Pediatric Arterial Ischemic Stroke Research Articles

Infection and Pediatric Arterial Ischemic Stroke Presumably Related to Focal Cerebral Arteriopathy: Data From the COVID-19 Pandemic.

Infection may trigger pediatric arterial ischemic stroke (PAIS), notably when related to focal cerebral arteriopathy. Community- and individual-level nonpharmaceutical interventions during the COVID-19 pandemic resulted in a major decrease in pediatric viral infections. We explored the consequences on the incidence of PAIS. Using national public health databases, we identified children hospitalized between 2015 and 2022 with PAIS. Using an age proxy (29 days to 7 years) and excluding patients with cardiac and hematologic conditions, we focused on children with PAIS presumably related to focal cerebral arteriopathy or with no definite cause. Considering the delay between infection and PAIS occurrence, we compared a prepandemic reference period, a period with nonpharmaceutical interventions, and a post-nonpharmaceutical intervention period. Interrupted time-series analyses of the monthly incidence of PAIS in this group showed a significant decrease in the nonpharmaceutical intervention period compared with the prepandemic period: -33.5% (95% CI, -55.2%, -1.3%); P=0.043. These data support the association between infection and PAIS presumably related to focal cerebral arteriopathy.

Pediatric arterial ischemic stroke; Risk factors, clinical presentation and short-term outcome of patients presenting at a tertiary care hospital.

Objective: To determine the risk factors, clinical presentation and short term outcome in children presenting with arterial ischemic stroke at a tertiary care hospital. Study Design: Prospective Observational study. Setting: Medical Units of National Institute of Child Health, Karachi, Pakistan. Period: November 2022 October 2023. Methods: Children of either gender aged between 1 month to 12 years and admitted with the diagnosis of pediatric arterial ischemic stroke during the study duration were analyzed. Detailed medical and neurological examinations were performed. Routine work up and laboratory investigations were done. Modified Rankin Scale (MRS) scores at the time of enrollment, discharge and after 3 month follow-up were recorded. Results: In a total of 35 children, 21 (60.0%) were boys the mean age was 6.89±3.63 years. The most frequent presenting clinical features were focal neurological deficits noted in 29 (82.9%) children whereas fever, and fits were reported in 26 (74.3%), and 22 (62.9%) children, respectively. Right hemiplegia was observed in 15 (42.9%) children. Stroke was secondary to moyamoya 8 (22.9%), infections in 6 (17.1%) children. Mortality was reported among 3 (8.6%) children while 3 others lost during the follow ups. Comparison of mean mRS scores at the time of admission, discharge and after 3 months showed significant reduction (p<0.001). Conclusion: Focal neurological deficits were the predominant clinical features, with a significant incidence of associated fever and seizures. Moyamoya and infections emerged as primary causative factors. Despite a mortality rate of 8.6%, there was an overall improvement in outcomes, as evidenced by a significant reduction in Modified Rankin Scale scores at admission, discharge, and after three months.

Mechanical Thrombectomy for Pediatric Arterial Ischemic Stroke from Acute M2 Occlusion.

Pediatric large-vessel occlusion has a poor natural history. Recent retrospective studies have demonstrated the potential benefits, feasibility, and safety profile of mechanical thrombectomy in children. However, the role of thrombectomy in pediatric M2 occlusions remains uncertain. In this clinical report, we present a multicenter series of 6 pediatric patients with acute M2 occlusion (female = 1, male = 5; age range, 0.9-16.0 years, mean = 9.2). All 6 patients having undergone thrombectomy had excellent clinical outcomes (pediatric mRS = 0-1) at 3 months and final available follow-up (median, 12 months; range, 3-72 months). Factors relevant to treatment decision-making in pediatric M2 occlusions are discussed, including the important role of multidisciplinary team discussions during acute management.

Development of Collateral Vessels after Anterior Circulation Large Vessel Occlusion in Pediatric Arterial Ischemic Stroke Relates to Stroke Etiology: A Longitudinal Study.

The characteristics of large vessel occlusion (LVO) in the acute phase of pediatric arterial ischemic stroke and their natural history according to stroke etiology are poorly explored. This studied aimed at describing the prevalence and the radiological evolution of LVO in pediatric AIS. This single-center retrospective study included consecutive non-neonate children with acute arterial ischemic stroke, intracranial proximal LVO in the anterior circulation (MCA, anterior cerebral artery, and/or ICA), and clinical and imaging follow-up for at least 18 months, during a 9-year period. Intracranial LVO was observed in 24.8% of patients with anterior circulation arterial ischemic stroke and adequate follow-up (n = 26/105), with a median age of 4.2 years (IQR 0.8-9), sex ratio 1.16. The main stroke etiology associated with LVO was unilateral focal cerebral arteriopathy (n = 12, 46%). During follow-up, a specific pattern of unilateral poststroke anastomotic bridge was observed in 8/26 patients, with the poststroke development of nonperforating collaterals forming a bridge in bypass of the LVO site with visible distal flow, within a median delay of 11 months. The development of unilateral poststroke anastomotic bridge was only observed in patients with unilateral focal cerebral arteriopathy. No patient with this pattern experienced stroke recurrence or further progressive vascular modifications. After stroke, the development of unilateral poststroke anastomotic bridge is specifically observed in children with focal cerebral arteriopathy, appearing in the first year after stroke. This clinical-radiologic pattern was not associated with stroke recurrence or arterial worsening, differentiating it from progressive intracranial arteriopathy, such as Moyamoya angiopathy.

Abstract TP96: Association Between Infarct Volume, Neighborhood-Level Deprivation, and Outcomes in Pediatric Stroke

Introduction: Recent studies in adults have reported an association between neighborhood-level deprivation, infarct volume and outcome. However, this is yet to be investigated in pediatric arterial ischemic stroke (AIS). Our study aimed to assess the relationship between neighborhood-level deprivation, infarct volume, and neurological outcome in children diagnosed with AIS. Methods: We conducted a study of a consecutive cohort of children aged > 28 days-18 years and diagnosed with AIS between 2004 and 2019 at a comprehensive stroke center. Patient demographic, clinical characteristics and neighborhood material deprivation data including household income, parental educational attainment, the proportion of single-parent families, and housing quality were collected. Lesion volumes were determined by conducting semi-automatic segmentation of diffusion-weighted MRI brain scans at stroke presentation. Neurological outcome was assessed using the Pediatric Stroke Outcome Measure Severity Classification System wherein poor outcome was defined as moderate-to-severe deficit at 18 months post-stroke. Wilcoxon rank sum test was conducted. Results: Seventy-two patients were included in the study (62% male, median age of stroke onset 6.1 years [IQR 1.0-12.7]). 39% of patients were White, 72% lived in an urban region, and 64% in highly deprived neighborhoods. 70% of patients arrived within 6 hours from onset of stroke. Cardiac disease and other risk factors including infection and head trauma represented the most common risk factor. 55% presented with moderate stroke severity (as per the PedNIHSS). Median lesion volume was 14 cm 3 (IQR 2-51) and a mean infarct volume of 3% was reported. Race, rurality, and neighborhood-level material deprivation were not significantly associated with either percent infarct volume or neurological outcome; however, percent infarct volume was significantly associated with neurological outcome at 18 months post-stroke (W = 79, p = 0.025). Conclusion: Our study findings confirm the relationship between infarct volume and pediatric AIS outcomes. Future multi-center studies are warranted to further understand the interplay between material deprivation, infarct volume, and post-AIS neurological outcomes in children.

Abstract TMP9: Flair Vascular Hyperintensities as Imaging Biomarker in Pediatric Arterial Ischemic Stroke

Background: FLAIR vascular hyperintensities (FVH) are high signal intensities on MRI resulting from sluggish flow through collateral vessels in patients with acute arterial ischemic stroke (AIS). Data from adults suggest they may be a marker of penumbra. In this first investigation of FVH in children, I measured the prevalence and identified risk factors for FVH in pediatric patients with AIS. Methods: Retrospective review of patients prospectively enrolled in the CHOP Stroke Registry from 2006-2022. Patients with AIS age 29 days to 18 years with MRI within 72 hours of last known well were included. Children with pre-existing strokes, vasculopathy, prior brain surgery, radiation, or vascular compression from intracranial mass were excluded. MRIs were assessed by a blinded reviewer and adjudicated by a neuroradiologist for presence of LVO, FVH score, modASPECTS score, and AIS lesion volume. Clinical data were abstracted from chart review. Independent sample t-test compared FVH score and LVO presence. Pearson's correlation assessed the relationship between total FVH score and age, stroke size, modASPECTS, and pedNIHSS scores. Multivariable logistic regression evaluated predictors of significant FVH (score >= 3) and included time to MRI, large vessel occlusion, modASPECTS, pedNIHSS, stroke size, and age as independent variables. Results: 83 patients met inclusion criteria. Median time to MRI was 26 hours (95% CI 26-33). FVH were present in 45 patients (54%). Mean FVH score was higher in patients with LVO (5.22 ± 0.64) compared to those without (1.21 ± 0.24; p = 0.00). There was a positive correlation between total FVH score and age (p < 0.05), stroke size (p < 0.0001), modASPECTS (p < 0.0000), and pedNIHSS (p < 0.0002). In the multivariate logistic regression, only older age (OR 1.50, 95% CI 1.12-2.01, p < 0.006) and presence of LVO (OR 0.002, 95% CI 4.85x10 -5 -0.08, p<0.001) were associated with significantly increased odds of high FVH burden. Conclusions: FVH are prevalent in children with AIS, with higher burden in older children. Similar to adults, large vessel occlusion and larger infarct size are associated with higher FVH burden. Further study is needed on whether FVH could be used to identify patients who would benefit from reperfusion therapies.

Abstract TP293: Juvenile Mice Are Susceptible to Infarct-Induced Neurodegeneration That Causes Cognitive Decline

Introduction: Over half of pediatric stroke survivors have permanent neurologic and cognitive deficits. Executive function and processing speed are two domains that are consistently affected on neuropsychiatric testing of pediatric stroke survivors. In adult mice, stroke triggers an immune-mediated, infarct-induced neurodegeneration that causes similar cognitive deficits. However, it is unknown whether similar pathophysiology causes children’s cognitive deficits after stroke. Hypothesis: We hypothesize that infarct-induced neurodegeneration occurs in a mouse model of pediatric arterial ischemic stroke. Methods: Male and female C57BL/6J mice were randomized to stroke or sham surgery at p28 to model stroke in late childhood and compared to adult 6-month-old mice. We used permanent distal MCAO followed by 60 minutes of hypoxia, an established model for focal ischemia that generates a purely cortical stroke. Mice underwent behavioral testing at 1- and 7-weeks post stroke with a standard Barnes Maze protocol used in adult mice, and with a protocol adapted for juveniles by increasing difficulty of the task. We performed immunostaining to quantify acute and chronic neuroinflammation, stroke size, myelination, and atrophy 3 days and 8 weeks after surgery. Results: At 7 weeks post-stroke, stroke mice performed significantly worse on Barnes Maze testing than sham mice (n = 7 stroke, 7 sham, p = 0.0265 2-way ANOVA with repeated measures) on the more difficult but not the standard protocol. Like adult mice, pediatric mice exhibited chronic B- and T- lymphocyte neuroinflammation in the stroke scar at 8 weeks after stroke and activated (CD68+) microglia in the scar and connected regions. Both groups had decreased subcortical myelin staining compared to age-equivalent sham mice. However, this decrease was more dramatic in pediatric mice at 65 ± 14% vs. 27% ± 9% in adults, p < 0.05). Conclusions: In a model of pediatric ischemic stroke, juvenile mice develop chronic neuroinflammation in the stroke and in white matter tracts that are connected to the stroke in conjunction with a delayed cognitive deficit. Our results suggest that infarct-induced neurodegeneration occurs after stroke in juvenile mice and may cause more severe dysmyelination than in adults.

Etiology and Risk Factors for Strokes in the Pediatric Population

Pediatric arterial ischemic stroke (AIS) and hemorrhagic stroke represent a relatively uncommon yet significant source of neurological challenges for neonates and children, resulting in outcomes such as hemiparesis, intellectual disabilities, and epilepsy. The etiology of pediatric strokes differs from the typical causes seen in adult stroke cases. Therefore, understanding the specific risk factors associated with strokes in children is crucial for facilitating early diagnosis, which regrettably remains frequently delayed. AIS incidence varies due to factors such as patient age, types of cerebral vascular diseases, other chronic conditions and geographic location. In this comprehensive review, we delve into the epidemiology, clinical manifestation and risk factors linked to arterial ischemic stroke and hemorrhagic stroke in neonates and children.

Sickle Cell Disease and Other Risk Factors for Pediatric Arterial Ischemic Stroke: A Systematic Review and Meta-Analysis

Purpose: The incidence and mortality rates of arterial ischemic stroke (AIS) among pediatric patients have been frequently reported. While pediatric stroke can have multiple severe effects, its risk factors have not been methodically examined. This systematic review and meta-analysis were completed to summarize the existing evidence regarding risk factors for AIS in pediatric patients.Methods: To gather relevant articles published in the past 15 years, searches were conducted of PubMed and Scopus. Multivariate odds ratios (ORs) and 95% confidence intervals (CIs) were analyzed using Review Manager 5.4.Results: From the initial screening of 507 articles, five articles comprising a total of 1,423 participants were selected for qualitative analysis. Two of these additionally underwent quantitative analysis. Among the total participants, 1,108 children with AIS (77.9%) had arteriopathy as the underlying disease. Types of arteriopathy included moyamoya disease (24.28%), arterial dissection (23.29%), focal cerebral arteriopathy (16.16%), and vasculitis (14.71%). The meta-analysis revealed that being between 6 and 9 years of age (OR, 2.19; 95% CI, 1.76 to 2.73; <i>P</i><0.00001) and having sickle cell disease (OR, 3.46; 95% CI, 2.38 to 5.05; <i>P</i><0.00001) were associated with arteriopathy in pediatric AIS.Conclusion: Arteriopathy is the most common risk factor for AIS in pediatric patients, and in turn, an age of 6 to 9 years and sickle cell disease are risk factors for arteriopathy within this demographic.

Imaging of Vertebral Artery Dissection in Children: An Underrecognized Condition with High Risk of Recurrent Stroke.

Vertebral artery dissection (VAD) is a common cause of a rare condition, pediatric posterior circulation arterial ischemic stroke (PCAIS). VAD is clinically important due to the risk of multifocal and continuing infarcts from artery-to-artery thromboembolism, with the potential for occlusion of arteries that perfuse the brainstem. Early diagnosis is important, as recurrent stroke is a common effect of VAD in children. Although the relative efficacies of different treatment regimens for VAD in children remain unsettled, early initiation of treatment can mitigate the risk of delayed stroke. Clinical diagnosis of PCAIS may be delayed due to multiple factors, including nonspecific symptoms and the inability of younger patients to express symptoms. In fact, subacute or chronic infarcts are often present at initial imaging. Although the most common cause of isolated PCAIS is VAD, imaging of the cervical arteries has been historically underused in this setting. Cervical vascular imaging (MR angiography, CT angiography, and digital subtraction angiography) for VAD must be optimized to detect the sometimes subtle findings, which may be identified at initial or follow-up imaging. Osseous variants of the craniocervical junction and upper cervical spine and other extrinsic lesions that may directly injure the vertebral arteries or lead to altered biomechanics have been implicated in some cases. The authors review characteristic imaging features and optimized imaging of VAD and associated PCAIS and related clinical considerations. Identification of VAD has important implications for evaluation, treatment, and imaging follow-up, as this condition may result in progressive arteriopathy and recurrent stroke. © RSNA, 2023 Supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

2 Associations Between Motor Functioning and Intellectual Abilities in Pediatric Arterial Ischemic Stroke

Objective:Motor impairments are one of the most common adverse outcomes after pediatric arterial ischemic stroke (AIS), affecting approximately half of survivors. The development of motor and cognitive skills is closely interrelated, and they share common neural substrates. The objective of this study was to examine whether motor functioning after the acute phase of stroke is associated with school-age intellectual abilities. We also examined associations between concurrent motor functioning and intellectual abilities. Finally, we explored clinical features associated with motor impairments.Participants and Methods:Participants were 64 children, 34 childhood AIS (Meanage= 11.90[2.38]); 30 perinatal AIS (Meanage= 8.75[2.22]), from the Children’s Stroke Program at SickKids Hospital. Motor functioning was assessed with the Pediatric Stroke Outcome Measure sensorimotor subscale at two timepoints, Time 1 or early recovery (childhood group between 30 days post-stroke to 1 year; perinatal group between 2-5 years of age) and Time 2, closest to neuropsychological testing. Intellectual abilities were measured using the Wechsler Intelligence Scale for Children 4th or 5th edition. Associations between motor and intellectual functioning were examined separately in childhood and perinatal AIS groups. Clinical features associated with motor impairment were examined across the full sample.Results:Motor functioning during early recovery was significantly associated with processing speed (r= -.391, p= .036) in the perinatal group and with overall intellectual functioning (r= -.414, p= .018) verbal intellectual abilities (r= -.444, p= .011), working memory (r= .393, p= .026), and processing speed (r= -.351, p= .042) in the childhood group. There were no associations between concurrent motor and intellectual functioning in the perinatal group, and only with processing speed (r= -.525, p= .002) in the childhood group. When motor functioning was dichotomized as no/mild motor deficit and moderate/severe motor deficit at Time 1, children in the perinatal group with moderate/severe motor deficit had significantly lower perceptual reasoning scores (f[28]= 2.15, p= .040) and participants in the childhood group with moderate/severe motor deficit had significantly lower perceptual reasoning (f[32]= 2.35, p= .025) and processing speed (f[32]= 2.14, p= 0.41) scores. There were no differences between no/mild and moderate/severe motor deficit groups for either perinatal or childhood AIS at Time 2. Clinical features associated with moderate/severe motor deficit at Time 1 were cortical+subcortical infarcts, large lesions, presenting with hemiparesis and seizures at time of neuropsychological assessment, and accessing occupational therapy and physical therapy.Conclusions:Results suggest that motor functioning during early stroke recovery is associated with intellectual outcome, whereas motor functioning at time closest to neuropsychological assessment is not. This may be related neuroplastic changes post-injury, likely in frontal-subcortical connections, that result in observable motor deficits after stroke and affect subsequent hierarchal brain maturational processes thereby impacting later cognitive outcome. Different patterns of associations between motor functioning and specific intellectual abilities in perinatal and childhood groups suggest possible age-mediated effects on this relationship.

PB0295 Off-Label Use of Rivaroxaban in the Management of Three Cases of Pediatric Arterial Ischemic Stroke

PB0295 Off-Label Use of Rivaroxaban in the Management of Three Cases of Pediatric Arterial Ischemic Stroke

Advances in the Diagnosis and Treatment of Pediatric Arterial Ischemic Stroke.

Though rare, stroke in infants and children is an important cause of mortality and chronic morbidity in the pediatric population. Neuroimaging advances and implementation of pediatric stroke care protocols have led to the ability to rapidly diagnose stroke and in many cases determine the stroke etiology. Though data on efficacy of hyperacute therapies, such as intravenous thrombolysis and mechanical thrombectomy, in pediatric stroke are limited, feasibility and safety data are mounting and support careful consideration of these treatments for childhood stroke. Recent therapeutic advances allow for targeted stroke prevention efforts in high-risk conditions, such as moyamoya, sickle cell disease, cardiac disease, and genetic disorders. Despite these exciting advances, important knowledge gaps persist, including optimal dosing and type of thrombolytic agents, inclusion criteria for mechanical thrombectomy, the role of immunomodulatory therapies for focal cerebral arteriopathy, optimal long-term antithrombotic strategies, the role of patent foramen ovale closure in pediatric stroke, and optimal rehabilitation strategies after stroke of the developing brain.

Lesion size and long-term cognitive outcome after pediatric stroke: A comparison between two techniques to assess lesion size

There is little consensus on how lesion size impacts long-term cognitive outcome after pediatric arterial ischemic stroke (AIS). This study, therefore, compared two techniques to assessed lesion size in the chronic phase after AIS and determined their measurement agreement in relation to cognitive functions in patients after pediatric stroke. Twenty-five patients after pediatric AIS were examined in the chronic phase (>2 years after stroke) in respect to intelligence, memory, executive functions, visuo-motor functions, motor abilities, and disease-specific outcome. Lesion size was measured using the ABC/2 formula and segmentation technique (3D Slicer). Correlation analysis determined the association between volumetry techniques and outcome measures in respect to long-term cognitive outcome. The measurements from the ABC/2 and segmentation technique were strongly correlated (r=0.878, p<.001) and displayed agreement in particular for small lesions. Lesion size from both techniques was significantly correlated with disease-specific outcome (p<.001) and processing speed (p<.005) after controlling for age at stroke and multiple comparison. The two techniques showed convergent validity and were both significantly correlated with long-term outcome after pediatric AIS. Compared to the time-consuming segmentation technique, ABC/2 facilitates clinical and research work as it requires relatively little time and is easy to apply.

Evaluation of risk factors, functionalities, and quality of life in patients with pediatric acute arterial ischemic stroke.

This study aimed to evaluate the etiology and prognosis of patients followed up for pediatric acute arterial ischemic stroke. The clinical characteristics and etiology of patients aged 1 month-18 years who had acute arterial ischemic stroke between January 2010 and December 2020 were retrospectively evaluated. At last follow-up, the patients` functionality (Barthel Index, Functional Independence Measure), quality of life (SF-36 questionnaire), and motor outcomes (Gross Motor Function Classification System) were recorded prospectively/crosssectionally. Forty children (25 boys) with a median current age of 112.5 months (range: 3.6-294) were included in the study. The most frequent etiology was prothrombotic disorders, and the most important factor associated with long-term mortality was valvular heart disease. Of the 27 (67.5%) surviving patients, 29.6% had positive motor outcomes and 29.6% were independent according to the Barthel Index. In terms of quality of life, SF-36 scores were highest in the pain scale and lowest in emotional role difficulty. Determining the etiology and evaluating prognosis are important to plan effective treatment and rehabilitation for pediatric acute arterial ischemic stroke.

Clinical and Imaging Clues of Arteriopathy-Related Pediatric Arterial Ischemic Stroke: A Single Center Experience.

Arteriopathy is a common etiology for childhood arterial ischemic stroke (AIS). In this study, we aimed to address clinical, demographic, and neuroimaging characteristics and the reversibility of vasculopathy in patients with childhood stroke due to arteriopathy by classifying them according to Childhood AIS Standardized Classification and Diagnostic Evaluation (CASCADE) criteria. We included 15 patients with AIS due to arteriopathy presented between 2013 and 2018. All patients were diagnosed and followed up using magnetic resonance imaging (MRI) studies. All acute AIS patients were classified by acute CASCADE criteria (1-4). Moreover, each group was categorized according to the chronic CASCADE criteria, including progressive, stable, reversible, and indeterminate courses. In the study population, CASCADE 2 patients were the most common group, and basal ganglia involvement was the most common involvement in CASCADE 2 patients. Of CASCADE 2 patients, 71.4% received steroids, which was compatible with a favorable outcome. In the study, trauma was present in 33.3% of patients, 60% of which was related to CASCADE 4. In the control visit on month 24, there were neuromotor sequelae of 60%, including hemiparesis, facial paralysis, and decreased fine motor skills; furthermore, the recurrence rate was 20%. We strongly emphasize that arteriopathy should be kept in mind in school-age children presenting with hemiparesis and headache. Moyamoya disease must be considered in the differential diagnosis with anterior circulation involvement, while focal cerebral arteriopathy (FCA) in patients with basal ganglia involvement was detected on MRI and dissection in the patients with a history of head-neck injury. We think that steroids have positive influences on neurologic prognosis in patients with FCA.

Expert consensus on diagnosis and treatment of pediatric arterial ischemic stroke

儿童动脉缺血性脑卒中（AIS）是常见的神经系统致残疾病之一，约2/3的AIS患儿遗留不同程度永久性神经系统后遗症，增加社会经济负担。由于我国暂无儿童AIS诊疗共识，影响个体化治疗方案制定。中华医学会儿科学分会神经学组主持，由多学科临床专家多次讨论达成“儿童动脉缺血性脑卒中诊疗专家共识”，旨在为儿科医师规范儿童AIS诊疗提供帮助。.

Diagnosis of Pediatric Stroke in Resource Limited Settings

Global awareness of stroke as a significant cause of neurologic sequelae and death in children has increased over the years as more data in this field becomes available. However, most published literature on pediatric stroke have limited geographic representation. Data on childhood stroke from developing countries remains limited. Thus, this paper reviewed geographic/ethnic differences in pediatric stroke risk factors highlighting those reported in low- and middle-income countries, and proposes a childhood arterial ischemic stroke diagnostic algorithm for resource limited settings. Stroke risk factors include cardiac disorders, infectious diseases, cerebral arteriopathies, hematologic disorders, inflammatory diseases, thrombophilia and genetic conditions. Infection of the central nervous system particularly tuberculous meningitis, is a leading cause of pediatric arterial ischemic stroke in developing countries. Stroke should be considered in children with acute focal neurologic deficit especially in the presence of aforementioned risk factors. Cranial magnetic resonance imaging with angiography is the neuroimaging modality of choice but if unavailable, cranial computed tomography with angiography may be performed as an alternative. If both are not available, transcranial doppler together with neurologic exam may be used to screen children for arterial ischemic stroke. Etiological diagnosis follows with the aid of appropriate laboratory tests that are available in each level of care. International collaborative research on stroke risk factors that are prevalent in low and middle income countries will provide information for drafting of stroke care guidelines that are universal yet inclusive taking into consideration regional differences in available resources with the goal of reducing global stroke burden.

The Role of Infection and Inflammation in the Pathogenesis of Pediatric Arterial Ischemic Stroke

Infections play an important role in the pathogenesis of acute ischemic stroke (AIS) in neonates and children. In neonates, chorioamnionitis or intrauterine inflammation has been implicated as a common risk factor for AIS. In infants and children, recent investigations demonstrated that even minor childhood infections are associated with subsequent increased risk for AIS. Post-infectious inflammatory mechanisms following infections with herpesviruses may lead to focal cerebral arteriopathy (FCA), one of the most common causes of AIS in a previously healthy child. Other agents such as parvovirus B19, dengue virus, and SARS-CoV-2 have recently been implicated as other potential triggers. Infections are compelling treatable stroke risk factors, with available therapies for both pathogens and downstream inflammatory effects. However, infections are common in childhood, while stroke is uncommon. The ongoing VIPS II (Vascular effects of Infection in Pediatric Stroke) study aims to identify the array of pathogens that may lead to childhood AIS and whether either unusual strains or unusual combinations of pathogens explain this paradox. Immune modulation with corticosteroids for FCA is another active area of research, with European and U.S. trials launching soon. The results of these new pediatric stroke studies combined with findings emerging from the larger field of immune-mediated post-infectious diseases will likely lead to new approaches to the prevention and treatment of pediatric stroke. This review highlights recent developments from both clinical and animal model research enhancing our understanding of this relationship between infection, inflammation, and stroke in neonates and children.

Analysis of 622 paediatric hospitalisations due to arterial ischaemic stroke in Poland - National Health Fund registry-based study from 2011 to 2020.

The present study aimed to evaluate the prevalence of arterial ischaemic stroke (AIS) in Polish children, as well as to analyse the parameters related to AIS hospitalisation, including age, gender, region, month and season of the year at admission, duration, and costs, based on data from National Health Fund (NHF) registry in 2011-2020. Data from the NHF were analysed statistically. The disease was identified according to the codes I63 and I64 of the International Classification of Diseases, 10th Revision (ICD-10), and patients included only individuals up to 18 years of age. We identified 622 hospitalisations due to paediatric AIS in Poland in the study period. The most frequent age subgroups were adolescents, followed by toddlers or pre-school children (34.73% and 24.12%, respectively), while the least frequent were neonates or infants (9.81%). ICD-10 procedures did significantly affect the duration and costs of hospitalisation (p < 0.001). The highest costs of hospitalisations concerned the I63.1 procedure (cerebral infarction due to embolism of precerebral arteries), which included thrombectomy. The duration and costs of hospitalisation were positively correlated with each other (r = 0.525, p < 0.001). Age correlated negatively with duration of hospitalisation (r = -0.154, p < 0.001) and positively with costs of hospitalisation (r = 0.133, p = 0.008). Data from the NHF registry proved that AIS occurs more often in boys than in girls and is more common in adolescents (15-18 years) than in younger children.