United Kingdom

IPSO 2023

Paediatric Strokes in Ibadan, Nigeria: current trends, risk factors and long term outcomes

technical paper

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:**

Raluca Tudorache¹, Manoelle Kossorotoff², Olivier Naggara², Gregoire Boulouis³

¹Prof Dr Alexandru Obregia Clinical Hospital, ²Univ Hospital Necker-Enfants malades, ³CHU Tours

**Abstract body:**

Introduction. Reducing management delays until revascularization in acute arterial ischemic stroke (AIS) is critical to improve outcomes, yet the determinants of such delays have not been reported in children. Hypothesis. We explored the determinants of delay between last-known-well (LKW) and initiation of recanalization treatment in children. Methods. This is an ancillary study of the national French KidClot study, which included consecutive pediatric patients with AIS and recanalization treatment (IV thrombolysis IVT and/or mechanical thrombectomy MT) from January 1, 2015 to May 31, 2018. We assessed the effect of i) pre-hospital triage (i.e. dispatching considering a potential stroke), ii) direct admission to a tertiary care center versus need for transfer, and iii) management in a pediatric vs adult unit on the delay from LKW to recanalization treatment, as well as on clinical outcomes (mRS at 1 year). Results 68 children were included, treated with IVT alone (n=31), MT alone (n=23), or combined IVT+MT (n=14). Median age was 11 years old [IQR 4-16] and initial PedNIHSS 13 [IQR 7-19]. Prehospital triage demonstrated a significant role in reducing LKW to first recanalization treatment delay (229 vs. 270 min, p=0.01), especially for delays to MT (p<0.001). No significant effect on treatment delay was associated with direct vs secondary admission to a tertiary care center, or management in an adult vs pediatric unit (although a tendency towards shorter delay to MT was observed in adult units: 370 vs 437 min, p=0.06). Prehospital triage was significantly associated with favorable outcome, with a shift towards lower mRS categories (p=0.021) despite similar presentation severity. Conclusions In children with AIS, prehospital triage seems to be the most significant factor associated with shorter recanalization treatment delays, and better outcomes in treated patients. These results present a major incentive to improve the prehospital part of pediatric stroke codes.

Hyperacute pediatric stroke pathway of care: what are the determinants for an earlier access to recanalization treatments and better outcomes? Data from the KidClot study.

**Abstract authors:**

Amr Elgehiny¹, Lakshmi Srivaths¹, Sishir Mannava¹, Shaikha AlQahtani¹, Jiasen He¹, Stuart Fraser¹

¹University of Texas health science center Houston

**Abstract body:**

Introduction: We present a case series of 5 children with spinal cord infarction (SCI). Our objectives are to study the clinical presentation, MRI findings, etiology, risk factors and treatment options for pediatric SCI. Methods: Descriptive analyses of 5 pediatric patients with SCI. Results: Median age was 8 years (range 0.2-15). There were 2 males and 3 females. 3 patients presented with lower extremity weakness (bilateral in 2, unilateral in 1) and 2 with hemiplegia. Pain was reported in 2 patients (back pain in 1, neck/shoulder pain in 1). MRI showed infarction involving thoracic spine in 3, cervical spine in 1, and cervical and thoracic spine in 1 patient. Notably, imaging was initially negative in 2 patients, with infarct visible on follow-up imaging 3-5 days later (Figure 1). Suspected etiologies included vascular malformation versus hemorrhagic infarct in 1, rotational arteriopathy in 1, and fibrocartilaginous embolism in 3 patients. Thrombosis was not found in any patient. Treatment was mainly supportive, though 2 patients received pulse steroids during the initial diagnostic period. 3 patients were started on prophylactic aspirin. At 3 months follow up, 4 patients had improved, with 1 asymptomatic, 3 ambulatory with mild to moderate deficits; 1 patient had spastic diplegia. Discussion/Conclusion: Pediatric SCI is mostly idiopathic. In our series, fibrocartilaginous embolism ,rotational arteriopathy, and vascular malformation were suspected etiologies. Thrombotic disorders have been associated with SCI, though none was found here. Sudden pain and neurological deficits can be presenting features. MRI was essential for diagnosis and follow-up. Thrombotic, infectious, and vessel-imaging work-up were required to evaluate the etiology. Treatment is mainly supportive. The utility of antiplatelet agents in idiopathic SCI is unclear. The outcome appears encouraging with all except one patient improved or recovered on follow-up.

Pediatric Spinal Cord Infarction - a Case Series

**Abstract authors:**

Ethan Luk¹, Kirstin Walker, Hannah Bernstein, Andrea Kassner¹, Amanda Robertson¹, Trish Domi¹, Pradeep Krishnan¹, Prakash Muthusami¹, Manohar Shroff¹, Nicholas Stence², Timothy Bernard², Gabrielle deVeber¹, Adam Kirton³, Helen Carlson³, Andrea Andrade⁴, Mubeen Rafay⁵, Bruce Bjornson⁶, Danny Kim⁷, Max Wintermark⁸, Nomazulu Dlamini¹

¹The Hospital for Sick Children, ²Children's Hospital Colorado, ³Alberta Health Services, ⁴London Health Services Centre, ⁵Health Sciences Centre Winnipeg, ⁶The University of British Columbia, ⁷BC Children's Hospital Research Institute, ⁸The University of Texas

**Abstract body:**

In this study, the impact of Cerebral Blood Flow (CBF) in non-ischemic brain regions is analyzed measure stroke severity. The hippocampus is a complex brain structure in the temporal lobe and plays a role in learning, memory and spatial navigation. Monitoring hippocampal CBF after AIS may help in understanding its role in childhood development, and allowing for stroke outcome predictions. CBF within the ipsilesional (stroke hemisphere) and contralesional (non-stroke hemisphere) hippocampi was assessed and associated with neurological and sensorimotor deficits observed at acute, subacute (3-7 days post-stroke) and chronic (3 months post-stroke) phases of stroke recovery. Nine pediatric stroke patients (mean age 14.89 ± 2.85, 4 Male) with unilateral, non-hippocampal stroke lesions were scanned using arterial spin labelling MRI in a 3T Siemens MRI scanner with a 2D pulsed labeling scheme. Neurological outcome was evaluated with the Pediatric Stoke Outcome Measure (PSOM) at 3-7 days and at 3 months post-stroke. Mean CBF at the hippocampi were compared to seven healthy controls (mean age 14.53 ± 1.43, 2 Male). Mean CBF (mL/100g/min) in the ipsilesional and contralesional hippocampi were 52.77 ± 10.98 and 54.69 ± 14.24 respectively. Mean CBF in the control group was found to be greater at 61.14 ± 12.30. ANOVA between groups revealed an F-statistic of F=1.24 (p=0.30) and a post hoc one tailed t-test between the ipsilesional and control group yielded a t-statistic of t=1.55 (p=.067). A negative correlation of ρ=-0.77 (p=.025) was observed between CBF ratios in intrasubject hippocampi and the PSOM score observed at the acute timepoint. CBF ratios against PSOM score at three months post-stroke showed a Spearman coefficient of ρ=-0.96 (p<<.001). Intrasubject CBF between hippocampi at the acute timepoint was found to be a strong indicator of neurological and sensorimotor deficits at three months ponths post-stroke. A larger sample size is required to determine validity.

Examining the Impact of Pediatric Arterial Ischemic Stroke on Cerebral Blood Flow within the Hippocampus and its Relationship with Observed Neurological Deficits

**Abstract authors:**

Daniel Sare¹, Daniel Li¹, Trish Domi¹, Adam Waspe¹, Nomazulu Dlamini², Andrea Kassner¹

¹Hospital for Sick Children, ²Senior Scientist - Neuroimaging

**Abstract body:**

INTRODUCTION Acute ischemic stroke (AIS) remains as a significant cause of neurological impairment and ranks as one of the top ten causes of death in childhood. While current research has revealed new treatment practices, risk factors, and neurological outcomes, there remains a gap in our understanding of the mechanisms of stroke in the developing brain, as well as limited therapies, especially beyond the perinatal or neonatal period. The photothrombotic 'ring' model causes ischemic damage within a given cortical area by photochemically induced platelet occlusion of cortical vasculature. Using this technique facilitates reproducible infarction sizes with delineated boundaries for precise lesion characterization. When considering treatment for AIS, use of HMG-CoA reductase inhibitors (statins) are a potential candidate. This study aims to longitudinally assess stroke and BBB damage following use of a statin in a juvenile photothrombotic rat stroke model using quantitative MRI. METHODS A photothrombotic stroke was induced in 10 male Sprague Dawley rats. 5 rats received 20 ml/kg of Atorvastatin and 5 rats received no treatment. Quantitative MRI (T2W, DWI, DCE) was performed at Day 0, 2, 7 on all rats using a 3T MRI system. 3D slicer was used to analyze the T2W images. The lesion was segmented for each slice to calculate lesion volume. Apparent diffusion coefficient (ADC) maps were created from DWI images and values were calculated for the lesion, penumbra, and control area. Permeability maps were generated from DCE images using the Patlak model and values were calculated within the lesion and control area. Student's t-tests, Benjamini-Hochberg corrected for multiple comparisons with an α level of 0.05, were conducted to compare both groups. RESULTS The measured T2W lesion volume was significantly reduced in the statin group on day 2 (p = 0.048) and 7 (p = 0.028) following AIS. ADC and BBB values showed no significant changes between groups over time.

Investigating the Use of Statins in a Juvenile Photothrombotic Rat Stroke Model

**Abstract authors:**

Joy Alejo¹, Ikeoluwa Lagunju¹, Michael Adeyekun¹

¹University College Hospital

**Abstract body:**

Introduction In Nigeria and sub-Saharan Africa, the commonest cause of strokes in childhood is sickle cell disease. Focal cerebral arteriopathy (FCA) accounts for up to 12% of paediatric strokes but is relatively under-diagnosed and under-reported in this part of the world. We report a case in a 4 year old girl. Case history A previously healthy 4 year old girl presented with a day's history of vomiting, left sided focal seizures and subsequent weakness of the left upper and lower limbs. Her haemogblobin phenotype is A. There was no antecedent history of a rash, fever, cough or coryza. Clinical examination revealed a moderately dehydrated young girl, with a left upper motor neurone facial nerve palsy, left sided hypotonia, hyper-reflexia and reduced power. A diagnosis of a right hemispheric cardiovascular accident of unknown cause was made. Clotting profile and full blood count iwere normal. Electrolytes, urea and creatinine were also normal. Fasting lipid profile was also within normal limits. Echocardiography was normal. Cranial CT revealed extensive acute right cerebral infarct in the right MCA & PCA territories (Figure 1). Brain MRI revealed extensive acute right cerebral infarct in the right MCA & PCA territories likely due to right ICA occlusion (Figure 2). MRA TOF as well as volume rendered images showed non-visualization of the ICA on the right with some signal intensity noted in the right MCA presumably from collateral flow from both ACA (Figure 3). Patient had aspirin and prednisolone, and commenced physiotherapy. Power gradually increased to 3+ in the left upper limb and 4 in the left lower limb. She has continued to improve. Conclusion Sickle cell disease is not the only cause of childhood ischaemic stroke in our region. FCA should be considered. Prognosis is favourable even in our setting.

Focal Cerebral Arteriopathy in a Nigerian Child

**Abstract authors:**

Stuart Fraser¹, Wilmot Bonnet², Michael Dowling², Sam Russo¹, Beth Anne Cavanaugh¹

¹Division of Child and Adolescent Neurology, ²Division of Child Neurology

**Abstract body:**

Objective: To describe patterns of ischemic infarction in cases of acute hydrocephalus. Methods: Authors identified recent cases from their institutions and shared clinical descriptors. Brief case reports and imaging findings are described below. Case 1: A 12 month old with dandy walker malformation and ventriculoperitoneal shunt presented for new onset seizures and altered mental status. Magnetic resonance imaging demonstrated worsening hydrocephalus and the patient went to the operating room for emergent shunt revision. Post-operative MRI the following day demonstrated watershed, posterior cerebral artery, and cerebellar infarctions (Figure 1) Case 2: A 16 year old male with a history of ventriculoperitoneal shunt and epilepsy presented in status epilepticus. MRI confirmed shunt failure and the patient was emergently taken to OR for hydrocephalus. He had delayed recovery after shunt revision, and MRI demonstrated posterior cerebral artery and cerebellar infarctions (Figure 2) Case 3: A 2 year old male with achondroplasia developed sudden onset confusion and lethargy. Emergent magnetic resonance imaging demonstrated acute hydrocephalus, as well as infarction in the occipital lobe and cerebellar hemispheres. After ventriculoperitoneal shunt placement, he had no further infarction (Figure 3). Conclusion: Acute hydrocephalus, associated with increased intracranial pressure, is associated with posterior cerebral artery and cerebellar infarction. The exact mechanism of infarction is unclear. We propose posterior cerebral artery infarctions may be mediated from tentorium cerebelli impinging on the posterior cerebral arteries. Cerebellar infarcts may also be mediated by a similar mechanism.

Patterns of Infarction in Acute Hydrocephalus

**Abstract authors:**

Abhijit Das¹, Alex Ankar¹, Alyssa Runco¹, Kristen Fisher¹, Sarah Risen¹, Daniel Davila Williams¹

¹Baylor College of Medicine

**Abstract body:**

Spinal cord infarction is difficult to diagnose in pediatrics, especially given symptomatic overlap with demyelinating/neuroinflammatory disease and its low incidence. Typical presentations involve acute, progressive loss of function at corresponding spinal levels, though autonomic symptoms are not well described in children. Here, we describe a pediatric patient presenting with neurogenic shock due to acute traumatic spinal cord infarction attributed to fibrocartilaginous emboli (FCE). A 10-year-old female presented after being found on the floor. She recalled a neck hyperextension-hyperflexion event while cheerleading the night prior. Hours later, she developed bilateral hand weakness and paresthesias in all extremities. In the morning, she fell when walking and could not get up. Initial vitals revealed hypothermia, normocardia, and hypotension requiring vasoactives. Head CT was normal. She was admitted to ICU for presumed urosepsis given pyuria. Neurologic exam was notable for intact mentation and sensation, 0/5 distal upper extremity (UE) strength in all modalities, UE areflexia, 3/5 proximal UE strength, and 4/5 lower extremity strength with intact reflexes. Spinal MRI revealed traumatic disc protrusion at C3-C4 and C4-C5 with associated edema; DWI showed diffusion restriction from C3-C7 suggestive of acute infarct from FCE. CSF evaluation was unrevealing for neuro-inflammation. She was later discharged to inpatient rehab. The incidence of neurogenic shock in cervical spinal cord injury has been reported at 29%, though it is unclear if incidence is higher among patients with cord ischemia. In the acute setting, other differentials, such as acute flaccid myelitis or transverse myelitis, can also present with vital signs that may be interpreted as dysautonomia rather than neurogenic shock. In patients presenting with acute, progressive myelopathy coupled with severe autonomic instability, it is imperative to consider ischemic injury in the differential diagnosis.

Traumatic Pediatric Spinal Cord Stroke Presenting with Acute Spinal Shock

**Abstract authors:**

Mahesh Chikkannaiah¹, Sarah Yu², Laura Fonseca¹, Ajay Goenka³, Gogi Kumar¹

¹Dayton Children's Hospital, ²Wright State University, ³Eternal Hospital

**Abstract body:**

Abstract Objective We report a 11-month-old under immunized girl from the United States with ischemic stroke associated with inflammatory focal cerebral arteriopathy secondary to tuberculous meningitis. Methods Diagnosis was based upon the head CT, brain MRI, and magnetic resonance angiography (MRA) of the head and neck, CSF evaluation, TB blood and skin test, and gastric aspirate culture. Results Patient presented to the local emergency department (ED) for left arm and leg weakness. Laboratory work was significant for hyponatremia. Head CT demonstrated an area of attenuation in the right basal ganglia and caudate nucleus, and a focus of gray and white matter differentiation loss in the right frontal cortex. MRI brain showed a right middle cerebral artery stroke. CSF evaluation showed pleocytosis with hypoglycorrhachia and elevated protein. Further testing showed mediastinal and hilar lymphadenopathy and additional history included exposure to a grandparent with active tuberculosis. Discussion This case emphasizes the importance of childhood vaccinations and considering CSF evaluation, which is usually not considered as part of routine pediatric stroke work up. With increasing international travel and global immigration, clinicians even in the non-endemic countries should consider tuberculosis in their differential diagnosis.

Pediatric stroke associated with inflammatory focal cerebral arteriopathy secondary to tuberculous meningitis in the United States

**Abstract authors:**

Melissa Fleming¹

¹Children's National Hospital

**Abstract body:**

Intro: Movement disorders following stroke are a rare but known phenomenon. Presentations includes chorea, dystonia, tremor, ballism, and parkinsonism. They can occur acutely or delayed; they can be transient or persistent. The basal ganglia are frequently involved. Presented here is a case of hemichorea following thrombectomy. Case: The patient is a 16-year-old male who presented to our ED with classic signs of left MCA stroke: acute right hemiparesis, facial droop, and aphasia. Imaging demonstrated thrombus at the left ICA terminus. He received TPA and was briefly transferred to an outside hospital for thrombectomy. He returned to our hospital the next day for ongoing management with a very different exam. His facial droop and aphasia were resolved, with only slight weakness in the right arm and leg. However, he had new involuntary movements on the right side, described as chorea. Seizure was ruled out with negative EEG. Repeat imaging showed left MCA territory infarct with some residual clot within the left MCA but improved flow. His hemichorea was thought to be the result of basal ganglia involvement of stroke. He was started on tetrabenazine for management. Discussion: Hemichorea following stroke is a rare finding, estimated at 1% based on literature review. Notably, these studies were in adults; prevalence among pediatric and adolescent stroke survivors could not be found. Imaging typically demonstrates basal ganglia involvement though other involved structures include the thalamus, subthalamic nuclei, and cortex. Chorea after ischemic stroke tends to present quickly, within hours. It is noteworthy that our patient initially presented with hemiparesis, but, following thrombectomy, had quick return of strength but acute hemichorea. Pharmacologic therapy options include antipsychotics, benzodiazepines, antiepileptics, and tetrabenazine. Improvement or resolution of chorea within 6 weeks is reported in most patients, though some will have persistent symptoms.

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Paediatric Strokes in Ibadan, Nigeria: current trends, risk factors and long term outcomes

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Hyperacute pediatric stroke pathway of care: what are the determinants for an earlier access to recanalization treatments and better outcomes? Data from the KidClot study.

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