Hemorrhagic Transformation Following Childhood Cardioembolic Stroke Is Not Increased in Anticoagulated Patients

Objective: To characterize the risk of hemorrhagic transformation following cardioembolic stroke in childhood, and whether anticoagulation impacts that risk. Methods: Ninety-five children (1 month-18 years) with cardioembolic arterial ischemic stroke between January 1, 2009, and December 31, 2019, at 2 institutions were identified for retrospective chart review. Neuroimaging was reviewed to assess for hemorrhagic transformation. Results: There were 11 cases of hemorrhagic transformation; 8 occurred within 2 days of stroke diagnosis. Risk of hemorrhagic transformation did not differ in patients with and without anticoagulation use (15% vs 9%, estimated risk difference 5%; CI –9%, 19%). Stroke size did not predict hemorrhagic transformation (OR 1.004, 95% CI 0.997, 1.010). Risk of hemorrhagic transformation was higher in strokes that occurred in the inpatient compared with the outpatient setting (16% vs 6%). Conclusion: Hemorrhagic transformation occurred in 11% of pediatric cardioembolic ischemic stroke, usually within 2 days of stroke diagnosis, and was not associated with anticoagulation or stroke size.

Impact of Age at Pediatric Stroke on Long-term Cognitive Outcome

Objectives:To investigate the impact of age at pediatric arterial ischemic stroke on long-term cognitive outcome in order to identify patients particularly at risk for the development of cognitive long-term cognitive sequelae.Methods:This cross-sectional study included patients in the chronic phase of stroke (> 2 years after stroke) previously diagnosed with neonatal or childhood arterial ischemic stroke and a control group. Participants with active epilepsy, severe learning difficulties, or behavioral problems hindering the cognitive assessment were excluded. Several cognitive domains, including intelligence, executive functions (working memory, inhibition, and cognitive flexibility), processing speed, memory, letter fluency, and visual-motor skills were assessed with neuropsychological tests. Cognitive long-term outcome was compared across patients after neonatal stroke (stroke between 0 and 28 days of life), early childhood stroke (stroke between 29 days and < 6 years) and late childhood stroke (stroke between ≥ 6 and < 16 years).Results:52 patients after neonatal or childhood arterial ischemic stroke (median age: 15.3 years, IQR = 10.6 – 18.7) and 49 healthy controls (median age: 13.6 years, IQR = 9.8 – 17.2) met the inclusion criteria. Cognitive outcome was significantly worse in the pediatric stroke group compared to the control group. A non-linear effect of age at stroke (irrespective of lesion size and lesion location) was found for cognitive flexibility, processing speed, and verbal learning with early childhood stroke (29 days to < 6 years) showing significantly worse cognitive outcome compared to neonatal or late childhood stroke (p < .05, FDR-corrected).Conclusion:Age at stroke is an important factor for post-stroke recovery and modulates long-term cognitive outcome irrespective of lesion size and lesion location. Children after early childhood stroke are at particular risk for alterations of long-term cognitive functions.

REHABILITATION OF STROKE IN CYANOTIC CONGENITAL SINGLE VENTRICLE HEART DEFECT PATIENT

Congenital heart disease consists of various conditions including tetralogy of Fallot, ventricular septal defect, Epstein’s anomaly, single ventricle, etc. Among these single ventricles is one of the gravest forms of cyanotic congenital heart disease. The cardiac diagnosis is associated with an increased risk of stroke among children. Pediatric arterial ischemic stroke (AIS) is an important cause of neurologic disease in children causing disability. The 14-year-old patient came to the hospital was presented with left side hemiplegia with severe exercise intolerance due to congenital heart disease. The patient has been advised to undergo Fontan procedure for single-ventricle condition 3 years back, but due to poor socioeconomic status, parents of patients refused to do so. The primary goal was to improve bed mobility and trunk balance without developing symptoms of exercise intolerance. The intervention was started with deep and segmental breathing exercises. Proprioceptive neuromuscular facilitation and constrained induced movement therapy were added in the program in addition to passive and active movements, bed mobility, functional reeducation, trunk control exercises, and balance exercises. Combinations of all of the above therapeutic approaches lead to increased functional independence in the patient. This case reports the effectiveness of a rehabilitation program for pediatric arterial ischemic stroke with preventive guidelines for exercise intolerance.

B.2 Neurologic outcome trajectory following neonatal arterial ischemic stroke (NAIS): A longitudinal observational study

Background: Studies evaluating long-term neurologic outcomes following NAIS are scanty. We aimed to study the emergence pattern of neurologic deficits following NAIS. Methods: Neonates diagnosed with AIS were prospectively enrolled and outcomes were evaluated using the validated Pediatric Stroke Outcome Measure-Severity Classification Scheme. Neurologic outcomes were classified as normal/mild, moderate or severe. Trend analysis was conducted using Cochran-Armitage test. Results: A total of 126 neonates (59% males) were followed for a median of 5.2 years (IQR:3.4-6.4 years). The proportion of children classified as normal/mild declined from 94% to 76% >5 years post-stroke (p<0.01). Moderate and severe outcomes increased from 5% to 15% and 1% to 8% (p=0.01), respectively. Sensorimotor, language and cognitive deficits emerged in 16%, 14%, and 17% of enrolled neonates, respectively. Of those who had normal/mild outcomes at baseline, 83 remained stable throughout the study. Improvement in neurologic outcomes was seen in 8 children. Thirty-five neonates had emerging deficits at one point during follow-up. Congenital heart disease predicted the emergence of deficits (odds ratio=3.3, 95% confidence interval:1.01-10.5). Conclusions: Emerging deficits following NAIS are not uncommon and can equally manifest in sensorimotor, language or cognitive domains. Thus, long-term follow-up and close monitoring of outcomes following NAIS is crucial.

B.3 The incidence of perinatal stroke is 1:1200 births in Southern Alberta: Population-based incidence of disease-specific perinatal stroke

Background: Perinatal stroke encompasses six cerebrovascular syndromes which occur between the 20th week of gestation and the 28th post-natal day. Subtypes are neonatal arterial ischemic stroke (NAIS), neonatal cerebral sinovenous thrombosis (CSVT), neonatal hemorrhagic stroke (NHS), arterial presumed perinatal ischemic stroke (APPIS), periventricular venous infarction (PVI), and presumed perinatal hemorrhagic stroke (PPHS). Inconsistent terminology and lack of population-based case series has limited accurate measurement of disease-specific perinatal stroke incidence. Our objective was to define the incidence of the subtypes of perinatal stroke using a population-based cohort. Methods: The Alberta Perinatal Stroke Project is a research cohort established in 2008 in Southern Alberta. Case acquisition included retrospective hospital and ICD code searches (1990-2008) and prospective enrollment from all NICU and neurology/stroke clinics (2008-2017). Results: The overall incidence of perinatal stroke in Southern Alberta was 9.0 cases per 10,000 births, or 1:1200 births. Per 10,000 births, the incidence of each subtype was: NAIS = 3.2 (~1:3000), APPIS =1.2 (~1:8500), PVI = 1.5 (~1:6500), CSVT = 1.0 (~1:9900), NHS = 1.4 (~1/7300), PPHS = 0.1 (1/82,000). Conclusions: The overall incidence of perinatal stroke in Southern Alberta is 1:1200 live births. Population-based sampling of disease-specific states may explain why this rate is much higher than previous estimates

P.066 Hemispheric Reorganization of Functional Language Networks Following Neonatal Stroke Supports Language Outcome

Background: Neonatal Arterial Ischemic Stroke (NAIS) is a common form of paediatric stroke often affecting classical language areas. The post-stroke reorganization of functional language networks may provide insight into later-emerging language deficits and may help to identify at-risk children with NAIS. Methods: A cross-sectional study of fourteen children with left (n=8; 2M; 11.1±2.2 years) or right (n=6; 3M; 12.4±4 years) middle cerebral artery (MCA) NAIS, as well as seven neurotypical children (5M; 13.4±2.7 years), was conducted. Children listened to correct/incorrect syntactic sentences while MEG was recorded, and task-related functional connectivity in the time window and frequency band of interest was determined. Language outcomes were assessed using a battery of neuropsychological tests. Results: A network-based analysis of syntactic language processing (4-7 Hz, 1.2-1.4s) revealed a dysfunctional bilateral frontal-temporal network involving language areas in patients (p=0.01). Patients with right-MCA stroke exhibited a positive correlation between left hemispheric connectivity and measures of language skill (p<0.01), resembling the neurotypical children. In left-MCA stroke patients, greater bilateral connectivity or right laterality in the language network is correlated with good outcome (p<0.05). Conclusions: Depending on the hemispheric location of stroke, certain patterns of language network reorganization may account for impairments in a bilateral frontal-temporal language subnetwork and support language outcome.

A Case-Based Review of Cerebral Venous Infarcts With Perfusion Imaging and Comparison to Arterial Ischemic Stroke

Cerebral venous thrombosis (CVT) and cerebral venous infarcts (CVI) are diagnostic dilemmas secondary to their rarity, non-specific symptomatology at presentation, and variable imaging features. Despite its relatively infrequence, CVT is particularly prevalent in the younger adult population and is a potentially life-threatening disease with devastating neurological complications if not addressed in a timely manner. However, when treated promptly, CVT has the potential for a more reversible course and favorable prognosis than arterial ischemic strokes (AIS). The pathophysiology of CVI is distinct from that of AIS and is closely related to its potentially reversible nature. Familiarity with the conventional and variant venous anatomy, as well as the temporal evolution of imaging findings, is crucial in establishing diagnostic confidence. The use of MR perfusion imaging (MRP) and arterial spin-labeling (ASL) can potentially aid in the diagnosis of CVT/CVI via characterization of cerebral blood flow. The presence and extent of a cerebral perfusion deficit on either CT or MRI may play a role in clinical outcomes for patients with CVT, although future larger studies must be performed. This review presents a case-based overview focusing on the classic imaging characteristics of CVT and CVI in conjunction with bolus MRP and ASL findings in the adult population.

ANTIPLATELET AGENTS IN THE TREATMENT AND SECONDARY PREVENTION OF PEDIATRIC ARTERIAL ISCHEMIC STROKE: THE STATE OF THE PROBLEM

Arterial ischemic stroke (AIS) in children is a potentially disabling disease with cumulative rates of relapse in the first year of 12–16%, necessitating secondary prevention of the disease. Both in adults and in pediatric clinical practice, acetylsalicylic acid is most commonly used, much less often – clopidogrel. However, the validity of the use of antiplatelet agents in children with ischemic stroke is still controversial, due to the low level of evidence-based studies and the paucity of publications. The article analyzes and summarizes data on the possibilities and limitations of the use of antiplatelet agents for secondary prevention of AIS in children.

Epilepsy in children with perinatal arterial ischemic stroke

Purpose: Perinatal ischemic stroke (PIS) is a frequent cause for perinatal brain structure defects resulting in epilepsy, cerebral palsy and disability. Since the severity of symptoms is variable, the aim of this study was to evaluate the outcome of children with PIS and seizures/epilepsy to aid parental counseling and therapy decisions. Material: We studied retrospectively patients with arterial PIS and structural epilepsy or seizures in the newborn treated at a single center in 2000-2019. Specifically, signs and symptoms of cerebral palsy (CP), developmental and motor delay, epilepsy and thrombophilia were assessed. Results: From the identified 69 individuals with arterial PIS, we only included the 50 patients (64% male) who had structural epilepsy at the time of investigation or previously in their medical history.The mean age of the included patients was 7.1 years (range 0.08-22) at last consultation. Infarct localisation was predominantly unilateral (86%), left sided (58%) and affecting the middle cerebral artery (94%). Genetic thrombophilia was identified in 52% of the patients examined with genetic testing. More than half of the individuals had CP (52%), and 38.5% had a cognitive outcome below average. First seizures occurred in the neonatal period in 58% of patients and developed into drug-refractory epilepsy in 24.1%. Children with late-onset of epilepsy were twice as likely to develop drug-refractory epilepsy (52.4%). Discussion: Our study shows that patients with PIS and seizures as common sequela often also develop CP. Children with later onset of epilepsy have a worse outcome. Patients with seizure onset in the neonatal period and reccuring seizures have a good response to treatment. Therefore, early diagnosis, follow-up examination and adequate therapy are important. Most children need intensive physiotherapy and speech therapy; however, participation in life is usually age-appropriate.