Pediatric stroke: Rehabilitation of focal injury in the developing brain

Social skill and social withdrawal outcomes in children following pediatric stroke

Pediatric stroke can result in long-term impairments across attention, functional communication and motor domains. The current paper utilized parent reports of the Behavioral Assessment System for Children 2nd Edition and the Pediatric Stroke Outcome Measure to examine children's social skills and withdrawal behavior within a pediatric stroke population. Using the Canadian Pediatric Stroke Registry at The Hospital for Sick Children, data were analyzed for 312 children with ischemic stroke. Children with ischemic stroke demonstrated elevated parent-reported social skills problems (observed = 20.51%, expected = 14.00%) and clinically elevated social withdrawal (observed = 11.21%, expected = 2.00%). Attentional problems significantly contributed to reduced social skills, F (3,164) = 30.68, p < 0.01, while attentional problems and neurological impairments accounted for increased withdrawal behavior, F (2, 164) = 7.47, p < 0.01. The presence of a motor impairment was associated with higher social withdrawal compared to individuals with no motor impairment diagnosis, t(307.73) = 2.25, p < .025, d = 0.25, 95% CI [0.42, 6.21]. The current study demonstrates that children with stroke who experience motor impairments, attentional problems, reduced functional communication skills, and neurological impairments can experience deficits in their social skills and withdrawal behavior.

Predictors of externalizing behavior outcomes following pediatric stroke

Children who experience pediatric stroke are at higher risk for future behavioral problems in childhood. We examined the prevalence of parent reported externalizing behaviors and executive function problems in children following stroke and neurological predictors. This study included 210 children with pediatric ischemic stroke (mean age 9.18 years (SD = 3.95)). The parent form of the Behavioral Assessment System for Children-Second Edition (BASC-2) and Behavior Rating Inventory of Executive Function (BRIEF) were used to evaluate externalizing behavior and executive function. No externalizing behavior or executive function differences were found between perinatal (n = 94) or childhood (n = 116) stoke, except for the shift subscale which had higher T-scores among the perinatal group (M = 55.83) than childhood group (M = 50.40). When examined together, 10% of children had clinically elevated hyperactivity T-scores as opposed to the expected 2%. Parents endorsed higher ratings of concern on the behavior regulation and metacognition indices of the BRIEF. Externalizing behaviors were correlated moderately to strongly with executive functions (r = 0.42 to 0.74). When examining neurological and clinical predictors of externalizing behaviors, only female gender was predictive of increased hyperactivity (p = .004). However, there were no significant gender differences in diagnosis of attention deficit hyperactivity disorder (ADHD). In summary, in this cohort, children with perinatal and childhood stroke did not differ on parent reported externalizing behavior or executive function outcomes. However, compared to normative data, children with perinatal or childhood stroke are significantly more likely to experience clinically elevated levels of hyperactivity.

Attention Please! Unravelling the Link Between Brain Network Connectivity and Cognitive Attention Following Acquired Brain Injury: A Systematic Review of Structural and Functional Measures

Traumatic brain injury (TBI) and stroke are the most common causes of acquired brain injury (ABI), annually affecting 69 million and 15 million people, respectively. Following ABI, the relationship between brain network disruption and common cognitive issues including attention dysfunction is heterogenous. Using PRISMA guidelines, we systematically reviewed 43 studies published by February 2023 that reported correlations between attention and connectivity. Across all ages and stages of recovery, following TBI, greater attention was associated with greater structural efficiency within/between executive control network (ECN), salience network (SN), and default mode network (DMN) and greater functional connectivity (fc) within/between ECN and DMN, indicating DMN interference. Following stroke, greater attention was associated with greater structural connectivity (sc) within ECN; or greater fc within the dorsal attention network (DAN). In childhood ABI populations, decreases in structural network segregation were associated with greater attention. Longitudinal recovery from TBI was associated with normalization of DMN activity, and in stroke, normalization of DMN and DAN activity. Results improve clinical understanding of attention-related connectivity changes after ABI. Recommendations for future research include increased use of electroencephalography (EEG) and functional near-infrared spectroscopy (fNIRS) to measure connectivity at the point of care, standardized attention and connectivity outcome measures and analysis pipelines, detailed reporting of patient symptomatology, and casual analysis of attention-related connectivity using brain stimulation.

Arterial Presumed Perinatal Ischemic Stroke: A Mini Review and Case Report of Cognitive and Speech-Language Profiles in a 5-Year-Old Girl

Arterial presumed perinatal ischemic stroke is a type of perinatal stroke that emerges due to late or delayed diagnostics of perinatal or neonatal arterial ischemic stroke. It is usually recognized before one year of life due to hemiparesis. This injury may lead to cognitive, behavioral, or motor symptoms, and life-long neurodevelopmental disabilities. In this case report, we describe a five-year-old girl with a history of arterial presumed perinatal ischemic stroke in the left hemisphere, which adversely affected her cognitive and language outcomes. The girl's cognitive development has been uneven, ranging from below average to average, and she had specific language acquisition deficits in comprehension, vocabulary, morphology, use of complex syntax, and narrative structure. The obtained results point to the specificity of each child whose development is influenced not only by the timing of the brain lesion and the degree of damage, but also by the child's neurobiological capacity. In addition, we provide an updated review of the literature that includes information on epidemiology, risk factors, diagnostics, clinical manifestations, outcomes, and potential therapies. The present article highlights the importance of early intervention and systematic monitoring of children with perinatal stroke with the aim of improving the child's development.

Implications of age at lesion onset for neuropsychological outcomes: A systematic review focusing on focal brain lesions

Theories of the relation between age at lesion onset and outcomes posit different views of the young brain: resilient and plastic (i.e., the so-called "Kennard Principle"), or vulnerable (i.e., the Early Vulnerability Hypothesis). There is support for both perspectives in previous research and questions about the "best" or "worst" times to sustain brain injury remain. Here, we present a systematic review investigating the influence of age at focal brain lesion onset on cognitive functioning. This systematic review identifies and qualitatively synthesizes empirical studies from 1985 to 2021 that investigated age at lesion onset as a variable of interest associated with neuropsychological outcomes. A total of 45 studies were identified from PubMed, PsycINFO, and CINAHL databases. Almost all studies indicated that brain injury earlier in the developmental period predicts worse cognitive outcomes when compared to onset either later in the developmental period or in adulthood. More specifically, the overwhelming majority of studies support an "earlier is worse" model for domains of intellect, processing speed, attention and working memory, visuospatial and perceptual skills, and learning and memory. Relatively more variability in outcomes exists for domains of language and executive functioning. Outcomes for all domains are influenced by various other age and injury variables (e.g., lesion size, lesion laterality, chronicity, a history of epilepsy). Continued interdisciplinary understanding and communication about the influence of age at lesion onset on neuropsychological outcomes will aid in promoting the best possible outcomes for patients.

Outcome in Childhood Stroke: Comparing Functional Outcome by Modified Rankin Scale with Neurological Outcome by Pediatric Stroke Outcome Measure

Different scales are used as outcome predictors following arterial ischemic stroke (AIS) in children. Pediatric stroke outcome measure (PSOM) gives information about neurological deficits and function and modified Rankin scale (mRS) about functional outcome. Research examining the relationship between the two measures is scarce. The aim of this study is to correlate the two different scales and to get some information on the long course of outcomes according to these outcome measures. Sixty-one children with the diagnosis of AIS and normal neurodevelopment prior to stroke were investigated. Results of outcome measures (PSOM and mRS) from ≥ 2 years of follow-up were analyzed. Changes of neurological deficits (subcategories of PSOM) over time (discharge, 6 months, and ≥2 years) and prognostic impact on the outcome of the Pediatric National Institutes of Health Stroke Scale and etiology/risk factors are presented.

Cramer's V with a coefficient of 0.836 (df-1) indicates a strong association between dichotomized total PSOM and mRS scores. The correlation between the total scales was strong (rho = 0.983, p < 0.001). The correlation coefficient was highest for sensorimotor (rho = 0.949, p < 0.001), then for language (rho = 0.464, p < 0.001) and cognitive (rho = 0.363, p = 0.004) subscales. PSOM scores improved at 6 months compared to the discharge state in sensorimotor (p<0.001) and language (p<0.026) domains, however, there was no statistically significant difference between PSOM scores at 6 months and >2 years follow-up. There was no improvement in cognitive PSOM scores during the follow-up period.

There was a high concordance level between the two scales, illustrating that long-term neurological deficits after stroke are related to poor functional outcome. Significant improvement of sensorimotor and language function happened within the period from onset to 6 months of follow-up. Thus, early mobilization of appropriate rehabilitative therapy might improve the outcome. We conclude that both outcome classifications are applicable for assessing outcome after childhood AIS.

Thalamic Volume Loss Is Greater in Children Than in Adults Following Middle Cerebral Artery Territory Arterial Ischemic Stroke

Background: Younger stroke patients may suffer worse outcomes than older patients; however, the extent to which age at stroke impacts remote areas of the brain remains unclear. The objective of this study was to determine thalamic volume changes ipsilateral to middle cerebral artery territory strokes based on age at acute ischemic stroke onset. Methods: Acute ischemic stroke patients <9 years, 9-18 years, and >18 years old were retrospectively recruited from a large quaternary care system. Each subject underwent an acute (<72 hours from AIS) and chronic (>90 days) magnetic resonance imaging (MRI) scan. Manual thalamic segmentation was performed. Results: Younger and older children had significantly greater stroke-side thalamic volume loss compared to adults (48.2%, P = .022; 40.7%, P = .044, respectively). Conclusions: Stroke-side thalamic volumes decreased across the age spectrum but to a greater degree in pediatric patients. This observation can affect functional and cognitive outcomes post stroke and warrants further research.

Stroke in pediatric ECMO patients: analysis of the National Inpatient Sample (NIS) database

BACKGROUND

The rates, outcomes, and long-term trends of stroke complicating the use of extracorporeal membrane oxygenation (ECMO) have been inconsistently reported. We compared the outcomes of pediatric ECMO patients with and without stroke and described the frequency trends between 2000 and 2017.

METHODS

Using the National Inpatient Sample (NIS) database, pediatric patients (age ≤18 years) who received ECMO were identified using ICD-9&amp;10 codes. Binary, regression, and trend analyses were performed to compare patients with and without stroke.

RESULTS

A total of 114,477,997 records were reviewed. Overall, 28,695 (0.025%) ECMO patients were identified of which 2982 (10.4%) had stroke, which were further classified as hemorrhagic (n = 1464), ischemic (n = 1280), or combined (n = 238). Mortality was higher in the hemorrhagic and combined groups compared to patients with ischemic stroke and patients without stroke. Length of stay (LOS) was significantly longer in stroke vs. no-stroke patients. Hypertension and septicemia were more encountered in the hemorrhagic group, whereas the combined group demonstrated higher frequency of cardiac arrest and seizures.

CONCLUSIONS

Over the years, there is an apparent increase in the diagnosis of stroke. All types of stroke in ECMO patients are associated with increased LOS, although mortality is increased in hemorrhagic and combined stroke only.

IMPACT

Stroke is a commonly seen complication in pediatric patients supported by ECMO. Understanding the trends will help in identifying modifiable risk factors that predict poor outcomes in this patient population.

Pediatric Stroke: Unique Implications of the Immature Brain on Injury and Recovery

Pediatric stroke causes significant morbidity for children resulting in lifelong neurological disability. Although hyperacute recanalization therapies are available for pediatric patients, most patients are ineligible for these treatments. Therefore the mainstay for pediatric stroke treatment relies on rehabilitation to improve outcomes. Little is known about the ideal rehabilitation therapies for pediatric patients with stroke and the unique interplay between the developing brain and our models of stroke recovery. In this review, we first discuss the consequences of pediatric stroke. Second, we examine the scientific evidence that exists between the mechanisms of recovery and how they are different in the pediatric developing brain. Finally, we evaluate potential interventions that could improve outcomes.

Cognitive and Academic Outcomes Following Childhood Cortical Stroke

The majority of pediatric neuropsychological stroke research has focused on perinatal stroke outcomes given its relative frequency. Meanwhile, childhood-onset stroke is under-represented in the literature, resulting in limited knowledge about its neurocognitive sequelae. This retrospective study examined cognitive outcomes in children and youth (n = 27) with childhood arterial ischemic stroke (stroke occurring between 29 days and 18 years of life) isolated to the cortical region. Intellectual, academic, language, visual-perception, visual-motor integration, fine motor coordination, and executive function scores were examined relative to normative means. Results indicate that although these children are doing well in terms of general intellectual ability, they demonstrate lower scores on tasks of processing speed and fine motor coordination. Exploratory analysis also revealed that of the personal and neurologic factors examined, age at stroke was positively correlated with perceptual reasoning and fine motor control, age at assessment was negatively correlated with math calculation abilities, and maternal education was positively correlated with working memory and parent-reported behavioral regulation and impulse inhibition abilities. While neurologic variables were not predictive of cognitive neuropsychological outcomes, those with significant poorer performance had higher rates of medium/large, right-sided lesions with frontal lobe involvement. Our results highlight the overall resilience of the injured developing brain but also the vulnerability of specific cognitive skills within this unique population.

Understanding Early Childhood Resilience Following Neonatal Brain Injury From Parents' Perspectives Using a Mixed-Method Design

OBJECTIVES

The current study used a mixed-method design to qualitatively examine parents' definitions of resilience and factors they believed optimized their child's early outcome following neonatal brain injury. This was followed by quantitative analyses of early developmental and mental health outcomes and their relation to salient biopsychosocial factors.

METHODS

Participants were parents of children diagnosed with neonatal brain injury due to stroke or hypoxic-ischemic encephalopathy (N=51; age range of children 18 months to 8 years). The Parent Experiences Questionnaire (PEQ) was used to qualitatively analyze parents' open-ended responses about their child's early experiences and outcome. The Child Behavior Checklist (CBCL) and Scales of Independent Behaviour Early Developmental Form (SIB-ED) parent ratings were used to measure child resilience from a quantitative perspective, identifying "at-risk" and "resilient" children using standard cutoffs. "Resilient" and "at-risk" children were compared on biopsychosocial variables using univariate t tests and chi-square analyses.

RESULTS

Parents provided five unique definitions of their child's positive outcomes, and many children demonstrated resilience based on parent perspectives and quantitative definitions. Supporting factors included close medical follow-up, early intervention, and intrinsic factors within the child and parent. Group comparisons of "resilient" and "at-risk" children highlighted the importance of parent mental health across these early developmental and mental health outcomes.

CONCLUSIONS

Many children were described as resilient during the early years by parents using qualitative and quantitative approaches. Findings highlighted the importance of parent well-being in promoting optimal early outcomes. (JINS, 2019, 25, 390-402.).

Predictors of Cognitive and Academic Outcome following Childhood Subcortical Stroke

Childhood arterial ischemic stroke often involves basal ganglia and thalamus but little is known about neuropsychological outcomes in this group. We examined intellectual ability, academics, attention, executive function, and psychological diagnoses in children and adolescents (6-20 years of age) with childhood stroke involving the basal ganglia (n = 32) or thalamus (n = 12). Intellectual ability was age-appropriate but working memory was significantly lower than expected. Compared to the normative mean, the stroke group exhibited significantly weaker performance in reading comprehension, math fluency, attention, and greater challenges with executive function. Children with basal ganglia stroke had weaker working memory and were more likely to receive diagnoses of Attention Deficit Hyperactivity Disorder and Anxiety Disorder than those with thalamic stroke. Lesion size was most important in predicting working memory ability, whereas age at stroke and age at test were important in predicting academic ability.

Tracking of neurocognitive outcomes over time in children with perinatal stroke and associated complex medical conditions: a case series

Neurocognitive outcomes in children with perinatal stroke are complicated by additional neurological/medical factors. The main objective of this study was to retrospectively examine long-term neurocognitive outcomes in five children with perinatal stroke with increasingly complex comorbidities; ages 5-7 at first evaluation. Results revealed that intelligence and academic skills were significantly decreased in cases with combined perinatal stroke and comorbidities. Early language development was particularly vulnerable to disruption over time in children with increasing medical complexity. The delayed emergence of neurocognitive deficits emphasizes the need for serial assessment of neurocognitive development to identify early services and interventions.

Trajectories of Motor Recovery in the First Year After Pediatric Arterial Ischemic Stroke

BACKGROUND

Neuromotor impairments are common after pediatric stroke, but little is known about functional motor outcomes. We evaluated motor function and how it changed over the first 12 months after diagnosis. We also examined differences in outcome according to age at diagnosis and whether fine motor (FM) or gross motor (GM) function at 12 months was associated with adaptive behavior.

METHODS

This prospective, longitudinal study recruited children (N = 64) from The Royal Children's Hospital, Melbourne who were diagnosed with acute arterial ischemic stroke (AIS) between December 2007 and November 2013. Motor assessments were completed at 3 time points after the diagnosis of AIS (1, 6, and 12 months). Children were grouped as follows: neonates (n = 27), preschool-aged (n = 19), and school-aged (n = 18).

RESULTS

A larger lesion size was associated with poorer GM outcomes at 12 months (P = .016). Neonatal AIS was associated with better FM and GM function initially but with a reduction in z scores over time. For the preschool- and school-aged groups, FM remained relatively stable over time. For GM outcomes, the preschool- and the school-aged age groups displayed similar profiles, with gradual recovery over time. Overall, poor FM and GM outcomes at 12 months were associated with poorer adaptive behavior scores.

CONCLUSIONS

Motor outcomes and the trajectory of recovery post-AIS differed according to a child's age at stroke onset. These findings indicate that an individualized approach to surveillance and intervention may be needed that is informed in part by age at diagnosis.

Determinants of cognitive outcomes of perinatal and childhood stroke: A review

Our understanding of cognitive and behavioral outcomes of perinatal and childhood stroke is rapidly evolving. A current understanding of cognitive outcomes following pediatric stroke can inform prognosis and direct interventions and our understanding of plasticity in the developing brain. However, our understanding of these outcomes has been hampered by the notable heterogeneity that exists amongst the pediatric stroke population, as the influences of various demographic, cognitive, neurological, etiological, and psychosocial variables preclude broad generalizations about outcomes in any one cognitive domain. We therefore aimed to conduct a detailed overview of the published literature regarding the effects of age at stroke, time since stroke, sex, etiology, lesion characteristics (i.e., location, laterality, volume), neurologic impairment, and seizures on cognitive outcomes following pediatric stroke. A key theme arising from this review is the importance of interactive effects among variables on cognitive outcomes following pediatric stroke. Interactions particularly of note include the following: (a) age at Stroke x Lesion Location; (b) Lesion Characteristics (i.e., volume, location) x Neurologic Impairment; (c) Lesion Volume x Time Since Stroke; (d) Sex x Lesion Laterality; and (e) Seizures x Time Since Stroke. Further, it appears that these relationships do not always apply uniformly across cognitive domains but, rather, are contingent upon the cognitive ability in question. Implications for future research directions are discussed.

Development, reliability, and validity of the Alberta Perinatal Stroke Project Parental Outcome Measure

BACKGROUND

Perinatal stroke is a leading cause of cerebral palsy and lifelong disability, although parent and family outcomes have not yet been studied in this specific population. The Alberta Perinatal Stroke Project Parental Outcome Measure was developed as a 26-item questionnaire on the impact of perinatal stroke on parents and families.

METHODS

The items were derived from expert opinion and scientific literature on issues salient to parents of children with perinatal stroke, including guilt and blame, which are not well captured in existing measures of family impact. Data were collected from 82 mothers and 28 fathers who completed the Parental Outcome Measure and related questionnaires (mean age, 39.5 years; mean child age, 7.4 years). Analyses examined the Parental Outcome Measure's internal consistency, test-retest reliability, validity, and factor structure.

RESULTS

The Parental Outcome Measure demonstrated three unique theoretical constructs: Psychosocial Impact, Guilt, and Blame. The Parental Outcome Measure has excellent internal consistency (Cronbach α = 0.91) and very good test-retest reliability more than 2-5 weeks (r = 0.87). Regarding validity, the Parental Outcome Measure is sensitive to condition severity, accounts for additional variance in parent outcomes, and strongly correlates with measures of anxiety, depression, stress, quality of life, family functioning, and parent adjustment.

CONCLUSIONS

The Parental Outcome Measure contributes to the literature as the first brief measure of family impact designed for parents of children with perinatal stroke.

Pediatric stroke

INTRODUCTION

Pediatric stroke, while increasingly recognized among practitioners as a clinically significant, albeit infrequent entity, remains challenging from the viewpoint of clinicians and researchers.

DISCUSSION

Advances in neuroimaging have revealed a higher prevalence of pediatric stroke while also provided a safer method for evaluating the child's nervous system and vasculature. An understanding of pathogenic mechanisms for pediatric stroke requires a division of ages (perinatal and childhood) and a separation of mechanism (ischemic and hemorrhagic). This article presents a review of the current literature with the recommended divisions of age and mechanism.

CONCLUSION

Guidelines for treatment, though limited, are also discussed.

Are we studying and treating schizophrenia correctly?

New findings are rapidly revealing an increasingly detailed image of neural- and molecular-level dysfunction in schizophrenia, distributed throughout interconnected cortico-striato-pallido-thalamic circuitry. Some disturbances appear to reflect failures of early brain maturation, that become codified into dysfunctional circuit properties, resulting in a substantial loss of, or failure to develop, both cells and/or appropriate connectivity across widely dispersed brain regions. These circuit disturbances are variable across individuals with schizophrenia, perhaps reflecting the interaction of multiple different risk genes and epigenetic events. Given these complex and variable hard-wired circuit disturbances, it is worth considering how new and emerging findings can be integrated into actionable treatment models. This paper suggests that future efforts towards developing more effective therapeutic approaches for the schizophrenias should diverge from prevailing models in genetics and molecular neuroscience, and focus instead on a more practical three-part treatment strategy: 1) systematic rehabilitative psychotherapies designed to engage healthy neural systems to compensate for and replace dysfunctional higher circuit elements, used in concert with 2) medications that specifically target cognitive mechanisms engaged by these rehabilitative psychotherapies, and 3) antipsychotic medications that target nodal or convergent circuit points within the limbic-motor interface, to constrain the scope and severity of psychotic exacerbations and thereby facilitate engagement in cognitive rehabilitation. The use of targeted cognitive rehabilitative psychotherapy plus synergistic medication has both common sense and time-tested efficacy with numerous other neuropsychiatric disorders.

Integrative circuit models and their implications for the pathophysiologies and treatments of the schizophrenias

A preponderance of evidence indicates that the heterogeneous group of schizophrenias is accompanied by disturbances in neural elements distributed throughout multiple levels of interconnected cortico-striato-pallido-thalamic circuitry. These disturbances include a substantial loss of, or failure to develop, both cells and/or appropriate cellular connections in regions that include at least portions of the hippocampus, parahippocampal gyrus, entorhinal cortex, amygdala, prefrontal and anterior cingulate cortex, superior and transverse temporal gyri, and mediodorsal, anterior, and pulvinar nuclei of the thalamus; they appear to reflect failures of early brain maturation, that become codified into dysfunctional circuit properties, that in the opinion of this author cannot be "undone" or even predictably remediated in any physiological manner by existing pharmacotherapies. These circuit disturbances are variable across individuals with schizophrenia, perhaps reflecting the interaction of multiple different risk genes and multiple different epigenetic events. Evidence for these complex circuit disturbances has significant implications for many areas of schizophrenia research, and for future efforts toward developing more effective therapeutic approaches for this group of disorders. The conclusion of this chapter is that such future efforts should focus on further developing and refining medications that target nodal or convergent circuit points within the limbic-motor interface, with the goal of constraining the scope and severity of psychotic exacerbations, to be used in concert with systematic rehabilitative psychotherapies designed to engage healthy neural systems to compensate for and replace dysfunctional higher circuit elements. This strategy should be applied in both preventative and treatment settings, and disseminated for community delivery via an evidence-based manualized format. In contrast to alternative treatment strategies that range from complex polypharmacy to gene therapies to psychosurgical interventions, the use of combined medication plus targeted cognitive and behavioral psychotherapy has both common sense and time-tested documented efficacy with numerous other neuropsychiatric disorders.