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Gilardone G, Viganò M, Cassinelli D, Fumagalli FM, Calvo I, Gilardone M, Sozzi M, Corbo M. [Formula: see text] Post-stroke acquired childhood aphasia. A scoping review. Child Neuropsychol 2023; 29:1268-1293. [PMID: 36548197 DOI: 10.1080/09297049.2022.2156992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022]
Abstract
Aphasia has a great impact on children's lives, with stroke being its most common and studied etiology. However, our knowledge about this disorder is limited, the studies on this topic are sparse, and a consensus regarding its definition is lacking. In particular, the interpretation of this condition varied over time: from the rigid description of the so-called "standard doctrine" to the adoption of adult models for post-stroke aphasia. Therefore, this review provides a critical overview of childhood aphasia after stroke, focusing on its epidemiology, definition, diagnosis, and clinical manifestation. The scoping review approach was adopted, following PRISMA-ScR guidelines. PubMed, Web of Science, and PsycInfo databases were searched for related peer-review papers in English. Forty-six records were identified; the majority were single cases and case series, only a few were reviews and observational studies. Epidemiologic data are scarce; a few studies report that aphasia affects about one-third of children post-stroke. Despite terminological differences, there is an overall agreement on the definition of post-stroke aphasia in children as a language disorder acquired after the age of two. Approaches for the diagnosis and evaluation vary widely, including both assessments for developmental language disorders and tests for aphasia in adults. The clinical manifestations described in children are numerous and varied, similar to those found in adults, in contrast with the "standard doctrine." This review highlights the need for further studies to improve the knowledge of this condition, develop validated and specific assessment tools, and standardize clinical management.
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Affiliation(s)
- Giulia Gilardone
- Department of Neurorehabilitation Sciences, Casa di Cura del Policlinico, Milan, Italy
| | - Mauro Viganò
- Department of Neurorehabilitation Sciences, Casa di Cura del Policlinico, Milan, Italy
- UMR 7023 Structures Formelles du Langage, CNRS & Université de Paris 8, Paris, France
| | - Dario Cassinelli
- Department of Neurorehabilitation Sciences, Casa di Cura del Policlinico, Milan, Italy
| | | | - Irene Calvo
- Department of Neurorehabilitation Sciences, Casa di Cura del Policlinico, Milan, Italy
| | - Marco Gilardone
- Department of Neurorehabilitation Sciences, Casa di Cura del Policlinico, Milan, Italy
| | - Matteo Sozzi
- Neurology Unit, Neuroscience Department ASST "A. Manzoni", Lecco, Italy
| | - Massimo Corbo
- Department of Neurorehabilitation Sciences, Casa di Cura del Policlinico, Milan, Italy
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Williams EER, Sghirripa S, Rogasch NC, Hordacre B, Attrill S. Non-invasive brain stimulation in the treatment of post-stroke aphasia: a scoping review. Disabil Rehabil 2023:1-22. [PMID: 37828899 DOI: 10.1080/09638288.2023.2259299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/10/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE Aphasia is an acquired language impairment that commonly results from stroke. Non-invasive brain stimulation (NIBS) might accelerate aphasia recovery trajectories and has seen mounting popularity in recent aphasia rehabilitation research. The present review aimed to: (1) summarise all existing literature on NIBS as a post-stroke aphasia treatment; and (2) provide recommendations for future NIBS-aphasia research. MATERIALS AND METHODS Databases for published and grey literature were searched using scoping review methodology. 278 journal articles, conference abstracts/posters, and books, and 38 items of grey literature, were included for analysis. RESULTS Quantitative analysis revealed that ipsilesional anodal transcranial direct current stimulation and contralesional 1-Hz repetitive transcranial magnetic stimulation were the most widely used forms of NIBS, while qualitative analysis identified four key themes including: the roles of the hemispheres in aphasia recovery and their relationship with NIBS; heterogeneity of individuals but homogeneity of subpopulations; individualisation of stimulation parameters; and much remains under-explored in the NIBS-aphasia literature. CONCLUSIONS Taken together, these results highlighted systemic challenges across the field such as small sample sizes, inter-individual variability, lack of protocol optimisation/standardisation, and inadequate focus on aphasiology. Four key recommendations are outlined herein to guide future research and refine NIBS methods for post-stroke aphasia treatment.
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Affiliation(s)
- Ellen E R Williams
- School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia
| | - Sabrina Sghirripa
- School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia
| | - Nigel C Rogasch
- School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia
- Turner Institute of Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Brenton Hordacre
- Innovation, IMPlementation and Clinical Translation (IIMPACT) in Health, Allied Health and Human Performance, The University of South Australia, Adelaide, Australia
| | - Stacie Attrill
- Speech Pathology, School of Allied Health Science and Practice, The University of Adelaide, Adelaide, Australia
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Sun LR, Lynch JK. Advances in the Diagnosis and Treatment of Pediatric Arterial Ischemic Stroke. Neurotherapeutics 2023; 20:633-654. [PMID: 37072548 PMCID: PMC10112833 DOI: 10.1007/s13311-023-01373-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/20/2023] Open
Abstract
Though rare, stroke in infants and children is an important cause of mortality and chronic morbidity in the pediatric population. Neuroimaging advances and implementation of pediatric stroke care protocols have led to the ability to rapidly diagnose stroke and in many cases determine the stroke etiology. Though data on efficacy of hyperacute therapies, such as intravenous thrombolysis and mechanical thrombectomy, in pediatric stroke are limited, feasibility and safety data are mounting and support careful consideration of these treatments for childhood stroke. Recent therapeutic advances allow for targeted stroke prevention efforts in high-risk conditions, such as moyamoya, sickle cell disease, cardiac disease, and genetic disorders. Despite these exciting advances, important knowledge gaps persist, including optimal dosing and type of thrombolytic agents, inclusion criteria for mechanical thrombectomy, the role of immunomodulatory therapies for focal cerebral arteriopathy, optimal long-term antithrombotic strategies, the role of patent foramen ovale closure in pediatric stroke, and optimal rehabilitation strategies after stroke of the developing brain.
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Affiliation(s)
- Lisa R Sun
- Divisions of Pediatric Neurology and Cerebrovascular Neurology, Department of Neurology, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Ste 2158, Baltimore, MD, 21287, USA.
| | - John K Lynch
- Acute Stroke Research Section, Stroke Branch (SB), National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
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Mrakotsky C, Williams TS, Shapiro KA, Westmacott R. Rehabilitation in Pediatric Stroke: Cognition and Behavior. Semin Pediatr Neurol 2022; 44:100998. [PMID: 36456041 DOI: 10.1016/j.spen.2022.100998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/11/2022] [Accepted: 09/12/2022] [Indexed: 10/14/2022]
Abstract
Pediatric stroke is associated with a range of maladaptive cognitive and behavioral outcomes that often require targeted intervention. Despite increasing research on neuropsychological outcomes over the past decade, evidence for effective therapies and interventions for the most commonly reported cognitive and behavioral challenges is still limited. The most widely prescribed interventions address more overt deficits in sensorimotor and speech/language functions, yet interventions for higher-order cognitive, linguistic and behavioral deficits are notably less defined. Moreover, concepts of rehabilitation in adult stroke cannot be easily translated directly to pediatric populations because the effect of stroke and recovery in the developing brain takes a very different course than in the mature brain. In pediatric stroke, neuropsychological deficits often emerge gradually over time necessitating a long-term approach to intervention. Furthermore, family and school context often play a much larger role. The goal of this review is to describe cognitive and behavioral interventions for perinatal and childhood stroke, as motor rehabilitation is covered elsewhere in this issue. We also discuss cognitive aspects of current rehabilitative therapies and technology. Acknowledging the current limited state of stroke-specific rehabilitation research in children, findings from pediatric acquired brain injury intervention and use of transdiagnostic approaches lend important insights. Because there is limited support for single domain (cognitive) trainings and translation of research rehabilitation programs to clinical practice can be challenging, the value of holistic multidisciplinary approaches to improve everyday function in children and adolescents following stroke is emphasized.
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Affiliation(s)
- Christine Mrakotsky
- Departments of Neurology & Psychiatry, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| | - Tricia S Williams
- Department of Psychology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Kevin A Shapiro
- Cortica Healthcare, Department of Neurology, Children's Hospital Los Angeles, Los Angeles, CA
| | - Robyn Westmacott
- Department of Psychology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Msigwa SS, Cheng X. The management of subacute and chronic vascular aphasia: an updated review. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2020. [DOI: 10.1186/s41983-020-00224-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Post-stroke aphasia (PSA) is an impairment of the generation or comprehension of language due to acute cerebrovascular lesions. Subacute phase span the 7th day to 24 weeks post-onset while > 6 months is termed chronic phase. Language recovery does not arise immediately in chronic PSA, unlike the acute phase. The majority of the treatment modalities in these two PSA phases are still in the infancy stage, facing dilemmas and considered experimental requiring constant updates. Hence, we aimed to upgrade the existing literature regarding available PSA management options, advances, and drawbacks pertaining to subacute and chronic phases.
Main text
In this review, we analyzed the management options for subacute and chronic vascular aphasia. MEDLINE, through PubMed, ScienceDirect, and Google Scholar were explored for English studies by utilizing the terms “stroke aphasia” Plus “vascular aphasia”; 160,753 articles were retrieved. The latest studies, published from 2016 to July 2020, were selected. Article headings and abstracts were analyzed for relevance and filtered; eventually, 92 articles were included in this review. Various management options were extracted as follows: noninvasive brain stimulation (NIBS), technology-based therapies, speech-language therapy (SLT), pharmacotherapy, music-based therapies, and psychosocial interventions.
Conclusion
The PSA therapy evolves towards more intense SLT therapy, yet the optimal dosage of the emerging high-intensity therapies is controversial. As spinal and cerebellar NIBS, Telespeech, and E-mental health mark PSA's future, distinct pharmacological options remain a dilemma. Across the continuum of care, PSA–depression comorbidity and inadequate PSA post-discharge education to patient’s families are the significant therapeutic challenges. Future therapeutic mechanisms, optimal dose/timing, and tolerability/safety exploration are obliged.
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Enhancing Stroke Recovery Across the Life Span With Noninvasive Neurostimulation. J Clin Neurophysiol 2020; 37:150-163. [DOI: 10.1097/wnp.0000000000000543] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Carlson HL, Sugden C, Brooks BL, Kirton A. Functional connectivity of language networks after perinatal stroke. Neuroimage Clin 2019; 23:101861. [PMID: 31141787 PMCID: PMC6536856 DOI: 10.1016/j.nicl.2019.101861] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 04/17/2019] [Accepted: 05/19/2019] [Indexed: 02/06/2023]
Abstract
Successful language acquisition during development is imperative for lifelong function. Complex language networks develop throughout childhood. Perinatal stroke may cause significant language disabilities but function can also be remarkably normal. Studying such very early brain injury populations may inform developmental plasticity models of language networks. We examined functional connectivity (FC) of language networks in children with arterial and venous perinatal stroke and typically developing controls (TDC) in a population-based, controlled, cohort study. Resting state functional MRI was performed at 3 T (TR/TE = 2000/30 ms, 150 volumes, 3.6mm3 voxels). Seed-based analyses used bilateral inferior frontal and superior temporal gyri. A subset of stroke participants completed clinical language testing. Sixty-six children participated (median age: 12.85±3.8y, range 6-19; arterial N = 17; venous N = 15; TDC N = 34]. Children with left hemisphere strokes had comparable FC in their right hemispheres compared to TDC. Inter- and intra-hemispheric connectivity strengths were similar between TDC and PVI but lower for AIS. Reduced FC was associated with poorer language comprehension. Language networks can be estimated using resting-state fMRI in children with perinatal stroke. Altered connectivity may occur in both hemispheres, is more pronounced with arterial lesions, and is associated with clinical function. Our results have implications for therapeutic language interventions after early stroke.
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Affiliation(s)
- Helen L Carlson
- Calgary Pediatric Stroke Program, Alberta Children's Hospital, Calgary, AB, Canada; Alberta Children's Hospital Research Institute (ACHRI), Calgary, AB, Canada; Department of Pediatrics, University of Calgary, Calgary, AB, Canada.
| | - Cole Sugden
- Calgary Pediatric Stroke Program, Alberta Children's Hospital, Calgary, AB, Canada
| | - Brian L Brooks
- Alberta Children's Hospital Research Institute (ACHRI), Calgary, AB, Canada; Department of Pediatrics, University of Calgary, Calgary, AB, Canada; Neuropsychology Service, Alberta Children's Hospital, Calgary, AB, Canada; Department of Psychology, University of Calgary, Calgary, AB, Canada
| | - Adam Kirton
- Calgary Pediatric Stroke Program, Alberta Children's Hospital, Calgary, AB, Canada; Alberta Children's Hospital Research Institute (ACHRI), Calgary, AB, Canada; Department of Pediatrics, University of Calgary, Calgary, AB, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada; Department of Radiology, University of Calgary, Calgary, AB, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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Tung YC, Lai CH, Liao CD, Huang SW, Liou TH, Chen HC. Repetitive transcranial magnetic stimulation of lower limb motor function in patients with stroke: a systematic review and meta-analysis of randomized controlled trials. Clin Rehabil 2019; 33:1102-1112. [PMID: 30864462 DOI: 10.1177/0269215519835889] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the effects of repetitive transcranial magnetic stimulation (rTMS) on the post-stroke recovery of lower limb motor function. DATA SOURCES We searched the databases of PubMed, Cochrane Library, and Embase. The randomized controlled trials were published by 25 January 2019. REVIEW METHODS We included randomized controlled trials that evaluated the effects of rTMS on lower limb motor recovery in patients with stroke. Two reviewers independently screened the searched records, extracted data, and assessed the risk of bias. The treatment effect sizes were pooled in a meta-analysis by using the RevMan 5.3 software. The internal validity was assessed using topics suggested by the Physiotherapy Evidence Database (PEDro). RESULTS Eight studies with 169 participants were included in the meta-analysis. Pooled estimates demonstrated that rTMS significantly improved the body function of the lower limbs (standardized mean difference (SMD) = 0.66; P < 0.01), lower limb activity (SMD = 0.66; P < 0.01), and motor-evoked potential (SMD = 1.13; P < 0.01). The subgroup analyses results also revealed that rTMS improved walking speed (SMD = 1.13) and lower limb scores on the Fugl-Meyer Assessment scale (SMD = 0.63). We found no significant differences between the groups in different mean post-stroke time or stimulation mode over lower limb motor recovery. Only one study reported mild adverse effects. CONCLUSION rTMS may have short-term therapeutic effects on the lower limbs of patients with stroke. Furthermore, the application of rTMS is safe. However, this evidence is limited by a potential risk of bias.
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Affiliation(s)
- Yi-Chun Tung
- 1 Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei
| | - Chien-Hung Lai
- 1 Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei.,2 Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei
| | - Chun-De Liao
- 3 Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City.,4 School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei
| | - Shih-Wei Huang
- 2 Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei.,3 Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City
| | - Tsan-Hon Liou
- 2 Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei.,3 Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City.,5 Graduate Institute of Injury Prevention and Control, Taipei Medical University, Taipei
| | - Hung-Chou Chen
- 2 Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei.,3 Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City.,6 Center for Evidence-Based Health Care, Shuang Ho Hospital, Taipei Medical University, New Taipei City
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Yu S, Carlson HL, Mineyko A, Brooks BL, Kuczynski A, Hodge J, Dukelow S, Kirton A. Bihemispheric alterations in myelination in children following unilateral perinatal stroke. NEUROIMAGE-CLINICAL 2018; 20:7-15. [PMID: 29988959 PMCID: PMC6034585 DOI: 10.1016/j.nicl.2018.06.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 06/04/2018] [Accepted: 06/06/2018] [Indexed: 01/16/2023]
Abstract
Background Stroke is a leading cause of perinatal brain injury with variable outcomes including cerebral palsy and epilepsy. The biological processes that underlie these heterogeneous outcomes are poorly understood. Alterations in developmental myelination are recognized as a major determinant of outcome in preterm brain injury but have not been explored in perinatal stroke. We aimed to characterize myelination in hemiparetic children after arterial perinatal stroke, hypothesizing that ipsilesional myelination would be impaired, the degree of which would correlate with poor outcome. Methods Retrospective, controlled cohort study. Participants were identified through the Alberta Perinatal Stroke Project (APSP), a population-based research cohort (n > 400). Inclusion criteria were: 1) MRI-confirmed, unilateral arterial perinatal stroke, 2) T1-weighted MRI after 6 months of age, 3) absence of other neurological disorders, 4) neurological outcome that included at least one of the following tests - Pediatric Stroke Outcome Measure (PSOM), Assisting Hand Assessment (AHA), Melbourne Assessment (MA), neuropsychological evaluation (NPE), and robotic sensorimotor measurements. FreeSurfer software measured hemispheric asymmetry in myelination intensity (primary outcome). A second method using ImageJ software validated the detection of myelination asymmetry. A repeated measures ANOVA was used to compare perilesional, ipsilesional remote, and contralesional homologous region myelination between stroke cases and typically developing controls. Myelination metrics were compared to clinical outcome measures (t-test, Pearson's correlation). Results Twenty youth with arterial stroke (mean age: 13.4 ± 4.2yo) and 27 typically developing controls (mean age: 12.5 ± 3.7yo) were studied in FreeSurfer. Participants with stroke demonstrated lower myelination in the ipsilesional hemisphere (p < 0.0001). Myelination in perilesional regions had lower intensity compared to ipsilesional remote areas (p < .00001) and contralesional homologous areas (p < 0.00001). Ipsilesional remote regions had decreased myelination compared to homologous regions on the contralesional hemisphere (p = 0.016). Contralesional myelination was decreased compared to controls (p < 0.00001). Myelination metrics were not strongly associated with clinical motor, robotic sensorimotor, or neuropsychological outcomes though some complex tests requiring speeded responses had moderate effect sizes. Conclusion Myelination of apparently uninjured brain in both the ipsilesional and contralesional hemispheres is decreased after perinatal stroke. Differences appear to radiate outward from the lesion. Further study is needed to determine clinical significance. Myelination is altered in the lesioned hemisphere after perinatal stroke. The uninjured, contralesional hemisphere also demonstrates differences in myelination. Simple software can estimate MRI myelination abnormalities in children with perinatal brain injury.
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Affiliation(s)
- Sabrina Yu
- Calgary Pediatric Stroke Program, University of Calgary, Calgary, AB, Canada
| | - Helen L Carlson
- Calgary Pediatric Stroke Program, University of Calgary, Calgary, AB, Canada; Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Aleksandra Mineyko
- Calgary Pediatric Stroke Program, University of Calgary, Calgary, AB, Canada; Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Brian L Brooks
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Andrea Kuczynski
- Calgary Pediatric Stroke Program, University of Calgary, Calgary, AB, Canada
| | - Jacquie Hodge
- Calgary Pediatric Stroke Program, University of Calgary, Calgary, AB, Canada
| | - Sean Dukelow
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Adam Kirton
- Calgary Pediatric Stroke Program, University of Calgary, Calgary, AB, Canada; Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.
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