Multicenter Study of Long-Term Outcomes and Quality of Life in PHACE Syndrome after Age 10

OBJECTIVE

To characterize long-term outcomes of PHACE syndrome.

STUDY DESIGN

Multicenter study with cross-sectional interviews and chart review of individuals with definite PHACE syndrome ≥10 years of age. Data from charts were collected across multiple PHACE-related topics. Data not available in charts were collected from patients directly. Likert scales were used to assess the impact of specific findings. Patient-Reported Outcomes Measurement Information System (PROMIS) scales were used to assess quality of life domains.

RESULTS

A total of 104/153 (68%) individuals contacted participated in the study at a median of 14 years of age (range 10-77 years). There were infantile hemangioma (IH) residua in 94.1%. Approximately one-half had received laser treatment for residual IH, and the majority (89.5%) of participants were satisfied or very satisfied with the appearance. Neurocognitive manifestations were common including headaches/migraines (72.1%), participant-reported learning differences (45.1%), and need for individualized education plans (39.4%). Cerebrovascular arteriopathy was present in 91.3%, with progression identified in 20/68 (29.4%) of those with available follow-up imaging reports. Among these, 6/68 (8.8%) developed moyamoya vasculopathy or progressive stenoocclusion, leading to isolated circulation at or above the level of the circle of Willis. Despite the prevalence of cerebrovascular arteriopathy, the proportion of those with ischemic stroke was low (2/104; 1.9%). PROMIS global health scores were lower than population norms by at least 1 SD.

CONCLUSIONS

PHACE syndrome is associated with long-term, mild to severe morbidities including IH residua, headaches, learning differences, and progressive arteriopathy. Primary and specialty follow-up care is critical for PHACE patients into adulthood.

Risk factors associated with in-hospital complications for pediatric sickle-cell disease-associated moyamoya syndrome: a nationwide cross-sectional study

PURPOSE

Sickle-cell disease-associated moyamoya syndrome (SCD-MMS) carries a high risk for recurrent strokes and cerebrovascular morbidity in children. However, few data are available about complications that occur in children hospitalized with SCD-MMS. The purpose of this analysis was to determine the risk factors for in-hospital complications in pediatric SCD-MMS admissions, and thus aid physicians in optimizing future treatment plans.

METHODS

A national database of pediatric hospital admissions was examined across the years 2003-2019. ICD-9 and ICD-10 diagnosis codes were analyzed to identify discharges with a primary diagnosis of SCD-MMS and identify in-hospital complications, defined as complication-associated diagnostic codes logged during the same admission. Patient demographics, comorbidities, and hospital characteristics were examined using univariate and multivariate logistic regression analyses to determine associations with in-hospital complications.

RESULTS

In total, 274 admissions with a primary diagnosis of SCD-MMS were identified. During 64 (23.4%) admissions, transfusion therapy was given, and in 86 admissions (31.4%), surgical revascularization was performed. In 10 admissions (3.6%), a total of 11 in-hospital complications were identified. After multivariate regression, both comorbid chronic lung disease (adjusted OR 5.3 [1.1, 26.9], P = 0.04) and surgical revascularization (adjusted OR 10.2 [2.0, 52.4], P = 0.006) were associated with development of complications.

CONCLUSIONS

In this nationwide database of pediatric SCD-MMS hospitalizations, comorbid chronic lung disease and surgical revascularization were associated with development of in-hospital complications. Patients with comorbid chronic lung disease or who are admitted for revascularization may warrant closer monitoring and greater medical optimization during the hospitalization.

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.

A comparison of incidental and symptomatic unruptured brain arteriovenous malformations in children

OBJECTIVE

Patients with unruptured brain arteriovenous malformations (AVMs) may present with headaches, seizures, and/or neurological deficits. A smaller number of cases may be discovered incidentally. These lesions remain incompletely understood due to their sparse reporting. Herein, the authors describe the largest series to date comparing the presentation, angioarchitecture, and management of incidental versus symptomatic unruptured AVMs in children.

METHODS

The authors performed a retrospective analysis of patients who presented with brain AVMs from 1998 to 2022 at the University of California, San Francisco. Inclusion criteria were age ≤ 18 years at the time of presentation and an angiographically proven unruptured AVM that had been diagnosed postnatally.

RESULTS

Of 76 children with unruptured AVMs, 66 (86.8%) presented with headaches, seizures, and/or neurological deficit. Ten AVMs (13.1%) were incidentally discovered through unrelated disease workup (50%), cranial trauma (40%), or research study participation (10%). Compared with patients with symptomatic unruptured AVMs, patients with incidental unruptured AVMs had a smaller mean ± SD maximum nidus diameter (2.82 ± 1.1 vs 3.98 ± 1.52 cm, p = 0.025) and fewer had deep venous drainage (20% of patients vs 61%, p = 0.036). They also presented at an earlier age (10 ± 5.2 vs 13.5 ± 4 years, p = 0.043) and with longer duration to first treatment (541 ± 922 vs 196 ± 448 days, p = 0.005). During the observation period, 1 patient developed recurring headaches and demonstrated AVM nidus growth. Four AVMs greater than 3 cm in size or in a deep location were treated with radiosurgery. Six other AVMs were treated with resection, with 2 receiving preoperative embolization. Eight AVMs (80%) were obliterated on last follow-up. Postprocedural complications included 2 transient neurological deficits after resection and 1 case of delayed seizure development after radiosurgery. The mean follow-up period was 5.7 ± 5.7 years without any hemorrhage episodes.

CONCLUSIONS

A substantial proportion of pediatric patients with unruptured AVMs are discovered incidentally. With earlier presentation and more elementary angioarchitecture than symptomatic unruptured AVMs, these incidental lesions provide a snapshot into the natural history of AVM before symptom development or rupture.

Abstract 52: Prevalence Of Somatic Activating Kras Mutations In Pediatric And Adult Sporadic Brain Arteriovenous Malformations

Introduction: Sporadic brain arteriovenous malformations (bAVMs) are a potentially treatable cause of stroke disproportionately affecting young people. Non-inherited somatic activating mutations in KRAS have been reported in ~50% of bAVM specimens primarily from adults. We hypothesized that KRAS mutations would be associated with an earlier age at diagnosis, larger bAVM size, or earlier time to hemorrhage.

Methods: Sporadic bAVM tissue and clinical data were collected from patients seen at our institution. Genotyping was performed by digital droplet polymerase chain reaction to detect KRAS mutations (p.G12D, p.G12V or p.Q61H) in three batches and coded as presence/absence of any KRAS mutation (primary predictor). Age at diagnosis was dichotomized into adults (18 years) or children (<18 years). Regression analyses adjusting for genotyping batch were performed to test association of KRAS mutations between children and adults (logistic), with bAVM size (linear), or with time from diagnosis to hemorrhage (survival), censoring at treatment or last follow-up.

Results: We analyzed data from 221 patients: median age at bAVM diagnosis was 20 years; 44% were diagnosed as children; 53% were female; and 56% were ruptured on presentation. Median bAVM diameter was 2.1 cm (IQR: 1.4 - 3.0). KRAS mutations were detected in 53% of samples. Childhood bAVMs were significantly more likely to harbor KRAS mutations than those diagnosed in adulthood (OR=2.20, 95% CI: 1.24 - 3.91, p=0.007). KRAS -mutant bAVMs tended to be larger than KRAS -wildtype bAVMs, but this did not reach significance (+0.29 cm, 95% CI: -0.03 - 0.62, p=0.08). No association was observed for time to hemorrhage (HR=1.31, 95% CI: 0.91 - 1.88, p=0.15).

Conclusions: Somatic activating KRAS mutations are more prevalent in bAVMs diagnosed in childhood than adulthood. Further work is required to elucidate mechanisms of mutagenesis and bAVM progression, which may differ in children and adults.

Abstract TP157: Interleukin Plasma Levels And Risk Of Hemorrhage In Pediatric Brain Arteriovenous Malformation Patients

Introduction: Brain arteriovenous malformations (bAVMs) are the leading cause of pediatric hemorrhagic stroke. Prior studies have implicated inflammation as a major contributor to bAVM pathogenesis, with increased inflammatory cell infiltration and IL-6 protein levels reported in bAVM tissue. However, few studies have evaluated circulating inflammatory proteins as biomarkers for bAVM or intracranial hemorrhage (ICH).

Hypothesis: We hypothesized that higher plasma levels of interleukin (IL)-1B and IL-6 would be associated with bAVM ICH at initial presentation.

Methods: Pediatric bAVM cases (<19 years) evaluated at our institution between 2005 and 2022 were enrolled into an ongoing cohort study. Plasma samples (n=119) were collected and analyzed using the OLINK Explore 384 Inflammation panel. Protein levels were quantified based on log-log standard curves, and log 2 -transformed for analysis. Multivariable regression analysis compared plasma protein levels between cases with and without ICH presentation, adjusting for sex, race, ethnicity, age, and time between initial presentation and first plasma collection. Exponentiated coefficients are presented as proportional increase (PI).

Results: Samples were collected a median of 23.5 days after presentation in the ICH group and 140 days in the non-ICH group. Plasma levels of IL-6 were higher in bAVM patients with ICH vs. those without ICH (PI=3.22, 95% CI=1.32-7.85, p=0.011), adjusting for age, sex, race and Hispanic ethnicity. After further adjustment for time to sample collection, the association between IL-6 levels and ICH was no longer significant. (PI =1.36, CI=0.57-3.29, p=0.478). There was no difference in plasma levels of IL-1B between groups (PI=0.85, 95% CI=0.65-1.12, p=0.26).

Conclusion: Plasma levels of IL-6 were associated with ICH presentation in this pediatric bAVM cohort; however, this association may reflect downstream effects of the hemorrhage. Further studies are needed to help clarify whether plasma IL-6 levels can be used to predict hemorrhage risk in patients with unruptured bAVMs.

Hemorrhagic Stroke in Children and Adults With Sickle Cell Anemia: The Post-STOP Cohort

BACKGROUND

Hemorrhagic stroke in young patients with sickle cell anemia remains poorly characterized.

METHODS

The Post-STOP (Stroke Prevention Trial in Sickle Cell Anemia) retrospective study collected follow-up data on STOP and STOP II clinical trial cohorts. From January 2012 to May 2014, a team of analysts abstracted data from medical records of prior participants (all with sickle cell anemia). Two vascular neurologists reviewed data to confirm hemorrhagic strokes defined as spontaneous intracerebral, subarachnoid, or intraventricular hemorrhage. Incidence rates were calculated using survival analysis techniques RESULTS: Follow-up data were collected from 2850 of 3835 STOP or STOP II participants. Patients (51% male) were a median of 19.1 (interquartile range, 16.6-22.6) years old at the time of last known status. The overall hemorrhagic stroke incidence rate was 63 per 100 000 person-years (95% CI, 45-87). Stratified by age, the incidence rate per 100 000 person-years was 50 (95% CI, 34-75) for children and 134 (95% CI, 74-243) for adults >18 years. Vascular abnormalities (moyamoya arteriopathy, aneurysm or cavernous malformation) were identified in 18 of 35 patients with hemorrhagic stroke.

CONCLUSIONS

The incidence rate of hemorrhagic stroke in patients with sickle cell anemia increases with age. Structural vascular abnormalities such as moyamoya arteriopathy and aneurysms are common etiologies for hemorrhage and screening may be warranted.

Socioeconomic factors associated with pediatric moyamoya disease hospitalizations: a nationwide cross-sectional study

OBJECTIVE

Healthcare disparities are widely described in adults, but barriers affecting access to care for pediatric patients with moyamoya disease (MMD) are unknown. Understanding socioeconomic factors impacting hospital access and outcomes is necessary to address pediatric healthcare disparities.

METHODS

In this cross-sectional observational study, the Kids' Inpatient Database was used to identify patients admitted with a primary diagnosis of MMD from 2003 to 2016. Patients ≤ 18 years with a primary diagnosis of MMD based on International Classification of Diseases (ICD) codes were included. Hospital admissions were queried for use of cerebral revascularization based on ICD procedure codes.

RESULTS

Query of the KID yielded 1449 MMD hospitalizations. After multivariable regression, Hispanic ethnicity (OR 0.52 [95% CI 0.33-0.81], p = 0.004) was associated with lack of surgical revascularization. Private insurance (OR 1.56 [95% CI 1.15-2.13], p = 0.004), admissions at medium- and high-volume centers (OR 2.01 [95% CI 1.42-2.83], p < 0.001 and OR 2.84 [95% CI 1.95-4.14], p < 0.001, respectively), and elective hospitalization (OR 3.37 [95% CI 2.46-4.64], p < 0.001) were positively associated with revascularization. Compared with Caucasian race, Hispanic ethnicity was associated with increased mean (± SEM) length of stay by 2.01 ± 0.70 days (p = 0.004) and increased hospital charges by $24,333.61 ± $7918.20 (p = 0.002), despite the decreased utilization of surgical revascularization. Private insurance was associated with elective admission (OR 1.50 [95% CI 1.10-2.05], p = 0.01) and admission to high-volume centers (OR 1.90 [95% CI 1.26-2.88], p = 0.002). African American race was associated with the development of in-hospital complications (OR 2.52 [95% CI 1.38-4.59], p = 0.003).

CONCLUSIONS

Among pediatric MMD hospitalizations, multiple socioeconomic factors were associated with access to care, whether surgical treatment is provided, and whether in-hospital complications occur. These results suggest that socioeconomic factors are important drivers of healthcare disparities in children with MMD and warrant further study.

Validation of the Ruptured Arteriovenous Malformation Grading Scale in a pediatric cohort

OBJECTIVE

Pediatric brain arteriovenous malformations (AVMs) are the leading cause of spontaneous intracranial hemorrhage (SICH) in children. Although the incidence of SICH is low in pediatric populations, such events cause substantial morbidity. The recently created Ruptured Arteriovenous Malformation Grading Scale (RAGS) is proposed as a reliable and novel grading system to specifically serve as a predictor of clinical outcomes in patients following AVM rupture, similar to the Hunt and Hess (HH) grade for ruptured aneurysms. While these data are promising, pediatric patients were notably absent from the original study validating the RAGS. Therefore, correlation of the RAGS score with clinical outcomes following AVM rupture in individuals younger than 18 years of age using the RAGS score is needed. The objective of this study was to validate the RAGS in a cohort of pediatric patients with AVMs who presented with hemorrhage, thereby demonstrating the score's generalizability, and expanding its external validity.

METHODS

A cohort of children with ruptured AVMs were retrospectively reviewed. Using disability, measured by the modified Rankin Scale (mRS), as the response variable, the area under the receiver operating characteristic curve (AUROC) was calculated for patients based on their RAGS scores for three time periods. The AUROC values were then compared with those generated by two commonly used clinical grading systems, the HH classification and Glasgow Coma Scale.

RESULTS

A total of 81 children who presented with ruptured AVMs were included in the study, with a mean follow-up duration of 4 years. The RAGS score outperformed other clinical grading scales in predicting mRS scores, with AUROC values of 0.81, 0.82, and 0.81 at three distinct follow-up periods.

CONCLUSIONS

The RAGS score correlated well with the clinical outcome after AVM rupture in pediatric patients. Additional validation studies across multiple treatment centers are needed to further demonstrate the generalizability of the scoring system.

Abstract TMP91: Healthcare Utilization For Headache And Anxiety After Surgical Revascularization In Children With Moyamoya Vasculopathy

Introduction: Headache and anxiety are poorly described in children with moyamoya vasculopathy following revascularization.

Hypothesis: Headache and anxiety in pediatric moyamoya patients are common co-morbidities and result in frequent healthcare utilization.

Methods: In this single-center retrospective cohort study, children (<18 years of age) with moyamoya syndrome or disease who underwent EC-IC bypass between 2007-2020 were identified from a UCSF registry. Data regarding headache or anxiety were abstracted from medical records of inpatient, outpatient and emergency (ED) encounters using standardized forms. ED encounters were attributed to headache or anxiety when they occurred in the absence of stroke or TIA and documented as the likely cause of symptoms for that visit. Summary statistics were used to describe outcomes.

Results: We identified 32 children (63% female, 53% white, 22% Hispanic) who underwent initial revascularization surgery at a median age of 8.3 years (range 0.8-17.4). Two or more EC-IC surgeries were completed in 84% of patients. During follow-up after surgery (median 6.7 years, interquartile range 3.2 - 8.2 years), 81% of patients reported headache and 53% reported anxiety (Table). Headaches led to 27 ED encounters among 10 patients (31%). Headache rescue medications were prescribed to 21 patients (66%), and headache prophylaxis was prescribed in 37.5%. Six patients (19%) were referred to a headache specialist. Symptoms attributed to anxiety led to six ED encounters among three patients, and 19% (6/32) reported panic attacks. A referral to mental health services was provided to 44% (14/32) of patients.

Conclusions: Headaches and anxiety are common symptoms among children with moyamoya after revascularization and may lead to significant healthcare consumption. Symptoms and prevention measures should be explored in future studies to improve quality of life and decrease healthcare utilization.

Factors associated with seizures at initial presentation in pediatric patients with cerebral arteriovenous malformations

OBJECTIVE

Children with cerebral arteriovenous malformations (AVMs) can present with seizures, potentially increasing morbidity and impacting clinical management. However, the factors that lead to seizures as a presenting sign are not well defined. While AVM-related seizures have been described in case series, most studies have focused on adults and have included patients who developed seizures after an AVM rupture. To address this, the authors sought to analyze demographic and morphological characteristics of AVMs in a large cohort of children.

METHODS

The demographic, clinical, and AVM morphological characteristics of 189 pediatric patients from a single-center database were studied. Univariate and multivariate logistic regression models were used to test the effect of these characteristics on seizures as an initial presenting symptom in patients with unruptured brain AVMs.

RESULTS

Overall, 28 of 189 patients initially presented with seizures (14.8%). By univariate comparison, frontal lobe location (p = 0.02), larger AVM size (p = 0.003), older patient age (p = 0.04), and the Supplemented Spetzler-Martin (Supp-SM) grade (0.0006) were associated with seizure presentation. Multivariate analysis confirmed an independent effect of frontal lobe AVM location and higher Supp-SM grade. All patients presenting with seizures had AVMs in the cortex or subcortical white matter.

CONCLUSIONS

While children and adults share some risk factors for seizure presentation, their risk factor profiles do not entirely overlap. Pediatric patients with cortical AVMs in the frontal lobe were more likely to present with seizures. Additionally, the Supp-SM grade was highly associated with seizure presentation. Future clinical research should focus on the effect of therapeutic interventions targeting AVMs on seizure control in these patients.

Seizure Incidence Rates in Children and Adults With Familial Cerebral Cavernous Malformations

BACKGROUND AND OBJECTIVES

Seizure incidence rates related to familial cerebral cavernous malformation (FCCM) are not well described, especially for children. To measure the seizure incidence rate, examine seizure predictors, and characterize epilepsy severity, we studied a cohort of children and adults with FCCM enrolled in the Brain Vascular Malformation Consortium (BVMC).

METHODS

Seizure data were collected from participants with FCCM in the BVMC at enrollment and during follow-up. We estimated seizure probability by age and tested whether cerebral cavernous malformation (CCM) counts or genotype were associated with earlier seizure onset.

RESULTS

The study cohort included 479 FCCM cases. Median age at enrollment was 42.5 years (interquartile range 22.5-55.0) and 19% were children (<18 years old). Median large CCM count was 3 (interquartile range 1-5). Among 393 with genotyping, mutations were as follows: CCM1 (Common Hispanic Mutation) (88%), another CCM1 mutation (5%), CCM2 mutations (5%), and CCM3 mutations (2%). Prior to or during the study, 202 (42%) had a seizure. The cumulative incidence of a childhood seizure was 20.3% (95% confidence interval [CI] 17.0-23.4) and by age 80 years was 60.4% (95% CI 54.2-65.7). More total CCMs (hazard ratio [HR] 1.24 per SD unit increase, 95% CI 1.1-1.4) or more large CCMs (HR 1.5 per SD unit increase, 95% CI 1.2-1.9) than expected for age and sex increased seizure risk. A CCM3 mutation also increased risk compared to other mutations (HR 3.11, 95% CI 1.15-8.45). Individuals with a seizure prior to enrollment had increased hospitalization rates during follow-up (incidence rate ratio 10.9, 95% CI 2.41-49.32) compared to patients without a seizure history.

DISCUSSION

Individuals with FCCM have a high seizure incidence and those with more CCMs or CCM3 genotype are at greater risk. Seizures increase health care utilization in FCCM.

Assessing the association of common genetic variants in EPHB4 and RASA1 with phenotype severity in familial cerebral cavernous malformation

Background

To investigate whether common variants in EPHB4 and RASA1 are associated with cerebral cavernous malformation (CCM) disease severity phenotypes, including intracranial hemorrhage (ICH), total and large lesion counts.

Methods

Familial CCM cases enrolled in the Brain Vascular Malformation Consortium were included (n = 338). Total lesions and large lesions (≥5 mm) were counted on MRI; clinical history of ICH at enrollment was assessed by medical records. Samples were genotyped on the Affymetrix Axiom Genome‐Wide LAT1 Human Array. We tested the association of seven common variants (three in EPHB4 and four in RASA1) using multivariable logistic regression for ICH (odds ratio, OR) and multivariable linear regression for total and large lesion counts (proportional increase, PI), adjusting for age, sex, and three principal components. Significance was based on Bonferroni adjustment for multiple comparisons (0.05/7 variants = 0.007).

Results

EPHB4 variants were not significantly associated with CCM severity phenotypes. One RASA1 intronic variant (rs72783711 A>C) was significantly associated with ICH (OR = 1.82, 95% CI = 1.21–2.37, p = 0.004) and nominally associated with large lesion count (PI = 1.17, 95% CI = 1.03–1.32, p = 0.02).

Conclusion

A common RASA1 variant may be associated with ICH and large lesion count in familial CCM. EPHB4 variants were not associated with any of the three CCM severity phenotypes.

Pediatric moyamoya MRI score: an imaging-based scale to predict outcomes in surgically treated pediatric patients with moyamoya

OBJECTIVE

Moyamoya is a progressive arteriopathy that predisposes patients to stroke due to stenosis of the intracranial internal carotid arteries and their proximal branches. Despite the morbidity caused by this condition, the ability to accurately predict prognosis for individual patients remains challenging. The goal of this study was to develop a systematic scoring method based on parenchymal findings on preoperative brain MRI to predict long-term outcomes for surgically treated pediatric patients with moyamoya.

METHODS

A retrospective surgical cohort of pediatric patients (≤ 18 years of age at the time of the initial surgery) with moyamoya from a single center were studied. Radiological variables with existing correlations between outcomes in moyamoya or other vascular diseases were chosen to score preoperative MRI based on easily defined parenchymal findings that could be rapidly assessed and used to make a numeric score. Calculated scores were correlated with clinical outcome measures using the Pearson correlation coefficient and area under the receiver operating characteristic curve (AUROC).

RESULTS

A total of 35 children with moyamoya disease or moyamoya syndrome were included in the study, with a median follow-up time of 2.6 years from the time of surgery. The pediatric moyamoya MRI score (PMMS) consists of ischemic changes (0-2; 0 = none, 1 = focal, 2 = diffuse), encephalomalacia (0-2; 0 = none, 1 = focal, 2 = diffuse), and hemorrhage (0-1; 0 = not present, 1 = present). PMMSs were highly correlated with pediatric modified Rankin Scale scores at the last follow-up (r = 0.7, 95% CI 0.44-0.84; p < 0.001) as a six-point scale, and when dichotomized (AUROC = 0.85).

CONCLUSIONS

The PMMS was found to be a simple tool based on preoperative MRI data that could be quickly and easily calculated and correlated with disability. This scoring method may aid future development of predictive models of outcomes for children with moyamoya disease and moyamoya syndrome.

Pediatric Ischemic Stroke: An Infrequent Complication of SARS-CoV-2

OBJECTIVE

Severe complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) include arterial ischemic stroke (AIS) in adults and multisystem inflammatory syndrome in children. Whether stroke is a frequent complication of pediatric SARS-CoV-2 is unknown. This study aimed to determine the proportion of pediatric SARS-CoV-2 cases with ischemic stroke and the proportion of incident pediatric strokes with SARS-CoV-2 in the first 3 months of the pandemic in an international cohort.

METHODS

We surveyed 61 international sites with pediatric stroke expertise. Survey questions included: numbers of hospitalized pediatric (≤ 18 years) patients with SARS-CoV-2; numbers of incident neonatal and childhood ischemic strokes; frequency of SARS-CoV-2 testing for pediatric patients with stroke; and numbers of stroke cases positive for SARS-CoV-2 from March 1 to May 31, 2020.

RESULTS

Of 42 centers with SARS-CoV-2 hospitalization numbers, 8 of 971 (0.82%) pediatric patients with SARS-CoV-2 had ischemic strokes. Proportions of stroke cases positive for SARS-CoV-2 from March to May 2020 were: 1 of 108 with neonatal AIS (0.9%), 0 of 33 with neonatal cerebral sinovenous thrombosis (CSVT; 0%), 6 of 166 with childhood AIS (3.6%), and 1 of 54 with childhood CSVT (1.9%). However, only 30.5% of neonates and 60% of children with strokes were tested for SARS-CoV-2. Therefore, these proportions represent 2.9, 0, 6.1, and 3.0% of stroke cases tested for SARS-CoV-2. Seven of 8 patients with SARS-CoV-2 had additional established stroke risk factors.

INTERPRETATION

As in adults, pediatric stroke is an infrequent complication of SARS-CoV-2, and SARS-CoV-2 was detected in only 4.6% of pediatric patients with ischemic stroke tested for the virus. However, < 50% of strokes were tested. To understand the role of SARS-CoV-2 in pediatric stroke better, SARS-CoV-2 testing should be considered in pediatric patients with stroke as the pandemic continues. ANN NEUROL 2021;89:657-665.

Asymptomatic rotational vertebral artery compression in a child due to head positioning for cranial surgery: illustrative case

BACKGROUND

The authors recently reported a series of children with vertebral artery (VA) compression during head turning who presented with recurrent posterior circulation stroke. Whether VA compression occurs during head positioning for cranial surgery is unknown.

OBSERVATIONS

The authors report a case of a child with incidental rotational occlusion of the VA observed during surgical head positioning for treatment of an intracranial arteriovenous fistula. Intraoperative angiography showed dynamic V₃ occlusion at the level of C2 with distal reconstitution via a muscular branch “jump” collateral, supplying reduced flow to the V₄ segment. She had no clinical history or imaging suggesting acute or prior stroke. Sequential postoperative magnetic resonance imaging scans demonstrated signal abnormality of the left rectus capitus muscle, suggesting ischemic edema.

LESSONS

This report demonstrates that rotational VA compression during neurosurgical head positioning can occur in children but may be asymptomatic due to the presence of muscular VA–VA “jump” collaterals and contralateral VA flow. Although unilateral VA compression may be tolerated by children with codominant VAs, diligence when rotating the head away from a dominant VA is prudent during patient positioning to avoid posterior circulation ischemia or thromboembolism.

Multiple Tumor-Associated Intracranial Aneurysms Adjacent to a Suprasellar Germ Cell Tumor: Case Report and Review of Literature

INTRODUCTION

Tumor-associated intracranial aneurysms are rare and not well understood.

CASE PRESENTATION

We describe a 4-year-old female with multiple intracranial aneurysms intimately associated with a suprasellar germ cell tumor (GCT). We provide the clinical history, medical, and surgical treatment course, as well as a comprehensive and concise synthesis of the literature on tumor-associated aneurysms.

DISCUSSION

We discuss mechanisms for aneurysm formation with relevance to the current case, including cellular and paracrine signaling pertinent to suprasellar GCTs and possible molecular pathways involved. We review the complex multidisciplinary treatment required for complex tumor and cerebrovascular interactions.

Validation of the pediatric stroke outcome measure for classifying overall neurological deficit

BACKGROUND

The pediatric stroke outcome measure (PSOM) is a standardized, disease-specific outcome measure. We aimed to validate the overall classification of neurological deficit severity using PSOM.

METHODS

We identified 367 neonates/children with arterial ischemic stroke (AIS) (Derivation Cohort). We analyzed the PSOM subscales (scored as 0 [no deficit], 0.5 [minimal/mild deficit; normal function], 1 [moderate deficit; slowing function], or 2 [severe deficit; missing function]) to derive severity levels using latent class analysis (LCA). We validated a severity classification scheme (PSOM-SCS) in: (a) children who had Pediatric Evaluation of Disability Inventory (PEDI; n = 63) and/or the Pediatric Quality-of-Life Inventory (PedsQL; n = 97) scored; and (b) an external cohort (AIS; n = 102) with concurrently scored modified Rankin Scale (mRS), King's Outcome Scale for Childhood Head-Injury (KOSCHI) and PSOM.

RESULTS

Within the Derivation Cohort, LCA identified three severity levels: "normal/mild," "moderate," and "severe" (83.7%, 13.3%, and 3%, respectively). We developed severity classification based on PSOM subscale scores: "normal/mild"-normal function in all domains or slowing in one domain, "moderate"-slowing in ≥2 domains or missing function in one domain, and "severe"-missing function in ≥2 domains or slowing in ≥1 plus missing in one domain. PEDI and PedsQL both differed significantly across the severity groups. PSOM-SCS displayed high concordance with mRS (agreement coefficient [AC2] = 0.88) and KOSCHI (AC2 = 0.79).

CONCLUSION

The PSOM-SCS constitutes a valid tool for classifying overall neurological severity emphasizing function and encompassing the full range of severity in pediatric stroke.

IMPACT

Arithmetic summing of the PSOM subscales scores to assess severity classification is inadequate.The prior severity classification using PSOM overestimates poor outcomes.Three distinct severity profiles using PSOM subscales are identified.The PSOM-SCS is in moderate to excellent agreement with other disability measures.PSOM-SCS offers a valid tool for classifying the overall neurological deficit severity.

Single-center series of boys with recurrent strokes and rotational vertebral arteriopathy

OBJECTIVE

To describe a pediatric stroke syndrome with chronic focal vertebral arteriopathy adjacent to cervical abnormalities.

METHODS

At a single pediatric stroke center, we identified consecutive children with stroke and vertebral arteriopathy of the V3 segment with adjacent cervical bony or soft tissue abnormalities. We abstracted clinical presentation, treatment, and follow-up data from medical charts.

RESULTS

From 2005 to 2019, 10 children (all boys, ages 6-16 years) presented with posterior circulation strokes and vertebral arteriopathy with adjacent cervical pathology. Two children had bony abnormalities: one had a congenital arcuate foramen and one had os odontoideum with cervical instability. In children without bony pathology, vertebral artery narrowing during contralateral head rotation was visualized by digital subtraction angiography. Eight boys had recurrent ischemic events despite anti-thrombotic treatment (including 5 with multiple recurrences) and were treated surgically to prevent additional stroke. Procedures included vertebral artery decompression (n = 6), endovascular stent and spinal fusion (n = 1), and vertebral artery endovascular occlusion (n = 1). In boys treated with decompression, cervical soft tissue abnormalities (ruptured atlantoaxial bursa, ruptured joint capsule, or connective tissue scarring) were directly visualized during open surgery. No other etiology for stroke or dissection was found in any of the cases. Two boys without recurrent stroke were treated with activity restriction and antithrombotics. At a median follow-up of 51 months (range 17-84), there have been no additional recurrences.

CONCLUSIONS

Children with V3 segmental vertebral arteriopathy frequently have stroke recurrence despite antithrombotics. Cervical bone imaging and angiography with neck rotation can identify underlying pathology.

Bringing high-grade arteriovenous malformations under control: clinical outcomes following multimodality treatment in children

OBJECTIVE

Brain arteriovenous malformations (AVMs) consist of dysplastic blood vessels with direct arteriovenous shunts that can hemorrhage spontaneously. In children, a higher lifetime hemorrhage risk must be balanced with treatment-related morbidity. The authors describe a collaborative, multimodal strategy resulting in effective and safe treatment of pediatric AVMs.

METHODS

A retrospective analysis of a prospectively maintained database was performed in children with treated and nontreated pediatric AVMs at the University of California, San Francisco, from 1998 to 2017. Inclusion criteria were age ≤ 18 years at time of diagnosis and an AVM confirmed by a catheter angiogram.

RESULTS

The authors evaluated 189 pediatric patients with AVMs over the study period, including 119 ruptured (63%) and 70 unruptured (37%) AVMs. The mean age at diagnosis was 11.6 ± 4.3 years. With respect to Spetzler-Martin (SM) grade, there were 38 (20.1%) grade I, 40 (21.2%) grade II, 62 (32.8%) grade III, 40 (21.2%) grade IV, and 9 (4.8%) grade V lesions. Six patients were managed conservatively, and 183 patients underwent treatment, including 120 resections, 82 stereotactic radiosurgery (SRS), and 37 endovascular embolizations. Forty-four of 49 (89.8%) high-grade AVMs (SM grade IV or V) were treated. Multiple treatment modalities were used in 29.5% of low-grade and 27.3% of high-grade AVMs. Complete angiographic obliteration was obtained in 73.4% of low-grade lesions (SM grade I-III) and in 45.2% of high-grade lesions. A periprocedural stroke occurred in a single patient (0.5%), and there was 1 treatment-related death. The mean clinical follow-up for the cohort was 4.1 ± 4.6 years, and 96.6% and 84.3% of patients neurologically improved or remained unchanged in the ruptured and unruptured AVM groups following treatment, respectively. There were 16 bleeding events following initiation of AVM treatment (annual rate: 0.02 events per person-year).

CONCLUSIONS

Coordinated multidisciplinary evaluation and individualized planning can result in safe and effective treatment of children with AVMs. In particular, it is possible to treat the majority of high-grade AVMs with an acceptable safety profile. Judicious use of multimodality therapy should be limited to appropriately selected patients after thorough team-based discussions to avoid additive morbidity. Future multicenter studies are required to better design predictive models to aid with patient selection for multimodal pediatric care, especially with high-grade AVMs.

Review on the Diagnosis and Treatment of Reversible Cerebral Vasoconstriction Syndrome in Children and Adolescents

Reversible cerebral vasoconstriction syndrome (RCVS) is a clinical–radiologic diagnosis that affects children and adolescents, but it is much more frequently reported in adults. Clinically, patients present with severe and commonly recurrent thunderclap headaches. Typical precipitating triggers include vasoactive substances, serotonergic agents, and the postpartum period. There may be associated neurologic complications at presentation or in the weeks following, such as convexity subarachnoid hemorrhage, stroke, cerebral edema, cervical artery dissection (CeAD), and seizures. Angiographically, the cerebral arteries demonstrate segmental vasoconstriction and dilation, although imaging early in the clinical course may be normal. Work-up is performed to exclude intracranial disorders such as vasculitis, subarachnoid hemorrhage due to ruptured aneurysm, meningitis, and intracranial venous sinus thrombosis. Within 1 month of initial symptom onset, clinical symptoms such as severe headache have ceased, and within 3 months, the cerebral vasoconstriction is much improved or resolved. Management involves avoidance of precipitating triggers and potentially short-term pharmacotherapy with calcium channel blockers for patients with associated neurologic complications. Steroids are not recommended and may worsen the clinical outcome. Prognosis is excellent in the large majority of patients, and only 5% of patients experience a recurrence of RCVS.

Abstract 89: Incidence and Characteristics of Hemorrhagic Stroke Among Post-STOP Participants

Introduction: The Stroke Prevention Trial in Sickle Cell Anemia (STOP) changed standards of care for stroke screening and treatment of high-risk children with sickle cell anemia (SCA), reducing the risk of ischemic stroke. However, the incidence of hemorrhagic stroke in young patients with SCA in the post-STOP era remains poorly characterized.

Methods: The Post-STOP multicenter cohort study collected follow-up data from prior participants (all with SCA) of the STOP or STOP II clinical trials. From 01/2012 – 05/2014, medical records analysts abstracted clinical, imaging and laboratory data collected after the STOP studies ended at 19 of the 26 original sites. Two stroke neurologists reviewed data to confirm hemorrhagic stroke, defined as primary spontaneous intracerebral, subarachnoid or intraventricular hemorrhage; we excluded traumatic hemorrhage or hemorrhagic conversion of ischemic infarcts. Incidence rates among those with no prior hemorrhagic stroke at the start of Post-STOP were calculated using survival analysis techniques.

Results: Follow-up data were collected from 2,851 of 3,835 participants participated in the STOP trials. Patients (51% male) were a median age of 10.4 years (interquartile range [IQR] 6.8-14.1) at the start of Post-STOP. Over a median of 10.3 (IQR 7.3-11.4) years of follow-up, 35 patients with hemorrhagic stroke were identified (Table 1). The incidence rate was 63 per 100,000 person-years overall (95% CI 45-87). Stratified by age, the incidence rate per 100,00 person-years was 50 (95% CI 34-75) for children less than 18 years old and 134 (95% CI 74-243) for adults over the age of 50.

Conclusion: In our cohort, we observed that the risk of hemorrhagic stroke in patients with SCA rises as patients age, most sharply after the first decade of life. Structural vascular abnormalities such as moyamoya syndrome and aneurysms are common etiologies for hemorrhage and screening may be warranted.

Arteriopathy Influences Pediatric Ischemic Stroke Presentation, but Sickle Cell Disease Influences Stroke Management

Background and Purpose- Sickle cell disease (SCD) and arteriopathy are pediatric stroke risk factors that are not mutually exclusive. The relative contributions of sickled red blood cells and arteriopathy to stroke risk are unknown, resulting in unclear guidelines for primary and secondary stroke prevention when both risk factors are present. We hypothesized that despite similarities in clinical presentation and radiographic appearance of arteriopathies, stroke evaluation and management differ in children with SCD compared with those without SCD. Methods- We compared presentation and management of children with and without SCD enrolled in the IPSS (International Pediatric Stroke Study) with acute arterial ischemic stroke, according to SCD and arteriopathy status. Regression modeling determined relative contribution of SCD and arteriopathy in variables with significant frequency differences. Results- Among 930 childhood arterial ischemic strokes, there were 98 children with SCD, 67 of whom had arteriopathy, and 466 without SCD, 392 of whom had arteriopathy. Arteriopathy, regardless of SCD status, increased likelihood of hemiparesis (odds ratio [OR], 1.94; 95% CI, 1.46-2.56) and speech abnormalities (OR, 1.67; 95% CI, 1.29-2.19). Arteriopathy also increased likelihood of headache but only among those without SCD (OR, 1.89; 95% CI, 1.40-2.55). Echocardiograms were less frequently obtained in children with SCD (OR, 0.58; 95% CI, 0.37-0.93), but the frequency of identified cardiac abnormalities was similar in both groups ( P=0.57). Children with SCD were less likely to receive antithrombotic therapy, even in the presence of arteriopathy (OR, 0.14; 95% CI, 0.08-0.22). Arteriopathy was associated with a significantly higher likelihood of antithrombotic therapy in children without SCD (OR, 5.36; 95% CI, 3.55-8.09). Conclusions- Arteriopathy, and not SCD status, was most influential of stroke presentation. However, SCD status influenced stroke management because children with SCD were less likely to have echocardiograms or receive antithrombotic therapy. Further work is needed to determine whether management differences are warranted.

Comparative study of posterior and anterior circulation stroke in childhood: Results from the International Pediatric Stroke Study

OBJECTIVE

To compare risk factors, clinical presentation, and outcomes after posterior circulation arterial ischemic stroke (PCAIS) and anterior circulation arterial ischemic stroke (ACAIS) in neonates and children.

METHODS

In this international multicenter observational study including neonates and children up to 18 years of age with arterial ischemic stroke (AIS), we compared clinical and radiologic features according to stroke location.

RESULTS

Of 2,768 AIS cases, 507 (18%) were located in the posterior circulation, 1,931 (70%) in the anterior circulation, and 330 (12%) involved both. PCAIS was less frequent in neonates compared to children (8.8% vs 22%, p < 0.001). Children with PCAIS were older than children with ACAIS (median age 7.8 [interquartile range (IQR) 3.1-14] vs 5.1 [IQR 1.5-12] years, p < 0.001), and more often presented with headache (54% vs 32%, p < 0.001) and a lower Pediatric NIH Stroke Scale score (4 [IQR 2-8] vs 8 [IQR 3-13], p = 0.001). Cervicocephalic artery dissections (CCAD) were more frequent (20% vs 8.5%, p < 0.001), while cardioembolic strokes were less frequent (19% vs 32%, p < 0.001) in PCAIS. Case fatality rates were equal in both groups (2.9%). PCAIS survivors had a better outcome (normal neurologic examination at hospital discharge in 29% vs 21%, p = 0.002) than ACAIS survivors, although this trend was only observed in children and not in neonates.

CONCLUSION

PCAIS is less common than ACAIS in both neonates and children. Children with PCAIS are older and have a higher rate of CCAD, lower clinical stroke severity, and better outcome than children with ACAIS.

Arterial Ischemic Stroke Secondary to Cardiac Disease in Neonates and Children

OBJECTIVE

We describe the risk factors for peri-procedural and spontaneous arterial ischemic stroke (AIS) in children with cardiac disease.

METHODS

We identified children with cardiac causes of AIS enrolled in the International Pediatric Stroke Study registry from January 2003 to July 2014. Isolated patent foramen ovale was excluded. Peri-procedural AIS (those occurring during or within 72 hours of cardiac surgery, cardiac catheterization, or mechanical circulatory support) and spontaneous AIS that occurred outside of these time periods were compared.

RESULTS

We identified 672 patients with congenital or acquired cardiac disease as the primary risk factor for AIS. Among these, 177 patients (26%) had peri-procedural AIS and 495 patients (74%) had spontaneous AIS. Among non-neonates, spontaneous AIS occurred at older ages (median 4.2 years, interquartile range 0.97 to 12.4) compared with peri-procedural AIS (median 2.4 years, interquartile range 0.35 to 6.1, P < 0.001). About a third of patients in both groups had a systemic illness at the time of AIS. Patients who had spontaneous AIS were more likely to have a preceding thrombotic event (16 % versus 9 %, P = 0.02) and to have a moderate or severe neurological deficit at discharge (67% versus 33%, P = 0.01) compared to those with peri-procedural AIS.

CONCLUSIONS

Children with cardiac disease are at risk for AIS at the time of cardiac procedures but also outside of the immediate 72 hours after procedures. Many have acute systemic illness or thrombotic event preceding AIS, suggesting that inflammatory or prothrombotic conditions could act as a stroke trigger in this susceptible population.

Abstract TMP51: Pre-existing Atherosclerotic Risk Factors Increase Short-Term Ischemic Stroke Risk After Traumatic Head or Neck Injury

Introduction: Trauma is an established risk factor for ischemic stroke in the young. We speculated that atherosclerotic disease, increasingly prevalent at younger ages, could predispose to dissection or artery-to-artery embolism after trauma. In a cohort of young patients with head or neck trauma, we aimed to measure the association of atherosclerotic risk factors with short-term ischemic stroke risk.

Methods: Nested case-control study of patients (birth to 50 years old) with head or neck trauma while enrolled in a population-based Northern California integrated healthcare delivery system, 1997-2011. Within the trauma cohort, we identified ischemic stroke ICD-9 codes within 4 weeks of head or neck injury. A panel of neurologists reviewed charts to confirm cases of arterial ischemic stroke and determine whether stroke was attributed to trauma. Three controls per case were randomly identified from the trauma cohort. Atherosclerotic risk factors were abstracted from charts only when documented prior to trauma. We compared cases to controls using logistic regression.

Results: The trauma cohort included 120,494 emergency encounters or hospital admissions for head or neck injury over the 15-year study period. We confirmed 45 cases of arterial ischemic stroke attributed to trauma and randomly identified 135 stroke-free controls for comparison. Stroke risk was not associated with sex or race/ethnicity, but was age-related: for each decade older, stroke risk increased 70% (OR 1.7, 95% CI 1.4-2.2). Other pre-existing atherosclerotic risk factors also increased stroke risk. Cases were more likely than controls to have atherosclerotic risk factors documented in the medical record prior to trauma, including hypertension, diabetes mellitus, elevated cholesterol, and history of smoking (Table).

Conclusions: Pre-existing atherosclerotic risk factors appear to increase short-term ischemic stroke risk after head or neck injury.

Socioeconomic determinants of outcome after childhood arterial ischemic stroke

OBJECTIVE

To determine whether lower socioeconomic status (SES) is associated with worse 1-year neurologic outcomes and reduced access to rehabilitation services in children with arterial ischemic stroke (AIS).

METHODS

From 2010 to 2014, the Vascular effects of Infection in Pediatric Stroke (VIPS) observational study prospectively enrolled and confirmed 355 children (age 29 days-18 years) with AIS at 37 international centers. SES markers measured via parental interview included annual household income (US dollars) at the time of enrollment, maternal education level, and rural/suburban/urban residence. Receipt of rehabilitation services was measured by parental report. Pediatric Stroke Outcome Measure scores were categorized as 0 to 1, 1.5 to 3, 3.5 to 6, and 6.5 to 10. Univariate and multivariable ordinal logistic regression models examined potential predictors of outcome.

RESULTS

At 12 ± 3 months after stroke, 320 children had documented outcome measurements, including 15 who had died. In univariate analysis, very low income (<US $10,000), but not other markers of SES, was associated with worse outcomes (odds ratio [OR] 3.13, 95% confidence interval [CI] 1.43-6.88, p = 0.004). In multivariable analysis, including adjustment for stroke etiology, this association persisted (OR 3.17, 95% CI 1.18-8.47, p = 0.02). Income did not correlate with receiving rehabilitation services at 1 year after stroke; however, quality and quantity of services were not assessed.

CONCLUSIONS

In a large, multinational, prospective cohort of children with AIS, low income was associated with worse neurologic outcomes compared to higher income levels. This difference was not explained by stroke type, neurologic comorbidities, or reported use of rehabilitation services. The root causes of this disparity are not clear and warrant further investigation.

Children with post-stroke epilepsy have poorer outcomes one year after stroke

Background Epilepsy is a common complication of pediatric stroke. Aim In this study, we aim to measure the association between epilepsy and neurologic outcome after childhood arterial ischemic stroke. Methods Prospective cohort study of children (29 days-19 years) enrolled after an acute arterial ischemic stroke at 21 international pediatric stroke centers and followed to identify epilepsy. One year post-stroke, outcomes were scored using the examination-based Pediatric Stroke Outcome Measure (range = 0-10); higher values reflect greater disability. Ordinal logistic regression was used to measure the association of Pediatric Stroke Outcome Measure scores (categorized as 0-1, 1.5-3, 3.5-6, 6.5-10) with epilepsy. Results Investigators enrolled 86 children (median age = 6.1 years, interquartile range (IQR) = 1.4-12.2 years) with acute stroke. At 1 year, 18/80 (23%) remained on an anticonvulsant including 8/80 (10%) with epilepsy. Among the 70 with Pediatric Stroke Outcome Measure scored, the median was 0.5 (IQR = 0-1.5) for children without epilepsy ( n = 63), and 6 (IQR = 0.5-10) for children with epilepsy ( n = 7). In univariable analyses, poorer 1-year outcome was associated with middle cerebral artery stroke, cortical infarcts, hemorrhagic transformation, hospital disposition not to home, and epilepsy. In multivariable analysis, middle cerebral artery stroke (odds ratio (OR) = 4.9, 95% confidence intervals (CI) = 1.1-21.3) and epilepsy (OR = 24.1, CI = 1.5-380) remained associated with poorer outcome. Conclusions Children who developed epilepsy during the first year post-stroke had poorer neurologic outcomes than those without epilepsy.

Abstract 18: Anticonvulsant Medication Practice Varies After Pediatric Arterial Ischemic Stroke

Introduction: Acute symptomatic seizures are common after pediatric arterial ischemic stroke (AIS). We sought to analyze practice variation in anticonvulsant medication treatment (ACM) after AIS. We hypothesized that ACM practice varies but is related to age, acute seizure frequency and duration, cortical involvement, and hemorrhagic conversion.

Methods: Seizures in Pediatric Stroke (SIPS), an international, prospective study, enrolled neonatal (<28 days) and childhood (<19 years) acute AIS patients 3/2011-8/2012. Seizures and ACM were recorded. Among patients with acute seizures (<7 days post-stroke), we used univariate Spearman’s correlations to determine association between ACM and clinical predictors at both discharge and 12-month time points. Variables with p <0.05 at univariate analysis were entered into a logistic regression model.

Results: Among 116 patients, 27 neonates and 31 children (ages 0.2-17 years) had an acute seizure. In neonates, 24 (89%) had ACM continued after discharge, but only 4 (15%) remained on ACM at 12 m (3 having had post-discharge seizure). Phenobarbital was the most common ACM in neonates at discharge (n=14) and 12m (n=2, levetiracetam = 2). In children, 23 (74%) had ACM at discharge, and 17 (57%) remained on ACM at 12m (7 having had a post-discharge seizure). All patients in study with post-discharge seizure were discharged on ACM. Two neonates and 1 child with post-discharge seizure were not on ACM at 12m. Levetiracetam was the most common ACM in children at discharge (n=11) and 12m (n=9). No single variable correlated with discharge ACM (Table). ACM at 12 m correlated with neonatal stroke, >10 seizures in acute period, and post-discharge seizure. In logistic regression, all variables remained significant.

Conclusion: ACM management after acute post-stroke seizures varies widely in pediatric stroke. Neonates rarely, but children frequently, are continued on ACM up to 1 year, even without further seizures.

Population-based study of ischemic stroke risk after trauma in children and young adults

OBJECTIVE

To quantify the incidence, timing, and risk of ischemic stroke after trauma in a population-based young cohort.

METHODS

We electronically identified trauma patients (<50 years old) from a population enrolled in a Northern Californian integrated health care delivery system (1997-2011). Within this cohort, we identified cases of arterial ischemic stroke within 4 weeks of trauma and 3 controls per case. A physician panel reviewed medical records, confirmed cases, and adjudicated whether the stroke was related to trauma. We calculated the 4-week stroke incidence and estimated stroke odds ratios (OR) by injury location using logistic regression.

RESULTS

From 1,308,009 trauma encounters, we confirmed 52 trauma-related ischemic strokes. The 4-week stroke incidence was 4.0 per 100,000 encounters (95% confidence interval [CI] 3.0-5.2). Trauma was multisystem in 26 (50%). In 19 (37%), the stroke occurred on the day of trauma, and all occurred within 15 days. In 7/28 cases with cerebrovascular angiography at the time of trauma, no abnormalities were detected. In unadjusted analyses, head, neck, chest, back, and abdominal injuries increased stroke risk. Only head (OR 4.1, CI 1.1-14.9) and neck (OR 5.6, CI 1.03-30.9) injuries remained associated with stroke after adjusting for demographics and trauma severity markers (multisystem trauma, motor vehicle collision, arrival by ambulance, intubation).

CONCLUSIONS

Stroke risk is elevated for 2 weeks after trauma. Onset is frequently delayed, providing an opportunity for stroke prevention during this period. However, in one-quarter of stroke cases with cerebrovascular angiography at the time of trauma, no vascular abnormality was detected.

Factors associated with long-term weight-loss maintenance following bariatric surgery in adolescents with severe obesity

BACKGROUND/OBJECTIVES

Bariatric surgery produces robust weight loss, however, factors associated with long-term weight-loss maintenance among adolescents undergoing Roux-en-Y gastric bypass surgery are unknown.

SUBJECTS/METHODS

Fifty adolescents (mean±s.d. age and body mass index (BMI)=17.1±1.7 years and 59±11 kg m^-2) underwent Roux-en-Y gastric bypass surgery, had follow-up visits at 1 year and at a visit between 5 and 12 years following surgery (Follow-up of Adolescent Bariatric Surgery at 5 Plus years (FABS-5+) visit; mean±s.d. 8.1±1.6 years). A non-surgical comparison group (n=30; mean±s.d. age and BMI=15.3±1.7 years and BMI=52±8 kg m^-2) was recruited to compare weight trajectories over time. Questionnaires (health-related and eating behaviors, health responsibility, impact of weight on quality of life (QOL), international physical activity questionnaire and dietary habits via surgery guidelines) were administered at the FABS-5+ visit. Post hoc, participants were split into two groups: long-term weight-loss maintainers (n=23; baseline BMI=58.2 kg m^-2; 1-year BMI=35.8 kg m^-2; FABS-5+ BMI=34.9 kg m^-2) and re-gainers (n=27; baseline BMI=59.8 kg m^-2; 1-year BMI=36.8 kg m^-2; FABS-5+ BMI=48.0 kg m^-2) to compare factors which might contribute to differences. Data were analyzed using generalized estimating equations adjusted for age, sex, baseline BMI, baseline diabetes status and length of follow-up.

RESULTS

The BMI of the surgical group declined from baseline to 1 year (-38.5±6.9%), which, despite some regain, was largely maintained until FABS-5+ (-29.6±13.9% change). The BMI of the comparison group increased from baseline to the FABS-5+ visit (+10.3±20.6%). When the surgical group was split into maintainers and re-gainers, no differences in weight-related and eating behaviors, health responsibility, physical activity/inactivity, or dietary habits were observed between groups. However, at FABS-5+, maintainers had greater overall QOL scores than re-gainers (87.5±10.5 vs 65.4±20.2, P<0.001) and in each QOL sub-domain (P<0.01 all).

CONCLUSIONS

Long-term weight outcomes for those who underwent weight-loss surgery were superior to those who did not undergo surgical treatment. While no behavioral factors were identified as predictors of success in long-term weight-loss maintenance, greater QOL was strongly associated with maintenance of weight loss among adolescents who underwent Roux-en-Y gastric bypass surgery surgery.

Abstract WMP111: Socioeconomic Determinants of Outcome After Childhood Arterial Ischemic Stroke

Introduction: Lower socioeconomic status (SES) is associated with poorer outcome after adult stroke. In a large cohort of children with arterial ischemic stroke (AIS), we determined 12-month neurological outcome and tested the hypothesis that SES is a determinant of outcome in children.

Methods: From 2009-2014, the Vascular Effects of Infection in Pediatric Stroke (VIPS) study enrolled 355 children with AIS (29 days-18 years) at 37 international centers, including 3 in lower and middle income (LAMI) countries. Outcome was assessed at 12 months via the recurrence and recovery questionnaire (RRQ) parental report of the pediatric stroke outcome measure (PSOM). Poor outcome was defined as a PSOM of ≥1.

Results: Of 355 children, outcome was available for 310 (87%) at a median of 12 months (IQR 11-13). Ten children died prior to hospital discharge and 4 by 12 months. Outcomes improved from discharge to 12 months (Figure). Of 23 cases in LAMI countries, 88% had an income <USD$10,000, compared to 11% of 287 cases in non-LAMI countries. Overall, only 39% LAMI cases had a good outcome, versus 61% of non-LAMI cases (p=0.052). There were too few cases to analyze outcome predictors in LAMI countries. However, in non-LAMI countries, income did not independently predict poor outcome (OR 1.7, 95% CI 0.57, 4.8, for income <$10,000 vs. >$100,000). Other markers of SES (maternal education level and rural/suburban/urban residence) also did not predict outcome. Independent predictors of poor outcome included moderate (OR 4.6, 95% CI 2.0, 11) or severe (OR 21, 95% CI 7.1, 60) neurological deficits at discharge (compared to no deficits) and recurrent stroke (OR 3.5, 95% CI 1.5, 8.3).

Conclusion: Outcomes after childhood stroke may be worse in LAMI countries, although we were underpowered to study this subgroup. Within non-LAMI countries, SES does not appear to impact outcome in children, unlike reports in adults, perhaps reflecting better access to rehabilitation services in the pediatric population.

Prolonged or recurrent acute seizures after pediatric arterial ischemic stroke are associated with increasing epilepsy risk

AIM

To determine epilepsy risk factors after pediatric stroke.

METHOD

A cohort of children with arterial ischemic stroke (birth-18y) was enrolled at 21 centers and followed for 1 year. Acute seizures (≤7d after stroke) and active epilepsy (at least one unprovoked remote seizure plus maintenance anticonvulsant at 1y) were identified. Predictors were determined using logistic regression.

RESULTS

Among 114 patients (28 neonates and 86 children) enrolled, 26 neonates (93%) and 32 children (37%) had an acute seizure. Acute seizures lasted longer than 5 minutes in 23 patients (40%) and were frequently recurrent: 33 (57%) had 2 to 10 seizures and 11 (19%) had more than 10. Among 109 patients with 1-year follow-up, 11 (10%) had active epilepsy. For each year younger, active epilepsy was 20% more likely (odds ratio [OR] 0.8, 95% confidence interval [CI] 0.6-0.99, p=0.041). Prolonged or recurrent acute seizures also increased epilepsy risk. Each additional 10 minutes of the longest acute seizure increased epilepsy risk fivefold (OR 4.7, 95% CI 1.7-13). Patients with more than 10 acute seizures had a 30-fold increased epilepsy risk (OR 30, 95% CI 2.9-305).

INTERPRETATION

Pediatric stroke survivors, especially younger children, have a high risk of epilepsy 1 year after stroke. Prolonged or recurrent acute seizures increase epilepsy risk in a dose-dependent manner.

Indirect and direct revascularization of ACTA2 cerebral arteriopathy: feasibility of the superficial temporal artery to anterior cerebral artery bypass with posterior auricular artery interposition graft: case report

Mutations in the smooth muscle-specific isoform of alpha actin (ACTA2) cause smooth muscle dysfunction in arteries. This rare loss-of-function mutation may cause a diffuse occlusive cerebral arteriopathy, resulting in stroke. While ACTA2 arteriopathy is often described as moyamoya-like, it has a distinct phenotype characterized by dilation of the proximal internal carotid artery (ICA) and occlusion of the terminal ICA and proximal middle cerebral artery. Intracranial arteries have an abnormally straight course, often with small aneurysms. There is limited experience with revascularization procedures for ACTA2 arteriopathy, and the safety and efficacy of these procedures are unknown. In this paper the authors present a symptomatic 6-year-old patient with ACTA2 cerebral arteriopathy who underwent both indirect revascularization and direct cerebrovascular bypass. Postoperatively, the patient suffered an ischemic infarct in a neighboring vascular territory. While direct cerebrovascular bypass is technically feasible, patients with ACTA2 arteriopathy may be at increased risk for perioperative stroke compared with patients with moyamoya disease.

Inflammatory Biomarkers in Childhood Arterial Ischemic Stroke: Correlates of Stroke Cause and Recurrence

BACKGROUND AND PURPOSE

Among children with arterial ischemic stroke (AIS), those with arteriopathy have the highest recurrence risk. We hypothesized that arteriopathy progression is an inflammatory process and that inflammatory biomarkers would predict recurrent AIS.

METHODS

In an international study of childhood AIS, we selected cases classified into 1 of the 3 most common childhood AIS causes: definite arteriopathic (n=103), cardioembolic (n=55), or idiopathic (n=78). We measured serum concentrations of high-sensitivity C-reactive protein, serum amyloid A, myeloperoxidase, and tumor necrosis factor-α. We used linear regression to compare analyte concentrations across the subtypes and Cox proportional hazards models to determine predictors of recurrent AIS.

RESULTS

Median age at index stroke was 8.2 years (interquartile range, 3.6-14.3); serum samples were collected at median 5.5 days post stroke (interquartile range, 3-10 days). In adjusted models (including age, infarct volume, and time to sample collection) with idiopathic as the reference, the cardioembolic (but not arteriopathic) group had higher concentrations of high-sensitivity C-reactive protein and myeloperoxidase, whereas both cardioembolic and arteriopathic groups had higher serum amyloid A. In the arteriopathic (but not cardioembolic) group, higher high-sensitivity C-reactive protein and serum amyloid A predicted recurrent AIS. Children with progressive arteriopathies on follow-up imaging had higher recurrence rates, and a trend toward higher high-sensitivity C-reactive protein and serum amyloid A, compared with children with stable or improved arteriopathies.

CONCLUSIONS

Among children with AIS, specific inflammatory biomarkers correlate with cause and-in the arteriopathy group-risk of stroke recurrence. Interventions targeting inflammation should be considered for pediatric secondary stroke prevention trials.

Neonatal seizures triple the risk of a remote seizure after perinatal ischemic stroke

OBJECTIVES

To determine incidence rates and risk factors of remote seizure after perinatal arterial ischemic stroke.

METHODS

We retrospectively identified a population-based cohort of children with perinatal arterial ischemic stroke (presenting acutely or in a delayed fashion) from a large Northern Californian integrated health care system. We determined incidence and predictors of a remote seizure (unprovoked seizure after neonatal period, defined as 28 days of life) by survival analyses, and measured epilepsy severity in those with active epilepsy (≥1 remote seizure and maintenance anticonvulsant treatment) at last follow-up.

RESULTS

Among 87 children with perinatal stroke, 40 (46%) had a seizure in the neonatal period. During a median follow-up of 7.1 years (interquartile range 3.2-10.5), 37 children had ≥1 remote seizure. Remote seizure risk was highest during the first year of life, with a 20% (95% confidence interval [CI] 13%-30%) cumulative incidence by 1 year of age, 46% (CI 35%-58%) by 5 years, and 54% (CI 41%-67%) by 10 years. Neonatal seizures increased the risk of a remote seizure (hazard ratio 2.8, CI 1.3-5.8). Children with neonatal seizures had a 69% (CI 48%-87%) cumulative incidence of remote seizure by age 10 years. Among the 24 children with active epilepsy at last follow-up, 8 (33%) were having monthly seizures despite an anticonvulsant and 7 (29%) were on more than one anticonvulsant.

CONCLUSIONS

Remote seizures and epilepsy, including medically refractory epilepsy, are common after perinatal stroke. Neonatal seizures are associated with nearly 3-fold increased remote seizure risk.

Pediatric obesity pharmacotherapy: current state of the field, review of the literature and clinical trial considerations

Despite the increasing number of medications recently approved to treat obesity among adults, few agents have been formally evaluated in children or adolescents for this indication. Moreover, there is a paucity of guidance in the literature addressing best practices with regard to pediatric obesity pharmacotherapy clinical trial design, and only general recommendations have been offered by regulatory agencies on this topic. The purposes of this article are to (1) offer a background of the current state of the field of pediatric obesity medicine, (2) provide a brief review of the literature summarizing pediatric obesity pharmacotherapy clinical trials, and (3) highlight and discuss some of the unique aspects that should be considered when designing and conducting high-quality clinical trials evaluating the safety and efficacy of obesity medications in children and adolescents. Suggestions are offered in the areas of target population and eligibility criteria, clinical trial end-point selection, trial duration, implementation of lifestyle modification therapy and recruitment and retention of participants. Efforts should be made to design and conduct trials appropriately to ensure that high-quality evidence is generated on the safety and efficacy of various medications used to treat pediatric obesity.

Abstract WP201: Ischemic Stroke Risk After Traumatic Head or Neck Injury

Introduction: Traumatic arterial dissection is an important cause of ischemic stroke in the young, but data are needed to guide selection of trauma patients to screen with cerebrovascular imaging.

Hypothesis: Ischemic stroke risk after head or neck trauma can be stratified by demographic and clinical factors.

Methods: In a Northern California integrated health care system, we identified people (age < 50) with head or neck trauma from 1997-2011 by ICD-9 searches (800-806, 850-854; 873, 874, 900, 920, 925, 950-953; excluding fifth digit codes for injury below the neck). Ischemic strokes within 4 weeks were identified by ICD-9 (433-438) and confirmed by chart review. We randomly selected 3 controls per case from the remaining cohort. Characteristics potentially associated with stroke were abstracted and examined using logistic regression. Stroke incidence rates were calculated using survival analysis, right censoring at death or 4 weeks post-trauma.

Results: From 120,494 trauma encounters in the emergency department or for hospital admission, we confirmed 45 ischemic strokes related to head or neck trauma. The 4-week stroke incidence was 0.04% (95% CI 0.03-0.05%) (Figure: Kaplan-Meier stroke failure function and 95% CI). The majority of ischemic strokes occurred early after trauma, with 40% on the day of the trauma. Stroke risk was not associated with gender or race/ethnicity, but was age-related: for each decade older, stroke risk increased 70% (OR 1.7, 95% CI 1.4-2.2%, P<0.001). Any neck trauma (OR 14, 95% CI 4.9-42, P<0.0001 compared to those with isolated head trauma) and altered mental status on exam (OR 18, 95% CI 6.7-46, P < 0.0001) were also associated with increased risk of ischemic stroke. Neck trauma and altered mental status remained independently associated with ischemic stroke even after age-adjustment.

Conclusions: Trauma patients with neck injuries or altered mental status have elevated stroke risk and should be considered for cerebrovascular imaging.

Abstract WMP103: Epilepsy is Associated With Poorer Neurologic Outcome After Pediatric Arterial Ischemic Stroke

Introduction: Post-stroke epilepsy is common in children, but the relationship of childhood epilepsy with stroke outcome is poorly understood.

Hypothesis: Children with epilepsy after arterial ischemic stroke have worse outcomes than those without epilepsy.

Methods: We prospectively enrolled children (birth-18 years) with arterial ischemic stroke and identified remote seizures (occurring ≥ 7 days post-stroke). At one-year, patients with active epilepsy (≥ 1 remote seizure + maintenance anti-convulsant) were identified and Pediatric Stroke Outcome Measure (PSOM) was scored. Total PSOM scores range from 0-10; higher values reflect more severe neurologic deficits. Ordinal logistic regression was used to evaluate the relationship between clinical factors and PSOM scores. PSOM scores were categorized 0-1, 1.5-3, 3.5-6, 6.5-10 to depict stratified distribution.

Results: Among 94 children (54% male; 20% Hispanic; 25% neonatal strokes; median age for childhood strokes 6.1 years, IQR 1.3-12), 12 had ≥ 1 remote seizure during the first year post-stroke. At one-year follow-up, 19 children were taking a maintenance anti-convulsant and 10 children had active epilepsy. Median PSOM score at one-year for the overall cohort was 0.5 (IQR 0-1.5). Median PSOM score among children with active epilepsy was 3.3 (IQR 0.5-6). Figure demonstrates distribution of categorized PSOM scores stratified by the presence of active epilepsy. On univariable regression analyses, older age (OR 1.1, 95% CI 1.0-1.1, P=0.02), maintenance anti-convulsant at one-year (OR 2.7, 95% CI 1.0-7.0, P=0.04) and active epilepsy (OR 6.3, 95% CI 1.7-25, P=0.007) were associated with higher total PSOM scores. After multivariable adjustment for age and maintenance anti-convulsant, active epilepsy remained associated with higher total PSOM score (OR 7.8, 95% CI 1.3-46, P=0.02).

Conclusions: Active epilepsy one-year after pediatric arterial ischemic stroke is associated with poorer neurologic outcome.

Community-based case-control study of childhood stroke risk associated with congenital heart disease

BACKGROUND AND PURPOSE

A better understanding of the stroke risk factors in children with congenital heart disease (CHD) could inform stroke prevention strategies. We analyzed pediatric stroke associated with CHD in a large community-based case-control study.

METHODS

From 2.5 million children (aged <20 years) enrolled in a Northern California integrated healthcare plan, we identified children with ischemic and hemorrhagic strokes and randomly selected age- and facility-matched stroke-free controls (3 per case). We determined exposure to CHD (diagnosed before stroke) and used conditional logistic regression to analyze stroke risk factors.

RESULTS

CHD was identified in 15 of 412 cases (4%) versus 7 of 1236 controls (0.6%). Cases of childhood stroke (occurring between ages 29 days to 20 years) with CHD had 19-fold (odds ratio, 19; 95% confidence interval 4.2-83) increased stroke risk compared to controls. History of CHD surgery was associated with >30-fold (odds ratio, 31; confidence interval 4-241) increased risk of stroke in children with CHD when compared with controls. After excluding perioperative strokes, the history of CHD surgery still increased the childhood stroke risk (odds ratio, 13; confidence interval 1.5-114). The majority of children with stroke and CHD were outpatients at the time of stroke, and almost half the cases who underwent cardiac surgery had their stroke >5 years after the most recent procedure. An estimated 7% of ischemic and 2% of hemorrhagic childhood strokes in the population were attributable to CHD.

CONCLUSIONS

CHD is an important childhood stroke risk factor. Children who undergo CHD surgery remain at elevated risk outside the perioperative period and would benefit from optimized long-term stroke prevention strategies.

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.

Abstract T MP66: Injury to the Head or Neck Increases Risk of Ischemic Stroke Three-fold After Trauma

Background: Over 2 million people under age 50 are seen in a U.S. emergency room monthly for non-fatal injuries. Our objective was to measure ischemic stroke incidence after traumatic injury in young patients and identify stroke risk factors.

Methods: We performed a population-based study of ischemic stroke after trauma among people <50 years old in a Northern Californian integrated health care system. We electronically identified a cohort of patients with diagnostic codes for trauma (ICD-9 800-959.9) in emergency and inpatient encounters from 1997-2011, then identified ischemic stroke outcomes within 4 weeks. To determine stroke, we required an ICD-9 stroke code (433-438) plus a radiology report of brain imaging containing a keyword: stroke, infarct#, thromb#, ischemi#, lacun#, or dissect#. A neurologist reviewed the reports to exclude those inconsistent with ischemic stroke. We obtained clinical data such as injury type from electronic databases to calculate stratified incidence rates and risk ratios.

Results: From 1.5 million trauma encounters, we identified 197 ischemic strokes. The 4-week stroke incidence after any traumatic injury was 0.013% (95% CI 0.011, 0.015). Patients with stroke had a mean age of 37.7 years (SD 12.2) versus 24.0 years (SD 13.8) in those without stroke (P<0.0001). Patients with injury to the head or neck were more likely to have a stroke compared to those with other types of injuries (Table). The 4-week stroke incidence after head or neck injury was 0.07% (95% CI 0.05, 0.09) among adults and 0.005% (95% CI 0.001, 0.01) among children (P<0.0001). Of the 197 stroke cases, 16% (95% CI 11, 22) had a diagnostic code for cranio-cervical dissection.

Conclusions: A 4-week stroke incidence of 0.013% suggests that 260 young people have an ischemic stroke after a traumatic injury every month in the U.S. Further research is needed to identify the highest risk groups, such as those with head or neck injury, and opportunities for stroke prevention.

Acute seizures predict epilepsy after childhood stroke

OBJECTIVE

To determine incidence rates and predictors of epilepsy after childhood stroke and compare these to published estimates of 3 to 5% cumulative epilepsy incidence by 5 years poststroke in adults.

METHODS

In a retrospective population-based study of children with stroke (29 days-19 years) in an integrated health care system (1993-2007), poststroke seizures were identified through electronic searches and confirmed by chart review. Stroke and seizure characteristics were abstracted from medical records. Survival analysis was used to determine rates and predictors of remote seizures and active epilepsy (anticonvulsant treatment for remote seizure within prior 6 months) at last follow-up.

RESULTS

From a population of 2.5 million children, we identified 305 stroke cases. Over a median follow-up of 4.1 years (interquartile range = 1.8-6.8), 49 children had a first unprovoked remote seizure. The average annual incidence rate of first remote seizure was 4.4% (95% confidence interval [CI] = 3.3-5.8) with a cumulative risk of 16% (95% CI = 12-21) at 5 years and 33% (95% CI = 23-46) at 10 years poststroke. The cumulative risk of active epilepsy was 13% (95% CI = 9-18) at 5 years and 30% (95% CI = 20-44) at 10 years. Acute seizures at the time of stroke predicted development of active epilepsy (hazard ratio = 4.2, 95% CI = 2.2-8.1). At last follow-up, ⅓ of the children with active epilepsy had a recent breakthrough seizure despite anticonvulsant usage.

INTERPRETATION

Unlike adults, children are uniquely vulnerable to epilepsy after stroke. Children with acute seizures at the time of stroke are at particularly high risk.

High critical care usage due to pediatric stroke: results of a population-based study

OBJECTIVES

To measure intensive care unit (ICU) admission, intubation, decompressive craniotomy, and outcomes at discharge in a large population-based study of children with ischemic and hemorrhagic stroke.

METHODS

In a retrospective study of all children enrolled in a Northern Californian integrated health care plan (1993-2003), we identified cases of symptomatic childhood stroke (age >28 days through 19 years) from inpatient and outpatient electronic diagnoses and radiology reports, and confirmed them through chart review. Data regarding stroke evaluation, management, and outcomes at discharge were abstracted. Intensive care unit (ICU) admission, intubation, and decompressive neurosurgery rates were measured, and multivariate logistic regression was used to identify predictors of critical care usage and outcomes at discharge.

RESULTS

Of 256 cases (132 hemorrhagic and 124 ischemic), 61% were admitted to the ICU, 32% were intubated, and 11% were treated with a decompressive neurosurgery. Rates were particularly high among children with hemorrhagic stroke (73% admitted to the ICU, 42% intubated, and 19% received a decompressive neurosurgery). Altered mental status at presentation was the most robust predictor for all 3 measures of critical care utilization. Neurologic deficits at discharge were documented in 57%, and were less common after hemorrhagic than ischemic stroke: 48% vs 66% (odds ratio 0.5, 95% confidence interval 0.3-0.8). Case fatality was 4% overall, 7% among children admitted to the ICU, and was similar between ischemic and hemorrhagic stroke.

CONCLUSIONS

ICU admission is frequent after childhood stroke and appears to be justified by high rates of intubation and surgical decompression.

Abstract 41: Acute Seizures and Neurologic Deficits Predict Epilepsy After Pediatric Stroke

Background: Epilepsy may be frequent after pediatric stroke. However, current incidence estimates are from tertiary referral centers and vary widely, and little is known about its risk factors.

Methods: We performed a population-based study of epilepsy within a cohort of children with stroke (birth-20 years) enrolled in a Northern California integrated health care system, from January 1993 through December 2007, to determine epilepsy incidence rates and predictors. Children with symptomatic ischemic and hemorrhagic stroke surviving to hospital discharge were included in the analysis. Seizures were identified using clinical databases, and epilepsy diagnoses were confirmed by independent record review by two neurologists with arbitration by a third. Based on International League Against Epilepsy proposed guidelines, epilepsy was defined as a confirmed unprovoked seizure > 30 days after stroke. Survival analysis was used to determine rates and predictors of epilepsy after stroke. Using multivariable analysis, hazard ratios (HR) were adjusted for gender, age (neonatal versus later childhood), stroke subtype (ischemic versus hemorrhagic), outcome at hospital discharge, and acute seizures at the time of stroke.

Results: From an initial study population of 2.4 million children, 371 children with stroke were included. Of these, 110 cases were neonatal and 261 were later childhood; 226 were ischemic and 145 were hemorrhagic. At stroke ictus, 36% had an acute seizure, and 66% had a neurologic deficit at hospital discharge. Median length of follow-up was 4.5 years (IQR 1.9-8.6). Post-stroke epilepsy occurred in 89 subjects. The average annual incidence rate of epilepsy was 6.4% (95% CI 5.2%, 8%), with a 5-year cumulative risk of 25% (95% CI 20%, 30%) and 10 year cumulative risk of 40% (95% CI 32%, 51%) ( Figure ). Predictors of epilepsy included neurologic deficit at hospital discharge (HR 1.8, 95% CI 1.07-3) and seizure at stroke ictus (HR 4.1, 95% CI 2.6-6.5) ( Figure ), but not gender, age or stroke subtype.

Conclusions: Epilepsy is common after stroke in children. Those with seizures at onset of stroke are at particularly high risk, in keeping with animal models of epileptogenesis and recent studies of human neonatal hypoxic ischemic brain injury. Future studies are needed to further identify children at greatest risk for post-stroke epilepsy.

Figure.

Recent advances in childhood arterial ischemic stroke

Although many underlying diseases have been reported in the setting of childhood arterial ischemic stroke, emerging research demonstrates that non-atherosclerotic intracerebral arteriopathies in otherwise healthy children are prevalent. Minor infections may play a role in arteriopathies that have no other apparent underlying cause. Although stroke in childhood differs in many aspects from adult stroke, few systematic studies specific to pediatrics are available to inform stroke management. Treatment trials of pediatric stroke are required to determine the best strategies for acute treatment and secondary stroke prevention. The high cost of pediatric stroke to children, families, and society demands further study of its risk factors, management, and outcomes. This review focuses on the recent findings in childhood arterial ischemic stroke.