Abstract TMP101: Magnetic Resonance Quantitative Arterial Tortuosity Reveals Evidence of Otherwise Occult Arteriopathy in Pediatric Patients With Cryptogenic Arterial Ischemic Stroke

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.

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Clinical diffusion mismatch to select pediatric patients for embolectomy 6 to 24 hours after stroke

Neurology ◽

10.1212/wnl.0000000000011107 ◽

2020 ◽

pp. 10.1212/WNL.0000000000011107

Author(s):

Peter B. Sporns ◽

Marios-Nikos Psychogios ◽

Ronald Straeter ◽

Uta Hanning ◽

Jens Minnerup ◽

...

Keyword(s):

Ischemic Stroke ◽

Pediatric Patients ◽

Time Window ◽

Secondary Analysis ◽

National Institutes Of Health ◽

Arterial Ischemic Stroke ◽

Neurological Outcomes ◽

Endovascular Recanalization ◽

Study Population

ObjectiveTo determine whether thrombectomy is safe in children up to 24 hours after onset of symptoms when selected by mismatch between clinical deficit and infarct.MethodsA secondary analysis of the Save ChildS Study (01/2000–12/2018) was performed, including all pediatric patients (<18 years), diagnosed with Arterial Ischemic Stroke who underwent endovascular recanalization at 27 European and United States stroke centers. Patients were included if they had a relevant mismatch between clinical deficit and infarct.ResultsTwenty children with a median age of 10.5 years (interquartile range; IQR 7–14.6) were included. Of those 7 were male (35%) and median time from onset to thrombectomy was 9.8 hours (IQR 7.8–16.2). Neurologic outcome improved from a median Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score of 12.0 (IQR, 8.8–20.3) at admission to 2.0 (IQR, 1.2–6.8) at day 7. Median modified Rankin Scale (mRS) score was 1.0 (IQR, 0–1.6) at 3 months and 0.0 (IQR, 0–1.0) at 24 months. One patient developed transient peri-interventional vasospasm; no other complications were observed. A comparison of the mRS to the mRS in the DAWN and DEFUSE 3 trials revealed a higher proportion of good outcomes in the pediatric compared to the adult study population.ConclusionsThrombectomy in pediatric ischemic stroke in an extended time window of up to 24 hours after onset of symptoms seems safe and neurological outcomes are generally good, if patients are selected by a mismatch between clinical deficit and infarct.Classification of evidenceThis study provides Class IV evidence that for children with acute ischemic stroke with a mismatch between clinical deficit and infarct size, thrombectomy is safe.

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Risk factors, types and outcomes of arterial ischemic stroke in Polish pediatric patients: a retrospective single-center study

Archives of Medical Science ◽

10.5114/aoms.2017.71805 ◽

2021 ◽

Vol 17 (1) ◽

pp. 62-70 ◽

Cited By ~ 1

Author(s):

Beata Sarecka-Hujar ◽

Ilona Kopyta ◽

Dorota Raczkiewicz

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Pediatric Patients ◽

Age At Onset ◽

Neurological Complications ◽

Arterial Ischemic Stroke ◽

Stroke Subtype ◽

Anterior Circulation ◽

Post Stroke ◽

Normal Outcome

IntroductionVarious neurological complications may occur as a consequence of arterial ischemic stroke (AIS) and have an impact on daily activity of the patients, costs of their medical care and rehabilitation. The aim of this study was to analyze risk factors, stroke symptoms and post-stroke consequences in Polish pediatric patients depending on stroke subtype.Material and methodsWe retrospectively reviewed 77 children under the age of 18 years following their first AIS. Patients were white, Polish Caucasians, recruited in the Department of Pediatric Neurology at the Medical University of Silesia in Katowice (Poland). Statistical analysis was performed using Statistica 12.0.ResultsGender differed significantly between stroke subgroups (p = 0.030). The presence of focal cerebral arteriopathy (FCA) and chronic diseases was associated with type of AIS (p = 0.003 and p = 0.050, respectively). An outcome without neurological deterioration (normal outcome) was observed in 43% of children with lacunar anterior circulation infarct (LACI). Hemiparesis was present in almost all children with total anterior circulation infarct (TACI), in two thirds of children with partial anterior circulation infarct (PACI) and in almost 50% of children with LACI or posterior circulation infarct (POCI). In every child with hemiplegia the stroke symptom evolved into hemiparesis at follow-up. Additionally, patients with a normal outcome were older at the time of AIS than those with at least one neurological consequence (OR = 0.894, p = 0.034).ConclusionsThe presence and number of neurological outcomes depend on stroke subtypes. A relation between the presence of post-stroke deficits and age at onset was observed. The odds of deficit after ischemic stroke decreases by an average of 10.6% if the child is 1 year older at the time of AIS.

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Incidence of Aspirin ’Resistance’ as Determined Using the PFA-100 in Pediatric Patients with Arterial Ischemic Stroke.

Blood ◽

10.1182/blood.v106.11.1882.1882 ◽

2005 ◽

Vol 106 (11) ◽

pp. 1882-1882 ◽

Cited By ~ 1

Author(s):

Margaret L. Rand ◽

Sylvain Lanthier ◽

Trish Domi ◽

Dewi Clark ◽

Anthony K.C. Chan ◽

...

Keyword(s):

Ischemic Stroke ◽

Platelet Function ◽

Pediatric Patients ◽

Aspirin Resistance ◽

Current Treatment ◽

Test Time ◽

Healthy Children ◽

Arterial Ischemic Stroke ◽

Normal Range ◽

Maximum Test

Abstract A significant benefit of aspirin (ASA) has been demonstrated in the prevention of arterial thrombotic events in high-risk adult patients. Despite ASA therapy, recurrence of thromboembolic events, or treatment failure, has been reported in 10–20% of patients, and this has been termed ASA ’resistance’. This term has also been applied to the failure of ASA to affect ASA-dependent laboratory tests. As there is little information on ASA ’resistance’ in children, we examined the efficacy of ASA treatment on platelets from pediatric stroke patients using the PFA-100. Pediatric arterial ischemic stroke afflicts 2–3 children per 100,000 per year, and is associated with recurrent arterial ischemic stroke or transient ischemic attack in 20–40% of cases. Current treatment includes ASA prophylaxis (3 – 5 mg/kg/day) to inhibit platelet function and prevent recurrence, but it is not known whether this ASA dosing regimen is adequate to inhibit platelet function. Our study population consisted of 95 consecutive children with an index arterial ischemic stroke at mean age 5.9 ± 4.8 yrs (range: 0.1 – 17.0 yrs) on active ASA therapy (2.9 ± 1.2 mg/kg/day). Citrated blood samples were obtained at mean age 9.8 ± 4.8 yrs (range: 0.9 – 19 yrs), and were used to measure primary, platelet-related hemostasis in the high-shear PFA-100 system; closure times (CTs) were determined with the collagen/epinephrine cartridge that is sensitive to ASA’s inhibition of thromboxane A2 formation via platelet cyclo-oxygenase 1. The mean CT for all 95 patients was 244 ± 68.1 sec, which is greater than 163 sec, the upper limit of the normal range that we have previously determined for healthy children. The majority of patients, 75/95 (79%), had prolonged CTs (172 sec to > 300 sec), indicating inhibition of platelet function by ASA, and they were thus responsive to ASA therapy. 45 of the 75 ASA responders (63%) had CTs > 300 sec, i.e. CTs greater than the maximum test time of 300 sec, demonstrating aperture non-closure. The remaining 20/95 patients (21%) were ASA ’resistant’, as they did not respond to ASA therapy, having CTs (93 – 163 sec) within the normal range. Mean ASA dosage did not differ between ASA responders (2.8 ± 1.2 mg/kg/day) and ASA ’resistant’ patients (3.0 ± 1.4 mg/kg/day). 6 of the ASA ’resistant’ patients had their ASA dosage increased, and on repeat PFA-100 testing, 5/6 showed increased CTs > 163 sec. In conclusion, in children with arterial ischemic stroke, the majority, 79%, demonstrate inhibition of platelet function, as determined using the PFA-100, by ASA therapy at a mean dose of 2.9 mg/kg/day. The reason for the lack of inhibition of platelet function in 21% of pediatric patients, whether increased ASA dosage or alternative anti-platelet agents (e.g. clopidogrel) should be used in ASA ’resistant’ patients, and the relationship between ASA ’resistance’ and recurrence of arterial thrombotic events in children require further studies.

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Does Device Selection Impact Recanalization Rate and Neurological Outcome?

Stroke ◽

10.1161/strokeaha.119.028221 ◽

2020 ◽

Vol 51 (4) ◽

pp. 1182-1189 ◽

Cited By ~ 4

Author(s):

Peter B. Sporns ◽

Ronald Straeter ◽

Jens Minnerup ◽

Heinz Wiendl ◽

Uta Hanning ◽

...

Keyword(s):

Ischemic Stroke ◽

Neurological Outcome ◽

Pediatric Patients ◽

Stent Retriever ◽

Complication Rates ◽

Arterial Ischemic Stroke ◽

First Line ◽

Outcome Parameters ◽

Neurological Outcomes ◽

Device Selection

Background and Purpose— The recent Save ChildS study provides multicenter evidence for the use of mechanical thrombectomy in children with large vessel occlusion arterial ischemic stroke. However, device selection for thrombectomy may influence rates of recanalization, complications, and neurological outcomes, especially in pediatric patients of different ages. We, therefore, performed additional analyses of the Save ChildS data to investigate a possible association of different thrombectomy techniques and devices with angiographic and clinical outcome parameters. Methods— The Save ChildS cohort study (January 2000–December 2018) analyzed data from 27 European and United States stroke centers and included all pediatric patients (<18 years), diagnosed with arterial ischemic stroke who underwent endovascular recanalization. Patients were grouped into first-line contact aspiration (A Direct Aspiration First Pass Technique [ADAPT]) and non-ADAPT groups as well as different stent retriever size groups. Associations with baseline characteristics, recanalization rates (modified Treatment in Cerebral Infarction), complication rates, and neurological outcome parameters (Pediatric National Institutes of Health Stroke Scale after 24 hours and 7 days; modified Rankin Scale and Pediatric Stroke Outcome Measure at discharge, after 6 and 24 months) were investigated. Results— Seventy-three patients with a median age of 11.3 years were included. Currently available stent retrievers were used in 59 patients (80.8%), of which 4×20 mm (width×length) was the most frequently chosen size (36 patients =61%). A first-line ADAPT approach was used in 7 patients (9.6%), and 7 patients (9.6%) were treated with first-generation thrombectomy devices. In this study, a first-line ADAPT approach was neither associated with the rate of successful recanalization (ADAPT 85.7% versus 87.5% No ADAPT) nor with the complication rate or the neurological outcome. Moreover, there were no associations of stent retriever sizes with rates of recanalization, complication rates, or outcome parameters. Conclusions— Our study suggests that neurological outcomes are generally good regardless of any specific device selection and suggests that it is important to offer thrombectomy in eligible children regardless of technique or device selection. Registration— URL: https://www.drks.de/ ; Unique identifier: DRKS00016528.

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THE CORRELATION BETWEEN MAGNETIC RESONANCE ANGIOGRAPHY FINDINGS AND THE AETIOLOGY OF CHILDHOOD ARTERIAL ISCHEMIC STROKE

Paediatrics Today ◽

10.5457/p2005-114.100 ◽

2014 ◽

Vol 10 (2) ◽

pp. 147-153

Author(s):

Christine Heller ◽

◽

Keyword(s):

Ischemic Stroke ◽

Magnetic Resonance ◽

Magnetic Resonance Angiography ◽

Arterial Ischemic Stroke

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Does the Occurrence of Particular Symptoms and Outcomes of Arterial Ischemic Stroke Depend on Sex in Pediatric Patients?—A Pilot Study

Brain Sciences ◽

10.3390/brainsci10110881 ◽

2020 ◽

Vol 10 (11) ◽

pp. 881

Author(s):

Ilona Kopyta ◽

Anna Dobrucka-Głowacka ◽

Agnieszka Cebula ◽

Beata Sarecka-Hujar

Keyword(s):

Ischemic Stroke ◽

Medical Records ◽

Pediatric Patients ◽

Arterial Ischemic Stroke ◽

Stroke Subtype ◽

Anterior Circulation ◽

Central Type ◽

Post Stroke ◽

Stroke Subtypes ◽

Posterior Circulation Infarct

Arterial ischemic stroke (AIS) in childhood is reported to occur more frequently in boys, which may lead to the assumption that the prevalence of post-stroke deficits is sex related. The present study aimed to evaluate sex-related differences in functional outcomes (hemiparesis, seizures, aphasia, and motor disturbances other than hemiparesis) in pediatric patients with AIS. A total of 89 children (52 boys and 37 girls; mean age at stroke onset: 8.4 ± 5.6 years) were evaluated retrospectively based on data from medical records. The patients were divided into subgroups according to age (i.e., infants and toddlers, children, and adolescents), stroke subtype (i.e., lacunar anterior circulation infarct (LACI), total anterior circulation infarct (TACI), partial anterior circulation infarct (PACI), posterior circulation infarct (POCI)) and stroke location (i.e., anterior stroke, posterior stroke). Significant differences in the prevalence of stroke subtypes between girls and boys were observed (p = 0.034). POCI stroke were found to be more frequent in boys than in girls (OR = 8.57 95%CI 1.05–70.23, p = 0.023). Males predominated in the total group and in all analyzed age subgroups. The proportions of boys within the subgroups according to stroke subtype were extremely high for the POCI and TACI stroke subgroups. On the other hand, girls predominated in the LACI stroke subgroup. Frequency of central type facial nerve palsy and other symptoms of AIS were found to significantly differ between male subgroups according to stroke subtype (p = 0.050 and p < 0.001, respectively), as well as between children with anterior stroke and those with posterior stroke (p = 0.059 and p < 0.001, respectively). Post-stroke seizures appeared significantly more commonly in girls with TACI and POCI stroke than in girls with LACI and PACI stroke (p = 0.022). In turn, the prevalence of post-stroke hemiparesis differed between stroke subtypes in boys (p = 0.026). In conclusion, sex may have an impact in predisposing to a certain type of AIS in the patient. Post-stroke seizure may be related to stroke subtype in girls and hemiparesis in boys. However, further studies are needed to confirm the results.

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Imaging findings and cerebral perfusion in arterial ischemic stroke due to transient cerebral arteriopathy in children

Einstein (São Paulo) ◽

10.1590/s1679-45082012000200021 ◽

2012 ◽

Vol 10 (2) ◽

pp. 239-241

Author(s):

Alcino Alves Barbosa Junior ◽

Saada Resende de Souza Ellovitch ◽

Rita de Cassia Maciel Pincerato

Keyword(s):

Ischemic Stroke ◽

Magnetic Resonance ◽

Magnetic Resonance Angiography ◽

Cerebral Perfusion ◽

Female Child ◽

Left Middle Cerebral Artery ◽

Arterial Ischemic Stroke ◽

Magnetic Resonance Perfusion ◽

Magnetic Resonance Imaging Perfusion ◽

Cerebral Arteriopathy

We report the case of a 4-year-old female child who developed an arterial ischemic stroke in the left middle cerebral artery territory, due to a proximal stenosis of the supraclinoid internal carotid artery, most probably related to transient cerebral arteriopathy of childhood. Computed tomography scan, magnetic resonance imaging, perfusion magnetic resonance and magnetic resonance angiography are presented, as well as follow-up by magnetic resonance and magnetic resonance angiography exams. Changes in cerebral perfusion and diffusion-perfusion mismatch call attention. As far as we know, this is the first report of magnetic resonance perfusion findings in transient cerebral arteriopathy.

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Pediatric Stroke: Clinical Findings and Radiological Approach

Stroke Research and Treatment ◽

10.4061/2011/172168 ◽

2011 ◽

Vol 2011 ◽

pp. 1-11 ◽

Cited By ~ 7

Author(s):

Giuseppe Lanni ◽

Alessia Catalucci ◽

Laura Conti ◽

Alessandra Di Sibio ◽

Amalia Paonessa ◽

...

Keyword(s):

Ischemic Stroke ◽

Magnetic Resonance ◽

Hemorrhagic Stroke ◽

Clinical Findings ◽

Pediatric Stroke ◽

Arterial Ischemic Stroke ◽

Venous Circulation ◽

Cerebral Sinovenous Thrombosis ◽

First Choice ◽

Sinovenous Thrombosis

This paper focuses on radiological approach in pediatric stroke including both ischemic stroke (Arterial Ischemic Stroke and Cerebral Sinovenous Thrombosis) and hemorrhagic stroke. Etiopathology and main clinical findings are examined as well. Magnetic Resonance Imaging could be considered as the first-choice diagnostic exam, offering a complete diagnostic set of information both in the discrimination between ischemic/hemorrhagic stroke and in the identification of underlying causes. In addition, Magnetic Resonance vascular techniques supply further information about cerebral arterial and venous circulation. Computed Tomography, for its limits and radiation exposure, should be used only when Magnetic Resonance is not available and on unstable patients.

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