Association Between Thrombectomy and Functional Outcomes in Pediatric Patients With Acute Ischemic Stroke From Large Vessel Occlusion.

Importance: Pediatric large vessel occlusion (LVO) stroke has a poor natural history. However, uptake of mechanical thrombectomy is hindered by a lack of clinical trial data in children. A randomized clinical trial is not feasible due to small sample sizes and absence of equipoise. Objective: To evaluate whether pediatric patients with acute LVO stroke who undergo thrombectomy have better clinical outcomes than matched patients managed conservatively. Design, Setting, and Participants: This matched case-control study used pooled stroke registry data from 5 tertiary referral hospitals in Australia and Canada from January 2011 to April 2022. Patients were aged 1 month to younger than 18 years with acute LVO stroke. Pooled data identified 31 thrombectomy patients and 46 control patients. Five patients undergoing thrombectomy with basilar artery occlusion were excluded due to insufficient controls. Using a hierarchal matching system (site of occlusion, age group, side of occlusion, and sex), deidentified consensus matching of patients and controls was undertaken while blinded to clinical outcome. Data were analyzed from July to November 2022. Exposure: In the case cohort, mechanical thrombectomy was undertaken for management of acute LVO stroke. The control cohort received medical treatment only. Main Outcomes and Measures: The primary outcome was the functional clinical status 3 months following stroke, measured by the pediatric modified Rankin Scale (mRS). Clinical outcomes were compared between groups using ordinal regression analysis. Results: Of 52 included patients, 31 (60%) were male, and the mean (SD) age was 10.3 (4.4) years. Matching was achieved for 26 children undergoing thrombectomy with 26 controls. There was no significant difference between groups for site or side of occlusion, age, sex, etiology, thrombolysis status, baseline Alberta Stroke Programme Early CT Score, or time since last seen well to presentation. Patients undergoing thrombectomy had superior clinical outcomes than control patients at 3 months on the pediatric mRS (odds ratio, 3.76; 95% CI, 1.32-10.67; P = .01). These superior outcomes were maintained at final follow-up (odds ratio, 3.65; 95% CI, 1.25-10.68; P = .02). Conclusions and Relevance: In the absence of a randomized clinical trial, this case-control study demonstrates better clinical outcomes with thrombectomy than medical management alone for pediatric patients aged 2 to 18 years with anterior circulation LVO stroke.

Visual outcomes in idiopathic intracranial hypertension in children.

OBJECTIVE: The purpose of this study was to report the clinical characteristics and long-term visual outcomes in a cohort of children with idiopathic intracranial hypertension (IIH). DESIGN: Retrospective, observational cohort study. PARTICIPANTS: Consecutive children who met the diagnostic criteria for definite IIH at a tertiary care pediatric hospital between 2009 and 2020. METHODS: The charts of pediatric patients with IIH were reviewed. The main outcome measure was long-term visual impairment, with an analysis of clinical features by age and risk factors for a poor visual outcome. RESULTS: There were 110 children (75 females) with IIH. At presentation, younger children with IIH were less likely to present with headaches (p = 0.01) and more likely to be asymptomatic (p = 0.03). There was a strong association with female sex (p < 0.001) and higher body mass index (p < 0.001) in adolescents in comparison to younger children. Of the 90 patients with long-term visual outcome data, only 8 (9%) had evidence of mild visual impairment (1 loss of visual acuity, 7 loss of visual field) with no cases of severe visual impairment. On risk factor analysis, the only variable associated with a poor visual outcome was greater severity of papilledema at diagnosis. CONCLUSIONS: In this large series of pediatric IIH, the long-term visual outcomes were favourable, with evidence of mild visual impairment in less than 10% of patients.

Correction to: Postoperative isolated lower extremity supplementary motor area syndrome: case report and review of the literature.

The original version of this article unfortunately contained an error. The author apologizes for having provided an incorrect name: "Ali Moghadammjou" should be "Ali Moghaddamjou". Given in this article is the correct author name.

Postoperative isolated lower extremity supplementary motor area syndrome: case report and review of the literature.

The supplementary motor area (SMA) syndrome is characterized by transient weakness and akinesia contralateral to the side of the affected hemisphere. The underlying pathology of the syndrome is not fully understood but is thought to be related to lesions in the SMA, residing principally in the mesial superior frontal gyrus (Broadmann's area 6c). Although the SMA syndrome a well-characterized clinical entity, we report herein, to our knowledge, the first case of isolated lower extremity SMA syndrome in the literature. This case highlights the importance of considering this rare clinical entity in the context of new or worsening postoperative neurologic deficits. Moreover, early studies did not support somatotopic organization of the SMA as in the primary motor cortex; emerging evidence suggests that delicate somatotopic representation may underlie distinct presentations like that reported in the present case.

Pediatric arterial ischemic stroke.

PURPOSE OF REVIEW: This article aims to provide a broad overview of pediatric arterial ischemic stroke, from recognition and diagnosis to the short-term and long-term management based on current available literature. RECENT FINDINGS: Arterial ischemic stroke in children represents a significant disorder with a concerning high rate of adverse outcomes, including potentially preventable recurrent stroke. Although awareness of pediatric stroke is increasing, diagnosis is still commonly delayed or missed altogether, particularly in younger children. Current vascular imaging techniques have limitations in accurate diagnosis of arteriopathies that are now recognized as an important cause of childhood stroke. Significant variability exists in treatment of pediatric stroke. Management is based on published consensus guidelines; however, individual children require an individualized approach. SUMMARY: As pediatric stroke specialists become increasingly available, the collaboration of such experts on individual management is crucial. Definitive evidence-based treatment for pediatric stroke awaits the development of randomized controlled trials.

Stroke recurrence in children with congenital heart disease.

OBJECTIVE: Pediatric arterial ischemic stroke (AIS) carries an important morbidity and mortality burden. Congenital heart disease (CHD) is among the most important risk factors for pediatric AIS. Data on stroke recurrence in childhood CHD are lacking, resulting in uncertainty regarding optimal strategies for preventing recurrence. METHODS: In the Canadian Pediatric Ischemic Stroke Registry-Toronto site, we identified children (birth to 18 years) with CHD diagnosed with AIS during 1992-2008. Data were abstracted from both stroke and cardiac surgery databases. Time-dependent outcomes (death and recurrent stroke) following sentinel stroke were parametrically modeled in competing risk analysis. Factors predicting stroke recurrence in parametric survival models were sought in parametric survival model analyses using backward variable selection of variables. RESULTS: A total of 135 patients (19 with recurrence, 116 without recurrence) were studied. In competing risk analysis, 10 years following sentinel stoke, 27% had experienced a stroke recurrence, 26% had died, and 47% were alive and free from recurrence. Stroke recurrence risk decreased over time from sentinel stroke. Approximately 50% of patients were receiving anticoagulation at recurrence. Significant factors associated with recurrence included the presence of a mechanical valve, prothrombotic condition, and an acute infection at the time of sentinel stroke. Hazard of mortality after recurrence was similar to mortality after sentinel stroke (hazard ratio, 1.3; p = 0.75). INTERPRETATION: Stroke recurrence was relatively common in neonates and children with CHD. Identified groups of patients at increased risk may require more aggressive secondary prophylaxis, especially in the early poststroke period.

Sagittal sinus compression is associated with neonatal cerebral sinovenous thrombosis.

OBJECTIVE: Neonatal cerebral sinovenous thrombosis (CSVT) causes lifelong morbidity. Newborns frequently incur positional occipital bone compression of the superior sagittal sinus (SSS). We hypothesized that SSS compression is associated with neonatal CSVT. METHODS: Our retrospective case-control study recruited neonates with CSVT (SickKids Children's Stroke Program, January 1992-December 2006). Controls were neonates without CSVT undergoing magnetic resonance or computed tomography venography (institutional imaging database, 2002-2005) who were matched 2 per each case patient. Blinded neuroimaging review by 2 experts quantified SSS compression and head position. Effect of SSS compression on the primary outcome of CSVT was determined (logistic regression). Secondary analyses included the relationship of head position to SSS compression (t test) and group comparisons (cases versus controls, cases with and without compression) for demographic, clinical, and CSVT factors (χ² and Wilcoxon Mann-Whitney tests). RESULTS: Case (n = 55) and control (n = 90) patients had similar ages and delivery modes. SSS compression was common (cases: 43%; controls: 41%). Controlling for gender and head position, SSS compression was associated with CSVT (odds ratio: 2.5 [95% confidence interval: 1.07-5.67]). Compression was associated with greater mean (SD) angle toward head flexion (101.2 [15.0] vs 111.5 [9.7]; P < .001). Among CSVT cases, neonates with and without compression had comparable gestational age, delivery mode, risk factors, anticoagulation treatment, thrombus location, propagation, infarction, recanalization, and outcome. Many idiopathic cases had SSS compression (79%). Interrater reliability of compression measurements was high (κ = 0.87). CONCLUSIONS: Neonatal SSS compression is common, quantifiable, and associated with CSVT. Optimizing head position and/or developing devices to alleviate mechanical SSS compression may represent a novel means to improve outcomes.