From the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (L.B.K., L.N., N.J.U.), Harvard Medical School, Boston, MA; Department of Pediatrics (B.L.A.), Geisel School of Medicine at Dartmouth, Hanover, NH; Pediatric Hematology/Oncology Massachusetts General Hospital for Children (M.S.H.), Harvard Medical School, Boston; Radiation Oncology (T.Y.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Pediatrics (D.C.B.), UT Southwestern Medical School, Dallas, TX; Department of Medicine (L.N.), Brigham and Women's Hospital, Boston, MA; Institutional Centers for Clinical and Translational Research (D.W.) and Department of Neurology (N.J.U.), Boston Children's Hospital, Harvard Medical School, MA; and Department of Oncology (M.M.H.), St. Jude Children's Research Hospital, Memphis, TN.
Neurology. 2022 Oct 18;99(16):e1755-e1766. doi: 10.1212/WNL.0000000000201014. Epub 2022 Aug 17.
There is insufficient evidence to support stroke prevention guidelines for childhood cancer survivors (CCS) treated with cranial irradiation for CNS tumors or other childhood cancers involving the CNS. We used a systematic consensus-building methodology to develop expert recommendations and define areas of controversy in managing asymptomatic CCS at risk for stroke.
A Delphi process was used to query a multispecialty panel of 45 physicians from the United States/Canada, with expertise in CCS, about their stroke screening and management practices (imaging, referrals, laboratory testing, and medications). Three iterative rounds of anonymous, scenario-based questionnaires, building on panelists' aggregate responses, were used to reach consensus (≥90% agreement), agreement (89%-70% agree), or to understand the rationale for disagreement (<70% agree).
All 45 physicians participated in the first 2 rounds and 44 in the third. Panelists reached consensus on indications for referral to neurology and laboratory screening for modifiable cerebral vascular disease (CVD) risk factors in most scenarios. Panelists agreed that aspirin therapy is not recommended in the scenario of normal neuroimaging (86% agreed). Decisions about aspirin therapy in scenarios with abnormal neuroimaging were deferred to specialists; almost all agreed with not using aspirin for cavernomas with no evidence for previous hemorrhage (93%) and using aspirin for both large vessel CVD (93%) and small vessel CVD with evidence of previous stroke (86%). Clinical decisions that remain controversial (less than 70% agreement) include neuroimaging to screen asymptomatic CCS for CVD, referral to neurology for cavernomas, aspirin use in the setting of cavernomas with previous hemorrhage, or with evidence for small vessel CVD and no previous stroke, and indications for statins. Overall, pediatric neurologists/neuro-oncologists and radiation oncologists were more likely to advocate for screening and interventions.
Despite lack of evidence to guide the management of CCS at risk for stroke, expert recommendations and rationale developed by consensus methodology are helpful to support clinical decision-making.
对于因中枢神经系统肿瘤或其他涉及中枢神经系统的儿童癌症而接受颅部放疗的儿童癌症幸存者（CCS），目前尚无足够的证据支持预防中风的指南。我们使用系统的共识建立方法来制定专家建议，并确定管理无症状中风风险 CCS 的争议领域。
使用德尔菲法对来自美国/加拿大的 45 名多学科专家小组进行调查，这些专家在 CCS 方面具有专长，内容涉及他们的中风筛查和管理实践（影像学、转介、实验室检查和药物治疗）。使用三轮迭代的匿名、基于情景的问卷，基于小组成员的综合反应，以达到共识（≥90%同意）、一致（89%-70%同意）或了解不同意的基本原理（<70%同意）。
所有 45 名医生都参加了前两轮，44 名参加了第三轮。在大多数情况下，小组成员就向神经病学转介和实验室筛查可改变的脑血管疾病（CVD）风险因素的指征达成了共识。小组成员一致认为，在神经影像学正常的情况下，不建议使用阿司匹林治疗（86%的人同意）。在神经影像学异常的情况下，阿司匹林治疗的决定被推迟给专家；几乎所有人都同意，对于没有先前出血证据的海绵状血管瘤，不使用阿司匹林（93%），对于大血管 CVD 和有先前中风证据的小血管 CVD，使用阿司匹林（86%）。仍存在争议的临床决策（少于 70%的人同意）包括为 CVD 筛查无症状 CCS 进行神经影像学检查、为海绵状血管瘤向神经病学转介、在先前出血或有小血管 CVD 证据且无先前中风的情况下使用阿司匹林，以及他汀类药物的适应证。总体而言，儿科神经科医生/神经肿瘤学家和放射肿瘤学家更倾向于主张进行筛查和干预。
尽管缺乏指导 CCS 中风风险管理的证据，但通过共识方法制定的专家建议和理由有助于支持临床决策。
