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BackgroundMethodResultsInterpretationMuch of the childhood stroke literature has not distinguished impacts for adolescents from those of younger children. Research has also focused on body impairments. With adolescence being a unique period, this scoping review aimed to identify the impacts of childhood stroke on activity, participation, and quality of life for adolescents 13–18 years, and identify how these impacts were determined.This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Data pertaining to non-impairment impacts of childhood stroke for adolescents, participant and study characteristics, and measurement instruments were extracted.Following screening, 79 articles were included, and 33 measurement instruments identified. Only 6 studies reported separate data for adolescents, identifying difficulties with daily activities, social and academic impacts, and reduced quality of life. Impacts of post-stroke communication difficulties on daily activities and schooling were also noted. Measurement instruments developed specifically for adolescents with stroke are lacking.The review identified limited research reporting non-impairment impacts of childhood stroke for adolescents. Further research specific to this population and the development of measurement instruments for adolescents who have experienced childhood stroke is required to support future research and clinicians working with this population. [ABSTRACT FROM AUTHOR]

AbstractPurposeMethodsResultsInterpretation\nIMPLICATIONS FOR REHABILITATIONThis scoping review aimed to inform future research priorities by collating evidence on neural correlates of speech and language recovery following childhood stroke.Neuroimaging, motor speech, or language outcomes following childhood stroke (28 days to 18 years age) in the subacute to chronic community stages (care occurring after acute medical management, including inpatient and outpatient rehabilitation, and community-based programs) were identified and extracted from Medline, Embase, PsycInfo, and Clinical databases.Of the 3990 studies screened, 11 met the inclusion criteria. Of the included articles, no papers formally assessed speech outcomes, 11 articles reported language outcomes through standardized testing, 11 utilized structural imaging (CT, MRI), and four reported functional neuroimaging outcomes (fMRI).This review revealed a rudimentary accounting of speech and language profiles in children post-stroke; limited by the use of varied and incomplete speech and language assessment batteries, inconsistent reporting of lesion locations associated with speech and language outcomes, a dearth of functional neuroimaging studies, and lack of information about speech and language function throughout the rehabilitation period, a time when the brain is most plastic and receptive to therapy. Future research should provide complete and accurate accounts of speech and language function and their neural correlates throughout rehabilitation and recovery to inform care, education, and employment planning.Although stroke is a top 10 cause of mortality in children, the current literature contains a rudimentary accounting of the speech and language profiles, and their neural correlates, following stroke in children.For rehabilitation professionals, our review demonstrates the need for comprehensive speech and language assessment in the subacute stage of recovery from childhood stroke.A complete and accurate account of speech and language functions, and their neural correlates, spanning recovery from childhood stroke is needed to inform clinical care.Although stroke is a top 10 cause of mortality in children, the current literature contains a rudimentary accounting of the speech and language profiles, and their neural correlates, following stroke in children.For rehabilitation professionals, our review demonstrates the need for comprehensive speech and language assessment in the subacute stage of recovery from childhood stroke.A complete and accurate account of speech and language functions, and their neural correlates, spanning recovery from childhood stroke is needed to inform clinical care. [ABSTRACT FROM AUTHOR]

Purpose: We present a case of an ischemic retinopathy with severe vision loss secondary to a childhood stroke. Methods: Case report. Results: An otherwise healthy 9-year-old girl presented with a 1-day history of impaired gait and speech. After performing computed tomography and magnetic resonance imaging, thrombosis of the left internal carotid artery was observed and a diagnosis of ischemic stroke was established. Serological autoimmune, coagulation, and viral panels were unrewarding. Cardiac, inflammatory, and coagulation disorders were ruled out. The cause was attributed to a focal cerebral arteriopathy, a common cause of childhood stroke. The patient was treated with mechanical thrombectomy followed by anticoagulation. The day after, the patient referred vision loss of 20/100 in the left eye. Fundus evaluation of the left eye depicted diffuse intraretinal hemorrhages and cotton-wool spots and there was retinal whitening at the posterior pole. Six weeks after, VA dropped to counting fingers. Conclusion: A macular optical coherence tomography revealed diffuse atrophic changes in the inner retinal layers at the macula, and the angio-optical coherence tomography showed an enlarged foveal avascular zone. We propose ischemiareperfusion as the primary explanation of this unusual event. [ABSTRACT FROM AUTHOR]

Childhood stroke can lead to lifelong disability. Developing algorithms for timely recognition of clinical and paraclinical signs is crucial to ensure prompt stroke diagnosis and minimize decision-making time. This study aimed to characterize clinical and paraclinical symptoms of childhood and neonatal stroke as relevant diagnostic criteria encountered in clinical practice, in order to develop algorithms for prompt stroke diagnosis. The analysis included data from 402 pediatric case histories from 2010 to 2016 and 108 prospective stroke cases from 2017 to 2020. Stroke cases were predominantly diagnosed in newborns, with 362 (71%, 95% CI 68.99–73.01) cases occurring within the first 28 days of birth, and 148 (29%, 95% CI 26.99–31.01) cases occurring after 28 days. The findings of the study enable the development of algorithms for timely stroke recognition, facilitating the selection of optimal treatment options for newborns and children of various age groups. Logistic regression serves as the basis for deriving these algorithms, aiming to initiate early treatment and reduce lifelong morbidity and mortality in children. The study outcomes include the formulation of algorithms for timely recognition of newborn stroke, with plans to adopt these algorithms and train a fuzzy classifier-based diagnostic model using machine learning techniques for efficient stroke recognition. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

ObjectivesThis study aims to investigate the long-term language outcome in children with unilateral childhood stroke in comparison to those with perinatal strokes and typically developing individuals and to explore the impact of lesion-specific modifiers.MethodsWe examined nine patients with childhood stroke, acquired between 0;2 and 16;1 years (CHILD; 3 female, median = 13.5 years, 6 left-sided), 23 patients with perinatal strokes (PERI; 11 female, median = 12.5 years, 16 left-sided), and 33 age-matched typically developing individuals (CONTROL; 15 female, median = 12.33 years). The language outcome was assessed using age-appropriate tasks of the Potsdam Illinois Test of Psycholinguistic Abilities (P-ITPA) or the Peabody Picture Vocabulary Test (PPVT). For group comparisons, study-specific language z-scores were calculated. Non-verbal intelligence was assessed using the Test of Non-verbal Intelligence (TONI-4), language lateralization with functional MRI, and lesion size with MRI-based volumetry.ResultsAll four patients with childhood stroke who initially presented with aphasic symptoms recovered from aphasia. Patients with childhood stroke showed significantly lower language scores than those in the control group, but their scores were similar to those of the patients with perinatal stroke, after adjusting for general intelligence (ANCOVA, language z-score CHILD = −0.30, PERI = −0.38, CONTROL = 0.42). Among the patients with childhood stroke, none of the possible modifying factors, including lesion side, correlated significantly with the language outcome.ConclusionChildhood stroke, regardless of the affected hemisphere, can lead to chronic language deficits, even though affected children show a “full recovery.” The rehabilitation of children and adolescents with childhood stroke should address language abilities, even after the usually quick resolution of clear aphasic symptoms.

Purpose: To provide an overview of the effects of pediatric stroke on emotional and social functioning in childhood. Methods: A literature review was completed in accordance with the Preferred Reporting Items for Systematic Reviews. A systematic search of studies on internalizing problems and social functioning after pediatric stroke in PsycInfo, PsycArticles, and PubMed databases was conducted from inception to November 2021. A total of 583 studies were identified, and 32 met the inclusion criteria. Results: The review suggests that children after stroke are at risk of developing internalizing problems and a wide range of social difficulties. Internalizing problems are often associated with environmental factors such as family functioning and parents' mental health. In addition, a higher risk of developing psychosocial problems is associated with lower cognitive functioning and severe neurological impairment. Conclusions: The assessment of psychological well-being and social functioning after pediatric stroke is helpful to provide adequate support to children and their families. Future studies are needed to better investigate these domains and to develop adequate methodologies for specific interventions. [ABSTRACT FROM AUTHOR]

Despite an increase in the number of genes associated with pediatric stroke, imaging phenotypes in children have not been well reported. Guidelines are needed to facilitate the identification and treatment of patients with monogenic causes of cerebrovascular disorders. We performed a retrospective review of imaging and medical records of patients aged zero to 21 years with monogenic causes of vascular malformations, small or large vessel disease, transient ischemic attacks, and/or ischemic or hemorrhagic stroke. We classified patients according to their imaging phenotype and reviewed neurological and systemic features and management strategies. We reviewed the literature to identify genes associated with cerebrovascular disorders presenting in childhood. We identified 18 patients with monogenic causes of cerebrovascular disorders and classified each patient as belonging to one or more of three cerebrovascular phenotypes according to predominant imaging characteristics: small vessel disease, large vessel disease, and/or vascular malformations. Preventative treatments included aspirin, N -acetylcysteine, tocilizumab, therapeutic low-molecular-weight heparin, and resection of vascular malformations. Classifying pediatric patients with cerebrovascular disorders by imaging phenotype can aid in determining the next steps in genetic testing and treatment. [ABSTRACT FROM AUTHOR]

Pediatric stroke, which is unique in that it represents a static insult to a developing brain, often leads to long-term neurological disability. Neuroplasticity in infants and children influences neurophysiologic recovery patterns after stroke; therefore outcomes depend on several factors including the timing and location of stroke and the presence of comorbid conditions. In this review, we discuss the unique implications of stroke occurring in the fetal, perinatal, and childhood/adolescent time periods. First, we highlight the impact of the developmental stage of the brain at the time of insult on the motor, sensory, cognitive, speech, and behavioral domains. Next, we consider the influence of location of stroke on the presence and severity of motor and nonmotor outcomes. Finally, we discuss the impact of associated conditions on long-term outcomes and risk for stroke recurrence. Hemiparesis is common after stroke at any age, although the severity of impairment differs by age group. Risk of epilepsy is elevated in all age groups compared with those without stroke. Outcomes in other domains vary by age, although several studies suggest worse cognitive outcomes when stroke occurs in early childhood compared with fetal and later childhood epochs. Conditions such as congenital heart disease, sickle cell disease, and moyamoya increase the risk of stroke and leave patients differentially vulnerable to neurodevelopmental delay, stroke recurrence, silent infarcts, and cognitive impairment. A comprehensive understanding of the interplay of various factors is essential in guiding the clinical care of patients with pediatric stroke. [ABSTRACT FROM AUTHOR]

Rationale: Early evidence for the benefit of mechanical thrombectomy (MT) in pediatric patients with intracranial large vessel occlusion has been shown in previous retrospective cohorts. Higher-level evidence is needed to overcome the limitations of these studies such as the lack of a control group and the retrospective design. Randomized trials will very likely not be feasible, and several open questions remain, for example, the impact of arteriopathic etiologies or a possible lower age limit for MT. Save ChildS Pro therefore aims to demonstrate the safety and effectiveness of MT in pediatric patients compared to the best medical management and intravenous thrombolysis. Design: Save ChildS Pro is designed as a worldwide multicenter prospective registry comparing the safety and effectiveness of MT to the best medical care alone in the treatment of pediatric arterial ischemic stroke (AIS). It will include pediatric patients (

Childhood stroke can lead to lifelong disability. Developing algorithms for timely recognition of clinical and paraclinical signs is crucial to ensure prompt stroke diagnosis and minimize decision-making time. This study aimed to characterize clinical and paraclinical symptoms of childhood and neonatal stroke as relevant diagnostic criteria encountered in clinical practice, in order to develop algorithms for prompt stroke diagnosis. The analysis included data from 402 pediatric case histories from 2010 to 2016 and 108 prospective stroke cases from 2017 to 2020. Stroke cases were predominantly diagnosed in newborns, with 362 (71%, 95% CI 68.99–73.01) cases occurring within the first 28 days of birth, and 148 (29%, 95% CI 26.99–31.01) cases occurring after 28 days. The findings of the study enable the development of algorithms for timely stroke recognition, facilitating the selection of optimal treatment options for newborns and children of various age groups. Logistic regression serves as the basis for deriving these algorithms, aiming to initiate early treatment and reduce lifelong morbidity and mortality in children. The study outcomes include the formulation of algorithms for timely recognition of newborn stroke, with plans to adopt these algorithms and train a fuzzy classifier-based diagnostic model using machine learning techniques for efficient stroke recognition.

Objectives. To perform a comparative analysis of symptoms in arterial ischemic stroke (AIS) and stroke-like conditions in children and to develop and analyze the Suspected Stroke Scale in Children for prehospital diagnosis of AIS in children (referred to as the Scale). Materials and methods. Emergency hospitalizations of children at the Stroke Center with suspected cerebrovascular pathology were analyzed. Symptoms detected in patients with suspected AIS were analyzed, referral and final diagnoses were compared, and the main maskers of stroke and their symptomatologies were identified. Data were compared with results obtained at an earlier phase in this research. Results. The study results suggest a predominance of motor and coordination disorders in AIS and cerebral symptoms in stroke-like conditions in children. The most common stroke masker was migraine. The study results led to proposal of the Scale, and preliminary assessment of the effectiveness of the Scale was carried out using examples of confirmed cases of AIS and stroke maskers. Conclusions. Prompt hospitalization of children with AIS can not only reduce mortality, but also allows up-to-date diagnostic and treatment methods to be used to reduce the extent of brain damage and provide the opportunity for complete restoration of motor and cognitive functions. Further analysis of the sensitivity and specificity of the proposed Scale is needed. [ABSTRACT FROM AUTHOR]

This study aimed to gain insight into the experiences in adolescence of people with aphasia following childhood stroke. Adolescence is a unique period of developmental changes, yet little is known about the impacts of childhood stroke and aphasia during this critical period. With YouTube emerging as an information sharing platform for adolescents, the perspectives shared by YouTubers who have experienced aphasia during adolescence can provide insight into lived experiences. Eleven videos were identified on YouTube via keyword searches. Included videos contained YouTubers' reports of childhood stroke and impacts of aphasia and/or stroke related language difficulties during adolescence (13–17 years). Videos were transcribed verbatim and analysed with reflexive thematic analysis. Five themes were generated from analysis. These themes revealed the various impairments adolescents experienced after their unexpected stroke, including language difficulties such as word finding, reading, and writing difficulties. The YouTubers shared sources that aided their recovery, aspirations for the future, and their desire to raise awareness of stroke and aphasia in adolescents. The perspectives identified can inform person-centred and tailored care for adolescents with aphasia after childhood stroke. Further, the need for increased public education about stroke and aphasia specifically during adolescence has been highlighted. [ABSTRACT FROM AUTHOR]

Though rare, stroke in infants and children is an important cause of mortality and chronic morbidity in the pediatric population. Neuroimaging advances and implementation of pediatric stroke care protocols have led to the ability to rapidly diagnose stroke and in many cases determine the stroke etiology. Though data on efficacy of hyperacute therapies, such as intravenous thrombolysis and mechanical thrombectomy, in pediatric stroke are limited, feasibility and safety data are mounting and support careful consideration of these treatments for childhood stroke. Recent therapeutic advances allow for targeted stroke prevention efforts in high-risk conditions, such as moyamoya, sickle cell disease, cardiac disease, and genetic disorders. Despite these exciting advances, important knowledge gaps persist, including optimal dosing and type of thrombolytic agents, inclusion criteria for mechanical thrombectomy, the role of immunomodulatory therapies for focal cerebral arteriopathy, optimal long-term antithrombotic strategies, the role of patent foramen ovale closure in pediatric stroke, and optimal rehabilitation strategies after stroke of the developing brain. [ABSTRACT FROM AUTHOR]

Background: Lacunar strokes in the pediatric population are very uncommon, as well as trauma-induced strokes. It is extremely rare for a head trauma induced ischaemic stroke to occur in children and young adults. Case report: We describe a case of a 13-year-old boy who reported acute ischaemic lesions, and in particular a right basal ganglia ischaemic stroke after falling from a height of 10 m, presumably secondary to the stretching-induced occlusion of the recurrent artery of Heubner, with a favorable outcome. Conclusion: Ischaemic strokes can rarely be subsequent to head trauma in young adults, in relationship with the degree of maturity of the perforating vessels. Although very rare, it is important to avoid the lack of recognition of this condition, thus awareness is necessary.

Background: Quantitative lesion net water uptake (NWU) has been described as an imaging biomarker reflecting vasogenic edema as an early indicator of infarct progression. We hypothesized that edema formation measured by NWU is higher in children compared to adults but despite this functional outcome may be better in children. Methods: This study analyzed children enrolled in the Save ChildS Study who had baseline and follow‐up computed tomography available and the data were compared to adult patients. Results: Some 207 patients, of whom 13 were children and 194 were adults, were analyzed. Median NWU at baseline was 7.8% (IQR: 4.3–11.3), and there were no significant differences between children and adults (7.5% vs. 7.8%; p = 0.87). The early edema progression rate was 3.0%/h in children and 2.3%/h in adults. Median ΔNWU was 15.1% in children and 10.5% in adults. Children had significantly more often excellent (mRS 0–1; children 10/13 = 77% vs. adults 28/196 = 14%; p < 0.0001) and favorable clinical outcomes (mRS 0–2, 12/13 = 92% vs. 39/196 = 20%; p < 0.0001). Conclusions: In this study, clinical outcomes in children with large vessel occlusion strokes were better than in adults despite similar clinical and imaging characteristics and similar edema formation. This may be impacted by the generally better outcomes of children after strokes but may demonstrate that the degree of early ischemic changes using Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and edema progression rate may not be a reason for exclusion from endovascular thrombectomy. [ABSTRACT FROM AUTHOR]

Due to the rare occurrence of childhood stroke, its impact on later cognitive functioning remains unclear. While it is often assumed that children recover better than adults, recent studies suggest that childhood stroke can negatively affect a wide range of cognitive domains, such as attention, language, and processing speed, among others. We examined the effect of unilateral stroke on children's visuoconstructive ability and visual memory. Seventeen children with left- or right-sided arterial ischemic stroke were tested using subtests of the Hamburg-Wechsler Intelligenztest für Kinder and the Rey-Osterrieth Complex Figure (ROCF). The ROCF was evaluated both quantitatively and qualitatively with the help of two separate scoring methods. We found that lesion laterality and age at stroke impacted childhood stroke patients' ability to recall certain elements of the figure. Regarding lesion laterality, left-sided stroke patients had more difficulties recalling internal details than right-sided stroke patients. In terms of age, patients with stroke onset before the age of 5 years remembered fewer structural elements than patients with stroke onset after the age of 5 years did. Moreover, the qualitative scoring method better differentiated between individuals and between groups than the more commonly used quantitative method. The results of this study not only highlight the importance of a qualitative assessment of the ROCF but could also aid clinicians in testing stroke patients more accurately and tailoring subsequent therapy to the patient's individual needs. • Childhood stroke impacts visuospatial processing. • Left-sided stroke patients demonstrate poorer visuoconstructive abilities. • Earlier stroke onset negatively influences patients' task performance. • Qualitative assessment detects subtle intra- and intergroup differences. [ABSTRACT FROM AUTHOR]

Moyamoya Angiopathy (MMA) is a chronic, progressive intracranial vasculopathy. Unlike Sickle-cell-disease, thalassemia-syndrome has rarely been described in association with MMA. This study was aimed to analyze the demographic, clinical, radiological features and long-term outcome (and possible factors influencing prognosis) of Moyamoya Syndrome (MMS) in the largest cohort of thalassemia-related-to-MMS. A single-centered, observational study with longitudinal follow-up was undertaken for 12 cases of MMS-related-to-thalassemia-syndrome amongst 160 consecutive MMA patients. The baseline demographic, clinical and radiological characteristics were noted; and were longitudinally followed-up to assess disease progression (clinical or radiological). Fifteen previously reported cases of thalassemia and MMA were retrieved by literature search in PubMed and Google-Scholar using keywords "Moyamoya" AND "thalassemia". The mean age at diagnosis of thalassemia-syndrome and diagnosis of MMS were 6.4 ± 6.55 years (mean ± SD) and 10.4 ± 8.68 years respectively in our 12 cases; 3.2 ± 2.25 years and 10.6 ± 6.1 years respectively in the previously reported 15 cases. Cerebral ischemic insult was the predominant brain lesion at base-line, noted in 91.7% of our cases and 80% of the previous cases. The mean hemoglobin, transfusion-dependency and previous splenectomy were seen in 8.7 ± 3.02 gm%, 33.3% and 8.3% of our cases respectively; 7.0 ± 3.04 gm%, 53.9% and 18.2% of previous cases. All our cases were medically managed for mean follow-up of 28.3 ± 13.9 months, none had evidence of angiographic progression, 1 of our 12 cases (8.3%) had new onset neuro-deficit and subsequent mortality, rest 11 of the 12 cases (91.7%) didn't have any appearance of silent cerebral infarction or evidence of progression of brain atrophy. Among the 15 previous cases, 5 out of 9 medically managed cases and 1 revascularized case described no further clinical recurrence. Thalassemia-related-MMS may not be so rare. Future development of consensus guidelines in diagnosing and managing cases of MMS-associated-with-thalassemia is of essence. • Thalassemia related MMS may not be so rare, probably under-recognized compared to SCD. • The pathophysiological basis between the MMS & thalassemia remains to be deciphered. • Cerebral ischemic insult was the predominant brain lesion. • Thalassemia type, severity of anemia & transfusion dependency can affect prognosis. • Consensus guideline for diagnosis & management of Thalassemia related MMS is needed. [ABSTRACT FROM AUTHOR]

Background Haemorrhagic stroke (HS) accounts for nearly half of the paediatric strokes. The aetiology of HS in childhood is not well defined in the Indian context. Objectives To study the aetiological profile and short-term neurological outcome of children with HS from North India. Methods In a prospective observational study, consecutive patients >28 days to <12 years of age admitted with a diagnosis of HS were enrolled. Demography, clinical, radiological details and investigations were recorded. Short-term outcomes were assessed at three months follow-up with the Paediatric Cerebral Performance Category scale and Paediatric Stroke Outcome Measure (PSOM). Results A total of 48 children with HS were enrolled. The median age was 6 months (1–58 months), and 33 (69%) were <2 years old. Vitamin K deficiency-related bleeding disorder (VKDB, 44%), central nervous system infections (19%), arteriovenous malformations (13%) and inherited coagulation disorders (8%) were the most common risk factors for HS. VKDB and inherited coagulation disorders were more frequent in children <2 years of age, and arteriovenous malformations were more frequent in children >2 years of age (p  = 0.001). During hospitalization, 21 (44%) children died. Older age, low Glasgow coma score (<8) at admission and paediatric intracerebral haemorrhage score ≥2 were associated with mortality at discharge (p  = <0.05). Among survivors, 15 (56%) children had neurological deficits (PSOM >0.5) at three month follow-up. Conclusion VKDB, inherited coagulation disorders, central nervous system infections and arteriovenous malformations were the most common risk factors for HS. VKDB is the single most important preventable risk factor for HS in infants. [ABSTRACT FROM AUTHOR]

The safety and efficacy of hyperacute reperfusion therapies in childhood stroke due to focal cerebral arteriopathy (FCA) with an infectious and inflammatory component is unknown. Lyme neuroborreliosis (LNB) is reported as a rare cause of childhood stroke. Intravenous thrombolysis (IVT) and endovascular therapy (EVT) have not been reported in LNB-associated stroke in children. We report two children with acute stroke associated with LNB who underwent hyperacute stroke treatment. A systematic review of the literature was performed to identify case reports of LNB-associated childhood stroke over the last 20 years. Patient 1 received IVT within 73 min after onset of acute hemiparesis and dysarthria; medulla oblongata infarctions were diagnosed on magnetic resonance imaging (MRI). Patient 2 received successful EVT 6.5 hr after onset of progressive tetraparesis, coma, and decerebrate posturing caused by basilar artery occlusion with bilateral pontomesencephalic infarctions. Both patients exhibited a lymphocytic cerebrospinal fluid (CSF) pleocytosis and elevated antibody index (AI) to Borrelia burgdorferi. Antibiotic treatment, steroids, and platelet inhibitors including tirofiban infusion in patient 2 were administered. No side effects were observed. On follow-up, patient 1 showed good recovery and patient 2 was asymptomatic. In the literature, 12 cases of LNB-associated childhood stroke were reported. LNB-associated infectious and inflammatory FCA is not a medical contraindication for reperfusion therapies in acute childhood stroke. Steroids are discussed controversially in inflammatory FCA due to LNB. Intensified antiplatelet regimes may be considered; secondary prophylaxis with acetyl-salicylic acid (ASA) is recommended because of a high risk of early stroke recurrence. [ABSTRACT FROM AUTHOR]

Introduction: Moyamoya angiopathy (MMA) is a chronic, progressive intracranial vasculopathy with variation in prevalence and clinical manifestations across different populations. This study was aimed to estimate the frequency of MMA as an etiology of stroke and its epidemiological features in the largest cohort of MMA patients in India. Method: A single-centered cross-sectional observational study over a period of 5 years (2016–2021) was undertaken among consecutive stroke and transient ischemic attack (TIA) patients to look for the presence of MMA angiographically. Each patient with angiographically proven MMA was further evaluated for demographic, clinical, and radiological characteristics. Results: Among 10,250 consecutive stroke and TIA patients (ischemic = 78%, hemorrhagic = 22%), frequency of MMA was 1.56% (n = 160); 15.3% among children. Female preponderance (Male:Female = 1:1.4) was noted among 160 MMA patients, with bimodal age distribution, first peak at 3–8 years, and a shorter second peak at 41–47 years. Childhood-onset MMA was seen in 75 (46.9%) with commonest initial neurological symptom of fixed-motor-weakness (44.0%), followed by TIA (26.7%); while 85 (53.1%) had adult-onset MMA with fixed-motor-weakness (50.6%) followed by headache (24.7%) as the predominant initial neurological symptom; seizure significantly higher in children (p < 0.001) and headache in adults (p = 0.012). Transient and fixed neurological manifestations constituted 87.5 and 69.4% respectively, of symptoms throughout the disease course. Cerebral infarction (45.0%) and TIA (21.9%) were the commonest types of MMA. On brain imaging, infarction was noted in 80.6%, hemorrhage in 11.3%, significantly higher among adults (p < 0.001). Cortical infarct and Gyral pattern were commoner in children (p = 0.004), subcortical infarcts in adults (p = 0.018). Frequent Suzuki staging observed was stage 4 (31.3%), followed by stage 3 (30.0%). Involvement of posterior circulation was detected in 55.6%, brain atrophy at the time of diagnosis was seen in 65.0%. Conclusion: MMA is an important etiological consideration in patients with stroke, especially in children. It can present with a myriad of transient neurological symptoms, frequently overlooked, leading to delayed diagnosis, and contributing to socio-economic burden. Indian MMA showed aberrations in its gender predisposition, age distribution, frequency of familial cases, disease manifestation, and type of stroke, in comparison to its Japanese and Caucasian counterparts pointing to the inter- and intra-continent differences of MMA phenotype. Future development of the Indian MMA national registry is of essence. [ABSTRACT FROM AUTHOR]

Abstract Secondary headache, fever, and upper motor neuron signs following facial herpes zoster during childhood should alert clinicians to the possibility of central nervous system complications of varicella‐zoster virus infection.

IMPORTANCE: Our understanding of risk factors for childhood stroke is incomplete. In adults, migraine with aura is associated with a two-fold increase in ischemic stroke risk. OBJECTIVE: In this cohort study we examine the association between migraine and stroke among children in Kaiser Permanente Northern California (KPNC). DESIGN, SETTING, AND PARTICIPANTS: Children ages 2-17 years who were members of KPNC for ≥6 months between 1997 and 2007 were included. Migraine cohort members had one or more of: an ICD-9 code for migraine, migraine listed as a significant health problem, or a prescription for a migraine-specific medication. The comparison group was children with no evidence of headache. MAIN OUTCOME MEASURES: Main outcome measures included stroke incidence rates and incidence rate ratios (IR). RESULTS: Among the 1,566,952 children within KPNC during the study period, 88,164 had migraine, and 1,323,142 had no evidence of headache. Eight migraineurs had a stroke (three (38%) hemorrhagic; five (63%) ischemic). Eighty strokes occurred in children without headache (53 (66%) hemorrhagic; 27 (34%) ischemic). The ischemic stroke incidence rate was 0.9/100,000 person-years in migraineurs vs. 0.4/100,000 person-years in those without headache; IR 2.0 (95% CI 0.8-5.2). A post-hoc analysis of adolescents (12-17 years) showed an increased risk of ischemic stroke among those with migraine; IR 3.4 (95% CI 1.2-9.5). The hemorrhagic stroke incidence rate was 0.5/100,000 person-years in migraineurs and 0.9/100,000 person-years in those without headache; IR 0.6 (95% CI 0.2-2.0). CONCLUSIONS: There was no statistically significant increase in hemorrhagic or ischemic stroke risk in pediatric migraineurs in this cohort study. A post-hoc analysis found that ischemic stroke risk was significantly elevated in adolescents with migraine. Future studies should focus on identifying risk factors for ischemic stroke among adolescent migraineurs. Based on adult data, we recommend that migraine aura status should be studied as a possible risk factor for ischemic stroke among adolescent migraineurs.

ImportanceOur understanding of risk factors for childhood stroke is incomplete. In adults, migraine with aura is associated with a two-fold increase in ischemic stroke risk.ObjectiveIn this cohort study we examine the association between migraine and stroke among children in Kaiser Permanente Northern California (KPNC).Design, setting, and participantsChildren ages 2-17 years who were members of KPNC for ≥6 months between 1997 and 2007 were included. Migraine cohort members had one or more of: an ICD-9 code for migraine, migraine listed as a significant health problem, or a prescription for a migraine-specific medication. The comparison group was children with no evidence of headache.Main outcome measuresMain outcome measures included stroke incidence rates and incidence rate ratios (IR).ResultsAmong the 1,566,952 children within KPNC during the study period, 88,164 had migraine, and 1,323,142 had no evidence of headache. Eight migraineurs had a stroke (three (38%) hemorrhagic; five (63%) ischemic). Eighty strokes occurred in children without headache (53 (66%) hemorrhagic; 27 (34%) ischemic). The ischemic stroke incidence rate was 0.9/100,000 person-years in migraineurs vs. 0.4/100,000 person-years in those without headache; IR 2.0 (95% CI 0.8-5.2). A post-hoc analysis of adolescents (12-17 years) showed an increased risk of ischemic stroke among those with migraine; IR 3.4 (95% CI 1.2-9.5). The hemorrhagic stroke incidence rate was 0.5/100,000 person-years in migraineurs and 0.9/100,000 person-years in those without headache; IR 0.6 (95% CI 0.2-2.0).ConclusionsThere was no statistically significant increase in hemorrhagic or ischemic stroke risk in pediatric migraineurs in this cohort study. A post-hoc analysis found that ischemic stroke risk was significantly elevated in adolescents with migraine. Future studies should focus on identifying risk factors for ischemic stroke among adolescent migraineurs. Based on adult data, we recommend that migraine aura status should be studied as a possible risk factor for ischemic stroke among adolescent migraineurs.

Background Childhood stroke is rare and can predispose to post-stroke epilepsy. The purpose of this study was to evaluate long-term quality of life (QoL) in patients with childhood stroke, focusing on epileptic aspects. Method This involves a retrospective study of 98 patients with childhood stroke (pre- and neonatal strokes excluded), who had been inpatients between 1986 and 2003 for early rehabilitation. Data were obtained via interviews using a standardized questionnaire: QoL evaluation with KINDL, functional outcome with Barthel Index, and motor handicaps-assessment with modified Rankin Score. Results Forty-nine of 98 patients (31 males, mean follow-up 16 years, range 8–25 years) were included. Six patients passed away (three of sudden unexpected death in epilepsy). At least one epileptic seizure occurred in 27/49 patients (occurrence: 2 days–13 years.; mean 3.3 years.). Epilepsy manifested in 19/49 patients. No correlation was found between the development of epilepsy and the location or etiology of the stroke. The presence of functional independence was significantly higher in seizure-free patients and in patients without epilepsy. For the external assessment (filled in for the patient by the parent/caregiver), there was no significant difference in QoL in patients with and without epilepsy; however, in the in-person KINDL questionnaire a significantly lower QoL was noted in epilepsy patients compared with patients without epilepsy. Conclusion One important finding in our study is that in the long-term course 39% of patients developed epilepsy after a childhood stroke. It occurred as late as 13 years after the acute episode and affected the QoL especially in cognitively less handicapped patients. [ABSTRACT FROM AUTHOR]

To evaluate the preoperative clinical and magnetic resonance imaging and angiography (MRI-MRA) characteristics in pediatric moyamoya patients. Analysis included 100 children with moyamoya angiopathy referred to our moyamoya center for preoperative evaluation. Clinical symptoms, neurological status using Pediatric Stroke Outcome Measurement (PSOM) and degree of disability on modified Rankin scale score (mRS) were evaluated. MRI-MRA evaluation included the assessment of ischemic lesions and involvement of posterior circulation. Data were analyzed for moyamoya disease (MMD), moyamoya syndrome (MMS) and age at disease onset. Stroke was a common presentation in both MMD and MMS patients. TIAs and headaches/migraine were more frequent in MMD. There was no evidence of a difference in stroke burden on MRI as well as in PCA involvement between the two subgroups. Children <2 years had higher odds of having a stroke (OR 15.5, 95% CI 3.8–62.4, p < 0.001), recurrent stroke (OR 11.8, 95%CI 2.9–46.7, p < 0.001) and unfavorable mRS (≥2) (OR 4.2, 95% CI 1.3–13.7, p = 0.01) when compared to those >5 years of age. There was some evidence of association of PCA involvement with recurrent strokes (OR 3.1, CI 1.0–9.6, p = 0.05), a poor PSOM (OR 3.0, 95% CI 1.1–8.2, p = 0.04) and mRS (OR 3.1, 95% CI 1.2–8.3, p = 0.02). Stroke seems to be a common presentation in both MMD and MMS patients. Early age at symptom onset and involvement of posterior circulation seem to be important risk factors for a high stroke burden and an unfavorable PSOM and mRS. • Age at first presentation i.e. symptom onset is an important risk parameter for unfavorable disease course. • Children < 2 years present with a high risk of recurrent cortical strokes, associated with functional deficit and epilepsy. • Children > 5 years frequently present with TIAs and headaches and atypical symptoms like drop attacks and limb shaking. • Posterior circulation involvement seems to be associated with a higher risk of stroke and unfavorable clinical presentation. [ABSTRACT FROM AUTHOR]

Objectives: This study aims to investigate the long-term language outcome in children with unilateral childhood stroke in comparison to those with perinatal strokes and typically developing individuals and to explore the impact of lesion-specific modifiers., Methods: We examined nine patients with childhood stroke, acquired between 0;2 and 16;1 years (CHILD; 3 female, median = 13.5 years, 6 left-sided), 23 patients with perinatal strokes (PERI; 11 female, median = 12.5 years, 16 left-sided), and 33 age-matched typically developing individuals (CONTROL; 15 female, median = 12.33 years). The language outcome was assessed using age-appropriate tasks of the Potsdam Illinois Test of Psycholinguistic Abilities (P-ITPA) or the Peabody Picture Vocabulary Test (PPVT). For group comparisons, study-specific language z -scores were calculated. Non-verbal intelligence was assessed using the Test of Non-verbal Intelligence (TONI-4), language lateralization with functional MRI, and lesion size with MRI-based volumetry., Results: All four patients with childhood stroke who initially presented with aphasic symptoms recovered from aphasia. Patients with childhood stroke showed significantly lower language scores than those in the control group, but their scores were similar to those of the patients with perinatal stroke, after adjusting for general intelligence (ANCOVA, language z -score CHILD = -0.30, PERI = -0.38, CONTROL = 0.42). Among the patients with childhood stroke, none of the possible modifying factors, including lesion side, correlated significantly with the language outcome., Conclusion: Childhood stroke, regardless of the affected hemisphere, can lead to chronic language deficits, even though affected children show a "full recovery." The rehabilitation of children and adolescents with childhood stroke should address language abilities, even after the usually quick resolution of clear aphasic symptoms., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Heimgärtner, Gschaidmeier, Schnaufer, Staudt, Wilke and Lidzba.)

Rationale: Early evidence for the benefit of mechanical thrombectomy (MT) in pediatric patients with intracranial large vessel occlusion has been shown in previous retrospective cohorts. Higher-level evidence is needed to overcome the limitations of these studies such as the lack of a control group and the retrospective design. Randomized trials will very likely not be feasible, and several open questions remain, for example, the impact of arteriopathic etiologies or a possible lower age limit for MT. Save ChildS Pro therefore aims to demonstrate the safety and effectiveness of MT in pediatric patients compared to the best medical management and intravenous thrombolysis. Design: Save ChildS Pro is designed as a worldwide multicenter prospective registry comparing the safety and effectiveness of MT to the best medical care alone in the treatment of pediatric arterial ischemic stroke (AIS). It will include pediatric patients (<18 years) with symptomatic acute intracranial arterial occlusion who underwent either MT or best medical treatment including intravenous thrombolysis. Outcomes: The primary endpoint of Save ChildS Pro is the modified Rankin Scale score at 90 days post-stroke. Secondary endpoints will comprise the decrease of the Pediatric National Institutes of Health Stroke Scale score from admission to discharge and rate of complications. Discussion: Save ChildS Pro aims to provide high-level evidence for MT for pediatric patients with AIS, thereby improving functional outcome and quality of life and reducing the individual, societal, and economic burden of death and disability resulting from pediatric stroke. Clinical Trial Registration: Save ChildS Pro is registered at the German Clinical Trials Registry (DRKS; identifier: DRKS00018960). [ABSTRACT FROM AUTHOR]

Background: Although stroke is rare among the pediatric population, it is nevertheless associated with serious or life-threatening consequences. The etiologic factors of acute ischemic stroke (AIS) are likely to vary over the course of childhood development. The incidence rates of AIS, not previously systematically examined by pediatric age subgroup, could guide studies of its etiology. Objective: The aim of this study is to evaluate the incidence rate of AIS by age-group in the pediatric population (aged 0–17/18 years) and identify any common trends or sources of variability across different countries. Methods: Rates of pediatric AIS were collated from a systematic literature review of published studies globally (1983–2020) and hospitalization records from Europe and the USA (2015–2018). Records that were included in the analysis reported the code or description used for AIS diagnosis and age-specific data for children aged 0–17/18 years. AIS incidence rates were summarized by age-group, data source, country, and geographic region. A meta-analysis was conducted to assess the heterogeneity of AIS rates in neonates. Results: The pooled AIS incidence rate was 5.6 per 100,000 children across all records. When only records reporting the AIS incidence rates for children across the full age range (0–17/18 years) were analyzed, the pooled AIS incidence rate was 4.6 per 100,000 children and ranged from 7.0 per 100,000 (Germany) to 1.3 per 100,000 (Denmark). The highest pooled rates were observed in the 0–28-day age-group (24.6 per 100,000 live births), declining to the lowest rates in the 5–9-year age-group, and rising again in the 10–17/18-year age-group. AIS rates were the most heterogeneous in the 0–28-day age-group and across European countries. Significantly higher AIS rates in neonates were observed from hospital databases (35.9 per 100,000) than in the literature (19.4 per 100,000). AIS rates may be underestimated as pediatric AIS events are rare and challenging to diagnose, and limited age-specific data are available. Conclusions: Incidence rates of pediatric AIS by age-groups followed a consistent overall pattern of a reverse J-shaped curve, with the highest rates in neonates, across predominantly European and North American countries. Further research is warranted to examine if this pattern is observed in other geographic regions and to identify AIS risk factors specific to different phases of childhood development. [ABSTRACT FROM AUTHOR]

BackgroundThere is increasing recognition of stroke as an important contributor to childhood morbidity and mortality. Current estimates of global childhood stroke burden and its temporal trends are sparse. Accurate and up-to-date estimates of childhood stroke burden are important for planning research and the resulting evidence-based strategies for stroke prevention and management.ObjectivesTo estimate the prevalence, mortality and disability-adjusted life years (DALYs) for ischemic stroke (IS), hemorrhagic stroke (HS) and all stroke types combined globally from 1990 to 2013.MethodologyStroke prevalence, mortality and DALYs were estimated using the Global Burden of Disease 2013 methods. All available data on stroke-related incidence, prevalence, excess mortality and deaths were collected. Statistical models and country-level covariates were employed to produce comprehensive and consistent estimates of prevalence and mortality. Stroke-specific disability weights were used to estimate years lived with disability and DALYs. Means and 95% uncertainty intervals (UIs) were calculated for prevalence, mortality and DALYs. The median of the percent change and 95% UI were determined for the period from 1990 to 2013.ResultsIn 2013, there were 97,792 (95% UI 90,564-106,016) prevalent cases of childhood IS and 67,621 (95% UI 62,899-72,214) prevalent cases of childhood HS, reflecting an increase of approximately 35% in the absolute numbers of prevalent childhood strokes since 1990. There were 33,069 (95% UI 28,627-38,998) deaths and 2,615,118 (95% UI 2,265,801-3,090,822) DALYs due to childhood stroke in 2013 globally, reflecting an approximately 200% decrease in the absolute numbers of death and DALYs in childhood stroke since 1990. Between 1990 and 2013, there were significant increases in the global prevalence rates of childhood IS, as well as significant decreases in the global death rate and DALYs rate of all strokes in those of age 0-19 years. While prevalence rates for childhood IS and HS decreased significantly in developed countries, a decline was seen only in HS, with no change in prevalence rates of IS, in developing countries. The childhood stroke DALY rates in 2013 were 13.3 (95% UI 10.6-17.1) for IS and 92.7 (95% UI 80.5-109.7) for HS per 100,000. While the prevalence of childhood IS compared to childhood HS was similar globally, the death rate and DALY rate of HS was 6- to 7-fold higher than that of IS. In 2013, the prevalence rate of both childhood IS and HS was significantly higher in developed countries than in developing countries. Conversely, both death and DALY rates for all stroke types were significantly lower in developed countries than in developing countries in 2013. Men showed a trend toward higher childhood stroke death rates (1.5 (1.3-1.8) per 100,000) than women (1.1 (0.9-1.5) per 100,000) and higher childhood stroke DALY rates (120.1 (100.8-143.4) per 100,000) than women (90.9 (74.6-122.4) per 100,000) globally in 2013.ConclusionsGlobally, between 1990 and 2013, there was a significant increase in the absolute number of prevalent childhood strokes, while absolute numbers and rates of both deaths and DALYs declined significantly. The gap in childhood stroke burden between developed and developing countries is closing; however, in 2013, childhood stroke burden in terms of absolute numbers of prevalent strokes, deaths and DALYs remained much higher in developing countries. There is an urgent need to address these disparities with both global and country-level initiatives targeting prevention as well as improved access to acute and chronic stroke care.

Sudden focal neurological symptoms or 'brain attacks' in children are a common scenario for acute paediatric care givers. A small proportion will have had a vascular stroke. Suspected stroke in adults, signalled by FAST (Face, Arms, Speech, Time) test positivity, is an accepted medical emergency. Children are rarely dealt with urgently unless there is coma. Barriers to stroke recognition and response in children are multifactorial. Childhood stroke is rare and may be 'FAST negative'. Overall, there is low awareness, low clinical suspicion and many logistic obstacles to timely detection and aspired treatment delivery. Yet stroke continues to affect hundreds of children in the UK each year, causing life-changing disability and, in some, death. This article highlights current key recommendations for the diagnosis and management of acute stroke set out in the 2017 Royal College of Paediatrics and Child Health (RCPCH) Stroke in childhood guideline. Evidence and rationale are discussed, and important practice points offered. There is focus on arterial ischaemic stroke in light of the proposed hyperacute management pathway, which includes thrombolysis. Ongoing challenges on the ground and how these may be overcome are considered. [ABSTRACT FROM AUTHOR]

The Carolina Reaper pepper is one of the spiciest edible peppers in the world. While localized symptoms such as mouth burning, mouth numbness, and even vomiting are the main risks of eating these peppers, recent case reports have revealed more serious complications of these potent foods. A 15-year-old healthy male ingested a Carolina Reaper pepper on a dare. Two days later, he developed an acute headache during football practice and was subsequently diagnosed with an acute cerebellar infarct and reversible cerebrovascular vasoconstriction syndrome. Reversible cerebral vasoconstriction syndrome should be considered in patients who present with severe headache after ingestion of ultraspicy peppers, and early treatment of reversible cerebral vasoconstriction syndrome should be initiated in patients with severe headache after pepper ingestion.

Childhood stroke results in long-term, multifaceted difficulties, affecting motor, cognitive, communication, and behavioral domains of function which impact on participation and quality of life. The Childhood Stroke Consensus Rehabilitation Guideline was developed to improve the care of children with stroke by providing health professionals with recommendations to assist in their rehabilitative treatment. Clinical questions were formulated to inform systematic database searches from 2001 to 2016, limited to English and pediatric studies. SIGN methodology and the National Health and Medical Research Council system were used to screen and classify the evidence. The Grade of Recommendation, Assessment, Development and Evaluation system was used to grade evidence as strong or weak. Where evidence was inadequate or absent, a modified Delphi consensus process was used to develop consensus-based recommendations. The guideline provides 56 recommendations (1 evidence-based recommendation and 55 consensus recommendations). These relate to the framework of rehabilitation service delivery as well as domain-specific rehabilitation treatment strategies for each domain of function. It is anticipated that this guideline will provide health professions with recommendations to improve the subacute care of children with stroke both in Australia and internationally. [ABSTRACT FROM AUTHOR]

Secondary headache, fever, and upper motor neuron signs following facial herpes zoster during childhood should alert clinicians to the possibility of central nervous system complications of varicella‐zoster virus infection. [ABSTRACT FROM AUTHOR]

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.

Background: The prevalence of cancer among children with stroke is unknown. This study sought to evaluate cancer- and tumor-associated childhood ischemic stroke in a multinational pediatric stroke registry.Methods: Children aged 29 days to less than 19 years with arterial ischemic stroke or cerebral sinovenous thrombosis enrolled in the International Pediatric Stroke Study between January 2003 and June 2019 were included. Data including stroke treatment and recurrence were compared between subjects with and without cancer using Wilcoxon rank sum and chi-square tests.Results: Cancer or tumor was present in 99 of 2968 children (3.3%) with arterial ischemic stroke and 64 of 596 children (10.7%) with cerebral sinovenous thrombosis. Among children in whom cancer type was identified, 42 of 88 arterial ischemic stroke cases (48%) had brain tumors and 35 (40%) had hematologic malignancies; 45 of 58 cerebral sinovenous thrombosis cases (78%) had hematologic malignancies and eight (14%) had brain tumors. Of 54 cancer-associated arterial ischemic stroke cases with a known cause, 34 (63%) were due to arteriopathy and nine (17%) were due to cardioembolism. Of 46 cancer-associated cerebral sinovenous thrombosis cases with a known cause, 41 (89%) were related to chemotherapy-induced or other prothrombotic states. Children with cancer were less likely than children without cancer to receive antithrombotic therapy for arterial ischemic stroke (58% vs 80%, P = 0.007) and anticoagulation for cerebral sinovenous thrombosis (71% vs 87%, P = 0.046). Recurrent arterial ischemic stroke (5% vs 2%, P = 0.04) and cerebral sinovenous thrombosis (5% vs 1%, P = 0.006) were more common among children with cancer.Conclusions: Cancer is an important risk factor for incident and recurrent childhood stroke. Stroke prevention strategies for children with cancer are needed. [ABSTRACT FROM AUTHOR]

Moyamoya disease (MMD) is characterized by bilateral, chronic progressive stenosis at the terminal portions of the internal carotid arteries and their proximal branches. The "smoke-like" appearance of the arterial collaterals in angiography gives the disease its name. The "ivy-sign" is the less-known magnetic resonance imaging (MRI) pattern of this disease. The leptomeningeal collaterals present as diffuse signal enhancement at the brain surface in contrast-enhanced T1-weighted image and fluid-attenuated inversion recovery sequences "as if overgrown with ivy." We report on three patients with MMD in whom the "ivy-sign" was already present but misinterpreted in the initial MRI of the brain. The correct diagnosis was made only after repeated MRI. Using three case studies, we describe the difficulties in the interpretation of the "ivy-sign" as an MRI pattern. Knowledge of the "ivy-sign" can be helpful, especially in diseases predisposing to MMD. If this MRI pattern is present, MMD should be considered and MR angiography should be added. [ABSTRACT FROM AUTHOR]

Objective: Childhood arterial ischaemic stroke (AIS) is rare, but causes significant morbidity and mortality. We aimed to investigate incidence, age-dependent clinical presentation, and risk factors and to discuss the medical care situation in Germany. Methods: This prospective epidemiological study was conducted via ESPED (Erhebungseinheit für Seltene Pädiatrische Erkrankungen in Deutschland), a hospital-based German nation-wide surveillance unit for rare pediatric diseases. Children aged 28 days–18 years with first AIS between January 2015 and December 2017 were included. Results: In the 3-year period, 164 children were reported. Incidence showed peaks in infants, children < 2 years of age, and adolescents (12–18 years), with a significant male predominance observed in adolescents only. Independent of age, most children (91%) presented with focal symptoms, particularly with acute hemiparesis. The occurrence of seizures in infants (57%) and more nonspecific symptoms in school-children and adolescents (54%) is considered noteworthy. Prothrombotic states (34%), cardiac disorders (29%), and arteriopathies (19%) were the most frequently identified risk factors. The majority of children (72/131, thus 55%) were discharged home after acute care phase. At time of discharge, most common neurological symptoms were hemiparesis (42%), facial palsy (15%), and speech disturbance (12%). Conclusion: This study provides population-based data of childhood AIS which may be useful for further research. The improvement of acute stroke management is needed for children, but also the standardization of post-stroke care in the outpatient setting has to be structured. Considering the higher stroke incidence in (male) adolescents, it is advisable to combine research activities in adolescents and young adults. [ABSTRACT FROM AUTHOR]

Purpose: Endovascular therapy benefits selected adults with acute stroke while data are lacking for children. The purpose of this study was to assess physician practice and institutional preparedness for endovascular therapy in pediatric stroke. Methods: A link to an anonymous online survey was sent to members of the International Pediatric Stroke Study (IPSS) group about physician experience with endovascular therapy, likelihood of treatment for provided clinical vignettes, and institutional readiness for the delivery of endovascular therapy to children. Results: Thirty-one pediatric physicians with a mean of 11 years (SD 7.1) of experience responded. All but two would consider endovascular therapy in a child, and 20 (64.5%) had recommended endovascular therapy for a child in the preceding year. Most (n = 19, 67.9%) did not commit to an age minimum for endovascular therapy. Sixteen (57.1%) would consider treatment up to 24 h after symptom onset with 19 (67.9%) respondents reporting that their practice changed after the 2018 American Heart Association guidelines extended the time window for endovascular therapy in adults. Seventeen (60.7%) preferred imaging that included perfusion in children presenting beyond 6 h. Nineteen (70.4%) had institutional endovascular therapy criteria. Physicians in larger pediatric groups had more "likely to treat" responses on the clinical vignettes than physicians working in smaller groups (11.7 vs. 6.1, p < 0.05). Conclusion: Pediatric stroke physicians are largely willing to consider endovascular therapy with most changing their practice according to adult guidelines, though experience and selection criteria varied. These findings may help to inform consensus guidelines and clinical trial development. [ABSTRACT FROM AUTHOR]

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