Pediatric Stroke Patients Research Articles

Arterial Ischemic Stroke in Pediatric Patients: A Tertiary Hospital Experience

Arterial Ischemic Stroke in Pediatric Patients: A Tertiary Hospital Experience

Indirect bypass surgery as a line of management of pediatric moyamoya disease

Moyamoya disease (MMD) is a chronic, rare cerebrovascular disorder of unknown cause featured by extensive narrowing of the terminal internal carotid artery (ICA) and its main branches. As a compensatory mechanism, perforators dilate forming fragile collateral vessels that appear as an abnormal vascular network resembling ‘puff of smoke drifting in the air’ observed via angiography around stenotic area in the brain.Patients and methodsThe database of the current hospital was retrospectively studied. All patients with ischemic strokes owing to MMD treated with surgical revascularization between January 2015 and December 2022 were included. MMD was identified on catheter-based digital subtraction angiography (DSA) by the presence of stenosis at the terminal portions of both internal carotid arteries and the development of abnormal collateral “moyamoya vessels” around the base of the brain. Clinical, radiological and follow-up data were retrospectively analyzed.ResultsDuring the mentioned time window, nine patients were diagnosed with moyamoya disease among all pediatric patients with established diagnosis of ischemic stroke in our institute; six of them underwent surgery. Unilateral EDMS was performed in 5 cases (83.3%), while one patient (16.67%) underwent staged bilateral surgeries with no added neurological deficit.ConclusionIndirect revascularization surgery for pediatric moyamoya-related stroke patients has high rates of reperfusion and promising outcomes.

Abstract TMP11: Cerebral Visual Impairment in Pediatric Stroke Patients Assessed by Virtual Reality Testing

Introduction: Pediatric stroke is one of the leading causes of disability in children, many of whom incur brain injury affecting critical visual anatomical networks. Dedicated ophthalmologic examinations that detect cerebral visual impairment (CVI) - the leading cause of congenital visual impairment in developed countries - are not standard of care and can delay diagnosis and interventions. There is limited CVI data in pediatric stroke patients, and in this work we present data defining visual processing deficits in pediatric stroke patients. Hypothesis: We hypothesize that pediatric stroke patients will (1) demonstrate greater visual-spatial processing impairments than controls and (2) demonstrate increasing performance impairment as a function of increasing visual task demands. Methods: Using a virtual reality (VR) based visual search task system, we characterized significant deficits in higher-order visual processing of pediatric stroke patients (n = 17) as compared to healthy controls (n = 13). Stroke patients suffered from a perinatal (n = 8) or pediatric (n = 9) stroke - confirmed with brain MRI - affecting various vascular territories of the anterior and posterior circulations. The task required searching for on-screen targets with increasing visual complexity. Metrics such as reaction time, gaze error, shifted ellipse area, success rate, and pursuit saccade ratio were analyzed using unpaired group-level t-tests and considered significant if p < 0.05. Results: Stroke patients took longer to identify the target (p = 0.001), were less accurate in finding it (p = 0.007), and exhibited greater impairment in performance with an increasing number of distractors compared to healthy children. Groups had comparable task compliance, as indexed by an off-screen count metric. Conclusion: This original work demonstrates that pediatric stroke patients, particularly those with strokes affecting the middle cerebral artery and posterior circulation vascular territories, exhibit impaired higher-order visual processing. This highlights the urgent need for standardized clinical testing to provide quantitative performance measures of cortical visual processing. This will allow timely detection and implementation of interventional therapies.

A scoping review of cerebral reperfusion therapies in childhood and adolescence with arterial ischemic stroke

AbstractBackgroundManagement of pediatric stroke is challenging because of the paucity of data supporting the efficacy of interventions. This scoping review details the treatments available for the acute phase of stroke in pediatric patients with arterial ischemic stroke.Summary of ReviewOverall, 68 relevant articles were published between 2001 and 2023. The primary study included 48 case reports (n = 48). Eleven articles reported the use of intravenous thrombolysis (IVT) with alteplase, eight used intra‐arterial (IA) alteplase, and 52 reported mechanical thrombectomy (MT). IVT was administered to 195 patients with a median of 5.5 h of stroke onset, and only four (2.0%) had intracranial hemorrhage after alteplase treatment. Of the 11 articles, nine used 0.9 mg/kg IVT administered as a 10% bolus, with the remaining 90% administered over one hour, and one study used 0.54 mg/kg. IA was performed in 17 patients with a median of 5.05 h of stroke onset, and three individuals (17.6%) had intracranial hemorrhage. Of the eight reports that document IA, two used 0.9 mg/kg; one each used 0.16 mg/kg, 0.1 mg/kg, 0.6 mg/kg, 100 mg/day, and 10 mg/day; and one article documented the use of urokinase 750 000 IU. MT was used in 434 and 215 individuals in a previous systematic review, with a median of 11.82 h of stroke onset, and only 2.9% had intracranial hemorrhage after the treatment. Stent retrievers were used in 33 reports (63.5%) and aspiration retrievers were mentioned in 15 articles (28.8%). Overall, the outcomes ranged from complete to moderate recovery for all modalities.ConclusionsIVT and MT are safer than IA; however, despite the lack of clinical trials, all modalities seem effective in improving clinical recovery. To guide clinical practice and determine better intervention modalities, clinicians should note the key messages from this review, such as using magnetic resonance imaging in the acute phase and identifying key risk factors and presenting symptoms.

Abstract 121: Misdiagnosis in a case of pediatric stroke

Introduction Pediatric patients presenting with atypical stroke symptoms pose a diagnostic challenge, which often causes delays in management. Around a quarter of pediatric stroke patients will present with new onset seizures. We report this case to emphasize the importance of early consideration of ischemia as a differential diagnosis. We also want to emphasize the collaborative approach between pediatric and adult neurologists in challenging cases. Methods Case report Results A 15‐year‐old male presented to an outside hospital for new onset seizure. The patient later mentioned that he had difficulty writing the morning of the seizure. Initial blood work, CBC, CMP, urine analysis and toxicology were unremarkable. A second seizure occurred while in the ED. CT head revealed a questionable area of decreased attenuation in the left frontal lobe, felt to be artifact. Patient was transferred to our hospital for higher level of care. MRI of the brain showed gyriform signal abnormality within the left frontal lobe with restricted diffusion, no abnormal enhancement. Serum MOG, NMDA, LGI1, NMO antibodies were sent. LP was done and there was no evidence of infection. MRI of the C, T and L spine were unremarkable. CTA/CTV of the head was done and there was no evidence of vessel abnormalities or sinus thrombosis. Patient was started on high dose steroids for possible autoimmune etiology on hospital day 2. On Hospital Day 3, the case was re‐evaluated, and the possibility of infarction was proposed. The case was discussed with an adult vascular neurology attending physician, thus further imaging was obtained. CT Perfusion of Brain revealed a subacute left frontal infarct and possible dural AVF. A diagnostic cerebral angiography revealed enhanced capillary blush consistent with shunt in region of left peri‐Sylvian infarct. There was no evidence of other vascular malformations. A hypercoagulable panel was unremarkable. The patient was discharged on Hospital Day 6 on Vimpat and aspirin with outpatient follow‐up. Echo revealed a PFO on Valsalva maneuver. MRI spectroscopy revealed depressed creatine peak, low NAA and a high choline peak in the left frontal opercular T2 hyperintensity ‐ findings consistent with an evolving infarct with increased choline due to gliosis. He is planned for PFO closure and has not had further recurrent seizures. Conclusion According to Hollist et al., pediatric stroke incidence is 2.5‐13 per 100,000 children per year [1]. There are thousands of stroke misdiagnoses every year [2]. Stroke misdiagnosis is more likely in younger patients [2, 3]. 60% of pediatric stroke patients will end up with disability and half will have a decreased quality of life [4]. Misdiagnosis also results in misutilization of health care resources. Similar to our case, a collaborative approach between adult stroke neurologists and pediatric neurologists, where pediatric stroke neurologists are not available, helps avoid stroke misdiagnosis. As a result, this helps better patient outcomes and avoids preventable morbidity and mortality.

Incidence, Characteristics, and Outcomes of Stroke in Pediatric Patients with Celiac Disease.

(1) Background: Celiac disease (CD) can cause long-term inflammation and endothelial dysfunction and has been cited as a risk factor for acute ischemic stroke (AIS) in pediatric patients. However, the rate and outcomes of AIS in pediatric patients with CD has not been explored in a large population. Our objective is to explore the rate, severity, and outcomes of CD amongst pediatric AIS patients on a nationwide level. (2) Methods: The National Inpatient Sample (NIS) database was queried from 2016 to 2020 for pediatric patients with a principal diagnosis of AIS. Patients with a concurrent diagnosis of CD (AIS-CD) were compared to those without (AIS). Baseline demographics and comorbidities, clinical variables of severity, hospital complications, and the rates of tissue plasminogen activator (tPA) and mechanical thrombectomy were compared between the two groups. The main outcomes studied were mortality, discharge disposition, length of stay (LOS), and total hospital charges. (3) Results: Of 12,755 pediatric patients with a principal diagnosis of AIS, 75 (0.6%) had concurrent CD. There were no differences in the severity, discharge disposition, or mortality between the AIS-CD and AIS patients. Patients with AIS-CD were more likely to receive tPA at an outside hospital within 24 h of admission (p < 0.01) and more likely to undergo mechanical thrombectomy (p < 0.01) compared to the AIS patients. (4) Conclusions: CD patients made up only 0.6% of all pediatric AIS patients. No differences in the severity, mortality, or discharge disposition suggests a minimal to absent role of CD in the etiology of stroke. The CD-AIS patients were more likely to receive a tPA or undergo a mechanical thrombectomy; studies are needed to confirm the safety and efficacy of these interventions in pediatric patients.

301 Natural History and Treatments of The Pediatrics’ Deep-Seated Brain Arteriovenous Malformations

INTRODUCTION: Literature is sparse about the hemorrhage risk associated with the pediatrics’ deep-seated brain AVMs (bAVMs) during the natural history and after treatment. METHODS: We retrospectively reviewed our institutional bAVM database from 1990 to 2019 and included pediatrics who had deep-seated bAVMs. We presented the annual hemorrhage risk; during the natural history and after treatments, and functional outcomes. RESULTS: After the screening of 914 patients, 31 pediatric cases; including 13 males and 18 females, with the mean (SD) age of 11.8 (4.4) were included. The most frequent presenting symptoms were headache (54.83%), weakness (38.7%), and seizure (22.5%). The mean (SD) of followed-up duration was 13.14 (12.5) years, during which 7(22.5%) AVMs were found obliterated, 10 (32.2%) individuals sustained hemorrhage, and the modified Rankin Score (mRS) worsened in 8 (25.8%) patients. The annual hemorrhage risk of natural history was 3.26% per patient, and the overall annual hemorrhage risk after treatment was 1.97% per patient. The annual hemorrhage risk in each treatment group was 0.64% per patient in radiosurgery, 6.3% per patient in surgery, and 6.29% per patient in embolization. Those with non-white race showed a trend of higher ruptured presentation (OR = 5 [0.84-41.68], p = 0.09). Female sex was associated with higher (OR = 13.076 [1.424-333.591], p = 0.048) and treatment radiosurgery was associated with lower (OR = 0.21 [0.03-1.02], p = 0.06) odds of follow-up hemorrhage. Headache presentation was associated with the lower odds of poor functional outcome (OR = 0.102 [0.011-0.670], p = 0.024). CONCLUSIONS: Given the substantial cumulative risk of lifelong hemorrhagic stroke in pediatric patients, timely definitive treatment is warranted. Radiosurgery treatment is beneficial when the risk-benefit profile is deemed favorable.

Abstract 64: Screening For Psychosocial Health In Pediatric Stroke

Introduction: Impaired psychosocial health after stroke in adults is well established, with high prevalence of post-stroke anxiety and depression. Behavioral health following pediatric stroke is less well described. Early data suggest that pediatric stroke patients may experience higher rates of anxiety, depression, ADHD and PTSD. Early detection and treatment of behavioral health concerns can lead to improved psychosocial outcomes. However, screening measures to assess psychosocial functioning in pediatric stroke patients have not yet been explored. Methods: This single-center retrospective cohort study (COMIRB 21-3536) examined behavioral health following pediatric stroke using the Pediatric Symptom Checklist (PSC-17) at an outpatient stroke clinic. The PSC-17 screens for a broad range of behavioral health symptoms including internalizing, externalizing, and attention concerns. This dataset included patients with a diagnosis of ischemic stroke, hemorrhagic stroke, CSVT, or periventricular venous infarction (PVI) between 0-18 years of age. Comparison data included all children seen at general outpatient pediatric appointments. Chi-square goodness of fit tests were performed to compare elevated PSC-17 score proportions in children with stroke to proportions found in the general pediatric population. Results: We identified 65 pediatric stroke patients with a parent-reported PSC-17. Global, internalizing, and externalizing scores were higher among pediatric stroke patients compared to the general pediatric population, but there was no statistically significant difference in attention measures. Conclusions: The PSC-17 identifies a higher prevalence of psychosocial health concerns among children who have experienced a stroke as compared to the general pediatric population. The PSC-17 may serve as an effective screening tool to identify pediatric stroke patients who may benefit from further psychosocial evaluation.

Abstract NS3: Are You Ready For Your Pediatric Stroke Patient?

Background: Our Comprehensive Stroke Center (CSC) located in Atlanta, had a pediatric patient present with stroke symptoms to our ED. We did not have a plan except to transfer to the closest Children’s Hospital approximately 15 miles away which In Atlanta, can be a 45-minute travel time. Our seasoned CSC treats over 2000 adult stroke patients annually however was not prepared for our pediatric patient population. After the patient was successfully enroute to Children's Hospital, a team quickly assembled to debrief and discuss a plan to treat. Since our hospital does not have a Pediatric Intensive Care, a "Drip and Ship" model would be the focus of care. Our hospital is a level 2 trauma center therefore keeping within the age range of &gt;14 through the 18th birthday. Purpose: Develop a "Drip and Ship" model for pediatric stroke patients using best practice for stroke treatment inside ages 14- &lt;18 years of age. This model utilizes our available Pediatric Emergency and Neurology teams while keeping the patient and family at the center of our care. Methods: Phase I included a interdisciplinary planning committee to review current literature, treatment parameters, medications, and dosing for the pediatric population related to acute stroke treatment. Risk assessment to ensure patient safety was a top priority for each step of the process. Clinical Practice Guidelines supports the rationale behind treating the pediatric stroke patient and transport to the Children’s Hospital. Phase II will include Neuro Endovascular evaluation for potential treatment with thrombectomy and subsequent admission to our Neuro ICU. Results: A “Drip and Ship” protocol was developed using evidence-based literature to guide emergent brain imaging, immediate consultation with Pediatric Neurologist and dosing guidelines for IV Alteplase. The team identified parameters and treatment for hypertension, angioedema and hemorrhagic conversion included in the newly developed pediatric stroke order set and Alaris pump build. Finally, a family centered brochure explaining the treatment for stroke along with directions to the Children’s Hospital completed this phase.

Pediatric Sickle Cell Disease and Stroke: A Literature Review.

Both ischemic and hemorrhagic strokes in children can be a complication of sickle cell disease, which also affects adults. The occurrence is high without any screening or preventative care.This review article found that although transcranial Doppler (TCD) has reduced the prevalence of stroke in pediatric patients, there is still a need for an epidemiological survey to define such screening for adults, the ideal dose of hydroxyurea to reduce the incidence of stroke, and to identify silent cerebral stroke to prevent its complications. Increased hydroxyurea prescription and specific antibiotic and vaccination regimes lowered the occurrence of this condition. In pediatric cases with a time-averaged mean of the maximal velocity greater than 200cm/s, transcranial Doppler screeningand preventive chronic transfusion for at least the first year have lowered the occurrence of stroke by up to 10 times. The ideal dose of hydroxyurea is still debatable, but it seems to reduce the risk of the first stroke to a comparable level in the average population. Adult ischemic and hemorrhagic stroke prevention has not yet received the same attention. Though there are fewer studies, sickle cell disease is also more common than age-matched controls in terms of silent cerebral infarctionon magnetic resonance imaging (MRI),as well as other neurological problems such as cognitive impairment, seizures, and headaches. Currently, there is no evidence-supported way to prevent ischemic stroke in adults at any age. Also, there is no defined ideal dose of hydroxyurea that can be helpful in preventing strokes. Data also lack a way to identify a silent cerebral infarction, so its complications can be prevented. An additional epidemiological survey may help in the prevention of the condition. The primary aim of this article was to emphasize the importance of information on clinical, neuropsychological, and quantitative MRI assessment of sickle cell patients to understand the epidemiology and etiology of stroke in sickle cell patients to prevent stroke and its related morbidity.

Natural history and treatment of deep-seated brain arteriovenous malformations in pediatric patients.

Pediatric deep brain arteriovenous malformations (bAVMs) represent a unique management challenge given their higher cumulative risk of hemorrhage as well as a higher risk of treatment. Better understanding of hemorrhage risk in this patient population will lead to a better decision-making process for patient management. The authors retrospectively reviewed their institutional bAVM database from 1990 to 2019 and included patients younger than 21 years who had deep-seated bAVMs. They present the annual hemorrhage risk, during the natural history and after treatment, and functional outcomes. Thirty-one pediatric patients were included in this study (13 males and 18 females) with a mean age of 11.8 (SD 4.4) years. The most frequent presenting symptoms were headache (54.8%), weakness (38.7%), and seizure (22.6%). The mean follow-up duration was 13.14 (SD 12.5) years, during which 7 (22.6%) AVMs were obliterated, 10 (32.3%) individuals experienced hemorrhage, and the modified Rankin Scale score worsened in 8 (25.8%) patients. The annual natural history risk of hemorrhage was 3.24% per patient, and the overall annual hemorrhage risk after treatment was 1.98% per patient. In particular, the risk was reduced to 0.64% per patient in the stereotactic radiosurgery (SRS) group. Non-White race showed a trend of higher rupture at presentation (OR 5 [95% CI 0.84-41.68], p = 0.09). Female sex was associated with higher odds (OR 13.076 [95% CI 1.424-333.591], p = 0.048) and SRS was associated with lower odds (OR 0.122 [95% CI 0.011-0.862], p = 0.049) of follow-up hemorrhage. Given the substantial cumulative risk of lifelong hemorrhagic stroke in pediatric patients, timely definitive treatment is warranted. SRS may be beneficial when the risk-benefit profile is deemed acceptable.

Impact of edema formation on functional outcome in pediatric stroke patients.

Quantitative lesion net water uptake (NWU) has been described as an imaging biomarker reflecting vasogenic edema as an early indicator of infarct progression. We hypothesized that edema formation measured by NWU is higher in children compared to adults but despite this functional outcome may be better in children. This study analyzed children enrolled in the Save ChildS Study who had baseline and follow-up computed tomography available and the data were compared to adult patients. Some 207 patients, of whom 13 were children and 194 were adults, were analyzed. Median NWU at baseline was 7.8% (IQR: 4.3-11.3), and there were no significant differences between children and adults (7.5% vs. 7.8%; p=0.87). The early edema progression rate was 3.0%/h in children and 2.3%/h in adults. Median ΔNWU was 15.1% in children and 10.5% in adults. Children had significantly more often excellent (mRS 0-1; children 10/13=77% vs. adults 28/196=14%; p < 0.0001) and favorable clinical outcomes (mRS 0-2, 12/13=92% vs. 39/196=20%; p < 0.0001). In this study, clinical outcomes in children with large vessel occlusion strokes were better than in adults despite similar clinical and imaging characteristics and similar edema formation. This may be impacted by the generally better outcomes of children after strokes but may demonstrate that the degree of early ischemic changes using Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and edema progression rate may not be a reason for exclusion from endovascular thrombectomy.

Neuroimaging in Pediatric Stroke

Pediatric stroke is unfortunately not a rare condition. It is associated with severe disability and mortality because of the complexity of potential clinical manifestations, and the resulting delay in seeking care and in diagnosis. Neuroimaging plays an important role in the multidisciplinary response for pediatric stroke patients. The rapid development of adult endovascular thrombectomy has created a new momentum in health professionals caring for pediatric stroke patients. Neuroimaging is critical to make decisions of identifying appropriate candidates for thrombectomy. This review article will review current neuroimaging techniques, imaging work-up strategies and special considerations in pediatric stroke. For resources limited areas, recommendation of substitute imaging approaches will be provided. Finally, promising new techniques and hypothesis-driven research protocols will be discussed.

Generating Items for a Novel Bedside Dysphagia Screening Tool Post Acute Pediatric Stroke.

Bedside dysphagia assessment protocols are not well developed in acute pediatric stroke unlike adults. The objective of this study was to identify items deemed relevant and feasible by expert consensus to inform the development of a bedside dysphagia screening tool for acute pediatric stroke. A two-phase study was conducted: (1) literature review and expert consultation generated a comprehensive list of dysphagia assessment items; (2) items were formatted in an online survey asking respondents opinion of relevance to acute pediatric stroke and feasibility for bedside administration by a trained health professional. The Dillman Tailored Design approach optimized response rate. Respondents were identified using the snowball method. Speech-language pathologists with > 2years in pediatric dysphagia were invited to complete the survey. Demographic and practice variables were compared using univariate statistics. Item relevance and feasibility were made using binary or ordinal responses, combined to derive item-content validity indices (I-CVI) to guide item reduction. Items with I-CVI > 0.78 (excellent content validity) were moved forward to tool development. Of the 71 invited respondents, 57(80.3%) responded, of which 34(59.6%) were from North America. Sixty-one items were generated of which 4(6.6%) items were rated 'to keep'. These were face symmetry (I-CVI:0.89), salivary control (I-CVI:0.95), alertness (I-CVI:0.89) and choking (I-CVI:0.84). Of all respondents, 31(54.4%) endorsed swallowing trials, of which 25(80.6%) endorsed thin liquid by teaspoon (n = 17, 68%) or open cup (n = 20, 80%). We identified candidate items for bedside dysphagia screening with excellent content validity for acute pediatric stroke patients. Next steps include assessment of the psychometric value of each item in identifying dysphagia in children in the acute stage of recovery from stroke.

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.

Abstract TMP88: Development Of An Interprofessional Pediatric Stroke Program Across A Fourteen Hospital Healthcare System In Southern California

Background: An annual estimate of 1.0 to 2.0 in every 100,000 children are affected by stroke. The American Stroke Association (ASA) recommends the development of education programs to expand provider knowledge and establish systems to facilitate efficient pediatric stroke care. We embarked on establishing a regionwide, multidisciplinary pediatric stroke program consistent with the ASA goals of prompt recognition and management of stroke in pediatric patients across the organization’s 14 hospitals. Methods: In February 2020, we established a workgroup consisting of a stroke neurologist, pediatric physicians, stroke coordinators, clinical nurse specialists, nurse educators, clinical informaticists, and clinical nurses. The objectives were to standardize the pediatric stroke algorithms for the inpatient, emergency, and ambulatory settings; identify documentation tools specific for pediatric stroke; and develop education modules. The primary goal was immediate specialty consultation and transfer of pediatric stroke patients to the appropriate level of care. Nursing flowsheets were enhanced to include the Pediatric NIH Stroke Scale. The pediatric stroke education was designed as a multimodal program tailored for each professional role and work area. Education was implemented utilizing strategic methods to initiate (interactive online modules), reinforce (huddles, skills day), and sustain (annual updates) knowledge on pediatric stroke recognition, escalation, and management. Results: The organization’s pediatric stroke algorithms, documentation tools, and online modules raised awareness on this low-volume, high-risk pediatric condition. It is anticipated that referrals to the regional telestroke and the comprehensive stroke center will increase, resulting in timely treatment and better outcomes. Conclusion: Development of a regionwide pediatric stroke program requires the support and commitment from leadership and clinical stakeholders. Next steps for the organization’s pediatric stroke workgroup will include establishment of quality metrics relevant to pediatric stroke, including timeliness of subspeciality assessment and transfers, and initiation of emergent interventions.

Abstract WP173: Children’s Post-Stroke Expressive Language Outcomes Are Affected By Bilingual Exposure

Introduction: Approximately 2/3 of children face neurological deficits following arterial ischemic stroke (AIS). In neurotypical development, bilingualism is thought to confer certain linguistic and cognitive advantages. However, research on whether this may affect development in bilingual pediatric stroke patients is scarce. Objectives: To evaluate the effects of bilingual vs. monolingual exposure on language and cognitive outcomes in children following arterial ischemic stroke across two studies: (1) large-scale group analysis using the Pediatric Stroke Outcome Measure (PSOM); (2) exploratory case studies using neuropsychological measures. Methods: An institutional stroke registry and chart review were used to gather patient and stroke data, including the Pediatric Stroke Outcome Measure (PSOM) and standardized neuropsychological measures performed at several timepoints post-stroke in children with AIS. In Study 1, growth curve modeling based on PSOM subscales, predicted by age at stroke groups, language groups and their interactions was used. In Study 2, comparative case studies were conducted with a monolingual-bilingual pair, aged 7 and 8 at stroke onset. Results: In Study 1, 237 patients were identified (44%, bilingual patients). Patients were stratified based on age at stroke onset i.e. neonatal (&lt;28 days of life), first-year (28 days-12 months) and childhood (13 months - 18 years). On the PSOM’s language expression subscale, an interaction revealed better post-stroke outcomes among bilingual children aged 1-12 months at stroke (beta = -0.32, t =-2.33, p = 0.02). In Study 2, the bilingual’s performance on neuropsychological assessments corroborated findings of Study 1, favoring a recovery of expressive language. Conclusion: Overall, we found no negative consequences of a bilingual environment on post-stroke outcomes. Additionally, it is possible that bilingualism has a faciliatory effect on expressive language development post-stroke. Further research should evaluate linguistic advantage effects prospectively in bilingual children with stroke and a control group.

Cost-Effectiveness of Endovascular Thrombectomy in Childhood Stroke: An Analysis of the Save ChildS Study.

Background and Purpose The Save ChildS Study demonstrated that endovascular thrombectomy (EVT) is a safe treatment option for pediatric stroke patients with large vessel occlusions (LVOs) with high recanalization rates. Our aim was to determine the long-term cost, health consequences and cost-effectiveness of EVT in this patient population. Methods In this retrospective study, a decision-analytic Markov model estimated lifetime costs and quality-adjusted life years (QALYs). Early outcome parameters were based on the entire Save ChildS Study to model the EVT group. As no randomized data exist, the Save ChildS patient subgroup with unsuccessful recanalization was used to model the standard of care group. For modeling of lifetime estimates, pediatric and adult input parameters were obtained from the current literature. The analysis was conducted in a United States setting applying healthcare and societal perspectives. Probabilistic sensitivity analyses were performed. The willingness-to-pay threshold was set to $100,000 per QALY. Results The model results yielded EVT as the dominant (cost-effective as well as cost-saving) strategy for pediatric stroke patients. The incremental effectiveness for the average age of 11.3 years at first stroke in the Save ChildS Study was determined as an additional 4.02 lifetime QALYs, with lifetime cost-savings that amounted to $169,982 from a healthcare perspective and $254,110 when applying a societal perspective. Acceptability rates for EVT were 96.60% and 96.66% for the healthcare and societal perspectives. Conclusions EVT for pediatric stroke patients with LVOs resulted in added QALY and reduced lifetime costs. Based on the available data in the Save ChildS Study, EVT is very likely to be a cost-effective treatment strategy for childhood stroke.

Dynamic Changes of Collateral Vessels After Encephaloduroarteriosynangiosis in Moyamoya Disease: Childhood to Adulthood

Moyamoya disease (MMD) often presents as ischemic stroke in pediatric patients and hemorrhage in adults. This situation raises questions as to whether the phenotype of moyamoya disease changes with age. We performed self-precontrol and postcontrol observation monitoring until adulthood on abnormal collateral vessels (ACVs) with the potential risk of bleeding to evaluate the chance of further hemorrhage. Fifteen pediatric patients with >10 years angiography-based follow-up were analyzed. The Matsushima grades were divided into 2 groups (good group, representing Matsushima stage A; and mild group, representing Matsushima stages B and C) to investigate the relationship between Matsushima grades and ACVs derived from vessels likely to cause intracranial hemorrhage. Four patients (26.7%) had infarction type and 11 (73.3%) patients had transient ischemic attack type. No patient experienced late-onset cerebral hemorrhagic events. One patient experienced recurrent ischemic stroke 6 months after the second surgery and recovered completely after the third surgery. The angiography-based follow-up was conducted at least 10 years after theencephaloduroarteriosynangiosis (EDAS). The good Matsushima group showed a significant positive correlation with the reduction of the anterior choroidal artery (odds ratio, 56.00; P= 0.003), whereas the posterior communicating artery showed no significant decrease before and after the EDAS procedure (odds ratio, 2.00; P= 1.00). The EDAS procedure can effectively attenuate the dilation and ACVs of the anterior choroidal artery, which may reduce the incidence of further hemorrhage in adulthood.

Long-term clinical and radiographic outcomes after pial pericranial dural revascularization: a hybrid surgical technique for treatment of anterior cerebral territory ischemia in pediatric moyamoya disease.

Isolated anterior cerebral artery (ACA) territory ischemia in pediatric moyamoya disease (MMD) is rare but has been increasingly recognized, particularly in children manifesting progression of disease in a delayed fashion after middle cerebral artery revascularization surgery. Surgical treatment is complicated by limited graft choices, with the small number of case series largely focused on complex, higher-risk operations (omental flap transfers, large interhemispheric rotational grafts); direct bypass (often untenable in children due to vessel size); or, alternatively, the technically simpler method of multiple burr holes (of limited efficacy outside of infants). Faced with the problem of a growing cohort of pediatric patients with MMD that could benefit from anterior cerebral revascularization, the authors sought to develop a solution that was specifically designed for children and that would be lower risk than the more complex approaches adapted from adult populations but more effective than simple burr holes. In this study, the authors aimed to describe the long-term clinical and radiographic outcomes of a novel approach of pial pericranial dural (PiPeD) revascularization, building on the principles of pial synangiosis but unique in using the pericranium and the dura mater as the primary vascular supply, and employing a larger craniotomy with arachnoid dissection to provide robust full-territory revascularization in all ages with reduced risk relative to more complex procedures. The medical records of all pediatric patients with MMD who presented at a single center between July 2009 and August 2019 were retrospectively reviewed to identify patients with MMD with anterior cerebral territory ischemia. Clinical characteristics, surgical indications, operative techniques, and long-term clinical and radiographic follow-up data were collected and analyzed. A total of 25 operations (5.6% of total procedures) were performed in 21 patients (mean age 9.4 years [range 1-16.5 years]; 12 female and 9 male). Almost one-third of the patients had syndromic associations, with no familial cases. Complications included 1 patient (4.7%) with a superficial infection, with no postoperative strokes, hemorrhage, seizures, or deaths. Long-term follow-up was available in 18 of 21 patients (mean 24.9 months [range 4-60 months]). Radiographic engraftment was present in 90.9% (20/22 hemispheres), and no new strokes were evident on MRI on long-term follow-up, despite radiographic progression of the disease. The use of the pericranium and the dura mater for indirect revascularization provided robust vascularized graft with great flexibility in location and high potential for engraftment, which may obviate more complex and higher-risk operations for ACA territory ischemia. Long-term follow-up demonstrated that PiPeD revascularization conferred durable, long-term radiographic and clinical protection from stroke in pediatric patients with MMD. Based on the results of the current study, the PiPeD technique can be considered an additional tool to the armamentarium of indirect revascularization procedures in select pediatric patients with MMD.