Pediatric Stroke Outcome Measure Research Articles

Inflammatory Type Focal Cerebral Arteriopathy of the Posterior Circulation in Children: A Comparative Cohort Study.

Inflammatory type focal cerebral arteriopathy (FCA-i) in the anterior circulation (AC) is well characterized, and the focal cerebral arteriopathy severity score (FCASS) reflects the severity of the disease. We identified cases of FCA-i in the posterior circulation (PC) and adapted the FCASS to describe these cases. In this comparative cohort study, patients from the Swiss NeuroPaediatric Stroke Registry with ischemic stroke due to FCA-i between January 2000 and December 2018 were analyzed. A comparison between PC and AC cases regarding pediatric National Institutes of Health Stroke Scale score and pediatric stroke outcome measure and FCASS was performed. We estimated infarct size by the modified pediatric Alberta Stroke Program Early Computed Tomography Score in children with AC stroke and the adapted Bernese posterior diffusion-weighted imaging score in the PC. Thirty-five children with a median age of 6.3 (interquartile range, 2.7-8.2 [95% CI, 0.9-15.6]; 20 male; 57.1%) years with FCA-i were identified. The total incidence rate was 0.15/100 000/year (95% CI, 0.11-0.21). Six had PC-FCA-i. Time to final FCASS was longer in the PC compared with AC; the evolution of FCASS did not differ. Initial pediatric National Institutes of Health Stroke Scale score was higher in children with FCA-i in the PC with a median of 10.0 (interquartile range, 5.75-21.0) compared with 4.5 (interquartile range, 2.0-8.0) in those with AC-FCA-i. Different from the anterior cases, PC infarct volume did not correlate with higher discharge, maximum, or final FCASS scores (Pearson correlation coefficient [r], 0.25, 0.35, and 0.54). FCA-i also affects the PC. These cases should be included in future investigations into FCA-i. Although it did not correlate with clinical outcomes in our cohort, the modified FCASS may well serve as a marker for the evolution of the arteriopathy in posterior FCA-i.

Social skill and social withdrawal outcomes in children following pediatric stroke

ABSTRACT Pediatric stroke can result in long-term impairments across attention, functional communication and motor domains. The current paper utilized parent reports of the Behavioral Assessment System for Children 2nd Edition and the Pediatric Stroke Outcome Measure to examine children’s social skills and withdrawal behavior within a pediatric stroke population. Using the Canadian Pediatric Stroke Registry at The Hospital for Sick Children, data were analyzed for 312 children with ischemic stroke. Children with ischemic stroke demonstrated elevated parent-reported social skills problems (observed = 20.51%, expected = 14.00%) and clinically elevated social withdrawal (observed = 11.21%, expected = 2.00%). Attentional problems significantly contributed to reduced social skills, F (3,164) = 30.68, p < 0.01, while attentional problems and neurological impairments accounted for increased withdrawal behavior, F (2, 164) = 7.47, p < 0.01. The presence of a motor impairment was associated with higher social withdrawal compared to individuals with no motor impairment diagnosis, t(307.73) = 2.25, p < .025, d = 0.25, 95% CI [0.42, 6.21]. The current study demonstrates that children with stroke who experience motor impairments, attentional problems, reduced functional communication skills, and neurological impairments can experience deficits in their social skills and withdrawal behavior.

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 &amp;gt; 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.

Brain injury and neurodevelopmental outcomes in children undergoing surgery for congenital heart disease

ObjectivesBrain injury is commonly seen on magnetic resonance imaging in infants with complex congenital heart disease. The impact of perioperative brain injury on neurodevelopmental outcomes is not well understood. We evaluate the association of brain injury and other markers on neurodevelopmental outcomes in patients undergoing surgery for congenital heart surgery during infancy. MethodsTerm newborns with infant cardiac surgery performed between 2008 and 2019 at a single tertiary center, and both preoperative and postoperative brain magnetic resonance imaging were included. Those with underlying genetic conditions were excluded. Brain injury was characterized using an magnetic resonance imaging scoring system. Neurodevelopmental outcomes were assigned using the Pediatric Stroke Outcome Measure and Glasgow Outcome Scale Extended. Independent risk factors for poor neurodevelopmental outcomes were determined by multivariable Cox regression. ResultsA total of 122 patients were included. New or progressive postoperative brain injury was noted in 69 patients (57%). A total of 101 patients (83%) had at least 1 neurodevelopmental assessment (median age 36 months) with an early assessment (5-24 months) performed in 95 children. Multivariable Cox regression analysis of early neurodevelopmental outcomes identified new stroke on postoperative magnetic resonance imaging to be an independent predictor of poor neurodevelopmental outcome. Postoperative peak lactate was an independent predictor of poor outcome assessed by the Pediatric Stroke Outcome Measure and Glasgow Outcome Scale Extended. ConclusionsOur study reveals that evidence of new stroke on magnetic resonance imaging after infant congenital heart surgery is a predictor of poor neurodevelopmental outcomes in early childhood. Postoperative lactic acidosis is associated with poor neurodevelopmental outcome and may be a surrogate biomarker for ischemic brain injury.

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.

Association of Acute Infarct Topography With Development of Cerebral Palsy and Neurological Impairment in Neonates With Stroke.

Research investigating neonatal arterial ischemic stroke (NAIS) outcomes have shown that combined cortical and basal ganglia infarction or involvement of the corticospinal tract predict cerebral palsy (CP). The research question was whether voxel-based lesion-symptom mapping (VLSM) on acute MRI can identify brain regions associated with CP and neurodevelopmental impairments in neonatal arterial ischemic stroke (NAIS). Newborns were recruited from prospective Australian and Swiss pediatric stroke registries. CP diagnosis was based on clinical examination. Language and cognitive-behavioral impairments were assessed using the Pediatric Stroke Outcome Measure, dichotomized to good (0-0.5) or poor (≥ 1), at ≥18 months of age. Infarcts were manually segmented using diffusion-weighted imaging, registered to a neonatal-specific brain template. VLSM was conducted using MATLAB SPM12 toolbox. A general linear model was used to correlate lesion masks with motor, language and cognitive-behavioral outcomes. Voxel-wise t-test statistics were calculated, correcting for multiple comparisons using family-wise error rate (FWE). Eighty-five newborns met inclusion criteria. Infarct lateralization was left hemisphere (62%), right (8%) and bilateral (30%). At median age 2.1 years (IQR 1.9-2.6), 33% developed CP and 42% had neurological impairments. 54 grey and white matter regions correlated with CP (t>4.33; FWE <0.05), including primary motor pathway regions, such as the precentral gyrus, and cerebral peduncle, and regions functionally connected to the primary motor pathway, such as the pallidum, and corpus callosum motor segment. No significant correlations were found for language or cognitive-behavioral outcomes. CP following NAIS correlates with infarct regions directly involved in motor control and, or in functionally connected regions. Areas associated with language or cognitive-behavioral impairment are less clear.

Pediatric Cerebral Sinovenous Thrombosis and Risk for Epilepsy

BackgroundCerebral sinovenous thrombosis (CSVT) is a rare form of pediatric stroke with significant morbidity. We determined cumulative incidence and predictors of acute seizures, remote seizures, and epilepsy after pediatric CSVT. MethodsRetrospective analysis of 131 neonates and children with neuroimaging-confirmed CSVT enrolled between 2008 and 2020 from a single-center prospective consecutive cohort. Acute seizures occurred within 7 days of CSVT. Remote seizures occurred >7 days after CSVT. Epilepsy was defined as 2 or more remote seizures at least 24 hours apart. Survival methods determined the incidence of and risk factors for remote seizures and epilepsy. ResultsAcute seizures occurred in 14/33 neonates (42%) and 19/98 children (19%). Among children, hemorrhage predicted acute seizures (OR 6.6, 95% CI 1.9 to 22.4, P = 0.003). Remote seizures occurred in six neonates; five developed epilepsy. Remote seizures occurred in 14 children; 10 developed epilepsy. In neonates, 1- and 3-year epilepsy-free survival were 86% (95% CI 62% to 95%) and 66% (95% CI 32% to 87%). One- and 3-year epilepsy-free survival in children were 88% (95% CI 76% to 92%) and 84% (95% CI 59% to 86%). In multivariable analysis for children, acute seizures predicted epilepsy (HR 3.8, 95% CI 1.1-13.3, P = 0.039). In both cohorts, Pediatric Stroke Outcome Measure scores at last follow-up were worse in those with epilepsy compared to those without. ConclusionsAcute seizures occurred in approximately one quarter of our cohort and are an epilepsy risk factor in children with CSVT. Neonates and children with epilepsy had worse outcomes than those without.

Seizures in Pediatric Moyamoya: Risk Factors and Functional Outcomes

BackgroundChildren with moyamoya arteriopathy are at high risk for stroke and seizures. Risk factors for seizures and the impact of seizures on neurological outcomes in children with moyamoya are unknown. MethodsThis is a single-center retrospective cohort study of children with moyamoya evaluated between 2003 and 2021. Functional outcome was assessed using the Pediatric Stroke Outcome Measure (PSOM). Associations between clinical variables and seizure occurrence were assessed using univariate and multivariable logistic regression. Associations between clinical variables and final PSOM score were assessed using ordinal logistic regression. ResultsEighty-four patients met inclusion criteria, and 34 (40%) children experienced seizure. Factors associated with seizures included moyamoya disease (vs syndrome; odds ratio [OR] 3.43, P = 0.008) and the presence of infarcts on baseline neuroimaging (OR 5.80, P = 0.002). Factors associated with decreased likelihood of experiencing seizures included older age at initial presentation (OR 0.82, P = 0.002) and asymptomatic (radiographic) presentation (OR 0.05, P = 0.006). Both older age at presentation (adjusted OR [AOR] 0.80, P = 0.004) and incidental radiographic presentation (AOR 0.06, P = 0.022) remained significant after adjusting for potential confounders. Seizures were associated with worse functional outcomes as assessed by the PSOM (regression coefficient 2.03, P < 0.001). This association remained significant after adjusting for potential confounders (adjusted regression coefficient 1.54, P = 0.025). ConclusionsYounger age and symptomatic presentation are associated with increased likelihood of seizures among children with moyamoya. Seizures are associated with worse functional outcomes. Prospective studies should clarify how seizures impact outcomes and how effective seizure treatment modifies this relationship.

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.

Outcomes in infants with unprovoked venous thromboembolism: A retrospective cohort study

BackgroundAlthough children aged <1 year have a relatively high rate of venous thromboembolism (VTE) compared to older children, most have additional prothrombotic risk factors. Unprovoked VTE is rare, and little is known about this population, particularly the risk of recurrent VTE. ObjectivesWe aimed to determine the rate of recurrent VTE in infants with prior unprovoked VTE and evaluate long-term, end-organ outcomes for infants with renal and intracranial vein thrombosis. MethodsInfants <1 year of age with an unprovoked VTE between 2003 and 2021 at a single institution were included. Time to recurrent event and anticoagulation duration were summarized using the Kaplan-Meier estimator. Neurologic outcomes were summarized with the pediatric stroke outcome measure for infants with cerebral sinovenous, medullary, or cortical vein thrombosis. Kidney outcomes were summarized with estimated glomerular filtration rates for infants with renal vein thrombosis. Anticoagulation was summarized. ResultsForty infants with intracranial, renal, portal, and extremity VTE met the inclusion criteria and were followed for a median of 4.7 years (IQR, 2.1-8.5). Most VTE events occurred during the first month of life. There was 1 recurrent event in 237 person-years of follow-up (incidence rate, 4 per 1000 [95% CI, 0.6-29.9] person-years). In outpatient follow-up, 40% of infants with intracranial thrombosis met criteria for moderate or severe neurologic outcomes and two-thirds of infants with a prior renal vein thrombosis had abnormal kidney function (estimated glomerular filtration rate < 90 mL/min/1.73 m2). ConclusionThere is a low rate of recurrent VTE but significant end-organ morbidity in infants with unprovoked VTE.

Neurodevelopmental outcomes of neonatal posthemorrhagic hydrocephalus and psychological effects on the parents

BackgroundNeonatal posthemorrhagic hydrocephalus remains a common complication in preterm infants, with high rates of mortality and morbidity, placing parents at high risk of anxiety and depression. We sought to investigate the neurodevelopmental outcomes of infants with posthemorrhagic hydrocephalus who underwent surgery and the psychological effect on their parents.MethodsWe retrospectively analysed all infants with posthemorrhagic hydrocephalus born between 2014 and 2020 in the Children’s Hospital of Chongqing Medical University, China. The neurodevelopmental outcomes of 28 patients were evaluated by the Pediatric Stroke Outcome Measure score, and the psychological states of the parents of survivors were assessed by the Hospital Anxiety and Depression Scale.ResultsThe families of the 28 patients were followed up for a median duration of 3 years; 6 (21.4%) patients died within 6 months after discharge, 12 (42.9%) patients had moderate to severe dysfunction, and only 10 (35.7%) patients had good outcomes. Regarding the 22 parents of the survivors, 5 (22.7%) and 4 (18.2%) had borderline anxiety and depression symptoms, respectively. Two (9.1%) caregivers had exact anxiety and depression symptoms. Leukomalacia after intraventricular haemorrhage was associated with adverse neurological outcomes. The infants' histories of epileptic seizures during the neonatal period were associated with the anxiety of their parents.ConclusionThe overall outcome of posthemorrhagic hydrocephalus patients is unsatisfactory, and children with leukomalacia after haemorrhage tend to have poor outcomes. A history of epileptic seizures during the course of the disease may exacerbate the anxiety of the caregivers.

Outcome in Childhood Stroke: Comparing Functional Outcome by Modified Rankin Scale with Neurological Outcome by Pediatric Stroke Outcome Measure

AbstractDifferent scales are used as outcome predictors following arterial ischemic stroke (AIS) in children. Pediatric stroke outcome measure (PSOM) gives information about neurological deficits and function and modified Rankin scale (mRS) about functional outcome. Research examining the relationship between the two measures is scarce. The aim of this study is to correlate the two different scales and to get some information on the long course of outcomes according to these outcome measures. Sixty-one children with the diagnosis of AIS and normal neurodevelopment prior to stroke were investigated. Results of outcome measures (PSOM and mRS) from ≥ 2 years of follow-up were analyzed. Changes of neurological deficits (subcategories of PSOM) over time (discharge, 6 months, and ≥2 years) and prognostic impact on the outcome of the Pediatric National Institutes of Health Stroke Scale and etiology/risk factors are presented.Cramer's V with a coefficient of 0.836 (df-1) indicates a strong association between dichotomized total PSOM and mRS scores. The correlation between the total scales was strong (rho = 0.983, p &lt; 0.001). The correlation coefficient was highest for sensorimotor (rho = 0.949, p &lt; 0.001), then for language (rho = 0.464, p &lt; 0.001) and cognitive (rho = 0.363, p = 0.004) subscales. PSOM scores improved at 6 months compared to the discharge state in sensorimotor (p&lt;0.001) and language (p&lt;0.026) domains, however, there was no statistically significant difference between PSOM scores at 6 months and &gt;2 years follow-up. There was no improvement in cognitive PSOM scores during the follow-up period.There was a high concordance level between the two scales, illustrating that long-term neurological deficits after stroke are related to poor functional outcome. Significant improvement of sensorimotor and language function happened within the period from onset to 6 months of follow-up. Thus, early mobilization of appropriate rehabilitative therapy might improve the outcome. We conclude that both outcome classifications are applicable for assessing outcome after childhood AIS.

Abstract TP159: Association Of Lesion Characteristics And Neurological Outcomes In Neonatal Arterial Ischemic Stroke Patients

Background: Neonatal arterial ischemic stroke (NAIS) occurs as a result of an acute focal cerebral arterial infarction between birth and 28 days of life in nearly 1:2500 live births. As there are few studies examining the relationship between NAIS lesion characteristics and clinical outcomes, this study aims to determine if lesion volume and lesion location are associated with abnormal neurological outcomes in NAIS. Methods: Semi-automated lesion segmentation of co-registered multi-modal images was conducted using ITK-SNAP. Semi-automated lesion segmentations with manual corrections were performed using ITK-SNAP software. Lesion volumes were corrected for head size by dividing lesion volumes by total intracranial volume, and correlated (using Kendall's Tau-b [τ b ]) with neurological outcome that was assessed with the Pediatric Stroke Outcome Measure (PSOM). Results: Participants included N=20 NAIS patients (mean [M] weeks gestation=39.5, +/-1.64; 55% male, 70% single infarct, 75% left-sided lesions). Outcome was assessed an average of 312, +/-7.6 days post-stroke. Neurological deficits were present in 50% (with seizures in 85%) at time of stroke, and infarct locations most commonly involved supratentorial cortical structures (75%), however none were correlated with outcome. Larger lesion volumes (M=5.35 mm 3 , +/-0.069) were correlated with poor outcome (τ b =.444, p=0.02). Conclusion: We found larger lesion volume to be associated with atypical clinical outcomes following NAIS. Further analysis is in progress that include changes over time in lesion characteristics and outcome. These results demonstrate a need for better characterize the relationship between lesion characteristics and outcomes in NAIS.

Abstract 159: Impact Of Health Inequities On Outcomes Of Stroke In Children

Introduction: Recent studies have reported access to initial imaging and underlying chronic disorders to be associated with post-stroke outcome in children. However, the influence of sociodemographic factors is yet to be investigated within the Canadian context. Our study explored the role of health inequities while considering the influence of clinical and radiological factors on post-stroke outcomes. Methods: A consecutive cohort of children &amp;gt;28 days-18 years of age diagnosed with arterial ischemic stroke between 2004 and 2019 at a comprehensive stroke centre in Ontario were included. Patient residential postal codes were linked to the Ontario Marginalization Index including area-level data on income, education, single-parent families, and housing quality. Post-stroke outcomes were assessed using the validated Pediatric Stroke Outcome Measure - Severity Classification System (PSOM-SCS). Poor outcome was defined as moderate-to-severe deficit at discharge or at 18 months from the onset of stroke. Univariable and multivariable logistic regression models were developed to examine the influence of material deprivation on neurological outcomes while controlling for demographic, clinical, and radiological factors. Results: Amongst 234 children, predictors of poor outcome at discharge included moderate-to-severe stroke at presentation (OR = 4.00, p &amp;lt; 0.05) while the presence of a single infarct may protect the patient from poor outcome at discharge (OR = 0.32, p &amp;lt; 0.05). Predictors of poor outcome at 18 months post-stroke included patients from moderately deprived neighborhoods (OR = 5.36, p &amp;lt; 0.05), stroke onset between 2014 and 2019 (OR = 7.44, p &amp;lt; 0.05), or presence of a left cerebral hemispheric infarction (OR = 8.20, p &amp;lt; 0.05). Conclusion: Our study demonstrated that stroke severity and the number of infarcts were important in determining outcome at discharge whereas neighbourhood-level material deprivation, year of onset, and infarct location predicted outcome at 18 months from the onset of stroke. Further research is needed to explore the role of broader social determinants of health in predicting stroke outcomes longitudinally over time.

Abstract TMP22: Exploring The Impact Of Material Deprivation, Clinical, And Radiological Features On Neurological Outcomes Of Neonatal Stroke

Introduction: Neonatal arterial ischemic stroke (AIS) is an important cause of neurologic disability in children. No research to date has examined the influence of determinants of health on outcomes in a neonatal AIS population. This study examined whether neighbourhood-level material deprivation was associated with long-term neurological outcomes in neonatal AIS patients, after accounting for the influence of clinical and radiological factors. Methods: Patients with neonatal AIS between 2004 and 2019 at a comprehensive stroke centre were included. The Ontario Marginalization Index (ON-Marg) was used to assess neighbourhood-level material deprivation. Participant postal codes were linked to census data and ON-Marg scores were reported. Neurological outcomes were assessed using the Pediatric Stroke Outcome Measure Severity Classification Scale (PSOM-SCS) at latest follow up (median = 49 months, range = 12 to 187 months). A poor outcome was defined as any neurologic deficit (i.e., mild, moderate, or severe). Univariable and multivariable logistic regression models were developed. Results: Amongst 154 participants, the majority of scores (66.23%) were within the normal range. Remaining participants demonstrated neurological deficits, including 25.97% mild and 7.79% moderate-to-severe. Predictors of poor outcome in the multivariable model included hemiparesis at stroke presentation (OR = 12.81, p &amp;lt; 0.05) and basal ganglia involvement (OR = 3.68, p &amp;lt; 0.05). Neighbourhood-level material deprivation was not significantly associated with poor outcome. Conclusions: Hemiparesis and basal ganglia involvement are important in determining long-term outcomes. Although material deprivation was not associated with poor outcomes in our study, it may be associated with neurological outcomes at later ages. Further research is needed to understand the role of socioeconomic factors in a neonatal stroke population, including the measurement of individual-level indicators and outcomes at later ages post-stroke. While outcomes after neonatal stroke are generally favourable, identifying predictors of poor outcomes may assist clinicians in developing a more precise risk evaluation regarding recovery after stroke.

Dynamics of clinical and neurological parameters and role of citicoline during therapeutic interventions in children with stroke

Aim: The rehabilitation of children who experience stroke is hampered by the lack of proven treatments and the choice of drugs and dosages. We compared clinical and neurological parameters in children receiving citicoline. Materials &amp; methods: We assessed 199 children (128 boys, 64.3%) with stroke using the Pediatric Stroke Outcome Measure–Short Neurological Exam. Results: Hemorrhagic infarction was diagnosed more often than ischemic stroke, most often owing to the child’s early age (before and after 3 months). The presence of disorders of consciousness in the most acute and acute periods is noteworthy. Conclusion: The Pediatric Stroke Outcome Measure–Short Neurological Exam scale can be used to predict adverse outcomes. Citicoline can be administered early and is especially effective during the first year of life.

Hyperacute Perfusion Imaging Before Pediatric Thrombectomy: Analysis of the Save ChildS Study.

Perfusion imaging can identify adult patients with salvageable brain tissue who would benefit from thrombectomy in later time windows. The feasibility of obtaining hyperacute perfusion sequences in pediatric stroke is unknown. The aim of this study was to determine whether contrast perfusion imaging delayed time to treatment and to assess perfusion profiles in children with large vessel occlusion stroke. The Save ChildS retrospective cohort study (January 2000-December 2018) enrolled children (1 month-18 years) with stroke who underwent thrombectomy from 27 European and U.S. stroke centers. This secondary analysis included patients with anterior circulation occlusion and available imaging for direct review by the neuroimaging core laboratory. Between-group comparisons were performed using the Wilcoxon rank-sum exact test for continuous variables or Fisher exact test for binary variables. Given the small number of patients, evaluation of perfusion imaging parameters was performed descriptively only. Of 33 patients with available neuroimaging, 15 (45.4%) underwent perfusion (CT perfusion n = 6; MR perfusion n = 9); all were technically adequate. The median time from onset to recanalization did not differ between groups {4 hours (interquartile range [IQR] 4-7.5) perfusion+; 3.4 hours (IQR 2.5-6.5) perfusion-, p = 0.158}. Target mismatch criteria were met by 10/15 (66.7%) patients and did not correlate with reperfusion status or functional outcome. The hypoperfusion intensity ratio (HIR) was favorable in 11/15 patients and correlated with older age but not NIHSS, time to recanalization, or stroke etiology. Favorable HIR was associated with better functional outcome at 6 months (Pediatric Stroke Outcome Measure 1.0 [IQR 0.5-2.0] vs 2.0 [1.5-3.0], p = 0.026) and modified Rankin Scale 1.0 [0-1] vs 2.0 [1.5-3.5], p = 0.048) in this small sample. Automated perfusion imaging is feasible to obtain acutely in children and does not delay time to recanalization. Larger prospective studies are needed to determine biomarkers of favorable outcome in pediatric ischemic stroke and to establish core and penumbral thresholds in children.

Closing the Gap in Pediatric Hemorrhagic Stroke: A Systematic Review

Pediatric hemorrhagic stroke (HS) accounts for a large proportion of childhood strokes, 1 of the top 10 causes of pediatric deaths. Morbidity and mortality lead to significant socio-economic and psychosocial burdens. To understand published data on recognizing and managing children with HS, we conducted a systematic review of the literature presented here. We searched PubMed, Embase, CINAHL and the Cochrane Library databases limited to English language and included 174 studies, most conducted in the USA (52%). Terminology used interchangeably for HS included intraparenchymal/intracranial hemorrhage, spontaneous ICH, and cerebrovascular accident (CVA). Key assessments informing prognosis and management included clinical scoring (Glasgow coma scale), and neuroimaging. HS etiologies reported were systemic coagulopathy (genetic, acquired pathologic, or iatrogenic), or focal cerebrovascular lesions (brain arteriovenous malformations, cavernous malformations, aneurysms, or tumor vascularity). Several scales were used to measure outcome: Glasgow outcome score (GOS), Kings outcome score for head injury (KOSCHI), modified Rankin scale (mRS) and pediatric stroke outcome measure (PSOM). Most studies described treatments of at-risk lesions. Few studies described neurocritical care management including raised ICP, seizures, vasospasm, or blood pressure. Predictors of poor outcome included ethnicity, comorbidity, location of bleed, and hematoma &gt;2% of total brain volume. Motor and cognitive outcomes followed independent patterns. Few studies reported on cognitive outcomes, rehabilitation, and transition of care models. Interdisciplinary approach to managing HS is urgently needed, informed by larger cohort studies targeting key clinical question (eg development of a field-guide for the clinician managing patients with HS that is reproducible internationally).

Clinical features and outcomes of paediatric moyamoya vasculopathy in Malaysia

Background: Moyamoya vasculopathy (MMV) is a chronic progressive occlusive cerebrovascular disease causing recurrent strokes in children. We describe the clinical features, treatment and outcomes of childhood MMV in Malaysia; and compared their neurological outcome with the published literature. Methods: A retrospective study between 2005–2020 of Malaysian children with MMV seen at 4 tertiary Malaysian hospitals. Their post-stroke outcomes were assessed using the modified Rankin scale (mRS) and Pediatric Stroke Outcome Measure (PSOM). Results: Twenty one cases were included with a median age of presentation at 5.8 years and a median follow-up period of 4.6 years. The female-to-male-ratio was 2:1. All patients had acute ischaemic cerebrovascular accidents. The anterior cerebral circulation was affected in all cases with additional three having also posterior circulation involvement. Among 17 (81%) patients neuroimaging showed bilateral moyamoya. Eight (30%) had preceding febrile illness and the commonest presenting symptom was hemiparesis seen in 8 (38%). Seven (35%) had surgical revascularisation whilst the remainder opted for conservative management. Nineteen (90%) achieved a good stroke outcome but 2 had a poor PSOM outcome and 1 also had a poor mRS outcome. Both these patients declined surgical revascularisation. Conclusion: Our cohort demonstrated the following MMV features: young age at the first presentation, female and Chinese preponderance; the main type of MMV was moyamoya disease; and ischaemic stroke as the commonest presentation. The overall neurological and functional outcomes were good despite the parental preference on medical therapy over surgical revascularization.

Pediatric Stroke: The Clinical and Etiological Spectrum: An Observational Study from a Tertiary Care Stroke Clinic, Kolkata, India

In different geographical regions, the clincoetiological spectrum of childhood stroke varies widely and studies from Eastern India is lacking. To determine the clinicoetiological spectrum of childhood stroke and their outcome. This study was conducted in a stroke clinic of a tertiary care hospital of Kolkata over a period of 18 months. All children below 12 years diagnosed as stroke were included. On the basis of clinical examination, relevant laboratory investigations and radioimaging etiologies were determined. Appropriate statistical methods were used to analyze the data gathered from these patients using a preformed proforma. Among the 70 pediatric stroke patients, the most common clinical presentation was found to be hemiparesis (61.42%) followed by seizure (30.00%) and aphasia (25.71%), respectively. Vasculopathies (30.00%) were found to be the most common etiology of childhood stroke followed by infective meningoencephalitis and craniocervical trauma (14.28% each). Ischemic stroke comprised 71.4% of cases. During discharge, 20 cases (28.57%) showed complete recovery, whereas 40 cases (57.14%) had persistent neurodeficit [Pediatric Stroke Outcome Measure (PSOM) score >1], 12 cases (17.14%) had recurrent stroke, 8 cases (11.42%) died, and only 2 (2.85%) patients were lost to follow-up. Out of those 40 cases having persistent neurodeficits during discharge had recovered too at follow-up at 18th month. At presentation PSOM score in 40 cases (57.14%) was >5 and at follow-up at 18th month, only 8 cases (11.42%) had PSOM score of >5. The commonest etiologies of stroke in pediatric patients presenting at our hospital were found to be intracranial vasculopathies, infection, and trauma. Ischemic stroke was the predominant type. Eighteen-month follow-up showed complete recovery from acute neurological deficits in most of the patients. Dubey S, Ghosh R, Chatterjee S, et al. Pediatric Stroke: The Clinical and Etiological Spectrum: An Observational Study from a Tertiary Care Stroke Clinic, Kolkata, India. Indian J Phys Med Rehab 2019;30(3):74–80.