United States

Introduction: Brainstem location of arteriovenous malformation occurs in 2-6% of all intracranial AVMs and more commonly presents as hemorrhage in adults with mean age of 25-38.5 years. This is the first local report of two cases presenting during the adolescent period with headaches. Case and Discussion The first case is a 13-year old male who had a one-year history of occipital headache eventually developing left hemiparesis, slurred speech and right-sided ataxia (mRS 3). Brain MRI revealed brainstem AVM extending to the right cerebellum (Figure 1) confirmed by angiography (Figure 2). After instituting medical supportive management, patient was sent home. Gradual improvement of the neurologic deficits (mRS 2) were noted three months after discharge. The second is an 18-year old female taking risperidone for Major Depressive Disorder and Post-Traumatic Stress Disorder who had recurrent episodes of migrainous-like headaches but consulted for galactorrhea. Cranial CT scan showed a midbrain AVM (Figure 3) confirmed by angiography (Figure 4). Endocrine work-up revealed risperidone-induced galactorrhea which resolved after drug withdrawal. Patient was discharged while waiting for definitive management. However, her AVM ruptured four months later manifesting as Weber syndrome (mRS 3). Patient was stabilized and eventually sent home. There is gradual improvement of the left hemiparesis (mRS 2) five months from the hemorrhagic stroke. Considering the poor prognosis of brainstem hemorrhage, these two cases illustrate the need for high-index of suspicion in seemingly benign headaches as early detection and management of this rare condition could spell the difference in their outcomes. Currently, treatment option for these patients is stereotactic radiosurgery. Keywords: pediatric hemorrhagic stroke, brainstem AVM.

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Brainstem arteriovenous malformation in two adolescent Filipinos

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Dear IPSO Virtual Conference Attendees:

Welcome to IPSO’s first-ever conference! We are delighted to bring together experts from multiple disciplines and six continents to provide a diverse perspective on pediatric cerebrovascular disease. 

A few quick words about what to expect. Two important goals of this conference are to (1) foster a sense of community and (2) identify global priorities for our field. Hence, the program includes short presentations on an array of clinical controversies and dedicates more time to panel discussions with a live chat function so that everyone can participate. We are excited to announce IPSO is able to offer 8.75 CME units for the virtual conference. If you would like to claim CME credits, please email <membership@internationalpediatricstroke.org>. 

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Welcome to the first IPSO Virtual Conference. The mission of the virtual conference is to unify the global community of professionals engaged in research and clinical care for children with cerebrovascular diseases, and chart a path forward for multinational, multidisciplinary efforts. Please go here to access the virtual conference platform- <a href="https://underline.io/events/157/reception">Reception page</a>.

Background Stroke is a recognised complication following congenital cardiac surgery. In 2017, RCPCH published a guideline outlining investigations to be performed in children with evidence of stroke. Objectives To determine adherence to the RCPCH Stroke Guideline in patients with evidence of stroke who had undergone congenital cardiac surgery. To perform a structured survey to explore reasons for non-adherence. Methods Records of all paediatric cardiac patients undergoing surgery between January 2014 and July 2020 were cross-referenced with patients recorded as having ischaemia on brain imaging. 34 patients were identified. 16 patients who died during admission were excluded. Records of the remaining 18 patients were examined to ascertain rates of adherence to the RCPCH's recommended investigations. Subsequently, a structured survey was conducted amongst paediatric intensive care doctors to explore reasons for non-adherence. Results Table 1 documents adherence to investigations recommended by the RCPCH. Of note, complete adherence was not achieved in any patients. Of 33 doctors surveyed, 10 (30%) were aware of the guideline. When asked how likely they were to use the term 'stroke' to describe focal ischaemia on imaging, 16 (48%) respondents stated they were likely/very likely, with 9 (27%) stating they would be unlikely/very unlikely. When asked about which laboratory investigations they would perform, various tests referenced in the guideline were mentioned, but no respondents mentioned iron, total iron binding capacity, plasma homocysteine, lipoprotein, 2GP1 or alpha galactosidase. Discussion Cardiac investigations and routine blood tests were performed as per guidelines on congenital cardiac surgery. Neurological imaging was generally performed in keeping with RCPCH guidelines. However, other investigations were performed on an ad-hoc basis. The survey results suggest that this may be due to a lack of awareness of both the stroke guideline and the significance of the laboratory tests. Furthermore, disparities in terminology may contribute to a lack of consideration of the stroke guideline. As a result of this audit, the RCPCH Stroke Guideline will be available through the NHS GG&C guidelines application. Education will be delivered to raise awareness, and a stroke checklist will be introduced.

Stroke post congenital cardiac surgery - Adherence to national guidelines and reasons for non-adherence

Last years there has been a tendency to increase the incidence of stroke in children, which may be associated with an improvement in the diagnosis of this pathology in the pediatric population. Aim. Analysis of the clinical synmptoms and the conformity of the diagnoses: guides (according to the ambulance) and the discharge one. Materials. From October 2018 to December 2019, 502 hospitalization in the Primary pediatric stroke center of Morozov Hospital by the Moscow Ambulance with diagnoses of arterial ischemic stroke (AIS), hemorrage stroke (HI) and transit ischemic attaсk (TIA) were analyzed. 48.8% boys and 51.2% girls were hospitalized. Results. Of 502 admissions, the directing diagnosis was TIA - 38.6%, AIS - 52,6%, HI - 8.8%. The symptoms were: headache -38.5%; dizziness - 25.5%, ataxia - 21.1%; sensory impairment - 10.6%, paresis - in 10%, speech impairment and visual impairment were detected in 9.6% and 5.4%, facial asymmetry - 6.2%, and seizures - 4%. In 30.7% patients, at the time of admission to the Center, there was no a neurological deficit. The average time from the onset of the first symptoms to hospitalization in the hospital was more 4 hours. Neuroimaging was performed in 54.8%. Computed tomography(CT)- 41.4%, magnetic resonance imaging (MRI) - 20.7% cases, in 7.9% both CT and MRI. AIS was confirmed in 11,2%, HI -9.1%. In confirmed AIS, the common symptoms were: paresis- 84.6%, ataxia- 84.6%; facial asymmetry- 61.5%; speech impairment and impaired sensitivity - 38.5%, respectively; visual impairment - 15.4%; nausea or vomiting and convulsions - 7.7%. In 84% patients, stroke was not confirmed. Conclusion Based on the analysis of the most frequent symptoms and "mistakes", the "Attention, stroke!" Scale was developed for ambulance doctors, which has been practiced since January 2020 in the Moscow Ambulance.

Early diagnostics of a stroke in children. Experience of Moscow primary pediatric stroke center and Moscow Ambulance

Introduction: Pediatric acute stroke is often misdiagnosed in the acute setting. Computed tomgraphy imaging has a low sensitivity and specificity for diagnoses in pediatric patients presenting with acute focal neurologic deficit. We established a collaborative protocol involving both the vascular neurology and pediatric neurology divisions in our institution for pediatric code stroke. Methods: Multidisciplinary meetings were held with the division of vascular neurology, endovascular surgery, child neurology, intensive care and emergency medicine to update our pediatric acute stroke protocol to prioritize magnetic resonance imaging over computed tomography. Educational lectures about pediatric acute stroke were given to the department of emergency medicine, division of vascular neurology, division of child neurology, and division of pediatric intensive care. Results: The protocol has been active for 18 months. There have been 20 pediatric code strokes. Magnetic resonance imaging was obtained first in 14 of 20 cases. The average time from code stroke to imaging in the emergency department was 60 minutes. The average time in the inpatient setting was 115 minutes. Final diagnosis was acute ischemic stroke in 3 patients. The other diagnoses were; RCVS (1), Methotrexate toxicity (1), Seizure (10), Metabolic (2), Migraine (1), Conversion (1), Bell's Palsy (1). 1 patient recieved tissue plasminogen activator and mechanical thrombectomy for basilar artery occlusion (Figures 1 and 2). Conclusions: Magnetic resonance imaging is a sensitive and specific first-line imaging choice in pediatric patients presenting with acute focal neurologic deficit. Multidisciplinary collaboration including both vascular and pediatric neurologists may improve diagnosis time for patients presenting with acute focal neurologic defict.

Pediatric code stroke: a single center experience

Background and purpose: The implementation of acute stroke response protocols has resulted in a decrease in the time to diagnosis of acute stroke in children at select institutions, and this is essential for expanding access to hyperacute therapies. We aim to describe existing pediatric acute stroke response protocols in the United States and Canada to better understand how pediatric centers might implement such protocols within the context of institution-specific structures. Methods: We performed a survey-based study of pediatric stroke specialists focused on institutional acute stroke protocols. The survey queried: hospital demographics; child neurology and pediatric stroke demographics; acute stroke response; imaging; and hyperacute treatment. Results: Forty-seven surveys were analyzed. Most respondents practice at large, free-standing children's hospitals with moderate-sized neurology departments and at least one neurologist with expertise in pediatric stroke. The majority of institutions have an acute stroke pathway or protocol, and all but one of these include the activation of a stroke alert page. Most institutions cite magnetic resonance imaging as the preferred imaging modality and employ abbreviated magnetic resonance imaging protocols for acute stroke imaging. Most institutions also have either computed tomography- or magnetic resonance-based perfusion imaging available. At least one patient had been treated with intravenous tissue plasminogen activator and/or mechanical thrombectomy at the majority of institutions in the year prior to our survey. Conclusions: An acute stroke response protocol is utilized in at least 41 pediatric centers in the United States and Canada. Most acute stroke response teams are multidisciplinary, have annual experience providing intravenous tissue plasminogen activator and/or mechanical thrombectomy, and prefer abbreviated magnetic resonance imaging over computed tomography for stroke diagnosis. Further studies are needed to standardize practices of pediatric acute stroke diagnosis and hyperacute management.

Pediatric acute stroke response protocols

Background: Twenty to forty percent of children who suffer a stroke will die. Of those who do live, 50-80% will have permanent neurologic deficits. Early identification and intervention increases survival and decreases sequelae yet recognition of a stroke is often missed. With an incidence of only 6.4/100.000 in children aged 0-15, the rarity, the atypical presentations compared to adults and potential confounding stroke mimickers often impede prompt diagnosis. Objective: Improve recognition that children do have strokes and expedite early assessment and diagnosis that is imperative to good outcomes. This presentation will advance nursing skills in the recognition of stroke types and symptoms to familiarize them with the tools needed, such as the Pediatric National Institute of Health Stroke Scale (PedNIHSS), to aid timely diagnoses. Design/Methods Retrospective institutional data review of children presenting with strokes between 07/2017-03/2018 was compared to the nationally recognized predisposing conditions. The prevalence of risk factors in this review exceeded what is commonly known and has been instrumental in refining our screening process, development of nurse assessment tools and a stroke alert protocol. Results: Seventy-five incidences of stroke were identified during an 8 month period, the majority were through the Emergency department with initial triage by a nurse. The causes and risk factors were categorized and 11 diagnostic groups were documented. There were 7 outliers to the commonly recognized associated conditions. All children who met assessment criteria for suspected stroke, average two -three per month, received the PedNIHSS evaluation. This screening process also identified stroke mimickers who did not require additional evaluations such as MRI. Those who were positive for PedNIHSS, defined as a score greater than 4, received timely intervention which has shown to improve long term outcomes. An acute stroke alert protocol that includes an electronic order set was developed and its efficacy continues to be evaluated at quarterly multidisciplinary meetings. Conclusion: Pediatric stroke is a reality and as pediatric providers we need to be knowledgeable and attentive to presenting symptoms. Stroke needs to be in our differential, we need to be familiar with the PedNIHSS and we need to intervene promptly for the best possible outcomes.

Is stroke on your differential? Acute stroke alert implementation in a pediatric ER

Introduction: Occupational therapy is one of the rehabilitative professions that treats children with hemiplegia secondary to perinatal and pediatric stroke (Rowland, Cooke, & Gustafsson, 2008). There is limited research on the assessment and rehabilitation of pediatric hemiplegia secondary to stroke (Marcroft, Tsutsumi, Pearse, Dulson, Embelton, & Basu, 2018). Aims: The goal is to demonstrate the effectiveness of combining pediatric constraint induced movement therapy (CIMT) with a collection of evidenced based rehabilitation interventions for the treatment of hemiplegia secondary to pediatric and perinatal stroke in occupational therapy. Hypothesis:The combined approach will yield increased quality of movement, more efficient motor patterns and spontaneous use of the affected side for participation in meaningful bilateral and unilateral tasks. Methods: This quasi-experimental, case series study examined children ages 7 to 13 years in a theme-based CIMT camp for 10 or 15 days for two consecutive or alternate years. Each of the six participants received multiple components of intervention combined with CIMT. Pre and post-test measures were taken to examine outcomes using the Abilhand-Kids and Goal Attainment Scaling to compare unilateral and bilateral function from the first round of camp were compared to the second round of intensive camp. Results: The analyses determined that the dosage of CIMT camp for pediatrics can be effective for 5 hours a day for 10 or 15 days especially for first time attendees. Additionally, there is significant sustained benefit to attending CIMT camp the following year or the alternate year. There is value in combining evidenced based practices with CIMT. These participants demonstrated an increase in mean difference for functional participation, range of motion and automaticity of use of the hemiparetic hand for meaningful activities after an intensive combined approach of CIMT, and collective evidence-based rehabilitation. Conclusion: Essential components of evidenced based rehabilitative interventions combined with CIMT can facilitate improvement of motor control for the pediatric stroke population. This work is the first to demonstrate an effective framework for the unilateral treatment of pediatric hemiplegia combining the use of essential multi-components. This report can be used as a guideline for pediatric stroke treatment in the field of occupational therapy for the purpose of knowledge translation.

Multi-component occupational therapy intervention in a pediatric constraint induced movement therapy camp setting

Introduction Childhood arterial ischemic stroke (AIS) is rare but associated with significant morbidity. Approximately 30% of new-borns and 50% of children diagnosed with AIS later develop hemiparesis. The relationship between their manual ability and participation at home, school and in the community has not been investigated. Patients and Methods Fourteen children with AIS (diagnosis at least 2 years ago, age 5 to 17 years) and 21 typically developing peers were examined. Participants were contacted by mail and asked to fill in questionnaires regarding their manual ability (ABILHAND-Kids) and participation (Participation and Environment Measure - Children and Youth [PEM-CY]). A Mann-Whitney-U test was used to calculate group differences, correlations were calculated using a Spearman Rank Correlation coefficient. Results There was a significant difference in manual ability between stroke patients and typically developing peers (p<0.001). While there were no significant group differences in participation frequency and involvement at home, school and in the community, parents of AIS patients desired significantly higher participation at school (p=0.022). There was a significant correlation between manual ability and the desired change in participation at school (p=0.026). Conclusion Although children after AIS seem to participate equally often and be equally well involved in participation at home, school and in the community, parents of children diagnosed with AIS appear to desire a higher level of participation at school - especially when manual ability is reduced. Future studies must investigate whether increased parental participation desires in this vulnerable patient group are associated with increased pressure to perform at school.

Participation and manual ability in children diagnosed with arterial ischemic stroke: Do parents of more affected children expect more from their children?

Neuropsychologists play an integral role in a comprehensive pediatric stroke team, and raising a perinatal stroke survivor provides unique insights when working with patients and their families. First, neuropsychologists can help parents understand their child's current and potential cognitive and behavioral outcomes as well as coping with uncertainty regarding their child's future. In addition, depending upon medical factors surrounding their child's stroke, parents may need help coping with their own psychological trauma and feelings of guilt. Parents may also benefit from guidance on how to manage changes in relationships with extended family and friends, and they should be prepared to model responses to questions from others regarding their child. In addition to developmental deficits, pediatric stroke survivors are at increased risk for behavioral dysregulation, and parents may need coaching in behavioral strategies or referrals to psychiatric treatment resources. As a child becomes more self-aware, parents can also benefit from support as they help their child understand his or her medical condition and grieve any newly appreciated losses that their child may experience. Because school is a child's job, parents may need to become their child's academic advocate, and they may be expected to educate school personnel about childhood stroke. In addition to a child's current challenges, parents should also help teachers understand that some stroke-related cognitive deficits may not become apparent until the child is older, and that his or her need for academic support may increase over time. Providing top-quality stroke care does not end with medical stabilization. Stroke survivors and their families should be treated from a lifespan perspective with an understanding of the far-reaching effects that a child's stroke can have upon the entire family system.

Neuropsychological treatment from the perspective of a parent of a perinatal stroke survivor

Background And Aims Existing research supports intensive therapy involving goal-directed training and practice of skills. Such programs are challenging to deliver in the ambulatory setting due to cost and logistics. We aimed to implement a Hand-Arm Bimanual Intensive Therapy (HABIT) program, measure and improve participant-reported outcomes, and expand program size while maintaining quality. Methods HABIT invovled a camp-like environment for 6 hours/day X 10 days, plus home programs. Fourteen campers (ages 6-11) completed the program in 3 groups. Caregiver education improvements were based on a pilot program (2017). Assisting Hand Assessment (AHA) hierarchy guided each camper's treatment (2018-2019). Program capacity increased from 4 to 6 campers. The role of psychology was was intensified yearly. Outcome assessments included AHA, Canadian Occupational Performance Measure (COPM), PROMIS Parent Proxy Upper Extremity Questionnaire, The Pediatric Outcomes Data Collection Instrument (PODCI), and participant surveys. Results: -Group AHA scores improved at program completion (P=.0006) and remained statistically significant at 30 days (P=.0007) despite a decreasing trend. Pattern consistent with literature. -8 of 13 achieved at least the smallest detectable difference (SDD), consistent with literature -Group exceeded criteria for clinically meaningful change -9 of 13 campers achieved clinically meaningful changes in performance and satisfaction -Improvements for 2018, sustained for 2019 Surveys show improved parent and patient-reported outcomes in 2018, sustained for 2019 Conclusions We implemented HABIT in our ambulatory care center with results comparable to the research literature. AHA score improvements were sustained at 30 days in an expanded program that was enhanced based on QI initiatives, with high satisfaction levels reported by participants.

Intensive bimanual therapy for pediatric chronic hemiparesis: implementing research and optimizing caregiver and patient-reported outcomes

Hemorrhage (HI) accounts for about half of all strokes in children. In total, vascular brain abnormalities accounted for 43.5% of all hemorrhages. Aim: to evaluate the incidence of HI in the primary pediatric stroke center of the Morozov Children City Clinical Hospital; revealed cerebral vascular anomalies without rupture, neurosurgical treatment options. Material: children who were treated in the primary pediatric stroke center from 2017 to 2019, with cerebrovascular diseases, and are included in the Moscow Pediatric Stroke Register. Results: 142 children were enrolled in the register in 2017: 62.2% of ischemic stroke and transient ischemic attacks (IS and TIA), 8.1% of sinus thrombosis (ST) and 29.7% of HI; in 2018, 282 children - 58% IS + TIA, 5.6% ST, 36.4% HI (7% cerebral vessel anomalies without rupture); in 2019, 235 children - 52.7% of IS and TIA, 12.8% of ST, 34.5% of HI (12.8% cerebral vessel anomalies without rupture). Cerebral angiography was performed in 90 patients, of which 45 (50%) patients did not have vascular pathology, 45 (50%) -pathology of cerebral vessels, of which: AVM-in 28 (62.2%) patients, arterial aneurysm - 6 (13.3%), venous angioma i- 4 (8.8%), arteriovenous fistula - 3 (6.6%) patients, ST - 2 (4.4%), Moya-Moya-2 (4.4%). Neurosurgical treatment of 14 patients (2017-2018): 11 (78.6%) with arteriovenous malformations, 2 (14.2%) with cavernomas, 1 (7.1%) aneurysm. Age ranged from 7 to 17 years. Ten of them (71.43%) were operated on: microsurgical -5 (50%), endovascular5 (50%). Conclusion: The neurosurgical service is an important part of the work of primary pediatric stroke centers. Improving diagnostic methods has improved the early detection of cerebral vascular anomalies with the optimal treatment tactics. According to the Moscow pediatric stroke Center, annually the number of first diagnosed cerebral vascular anomalies increases by 30-40%, with the predominance of AVM.

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