Ischemic Stroke In Children Research Articles

Clinical, Aetiological and Scannographic Aspects of Ischaemic Stroke in Children Aged 1 Month to 15 years at the Ignace Deen National Hospital

Clinical, Aetiological and Scannographic Aspects of Ischaemic Stroke in Children Aged 1 Month to 15 years at the Ignace Deen National Hospital

Classification of childhood arterial ischemic stroke

The etiology of childhood arterial ischemic stroke is complex, and identifying the underlying cause is crucial for optimizing treatment and preventing recurrence. Currently, the classification methods for childhood arterial ischemic stroke are largely based on data from international studies, but a unified consensus have not yet been reached. This paper reviews the existing classification methods and their subtype definitions, and points out some doubts and ambiguities. On this basisi, combined with the data collected by Beijing Children's Hospital on Chinese children with arterial ischemic stroke, a new classification method (COIST) was proposed according to the etiology and pathogenesis, namely: inflammation (I), abnormal vascular structure (S), thrombophilia (T), heart disease (C), other identifiable causes (O), and uncertain causes; and various subtypes are listed. It is hoped that this new classification method can attract the attention and discussion of domestic colleagues, with the aim of further refinement, in order to help clinicians better understand and quickly identify the etiologies of childhood ischemic stroke.

The association between lipoprotein(a) levels and ischemic stroke in children: A case-control study.

Pediatric arterial ischemic stroke (AIS) is a rare disorder, associated with severe morbidity. In adults, elevated lipoprotein(a) (Lp(a)), a cholesterol-like particle, is associated with ischemic stroke. However, data on Lp(a) and pediatric AIS are scarce. Therefore, we evaluated the association between Lp(a) levels and pediatric AIS. We included children who suffered an AIS (≤18years) and were treated in a tertiary center in Amsterdam, the Netherlands. Two groups of children with AIS were identified: (i) neonates and (ii) children older than 29days. A case-control study was performed, with the latter group as cases and children without AIS as control group. Cases and controls were matched for age of Lp(a) testing and sex. Multivariable logistic regression models were used. Thirteen neonates and 23 children were included. Mean (SD) age of AIS was 0.6 (2.0) days and 9.2 (6.3) years, respectively. Children with AIS were matched to 62 controls. Lp(a) levels of greater than 50mg/dL were more prevalent in children with AIS compared to controls (21.7% vs. 3.2%, p=.02). A significant association was found between Lp(a) and AIS (odds ratio [OR] adjusted for age at Lp(a) testing, body mass index [BMI], measurement assay: 1.36 per 10mg/dL increase of Lp(a), 95% confidence interval [CI]: 1.02-1.82, p=.041). In this study, Lp(a) levels were positively associated with the risk of AIS in children, suggesting that high Lp(a) might be an independent risk factor for AIS. This underlines the importance of Lp(a) measurement in children with AIS.

Lipoprotein (a) and cerebrovascular disease.

The role of lipoprotein (a) [Lp(a)] in cerebrovascular disease is a topic of importance. In this narrative review, pertinent studies have been leveraged to comprehensively examine this relationship from diverse perspectives.Lp(a) shares structural traits with low-density lipoprotein cholesterol. Lp(a) is synthesized by hepatocytes, and its plasma levels are genetically determined by the LPA gene, which produces apolipoprotein (a).Numerous epidemiological studies have confirmed the positive correlation between elevated serum Lp(a) levels and the occurrence or recurrence of cerebrovascular events, especially ischemic strokes, in adults. It should be noted that the correlation strength varies among studies and is marginal in Mendelian randomization studies.Regarding pediatric patients, screening is currently limited to those with a relevant medical history. Lp(a) seems to play a significant role in the pathogenesis of arterial ischemic stroke in children because environmental thrombotic and atherogenic factors are generally not present.Phase 3 trials of novel Lp(a) targeting agents, such as pelacarsen and olpasiran, are anticipated to demonstrate their efficacy in reducing the incidence of stroke. Given the richness of the literature, new guidelines regarding Lp(a) screening and management in targeted populations are warranted to provide more effective primary and secondary prevention.

PROFILE OF ISCHEMIC STROKE IN CHILDREN: EXPERIENCE OF THE UNIVERSITY HOSPITAL CENTER OF OUJDA

Ischemic strokes (IS) in children are rare but critical, presenting unique challenges due to age-specific factors. Defined by the American Heart Association as episodes of neurological dysfunction caused by focal infarctions, IS can lead to severe outcomes if not promptly addressed. Despite their rarity, pediatric IS requires careful management, complicated by the lack of validated treatment data for children. This study from the University Hospital Center of Oujda examines the management of acute IS in children, analyzing epidemiological aspects, clinical presentations, and therapeutic approaches. Results : 1. Population: 29 children, average age 3.5 years, slight male predominance (sex ratio: 1.2). 2. Consultation Delay: 14% were seen within 24 hours 50% after 7 days. 3. Symptoms: Motor deficit was the most common (82.7%). 4. Diagnostics: CT confirmed IS in 85% of cases MRI established etiological diagnosis in 51.8%, showing sylvian artery involvement in all patients. 5. Etiologies: Embolic cardiopathies (31.03%), vasculopathies (20.06%), and others such as hypertension and neurofibromatosis. 6. Treatments: Symptomatic management, motor physiotherapy, aspirin, and heparin. 7. Outcomes: 74% had complete regression of motor deficits, 20.6% had partial regression, and there were two deaths due to cardiogenic shock. The study underscores the need for a multidisciplinary approach to effectively manage IS in children and improve clinical outcomes.

4 The Association Between Pro-Inflammatory Cytokines and C-Reactive Protein and the Cognitive and Neurological Outcome in Stroke Survivors: A Systematic Review

Objective:Childhood ischemic and hemorrhagic stroke is often associated with neuropsychological and cognitive deficits. Stroke induces an inflammatory response in the central and peripheral nervous systems. High levels of inflammatory markers in the plasma have been associated with poorer cognitive outcomes. The role of inflammation in neurological prognosis of stroke has been studied previously; however, there is a limited understanding of the association between inflammatory markers and neuropsychological outcome post-stroke. The present review examined the existing literature on the association between inflammatory markers and post-stroke functioning.Participants and Methods:Data bases (PsycINFO, PubMed, Web of Science, and Ovid) were reviewed in October 2020. Articles were restricted to English-language literature. Articles were included regardless of recruitment setting, number of strokes, mechanism of stroke, timing of blood collection and outcome assessment. The articles focused on patients with stroke (between the ages of 0 to 95), measured post-stroke outcome by neurological and cognitive outcome measures (i.e., it included findings on any aspect of cognition such as memory, information processing, or attention), and on pro-inflammatory cytokines and c-reactive proteins as measures of inflammation. The systematic literature search retrieved 954 articles to review against inclusion criteria. Descriptive statistics were performed using IBM SPSS 27.0 Statistics Software.Results:A total of 18 articles were included in this review. The population age ranged from 21 to 95, and, when reported (n=17), mean participant age was 66.31. Among stroke patient populations, ischemic stroke was most researched (n=15). The most widely investigated biomarkers were CRP (n=9), IL-6 (n=8), TNF- a (n=7), IL-1 b (n=5), and IL-10 (n=5). The time of initial blood collection ranged from on admission to within 3 months poststroke. Equal number of studies used both neurological and cognitive tests (n=7), or only neurological (n=7), 2 studies only used cognitive tests, and one study used all three types of measures. The most commonly used cognitive test was the Mini Mental State Examination, MMSE (n=7). The next commonly used cognitive test was the Montreal Cognitive Assessment (MoCA), (n=4). Only two studies used a comprehensive neuropsychological battery.Conclusions:There is a lack of research into diverse stroke populations. All the studies examined the association between inflammatory markers and the post-stroke outcomes in adult populations and mostly in patients with ischemic stroke. The lack of research on pediatric and young adult stroke represents a significant gap in understanding predictors of neurological and cognitive outcomes. Further, the review revealed a lack of comprehensive neurocognitive assessment post stroke, with most studies measuring neuropsychological outcome using brief cognitive instruments. Our findings highlight a critical need for addressing the above gaps to help elucidate the role of inflammatory markers in the neuropsychological prognosis of stroke in younger populations.

Ischemic Stroke in Childhood; Case Report

Pediatric stroke is a severe pathology, with lasting devastating consequences on motor and cognitive abilities, school and social integration, and overall life projects. Awareness of initial symptoms, implementation of pediatric stroke code protocols using MRI first and only and adapted management in the acute phase, personalized recanalization treatment strategies and multidisciplinary rehabilitation programs with specific goal-focused actions are key elements to improve pediatric AIS management and outcomes. We report here the case of a 1-year-old child with Avci with optimal management.

A quantitative EEG index for the recognition of arterial ischemic stroke in children

ObjectiveTo describe and assess performance of the Correlate Of Injury to the Nervous system (COIN) index, a quantitative electroencephalography (EEG) metric designed to identify areas of cerebral dysfunction concerning for stroke. MethodsCase-control study comparing continuous EEG data from children with acute ischemic stroke to children without stroke, with or without encephalopathy. COIN is calculated continuously and compares EEG power between cerebral hemispheres. Stroke relative infarct volume (RIV) was calculated from quantitative neuroimaging analysis. Significance was determined using a two-sample t-test. Sensitivity, specificity, and accuracy were measured using logistic regression. ResultsAverage COIN values were −34.7 in the stroke cohort compared to −9.5 in controls without encephalopathy (p = 0.003) and −10.5 in controls with encephalopathy (p = 0.006). The optimal COIN cutoff to discriminate stroke from controls was −15 in non-encephalopathic and −18 in encephalopathic controls with >92% accuracy in strokes with RIV > 5%. A COIN cutoff of −20 allowed discrimination between strokes with <5% and >5% RIV (p = 0.027). ConclusionsWe demonstrate that COIN can identify children with acute ischemic stroke. SignificanceCOIN may be a valuable tool for stroke identification in children. Additional studies are needed to determine utility as a monitoring technique for children at risk for stroke.

Endovascular treatment of acute ischemic stroke in childhood: A comprehensive literature review based on the experience of a single center

Acute ischemic stroke (AIS) in childhood is a relatively rare but significant condition that can result in long-term disabilities. There is a lack of standardized strategies for diagnosing and treating pediatric AIS due to limited evidence-based data on thrombolytic and endovascular treatments in children. This comprehensive literature review focuses on the experience of a single center in Italy and aims to highlight the main peculiarities of endovascular treatment (EVT) for AIS in childhood.The review covers the diagnostic workup, the endovascular procedures, and the need for a specific thrombectomy program for pediatric AIS.The review discusses the indications and considerations for thrombectomy in children, including the risk of complications and the challenges of extrapolating results from adult studies. The diagnostic protocols for pediatric AIS are also discussed, emphasizing the use of MRI to avoid X-ray and contrast medium exposure in children.The combination of intravenous thrombolysis and mechanical thrombectomy has been examined, considering the differences between pediatric and adult thrombi. Technical considerations related to the size of pediatric patients are addressed, including the use of large bore catheters and potential concerns with access points.The organization of a thrombectomy program for pediatric AIS is discussed, emphasizing the need for specialized facilities and expertise.Although evidence for EVT in the pediatric population is based on case series, the importance of specialized centers and the lack of validated guidelines are evident.

Moyamoya Angiopathy: An Underdiagnosed Cause of Ischemic Stroke in a Tunisian Pediatric Cohort

BackgroundMoyamoya angiopathy is a rare cerebral vasculopathy and an underdiagnosed cause of arterial ischemic stroke in children. We aim to report the clinical and radiological presentations in a Tunisian pediatric cohort. MethodsWe identified moyamoya angiopathy in pediatric patients managed at the Child Neurology Department of Hedi Chaker Sfax University Hospital between 2008 and 2020 and reviewed their clinical and radiological data as well as their evolutionary profile. ResultsWe collected 14 patients with median age 40.6 months and a female predominance (sex ratio of 0.75). An arterial ischemic stroke (AIS) revealed the disease in all patients, with the major symptom being a motor deficit. Symptoms related to a transient ischemic attack before the diagnostic consultation were reported in four patients. Carotid territory was, clinically and radiologically, the most frequently involved. Brain magnetic resonance imaging with angiography was performed in 12 patients confirming the diagnosis by revealing the development of collateral vessels. All the investigations concluded to moyamoya disease in 57.2% and moyamoya syndrome in 42.8%. The latter was related to Down syndrome in five patients and neurofibromatosis type 1 in one patient. With a mean follow-up of 2.35 years, two patients had at least two more AISs during the first two years following diagnosis and 42.8% of patients were diagnosed with vascular or poststroke epilepsy. Full recovery was noted in 14.3% of cases. ConclusionsMoyamoya angiopathy in children is a serious condition that needs to be recognized due to the high risk of recurrent ischemic strokes.

Possibilities of magnetic resonance imaging in the diagnosis of ischemic stroke in children

Research objective. To study the features of visualization of ischemic stroke in children at the early stages of the formation of the pathological process using magnetic resonance imaging.Material and methods. The results of magnetic resonance imaging (MRI) examination of 34 children with clinical manifestations of ischemic stroke (IS) were analyzed. The analyzed group included patients aged from the 29th day of life to 18 years who had focal changes in the brain substance (BS) during an MRI examination within a period of not more than 48 hours from the onset of neurological symptoms.Results. MRI makes it possible to establish in the early stages of the development of the pathological process the ischemic lesion of the BS in 100% of cases, as well as to evaluate the time indicators of the occurrence of focal changes, based on the analysis and comparison of pulsed MRI sequences, which allow characterizing the severity of the process.Discussion. The analysis of data obtained confirms the results of studies described earlier in the foreign and domestic literature. Moreover, there is a difference in the MR signal specifications from the IS focus during the first 6 hours upon occurrence of the neurological symptoms.Conclusions/findings. The MRI studies in children are important and necessary to determine the IS formation, evaluate the onset and dynamics of the pathological process that contribute to the timely detection of focal changes in the brain structures at the early stages.

Language and Cognitive Outcomes Following Ischemic Stroke in Children With Monolingual and Bilingual Exposure.

Aim: Although many children who experience ischemic stroke come from bilingual backgrounds, it is unclear whether bilingual exposure affects poststroke development. Our research evaluates bilingual and monolingual exposure on linguistic/cognitive development poststroke across 3 stroke-onset groups. Method: An institutional stroke registry and medical charts were used to gather data on 237 children across 3 stroke-onset groups: neonatal, <28 days; first-year, 28 days to 12 months; and childhood, 13 months to 18 years. The Pediatric Stroke Outcome Measure (PSOM), administered several times poststroke, was used to evaluate cognition and linguistic development. Results: Similar cognitive outcomes were observed across language groups. However, an interaction effect with stroke-onset group was observed, with monolinguals in the first-year group having worse productive language outcomes as compared to bilinguals. Interpretation: Overall, no detrimental effects of bilingualism were found on children's poststroke cognition and linguistic development. Our study suggests that a bilingual environment may facilitate language development in children poststroke.

Thrombectomy for a basilar artery occlusion in a 2-year-old child: A focus on anatomical and technical aspects.

Endovascular treatment (EVT) for large vessel, acute ischemic stroke in children remains a subject of debate, with evidence for its benefits derived from case series and individual case reports. At present, guidelines are cautious in recommending EVT for children under 5 years of age, mainly due to a lack of data and incomplete cerebral and femoral vessel development. However, based on the small number of cases reported in the literature, EVT appears to be safe and effective for pediatric use and arterial diameters can accommodate currently available devices. Available evidence shows that in patients with a normal arterial development, a 6-Fr femoral approach can be safely used by 2 years of age. We describe the case of a 2-year-old child who benefited from late-window EVT for a basilar occlusion. The procedure was safely performed using a 6-Fr femoral introducer, a 6-Fr guide catheter, and a 5-Fr aspiration catheter. We discuss also normal cerebral and femoral vessel development, providing descriptive tables of compatibility between femoral and cerebral arterial diameters by age groups and currently available endovascular devices.

Pediatric stroke: a review

Background &amp; Objectives:&#x0D; Pediatric stroke is a focal neurological deficit lasting more than 24 hours because of stenosis, occlusion or rupture of cerebral blood vessels. Variable etiological factors are involved ranging from cardiac, haematological, infectious, immune mediated to arteriopathies which is emerging as most important cause of arterial ischemic stroke in children. In this review article we will discuss paediatric stroke with its epidemiology, etiological factors in particular arteriopathies, diagnostic modalities, management protocols and outcome.&#x0D; Methods: &#x0D; We searched stroke in Pubmed and found 15315 articles, narrowed down to stroke in children (3814) and selected 45 articles for review.&#x0D; Review:&#x0D; Stroke in children is defined as a focal neurological deficit that persists for more than 24 hours and is caused by stenosis, occlusion or rupture of cerebral blood vessels. Stroke may be arterial, venous or because of occlusion of venous sinuses. Arterial strokes may be ischemic, haemorrhagic or ischemic-haemorrhagic.&#x0D; About half of strokes in children are of arterial ischemic strokes in contrast to adults where about 80-85% strokes are of arterial ischemic strokes. Stroke in children is comparable to brain tumors and is one of top ten common causes of death in children.&#x0D; Arterial ischemic stroke in children has significant risk of mortality and morbidity leading to functional disability of patient along with financial burden over family and society. In one study it was estimated that 10-25% of children with stroke die, 25% have recurrence and about 66% of children have neurological deficit after recovery from acute illness or have future epilepsy, behaviour disorder or learning disabilities.&#x0D; Early recognition and prompt treatment of paediatric stroke can reduce mortality, morbidity and in return can reduce both social and financial burden over society.&#x0D; Conclusion:&#x0D; In this review article we will discuss paediatric strokes, epidemiology, risk factors, differential diagnosis, investigations, management protocols, preventive measures and outcome.

Case Report: Successful Anterior Circulation Thrombectomy After 24 Hours in an Adolescent

BackgroundArterial ischemic stroke in children comes with the potential for morbidity and mortality and can result in high cost of care and decreased quality of life among survivors. Children with arterial ischemic stroke are increasingly being treated with mechanical thrombectomy, but little is known about the risks and benefits 24 hours after a patient’s last known well (LKW) time. MethodsA 16-year-old female presented with acute onset of dysarthria and right hemiparesis with LKW time 22 hours prior. Pediatric National Institutes of Health Stroke Scale score was 12. Magnetic resonance imaging showed diffusion restriction and T2 hyperintensity primarily in the left basal ganglia. Magnetic resonance angiography revealed left M1 occlusion. Arterial spin labeling showed a large apparent perfusion deficit. She underwent thrombectomy with TICI3 recanalization 29.5 hours after LKW time. ResultsAt 2-month follow-up, her examination showed moderate right-hand weakness and mild diminished sensation of the right arm. ConclusionsAdult thrombectomy trials include patients up to 24 hours from their LKW time and suggest that some patients maintain a favorable perfusion profile for over 24 hours. Without intervention many go on to experience infarct expansion. The persistence of a favorable perfusion profile likely reflects robust collateral circulation. We hypothesized our patient was relying on collateral circulation to maintain the noninfarcted areas of her left middle cerebral artery territory. Owing to concern for eventual collateral failure, thrombectomy outside of the 24-hour window was performed. This case serves as a call to action to better understand the impact of collateral circulation on cerebral perfusion in children with large vessel occlusions and delineate which children may benefit from thrombectomy in a delayed time window.

Visuospatial processing skills following unilateral arterial ischemic stroke in childhood.

Due to the rare occurrence of childhood stroke, its impact on later cognitive functioning remains unclear. While it is often assumed that children recover better than adults, recent studies suggest that childhood stroke can negatively affect a wide range of cognitive domains, such as attention, language, and processing speed, among others. We examined the effect of unilateral stroke on children's visuoconstructive ability and visual memory. Seventeen children with left- or right-sided arterial ischemic stroke were tested using subtests of the Hamburg-Wechsler Intelligenztest für Kinder and the Rey-Osterrieth Complex Figure(ROCF). The ROCF was evaluated both quantitatively and qualitatively with the help of two separate scoring methods. We found that lesion laterality and age at stroke impacted childhood stroke patients' ability to recall certain elements of the figure. Regarding lesion laterality, left-sided stroke patients had more difficulties recalling internal details than right-sided stroke patients. In terms of age, patients with stroke onset before the age of 5 years remembered fewer structural elements than patients with stroke onset after the age of 5 years did. Moreover, the qualitative scoring method better differentiated between individuals and between groups than the more commonly used quantitative method. The results of this study not only highlight the importance of a qualitative assessment of the ROCF but could also aid clinicians in testing stroke patients more accurately and tailoring subsequent therapy to the patient's individual needs.

Abstract 12624: Smooth Muscle Cell Alpha-Actin Pathogenic Variant That Predisposes to Moyamoya-Like Cerebrovascular Disease Alters Smooth Muscle Cell Phenotype and Metabolism

Pathogenic variants in ACTA2 , which encodes smooth muscle α-actin ( α-SMA ), predispose to thoracic aortic disease. ACTA2 variants disrupting arginine 179 ( R179 ) also predispose to moyamoya-like ( MMD ) cerebrovascular disease, characterized by occlusion of the distal internal carotid arteries by neointimal cells that stain positive for smooth muscle cell ( SMC ) markers. Mice with conditional knockin of the Acta2 R179C mutation specifically in SMCs were generated ( Acta2 SMC-R179C/+ ). RNA sequencing and 2D gel electrophoresis confirmed presence of the mutation. Acta2 SMC-R179C/+ SMCs are not fully differentiated, maintain stem cell marker expression, and proliferate and migrate faster than wildtype ( WT ) SMCs. Seahorse analyses show increased glycolysis and decreased oxidative respiration ( OXPHOS ) in Acta2 SMC-R179C/+ SMCs, which have reduced mitochondrial mass and complex I activity, suggestive of deficient electron transport chain activity. Nicotinamide riboside ( NR ) augments complex I activity to boost OXPHOS without altering mitochondrial mass in Acta2 SMC-R179C/+ SMCs. NR also increases differentiation and reduces migration in Acta2 SMC-R179C/+ SMCs. With left carotid artery ligation ( LCAL ), 33% of Acta2 SMC-R179C/+ mice die within 4 days due to strokes, and 100% of surviving Acta2 SMC-R179C/+ mice at postop day 21 have occlusive lesions in the injured artery (8% in WT mice) containing α-SMA+ cells and fibrin deposits. Acta2 SMC-R179C/+ mice also exhibit markedly increased left carotid artery diameter and increased number, diameter, and tortuosity of left-sided collateral vessels compared to WT mice at postop day 21. NR treatment reduces deaths of LCAL-injured Acta2 SMC-R179C/+ mice to 8%, completely resolves occlusive lesion formation in 50% of mutant mice, and attenuates collateral formation and remodeling. These data suggest that immature SMCs with the ACTA2 R179C variant proliferate and migrate into the neointima causing MMD-like occlusive disease. Shifting metabolism to OXPHOS with NR drives differentiation and reduces migration, which diminishes arterial lesions in Acta2 SMC-R179C/+ mice. These data support the use of NR as a therapeutic to prevent MMD-like lesions and ischemic strokes in children with ACTA2 p.R179 variants.

A Review of Patient Population Requiring Novel Critical Care Pediatric Transport Stroke Clinical Practice Guideline: A Three Year Single Site Analysis

<h3>Objectives</h3> 1. To identify patients transported by a pediatric critical care transport team for suspected or confirmed acute ischemic stroke who met qualifications of stroke activation. 2. Retrospective calculation of Large Vessel Occlusion (LVO) score of patients meeting criteria for transport stroke protocol activation. <h3>Background</h3> There are many pre-hospital Emergency Medical Service (EMS) and transport protocols as well as Large Vessel Occlusion (LVO) screening tools that exist for rapid transport of an adult patient with suspected or confirmed acute ischemic stroke to the nearest stroke center for rapid diagnosis. These screening algorithms aid in identifying adult patients who benefit from transport directly to an adult comprehensive stroke center. No data has been published on pre-hospital and transport evaluation and treatment algorithms for suspected acute ischemic stroke in children. Our institution created and implemented a transport stroke clinical practice guideline specific to pediatric stroke to improve recognition and management of patients with suspected stroke by our interfacility critical care transport team. <h3>Methods</h3> A retrospective chart review of patients transported by our institution's critical care transport teams from September 1, 2016 and March 1, 2020 meeting institutional criteria for stroke activation. LVO scores were calculated retrospectively based on clinical information documented within the transport medical record. <h3>Results</h3> Of the 17,244 patients transported by our institution's critical care transport, 17 patients met criteria during the defined study period. Average/median age was 173 months, or 14.4 years old. 4 of 17 had radiographic evidence of thrombus with 3 of those 4 underwent definitive management with tPA or endovascular retrieval. Hemiplegia is the most common presenting symptom with confirmed stroke in this population. The confirmed stroke group scored significantly lower on Glasgow Coma Scale (median of 8 vs. 15, p = 0.014), significantly higher on the LAMS LVO score (median 4 vs. 0, p = 0.021) and significantly higher on the RACE LVO (median 4 vs. 0, p = 0.036). <h3>Conclusion</h3> Acute ischemic stroke is a rare occurrence in pediatric patients. A standardized clinical practice guideline for transport can facilitate early recognition, appropriate management, and transport to a pediatric specific stroke care for timely diagnosis and intervention. LVO scores designed for adult population have not been validated for use in pediatric patients for suspected stroke, but may be useful in triage of pediatric patients with stroke-like symptoms to a stroke center with specialized care in pediatric stroke.

Etiological Risk Factors Profile of Arterial Ischemic Stroke in Children at A Tertiary Care Children's Hospital

Objective: To determine the etiological risk factors of arterial ischemic stroke (AIS) in children. Study Design: An observational cohort study. Place and Duration of the Study: Neurology department of “The Children's Hospital and Institute of Child Health, Multan”, from January 2020 to December 2020. Methods: Children in the age group from one month of age to 12 years with a history of acute onset of focal neurological deficit of upper motor nerve and positive findings on neuroimaging were included in the study. The workup included baseline lab testing, neuroimaging, cardiac evaluation, and cerebro-spinal fluid (CSF) laboratory testing. We used predesigned proforma for recording the patient's details and the possible etiology of the stroke. Results: In a total of 84 children, 28 (33.3%) were male and 56 (66.7%) were female. Age ranged from 4 months to 11 years with a mean age of 3.4±2.2 years. Etiological risk factors identified in 62 (73.8%) patients and were remained undetermined in 22 (26.2%) patients. The risk factors identified were central nervous system infection arteriopathy in 22 (26.2%), iron deficiency anemia 20 (23.8%), cardiac disorders 11 (13.1%), moyamoya disease in 5 (6.0%), and mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes in 4 (4.8%) patients. Practical Implications: It is essential to know the etiology of risk factors responsible for AIS as the management and prognosis are directly influenced by them. Conclusion: Infection-associated arteriopathy was the most common etiological risk factor for arterial ischemic stroke in our study population. Keywords: Anemia, arterial ischemic stroke, central nervous system, moamoya

Age-specific trends in intravenous thrombolysis and mechanical thrombectomy utilization in acute ischemic stroke in children under age 18.

To evaluate current trends in the utilization of intravenous thrombolysis (IV-tPA) and mechanical thrombectomy (MT) in acute ischemic stroke (AIS) in various age groups of children in the United States. We conducted a serial cross-sectional study using primary AIS admissions in children ⩽ 17 years (weighted n = 2807) contained in the 2009-2019 KIDS Inpatient Database. Age-specific utilization frequency of IV-tPA and MT were calculated. Multivariable-adjusted models were used to evaluate demographic predictors of treatment. From 2009 to 2019, there were 2807 AIS admissions in children in the KID of which 55.9% were in boys and 29.9% were 15-17 years old.128 (4.6%) received IV-tPA. IV-tPA utilization differed by age (5-9 years: 3.1%, 15-17 years 8.1% p value < 0.001). Overall MT usage was 2.3% and this also varied by age (1-4 years: 0.9% and 15-17years 4.0%, p value = 0.006). IV-tPA utilization almost tripled across the study period (2.5% 2009 to 6.5% in 2019, p value = 0.001) while MT use more than doubled over time (1.2% in 2009 and 3.0% in 2019, p value = 0.048). Increased IV-tPA utilization was seen primarily in children 10-14 years (0.8% in 2009 to 7.2% 2019, p value = 0.005) and 15-17 years (5.4% in 2009 to 10.4% in 2019, p value = 0.045). Utilization in younger age groups remained unchanged over time. MT usage was very variable across various age groups over time. IV-tPA and MT utilization increased over time in nonchildren's hospitals (both p values < 0.05) but usage in designated children's hospitals did not change significantly over time. In multivariable models, there was no significant difference in odds of IV-tPA and MT use by sex, race or insurance status. IV-tPA and MT utilization in pediatric AIS increased in the United States over the past decade mainly in older children 10-17 years. Utilization increased mainly in patients hospitalized in nonchildren's hospitals. Usage in children's hospitals did not change significantly over time.