The 5-year direct medical cost of neonatal and childhood stroke in a population-based cohort

Global, Regional, and National Burdens of Stroke in Children and Adolescents From 1990 to 2019: A Population-Based Study

BACKGROUND

Stroke is one of the leading causes of death among children, yet evidence on stroke incidence and prognosis in this population is largely neglected worldwide. The aim of this study was to estimate the latest burden of childhood stroke, as well as trends, risk factors, and inequalities from 1990 to 2019, at the global, regional, and national levels.

METHODS

The Global Burden of Disease 2019 study was utilized to evaluate the prevalence, incidence, years lived with disability, years of life lost (YLLs), and average annual percentage changes in stroke among populations aged 0 to 19 years from 1990 to 2019.

RESULTS

The global age-standardized incidence of stroke increased (average annual percentage change, 0.15% [95% uncertainty interval, 0.09%-0.21%]), while YLLs decreased substantially (average annual percentage change, -3.33% [95% uncertainty interval, -3.38% to -3.28%]) among children and adolescents between 1990 and 2019. Ischemic stroke accounted for 70% of incident cases, and intracerebral hemorrhage accounted for 63% of YLLs. Children under 5 years of age had the highest incidence of ischemic stroke, while adolescents aged 15 to 19 years had the highest incidence of hemorrhagic stroke. In 2019, low-income and middle-income countries were responsible for 84% of incident cases and 93% of YLLs due to childhood stroke. High-sociodemographic index countries had a reduction in YLLs due to stroke that was more than twice as fast as that of low-income and middle-income.

CONCLUSIONS

Globally, the burden of childhood stroke continues to increase, especially among females, children aged <5 years, and low-sociodemographic index countries, such as sub-Saharan Africa. The burden of childhood stroke is likely undergoing a significant transition from being fatal to causing disability. Global public health policies and the deployment of health resources need to respond rapidly and actively to this shift.

Risk factors for pediatric ischemic stroke and intracranial hemorrhage: A national electronic health record based study

Background

Stroke is an important cause of morbidity in pediatrics. Large studies are needed to better understand the epidemiology, pathogenesis and risk factors associated with pediatric stroke. Large administrative datasets can provide information on risk factors in perinatal and childhood stroke at low cost. The aim of this hypothesis-generating study was to use a large administrative dataset to assess for prevalence and odds-ratios of rare exposures associated with pediatric stroke.

Methods

The data for patients aged 0-18 with a diagnosis of either ischemic stroke or intracranial hemorrhage were extracted from the Cerner Health Facts EMR Database from 2000 to 2018. Prevalence of various possible risk factors for pediatric and adult stroke was assessed using ICD 9 and 10 codes. Odds ratios were calculated using a control group of patients without stroke.

Results

10,688 children were identified with stroke. 6339 (59 %) were ischemic and 4349 (41 %) were hemorrhagic. The most frequently identified risk factors for ischemic stroke across age groups were hypertension (29-44 %), trauma (19-33 %), and malignancy (11-24 %). The most common risk factors seen with hemorrhagic stroke were trauma (32-64 %), malignancy (5-19 %) and arrhythmia (9-12 %). Odds ratios across all age groups for dyslipidemia (17-64), hypertension (20-63), and tobacco exposure (3-59) were high in the ischemic stroke cohort.

Conclusion

This is the largest retrospective study of pediatric stroke of its kind from hospitals across the US in both academic and non-academic clinical settings. Much of our data was consistent with prior studies. ICD codes for tobacco exposure, hyperlipidemia, diabetes, and hypertension all had high odds ratios for stroke in children, which suggest a relationship between these conditions and pediatric stroke. However, ascertainment bias is a major concern with electronic health record-based studies. More focused study is needed into the role of these exposures into the pathogenesis of pediatric stroke.

Gut Microbiota Ecological and Functional Modulation in Post-Stroke Recovery Patients: An Italian Study

Ischemic stroke (IS) can be caused by perturbations of the gut-brain axis. An imbalance in the gut microbiota (GM), or dysbiosis, may be linked to several IS risk factors and can influence the brain through the production of different metabolites, such as short-chain fatty acids (SCFAs), indole and derivatives. This study examines ecological changes in the GM and its metabolic activities after stroke. Fecal samples of 10 IS patients were compared to 21 healthy controls (CTRLs). GM ecological profiles were generated via 16S rRNA taxonomy as functional profiles using metabolomics analysis performed with a gas chromatograph coupled to a mass spectrometer (GC-MS). Additionally fecal zonulin, a marker of gut permeability, was measured using an enzyme-linked immuno assay (ELISA). Data were analyzed using univariate and multivariate statistical analyses and correlated with clinical features and biochemical variables using correlation and nonparametric tests. Metabolomic analyses, carried out on a subject subgroup, revealed a high concentration of fecal metabolites, such as SCFAs, in the GM of IS patients, which was corroborated by the enrichment of SCFA-producing bacterial genera such as Bacteroides, Christensellaceae, Alistipes and Akkermansia. Conversely, indole and 3-methyl indole (skatole) decreased compared to a subset of six CTRLs. This study illustrates how IS might affect the gut microbial milieu and may suggest potential microbial and metabolic biomarkers of IS. Expanded populations of Akkermansia and enrichment of acetic acid could be considered potential disease phenotype signatures.

A quantitative EEG index for the recognition of arterial ischemic stroke in children

OBJECTIVE

To describe and assess performance of the Correlate Of Injury to the Nervous system (COIN) index, a quantitative electroencephalography (EEG) metric designed to identify areas of cerebral dysfunction concerning for stroke.

METHODS

Case-control study comparing continuous EEG data from children with acute ischemic stroke to children without stroke, with or without encephalopathy. COIN is calculated continuously and compares EEG power between cerebral hemispheres. Stroke relative infarct volume (RIV) was calculated from quantitative neuroimaging analysis. Significance was determined using a two-sample t-test. Sensitivity, specificity, and accuracy were measured using logistic regression.

RESULTS

Average COIN values were -34.7 in the stroke cohort compared to -9.5 in controls without encephalopathy (p = 0.003) and -10.5 in controls with encephalopathy (p = 0.006). The optimal COIN cutoff to discriminate stroke from controls was -15 in non-encephalopathic and -18 in encephalopathic controls with >92% accuracy in strokes with RIV > 5%. A COIN cutoff of -20 allowed discrimination between strokes with <5% and >5% RIV (p = 0.027).

CONCLUSIONS

We demonstrate that COIN can identify children with acute ischemic stroke.

SIGNIFICANCE

COIN may be a valuable tool for stroke identification in children. Additional studies are needed to determine utility as a monitoring technique for children at risk for stroke.

Chronic changes in oligodendrocyte sub-populations after middle cerebral artery occlusion in neonatal mice

Neonatal stroke is common and causes life-long motor and cognitive sequelae. Because neonates with stroke are not diagnosed until days-months after the injury, chronic targets for repair are needed. We evaluated oligodendrocyte maturity and myelination and assessed oligodendrocyte gene expression changes using single cell RNA sequencing (scRNA seq) at chronic timepoints in a mouse model of neonatal arterial ischemic stroke. Mice underwent 60 min of transient right middle cerebral artery occlusion (MCAO) on postnatal day 10 (p10) and received 5-ethynyl-2'-deoxyuridine (EdU) on post-MCAO days 3-7 to label dividing cells. Animals were sacrificed 14 and 28-30 days post-MCAO for immunohistochemistry and electron microscopy. Oligodendrocytes were isolated from striatum 14 days post-MCAO for scRNA seq and differential gene expression analysis. The density of Olig2+ EdU+ cells was significantly increased in ipsilateral striatum 14 days post-MCAO and the majority of oligodendrocytes were immature. Density of Olig2+ EdU+ cells declined significantly between 14 and 28 days post-MCAO without a concurrent increase in mature Olig2+ EdU+ cells. By 28 days post-MCAO there were significantly fewer myelinated axons in ipsilateral striatum. scRNA seq identified a cluster of "disease associated oligodendrocytes (DOLs)" specific to the ischemic striatum, with increased expression of MHC class I genes. Gene ontology analysis suggested decreased enrichment of pathways involved in myelin production in the reactive cluster. Oligodendrocytes proliferate 3-7 days post-MCAO and persist at 14 days, but fail to mature by 28 days. MCAO induces a subset of oligodendrocytes with reactive phenotype, which may be a therapeutic target to promote white matter repair.

Pediatric Stroke in the Southern Region of Iran: A Retrospective Prognostic Cohort Study

Objective

Childhood stroke is linked to high personal costs for affected children and their families since more than half of the survivors are impaired for a long time, hampering their normal development and lifestyle. Thus, the present study aimed to evaluate the neurological developmental outcomes of children admitted to Namazi hospital, Shiraz, Iran, for ischemic and hemorrhagic stroke with a five-year follow-up. Ma a retrospective cohort study on children admitted to Namazi Hospital due to ischemic and hemorrhagic stroke during the past three years (2012-2015). The information was collected by reviewing the medical records and clinically visiting the patients on follow-up. The SPSS 21.0 software was used for statistical analysis.

Materials & Method

This is a retrospective cohort study on children admitted to Namazi hospital due to ischemic and hemorrhagic stroke during past three years (2012-2015). The information was collected by reviewing the medical records and clinically visiting the patients at the time of follow up. The SPSS 21.0 software was used for statistical analysis Settings.

Results

The patients' mean age at the time of stroke was 6.87 ± 4.60 years. The mean follow-up period was 3.5 ± 1.64 years. 53.1% of the children (N=17) were diagnosed with hemorrhagic stroke, and 46.9% (N=15) with ischemic stroke. The most frequent symptoms first presented by the study population were a decrease in the level of consciousness (LOC) (40.6%), headaches (37.5 %), and hand/arm/leg weakness (34.4%), respectively. The number of patients in the poor.and severe outcome group was 73.3% in the ischemic and 52.9% in the hemorrhagic group.

Conclusion

Hemorrhagic stroke was slightly more frequent than ischemic stroke, and stroke was more frequent in boys. A decrease in LOC and headaches were the most common symptoms upon admission. The left sensorimotor area was the most involved in both ischemic and hemorrhagic groups. In addition, trauma was the most common cause of stroke in this study population.

Neurological and Functional Outcomes after Pediatric Stroke

Pediatric stroke results in life-long morbidity for many patients, but the outcomes can vary depending on factors such as age of injury, or mechanism, size, and location of stroke. In this review, we summarize the current understanding of outcomes in different neurological domains (eg, motor, cognitive, language) for children with stroke of different mechanisms (ie, arterial ischemic stroke, cerebral sinus venous thrombosis, and hemorrhagic stroke), but with a focus on World Health Organization International Classification for Functioning, Disability, and Health (ICF-CY) framework for measuring health and disability for children and youth. We describe outcomes for the population as a whole and certain factors that may further refine prognostication.

Changes in childhood stroke mortality from 1990 to 2019 in Brazil and its federative units

This research analyzed the temporal trend of stroke mortality in children aged 0-14 years, from 1990 to 2019, in Brazil and its federative units. This ecological study used data from the Global Burden of Disease, a study led by the Institute for Health Metrics and Evaluation. Stroke definition considered the International Classification of Diseases according to codes G45, G46, and I60-I69. Age-standardized mortality rates and the mean annual percentage change (APC) in mortality rates were estimated. Stroke mortality trends decreased, with an APC of - 3.9% (95% CI - 4.5; - 3.3; p < 0.001). Reducing trends were found in all but two states, where they were stationary. Maranhão (- 6.5%; 95% CI - 7.6; - 5.4; p < 0.001) had the greatest reduction and Rondônia, the smallest (- 1.2%; 95% CI - 2.3; - 0.1, p = 0.027). Decrease was more important in children < 5 (- 5.8%; 95% CI - 6.3; - 5.2; p < 0.001) compared to 5-14 years old (- 2.1%; 95% CI - 2.9; - 1.3; p < 0.001); additionally, it was greater in girls (- 4.1%; 95% CI - 4.6; - 3.5; p < 0.001) than in boys (- 3.8%; 95% IC - 4.5; - 3.1; p < 0.001). Ischemic stroke had the highest APC (- 6.1%; 95% CI - 6.8; - 5.3; p < 0.001), followed by intracranial hemorrhage (- 5.3%; 95% CI - 6.1; - 4.5; p < 0.001) and subarachnoid hemorrhage (- 2.7%; 95% CI - 3.3; - 2.1; p < 0.001). Largest reductions were seen in states with more vulnerable socioeconomic contexts. The stationary trends and lowest APCs were concentrated in the northern region, which had greater impact of diseases and less favorable outcomes.

Neonatal Arterial Ischaemic Stroke: Advances in Pathologic Neural Death, Diagnosis, Treatment, and Prognosis

Neonatal arterial ischaemic stroke (NAIS) is caused by focal arterial occlusion and often leads to severe neurological sequelae. Neural deaths after NAIS mainly include necrosis, apoptosis, necroptosis, autophagy, ferroptosis, and pyroptosis. These neural deaths are mainly caused by upstream stimulations, including excitotoxicity, oxidative stress, inflammation, and death receptor pathways. The current clinical approaches to managing NAIS mainly focus on supportive treatments, including seizure control and anticoagulation. In recent years, research on the pathology, early diagnosis, and potential therapeutic targets of NAIS has progressed. In this review, we summarise the latest progress of research on the pathology, diagnosis, treatment, and prognosis of NAIS and highlight newly potential diagnostic and treatment approaches.

Closing the Gap in Pediatric Hemorrhagic Stroke: A Systematic Review

Pediatric hemorrhagic stroke (HS) accounts for a large proportion of childhood strokes, 1 of the top 10 causes of pediatric deaths. Morbidity and mortality lead to significant socio-economic and psychosocial burdens. To understand published data on recognizing and managing children with HS, we conducted a systematic review of the literature presented here. We searched PubMed, Embase, CINAHL and the Cochrane Library databases limited to English language and included 174 studies, most conducted in the USA (52%). Terminology used interchangeably for HS included intraparenchymal/intracranial hemorrhage, spontaneous ICH, and cerebrovascular accident (CVA). Key assessments informing prognosis and management included clinical scoring (Glasgow coma scale), and neuroimaging. HS etiologies reported were systemic coagulopathy (genetic, acquired pathologic, or iatrogenic), or focal cerebrovascular lesions (brain arteriovenous malformations, cavernous malformations, aneurysms, or tumor vascularity). Several scales were used to measure outcome: Glasgow outcome score (GOS), Kings outcome score for head injury (KOSCHI), modified Rankin scale (mRS) and pediatric stroke outcome measure (PSOM). Most studies described treatments of at-risk lesions. Few studies described neurocritical care management including raised ICP, seizures, vasospasm, or blood pressure. Predictors of poor outcome included ethnicity, comorbidity, location of bleed, and hematoma &gt;2% of total brain volume. Motor and cognitive outcomes followed independent patterns. Few studies reported on cognitive outcomes, rehabilitation, and transition of care models. Interdisciplinary approach to managing HS is urgently needed, informed by larger cohort studies targeting key clinical question (eg development of a field-guide for the clinician managing patients with HS that is reproducible internationally).

Neonatal stroke surveillance study protocol in the United Kingdom and Republic of Ireland

Neonatal stroke is a devastating condition that causes brain injury in babies and often leads to lifelong neurological impairment. Recent prospective population studies of neonatal stroke are lacking. Neonatal strokes are different from those in older children and adults. A better understanding of its aetiology, current management, and outcomes could reduce the burden of this rare condition. The study aims to explore the incidence and 2 year outcomes of neonatal stroke across an entire population in the UK and Republic of Ireland. This is an active national surveillance study using a purpose-built integrated case notification-data collection online platform. Over a 13 month period, with a potential 6 month extension, clinicians will notify neonatal stroke cases presenting in the first 90 days of life electronically via the online platform monthly. Clinicians will complete a primary questionnaire via the platform detailing clinical information, including neuroimaging, for analysis and classification. An outcome questionnaire will be sent at 2 years of age via the platform. Appropriate ethics and regulatory approvals have been received. The neonatal stroke study represents the first multinational population surveillance study delivered via a purpose-built integrated case notification-data collection online platform and data safe haven, overcoming the challenges of setting up the study.

Initial Diagnostic Evaluation of the Child With Suspected Arterial Ischemic Stroke

ABSTRACT

Numerous factors make the initial diagnostic evaluation of children with suspected arterial ischemic stroke (AIS) a relatively unsettling challenge, even for the experienced stroke specialist. The low frequency of pediatric AIS, diversity of unique age-oriented stroke phenotypes, and unconventional approaches required for diagnosis and treatment all contribute difficulty to the process. This review aims to outline important features that differentiate pediatric AIS from adult AIS and provide practical strategies that will assist the stroke specialist with diagnostic decision making in the initial phase of care.

Pediatric Patient with Ischemic Stroke: Initial Approach and Early Management

Acute Ischemic Stroke (AIS) in children is an acute neurologic emergency associated with significant morbidity and mortality. Although the incidence of AIS in pediatric patients is considerably lower than in adults, the overall cumulative negative impact of the quality of life could be even higher in children. The age-related variable clinical presentation could result in a delay in diagnosis and could negatively influence the overall outcome. The early management should be based on early recognition, acute transfer to pediatric AIS centre, standardised approach (ABCDE), early neurologic examination together with neuroimaging (preferable Magnetic Resonance Imaging—MRI). The treatment is based on supportive therapy (normoxemia, normocapnia, normotension and normoglycemia) in combination with intravenous/intraarterial thrombolytic therapy and/or mechanical thrombectomy in selected cases. Pediatric stroke centres, together with the implementation of local stroke management protocols, could further improve the outcome of pediatric patients with AIS.

Recanalization strategies in childhood stroke in Germany

Childhood arterial ischemic stroke (CAIS) is a rare event. Diverse etiologies, risk factors, symptoms and stroke mimics hamper obtaining a fast diagnosis and implementing immediate recanalization strategies. Over a period of 3 years (2015–2017), the data of 164 pediatric patients (> 28 days of life-18 years) with a first episode of AIS were submitted to a hospital-based nationwide surveillance system for rare disorders (ESPED). We report a subgroup analysis of patients who have undergone recanalization therapy and compare these data with those of the whole group. Twenty-eight patients (17%) with a median age of 12.2 years (range 3.3–16.9) received recanalization therapy. Hemiparesis, facial weakness and speech disturbance were the main presenting symptoms. The time from onset of symptoms to confirmation of diagnosis was significantly shorter in the intervention group (4.1 h vs. 20.4 h, p ≤ 0.0001). Only in one patient occurred a minor bleed. Cardiac disease as predisposing risk factor was more common in the recanalization group. Recanalization therapies are feasible and increasingly applied in children with AIS. High awareness, timely diagnosis and a large amount of expertise may improve time to treatment and make hyperacute therapy an option for more patients.

Endovascular Treatment for Acute Ischemic Stroke in Children: Experience From the MR CLEAN Registry

BACKGROUND AND PURPOSE

Multiple trials have shown the efficacy and safety of endovascular therapy (EVT) of acute ischemic stroke in adults. Trials in children are lacking and only case reports and case series exist. However, the long-term outcome of children with acute ischemic stroke can be devastating with significant mortality and morbidity. In this study, we describe the safety and efficacy of EVT in children with anterior circulation acute ischemic stroke who were included in the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands).

METHODS

Patients under the age of 18 years who were treated with EVT for acute ischemic stroke between March 2014 and July 2017 were retrospectively reviewed up to 6 months after EVT. Nine children, aged 13 months to 16 years (median 14 years, interquartile range, 3-15 years), underwent EVT. Stroke cause was thromboembolism in children with end-stage heart failure on left ventricular assist device (4 of these 9 cases). Median time from onset to imaging was 133 minutes. Four children received intravenous alteplase before EVT, with median onset to needle time of 165 minutes. In all but one patient, EVT was technically successful. No major periprocedural complications occurred.

RESULTS

At 24 hours after EVT, 3 children completely recovered and 4 children showed partial recovery (median National Institutes of Health Stroke Scale, 3.5), whereas 2 patients on left ventricular assist device died within the first week due to the occurrence of multiple strokes. One patient on left ventricular assist device developed a fatal massive intracranial hemorrhage and another child died due to left ventricular assist device-related complications. Among the 5 stroke survivors, all had a favorable outcome (modified Rankin Scale score, 0-2) at 6 months follow-up.

CONCLUSIONS

EVT of children with acute ischemic stroke seems safe and feasible. However, these findings should be interpreted with caution as more and larger studies are needed to clarify the trade-off between risks and benefits of this treatment.

Hospitalization Expenditures and Out-Of-Pocket Expenses in Patients With Stroke in Northeast China, 2015-2017: A Pooled Cross-Sectional Study

Background: Stroke is the second most common cause of mortality worldwide and the leading cause of death in China. It imposes a heavy financial burden on patients, especially for some social groups that are vulnerable to economic risks.

Objective: This study aimed to comprehensively assess the magnitude of hospital and out-of-pocket (OOP) costs associated with stroke in Northeast China.

Methods: Patients were selected via a multistage stratified cluster random sampling approach. We reviewed all patients’ records from 39 hospitals across six cities in Liaoning Province between 2015 and 2017. Cost characteristics of four major stroke types were analyzed. Multivariate linear regression analyses were employed to examine the determinants of hospitalization costs and OOP expenses.

Results: A total of 138,757 patients were assessed for the medical costs. The mean hospitalization costs were $1,627, while the mean OOP expenses were $691, accounting for 42.5% of the total expenditures. Medication expenses were the largest contributor to hospitalization costs. The regression analysis suggested that age, length of stay (LOS), social identity, type of stroke, surgery, intensive care unit (ICU) admission, hospital level and hospital type were significantly correlated with hospitalization costs and OOP expenses.

Conclusion: Stroke imposes a heavy financial burden on both patients and society in Liaoning Province, Northeast China. Results showed that there are some differences in the individual and social economic burden among different types of stroke. In addition, stroke patients share a high proportion of costs through OOP expenses, especially for poor social-economic status patients. Targeted intervention measures and specific policies are needed to reduce the individual and social economic burden of stroke as well as improve equity in health care among different social groups.

Ischemic stroke following operated head trauma in children: Discussion of a rare clinical case

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Strokes are rare in paediatric population.

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Posttraumatic strokes in children may be the result of several linked factors.

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Postoperative strokes may occur even several days after surgery thus the need for extended follow up.

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Based on trauma mechanism and consequences, children presenting stroke risk should be early identified.

Introduction

Traumatic brain injury (TBI) is the leading cause of morbidity and mortality in children. TBI in children are responsible for a range of clinical symptoms and signs that are comparable to those in adults, but present several differences in both physiopathology and management. Many postoperative complications may occur, ischemic stroke among others, which is generally related to an injury of an intracranial artery. Out of this case, it may be more difficult to find a suitable explanation to this complication.

Case presentation

We report the case of a child aged years old, who was collided by a car causing a polytrauma with head and chest injury. On body scan, she had a fracture of the sixth left rib, and a frontal cranio-cerebral wound. The patient was operated for debridement of the wound, and tight closure of the injured dura mater. Initial postoperative course was uneventful, but 5 days after first surgery patient presented an acute onset of a right hemiplegia followed by an alteration of her state of consciousness, and a left anisocoria. Follow up CT scan showed a stroke of the whole left carotid territory. The patient was re-operated through a left decompressive craniectomy. Following the second surgery, she showed an improvement of her level of consciousness and a normalization of the size of her pupils, but aphasia and a right hemiplegia persisted. 2 weeks after surgery, the patient had a progressive necrosis of the surgical scar, followed by an exposure of the underlying cerebral cortex. Despite of intensive local care, a plastic surgery to recover the wound and antibiotics, the patient presented a meningitis, followed by a septic shock and death.

Clinical discussion and conclusions

Ischemic stroke is probably the most harsh and unpredictable complication that may occur after TBI, mainly in children. Only rigorous surgical approach followed by stringent post-operative care may prevent such outcomes.

ACR Appropriateness Criteria® Cerebrovascular Disease-Child

Stroke is an uncommon but an important and under-recognized cause of morbidity and mortality in children. Strokes may be due to either brain ischemia or intracranial hemorrhage. Common symptoms of pediatric acute stroke include headache, vomiting, focal weakness, numbness, visual disturbance, seizures, and altered consciousness. Most children presenting with an acute neurologic deficit do not have an acute stroke, but have symptoms due to stroke mimics which include complicated migraine, seizures with postictal paralysis, and Bell palsy. Because of frequency of stroke mimics, in children and the common lack of specificity in symptoms, the diagnosis of a true stroke may be delayed. There are a relatively large number of potential causes of stroke mimic and true stroke. Consequently, imaging plays a critical role in the assessment of children with possible stroke and especially in children who present with acute onset of stroke symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Pediatric ASPECTS predicts outcomes following acute symptomatic neonatal arterial stroke

Objective

To test the hypothesis that the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) is useful in determining outcomes after neonatal arterial ischemic stroke (NAIS), we assessed accuracy of the modified pediatric ASPECTS (pedASPECTS) to predict cerebral palsy (CP), neurologic impairment, and epilepsy.

Methods

Cross-sectional study included newborns with acute NAIS whose outcomes were assessed at ≥18 months after stroke. PedASPECTS accuracy to predict outcomes was determined by sensitivity, specificity, and receiver operator characteristic (ROC) curves, and correlation between pedASPECTS and infarct volume was determined by the Spearman correlation coefficient.

Results

Ninety-six children met the inclusion criteria. Median percentage infarct to supratentorial brain volume was 6.8% (interquartile range [IQR] 3.0%–14.3%). Median pedASPECTS was 7 (IQR 4–10). At a median age of 2.1 years, 35% developed CP, 43% had neurologic impairment, and 7% had epilepsy. Median pedASPECTS predicted outcomes of interest: CP (10, IQR 8–12) vs no CP (5, IQR 4–8) (p < 0.0001), poor (9, IQR 7–12) vs good (6, IQR 4–8) neurologic outcomes (p < 0.0001), and epilepsy (10, IQR 8–12) vs no epilepsy (7, IQR 4–10) (p = 0.033). PedASPECTS accuracy was good for CP (ROC 0.811) and fair for neurologic impairment (ROC 0.760) and epilepsy (ROC 0.761). A pedASPECTS ≥8 had ≥69% sensitivity and ≥54% specificity for clinical outcomes. PedASPECTS correlated with infarct volume (Spearman rank 0.701, p < 0.0001).

Conclusions

This study provides Class II evidence that pedASPECTS has fair to good accuracy for predicting CP, neurologic impairment, and epilepsy after NAIS and correlates with infarct volume. PedASPECTS may assist with early identification of babies requiring close developmental surveillance.

Predicting Ischemic Risk Using Blood Oxygen Level-Dependent MRI in Children with Moyamoya

BACKGROUND AND PURPOSE

Moyamoya is a progressive steno-occlusive arteriopathy. MR imaging assessment of cerebrovascular reactivity can be performed by measuring the blood oxygen level-dependent cerebrovascular reactivity response to vasoactive stimuli. Our objective was to determine whether negative blood oxygen level-dependent cerebrovascular reactivity status is predictive of ischemic events in childhood moyamoya.

MATERIALS AND METHODS

We conducted a retrospective study of a consecutive cohort of children with moyamoya who underwent assessment of blood oxygen level-dependent cerebrovascular reactivity. The charts of patients with written informed consent were reviewed for the occurrence of arterial ischemic stroke, transient ischemic attack, or silent infarcts. We used logistic regression to calculate the OR and 95% CI for ischemic events based on steal status. Hazard ratios for ischemic events based on age at blood oxygen level-dependent cerebrovascular reactivity imaging, sex, and moyamoya etiology were calculated using Cox hazards models.

RESULTS

Thirty-seven children (21 female; median age, 10.7 years; interquartile range, 7.5-14.7 years) were followed for a median of 28.8 months (interquartile range, 13.7-84.1 months). Eleven (30%) had ischemic events, 82% of which were TIA without infarcts. Steal was present in 15 of 16 (93.8%) hemispheres in which ischemic events occurred versus 25 of 58 (43.1%) ischemic-free hemispheres (OR = 19.8; 95% CI, 2.5-160; P = .005). Children with idiopathic moyamoya were at significantly greater risk of ischemic events (hazard ratio, 3.71; 95% CI, 1.1-12.8; P = .037).

CONCLUSIONS

Our study demonstrates that idiopathic moyamoya and the presence of steal are independently associated with ischemic events. The use of blood oxygen level-dependent cerebrovascular reactivity could potentially assist in the selection of patients for revascularization surgery and the direction of therapy in children with moyamoya.

Australian Clinical Consensus Guideline: The diagnosis and acute management of childhood stroke

Stroke is among the top 10 causes of death in children and survivors carry resulting disabilities for decades, at substantial cost to themselves and their families. Children are not currently able to access reperfusion therapies, due to limited evidence supporting safety and efficacy and long diagnostic delays. The Australian Clinical Consensus Guideline for the Diagnosis and Acute Management of Childhood Stroke was developed to minimize unwarranted variations in care and document best evidence on the risk factors, etiologies, and conditions mimicking stroke that differ from adults. Clinical questions were formulated to inform systematic database searches from 2007 to 2017, limited to English and pediatric studies. SIGN methodology and the National Health and Medical Research Council system were used to screen and classify the evidence. The Grades of Recommendation, Assessment, Development, and Evaluation system (GRADE) was used to grade evidence as strong or weak. The Guideline provides more than 60 evidence-based recommendations to assist prehospital and acute care clinicians in the rapid identification of childhood stroke, choice of initial investigation, to confirm diagnosis, determine etiology, selection of the most appropriate interventions to salvage brain at risk, and prevent recurrence. Recommendations include advice regarding the management of intracranial pressure and congenital heart disease. Implementation of the Guideline will require reorganization of prehospital and emergency care systems, including the development of regional stroke networks, pediatric Code Stroke, rapid magnetic resonance imaging and accreditation of primary pediatric stroke centers with the capacity to offer reperfusion therapies. The Guideline will allow auditing to benchmark timelines of care, access to acute interventions, and outcomes. It will also facilitate the development of an Australian childhood stroke registry, with data linkage to international registries, to allow for accurate data collection on stroke incidence, treatment, and outcomes.

Risk Factors of Pediatric Arterial Ischemic Stroke; A Regional Survey

Background:

Considering that better understanding of the underlying mechanisms and risk factors of arterial ischemic stroke (AIS) would be helpful for better management of stroke and its outcome in children as well as preventing or reducing the occurrence of its related potential disabilities, the aim of this study was to investigate the most common risk factors and causes of AIS in patients referred to the referral hospitals in Tehran and Isfahan cities of Iran.

Methods:

In this study, medical files of all pediatric patients admitted to the Mofid and Imam Hossein children's hospitals with the diagnosis of AIS from 2001 to 2011 and 2011 to 2016, respectively, were evaluated. Identified risk factors of AIS were categorized as arteriopathies, cardiac disorders (CDs), infection, acute head-and-neck disorders, acute systemic conditions, chronic systemic conditions, prothrombotic states, chronic head-and-neck disorders, atherosclerosis-related RFs, and others.

Results:

In this study, 61 patients were evaluated. Mean (standard deviation) age of the patients was 5.1 (3.9) years. About 62.3% of the patients were boys while 37.7% were girls (P < 0.01). A total of 36 patients (59%) had at least one risk factor for AIS. About 40.9% of patients had undetermined risk factors. CDs (21.31%) and vascular disease (21.31%) were the most common risk factors of AIS in the studied children. Nearly 11.5% of the patients had moyamoya vascular disease (MMD).

Conclusion:

The findings of our study indicated that the most common risk factors for AIS in the two studied regions are congenital heart and vascular diseases. The results of the current study could be used for planning more preventive strategies in patients suffering from the mentioned diseases. In addition, the obtained data could be used for conducting targeted education and management of high-risk patients.

[Stroke in children and adolescents]

The occurrence of a stroke in children and adolescents constitutes a rare, critical event that is associated with substantial morbidity and mortality. In addition to the individual suffering for the young patient and the medical burden for the affected family, a stroke is also associated with high follow-up costs for the health system because of the necessary long-term rehabilitative treatment. Establishing an early and prompt diagnosis is of great therapeutic importance. Because of the rarity of the illness and the plethora of clinical manifestations, diagnosis is often delayed. The most frequent clinical presentation is an acute focal-neurological deficit, usually in the form of hemiparesis, but headache, seizures or alteration of consciousness may also be seen. Nowadays, the prompt performance of diffusion-weighted, blood-sensitive magnetic resonance imaging (MRI) constitutes the gold standard. The most relevant risk factors for the occurrence of a stroke in this age cohort are vasculopathies, infections, pathological cardiac conditions or coagulopathies. Recurrence of stroke is dependent on the underlying risk factors. In a substantial percentage of patients, residual neurological deficits are seen.Owing to a lack of randomized controlled trials in children and adolescents with stroke, the optimal treatment approach is still under debate. In addition to anti-platelet medication and heparinization, systematic intravenous thrombolysis and endovascular thrombectomy are other potentially effective treatment options. The long-term prognosis in children is dependent on establishing a correct, early diagnosis.

Childhood Stroke: Awareness, Interest, and Knowledge Among the Pediatric Community

Objective: Acute childhood stroke is an emergency requiring a high level of awareness among first-line healthcare providers. This survey serves as an indicator of the awareness of, the interest in, and knowledge of childhood stroke of German pediatricians. Methods: Thousand six hundred and ninety-seven physicians of pediatric in- and outpatient facilities in Bavaria, Germany, were invited via email to an online-survey about childhood stroke. Results: The overall participation rate was 14%. Forty-six percent of participants considered a diagnosis of childhood stroke at least once during the past year, and 47% provide care for patients who have suffered childhood stroke. The acronym FAST (Face-Arm-Speech-Time-Test) was correctly cited in 27% of the questionnaires. Most commonly quoted symptoms of childhood stroke were hemiparesis (90%), speech disorder (58%), seizure (44%), headache (40%), and impaired consciousness (33%). Migraine (63%), seizure (39%), and infections of the brain (31%) were most frequently named as stroke mimics. Main diagnostic measures indicated were magnetic resonance imaging (MRI) (96%) and computer tomography (CT) (55%). Main therapeutic strategies were thrombolysis (80%), anticoagulation (41%), neuroprotective measures, and thrombectomies (15% each). Thirty-nine percent of participants had taken part in training sessions, 61% studied literature, 37% discussed with colleagues, and 25% performed internet research on childhood stroke. Ninety-three percent of participants approve skill enhancement, favoring training sessions (80%), publications (43%), and web based offers (35%). Consent for offering a flyer on the topic to caregivers in facilities was given in 49%. Conclusion: Childhood stroke constitutes a topic of clinical importance to pediatricians. Participants demonstrate a considerable level of comprehension concerning the subject, but room for improvement remains. A multi-modal approach encompassing an elaborate training program, regular educational publications in professional journals, and web based offers could reach a broad range of health care providers. Paired with a public adult and childhood stroke awareness campaign, these efforts could contribute to optimize the care for children suffering from stroke.

Pediatric Stroke Clinical Pathway Improves the Time to Diagnosis in an Emergency Department

BACKGROUND

Identified barriers to the diagnosis of pediatric stroke include delays in provider recognition and definitive neuroimaging (magnetic resonance imaging). Clinical pathways are recommended to address these barriers; yet few studies have evaluated their impact. Our aim is to describe the effect of a pediatric stroke clinical pathway on the diagnosis of stroke in patients presenting with focal neurological dysfunction to a pediatric emergency department.

METHODS

The pediatric stroke clinical pathway was implemented in our level 1 pediatric emergency department in June 2014 for children aged one month to 18 years. Demographic and clinical data were collected for patients ultimately diagnosed with stroke using the pediatric stroke clinical pathway and compared with data collected on patients diagnosed with stroke before implementation of the pediatric stroke clinical pathway.

RESULTS

The pediatric stroke clinical pathway was activated for 36 patients. Stroke was diagnosed in 11 patients (33%), of whom 55% were male with a median age 11 ± 7 years. Focal deficits (82%) and headache (55%) were common presenting complaints. There was a significant improvement in the median time to magnetic resonance imaging from arrival to the emergency department (before implementation of the pediatric stroke clinical pathway: 17 hours [interquartile range 6, 22] versus after implementation of the pediatric stroke clinical pathway: four hours [interquartile range 3, 12]; P = 0.02).

CONCLUSIONS

The pediatric stroke clinical pathway improved time to definitive diagnosis and streamlined the care provided to children presenting to the pediatric emergency department with focal neurological dysfunction.

Missed Opportunities for Transcranial Doppler Screening Among Children With Sickle Cell Disease

Transcranial Doppler (TCD) screening rates remain low among children with sickle cell disease (SCD). We assessed TCD screening rates and missed opportunities for TCD screening. Children 2 to 16 years old with SCD enrolled in Michigan Medicaid for ≥1 year (2007-2011) were identified through newborn screening. Receipt of TCD screening and presence of a missed opportunity (≥1 SCD-related outpatient visit, no TCD screening) were identified through administrative claims. Potential correlates of missed opportunities included SCD-related health services, comorbidities, and demographics. Logistic regression with generalized estimating equations modeled associations between a missed opportunity and correlates. Overall, 353 children contributed 1066 person-years. TCD screening was low yearly (10%-32%); missed opportunities occurred in 73% of the person-years. Increasing age (odds ratio [OR] = 1.11; confidence interval CI = 1.07, 1.15), previous TCD screening (OR = 0.26; CI = 0.16, 0.41), and 4 to 5 (OR = 0.48; CI = 0.26, 0.87) or ≥6 outpatient visits (OR = 0.26; CI = 0.14, 0.49) were associated with a missed opportunity. Reduction of missed opportunities is a potential strategy to increase TCD screening rates.

Stroke in Acquired and Congenital Heart Disease Patients and Its Relationship to Hospital Mortality and Lasting Neurologic Deficits

OBJECTIVE

To describe strokes in patients with acquired or congenital heart disease and investigate risk factors for in-hospital mortality and ongoing neurologic deficits.

DESIGN

Single-center, retrospective review of cardiac, neurologic, and radiologic patient databases.

SETTING

Tertiary care children's hospital.

PATIENTS

All patients with acquired or congenital heart disease admitted from January 2010 to October 2014 identified with stroke.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Eighty-four stroke events were identified in 83 patients (median age, 5.9 mo; interquartile range, 0.8-33.4). Thirty-two patients (38%) had single ventricle congenital heart disease. Eight patients (9%) presented with symptoms at home, and the remainder was diagnosed while already admitted to the hospital. Forty patients (48%) presented with clinically evident neurologic deficits (e.g., weakness, seizures). Fifty-eight patients (69%) had arterial ischemic strokes, and 13 (15%) had parenchymal hemorrhages. At diagnosis, 54 patients (64%) were on inotropes. Twenty-nine patients (35%) had greater than or equal to 3 cardiac procedures during their hospitalization before stroke diagnosis. In-hospital mortality occurred in 28 patients (33%). Under multivariate analysis, inotropes, number of cardiac procedures, lack of seizure, and parenchymal hemorrhage were independently associated with in-hospital mortality (p < 0.05). Fifty-four percent of survivors with neurologic follow-up had ongoing neurologic deficits attributable to strokes (median follow-up, 15.3 mo; interquartile range, 7.0-29.9). With multivariate analysis, longer hospital stay (p = 0.02) was independently associated with ongoing deficits.

CONCLUSIONS

A majority of patients with acquired or congenital heart disease who suffer stroke present while hospitalized and without focal neurologic findings. In-hospital mortality is associated with inotropes, cardiac procedures, lack of seizure, and parenchymal hemorrhage. The majority of survivors have lasting neurologic deficits associated with longer hospital stay.

Guidelines for Urgent Management of Stroke in Children

Stroke in children carries lasting morbidity. Once recognized, it is important to evaluate and treat children with acute stroke efficiently and accurately. All children should receive neuroprotective measures. It is reasonable to consider treatment with advanced thrombolytic and endovascular agents. Delivery of such care requires purposeful institutional planning and organization in pediatric acute care centers. Primary stroke centers established for adults provide an example of the multidisciplinary approach that can be applied to the evaluation and treatment of children who present with acute stroke. The organizational infrastructure of these centers can be employed and adapted for treatment of children with acute stroke. It is likely that care for children with acute stroke can best be delivered by regional pediatric primary stroke centers dedicated to the care of children with pediatric stroke.

Brain attacks and stroke in children

Emergency physicians are often the first point of contact in children presenting with acute neurological disorders. Differentiating serious disorders, such as stroke, from benign disorders, such as migraine, can be challenging. Clinical assessment influences decision-making, in particular the need for emergent neuroimaging to confirm diagnosis. This review describes the spectrum of disorders causing 'brain attack' symptoms, or acute onset focal neurological dysfunction, with particular emphasis on childhood stroke, because early recognition is essential to improve access to thrombolytic treatments, which have improved outcomes in adults. Clues to diagnosis of specific conditions are discussed. Symptoms and signs, which discriminate stroke from mimics, are described, highlighting differences to adults. Haemorrhagic and ischaemic stroke have different presenting features, which influence choice of the most appropriate imaging modality to maximise diagnostic accuracy. Improvements in the care of children with brain attacks require coordinated approaches and system improvements similar to those developed in adults.

In vivo target bio-imaging of cerebral ischemic stroke by real-time labeling of zinc

Through intravenous injection of zinc gluconate, we could readily realize in vivo fluorescence imaging by real-time labeling the relevant brain regions of CIS model mice based on the in situ biosynthesis of fluorescence zinc nanoclusters in target diseased sites.

Paediatric arterial ischemic stroke: acute management, recent advances and remaining issues

Stroke is a rare disease in childhood with an estimated incidence of 1-6/100.000. It has an increasingly recognised impact on child mortality along with its outcomes and effects on quality of life of patients and their families. Clinical presentation and risk factors of paediatric stroke are different to those of adults therefore it can be considered as an independent nosological entity. The relative rarity, the age-related peculiarities and the variety of manifested symptoms makes the diagnosis of paediatric stroke extremely difficult and often delayed. History and clinical examination should investigate underlying diseases or predisposing factors and should take into account the potential territoriality of neurological deficits and the spectrum of differential diagnosis of acute neurological accidents in childhood. Neuroimaging (in particular diffusion weighted magnetic resonance) is the keystone for diagnosis of paediatric stroke and other investigations might be considered according to the clinical condition. Despite substantial advances in paediatric stroke research and clinical care, many unanswered questions remain concerning both its acute treatment and its secondary prevention and rehabilitation so that treatment recommendations are mainly extrapolated from studies on adult population. We have tried to summarize the pathophysiological and clinical characteristics of arterial ischemic stroke in children and the most recent international guidelines and practical directions on how to recognise and manage it in paediatric emergency.

iPSC Transplantation increases regeneration and functional recovery after ischemic stroke in neonatal rats

Limited treatments are available for perinatal/neonatal stroke. Induced pluripotent stem cells (iPSCs) hold therapeutic promise for stroke treatment, but the benefits of iPSC transplantation in neonates are relatively unknown. We hypothesized that transplanted iPSC-derived neural progenitor cells (iPSC-NPCs) would increase regeneration after stroke. Mouse pluripotent iPSCs were differentiated into neural progenitors using a retinoic acid protocol. Differentiated neural cells were characterized by using multiple criteria and assessments. Ischemic stroke was induced in postnatal day 7 (P7) rats by occluding the right middle cerebral artery and right common carotid artery. iPSC-NPCs (400,000 in 4 µl) were transplanted into the penumbra via intracranial injection 7 days after stroke. Trophic factor expression in the peri-infarct tissue was measured using Western blot analysis. Animals received daily bromodeoxyuridine (BrdU) injections and were sacrificed 21 days after stroke for immunohistochemistry. The vibrissae-elicited forelimb placement test was used to evaluate functional recovery. Differentiated iPSCs expressed mature neuronal markers, functional sodium and potassium channels, and fired action potentials. Several angiogenic and neurogenic trophic factors were identified in iPSC-NPCs. Animals that received iPSC-NPC transplantation had greater expression of stromal cell-derived factor 1-α (SDF-1α) and vascular endothelial growth factor (VEGF) in the peri-infarct region. iPSC-NPCs stained positive for neuronal nuclei (NeuN) or glial fibrillary acidic protein (GFAP) 14 days after transplantation. iPSC-NPC-transplanted animals showed greater numbers of BrdU/NeuN and BrdU/Collagen IV colabeled cells in the peri-infarct area compared with stroke controls and performed better in a sensorimotor functional test after stroke. iPSC-NPC therapy may play multiple therapeutic roles after stroke by providing trophic factors, increasing angiogenesis and neurogenesis, and providing new cells for tissue repair.

Cost and Outcome in Pediatric Ischemic Stroke

The cost of childhood stroke receives little notice. The authors examined potential drivers of cost and outcome to test whether (1) neonatal strokes cost less than childhood strokes, (2) associated diseases influence cost, (3) arterial ischemic stroke is more costly than sinovenous thrombosis, and (4) cost correlates with outcome. The authors reviewed records of 111 children who sustained arterial ischemic stroke or sinovenous thrombosis between 2005 and 2010 to identify costs for the following year. They assessed outcomes in 46 with the Recovery and Recurrence Questionnaire and the Pediatric Quality of Life Inventory. Neonatal strokes cost less than childhood stroke. Strokes associated with congenital heart disease or vasculopathy cost the most, while perinatal or idiopathic strokes cost the least. Higher costs are correlated with worse impairment and poorer quality of life. Stroke etiology significantly influences the cost of pediatric stroke. Future cost-benefit studies must consider etiology when estimating the incremental costs associated with stroke.

Computer-assisted volumetric measurement of core infarct volume in pediatric patients: feasibility for clinical use and development of quantitative metrics for outcome prediction

BACKGROUND AND PURPOSE

Infarct volume may predict clinical outcome in acute stroke, but manual segmentation techniques limit its routine use. We hypothesized that computer-assisted volumetric analysis to quantify acute infarct volume will show no difference compared with manual segmentation but will show increased speed of performance and will correlate with outcome.

MATERIALS AND METHODS

Patients with acute stroke younger than 18 years were included. Infarct volume on diffusion-weighted imaging was quantified by using computer-assisted volumetric and manual techniques. The Pediatric Stroke Outcome Measure scored clinical outcome. Computer-assisted volumetric and manual techniques were compared with correlation coefficients. Linear regression analysis compared Pediatric Stroke Outcome Measure with core infarct volume and percentage volume of brain infarction.

RESULTS

Twenty-three patients were analyzed (mean age, 4.6 years). Mean infarct volume from computer-assisted volumetric and manual approaches was 65.6 and 63.7 mL, respectively (P = .56). Concordance correlation between methods was 0.980, and between users, 0.968. The mean times for segmentation between computer-assisted volumetric and manual techniques were <1 minute and 7.3 minutes (P < .001). The mean infarct volumes for good and poor outcome groups were 7.4 and 75.7 mL (P < .007). The mean percentages of infarcted brain parenchyma for good and poor outcome groups were 0.6% and 10.4% (P < .006). Volumes of 32 mL and 3% for infarcted brain were associated with poor outcome in all patients.

CONCLUSIONS

Computer-assisted volumetric quantification of infarct volume is reproducible, is significantly faster than manual techniques, and may have important applications for future clinical workflow. Core infarct volumes and infarct percentage correlated with outcome severity.

Out-of-pocket costs for childhood stroke: the impact of chronic illness on parents' pocketbooks

OBJECTIVE

Direct costs for children who had stroke are similar to those for adults. There is no information regarding the out-of-pocket costs families encounter. We described the out-of-pocket costs families encountered in the first year after a child's ischemic stroke.

METHODS

Twenty-two subjects were prospectively recruited at four centers in the United States and Canada in 2008 and 2009 as part of the "Validation of the Pediatric NIH Stroke Scale" study; families' indirect costs were tracked for 1 year. Every 3 months, parents reported hours they did not work, nonreimbursed costs for medical visits or other health care, and mileage. They provided estimates of annual income. We calculated total out-of-pocket costs in US dollars and reported costs as a proportion of annual income.

RESULTS

Total median out-of-pocket cost for the year after an ischemic stroke was $4354 (range, $0-$28,666; interquartile range, $1008-$8245). Out-of-pocket costs were greatest in the first 3 months after the incident stroke, with the largest proportion because of lost wages, followed by transportation, and nonreimbursed health care. For the entire year, median costs represented 6.8% (range, 0%-81.9%; interquartile range, 2.7%-17.2%) of annual income.

CONCLUSIONS

Out-of-pocket expenses are significant after a child's ischemic stroke. The median costs are noteworthy provided that the median American household had cash savings of $3650 at the time of the study. These results with previous reports of direct costs provide a more complete view of the overall costs to families and society. Childhood stroke creates an under-recognized cost to society because of decreased parental productivity.

Arterial ischemic stroke in children: risk factors and etiologies

Stroke is increasingly recognized as a significant cause of morbidity and mortality in children, and as a financial burden for families and society. Recent studies have identified and confirmed presumptive risk factors, and have identified novel associations with childhood arterial ischemic stroke. A better understanding of risk factors for stroke in children, which differ from the atherosclerotic risk factors in adults, is the first step needed to improve strategies for stroke prevention and intervention, and ultimately minimize the physical, mental, and financial burden of arterial ischemic stroke. Here, we discuss recent advances in research for selected childhood stroke risk factors, highlighting the progress made in our understanding of etiologic mechanisms and pathophysiology, and address the future directions for acute and long-term treatment strategies for pediatric stroke.

Costs of pediatric stroke care in the United States: a systematic and contemporary review

A substantial literature exists regarding cost-of-care outcomes in adult stroke, however less is known about pediatric stroke. The objective of this review of the literature was to examine studies of costs associated with pediatric stroke care. Six studies reporting data from individuals who experienced a pediatric stroke were included in the review. Cost data (charges and payments) were generally limited to one year and ranged from approximately US$15,000-140,000 depending upon stroke type. Pediatric stroke is linked to substantial costs but studies primarily emphasize the direct cost of care during the first year post-stroke onset. However, since many pediatric stroke survivors experience normal lifespans, they can also accumulate a significantly greater long term cost of care than strokes that occur in adulthood. Future studies are needed to examine long term direct costs, short and long term indirect costs and other economic outcomes in this population.

Early intervention after perinatal stroke: opportunities and challenges

Perinatal stroke is the most common cause of hemiplegic cerebral palsy. No standardized early intervention exists despite evidence for a critical time window for activity-dependent plasticity to mould corticospinal tract development in the first few years of life. Intervention during this unique period of plasticity could mitigate the consequences of perinatal stroke to an extent not possible with later intervention, by preserving the normal pattern of development of descending motor pathways. This article outlines the broad range of approaches currently under investigation. Despite significant progress in this area, improved early detection and outcome prediction remain important goals.

Functioning and disability after stroke in children: using the ICF-CY to classify health outcome and inform future clinical research priorities

AIM

The International Classification of Functioning Disability and Health, Child-Youth version (ICF-CY) provides a framework for describing and evaluating health, intervention outcomes, and needs assessment. It can, however, also serve as a system for classifying the focus of outcome studies and identification of gaps in current knowledge.

METHOD

The paediatric arterial ischaemic stroke (AIS) population was targeted. Multiple databases were systematically searched for AIS outcome studies focussing on functioning or disability. Findings were rated using the ICF-CY framework.

RESULTS

Twenty-eight studies were identified. Most were cross-sectional and age range at assessment varied widely. Sixty-seven different standardized measures were used, predominantly evaluating body functions. The most common domains of activity and participation reported were learning and applying knowledge, general tasks and demands, and self-care skills. Health-related quality of life was measured in nine papers. Environmental factors were rarely evaluated.

INTERPRETATION

AIS outcome studies addressing the relationship between body structures and functions (e.g. brain lesion characteristics, neurological examination findings) and activities, participation, and quality of life have emerged in recent years. Comparison of findings across studies is complicated by design and tool selection. The relationship between components of activity limitation and participation restriction is rarely explored.