Pediatric Ischemic Stroke Research Articles

Academic outcome in pediatric ischemic stroke

ABSTRACT An important cause of acquired brain injury in children, pediatric ischemic stroke can cause sequelae across a wide range of cognitive domains, including verbal reasoning and processing speed. As a result, survivors are especially vulnerable to academic difficulties and face unique challenges compared to their peers. Despite this knowledge, pediatric stroke remains an understudied neurological condition, and its impact on school functioning poorly understood. The present clinical study addressed academic outcome in this population using a multifaceted approach. Patients were recruited for participation from the Children’s Stroke Program at the Hospital for Sick Children in Toronto, Canada. A battery of standardized neuropsychological tests was administered, and additional data was collected through parent-rated measures and review of recent academic report cards. Compared to peers, youth with stroke exhibited deficits in processing speed, verbal reasoning, and core academic skills spanning reading, reading comprehension, writing, and math. Lesion laterality did not affect cognitive and academic scores. Youth with a combined cortical-subcortical lesion scored lower on a test of nonverbal reasoning compared to youth with either cortical or subcortical lesions. Compared to healthy peers, the pediatric stroke group was more likely to report requiring extra help at school, accommodations, individual education plans, and assistive technology. They were also more likely to be diagnosed with a learning disability, but not Attention Deficit/Hyperactivity Disorder. Nonverbal reasoning skills, school grades, and school-related quality of life were comparable between groups. The present study contributed to a more nuanced understanding of the impact of pediatric stroke on academic outcome.

Arterial Ischemic Stroke in the Pediatric Population

Recognizing childhood arterial ischemic stroke risk factors and presentation are extremely important for a prompt diagnosis and administration of hyperacute treatment requiring a high level of clinical suspicion. Stroke presentation in the pediatric population is not very specific, yet it is imperative to distinguish it from other mimics that may require different medical management. Vascular imaging studies, including MRA, CTA, and advanced neuroimaging techniques (eg, arterial wall imaging and CT/MR perfusion images) are extremely useful in the diagnosis of arterial ischemic stroke. This article offers a review of arterial pediatric ischemic stroke risk factors, clinical presentation, and the imaging appearance of the most common arterial ischemic stroke etiologies.Learning Objective: To recognize multiple risk factors, etiologies, and imaging presentations of pediatric arterial ischemic strokes.

The relationships between carrying thrombophilic genes’ polymorphisms and forecast of pediatric arterial ischemic strokes: the result of investigation using logistic regression

The relationships between carrying thrombophilic genes’ polymorphisms and forecast of pediatric arterial ischemic strokes: the result of investigation using logistic regression

Mechanical thrombectomy in pediatric stroke: systematic review, individual patient data meta-analysis, and case series.

The role of mechanical thrombectomy in pediatric acute ischemic stroke is uncertain, despite extensive evidence of benefit in adults. The existing literature consists of several recent small single-arm cohort studies, as well as multiple prior small case series and case reports. Published reports of pediatric cases have increased markedly since 2015, after the publication of the positive trials in adults. The recent AHA/ASA Scientific Statement on this issue was informed predominantly by pre-2015 case reports and identified several knowledge gaps, including how young a child may undergo thrombectomy. A repeat systematic review and meta-analysis is warranted to help guide therapeutic decisions and address gaps in knowledge. Using PRISMA-IPD guidelines, the authors performed a systematic review of the literature from 1999 to April 2019 and individual patient data meta-analysis, with 2 independent reviewers. An additional series of 3 cases in adolescent males from one of the authors' centers was also included. The primary outcomes were the rate of good long-term (mRS score 0-2 at final follow-up) and short-term (reduction in NIHSS score by ≥ 8 points or NIHSS score 0-1 at up to 24 hours post-thrombectomy) neurological outcomes following mechanical thrombectomy for acute ischemic stroke in patients < 18 years of age. The secondary outcome was the rate of successful angiographic recanalization (mTICI score 2b/3). The authors' review yielded 113 cases of mechanical thrombectomy in 110 pediatric patients. Although complete follow-up data are not available for all patients, 87 of 96 (90.6%) had good long-term neurological outcomes (mRS score 0-2), 55 of 79 (69.6%) had good short-term neurological outcomes, and 86 of 98 (87.8%) had successful angiographic recanalization (mTICI score 2b/3). Death occurred in 2 patients and symptomatic intracranial hemorrhage in 1 patient. Sixteen published thrombectomy cases were identified in children < 5 years of age. Mechanical thrombectomy may be considered for acute ischemic stroke due to large vessel occlusion (ICA terminus, M1, basilar artery) in patients aged 1-18 years (Level C evidence; Class IIb recommendation). The existing evidence base is likely affected by selection and publication bias. A prospective multinational registry is recommended as the next investigative step.

Mechanical Thrombectomy Using Retrievable Stents in Pediatric Acute Ischemic Stroke

To report efficacy and outcome of mechanical thrombectomy for treatment of pediatric acute ischemic stroke with large vessel occlusion using stent retrievers. Retrospective record review of institutional database for patients <18 years of age. Five boys aged between 6 to 17 years received reperfusion therapy using mechanical thrombectomy for acute ischemic stroke with large vessel occlusion (2 basilar, 2 middle cerebral and 1 internal carotid artery). Pediatric National Institute of Health Stroke Scale (PedNIHSS) at onset ranged from 12 to 21. Complete recanalization as defined by the modified Treatment In Cerebral Infarction scale (mTICI 3 or 2b) was achieved in all, using stent retreivers. Favorable outcome as per the modified Rankin scale (mRS 0-1) was achieved in all with no peri-procedural complications. Mechanical thrombectomy using retrievable stents is a safe and effective therapy for pediatric ischemic stroke due to large vessel occlusion, and may be offered in carefully selected patients.

Remote poststroke headache in children: Characteristics and association with stroke recurrence.

New-onset headache after stroke is common among adult stroke survivors. However, pediatric data are limited. The primary aim of this study was to investigate the prevalence of new-headache after pediatric ischemic stroke. Secondary outcomes were to describe the characteristics of patients experiencing poststroke headache and the association between poststroke headache and stroke recurrence. We conducted a single-center retrospective study on children aged 30 days to 18 years with a confirmed radiographic diagnosis of arterial ischemic stroke (AIS) from January 1, 2008, to December 31, 2016. Patients were identified from an internal database, with additional data abstracted from the electronic medical record. Poststroke headache (occurring >30 days after stroke) was identified through electronic searches of the medical record and confirmed by chart review. Of 115 patients with confirmed AIS, 41 (36%) experienced poststroke headache, with headache developing a median of 6 months after stroke. Fifty-one percent of patients with poststroke headache presented to the emergency department for headache evaluation; 81% of the patients had an inpatient admission for headache. Older age at stroke (odds ratio [OR] 21.5; p = 0.0001) and arteriopathy (OR 8.65; p = 0.0029) were associated with development of poststroke headache in a multivariable analysis. Seventeen patients (15%) had a recurrent stroke during the study period. Poststroke headache was associated with greater risk for stroke recurrence (p = 0.049). Remote poststroke headache is a common morbidity among pediatric stroke survivors, particularly in older children. Headaches may increase health care utilization, including neuroimaging and hospital admissions. We identified a possible association between poststroke headache and stroke recurrence.

Arteriopathy Influences Pediatric Ischemic Stroke Presentation, but Sickle Cell Disease Influences Stroke Management.

Background and Purpose- Sickle cell disease (SCD) and arteriopathy are pediatric stroke risk factors that are not mutually exclusive. The relative contributions of sickled red blood cells and arteriopathy to stroke risk are unknown, resulting in unclear guidelines for primary and secondary stroke prevention when both risk factors are present. We hypothesized that despite similarities in clinical presentation and radiographic appearance of arteriopathies, stroke evaluation and management differ in children with SCD compared with those without SCD. Methods- We compared presentation and management of children with and without SCD enrolled in the IPSS (International Pediatric Stroke Study) with acute arterial ischemic stroke, according to SCD and arteriopathy status. Regression modeling determined relative contribution of SCD and arteriopathy in variables with significant frequency differences. Results- Among 930 childhood arterial ischemic strokes, there were 98 children with SCD, 67 of whom had arteriopathy, and 466 without SCD, 392 of whom had arteriopathy. Arteriopathy, regardless of SCD status, increased likelihood of hemiparesis (odds ratio [OR], 1.94; 95% CI, 1.46-2.56) and speech abnormalities (OR, 1.67; 95% CI, 1.29-2.19). Arteriopathy also increased likelihood of headache but only among those without SCD (OR, 1.89; 95% CI, 1.40-2.55). Echocardiograms were less frequently obtained in children with SCD (OR, 0.58; 95% CI, 0.37-0.93), but the frequency of identified cardiac abnormalities was similar in both groups ( P=0.57). Children with SCD were less likely to receive antithrombotic therapy, even in the presence of arteriopathy (OR, 0.14; 95% CI, 0.08-0.22). Arteriopathy was associated with a significantly higher likelihood of antithrombotic therapy in children without SCD (OR, 5.36; 95% CI, 3.55-8.09). Conclusions- Arteriopathy, and not SCD status, was most influential of stroke presentation. However, SCD status influenced stroke management because children with SCD were less likely to have echocardiograms or receive antithrombotic therapy. Further work is needed to determine whether management differences are warranted.

Neuroimaging of Pediatric Arteriopathies.

Pediatric arteriopathies are increasingly recognized in school-aged children with a variety of presenting symptoms ranging from headache, seizures, encephalopathy, and neuropsychiatric symptoms as well as focal neurologic deficits due to acute ischemic strokes. However, unlike the adult stroke population, there are differences in the clinical manifestations, the stroke mechanism, and risk factors in pediatric ischemic stroke. There has been increasing awareness and recognition of pediatric cerebral arteriopathies as a predominant stroke etiology. Prompt diagnosis of arteriopathies is essential to limit injury and prevent recurrent stroke. Based on predominant vessels involved and clinical symptoms, these arteriopathies can be broadly divided into two categories: large-medium size arteriopathies and small vessel arteriopathies. Each category can be further divided into inflammatory and noninflammatory according to their etiologies. The ability to distinguish between inflammatory and noninflammatory etiologies carries major prognostic implications for acute management and secondary stroke prevention as well as screening for systemic complications and counseling.

Abstract WMP120: The Role of Age, Lesion Location and Volume in Predicting Long-Term Neurological Outcomes in Pediatric Ischemic Stroke

Introduction: The balance of plasticity versus vulnerability to acute ischemic injury in the immature brain across development remains controversial. We aimed to investigate the relationship between age at stroke and lesion location and volume with long-term outcomes following arterial ischaemic stroke (AIS). Hypothesis: Age at stroke onset interacts with lesion location and volume to predict long-term neurological outcomes. Methods: In a single-centre prospective study, children aged term birth to 18 years with acute symptomatic AIS from 1992 to 2016 who underwent neuroimaging (CT/MRI) within 14 days of stroke onset were studied. Long term outcomes were assessed with the Pediatric Stroke Outcome Measure (PSOM). Outcomes were defined as normal (score 0-0.5 on 1-5 PSOM subscales), otherwise abnormal. AIS lesions were classified based on major (anterior, middle, posterior, other) cerebral arteries and branch sub-territories (e.g. MCA-lateral lenticulostriate). For each vascular territory, the proportion of infarcted brain was estimated as ‘small’ (≤50% territory) or ‘large’ (&gt;50% territory). Factors predictive of long term outcomes were evaluated using logistic regression models. Results: Among 285 children, median age at stroke onset was 22 months (IQR: 0.03-101), 41% were females. PSOM scoring at median 9 years (IQR: 4-15) post-stroke was normal in 61%. Abnormal outcome was associated with age 1-4 years (OR=2.2, 95% CI: 1.02-4.9), ‘large’ proportion infarcts involving cortex within any major artery territory (OR=6.1, 95% CI: 2.6-14.4), and subcortical infarcts: OR= 2.7 (95% CI: 1.4-5.4) for small proportion infarcts; OR=8.3 (95% CI: 4.2-16.6) for large proportion infarcts in either medial or lateral lenticulostriate arteries; OR=15.8 (95% CI: 5-50.3) for large volume lesions in both lenticulostriate territories. In multivariate logistic regression, age, cortical and subcortical infarcts predicted long-term neurologic outcomes. Conclusions: In addition to age at stroke onset, infarct location including volume plays a key role in predicting long-term neurological outcomes in children. While the relationship between age and neurological outcomes seems to be bimodal, a linear effect of lesion volume on stroke outcomes is evident.

Pediatric ischemic stroke – an unlikely diagnosis: a report of three cases

Pediatric ischemic stroke is a rare and devastating disease. A patient presenting with acute neurological deficit should raise suspicion of a possible stroke. However, stroke “mimics” account for a majority of suspected stroke cases in childhood. We present three cases of pediatric acute is-chemic stroke, two of which are arterial, and one caused by thrombosis of venous sinuses. In the first case, we present a 16-year old male patient was admitted to our hospital due to a rare Artery of Percheron occlusion. The second case represents a 17-year old female patient with thrombosis of multiple cerebral venous sinuses, venous infarctions and secondary hemorrhages. As the third case, we present 6-year old male patient with a herpes simplex infec-tion and a vertebrobasilar stroke. All three patients had experienced an altered mental status and other nonspecific symptoms. Due to its rarity, diverse clinical presenta-tion, and lack of randomized control trials regarding treatment, ischemic stroke poses a great challenge to pediatricians.

Neuroprotective Effect of IRL-1620, an Endothelin B Receptor Agonist, on a Pediatric Rat Model of Middle Cerebral Artery Occlusion.

Objective: The purpose of this study was to determine the potential neuroprotective effect of endothelin B (ETB) receptor agonist IRL-1620 treatment in a pediatric model of ischemic stroke.Design: A prospective, animal model study.Setting: An experimental laboratory.Subjects: Three-month-old male Wistar Han rats.Interventions: The rats underwent permanent middle cerebral artery occlusion (MCAO). At 2, 4, and 6 h post MCAO, they were treated with saline, IRL-1620 (5 μg/kg, IV), and/or ETB antagonist BQ788 (1 mg/kg, IV).Measurements and Main Results: The rats were evaluated over the course of 7 days for neurological and motor deficit, cerebral blood flow (CBF), and infarct volume. Young rats treated with IRL-1620 following MCAO improved significantly in neurological and motor assessments as compared to the vehicle-treated group, as measured by neurological score (P = 0.00188), grip test (P < 0.0001), and foot-fault error (P = 0.0075). CBF in the infarcted hemisphere decreased by 45–50% in all groups immediately following MCAO. After 7 days, CBF in the infarcted hemisphere of the IRL-1620 group increased significantly (P = 0.0007) when compared to the vehicle-treated group (+2.3 ± 23.3 vs. −45.4 ± 10.2%). Additionally, infarct volume was significantly reduced in IRL-1620-treated rats as compared to vehicle-treated rats (P = 0.0035, 41.4 ± 35.4 vs. 115.4 ± 40.9 mm3). Treatment with BQ788 blocked the effects of IRL-1620.Conclusions: IRL-1620 significantly reduced neurological and motor deficit as well as infarct volume while increasing CBF in a pediatric rat model of cerebral ischemia. These results indicate that selective ETB receptor stimulation may provide a novel therapeutic strategy in the treatment of pediatric ischemic stroke as has been demonstrated in adult ischemic stroke.

A Pediatric and Neonatal Critical Care Transport Team's Standard of Care for Suspected Stroke of a Pediatric Patient

Background A 314 bed free standing Children's Hospital is the region's first and only dedicated pediatric stroke center offering comprehensive, individualized treatment protocols for children (Children's Mercy, 2018). The WHO estimates 1-2/210,000 children will have a stroke. Mortality is 2-11% but persistent neurological deficit will occur in 68-73% of children who experience a stroke (Bernard Ann Neurol 2008). Recognition and early intervention are critical to minimizing brain damage (Mutka Sharma, MD). Depending on the length of time since the stroke, treatment options can vary. Rapid identification and treatment can be lifesaving and/or potentially improve neurologic outcomes (Children's Mercy 2018). Objectives To provide a Pediatric and Neonatal Critical Care Transport team the training, job aides and standardization for the recognition and treatment of a pediatric patient with stroke symptoms requiring transport to a Pediatric Stroke Center. ●Identify pediatric patients with symptoms concerning for stroke ●Initiate a Stroke Alert Protocol if child has focal neurologic deficit and meets criteria for activation ●Aid in the pre Pediatric Stroke Center triage process and stroke evaluation ●Provide rapid assessment, stabilization, and transport of children with stroke-like symptoms to pediatric center ●Initiate neuroprotective measures designed to minimize secondary neurologic injury IMPLEMENTATION ●Clinical Practice Guideline ●Suspected Stroke Checklist ●tPA Administration and Monitoring Guidelines Results Because symptoms of a pediatric ischemic stroke can vary greatly from an adult ischemic stroke, our Critical Care Transport Team is specially trained and prepared to transport a pediatric patient with stroke symptoms from anywhere in the area. If a pediatric ischemic stroke is suspected by a referral and/or our transport team, our collaborative team of Medical Control Physicians (MCP), Transport Personnel, Referral Physicians and Emergency Room Physicians are all specially trained to activate our stroke protocol immediately should a patient present with stroke symptoms. Since implementation we have transported and treated 2 patients with basilar artery stroke. Both patients had successful clot retrieval and full neurological recovery! Several other critical diagnosis as a result of being a stroke mimicker were made during the stroke alert and/or stroke activation procedure including brain tumor, HSV encephalitis, brain abscess, Schawannoma and Moya Moya disease. Conclusion There has been an increase in rapid diagnosis, early recognition and treatment of pediatric patients with acute ischemic stroke and other stroke mimickers that required emergent intervention following implementation of our Stroke Alert Protocol, Clinical Practice Guideline, Suspected Stroke Checklist and tPA Administration and monitoring Guideline for Pediatric and Neonatal Critical Care Transport.

Upstream Stimulating Factor 1 (USF-1) Gene Polymorphisms and the Risk, Symptoms, and Outcome of Pediatric Ischemic Stroke

Pediatric ischemic stroke is an important cause of morbidity and mortality. As previous studies of children after stroke showed, dyslipidemias were very common in Polish and other European populations. Thus, looking for genetic factors predisposing to pediatric stroke, its symptoms, and outcome, we have analyzed 2 polymorphisms of the upstream stimulating factor 1 (USF-1) gene. The study group consisted of 82 children with stroke, 156 parents, and 146 controls. We used 2 alternative methods: the case-control model and the analysis of families using the transmission disequilibrium test. The 2 polymorphisms, rs2516839 and rs3737787, were genotyped using the TaqMan Pre-Designed SNP Genotyping Assay. The Statistica 10.0 software was used in all statistical analyses. We did not observe any statistical differences in genotype and allele frequencies between patients and controls. There were also no significant differences in the transmission of alleles from the parents to the affected children. However, we have observed that the TT genotype of the rs2516839 polymorphism was more common in patients with epilepsy and dysarthria, whereas the TT genotype of the rs3737787 polymorphism was more frequent in the group of patients with a decrease in intellectual functioning. Our study did not show any associations between the 2 analyzed polymorphisms of the USF-1 gene and pediatric ischemic stroke. However, we have observed an influence of specific genotypes on the outcome of stroke, including epilepsy, dysarthria, and a decrease in intellectual functioning.

Role of Imaging in Acute Ischemic Stroke

Rapid multimodal imaging is essential in the workup and management of acute ischemic stroke. Early parenchymal findings on noncontrast computed tomography or standard magnetic resonance imaging are used to triage patients for intravenous thrombolysis and to provide insight on prognosis. In the wake of recent endovascular stroke trials, advanced techniques including perfusion imaging and noninvasive vascular imaging are becoming important tools to guide potential endovascular treatment or expand therapy windows. Advanced imaging is also important in pediatric ischemic stroke which requires a slightly different workflow and treatment approach. Here, we will discuss key imaging findings in acute ischemic stroke, as well as the present and future of neuroimaging in light of recent and ongoing clinical trials.

Ballismus as a rare presenting sign of pediatric ischemic stroke: Case report and review of the literature

Ballismus as a rare presenting sign of pediatric ischemic stroke: Case report and review of the literature

Pediatric hemispherotomy following perinatal pediatric ischemic stroke in children: 63 cases with classical and unusual indications

Pediatric hemispherotomy following perinatal pediatric ischemic stroke in children: 63 cases with classical and unusual indications

Thrombectomy and thrombolysis in pediatric acute ischemic stroke (S8.007)

Thrombectomy and thrombolysis in pediatric acute ischemic stroke (S8.007)

Acute Pediatric Ischemic Stroke Management: a window for opportunity? (P4.175)

Acute Pediatric Ischemic Stroke Management: a window for opportunity? (P4.175)

Abstract WMP115: Thrombolysis and Thrombectomy in Pediatric Ischemic Stroke

Introduction: Stroke is a devastating disease at any age. There are few studies on utility of intravenous thrombolysis (tPA) or intra-arterial thrombectomy (IAT) in pediatric acute ischemic stroke (AIS). Hypothesis: To describe and compare clinical outcomes of pediatric AIS patients who did and did not receive tPA+/-IAT. Methods: We retrospectively reviewed all pediatric AIS cases, aged 0-17, from the 2006-2010 Nationwide Inpatient Survey, a 20% stratified sample of all U.S. community hospitals. Demographics, outcomes, cost of stay, and comorbidities were assessed. Results: Overall, 20,587 patients were analyzed. Mean age was 6.0 years (SD 13.9); female 43.9%; white 47.7%. Of those, 198 patients received intervention: 169 tPA, 5 IAT, and 24 tPA+IAT. Treated patients were older (10.0 years vs 5.9 years, p&lt;0.0001). Mortality for pediatric AIS patients was 7.8%; 13.8% in tPA patients compared to 7.7% in the untreated. No deaths in the IAT group. Non-treated patients were more likely to be discharged home than those receiving tPA+/-IAT (67.8% vs. 47.5%, p&lt;0.0001). Cost for treated patients was higher ($200,346 vs. $123,015, p=0.01). Intracerebral hemorrhage (ICH) was more common in treated patients (10.1% vs. 3.8%, p&lt;0.0001). Comorbidities included Moyamoya disease (12.4%), cardiac valvular disease (6.6%), and sickle cell disease (6.5%). The treated group had higher prevalence of pneumonia/influenza (17.2% vs. 7.6%, p&lt;0.0001), procoagulable conditions (15.2% vs. 2%, p&lt;0.0001), and cardiac valvular disease (15.2% vs. 6.5%, p&lt;0.0001). Conclusions: In the pediatric AIS population, tPA was associated with increased mortality. Treatment with tPA+/-IAT was associated with decreased discharge home, increased cost, and higher prevalence of ICH. Prevalence of ICH is not explained by the presence of Moyamoya or sickle cell as those patients were less likely to receive treatment. Limitations of this study include small numbers of treated patients, lack of data on stroke severity or functional outcome, and data from years prior to newer thrombectomy devices. Studies of AIS treatment in adults cannot necessicarily be extrapolated given the difference in etiologies of pediatric AIS. Pediatric AIS is on the rise, so more research for effective treatment is necessary.

Epidemiology and Outcomes of Arterial Ischemic Stroke in Children: The Canadian Pediatric Ischemic Stroke Registry

BackgroundPediatric arterial ischemic stroke remains incompletely understood. Population-based epidemiological data inform clinical trial design but are scant in this condition. We aimed to determine age-specific epidemiological characteristics of arterial ischemic stroke in neonates (birth to 28 days) and older children (29 days to 18 years). MethodsWe conducted a 16-year, prospective, national population-based study, the Canadian Pediatric Ischemic Stroke Registry, across all 16 Canadian acute care children's hospitals. We prospectively enrolled children with arterial ischemic stroke from January 1992 to December 2001 and documented disease incidence, presentations, risk factors, and treatments. Study outcomes were assessed throughout 2008, including abnormal clinical outcomes (stroke-related death or neurological deficit) and recurrent arterial ischemic stroke or transient ischemic attack. ResultsAmong 1129 children enrolled with arterial ischemic stroke, stroke incidence was 1.72/100,000/year, (neonates 10.2/100,000 live births). Detailed clinical and radiological information were available for 933 children (232 neonates and 701 older children, 55% male). The predominant clinical presentations were seizures in neonates (88%), focal deficits in older children (77%), and diffuse neurological signs (54%) in both. Among neonates, 44% had no discernible risk factors. In older children, arteriopathy (49% of patients with vascular imaging), cardiac disorders (28%), and prothrombotic disorders (35% of patients tested) predominated. Antithrombotic treatment increased during the study period (P < 0.001). Stroke-specific mortality was 5%. Outcomes included neurological deficits in 60% of neonates and 70% of older children. Among neonates, deficits emerged during follow-up in 39%. Overall, an initially decreased level of consciousness, a nonspecific systemic presentation, and the presence of stroke risk factors predicted abnormal outcomes. For neonates, predictors were decreased level of consciousness, nonspecific systemic presentation, and basal ganglia infarcts. For older children, predictors were initial seizures, nonspecific systemic presentation, risk factors, and lack of antithrombotic treatment. Recurrent arterial ischemic stroke or transient ischemic attack developed in 12% of older children and was predicted by arteriopathy, presentation without seizures, and lack of antithrombotic treatment. Emerging deficit was predicted by neonatal age at stroke and by cardiac disease. ConclusionsThis national data set provides a population-based disease incidence rate and demonstrates the protective effect of antithrombotic treatment in older children, and frequent long-term emerging deficits in neonates and in children with cardiac disorders. Further clinical trials are required to develop effective age-appropriate treatments for children with acute arterial ischemic stroke.