Pediatric Stroke: A Review of Common Etiologies and Management Strategies

Research progress of cervicocerebral artery dissection, from mechanism to clinic: A scoping review

Cervicocerebral artery dissection (CAD) commonly occurs in young individuals, and its clinical manifestations lack specificity. It can present as either ischemic or hemorrhagic events. Due to variations in the location, timing of formation, and severity of the lesion in CAD, clinical presentations vary widely, making imaging crucial for accurate diagnosis. Currently, the primary treatment for CAD focuses on anti-thrombotic therapy, and evidence supporting venous thrombolysis is still inconclusive. With advancements in scientific technology, the concepts of the etiology and surgical treatment of CAD continue to evolve over time. As of now, the literature on CAD has experienced an exponential growth in the number of articles. However, there is still a lack of comprehensive discussion on the latest perspectives regarding the pathogenic mechanisms and treatment approaches for CAD. This study combines discussions on the etiology, pathogenesis, clinical characteristics, auxiliary examinations, and treatment of CAD, aiming to provide readers with a comprehensive understanding of CAD.

Occurrence of stroke in children and young adults in Indonesia: a multicenter private hospital study

BACKGROUND

Most studies that estimate the occurrence of childhood stroke use heterogeneous methods and rely on International Classification of Diseases codes, a strategy that may be unreliable.

PURPOSE

This study aimed to estimate the occurrence of childhood stroke in Indonesia using imaging and clinical data from a private hospital network.

METHODS

This cross-sectional study used consecutive retrospective multicenter data samples collected in 2019- 2023. The study cohort included children aged >28 days to young adults aged 24 years with confirmed ischemic or hemorrhagic stroke on computed tomography (CT) or magnetic resonance imaging (MRI). The 1-year occurrence was calculated, and the data analysis was performed using IBM SPSS Statistics ver. 26.0.

RESULTS

Over 5 years, the performance of 8,987 CT and 6,133 MRI scans resulted in the identification of 1,074 stroke cases. The average patient age was 14.8±7.0 years. Stroke occurrence was highest in 2021 (9.08%) and lowest in 2022 (5.91%). Male patients accounted for 67.9% of cases, with hemorrhagic strokes accounting for 83.4% of the total, primarily resulting from accidents (73.2%) and predominantly occurring in the frontal region (37.1%). A significant majority of cases (66.7%) were reported in Java. Males had a relative risk of 1.93 (95% confidence interval, 1.48-2.52; P<0.001) for hemorrhagic stroke versus females.

CONCLUSION

The incidence of childhood stroke revealed critical epidemiological trends and disparities, emphasizing the need for targeted public health interventions and enhanced stroke prevention strategies in Indonesia.

Bilateral medial medullary and spinal cord infarctions presenting as locked-in syndrome in an adolescent with primary antiphospholipid syndrome

Bilateral medial medullary infarction (BMMI) is a rare stroke subtype in the paediatric population characterised by quadriplegia, cranial nerve dysfunction and respiratory failure. MRI typically reveals a 'heart-shaped' sign in the medial medulla on diffusion-weighted imaging (DWI). Paediatric stroke aetiologies, including vasculopathy, thrombophilia and cardioembolic disease, differ from those in adults. Antiphospholipid syndrome (APS) is a rare but important cause of paediatric stroke.We report an adolescent male presenting with acute quadriplegia, bulbar dysfunction and respiratory failure with intact cognition, consistent with locked-in syndrome. MRI confirmed BMMI with concurrent spinal cord infarction, and APS was diagnosed based on persistently elevated anticardiolipin antibodies. Anticoagulation therapy and rehabilitation were initiated. However, minimal neurological improvement was observed at 1-year follow-up. This case highlights the rarity of BMMI in children and underscores the importance of early diagnosis and management as well as the recognition of uncommon causes such as APS.

Clinical and Radiological Outcomes of Angiographically Proven Central Nervous System Arteriopathy

OBJECTIVE

 Childhood stroke is a significant contributor to neurological morbidity often leading to debilitating outcomes. This study aimed to assess the clinical and radiological outcomes of angiographically proven central nervous system (CNS) arteriopathy in children.

MATERIAL AND METHODS

 This prospective cohort study was conducted from June 2023 to May 2024 at The Children's Hospital, Lahore, Pakistan. The clinical outcomes were assessed using the Pediatric National Institute of Health Stroke Scale (PedNIHSS) at baseline and compared at six-month follow-up, while radiological outcomes were categorized as stable, regressive, or progressive disease. Clinical presentation, etiology, baseline PedNIHSS score, and arterial involvement were correlated with motor outcomes.

RESULTS

 Out of the 38 patients, 63.2% were female patients with a mean age of 4.27±2.43 years. The most common age group was 2-5 years (50.0%), followed by >5-10 years (31.6%). Global clinical presentation was seen in 60.5%, while 29.0% had a recurrence of stroke. Moyamoya disease (21.1%) was the most common etiological factor, followed by primary CNS angiitis (13.0%), infections (8.0%), and post-varicella focal cerebral arteriopathy (8.0%). Bilateral infarcts (55.3%) and anterior circulation involvement (68.4%) were the most affected areas, with the middle cerebral artery (MCA) being the most affected with complete involvement in 18.4% and partial involvement in 81.5% of cases. The mean baseline PedNIHSS score was 29±6.4, which improved to 19±4.8 at the six-month follow-up. Radiological outcomes showed in 42.2% of cases, with a progression of the disease on follow-up MRA; 31.6% had stable disease, while 21.0% had regressive disease. Significant factors associated with poor motor outcomes included global presentation (p=0.000008), etiological factors (p=0.047), bilateral infarcts (p=0.050), severe baseline PedNIHSS (p=0.000019), and progressive radiological disease (p=0.003).

CONCLUSION

 This study highlights the significant neurological impact of pediatric stroke. Early diagnosis, investigation of underlying causes, and identification of recurrence risk factors are crucial in preventing immediate and long-term complications.

Clinical characteristics and quality care indicators of pediatric stroke in a referral center of Colombia: eleven-year experience (pediastroke)

Objective

This study aims to describe clinical variables and quality care indicators in pediatric stroke management at a high-complexity pediatric care center in Latin America.

Methods

Retrospective study of patients with stroke, aged 2-18 years from 2011 to 2021. The principal outcomes were the mRs and mortality. Differences between groups were assessed using Fisher's exact test and the Mann-Whitney U test. We used logistic regression to explore the association between characteristics reported as relevant in literature and mortality.

Results

One hundred thirty six patients included, with a median age of 11 years, 54% were male. 47% were hemorrhagic strokes, followed by ischemic strokes at 39%. One-third of the cases presented in hospital. 51% of the patients had no prior medical history. The most common symptoms were altered consciousness, headache, and hemiparesis. The median door-to-image time was 123 min. The most frequent etiologies in ischemic stroke were arteriopathies and cardiac pathology, while vascular malformation and coagulopathies were predominant in hemorrhagic stroke. No patient received reperfusion therapy. At discharge, 48% of patients had a favorable mRs. The mortality rate was 21%. Patients with in-hospital stroke have approximately 7.37 times the odds of dying compared to those with out-of-hospital stroke. Patients with hemorrhagic stroke have approximately 7.46 times the odds of dying compared to those with ischemic stroke.

Conclusion

Significant gaps exist in the epidemiology and quality indicators of pediatric stroke care compared to adult protocols. Implementing a "Pediatric code stroke" protocol and conducting prospective studies are crucial for improving pediatric stroke care and outcomes.

Enforced hematopoietic cell E-selectin/L-selectin ligand expression enhances bone marrow stromal cells homing and amelioration of cerebral ischemia-reperfusion injury via induction of prostaglandin E2

Ischemic stroke (IS) is a significant and potentially life-threatening disease with limited treatment options, often resulting in severe disability. Bone marrow stromal cells (BMSCs) transplantation has exhibited promising neuroprotection following cerebral ischemia-reperfusion injury (CIRI). However, the effectiveness is hindered by their low homing rate when administered through the vein. In this study, we aimed to enhance the homing ability of BMSCs through lentivirus transfection to express fucosyltransferase 7. This glycosylation engineered CD44 on BMSCs to express hematopoietic cell E-selectin/L-selectin ligand (HCELL), which is the most potent E-selectin ligand. Following enforced HCELL expression, the transplantation of BMSCs was then evaluated in a middle cerebral artery occlusion model. Results showed that HCELL+BMSCs significantly ameliorated neurological deficits and reduced the volume of cerebral infarction. Furthermore, the transplantation led to a decrease in apoptosis by upregulating BCL-2 and downregulating BAX, also reduced the mRNA levels of inflammatory factors, such as interleukin-1β (IL-1β), IL-2, IL-6, and tumor necrosis factor-alpha (TNF-α) in the ischemic brain tissue. Notably, enforced HCELL expression facilitated the migration of BMSCs toward cerebral ischemic lesions and their subsequent transendothelial migration through the upregulation of PTGS-2, increased production of PGE2 and activation of VLA-4. In summary, our study demonstrates that transplantation of HCELL+BMSCs effectively alleviates CIRI, and that enforced HCELL expression enhances the homing of BMSCs to cerebral ischemic lesions and their transendothelial migration via PTGS-2/PGE2/VLA-4. These findings indicate that enforced expression of HCELL on BMSCs could serve as a promising therapeutic strategy for the treatment of ischemic stroke.

Arterial Ischemic Stroke in Children

Arterial ischemic stroke (AIS) in children has a high mortality and life-long disability rate in surviving patients. Diagnostic delays are longer and risk factors are different compared with AIS in the adult population. Congenital heart disease, cervical arterial dissection, and intracranial arteriopathies are the main causes of AIS in children. New revascularization time windows in children require the definition of diagnostic protocols for stroke in each referral center. In this article, we discuss the neuroimaging techniques and protocols, describe the main underlying causes, and review the current treatment options for pediatric and perinatal AIS.

Hemorrhagic stroke in children

Hemorrhagic stroke (HS) in childhood accounts for almost 50% of childhood strokes, is among the top ten causes of deaths, or determines lifelong disability. These facts form significant socio-economic and demographic problems. The purpose of this review is to analyze current knowledge about HS in children. The data on HS terminology are presented, taking into account the International Classification of Diseases 11 edition. Attention is paid to the epidemiology of HS in children, including the results of individual local studies. The risk factors of HS in children were studied with an analysis of the causal, pathophysiological mechanisms of HS of various etiologies. The ideas about the clinical manifestations of HS in children are described. The analysis of HS treatment in children was carried out with an emphasis on achievements in neurointensive therapy of the acute period of HS. This review also includes information on the outcomes of HS in children.

Steno-occlusive Intracranial Large Vessel Arteriopathies in Childhood: A Pattern Oriented Approach to Neuroimaging Diagnosis

Intracranial steno-occlusive large vessel arteriopathies refer to abnormalities of the arterial wall that typically express luminal stenosis. Notably, some entities that can find themselves within this category may also express luminal dilation, and/or aneurysm formation as an alternative phenotype. Intracranial steno-occlusive large vessel arteriopathies are a leading cause of arterial ischemic stroke (AIS) in children, often progress, and can predispose to recurrent brain infarction. Intracranial arterial dissections account for a subset of cases expressing the focal cerebral arteriopathy (FCA) phenotype because the affected arterial segment, clinical presentation, and AIS patterns are very similar to the inflammatory subtype of FCA.

Arterial Ischemic Stroke in Pediatric Patients: A Tertiary Hospital Experience

INTRODUCTION

Childhood arterial ischemic stroke is a rare condition. Its true incidence is unknown as it is likely underdiagnosed. Outcomes are generally favorable but it is still a significant cause of mortality and morbidity in children. We aimed to characterize patients with childhood arterial ischemic stroke regarding risk factors, etiology, treatment, and outcome.

METHODS

This was a retrospective observational study that analyzed demographic and clinical data of patients aged 28 days to 18 years of age diagnosed with arterial ischemic stroke and admitted to the neuropediatric department at a tertiary hospital in Coimbra, Portugal, between 2015 and 2022.

RESULTS

A total of 19 patients were included, with a median age of 12.13 years; 10 (53%) were male children and 13 (63%) had a pre-existing medical condition. Eleven patients (58%) presented with sudden focal deficit and eight (42%) with only unspecific/non-localizing symptoms (headache, altered mental status, and seizure). The middle cerebral artery was the most affected (n=13, 68%) and regarding etiology, seven (37%) were cardioembolic and another seven (37%) were unilateral focal cerebral arteriopathy. Conservative measures were used for the treatment of 11 (90%) patients and two underwent mechanical thrombectomy successfully. Regarding sequelae, four patients (21%) had moderate to severe disability. The main sequelae was chronic motor deficit (n=8, 42%), followed by cortical deficit (n=4, 21%). Two patients developed vascular epilepsy.

CONCLUSIONS

While most patients presented with a sudden focal deficit, the occurrence of non-localizing symptoms was high. Conservative treatment was the most used, but there were good results in patients submitted to invasive treatment. Our results corroborate the high morbidity associated with childhood arterial ischemic stroke and the need for a high clinical suspicion to identify these cases and treat them promptly.

Deletion of endothelial IGFBP5 protects against ischaemic hindlimb injury by promoting angiogenesis

BACKGROUND

Angiogenesis is critical for forming new blood vessels from antedating vascular vessels. The endothelium is essential for angiogenesis, vascular remodelling and minimisation of functional deficits following ischaemia. The insulin-like growth factor (IGF) family is crucial for angiogenesis. Insulin-like growth factor-binding protein 5 (IGFBP5), a binding protein of the IGF family, may have places in angiogenesis, but the mechanisms are not yet completely understood. We sought to probe whether IGFBP5 is involved in pathological angiogenesis and uncover the molecular mechanisms behind it.

METHODS AND RESULTS

IGFBP5 expression was elevated in the vascular endothelium of gastrocnemius muscle from critical limb ischaemia patients and hindlimb ischaemic (HLI) mice and hypoxic human umbilical vein endothelial cells (HUVECs). In vivo, loss of endothelial IGFBP5 (IGFBP5EKO) facilitated the recovery of blood vessel function and limb necrosis in HLI mice. Moreover, skin damage healing and aortic ring sprouting were faster in IGFBP5EKO mice than in control mice. In vitro, the genetic inhibition of IGFBP5 in HUVECs significantly promoted tube formation, cell proliferation and migration by mediating the phosphorylation of IGF1R, Erk1/2 and Akt. Intriguingly, pharmacological treatment of HUVECs with recombinant human IGFBP5 ensued a contrasting effect on angiogenesis by inhibiting the IGF1 or IGF2 function. Genetic inhibition of IGFBP5 promoted cellular oxygen consumption and extracellular acidification rates via IGF1R-mediated glycolytic adenosine triphosphate (ATP) metabolism. Mechanistically, IGFBP5 exerted its role via E3 ubiquitin ligase Von Hippel-Lindau (VHL)-regulated HIF1α stability. Furthermore, the knockdown of the endothelial IGF1R partially abolished the reformative effect of IGFBP5EKO mice post-HLI.

CONCLUSION

Our findings demonstrate that IGFBP5 ablation enhances angiogenesis by promoting ATP metabolism and stabilising HIF1α, implying IGFBP5 is a novel therapeutic target for treating abnormal angiogenesis-related conditions.

Be aware of childhood stroke: Proceedings from EPNS Webinar

Childhood arterial ischaemic stroke (AIS) is a significant health concern with increasing incidence. This review aims to provide an overview of the current understanding of childhood AIS. The incidence of childhood AIS is on the rise especially in developing countries, likely due to improved awareness and diagnostic capabilities. Aetiology of childhood AIS is multifactorial, with both modifiable risk factors and genetic predisposition playing important roles. Identifying and addressing these risk factors, such as infection, sickle cell disease, and congenital heart defects, is essential in prevention and management. Identifying underlying conditions through genetic testing is important for appropriate management and long-term prognosis. Clinically, distinguishing stroke from stroke mimics can be challenging. Awareness of important stroke mimics, including migraines, seizures, and metabolic disorders, is crucial to avoid misdiagnosis and ensure appropriate treatment. The diagnostic approach to childhood AIS involves a comprehensive "chain of care," including initial assessment, neuroimaging, and laboratory investigations. National guidelines play a pivotal role in standardizing and streamlining the diagnostic process, ensuring prompt and accurate management. Early intervention is critical in the management of childhood AIS. Due to the critical time window, the question if mechanical thrombectomy is feasible and beneficial should be addressed as fast as possible. Early initiation of antiplatelet or anticoagulation therapy and, in select cases, thrombolysis can help restore blood flow and minimize long-term neurological damage. Additionally, rehabilitation should start as soon as possible to optimize recovery and improve functional outcomes. In conclusion, childhood AIS is a growing concern. Understanding the increasing incidence, age distribution, risk factors, clinical presentation, diagnostic approach, and management strategies is crucial for optimized management of these patients.

Stroke in children and adolescents: Analysis of electrophysiological and behavioral assessment findings of auditory processing

PURPOSE

This study aimed to analyze the auditory processing behavior of children and adolescents diagnosed with stroke and compare it with that of typically developing individuals.

METHODS

This was an analytical cross-sectional study involving 48 participants aged between 7 and 17 years with adequate schooling for age and grade, allocated equally to two groups: Stroke (SG) and Control Groups (CG). For the SG, cases identified between 2003 and 2018 were considered. In the CG, school-aged participants with typical development were randomized. After screening for differential audiological assessment and confirmation of auditory pathway integrity at the brainstem level, binaural analyses of the auditory processing behavior were conducted using the Dichotic Digit Test (DDT), Frequency Pattern Test (FPT), and electrophysiological assessment (P300). The Shapiro-Wilk test for normality was conducted, followed by the T and Mann-Whitney tests, with a 95 % confidence level and significance offset at p < 0.05, using the SPSS software (IBM®, v. 22.) RESULTS: The CG performed better in terms of auditory processing. These differences were significant (p < 0.0001) for the binaural integration of DDT, FPT humming and Labeling, and P300 latency. The P300 results were similar; however, with a greater amplitude in the SG.

CONCLUSION

This study showed that children and adolescents with stroke performed worse in electrophysiological and behavioral tests of auditory processing assessed using the auditory evoked potentials. These data reinforce the hypothesis that stroke-related lesions compromise the neural mechanisms underlying auditory processing.

Neuroimmune Support of Neuronal Regeneration and Neuroplasticity following Cerebral Ischemia in Juvenile Mice

Ischemic damage to the brain and loss of neurons contribute to functional disabilities in many stroke survivors. Recovery of neuroplasticity is critical to restoration of function and improved quality of life. Stroke and neurological deficits occur in both adults and children, and yet it is well documented that the developing brain has remarkable plasticity which promotes increased post-ischemic functional recovery compared with adults. However, the mechanisms underlying post-stroke recovery in the young brain have not been fully explored. We observed opposing responses to experimental cerebral ischemia in juvenile and adult mice, with substantial neural regeneration and enhanced neuroplasticity detected in the juvenile brain that was not found in adults. We demonstrate strikingly different stroke-induced neuroimmune responses that are deleterious in adults and protective in juveniles, supporting neural regeneration and plasticity. Understanding age-related differences in neuronal repair and regeneration, restoration of neural network function, and neuroimmune signaling in the stroke-injured brain may offer new insights for the development of novel therapeutic strategies for stroke rehabilitation.

PRISMA Systematic Literature Review, including with Meta-Analysis vs. Chatbot/GPT (AI) regarding Current Scientific Data on the Main Effects of the Calf Blood Deproteinized Hemoderivative Medicine (Actovegin) in Ischemic Stroke

BACKGROUND

Stroke is a significant public health problem and a leading cause of death and long-term disability worldwide. Several treatments for ischemic stroke have been developed, but these treatments have limited effectiveness. One potential treatment for this condition is Actovegin®/AODEJIN, a calf blood deproteinized hemodialysate/ultrafiltrate that has been shown to have pleiotropic/multifactorial and possibly multimodal effects. The actual actions of this medicine are thought to be mediated by its ability to reduce oxidative stress, inflammation, and apoptosis and to enhance neuronal survival and plasticity.

METHODS

To obtain the most up-to-date information on the effects of Actovegin®/AODEJIN in ischemic stroke, we systematically reviewed the literature published in the last two years. This review builds upon our previous systematic literature review published in 2020, which used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method to search for and select related articles over almost two decades, between 1 January 2001 and 31 December 2019. Additionally, we compared the results of our PRISMA search (human intelligence-based) with those obtained from an interrogation of a GPT-based chatbot (ChatGPT) in order to ensure comprehensive coverage of potentially relevant studies.

RESULTS

Our updated review found limited new evidence on the use of Actovegin®/AODEJIN in ischemic stroke, although the number of articles on this subject consistently increased compared to that from our initial systematic literature review. Specifically, we found five articles up to 2020 and eight more until December 2022. While these studies suggest that Actovegin®/AODEJIN may have neuroprotective effects in ischemic stroke, further clinical trials are needed to confirm these findings. Consequently, we performed a funnel analysis to evaluate the potential for publication bias.

DISCUSSION

Our funnel analysis showed no evidence of publication bias, suggesting that the limited number of studies identified was not due to publication bias but rather due to a lack of research in this area. However, there are limitations when using ChatGPT, particularly in distinguishing between truth and falsehood and determining the appropriateness of interpolation. Nevertheless, AI can provide valuable support in conducting PRISMA-type systematic literature reviews, including meta-analyses.

CONCLUSIONS

The limited number of studies identified in our review highlights the need for additional research in this area, especially as no available therapeutic agents are capable of curing central nervous system lesions. Any contribution, including that of Actovegin (with consideration of a positive balance between benefits and risks), is worthy of further study and periodic reappraisal. The evolving advancements in AI may play a role in the near future.