Consensus-Based Evaluation of Outcome Measures in Pediatric Stroke Care: A Toolkit

A national consensus-based framework on preferred assessments and interventions in current treatment for young people with acquired brain injury in Dutch rehabilitation centers

PURPOSE

Acquired brain injury (ABI) is prevalent among young people (4-25 years). When ABI-related problems persist, treatment in a rehabilitation center (RC) may be indicated. However, there is wide variability regarding the delivery of care across Dutch RCs, including assessments, interventions, and psychoeducational (PE) materials. The aim was to create a consensus-based framework with preferred assessments, interventions, and PE-materials to be used in pediatric ABI rehabilitation. A national framework could optimize the delivery of comparable care for this population.

METHODS

For this three-round Delphi study, healthcare professionals (physiatrists, psychologists, social workers, physical/occupational/speech/language therapists) from RCs providing care for young people with ABI were invited to participate. In the first two (online) rounds, currently used assessments/interventions/PE-materials were collected, stepwise-prioritized, subsequently listed per discipline, and classified per International Classification of Functioning (ICF) domain. Results from rounds one/two were discussed in a consensus meeting (in person), aiming to reach agreement on assessments/interventions/PE-materials in the national framework and how to use them in current practice.

RESULTS

Seventy-four healthcare professionals from 12 RCs participated. After Delphi round one, 163 assessments, 39 interventions, and 64 PE-materials were collected. After round two, the selection was narrowed down to n = 51/n = 34/n = 28, respectively. After round three, consensus was reached on 37 assessments, 25 interventions (divided over all disciplines/classified per ICF domain), 27 PE-materials, as well as on the use of the framework by all participating RC to enhance clinical reasoning in current practice.

CONCLUSION

A consensus-based national framework in ABI rehabilitation has been developed and is now available to optimize the delivery of care for young people with ABI across Dutch RCs.

Association of Physiologic Parameters with Neurologic Outcome After Arteriovenous Malformation Rupture in Children

Evidence to guide the critical care management of children with ruptured brain arteriovenous malformations is lacking. We aimed to determine whether there are associations between physiologic parameters and outcome in children with ruptured brain arteriovenous malformations. We performed a single-center retrospective review of patients ≤18 years of age with a ruptured brain arteriovenous malformation from 2011 to 2023. Categorization of outcome was based on the Pediatric Stroke Outcome Measure. Descriptive statistics were used. Most patients with an arteriovenous malformation rupture had a poor outcome at discharge (31/49, 63%) and in follow-up at 3-12 months (21/37, 57%). Patients who were normothermic and normoglycemic for the first 7 days after arteriovenous malformation rupture were less likely to have a poor outcome at discharge than those who had a temperature ≥38 °C (odds ratio [OR] 0.14, 95% confidence interval [CI] 0.04-0.52; P = .01) or a blood glucose ≥200 mg/dL (OR 0.11, 95% CI 0.01-0.92; P = .04). A lower minimum hemoglobin concentration (10.00 g/dL [standard deviation (SD) 1.67] vs 12.46 g/dL [SD 6.29], t(47) 2.07, P = .04) and a higher average partial pressure of carbon dioxide (Paco2) (40.98 mm Hg [SD 4.30] vs 35.58 mm Hg [SD 7.72], t(47) -2.09, P = .046) were also associated with a poor discharge outcome. A higher average maximum temperature was associated with a poor outcome in follow-up (37.46° C [SD 0.49] vs 37.09 °C [SD 0.59], t(47) -2.09; P = .04). Temperature, blood glucose, hemoglobin concentration, and Paco2 are potentially modifiable parameters that could be targeted by quality improvement interventions to improve outcomes in this population.

Neurodevelopmental outcome of perinatal intracranial haemorrhage in patients born at term: A prospective study

AIM

To assess the neurological and neurodevelopmental outcome of infants born at term with perinatal intracranial haemorrhage (pICH) and examine the clinical and neuroimaging associations.

METHOD

A prospective, consecutive, single-center observational study of longitudinally followed children with pICH identified in the fetal or neonatal period (≤28 days of life) between January 2014 and November 2022. Neurodevelopmental outcome was rated using the Pediatric Stroke Outcome Measure (PSOM) and the modified Rankin Scale (mRS).

RESULTS

Sixty-eight infants were included (67.6% diagnosed postnatally and 32.4% diagnosed antenatally). Intraventricular haemorrhage was the most common bleeding type (n = 43, 63.2%) and was more common in infants diagnosed prenatally (p = 0.004). Twenty-nine (42.6%) infants were diagnosed with cerebral palsy and 19.1% with remote epilepsy. PSOM was performed at a median age of 3 years 8 months (range = 1 year-9 years 5 months). According to the PSOM, outcome was normal in 29 (42.6%) infants. Twelve (17.6%) patients had mild impairment, 11 (16.2%) had moderate impairment, and 16 (23.5%) had severe impairment. There was no difference in neurological outcomes between patients diagnosed antenatally or postnatally. Remote epilepsy (p = 0.002), multi-compartment ICH (p = 0.048), vermian hemorrhage (p = 0.048), posthaemorrhagic ventricular dilatation (p = 0.037), thalamic volume loss (p = 0.037), white matter loss (p = 0.048), Wallerian degeneration (p = 0.026), and abnormal myelination in the posterior limb of the internal capsule (p = 0.005), were associated with less favourable PSOM scores. Anterior horn width correlated with PSOM total scores (r = 0.6).

INTERPRETATION

pICH carries a significant risk of long-term adverse neurological outcomes with no difference in neurological outcome between those diagnosed antenatally or postnatally. Epilepsy and neuroradiological markers are associated with unfavourable neurodevelopmental outcomes.

Does Time and Experience Matter in Pediatric Arterial Ischemic Stroke (AIS) Intervention in Patients with an Initial Clinical Presentation of Mild/Moderate Severity? Long-Term Follow-Up Experience of a Single Tertiary Clinic

INTRODUCTION

This study presents long-term data of pediatric AIS patients with a favorable initial clinical presentation who were followed by a tertiary pediatric neurology clinic with a well-organized stroke team.

METHOD

Patients who were diagnosed with AIS at pediatric age (28 days-18 years) and followed for at least 5 years by the same clinic were included in this study. The clinical and demographical characteristics of the patients were retrospectively collected from their medical records. At their last visit, the modified Rankin scale (mRS) and Pediatric Stroke Outcome Measure Short Neuro Exam (PSOM-SNE) were administered, and a neurological examination was performed.

RESULTS

A total of 32 patients (20 of whom were male, 62.5%) were included in this study. Their mean age at the time of the study was 162.62 ± 64.4 (62-300) months. The mean age at first ischemic stroke was 77.39 ± 61.93 (0.5-180) months, and the mean follow-up duration was 85.44 ± 20.52 (60-121) months. Seventeen patients (53.3%) reported normal daily functions at the last visit. A younger presentation age (≤60 months) was related to a longer hospital admission duration (24 h vs. 9 h) and worse long-term functional outcomes (p = 0.023). The affected vascular territory did not have any significant effect on long-term clinical outcomes (p = 0.550). Anticoagulant treatment alone was consistent with a worse prognosis compared to antithrombotic treatment alone or the combination of both (p = 0.026). PSOM-SNE scores were helpful in detecting some mild cognitive and language dysfunctions in patients with favorable mRS scores and subtle neurological sequelae.

CONCLUSIONS

Pediatric AIS with a mild presentation has some degree of long-term morbidity, even when handled at well-organized stroke centers. A younger presentation age has the highest risk of long-term neurological sequelae.

Endovascular thrombectomy for childhood stroke (Save ChildS Pro): an international, multicentre, prospective registry study

BACKGROUND

Emerging evidence suggests that endovascular thrombectomy is beneficial for treatment of childhood stroke, but the safety and effectiveness of endovascular thrombectomy has not been compared with best medical treatment. We aimed to prospectively analyse functional outcomes of endovascular thrombectomy versus best medical treatment in children with intracranial arterial occlusion stroke.

METHODS

In this prospective registry study, 45 centres in 12 countries across Asia and Australia, Europe, North America, and South America reported functional outcomes for children aged between 28 days and 18 years presenting with arterial ischaemic stroke caused by a large-vessel or medium-vessel occlusion who received either endovascular thrombectomy plus best medical practice or best medical treatment alone. Intravenous thrombolysis was considered part of best medical treatment and therefore permitted in both groups. The primary outcome was the difference in median modified Rankin Scale (mRS) score between baseline (pre-stroke) and 90 days (±10 days) post-stroke, assessed by the Wilcoxon rank test (α=0·05). Efficacy outcomes in the endovascular thrombectomy and best medical treatment groups were compared in sensitivity analyses using propensity score matching. The Save ChildS Pro study is registered at the German Clinical Trials Registry, DRKS00018960.

FINDINGS

Between Jan 1, 2020, and Aug 31, 2023, of the 241 patients in the Save ChildS Pro registry, 208 were included in the analysis (115 [55%] boys and 93 [45%] girls). 117 patients underwent endovascular thrombectomy (median age 11 years [IQR 6-14]), and 91 patients received best medical treatment (6 years [3-12]; p<0·0001). The median Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score on admission was 14 (IQR 10-19) in the endovascular thrombectomy group and 9 (5-13) in the best medical treatment group (p<0·0001). Both treatment groups had a median pre-stroke mRS score of 0 (IQR 0-0) at baseline. The change in median mRS score between baseline and 90 days was 1 (IQR 0-2) in the endovascular thrombectomy group and 2 (1-3) in the best medical treatment group (p=0·020). One (1%) patient developed a symptomatic intracranial haemorrhage (this patient was in the endovascular thrombectomy group). Six (5%) patients in the endovascular thrombectomy group and four (5%) patients in the best medical treatment group had died by day 90 (p=0·89). After propensity score matching for age, sex, and PedNIHSS score at hospital admission (n=79 from each group), the change in median mRS score between baseline and 90 days was 1 (IQR 0-2) in the endovascular thrombectomy group and 2 (1-3) in the best medical treatment group (p=0·029). Regarding the primary outcome for patients with suspected focal cerebral arteriopathy, endovascular thrombectomy (n=18) and best medical treatment (n=33) showed no difference in 90-day median mRS scores (2 [IQR 1-3] vs 2 [1-4]; p=0·074).

INTERPRETATION

Clinical centres tended to select children with more severe strokes (higher PedNIHSS score) for endovascular thrombectomy. Nevertheless, endovascular thrombectomy was associated with improved functional outcomes in paediatric patients with large-vessel or medium-vessel occlusions compared with best medical treatment. Future studies need to investigate whether the positive effect of endovascular thrombectomy is confined to older and more severely affected children.

FUNDING

None.

An Initial Psychometric Evaluation of a Novel Upper Extremity Pediatric Stroke Hemiplegic Motor Impairment Scale

BACKGROUND

Our team designed an innovative, observation-based motor impairment measure-the Pediatric Stroke Hemiplegic Motor Impairment Scale (Pedi HEMIs). Here we present the results of a survey describing common practices in the pediatric stroke community and the initial psychometric properties of the upper extremity subscale of the Pedi HEMIs (Pedi HEMIs-UE).

METHODS

This is a cross-sectional study whereby participants completed a battery of assessments including the novel Pedi HEMIs-UE. Internal consistency was measured via Cronbach alpha (α). Intraclass correlation (ICC) was used to assess inter-rater reliability (IRR). Concurrent validity was investigated using Pearson or polychoric correlations and simple linear regressions.

RESULTS

The study sample consisted of 18 children aged 1.08 to 15 years. Two participants completed two sets of evaluations, totaling 20 data sets. Cronbach α, a measure of internal consistency, was on average 0.91 (range: 0.89 to 0.92). IRR was excellent with the six raters in almost perfect agreement (ICC = 0.91; 95% confidence interval [CI]: 0.83 to 0.96). Pearson correlation coefficient between the Pedi HEMIs-UE and logit Assisting Hand Assessment (AHA)/mini-AHA was -0.938 (95% CI: -0.979 to -0.827, P < 0.001), indicating excellent concurrent validity.

CONCLUSIONS

We found excellent feasibility, reliability, and validity of the Pedi HEMIs-UE in a convenience sample of youth with hemiparesis after stroke.

Factor analysis of neuropsychological domains in a preschool clinic

INTRODUCTION

The clinical practice of preschool neuropsychology assumes that our assessment tools are measuring underlying neuropsychological functions, and that these functions are negatively impacted by early life neurological injury, disease, and disorder. This study hypothesized that general intellectual capacity and specific cognitive skills, both "broad" neuropsychological domains and "specific" subdomains within those broader clusters, would be differentiable in a preschool-age clinical population.

METHODS

Using neuropsychological data from 580 children (6 and 71 months) seen for a clinical neuropsychological evaluation in the Preschool and Infant Neuropsychological Testing (PINT) Clinic, exploratory factor analyses (EFA) were conducted. Results: A one-factor model provided a good fit when considering verbal, nonverbal, and adaptive functions. Consideration of one- versus two-factor solutions for broad neuropsychological domains indicated that a 2-factor solution provided a significantly better fit for the data. Factor 1 was defined by motor, language, and nonverbal reasoning abilities; Factor 2 was defined by inhibitory control and attention. Further consideration of specific neuropsychological functions also supported a 2-factor solution. Factor 1 ("thinking") was defined by nonverbal reasoning, receptive language, and expressive language; Factor 2 ("processing") was defined by impulse control, inhibitory control, inattention, visual-motor integration, and visuo-constructional abilities. Motor skills cross-loaded onto both factors. Secondary analyses suggest these models provide the best fit for preschool-aged children with > 70 overall intellectual functioning and no comorbid medical diagnosis.

CONCLUSIONS

In a clinical sample of preschool-age children, neuropsychological assessment data appears to assess a general level of intellectual capacity or functioning. Further differentiation between assessing "thinking" (knowledge and reasoning skills) and "processing" (cognitive attention and processing of information) can be considered clinically. Next steps include more recent clinical sample replication, consideration of whether neuropsychological profiles are detectable in the preschool-age range and whether the results of early life assessment are predictive of future functioning.