Abstract WMP102: Infantile Spasms After Early Pediatric Arterial Ischemic Stroke.

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Aleksandra Mineyko ◽  
Morris Scantlebury ◽  
Adam Kirton
Keyword(s):  
Ischemic Stroke ◽  
Neurological Outcome ◽  
Rare Complication ◽  
Epileptic Encephalopathy ◽  
Infantile Spasms ◽  
Pediatric Stroke ◽  
Genetic Syndromes ◽  
Arterial Ischemic Stroke ◽  
Poor Prognostic Factor

Introduction: Symptomatic infantile spasms (SIS) constitute a debilitating epileptic encephalopathy due to an identifiable lesion in the developing brain. Perinatal and infantile arterial ischemic stroke (AIS) result in a large spectrum of developmental outcomes. Risk factors for worse outcome are not well understood, with epilepsy diagnosis being a poor prognostic factor. As a focal injury in an otherwise healthy brain, early stroke provides unique insight into the developmental effects of epileptic encephalopathy. Hypothesis: SIS are a rare complication of AIS in infancy/early childhood. Additional neurological comorbidities are seen in stroke patients with SIS. Methods: A population-based cohort of pediatric stroke (Calgary Pediatric Stroke Program) was screened. Inclusion criteria were: (1) MRI-confirmed AIS (2) age at stroke <2 years (3) EEG with hypsarrhythmia, and (4) clinical diagnosis of infantile spasms. Pediatric Stroke Outcome Measure (PSOM) was used to determine neurological outcome at follow up. Poor outcomes included total PSOM >2 and non-motor outcomes >1. Results: One hundred and sixty-three children with AIS at <2 years of age were screened. EEGs were available for 92 (56%). Five (3%) of all patients had SIS (3 symptomatic neonatal, 1 presumed perinatal, 1 childhood AIS). Four patients (80%) were male. Strokes were unilateral and involving MCA (4) and PCA (1) territories. Median age at diagnosis was 7 months (range 2-22). Four responded to either vigabatrin and/or ACTH/steroids. One was refractory to several treatments. Compared to 28/158 (18%) in the non-SIS group, 4/5 with SIS (80%) had comorbid neurological diagnoses including genetic syndromes (2), premature brain injury (1), or hypoxic ischemic encephalopathy (1). At a median follow-up of 29 months (range 6-56), all but one patient had poor neurological outcome. One patient with good outcome had no comorbidities. One patient died of causes unrelated to stroke. Conclusions: Early AIS can be complicated by infantile spasms but usually only in the context of additional neurological comrobidity. Neurological outcomes are poor but discerning the contribution of the epileptic encephlapathy is challenging as in other IS populations.

scholarly journals Diffusion imaging of cerebral diaschisis in neonatal arterial ischemic stroke

2015 ◽  
Vol 42 (S1) ◽  
pp. S15-S15
Author(s):  
R Srivastava ◽  
T Rajapakse ◽  
J Roe ◽  
X Wei ◽  
A Kirton
Keyword(s):  
Ischemic Stroke ◽  
Diffusion Imaging ◽  
Population Based ◽  
Pediatric Stroke ◽  
Arterial Ischemic Stroke ◽  
Long Term Outcomes ◽  
Primary Injury

Background: Neonatal arterial ischemic stroke (NAIS) is a leading cause of brain injury and cerebral palsy. Diffusion-weighted imaging (DWI) has revolutionized NAIS diagnosis and outcome prognostication. Diaschisis refers to changes in brain areas functionally connected but structurally remote from primary injury. We hypothesized that acute DWI can demonstrate cerebral diaschisis and evaluated associations with outcome. Methods: Subjects were identified from a prospective, population-based research cohort (Calgary Pediatric Stroke Program). Inclusion criteria were unilateral middle cerebral artery NAIS, DWI MRI within 10 days of birth, and >12-month follow-up (Pediatric Stroke Outcome Measure, PSOM). Diaschisis was quantified using a validated software method. Diaschisis-scores were corrected for infarct size and compared to outcomes (Mann-Whitney). Results: From 20 eligible NAIS, 2 were excluded for image quality. Of 18 remaining, 16 (89%) demonstrated diaschisis. Thalamus (88%) was most often involved. Age at imaging was not associated with diaschisis. Long-term outcomes available on 13 (81%) demonstrated no association between diaschisis score and PSOM categories. Conclusion: Cerebral diaschisis occurs in NAIS and can be quantified with DWI. Occurrence is common and should not be mistaken for additional infarction. Determining additional clinical significance will depend on larger samples with long-term outcomes.

Etiologic Profile of Childhood Stroke from North India: Is It Different from Developed World?

2021 ◽  
pp. 088307382199129
Author(s):  
Abhinandan Sood ◽  
Renu Suthar ◽  
Jitendra K. Sahu ◽  
Arun K. Baranwal ◽  
Arushi G. Saini ◽  
...  
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Moyamoya Disease ◽  
Neurologic Outcome ◽  
Pediatric Stroke ◽  
Stroke Survivors ◽  
Arterial Ischemic Stroke ◽  
Short Term ◽  
Neurologic Disability

Objective: To describe the etiology of childhood arterial-ischemic stroke from a developing country and assess short-term neurologic outcome. Methods: Prospective observational study. Consecutive children between the age of >28 days to <12 years, admitted with the diagnosis of arterial-ischemic stroke were enrolled during the study period from January 2017 to December 2018. Short-term neurologic outcome was assessed with Pediatric Cerebral Performance Category (PCPC) scale and Pediatric Stroke Outcome Measure (PSOM). Results: We enrolled 76 children with arterial-ischemic stroke, with a median age of 24 months (interquartile range 12-69), and 43 (57%) were boys. The most common risk factor for childhood arterial-ischemic stroke was arteriopathy in 59 (77%), followed by cardiovascular disorder in 12 (16%) children. Among 59 children with arteriopathy, 32 (42%) had infection-associated arteriopathies, 10 (13%) had mineralizing angiopathy, 10 (13%) had moyamoya disease. Pediatric stroke risk factors were classified according to Pediatric Stroke Classification and CASCADE primary classification. Short-term neurologic outcome was assessed at 3 months in 62 (82%) survivors. Among stroke survivors, 33 (61%) had sensory-motor deficits, and 24 (39%) had severe neurologic disability (PCPC ≥ 4). The presence of fever, encephalopathy, low Glasgow coma score at presentation, seizures, and infection-associated arteriopathy predicted severe neurologic disability at follow-up. Conclusion: The risk factors for pediatric arterial-ischemic stroke are different from developed countries in our cohort. Infection-associated arteriopathies, mineralizing angiopathy, and moyamoya disease are the most common risk factors in our cohort. Two-thirds of pediatric stroke survivors have neurologic disability at short-term follow-up.

Pediatric Hyperacute Arterial Ischemic Stroke Pathways at Canadian Tertiary Care Hospitals

2021 ◽  
pp. 1-8
Author(s):  
Maria Gladkikh ◽  
Hugh J. McMillan ◽  
Andrea Andrade ◽  
Cyrus Boelman ◽  
Ishvinder Bhathal ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Tertiary Care ◽  
Pediatric Stroke ◽  
Arterial Ischemic Stroke ◽  
Pediatric Hospitals ◽  
First Choice ◽  
Similarities And Differences ◽  
Pre Treatment ◽  
Magnetic Resonance Imaging Mri ◽  
Iv Tpa

ABSTRACT: Background: Childhood acute arterial ischemic stroke (AIS) is diagnosed at a median of 23 hours post-symptom onset, delaying treatment. Pediatric stroke pathways can expedite diagnosis. Our goal was to understand the similarities and differences between Canadian pediatric stroke protocols with the aim of optimizing AIS management. Methods: We contacted neurologists at all 16 Canadian pediatric hospitals regarding AIS management. Established protocols were analyzed for similarities and differences in eight domains. Results: Response rate was 100%. Seven (44%) centers have an established AIS protocol and two (13%) have a protocol under development. Seven centers do not have a protocol; two redirect patients to adult neurology, five rely on a case-by-case approach for management. Analysis of the seven protocols revealed differences in: 1) IV-tPA dosage: age-dependent 0.75–0.9 mg/kg (N = 1) versus age-independent 0.9 mg/kg (N = 6), with maximum doses of 75 mg (N = 1) or 90 mg (N = 6); 2) IV-tPA lower age cut-off: 2 years (N = 5) versus 3 or 10 years (each N = 1); 3) IV-tPA exclusion criteria: PedNIHSS score <4 (N = 3), <5 (N = 1), <6 (N = 3); 4) first choice of pre-treatment neuroimaging: computed tomography (CT) (N = 3), magnetic resonance imaging (MRI) (N = 2) or either (N = 2); 5) intra-arterial tPA use (N = 3) and; 6) mechanical thrombectomy timeframe: <6 hour (N = 3), <24 hour (N = 2), unspecified (N = 2). Conclusions: Although 44% of Canadian pediatric hospitals have established AIS management pathways, several differences remain among centers. Some criteria (dosage, imaging) reflect adult AIS literature. Canadian expert consensus regarding IV-tPA and endovascular treatment should be established to standardize and implement AIS protocols across Canada.

Diffusion imaging of cerebral diaschisis in childhood arterial ischemic stroke

2016 ◽  
Vol 11 (9) ◽  
pp. 1028-1035 ◽  
Author(s):  
Adam Kirton ◽  
Elizabeth Williams ◽  
Michael Dowling ◽  
Sarah Mah ◽  
Jacquie Hodge ◽  
...  
Keyword(s):  
Magnetic Resonance Imaging ◽  
Ischemic Stroke ◽  
Magnetic Resonance ◽  
Diffusion Weighted Imaging ◽  
Infarct Volume ◽  
Resonance Imaging ◽  
Arterial Ischemic Stroke ◽  
Diffusion Weighted ◽  
Motor Outcome

Background Diffusion-weighted imaging magnetic resonance imaging may detect changes in brain structures remote but connected to stroke consistent with neuropathological descriptions of diaschisis. Early diffusion-weighted imaging demonstrates restriction in corticospinal pathways after arterial ischemic stroke of all ages that correlates with motor outcome. Aim/hypothesis We hypothesized that cerebral diaschisis is measurable in childhood arterial ischemic stroke and explored associations with outcome. Methods This sub-study of the validation of the Pediatric NIH Stroke Scale study prospectively enrolled children with acute arterial ischemic stroke and both acute and early follow-up (5–14 days) diffusion-weighted imaging. Inclusion criteria were (1) unilateral middle cerebral artery arterial ischemic stroke, (2) acute and subacute diffusion-weighted imaging ( b = 1000), and (3) 12 month neurological follow-up (Pediatric Stroke Outcome Measure). A validated method using ImageJ software quantified diffusion-weighted imaging diaschisis in anatomically connected structures. Diaschisis measures were corrected for infarct volume, compared to age, imaging timing, and outcomes (Chi square/Fisher, Mann–Whitney test). Results Nineteen children (53% male, median 8.1 years) had magnetic resonance imaging at medians of 21 and 168 h post-stroke onset. Diaschisis was common and evolved over time, observed in one (5%) on acute but eight (42%) by follow-up diffusion-weighted imaging. Thalamic and callosal diaschisis were most common (5, 26%). Estimates of perilesional diaschisis varied (54 ± 18% of infarct volume). Children with diaschisis tended to be younger (7.02 ± 5.4 vs. 11.82 ± 4.3 years, p = 0.08). Total diaschisis score was associated with poor cognitive outcomes ( p = 0.03). Corticospinal tract diaschisis was associated with motor outcome ( p = 0.004). Method reliability was excellent. Conclusions Diffusion-weighted imaging diaschisis occurs in childhood arterial ischemic stroke. Mistaking diaschisis for new areas of infarction carries important clinical implications. Improved recognition and study are required to establish clinical relevance.

Abstract WMP113: Headache At Stroke Onset Is Present In Half Of All Older Children With Arterial Ischemic Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Lori L Billinghurst ◽  
Adam Kirton ◽  
Steven Pavlakis ◽  
Jo Ellen Lee ◽  
Luigi Titomanlio ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Right Hemisphere ◽  
Female Gender ◽  
Stroke Onset ◽  
Pediatric Stroke ◽  
Arterial Ischemic Stroke ◽  
Anterior Circulation ◽  
Stroke Registry ◽  
Young Infants ◽  
Individual Site

Introduction: Headache at stroke onset occurs in up to a quarter of adults and is associated with younger age, female gender, right hemisphere and cerebellar infarcts. Little is known about headache at stroke onset in children. Methods: Children (29 days-18 years) with clinical and radiographic confirmation of arterial ischemic stroke were prospectively enrolled in the International Pediatric Stroke Study from 2003-2014. Details regarding demographics, stroke presentation and infarct location were obtained from the multi-center, pediatric stroke registry. Headache at stroke presentation was classified and annotated in the registry by the individual site investigators as present, absent or unclear. Results: We analyzed 2103 children. Half of all subjects ≥ 6 yo reported headache at stroke onset (N=509/1047, 49%; Figure). Headache was less prevalent in children < 6 yo (N=112/1056, 11%; p<0.001), though headache presentation was more commonly classified as unclear (10% vs 32%; p<0.001). In children ≥ 6 yo, headache was significantly associated with papilledema (p = 0.03) and vertigo (p = 0.01), but not with hemiparesis (p = 0.11), visual field deficit (p = 0.90), aphasia (p = 0.35), dysarthria (p = 0.44), or ataxia (p = 0.50). Headache was more common in posterior than anterior circulation infarcts (p<0.001). There was a significant association between headache and right or bilateral hemisphere infarcts (p = 0.04) but not with gender (p = 0.76). Conclusion: Headache is more prevalent in children than adults at stroke ictus and shares similar associations, including infarcts involving the posterior circulation and right hemisphere. Headache may be under-reported in young infants and children due to pre-verbal stages of development. These findings have implications for early identification and treatment of pediatric stroke and warrant further investigation in prospective studies to distinguish stroke from more common benign mimics, including migraine.

scholarly journals Socioeconomic determinants of outcome after childhood arterial ischemic stroke

Neurology ◽  
2018 ◽  
Vol 91 (6) ◽  
pp. e509-e516 ◽  
Author(s):  
Lori C. Jordan ◽  
Nancy K. Hills ◽  
Christine K. Fox ◽  
Rebecca N. Ichord ◽  
Paola Pergami ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Low Income ◽  
Maternal Education ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Rehabilitation Services ◽  
Pediatric Stroke ◽  
Arterial Ischemic Stroke ◽  
Annual Household Income ◽  
Neurologic Outcomes

ObjectiveTo determine whether lower socioeconomic status (SES) is associated with worse 1-year neurologic outcomes and reduced access to rehabilitation services in children with arterial ischemic stroke (AIS).MethodsFrom 2010 to 2014, the Vascular effects of Infection in Pediatric Stroke (VIPS) observational study prospectively enrolled and confirmed 355 children (age 29 days–18 years) with AIS at 37 international centers. SES markers measured via parental interview included annual household income (US dollars) at the time of enrollment, maternal education level, and rural/suburban/urban residence. Receipt of rehabilitation services was measured by parental report. Pediatric Stroke Outcome Measure scores were categorized as 0 to 1, 1.5 to 3, 3.5 to 6, and 6.5 to 10. Univariate and multivariable ordinal logistic regression models examined potential predictors of outcome.ResultsAt 12 ± 3 months after stroke, 320 children had documented outcome measurements, including 15 who had died. In univariate analysis, very low income (<US $10,000), but not other markers of SES, was associated with worse outcomes (odds ratio [OR] 3.13, 95% confidence interval [CI] 1.43–6.88, p = 0.004). In multivariable analysis, including adjustment for stroke etiology, this association persisted (OR 3.17, 95% CI 1.18–8.47, p = 0.02). Income did not correlate with receiving rehabilitation services at 1 year after stroke; however, quality and quantity of services were not assessed.ConclusionsIn a large, multinational, prospective cohort of children with AIS, low income was associated with worse neurologic outcomes compared to higher income levels. This difference was not explained by stroke type, neurologic comorbidities, or reported use of rehabilitation services. The root causes of this disparity are not clear and warrant further investigation.

scholarly journals Incidence and predictors of epilepsy after pediatric arterial ischemic stroke

Neurology ◽  
2017 ◽  
Vol 88 (7) ◽  
pp. 630-637 ◽  
Author(s):  
Lori L. Billinghurst ◽  
Lauren A. Beslow ◽  
Nicholas S. Abend ◽  
Michael Uohara ◽  
Laura Jastrzab ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Cumulative Incidence ◽  
Arterial Ischemic Stroke ◽  
Clinical Predictors ◽  
Entire Cohort ◽  
Increased Risk ◽  
Neurologic Sequelae ◽  
Symptomatic Seizures ◽  
Acute Symptomatic Seizures

Objective:To determine the cumulative incidence and clinical predictors of remote symptomatic seizures and epilepsy after pediatric arterial ischemic stroke (AIS).Methods:We performed a retrospective analysis of 218 participants with neonatal AIS (NAIS), presumed perinatal AIS (PPAIS), and childhood AIS (CAIS) from a single-center prospective consecutive cohort enrolled from 2006 to 2014. Medical records were reviewed for timing, semiology, and treatment of acute symptomatic seizures, remote symptomatic seizures (RSS), and epilepsy. Cumulative incidence of RSS and epilepsy were assessed using survival analysis.Results:Acute symptomatic seizures occurred in 94% of NAIS (n = 70/74) and 17% of CAIS (n = 18/105). Younger children were more likely to present with seizures at stroke ictus, and acute symptomatic seizures were predictive of later RSS and epilepsy in CAIS. Median follow-up for the entire cohort was 34 months, interquartile range 44.9 months (16.3–61.2). Estimated cumulative incidence of RSS at 2 years was 19% in NAIS, 24% in PPAIS, and 7% in CAIS. Estimated cumulative incidence of epilepsy at 2 years was 11% in NAIS, 19% in PPAIS, and 7% in CAIS. The median time to these outcomes was <2 years in all stroke subtypes. Among participants developing epilepsy (n = 34), seizures were often well-controlled at last follow-up with median Engel class of ≤2 (<1 seizure/month).Conclusions:RSS and epilepsy are important neurologic sequelae of pediatric AIS. Children with perinatal stroke and CAIS with acute symptomatic seizures are at increased risk of these outcomes. These cohorts need further study to identify biomarkers and potential therapeutic targets for epileptogenesis.

Acute Treatments and Early Outcomes of Childhood Arterial Ischemic Stroke: First Analysis of the International Pediatric Stroke Study.

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 1978-1978 ◽  
Author(s):  
Neil A Goldenberg ◽  
Timothy J. Bernard ◽  
Anne Gordon ◽  
Heather J. Fullerton ◽  
Gabrielle A. deVeber
Keyword(s):  
Ischemic Stroke ◽  
South America ◽  
Antithrombotic Therapy ◽  
Geographic Region ◽  
Treatment Selection ◽  
Pediatric Stroke ◽  
Arterial Ischemic Stroke ◽  
Antithrombotic Treatment ◽  
Stroke Study ◽  
International Pediatric

Abstract Background: In pediatric arterial ischemic stroke (AIS) clinical treatment trials are lacking and treatment practices variable. Factors determining treatment selection and outcomes are important to delineate. Objective: We aimed to (1) describe acute treatments and outcomes in childhood AIS, and (2) test putative variables for treatment selection, and outcome in a prospective-retrospective multicenter international study. Methods: We evaluated treatments and early outcomes of children enrolled in the International Pediatric Stroke Study with AIS diagnosed at &gt;28 days and &lt;18 years of age from 2003 to 2007. Putative predictor variables for antithrombotic treatment selection included age, clinical AIS subtypes, geographic region (Asia, Australia, Canada, Europe, South America, and U.S.), and diagnosis pre- versus post-2004 (when pediatric AIS guidelines published). Results: Among 676 children with acute AIS, anticonvulsants and antibiotics were administered acutely in 57% and 40%, respectively; use of each decreased with age (P&lt;0.001). Acute anticoagulants (AAC; with/without concomitant anti-platelet therapy) were selected more frequently than either acute anti-platelet agents (AAP) alone or no acute antithrombotic treatment (NAAT) (43% AAC vs. 28% AAP alone and 29% NAAT). NAAT decreased with increasing age. AAC was most frequent in cerebral/cervical arterial dissection (n=52; 75% AAC vs. 6% AAP) and least frequent with moyamoya syndrome (n=72; 31% AC vs. 43% AAP). AAC was most common in Europe and Canada, AAC vs. AAP relatively balanced in the U.S., and AAP most common in Asia and South America. AAC use was similar pre- versus post-2004. At hospital discharge 71% had neurological deficits independent of age, subtype, or geographical region. Mortality at discharge was 3%. Conclusions: Acute anticoagulation is frequently but not uniformly employed in childhood AIS. With current treatment, the prevalence of neurological deficit at hospital discharge is high. These findings reflect disparity in published guidelines and highlight the need for clinical trials to reduce adverse outcomes. Figure 1. Acute antithrombotic therapy in childhood AIS, by geographic region. Figure 1. Acute antithrombotic therapy in childhood AIS, by geographic region.

scholarly journals Focal Cerebral Arteriopathy of Childhood: Clinical and Imaging Correlates

Stroke ◽  
2021 ◽  
Author(s):  
Gabriela Oesch ◽  
Francisco A. Perez ◽  
Mark S. Wainwright ◽  
Dennis W.W. Shaw ◽  
Catherine Amlie-Lefond
Keyword(s):  
Ischemic Stroke ◽  
Pacific Northwest ◽  
Outcome Measure ◽  
Stroke Recurrence ◽  
Pediatric Stroke ◽  
Stroke Outcome ◽  
Arterial Ischemic Stroke ◽  
Electronic Health Record Data ◽  
Anterior Circulation ◽  
Cerebral Arteriopathy

Background and Purpose: Focal cerebral arteriopathy (FCA) of childhood with unilateral stenosis of the anterior circulation is reported to account for up to one-quarter of childhood arterial ischemic stroke, with stroke recurrence in 25% of cases. Limited knowledge regarding pathophysiology and outcome results in inconsistent treatment of FCA. Methods: Children with arterial ischemic stroke due to FCA between January 1, 2009, and January 1, 2019, were retrospectively identified at our institution which serves the US Pacific Northwest region. Electronic health record data, including neuroimaging studies, were reviewed, and the Pediatric Stroke Outcome Measure at 1 year was determined as the primary clinical end point. Results: Fifteen children were diagnosed with FCA, accounting for 19% of children with cerebral arteriopathies (n=77). Among children with FCA, the median age at the time of stroke was 6.8 years (Q1–Q3, 1.9–14.0 years). Four (20%) patients had worsening stroke, 3 of whom had concurrent infection. Three (20%) FCA cases were treated with steroids, one of whom had worsening stroke. Median Pediatric Stroke Outcome Measure at 1 year was 1.0 (Q1–Q3, 0.6–2.0). Variability in arteriopathy severity was observed within many patients. Patients with more severe arteriopathy using the Focal Cerebral Arteriopathy Severity Score had larger strokes and were more likely to have worsening stroke. The most common long-term neurological deficit was hemiparesis, which was present in 11 (73%) patients and associated with middle cerebral artery arteriopathy and infarcts. Conclusions: FCA may be less common than previously reported. Neuroimaging in FCA can help identify patients at greater risk for worsening stroke.

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