United Kingdom

**Abstract authors:**

Trish Domi¹, Darcy Fehlings², Pradeep Krishnan¹, Mahohar Shroff¹, Matylda Machnowska³, Amanda Robertson¹, Gabrielle deVeber¹, on behalf of the CP-NET Group⁴

¹Hospital for Sick Children, ²Holland Bloorview Rehabilitation Hospital, ³Sunnybrooke Health Sciences Center, ⁴Holland Bloorview Rehabiliation Center

**Abstract body:**

Objective: We sought to determine risk factors for hemiplegic cerebral palsy (HCP) associated with perinatal arterial ischemic stroke (AIS) or periventricular venous infarction (PVI). Methods: We studied children with hemiplegic cerebral palsy (HCP) enrolled at nine rehabilitation centres across Ontario. We compared children with underlying AIS or PVI on clinically acquired brain imaging. In addition, we analyzed prenatal (maternal, prenatal/gestational) and perinatal (obstetrical, neonatal) characteristics collected from birth records and standardized parent interviews. Results: The 144 children with HCP (62% male) included 95 with AIS and 49 with PVI. On multivariate analysis, children with PVI had increased rates of maternal fertility treatment (OR=4.7;95%CI=1.0-28.7;p=0.0379) and decreased rates of neonatal seizures (OR=0.03;95%CI=0.0002-0.255;p=0.0001), systemic blood clots (OR=0.082;95%CI=0.0006-0.795;p=0.0278) and emergency cesarian section (OR=0.3;95%CI=0.093-0.896). Preterm delivery rates were similar for AIS and PVI. Conclusion: We determined novel risk factors differentiating the two most typical forms of focal ischemic brain injury in children with hemiplegic CP. These include fertility treatments, mode of delivery, neonatal seizures and systemic blood clots. These findings provide direction for further research exploring causal pathways of focal brain injury and cerebral palsy.

IPSO 2023

Risk factors for Hemiplegic Cerebral Palsy due to Arterial Ischemic Stroke or Periventricular Venous Infarction

poster

Dear IPSO Virtual Conference Attendees:

Welcome to the IPSO 2023 Virtual 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. We encourage you to express your thoughts live in through the chat function to provide a global perspective on all topics. Please introduce yourself in the chat, so everyone knows where you are attending from.

We are excited to announce IPSO is able to offer 9.5 CME units for the virtual conference. If you would like to claim CME credits, please email membership@internationalpediatricstroke.org. 

We want to hear from you! Planning for IPSO 2024 Congress on March 22nd-24th in Toronto, Canada, will commence as soon as the Virtual Conference ends. Let us know your priorities through the live chat function, via email, or by submitting a symposium idea. Based on your input, the Scientific Program Committee will select the topics that we will address in greater depth when we meet again in the spring.

We hope you find the Virtual Conference both interesting and educational, and hope to see you in person in Toronto, or at another IPSO meeting in the future.

Warm regards,

Heather Fullerton, IPSO President 
Maja Steinlin, IPSO Vice-President 
Lori Jordan, IPSO Secretary & Treasurer 
Noma Dlamini, IPSO Scientific Program Committee Chair 


The International Pediatric Stroke Organization (IPSO) 2023 Virtual Conference is April 28-29th, 2023. 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. Similar to the IPSO 2021 Virtual Conference, IPSO has partnered with Underline to host this virtual conference. 

The 2023 IPSO Virtual Conference will offer:

* A highly interactive format: brief recorded talks followed by live panel discussions with audience participation through a chat function and live audience surveys
* Optional break-out groups for IPSO committees, working groups, councils
* Poster sessions available on-demand throughout the conference with a chat function for the audience to comment for ask questions of the presenters

Disclaimer: This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of UCSF and the International Pediatric Stroke Organization (IPSO) and Hospital for Sick Children, and Vanderbilt University Medical Center. UCSF is accredited by the ACCME to provide continuing medical education for physicians.

 UCSF designates this live activity for a maximum of 9.5 AMA PRA Category 1 credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Contact membership@internationalpediatricstroke.org if you would like to claim CME for the IPSO 2023 Virtual Conference. 

**About** 
Founded in February, 2019, we are an organization of health professionals, scientists and patient advocates who care about stroke and other cerebrovascular diseases in childhood. We developed out of our original collaborative network, the International Pediatric Stroke Study (IPSS), and now aim to broaden the scope of our mission beyond research.

* Our mission is to improve the lives of children worldwide with cerebrovascular disease through research, education, clinical care and advocacy.

* Our Vision is a world in which international, multidisciplinary collaborations advance the understanding, care, and outcomes of childhood cerebrovascular disease.

To access IPSO 2023 site, please register [here](https://internationalpediatricstroke.org/2023-virtual-conference/registration/). 

The mission of the International Pediatric Stroke Organization (IPSO) 2023 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. 



**Abstract authors:**

Moran Hausman-Kedem¹, Stephanie Libzon¹, Aviva Fattal-Valevski², Gustavo Malinger³, Shlomi Constantini², Nina Kreiden², Jonathan Roth², Liat Ben Sira², Shelly Shiran²

¹Tel Aviv Sourasky Medical Center, ²Dana Children's Hospital, Tel Aviv Sourasky Medical Center, ³Lis Maternity Hospital, Tel Aviv Sourasky Medical Center

**Abstract body:**

OBJECTIVE: to characterize clinical, neuroimaging data and etiology of spontaneous perinatal intracranial hemorrhage (spICH) in non-preterm. METHODS: a prospective, single-center study of 102 consecutive cases with spICH identified in the fetal/neonatal period between 2014-2022. RESULTS: Fifty-nine cases (58%) were diagnosed antenatally (termination of pregnancy-n=22). Intraventricular hemorrhage (IVH) was the most common hemorrhage type (73%), followed by periventricular hemorrhagic venous infarction (PVHI) (54%), parenchymal (13%), subdural (12%) and subpial (10%) hemorrhage. IVH was more commonly diagnosed prenatally (p=0.003), whereas subpial hemorrhage was exclusively diagnosed postnataly (p<0.001). Of the 73 born neonates, those with prenatal diagnosis were less likely to show symptoms in the perinatal period (p=0.005). There was no difference between prenatal versus postnatal cases or between types of hemorrhage in terms of maternal age, parity status, and mode of delivery. Intrauterine growth retardation was associated with parenchymal hemorrhage (p=0.039). Germinal matrix was the most common origin of hemorrhage (48%) and was more common in the prenatal group (65% vs. 28%, p<0.001), followed by choroid plexus (46%), hemorrhagic transformation of venous infarction (8%), bleeding diathesis (3%), vascular malformation (2%) and congenital tumor (1%). A family history of thrombophilia or coagulopathy was associated with subpial hemorrhage (p=0.033), and post-natal IVH (p=0.009). Genetic workup was performed in 42%, yielded a diagnosis in 35% of them, mostly with antenatal bleeding (p=0.003), and was associated with prenatal PVHI (p=0.029). Conclusion: Patterns of hemorrhage, as well as mechanisms, were different between the prenatal and postnatal cases, suggesting different disease mechanisms. Coagulopathy may contribute to spICH presenting in the postnatal period, whereas genetic factors play a major role in prenatal ICH.

Spontaneous perinatal intracranial hemorrhage-clinical, neuro-imaging and etiological correlates

**Abstract authors:**

Meghan Maiani, Alicia Hilderley¹, Catherine Lebel¹, Helen Carlson¹, Adam Kirton¹

¹University of Calgary

**Abstract body:**

Introduction: Perinatal stroke (PS) occurs in 1:1100 births and impairment can affect independence throughout the lifespan. The most common types of PS are arterial ischemic stroke (AIS) and periventricular venous infarction (PVI). Cerebral visual impairment is common after PS but mechanisms remain under-investigated. Understanding the structural development and plasticity of visual pathways will support the advancement of prognostic tools and contribute to validated therapies reducing impairment. Hypothesis: White matter microstructure of the afferent visual pathway will be altered in PS compared with typically developing controls (TDCs), with the greatest differences in children with AIS. Methods: White matter diffusion imaging and tractography were used to isolate optic radiations. Diffusion and T1-weighted anatomical sequences were obtained using a 3T GE MR750w scanner. Probabilistic white matter tractography was completed using anatomically placed regions of interest combined with a constrained spherical deconvolution model.. Mean fractional anisotropy (FA) was extracted for each optic radiation and compared between PVI, AIS and TDCs using ANCOVA, controlled for age. FA was compared between hemispheres using paired t-tests. Results: Ninety-three children aged 6-18 years (N=22 AIS, N=28 PVI) as well as similarly aged TDCs (N=43) were recruited. Both AIS and PVI groups showed lower FA in both the lesioned and non-lesioned hemispheres compared to controls (p<0.001). Between-hemisphere differences in FA were present in the AIS group (p<0.001), but not in PVI (p=0.21). Conclusion: Analysis of white matter in visual pathways shows bihemispheric differences in microstructure between children with different PS types and healthy controls, with the greatest differences observed in the AIS group. Future research will investigate perceptual and ophthalmological outcomes to determine prevalence and severity of visual impairment in children with PS, specifically AIS.

White matter tractography of visual pathways in children with perinatal stroke

**Abstract authors:**

Inna Shchederkina¹, Natalia Bronina¹, Aleksandra Kuznetsova¹, Matvey Livshits¹, Ella Kumirova¹

¹Morozov Children's Clinical Hospital

**Abstract body:**

Risk factors of stroke in oncological diseases are: direct effects of the tumor, infection, coagulopathy, diagnostic and treatment procedures, chemotherapy and radiation therapy, bone marrow transplantation, and hematopoietic factors. Material and methods: The study included children treated at the Morozov Children's Clinical Hospital who had a diagnosis of cancer with cerebrovascular complications from 2018 to 2020. Methods: clinical, anamnestic, laboratory, neuroimaging. Results: For the period 2018-2020, 369 children were included in the Moscow register of cerebrovascular diseases, of which 41 patients (11.1%) had cancer. The average age was 7.5 years, of which 51.2% were boys. Group 1 - patients with brain tumor - 21 patients (51.2%); group 2 - patients with leukemia - 22%, group 3 - patients with extracranial tumor - 26.8%. Arterial ischemic stroke (AIS) was observed in 14 children - 10.4% of all AIS in stroke register, hemorrhagic stroke (HI) in 21 children, which accounted for 11.7%, sinus thrombosis (ST) in 6 patients - 10.7%. In group 1, the distribution was as follows: AIS 38%, HI 47.6%, ST 9.5%. Death was in 8 patients (19,5%), among all deaths due to cerebrovascular disease - 22.8%. In group 1, death was 14.2%, in group 2 - 44%, in group 3 - 9%. Conclusion.Cerebrovascular complications in oncology diseases are not rare. In patients with neurooncology HI predominated. Cerebrovascular complications increased mortality among cancer patients.

Cerebrovascular complications in oncology diseases in children: experience of the Primary Pediatric Stroke Center and pediatric oncological Center of Moscow .

**Abstract authors:**

Débora Sanz¹, María Vazquez¹, Ana Jové¹, Yolanda Ruiz¹, Paula Vazquez¹, Jesús López-Herce¹

¹Hospital Universitario Gregorio Marañon

**Abstract body:**

Background and Aims Paediatric stroke is a rare event, ~2/100.000 children, but it has an important morbidity, being the main cause of acute acquired cerebral injury. Stroke alerts and care pathways have become an integral part of acute paediatric stroke care and their implementation is recommended by several Stroke and Neurology Associations. Methods A prospective, observational study was performed, in our tertiary paediatric institution, from February 2019 to December 2022, since implementation of a multidisciplinary stroke alert system and care pathway in our county and hospital. Demographic, clinical and neuroimaging data was collected and analysed. Results There were 92 stroke alert activations during the study period, but only 27 (29.3%) were true strokes. 19 of them were ischemic (70.4%), 7 haemorrhagic strokes (25.9%) and 1 sinus venous thrombosis (3.7%). Age range for patients who suffered a stroke was 6 months to 15 years old, with a peak incidence in patients older than 10 years, 14 patients (51.9%). 70.4% were males. 17 patients required more than one neuroimaging technique for the diagnosis of stroke, generally cranial computed tomography (CT) followed by magnetic resonance image (MRI). Invasive intracranial pressure monitoring was used in 3 patients. Only 2 patients with ischemic stroke received acute treatment with thrombolysis, and 1 of them received also thrombectomy. 3 patients with haemorrhagic strokes underwent surgery. 4 patients underwent endovascular treatment, 3 of them had a diagnosis of cerebral AVM and 1 had a basilar aneurysm. 2 patients died (7.4%). 19 patients of 25 survivors (76%) suffered sequelae after stroke, most of them hemiparesis 15 (78.9%). Conclusions A stroke was detected in almost a third of stroke alert activations and acute treatment was uncommon in our cohort. The implementation of a multidisciplinary alert system improves diagnosis and treatment of stroke patients.

Stroke diagnosis and characteristics after implementing a multidisciplinary stroke alert system

**Abstract authors:**

Ria Pal¹, Katherine Xiong¹, Sarah Lee¹

¹Stanford University

**Abstract body:**

Introduction Rapid stroke diagnosis via emergent neuroimaging can prevent secondary injury. Pediatric stroke alerts, however, are infrequent, leading to limited opportunities to practice protocols. Pediatric stroke alerts also require urgent collaboration between multiple discrete teams to coordinate imaging, sedation, hyperacute treatments, and other aspects of care. This can result in communication breaks, logistical challenges, and unclear divisions of responsibility. Objective By identifying stakeholder needs across disciplines, we sought to streamline our ED stroke alert process and improve time-to-imaging for children presenting acutely with suspected stroke. Methods We performed a retrospective assessment of stroke alerts in the Stanford pediatric ED from 2016-2021. Root cause analysis was performed using the 5 Whys methodology and fishbone diagram. Surveys were conducted with neurology, emergency medicine, pediatric anesthesia, neuro-IR, and neuroradiology stakeholders regarding potential sources of imaging delays. Staged interventions were implemented between January-June 2022 using Plan-Do-Study-Act cycles. Time-to-imaging was measured for each stroke alert pre- and post-intervention. Results Surveys indicated that key drivers of imaging delays could be categorized as provider protocol familiarity, information and equipment availability, and process and outcome transparency. Interventions were designed to address each key driver (Figure 1). Post-implementation, short-term analysis demonstrated a consistent but as yet-statistically insignificant decrease in mean time-to-imaging for CT (47±31 to 22±13 minutes, p=0.26), MRI without sedation (67±52 to 49±22 minutes, p=0.15), and MRI with sedation (151±42 to 92±7 minutes, p=0.07, Figure 2 ). Conclusions Communication across teams is essential for effective pediatric stroke care. We offer our process improvement experience with adaptable interventions at a large, tertiary-care hospital system.

Fostering Collaboration in Acute Pediatric Stroke Care: Lessons from Creating an Interdisciplinary Alert System

**Abstract authors:**

Akshat Pai¹, Samyami Chowdhury¹, Daniel Nichol¹, Heather Fullerton², Sahar Hassanein³, Lauren Beslow⁴, Christine Fox², Nomazulu Dlamini¹, On Behalf of IPSS Investigators

¹Hospital for Sick Children, ²UCSF Benioff Children's Hospital, ³Ain Shams University, ⁴Children's Hospital of Philadelphia

**Abstract body:**

Introduction Although pediatric hemorrhagic stroke (HS) accounts for 50% of childhood strokes, large pediatric stroke registries like the International Pediatric Stroke Study (IPSS) have focused on ischemic stroke. Previously, the IPSS has not collected data on social determinants of health (SDOH). Objective We sought to expand the IPSS registry to include HS and begin novel data collection on SDOH. Methods We developed new IPSS data collection forms related to HS and SDOH. After IRB approval, IPSS sites enrolled children (aged >28 days - 18 years) who had HS between 2004 and 2023. Local sites conducted a retrospective chart review. SDOH were collected by guardian report. We centrally analyzed data including frequencies and proportions of age, sex, race, ethnicity, language, educational attainment, and household income. Preliminary Results To date, ten IPSS sites enrolled 120 children (58% male) with HS. The median age at onset of stroke was 9.9 years (IQR 4.3-14.0). Vascular malformations were identified in 53 patients (44%). Arteriovenous malformation (n = 33) was the most commonly reported etiology, followed by aneurysm (n = 6) and cavernous malformation (n = 2). Race and ethnicity data were available in 115 (95%) patients (Table 1). SDOH were reported for 50 (42%) families. Among these, 15 (30%) reported speaking a different language than their healthcare provider and 8 (53%) required an interpreter. Of 36 families for whom primary caregiver educational attainment data and household income data was available, 19 (53%) obtained a Bachelors degree or higher, whereas 28 (78%) reported their household income. Significance This is a preliminary analysis of a novel international HS registry. Our interim analysis suggests that a significant proportion of families of children with HS may have language barriers. In this ongoing registry study, we plan to further examine SDOH in children with hemorrhagic stroke.

Social Determinants of Health and Pediatric Hemorrhagic Stroke: A New Facet of the IPSS

**Abstract authors:**

Alex Devarajan¹, Mais Al-Kawaz¹, Jessica Bonet¹, Daryl Goldman¹, Christina Rossitto¹, Michelle Sorscher¹, Peter Morgenstern¹, Tomoyoshi Shigematsu¹, Alejandro Berenstein¹, Johanna Fifi¹

¹Icahn School of Medicine at Mount Sinai

**Abstract body:**

Introduction Patients with Vein of Galen malformations (VOGM) can develop significant angiogenesis leading to hemodynamic and structural remodeling. This results in an extensive fine angiogenic network fistulizing to the vein of Galen. In patients with angiogenic networks, transarterial embolization (TAE) is challenging due to poor penetration and access while transvenous approaches (TVE) carry a risk of hemorrhage from pathologic vasculature. These patients present early and symptomatically and can have devastating outcomes if not treated. Objective We illustrate the case of a pediatric patient who presented with an angiogenic VOGM ultimately treated by staged TAE with a miniature dual-lumen balloon microcatheter (DLBC) and curative TVE. Case Presentation A 12-month-old boy presented after VOGM was identified during workup for progressive hydrocephalus. Endovascular embolization was offered. The infant underwent five staged TAE, followed by curative TVE via pressure cooker technique. Initial pre-embolization angiogram demonstrated a diffuse vascular network within the third ventricle and choroidal fissure superiorly feeding the malformation. Because the network complicated fistulous point access, a miniature DLBC was utilized to achieve distal pedicle flow arrest and partial network devascularization. Postoperatively, the embolization was complicated by IVH and hydrocephalus requiring an ETV with no lasting neurological deficit. For the final embolization, given the arterial morphology and progressive venous reduction, TVE was the technically easiest choice to achieve angiographic cure. Follow-up angiogram demonstrated complete obliteration of the malformation and subsequent clinical follow-up demonstrated improvements in milestones. Conclusion Through a combination of new technologies and techniques, technically challenging VOGMs are now curable. The patient is able to achieve a relatively normal quality of life due to timely and effective treatment.

Angiographic Cure of a Highly Angiogenic Vein of Galen Malformation by Staged Transarterial and Transvenous Embolization: Case Report

**Abstract authors:**

Alex Devarajan¹, Jessica Bonet¹, Alexander Schupper¹, Christina Rossitto¹, Michelle Sorscher¹, Alejandro Berenstein¹, Johanna Fifi¹, Tomoyoshi Shigematsu¹

¹Icahn School of Medicine at Mount Sinai

**Abstract body:**

Introduction Vein of Galen Malformations (VOGM) are congenital arteriovenous malformations (AVM) primarily treated by endovascular embolization via transarterial (TAE) or transvenous (TVE) approaches. TVE can be utilized to close the malformation but carries risk of venous congestion and redirection of venous outflow with significant neurologic consequences. Objective Here, we illustrate the atypical use of an intracranial venous sinus stent to improve normal venous outflow after TVE in the case of a pediatric patient with VOGM. Case A 3-year-old girl presented for continued management of VOGM. She had received six prior TAEs at the senior author's institution: after progressive reduction of the malformation, she was a suitable candidate for TVE. Pre-embolization angiogram demonstrated a choroidal type VOGM with venous hypertension: the vein of Galen drained retrograde through the vein of Labbe, the left transverse sinus drained into cortical cerebellar veins without opacification of the left sigmoid sinus, and stenosis of the right sigmoid-jugular junction was present. Balloon angioplasty of the right sigmoid-jugular junction was performed to aid guide catheter navigation. After TVE by pressure cooker technique, balloon-assisted venous sinus stenting was performed at the right sigmoid-jugular junction to aid normal venous sinus drainage. Post-embolization angiogram demonstrated reduced shunting through the malformation and reduced aberrant cortical venous drainage. Shunted blood mainly drained to the right transverse-sigmoid sinuses with marked improvement of venous diameter and flow. The patient experienced no postoperative complications and clinical follow-up demonstrated improvement in milestones. A second TVE resulted in complete occlusion. Conclusion In patients with VOGM and venous hypertension receiving TVE, venous sinus stenting may be a safe and effective option to reduce aberrant cortical venous drainage and improve normal outflow.

Adjunctive Venous Sinus Stenting in Transvenous Embolization of Vein of Galen Malformation: Case Report

**Abstract authors:**

Zokirzhon Zokhidov¹, Matvey Livshits¹, Inna Shchederkina¹, Gennady Chmutin¹, Sergey Ozerov¹, Alexander Levov¹, Madina Berdieva¹, Anastasia Vergizovа¹

¹Morozov Children's Clinical Hospital

**Abstract body:**

Relevance: Arteriovenous malformation (AVM) in children is a risk factor for hemorrhagic stroke. Materials: The study included 72 children who applied to "Morozov Children's City Clinical Hospital, with a diagnosis of AVM of the cerebral vessels with the presence of intracerebral hematoma. Age ranged from 1 month. up to 18 years old, the median age at diagnosis was 9.6. Boys vs girls-36(50%) vs 35 (50%) Methods: Of 72 children, surgical treatment was performed in 61. Seven patients were not operated on, after stabilization of their condition, they were referred for stereotaxic radiosurgery. 4 patients died. Cerebral deficit was the leading symptom in 52 patients. In 17 patients, the assessment of focal symptoms was difficult due to the severity of the condition. The level of impaired consciousness: clear consciousness in 17 (23.6%), stunning in 23 (31.9%), stupor in 15 (20.9%), coma in 17 (23.6%). The most common localization of AVMs is the parietal lobe. Distribution of patients according to Spetzler-Martin gradation: AVM: type I -- 9 (12.5% %), type II -- 21 (29.2%), type III -- 26 (36.1%), IV -- 13 (18, 1%), V -- 3 (4.1%) patients. The volume of intracranial hematoma ranged from 9 ml to 130 ml. The results: based on the timing of admission to the hospital, the severity of the patient's condition, the size and location of the hematoma, its relationship to the mid-stem and basal structures, a decision was made on the need and extent of surgical intervention. Type of operation: microsurgical in 31 (51%) patients, embolization in 12 (20%) patients and combined intervention (microsurgery + embolization) - in 18 (29%) patients. Outcome: complete regression of neurological symptoms in 34 (55.7%) patients, moderate disability in 20 (32.8%) patients, severe disability in -7 (11.5%) patients. Conclusion: Surgical tactics as early as possible allows to achieve good outcomes in most patients.

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Risk factors for Hemiplegic Cerebral Palsy due to Arterial Ischemic Stroke or Periventricular Venous Infarction

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Spontaneous perinatal intracranial hemorrhage-clinical, neuro-imaging and etiological correlates

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