebral blood flow (rCBF(DCS)); and oxygen metabolism (rCMRO(2)). Concurrent measurements with arterial spin-labeled magnetic resonance imaging (rCBF(ASL-MRI), n=12) cross-validate rCBF(DCS) against rCBF(ASL-MRI), showing good agreement (R=0.7, p=0.01). The study demonstrates use of NIRS-DCS on a critically ill neonatal population, and the results indicate that the optical technology is a promising clinical method for monitoring this population.

    Title Reference Range for Cerebrospinal Fluid Opening Pressure in Children.
    Date September 2010
    Journal The New England Journal of Medicine
    Title Neuropsychological Status in Children After Repair of Acyanotic Congenital Heart Disease.
    Date September 2010
    Journal Pediatrics
    Excerpt

    The majority of previous studies that described the neuropsychological effects of cardiopulmonary bypass (CPB) in children were performed after surgery in infancy for complex congenital heart disease (CHD). We sought to limit confounding variables and isolate potential independent effects of CPB by describing neuropsychological function in school-aged children after repair of acyanotic CHD.

    Title Patient Position During Lumbar Puncture Has No Meaningful Effect on Cerebrospinal Fluid Opening Pressure in Children.
    Date August 2010
    Journal Journal of Child Neurology
    Excerpt

    The recommendation to measure cerebrospinal fluid opening pressure in the extended, rather than the flexed lateral recumbent position to avoid false elevation of the opening pressure has not been formally evaluated in children. This single-center prospective cohort study includes 53 children who had their opening pressure measured in both the flexed and extended lateral recumbent positions prior to removing any cerebrospinal fluid (mean age = 11.7 years; 60% male). The mean opening pressure was higher in the flexed (25.1 +/- 9.2 cm H2O) compared with the extended (24.4 +/- 8.4 cm H2O) position (mean difference = 0.6 +/- 2.2 cm H2O; Z = 2.021, P < .03). Most (92.4%) opening pressure measurements had less than a 5 cm H2O difference between positions. Lumbar puncture performed in the extended, rather than the flexed lateral recumbent position results in a statistically significant decrease in cerebrospinal fluid opening pressure, although the magnitude of the difference is small and of doubtful clinical significance.

    Title Abc/xyz Estimates Intracerebral Hemorrhage Volume As a Percent of Total Brain Volume in Children.
    Date May 2010
    Journal Stroke; a Journal of Cerebral Circulation
    Excerpt

    Intracerebral hemorrhage volume (ICHV) as a percentage of total brain volume (TBV) is a strong predictor of outcome in childhood intracerebral hemorrhage with ICHV/TBV >2% associated with functional impairment. We aimed to determine whether easily performed approximations of intracerebral hemorrhage and brain volume can accurately and reliably stratify intracerebral hemorrhage by size.

    Title Noninvasive Cerebral Perfusion Imaging in High-risk Neonates.
    Date April 2010
    Journal Seminars in Perinatology
    Excerpt

    Advances in medical and surgical care of the high-risk neonate have led to increased survival. A significant number of these neonates suffer from neurodevelopmental delays and failure in school. The focus of clinical research has shifted to understanding events contributing to neurological morbidity in these patients. Assessing changes in cerebral oxygenation and regulation of cerebral blood flow (CBF) is important in evaluating the status of the central nervous system. Traditional CBF imaging methods fail for both ethical and logistical reasons. Optical near infrared spectroscopy (NIRS) is increasingly being used for bedside monitoring of cerebral oxygenation and blood volume in both very low birth weight infants and neonates with congenital heart disease. Although trends in CBF may be inferred from changes in cerebral oxygenation and/or blood volume, NIRS does not allow a direct measure of CBF in these populations. Two relatively new modalities, arterial spin-labeled perfusion magnetic resonance imaging and optical diffuse correlation spectroscopy, provide direct, noninvasive measures of cerebral perfusion suitable for the high-risk neonates. Herein we discuss the instrumentation, applications, and limitations of these noninvasive imaging techniques for measuring and/or monitoring CBF.

    Title Predictors of Outcome in Childhood Intracerebral Hemorrhage: a Prospective Consecutive Cohort Study.
    Date February 2010
    Journal Stroke; a Journal of Cerebral Circulation
    Excerpt

    The purposes of this study were to describe features of children with intracerebral hemorrhage (ICH) and to determine predictors of short-term outcome in a single-center prospective cohort study.

    Title Cerebral Hemodynamics in Preterm Infants During Positional Intervention Measured with Diffuse Correlation Spectroscopy and Transcranial Doppler Ultrasound.
    Date November 2009
    Journal Optics Express
    Excerpt

    Four very low birth weight, very premature infants were monitored during a 12 degrees postural elevation using diffuse correlation spectroscopy (DCS) to measure microvascular cerebral blood flow (CBF) and transcranial Doppler ultrasound (TCD) to measure macrovascular blood flow velocity in the middle cerebral artery. DCS data correlated significantly with peak systolic, end diastolic, and mean velocities measured by TCD (p(A) =0.036, 0.036, 0.047). Moreover, population averaged TCD and DCS data yielded no significant hemodynamic response to this postural change (p>0.05). We thus demonstrate feasibility of DCS in this population, we show correlation between absolute measures of blood flow from DCS and blood flow velocity from TCD, and we do not detect significant changes in CBF associated with a small postural change (12 degrees ) in these patients.

    Title Intravenous Levetiracetam in Critically Ill Children with Status Epilepticus or Acute Repetitive Seizures.
    Date October 2009
    Journal Pediatric Critical Care Medicine : a Journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
    Excerpt

    Intravenous (IV) levetiracetam (LEV) is approved for use in patients older than 16 years and may be useful in critically ill children, although there is little data available regarding pharmacokinetics. We aim to investigate the safety, an appropriate dosing, and efficacy of IV LEV in critically ill children.

    Title Child Neurology: a Case Illustrating the Role of Imaging in Evaluation of Sudden Infant Death.
    Date September 2009
    Journal Neurology
    Title Prediction of Periventricular Leukomalacia. Part I: Selection of Hemodynamic Features Using Logistic Regression and Decision Tree Algorithms.
    Date August 2009
    Journal Artificial Intelligence in Medicine
    Excerpt

    Periventricular leukomalacia (PVL) is part of a spectrum of cerebral white matter injury which is associated with adverse neurodevelopmental outcome in preterm infants. While PVL is common in neonates with cardiac disease, both before and after surgery, it is less common in older infants with cardiac disease. Pre-, intra-, and postoperative risk factors for the occurrence of PVL are poorly understood. The main objective of the present work is to identify potential hemodynamic risk factors for PVL occurrence in neonates with complex heart disease using logistic regression analysis and decision tree algorithms.

    Title Prediction of Periventricular Leukomalacia. Part Ii: Selection of Hemodynamic Features Using Computational Intelligence.
    Date August 2009
    Journal Artificial Intelligence in Medicine
    Excerpt

    The objective of Part II is to analyze the dataset of extracted hemodynamic features (Case 3 of Part I) through computational intelligence (CI) techniques for identification of potential prognostic factors for periventricular leukomalacia (PVL) occurrence in neonates with congenital heart disease.

    Title Neurological Complications Associated with the Treatment of Patients with Congenital Cardiac Disease: Consensus Definitions from the Multi-societal Database Committee for Pediatric and Congenital Heart Disease.
    Date April 2009
    Journal Cardiology in the Young
    Excerpt

    A complication is an event or occurrence that is associated with a disease or a healthcare intervention, is a departure from the desired course of events, and may cause, or be associated with suboptimal outcome. A complication does not necessarily represent a breech in the standard of care that constitutes medical negligence or medical malpractice. An operative or procedural complication is any complication, regardless of cause, occurring (1) within 30 days after surgery or intervention in or out of the hospital, or (2) after 30 days during the same hospitalization subsequent to the operation or intervention. Operative and procedural complications include both intraoperative/intraprocedural complications and postoperative/postprocedural complications in this time interval. The MultiSocietal Database Committee for Pediatric and Congenital Heart Disease has set forth a comprehensive list of complications associated with the treatment of patients with congenital cardiac disease, related to cardiac, pulmonary, renal, haematological, infectious, neurological, gastrointestinal, and endocrine systems, as well as those related to the management of anaesthesia and perfusion, and the transplantation of thoracic organs. The objective of this manuscript is to examine the definitions of operative morbidity as they relate specifically to the neurological system. These specific definitions and terms will be used to track morbidity associated with surgical and transcatheter interventions and other forms of therapy in a common language across many separate databases. Although neurological injury and adverse neurodevelopmental outcome can follow procedures for congenital cardiac defects, much of the variability in neurological outcome is now recognized to be more related to patient specific factors rather than procedural factors. Additionally, the recognition of pre and postoperative neurological morbidity requires procedures and imaging modalities that can be resource-intensive to acquire and analyze, and little is known or described about variations in "sampling rate" from centre to centre. The purpose of this effort is to propose an initial set of consensus definitions for neurological complications following congenital cardiac surgery and intervention. Given the dramatic advances in understanding achieved to date, and those yet to occur, this effort is explicitly recognized as only the initial first step of a process that must remain iterative. This list is a component of a systems-based compendium of complications that may help standardize terminology and possibly enhance the study and quantification of morbidity in patients with congenital cardiac malformations. Clinicians caring for patients with congenital cardiac disease may be able to use this list for databases, initiatives to improve quality, reporting of complications, and comparing strategies of treatment.

    Title Brain Maturation is Delayed in Infants with Complex Congenital Heart Defects.
    Date April 2009
    Journal The Journal of Thoracic and Cardiovascular Surgery
    Excerpt

    Small head circumferences and white matter injury in the form of periventricular leukomalacia have been observed in populations of infants with severe forms of congenital heart defects. This study tests the hypothesis that congenital heart defects delay in utero structural brain development.

    Title Arterial Spin Labeling Perfusion Mri in Pediatric Arterial Ischemic Stroke: Initial Experiences.
    Date March 2009
    Journal Journal of Magnetic Resonance Imaging : Jmri
    Excerpt

    To investigate the feasibility and utility of arterial spin labeling (ASL) perfusion MRI for characterizing alterations of cerebral blood flow (CBF) in pediatric patients with arterial ischemic stroke (AIS).

    Title Preoperative Brain Injury in Transposition of the Great Arteries is Associated with Oxygenation and Time to Surgery, Not Balloon Atrial Septostomy.
    Date March 2009
    Journal Circulation
    Excerpt

    Preoperative brain injury is an increasingly recognized phenomenon in neonates with complex congenital heart disease. Recently, reports have been published that associate preoperative brain injury in neonates with transposition of the great arteries with the performance of balloon atrial septostomy (BAS), a procedure that improves systemic oxygenation preoperatively. It is unclear whether BAS is the cause of brain injury or is a confounder, because neonates who require BAS are typically more hypoxemic. We sought to determine the relationship between preoperative brain injury in neonates with transposition of the great arteries and the performance of BAS. We hypothesized that brain injury results from hypoxic injury, not from the BAS itself.

    Title Role of Diffusion Mri in Diagnosis of Spinal Cord Infarction in Children.
    Date January 2009
    Journal Neuropediatrics
    Excerpt

    Anterior spinal artery (ASA) infarction is a rare but well-described cause of flaccid paraparesis in adults, presenting with a high thoracic spinothalamic sensory level and preservation of dorsal column function. Careful sensory examination, demonstrating loss of spinothalamic modalities with preservation of dorsal column modalities, supports a clinical diagnosis of ASA infarction. Findings on conventional MRI of the spinal cord are often non-specific, and diffusion-weighted imaging (DWI) is not routinely performed. We describe four children with ASA infarction after minor trauma. DWI was performed in all cases and confirmed the clinical diagnosis.

    Title Predicting Outcome in Children with Hypoxic Ischemic Encephalopathy.
    Date June 2008
    Journal Pediatric Critical Care Medicine : a Journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
    Excerpt

    OBJECTIVE: Hypoxic ischemic encephalopathy (HIE) is common in children, and providing accurate and timely prognostic information is important in determining the appropriate level of care. While practice parameters are available for prognostication in adults, similar reviews are not available for children. This article reviews the current evidence in domains used to provide prognostic information in children with coma due to HIE. These include historical features of the event; physical exam signs; neurophysiologic studies, such as electroencephalogram and evoked potentials; and neuroimaging. DATA SOURCE: A literature search of MEDLINE was performed using the search terms HIE and prognosis cross-referenced in series with specific domains used to provide prognostic information, including physical examination, electroencephalogram, evoked potentials, neuroimaging, and magnetic resonance imaging. The results of these searches were scanned by the authors to identify articles pertaining to children (nonneonates). Further literature was identified from the reference lists of the literature identified by MEDLINE search. Clinical, preclinical, and review articles were identified that were related to the current understanding of prognosis in pediatric HIE. Only literature in English was reviewed. RESULTS: When performed at least 24 hrs after the inciting event, abnormal exam signs (pupil reactivity and motor response), absent N20 waves bilaterally on somatosensory evoked potentials, electrocerebral silence or burst suppression patterns on electroencephalogram (not due to metabolic or medication etiology), and abnormal magnetic resonance imaging with diffusion restriction in the cortex and basal ganglia are each highly predictive of poor outcome. Combining these modalities improves the overall predictive value. CONCLUSIONS: All testing provides the best prognostic information several days after hypoxic-ischemic injury, and often multiple tests are required to improve prognostic ability and rule out potentially confounding conditions. Thus, when decisions can be postponed several days, neurologic consultation and testing can provide the best prognostic information to families.

    Title The Cerebral Vasculopathy of Phaces Syndrome.
    Date February 2008
    Journal Stroke; a Journal of Cerebral Circulation
    Excerpt

    BACKGROUND AND PURPOSE: PHACES syndrome is a neurocutaneous disorder of unknown etiology. We studied the spectrum of associated congenital and progressive cerebral vascular anomalies. METHODS: The medical records of 7 patients with PHACES syndrome were reviewed and combined with an additional 108 PHACES cases identified from the literature. We reviewed the clinical characteristics, calculated the relative frequencies of each type of vascular anomaly, and assessed site of vessel involvement relative to hemangioma location. RESULTS: Among a total of 115 PHACES cases, 89 (77.4%) had congenital and/or progressive cerebral vascular anomalies. The most commonly detected congenital arterial anomalies included dysplasia, aberrant origin or course, hypoplasia, and absence or agenesis. Arterial occlusions and stenoses were detected in 24 (20.9%) and 21 (18.3%) cases, respectively. Twenty (17.4%) had persistent embryonic arteries; 15 (13%) had saccular aneurysms. There appears to be a close relation between the regional distributions of cervicofacial hemangiomas and the locations of intracranial and extracranial vascular (and cardiac) anomalies. CONCLUSIONS: The vasculopathy of PHACES chiefly comprises a spectrum of congenital and progressive large artery lesions. Based on known embryology and the relative frequencies of specific congenital vascular anomalies, we can predict that the initial cerebral vascular changes occur early in embryogenesis, by the fifth gestational week or earlier. There appears to be both a temporal and a regional link between the arterial anomalies of PHACES and the cutaneous infantile hemangioma.

    Title Clinical Neonatal Brain Mri Segmentation Using Adaptive Nonparametric Data Models and Intensity-based Markov Priors.
    Date January 2008
    Journal Medical Image Computing and Computer-assisted Intervention : Miccai ... International Conference on Medical Image Computing and Computer-assisted Intervention
    Excerpt

    This paper presents a Bayesian framework for neonatal brain-tissue segmentation in clinical magnetic resonance (MR) images. This is a challenging task because of the low contrast-to-noise ratio and large variance in both tissue intensities and brain structures, as well as imaging artifacts and partial-volume effects in clinical neonatal scanning. We propose to incorporate a spatially adaptive likelihood model using a data-driven nonparametric statistical technique. The method initially learns an intensity-based prior, relying on the empirical Markov statistics from training data, using fuzzy nonlinear support vector machines (SVM). In an iterative scheme, the models adapt to spatial variations of image intensities via nonparametric density estimation. The method is effective even in the absence of anatomical atlas priors. The implementation, however, can naturally incorporate probabilistic atlas priors and Markov-smoothness priors to impose additional regularity on segmentation. The maximum-a-posteriori (MAP) segmentation is obtained within a graph-cut framework. Cross validation on clinical neonatal brain-MR images demonstrates the efficacy of the proposed method, both qualitatively and quantitatively.

    Title Management of Common Neurologic Symptoms in Pediatric Palliative Care: Seizures, Agitation, and Spasticity.
    Date December 2007
    Journal Pediatric Clinics of North America
    Excerpt

    Palliative care for children is complex and focuses on patients' comfort. Some of the most troublesome symptoms as patients approach the end of life are seizures, agitation, and spasticity. Many doctors caring for children at the end of life are uncomfortable or untrained in managing these symptoms in children. Our goal is to help physicians recognize and treat these neurologic symptoms optimally.

    Title Status Epilepticus Secondary to Hypertensive Encephalopathy As the Presenting Manifestation of Guillain-barré Syndrome.
    Date October 2007
    Journal Pediatric Emergency Care
    Excerpt

    Malignant hypertension due to autonomic dysfunction is a known complication of Guillain-Barré syndrome. We describe a child who presented with status epilepticus secondary to hypertensive encephalopathy who, in recovery, was found to be areflexic. Nerve conduction studies confirmed the clinical diagnosis of Guillain-Barré syndrome. She was treated with antihypertensive and antiseizure medications and intravenous immune globulin with complete resolution of her autonomic symptoms and improvement in her weakness. Guillain-Barré syndrome may result in hypertensive encephalopathy that can manifest as status epilepticus before the onset of motor symptoms.

    Title Lupus Anticoagulant and Thrombosis Following Henoch-schonlein Purpura.
    Date August 2007
    Journal Pediatric Neurology
    Excerpt

    A male adolescent developed a sinovenous thrombosis 4 weeks following a Henoch-Schonlein purpura episode. A hypercoagulation evaluation revealed a positive lupus anticoagulant. This suggests an association between Henoch-Schonlein purpura and antiphospholipid antibody syndrome and is the first report of sinovenous thrombosis after Henoch-Schonlein purpura that was likely due to elevated antiphospholipids. Children who develop Henoch-Schonlein purpura with neurologic features including headache should be evaluated for sinovenous thrombosis and a hypercoagulable state.

    Title Neurologic Complications in Children Hospitalized with Influenza: Characteristics, Incidence, and Risk Factors.
    Date March 2007
    Journal The Journal of Pediatrics
    Excerpt

    OBJECTIVE: To determine the characteristics, incidence, and risk factors for influenza-related neurologic complications (INC). STUDY DESIGN: A retrospective cohort study of INC in children hospitalized with laboratory-confirmed influenza infection (LCI) from June 2000 to May 2004 was conducted. Systematic chart review was performed to identify clinical characteristics and outcomes. A neighborhood cohort was constructed to estimate the incidence of INC. Logistic regression was used to identify independent risk factors for INC. RESULTS: Of 842 patients with LCI, 72 patients had an INC: influenza-related encephalopathy (8), post-infectious influenza encephalopathy (2), seizures (56), and other (6). Febrile seizures were the most common type of seizures (27). No patient died from an INC. In our neighborhood cohort, the incidence of INC was 4 cases per 100,000 person-years. An age of 6 to 23 months (odds ratio [OR], 4.2; 95% CI, 1.4-12.5) or 2 to 4 years (OR, 6.3; 95% CI, 2.1-19.1) and an underlying neurologic or neuromuscular disease (OR, 5.6; 95% CI, 3.2-9.6) were independent risk factors for the development of INC. CONCLUSION: Seizures are the most common neurologic complication experienced by children hospitalized with influenza. In the United States, encephalopathy is uncommon. Young children and patients with neurologic or neuromuscular disease are at increased risk for INC.

    Title Why Perfusion in Neonates with Congenital Heart Defects is Negative--technical Issues Related to Pulsed Arterial Spin Labeling.
    Date September 2006
    Journal Magnetic Resonance Imaging
    Excerpt

    Pulsed arterial spin labeling (PASL) perfusion MRI has unique advantages for measuring cerebral blood flow (CBF) in the pediatric population. In neonates with congenital heart defects (CHDs), however, a considerable number of negative CBF values were observed in PASL perfusion images. A set of specific physiological and biophysical conditions were proposed as plausible explanations for this phenomenon, including small body size, low blood flow, prolonged tracer life time (blood T1) and the "shunt" between pulmonary and systemic circulations in CHD. An optimized PASL scheme with a restricted label volume was proposed, and experimental data demonstrated reduced spurious negative values and lower intersubject variability of perfusion measurements in neonates with CHD as compared to standard PASL sequences.

    Title Mimics of Childhood Stroke: Characteristics of a Prospective Cohort.
    Date September 2006
    Journal Pediatrics
    Excerpt

    BACKGROUND: Little is known about the clinical features and spectrum of diagnoses in children with "stroke mimics," those with acute neurologic deficits but without cerebrovascular diseases. OBJECTIVES: Our goal was to describe patients with stroke mimics and to determine if clinical features predict benign diagnoses. METHODS: Our stroke consult team registered a prospective consecutive cohort of 143 patients with acute presentations suspicious for cerebrovascular disease from November 2003 to November 2004. Cases in which stroke was ruled out (stroke mimics) were reviewed for clinical features and diagnostic test results and were classified "benign" if there was no structural brain lesion and there was an expectation of complete recovery. RESULTS: Of the 143 cases evaluated for suspected stroke, 30 (21%) had stroke mimics. Presenting signs included seizure (n = 11), headache (n = 9), mental status change (n = 6), focal weakness (n = 14), and focal sensory change (n = 7). Eleven patients had "benign" diagnoses (3 migraine, 3 psychogenic diagnoses, 3 musculoskeletal abnormalities, 1 delirium, and 1 episodic vital sign changes). Nineteen patients had "not-benign" diagnoses (3 reversible posterior leukoencephalopathy syndrome, 3 neonatal seizures, 2 vascular anomalies, 2 inflammatory disease, 2 intracranial infection, 2 epilepsy, 2 metabolic stroke, 1 tumor, 1 drug toxicity, and 1 idiopathic intracranial hypertension). Except for the presence of seizures, there were no significant differences in presentation or risk factors between benign and not-benign cases. CONCLUSIONS: Many disorders mimic childhood stroke. History and clinical presentation often do not distinguish the one third of patients with benign disorders from the two thirds with more serious problems, necessitating timely comprehensive investigations, especially brain MRI.

    Title Pediatric Perfusion Mr Imaging Using Arterial Spin Labeling.
    Date May 2006
    Journal Neuroimaging Clinics of North America
    Excerpt

    Cerebral blood flow (CBF, cerebral perfusion) mirrors cerebral metabolic demand and neuronal function, and therefore, is a vital parameter in the evaluation of pediatric brain injury and recovery. Until recently, measurement of CBF involved intravenous bolus injection of contrast agents or nuclear medicine methods that were technically difficult or ethically problematic in pediatrics. The development of arterial spin label (ASL) perfusion MR imaging as a noninvasive method for measuring CBF allows for the increased ability to measure this vital physiologic parameter in any age group. This article presents the technical aspects of performing ASL perfusion MR imaging in pediatrics, and discusses its current use in clinical studies and its potential for influencing important management strategies in specific disease entities.

    Title Neurological and Neuromuscular Disease As a Risk Factor for Respiratory Failure in Children Hospitalized with Influenza Infection.
    Date November 2005
    Journal Jama : the Journal of the American Medical Association
    Excerpt

    CONTEXT: The Advisory Committee on Immunization Practices (ACIP) recommends annual influenza vaccination for children with certain chronic medical conditions to prevent serious complications of influenza infection. Little is known about the relative contribution of each of these chronic medical conditions to the development of serious influenza-associated complications. OBJECTIVE: To identify chronic medical conditions that are associated with respiratory failure in children hospitalized with community-acquired laboratory-confirmed influenza. DESIGN, SETTING, AND PATIENTS: A retrospective cohort study of patients aged 21 years or younger hospitalized at The Children's Hospital of Philadelphia with community-acquired laboratory-confirmed influenza during 4 consecutive influenza seasons (June 2000 through May 2004). We examined 9 ACIP-designated high-risk chronic medical conditions and 3 additional chronic medical conditions (neurological and neuromuscular disease [NNMD], gastroesophageal reflux disease [GERD], and history of prematurity) that in recent studies have been associated with influenza hospitalization and severe influenza-related complications. MAIN OUTCOME MEASURES: Rate and odds ratio (OR) of respiratory failure, defined as need for mechanical ventilation. RESULTS: Of 745 children hospitalized with community-acquired laboratory-confirmed influenza, 322 (43%) had 1 or more ACIP-designated high-risk chronic medical conditions. Neurological and neuromuscular disease, GERD, and history of prematurity were present in 12%, 14%, and 3%, of children, respectively. Thirty-two children (4.3%) developed respiratory failure. In multivariate logistic regression analyses, conditions associated with respiratory failure included NNMD (OR, 6.0; 95% confidence interval [CI], 2.7-13.5), chronic pulmonary disease other than asthma (OR, 4.8; 95% CI, 1.5-15.1), and cardiac disease (OR, 4.0; 95% CI, 1.6-10.2). The predicted probabilities of respiratory failure derived from the multivariate model were 12% (95% CI, 7%-20%), 9% (95% CI, 3%-23%), and 8% (95% CI, 4%-18%) for children with NNMD, chronic pulmonary disease, and cardiac disease, respectively. CONCLUSIONS: These results support the ACIP's recent decision to add NNMD to the list of conditions for which annual influenza vaccine is recommended in children. Neurologists and primary care pediatricians should be alerted to the increased risk of respiratory failure and the importance of influenza vaccination in children with NNMD.

    Title Pediatric Palliative, End-of-life, and Bereavement Care.
    Date September 2005
    Journal Pediatric Clinics of North America
    Excerpt

    The pediatric hospitalist plays an integral role in providing palliative, end-of-life, and bereavement care for children and families. This article focuses on a multifaceted approach to this domain of care in which the physician is a key member of an interdisciplinary team. We believe that we can improve quality of life and relieve suffering only by paying attention to the medical, emotional, spiritual, and practical needs and goals of dying children and their loved ones.

    Title Pediatric Central Nervous System Infections and Inflammatory White Matter Disease.
    Date September 2005
    Journal Pediatric Clinics of North America
    Excerpt

    This article reviews the immunology of the central nervous system and the clinical presentation, diagnosis, and treatment of children with viral or parainfectious encephalitis. The emphasis is on the early recognition of treatable causes of viral encephalitis (herpes simplex virus), and the diagnosis and treatment of acute disseminated encephalomyelitis are described in detail. Laboratory and imaging findings in the two conditions also are described.

    Title Preoperative Cerebral Blood Flow is Diminished in Neonates with Severe Congenital Heart Defects.
    Date January 2005
    Journal The Journal of Thoracic and Cardiovascular Surgery
    Excerpt

    OBJECTIVE: Impaired neurodevelopmental outcome represents a major morbidity for survivors of infant heart surgery for congenital heart defects. Previous studies in these neonates have reported preoperative microcephaly, periventricular leukomalacia, and other findings. The hypothesis of this study is that preoperative cerebral blood flow is substantially diminished and might relate to preoperative neurologic conditions. METHODS: Preoperative brain magnetic resonance imaging was performed. Cerebral blood flow measurements in infants with congenital heart defects were obtained by using a novel noninvasive magnetic resonance imaging technique, pulsed arterial spin-label perfusion magnetic resonance imaging. Cerebral blood flow was measured before the operation under standard ventilation and repeated after increased carbon dioxide. RESULTS: A total of 25 term infants were studied. The average age at the time of the operation was 4.4 +/- 4.6 days. Congenital heart defects varied widely. Microcephaly occurred in 24% (6/25). Baseline cerebral blood flow was 19.7 +/- 9.2 mL . 100 g -1 . min -1 (8.0-42.2 mL . 100 g -1 . min -1 ). Five patients had cerebral blood flow measurements of less than 10 mL . 100 g -1 . min -1 . Mean hypercarbic cerebral blood flow increased to 40.1 +/- 20.3 mL . 100 g -1 . min -1 (11.4-94.0 mL . 100 g -1 . min -1 , P < .001). Pairwise analyses found that low hemoglobin levels were associated with higher baseline cerebral blood flow values ( P = .04). Periventricular leukomalacia occurred in 28% (7/25) and was associated with decreased baseline cerebral blood flow values ( P = .05) and a smaller change in cerebral blood flow with hypercarbia ( P = .003). CONCLUSIONS: Structural brain abnormalities are common in these neonates before surgical intervention. Preoperative cerebral blood flow for this cohort was low and drastically reduced in some patients. Low cerebral blood flow values were associated with periventricular leukomalacia. Carbon dioxide reactivity was preserved but might be compromised by some aspects of the cardiac anatomy. The full spectrum of cerebral blood flow measurements with this technique in congenital heart defects and their long-term significance require continued investigation.

    Title Tracking Levels of Psychiatric Distress Associated with the Terrorist Events of September 11, 2001: a Review of the Literature.
    Date February 2004
    Journal Journal of Insurance Medicine (new York, N.y.)
    Excerpt

    BACKGROUND: Early publicized predictions of an onslaught of psychiatric distress following the terrorist events of September 11, 2001, have not materialized, and it remains unlikely at present that the medical and insurance communities will experience a significant increase in psychiatric utilization rates secondary to September 11. A handful of research studies have begun to characterize the psychiatric impact of the events associated with the September 11 terrorist attacks. Information related to the manifestation of psychiatric distress following disasters is of particular interest to the scientific, clinical and disability insurance communities given the ongoing threat of further terrorist attacks. METHODS: A comprehensive literature search was completed to identify articles that address our current understanding of posttraumatic stress disorder (PTSD) and patterns of psychiatric distress that typically follow manmade disasters. To help in conveying such a conceptual framework, we integrated basic research relating to PTSD with epidemiological data relating to past disasters (e.g., the Oklahoma City bombing) and the events of September 11. RESULTS AND CONCLUSIONS: A critical analysis of the September 11 research literature is offered with suggestions for research that would strengthen our understanding of the manifestation of psychiatric distress associated with manmade disasters.

    Title Pediatric Perfusion Imaging Using Pulsed Arterial Spin Labeling.
    Date January 2004
    Journal Journal of Magnetic Resonance Imaging : Jmri
    Excerpt

    PURPOSE: To test the feasibility of pediatric perfusion imaging using a pulsed arterial spin labeling (ASL) technique at 1.5 T. MATERIALS AND METHODS: ASL perfusion imaging was carried out on seven neurologically normal children and five healthy adults. The signal-to-noise ratio (SNR) of the perfusion images along with T1, M(0), arterial transit time, and the temporal fluctuation of the ASL image series were measured and compared between the two age groups. In addition, ASL perfusion magnetic resonance (MR) was performed on three children with neurologic disorder. RESULTS: In the cohort of neurologically normal children, a 70% increase in the SNR of the ASL perfusion images and a 30% increase in the absolute cerebral blood flow compared to the adult data were observed. The measures of ASL SNR, T1, and M(0) were found to decrease linearly with age. Transit time and temporal fluctuation of the ASL perfusion image series were not significantly different between the two age groups. The feasibility of ASL in the diagnosis of pediatric neurologic disease was also illustrated. CONCLUSION: ASL is a promising tool for pediatric perfusion imaging given the unique and reciprocal benefits in terms of safety and image quality.

    Title Incidental Intracranial Hemorrhage After Uncomplicated Birth: Mri Before and After Neonatal Heart Surgery.
    Date June 2003
    Journal Neuroradiology
    Excerpt

    We investigated the prevalence of intracranial hemorrhage (ICH) before and after neonatal heart surgery. We carried out pre- and postoperative MRI looking for brain lesions in 24 full-term newborns with known congenital heart disease. They underwent heart surgery with cardiopulmonary bypass (CPB), usually with deep hypothermic circulatory arrest (DHCA). The first MRI was 1-22 days after birth. There were 21 children born after uncomplicated vaginal delivery and three delivered by cesarean section (CS). ICH was seen in 13 (62%) of the vaginal delivery group but in none of the CS group. We saw subdural bleeding along the inferior surface of the tentorium in 11 (52%) and supratentorially in six (29%) of the 21 children with ICH. Small hemorrhages were present in the choroid plexus in seven (33%), in the parenchyma in one (5%) and in the occipital horn in one (5%). There were 26 foci of bleeding in these 21 patients (1.2 per patient). None was judged by formal neurologic examination to be symptomatic from the hemorrhage. Follow-up MRI after cardiac surgery was obtained in 23 children, showing 37 foci of ICH (1.6 per patient), but all appeared asymptomatic. Postoperatively, ICH had increased in 10 children (43%), was unchanged in seven (30%) and was less extensive in six (26%).

    Title Juvenile Dentatorubral-pallidoluysian Atrophy: New Clinical Features.
    Date June 2002
    Journal Pediatric Neurology
    Excerpt

    Dentatorubral-pallidoluysian atrophy is a rare autosomal-dominant neurodegenerative disorder caused by an expansion of a CAG repeat in the atrophin-1 gene on chromosome 12. Dentatorubral-pallidoluysian atrophy is characterized clinically by prominent anticipation and a wide variety of symptoms that depend on age of onset and number of trinucleotide repeats. The juvenile type of dentatorubral-pallidoluysian atrophy, like Huntington's disease, is most commonly inherited via paternal transmission of the gene and most frequently presents with early-onset progressive myoclonus epilepsy with mental retardation and ataxia. We present six affected individuals with dentatorubral-pallidoluysian atrophy from a black family living in North America. This pedigree includes two severe juvenile-onset cases, one of maternal transmission and the other of paternal transmission. Both cases of juvenile-onset disease presented with autistic features and seizures. Interestingly, cranial magnetic resonance imaging performed on the more affected child revealed only mild cerebellar atrophy. The present family expands the clinical description of juvenile-onset dentatorubral-pallidoluysian atrophy and emphasizes the importance of considering dentatorubral-pallidoluysian atrophy in children with progressive myoclonus epilepsy.

    Title Reversible Subacute Combined Degeneration of the Spinal Cord in a 14-year-old Due to a Strict Vegan Diet.
    Date December 2001
    Journal Clinical Pediatrics
    Title More on the Obesity Problem.
    Date June 1998
    Journal The New England Journal of Medicine
    Title Intravenous Levetiracetam Terminates Refractory Focal Status Epilepticus.
    Date
    Journal Neurocritical Care
    Excerpt

    DISCUSSION: We report a 23-year-old with complex partial status epilepticus, possibly related to underlying stroke-like migraine attacks after radiation therapy syndrome, that was refractory to benzodiazepines and phenytoin but was terminated by administration of intravenous levetiracetam.

    Title Effects of Congenital Heart Disease on Brain Development.
    Date
    Journal Progress in Pediatric Cardiology
    Excerpt

    Brain and heart development occurs simultaneously in the fetus with congenital heart disease. Early morphogenetic programs in each organ share common genetic pathways. Brain development occurs across a more protracted time-course with striking brain growth and activity-dependent formation and refinement of connections in the third trimester. This development is associated with increased metabolic activity and the brain is dependent upon the heart for oxygen and nutrient delivery. Congenital heart disease leads to derangements of fetal blood flow that result in impaired brain growth and development that can be measured with advanced magnetic resonance imaging. Delayed development results in a unique vulnerability to cerebral white matter injury in newborns with congenital heart disease. Delayed brain development and acquired white matter injury may underlay mild but pervasive neurodevelopmental impairment commonly observed in children following neonatal congenital heart surgery.

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