Multimodal Neuromonitoring in the ICU Management of Acute Stroke and Traumatic Cerebrovascular Injuries

Advances in the Critical Care of Neonates and Children with Stroke

Objectives: The prevalence of cancer among children with ischemic stroke is unknown. This study sought to evaluate cancer-associated childhood ischemic stroke in a multinational pediatric stroke registry. Methods: Children between 29 days and 19 years of age with arterial ischemic stroke (AIS) and/or cerebral sinovenous thrombosis (CSVT) enrolled in the International Pediatric Stroke Study between January 2003 and June 2019 were included. Data including types of cancer, stroke etiology, and stroke treatment were compared between subjects with and without cancer using Wilcoxon rank sum and chi-square tests. Results: Remote or active cancer was present in 99 of 2968 children (3.3%) with AIS and 64 of 596 children (10.7%) with CSVT. Children with cancer were older than children without cancer in both the AIS (9.5 versus 5.7 years, p=0.0001) and CSVT groups (8.2 versus 6.3 years, p=0.014). Among children in whom cancer type was identified, 42 of 88 (48%) AIS cases had brain tumors and 35 (40%) had hematologic malignancies; 45 of 58 (78%) CSVT cases had hematologic malignancies and 8 (14%) had brain tumors. Primary causes most commonly reported in children with cancer-associated AIS included: arteriopathy (n=34, 62%), cardioembolic (n=9, 16%), prothrombotic state (n=4, 7%), and infection (n=4, 7%). The most frequently reported primary cause of CSVT in children with cancer was prothrombotic state (n=38, 83%). Children with cancer were less likely to receive any antithrombotic therapy for AIS (58 % v. 80%, p=0.007) and anticoagulation for CSVT (71% v. 87%, p=0.046), compared with children without cancer. Recurrent AIS (5% v. 2%, p=0.04) and CSVT (5% v. 1%, p=0.006) were more common among children with cancer. CONCLUSION: Cancer is an important risk factor for incident and recurrent childhood stroke. Although multiple risk factors for stroke were noted in children with cancer, presence of cerebral arteriopathy in children with AIS and prothrombotic state in children with CSVT appear to be the most significant underlying mechanisms contributing to increased risk for stroke in this population. Future research investigating the role of stroke prophylaxis in the high-risk subpopulations identified in this study are warranted.

Cancer-associated stroke in children: Results from the International Pediatric Stroke Study (IPSS)

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

Introduction: Management after hemorrhagic stroke from cerebral arteriovenous malformation (AVM) rupture remains controversial due to strategies to prevent hemorrhagic expansion while maintaining cerebral autoregulation (CA). We investigated associations of hemodynamics on outcomes after pediatric AVM rupture. Hypotheses: Measures of CA, baroreflex sensitivity (BRs) and heart rate variability (HRV) are associated with outcome at 12 months after pediatric cerebral AVM rupture. Methods: Children (<18 years old) with ruptured cerebral AVMs at a single critical care unit over 5 years were retrospectively analyzed. Continuous measurements of data including arterial blood pressure (ABP), intracranial pressure (ICP), cerebral perfusion pressure (CPP) and heart rate (HR) were evaluated. CA measures include pressure reactivity index (PRx), weighted pressure-reactivity index (wPRx), pulse-amplitude index (PAx), and correlation coefficient between ICP pulse amplitude (AMP) and CPP (RAC). Model-based indices of HRV, BRs, CA and estimations of optimal CPP (CPP-Opt) were computed along with percent of time below lower limits of autoregulation (LLA). Outcomes were determined using Pediatric Glasgow Outcome Score - Extended (GOSE-Peds) at 12 months. Patients with scores below 5 were grouped as "unfavorable outcomes". Association of biomarkers with outcome was determined with Wilcoxon singed rank test. Results: 14 children who underwent multimodal monitoring (6 female; mean [IQR] age, 10.57 [1.5]) were included. 8/14 children underwent intraparenchymal ICP monitoring from which CA was measured. Unfavorable outcomes were associated with lower median BRs values as compared to favorable outcomes (p=0.001) and lower HRV as compared to favorable outcome (p=0.026). Favorable outcome was consistent with decreased percent time below LLA based upon PAx and RAC, although this study was not powered for statistical significance (p=0.057). Conclusion: Decreased BRs and HRV were associated with unfavorable outcomes in children after hemorrhagic stroke from AVM rupture. Prospective studies are warranted to understand CA and its impact on outcomes.

Multimodal assessment of cerebral hemodynamics after pediatric hemorrhagic stroke secondary to cerebral arteriovenous malformation rupture

**Moderators:** [Janette Mailo, MD, PhD, FRCPC](https://underline.io/speakers/120495-janette) | Neurocritical Care | Edmonton, Canada and [Melissa Chung, MD](https://underline.io/speakers/119851-melissa-chung) | Neurocritical Care | Columbus, United States

Speaker Session: Advances in the Critical Care of Neonates and Children with Stroke

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/). 

IPSO 2023

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. 



panel

On demand posters are available for viewing at your leisure. 

*Click 'see all' to the right hand side of the screen to scroll through all posters*

Posters: A - Acute treatment
 Posters: B - Endovascular treatment
 Posters: C - Imaging
 Posters: D - Moyamoya
 Posters: E - Outcomes
 Posters: F - Perinatal stroke
 Posters: H - Stroke readiness & guidelines
 Posters: I - Stroke rehabilitation
 Posters: J - Vascular malformations & ICH
 Posters: K - Venous sinus thrombosis

**[Download poster proceedings] (https://drive.google.com/file/d/1InZvhyYxC6ZeuwwDT9tR9bod3kk0Knuz/view?usp=sharing)**

On Demand Posters

poster

**[Download Full Agenda](https://drive.google.com/file/d/1Dm9lJyTfJrvd7-StaHFmUmhXC-J_UgTj/view?usp=sharing)**

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>. 

We want to hear from you! Planning for the [IPSO Founding Members’ Congress](https://internationalpediatricstroke.org/2022-congress/) in Vienna, April 24-26, 2022, 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 Vienna, or at another IPSO meeting in the future. 

Warm regards,

Heather Fullerton, IPSO President

Adam Kirton, IPSO Vice-President

Lori Jordan, IPSO Secretary & Treasurer


![](https://assets.underline.io/uploads/markdown_image/1/image/1c71a0aebc49947c923a7920d9f28857.jpg)



 
 
 


 



*Header Photo Credit: Helen Carlson, Ph.D, Alberta Children's Hospital*

To access IPSO 2021, you must pre-register for the conference.  Instructions on how to access the event will be provided directly to attendees and included on the IPSO 2021 conference website. [Register now](https://internationalpediatricstroke.org/2021-congress/registration/).

IPSO 2021

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>.

Brian Appavu

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SHORT BIO

Presentations

Multimodal Neuromonitoring in the ICU Management of Acute Stroke and Traumatic Cerebrovascular Injuries

Advances in the Critical Care of Neonates and Children with Stroke

Cancer-associated stroke in children: Results from the International Pediatric Stroke Study (IPSS)

Pediatric acute stroke response protocols

Multimodal assessment of cerebral hemodynamics after pediatric hemorrhagic stroke secondary to cerebral arteriovenous malformation rupture

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