Cerebral Perfusion in Pediatric Stroke: Children Are Not Little Adults

No clear relationship between circadian rhythm and cerebral perfusion parameters in pediatric and early adult populations

BACKGROUND

Recent literature suggests circadian rhythm influences cerebral perfusion parameters in adults experiencing an acute large vessel occlusion, but this has never been investigated in the pediatric and young adult populations.

METHODS

We queried the United States RAPID Insights database (10/05/2018-09/29/2023) for unique patients between 2 and 25 years with computed tomography perfusion (CTP). Included scans had a minimum ischemic core volume (rCBF <30 %) of >0 cc and a Tmax volume of >0 cc. Intracerebral hemorrhage cases were excluded. Anterior circulation large vessel occlusion cases were segregated and reported separately. Imaging time was subdivided into three epochs: Night (23:00 h-06:59 h), Day (07:00 h-14:59 h), and Evening (15:00 h-22:59 h). Age was analyzed by pre-defined strata: 2-5, 6-11, 12-18, and 19-25 years. Perfusion parameters were stratified by age and time epochs. We used non-parametric testing for variables with non-normal distributions.

RESULTS

We included 2415 CTP scans, with 307 identified as LVO. There were 637 patients 18 or younger, with 85 LVOs. In the overall cohort, LVOs had higher penumbral volumes (75.0 cc [25.0-156.0] vs 26.0 cc [8.0-78.0], p < 0.0001) and mismatch volumes (54.0 cc [18.0-120.0] vs 21.0 cc [7.0-62.0], p < 0.0001). In the LVO subgroup, there was a trend towards higher mismatch volumes at night (58.0 cc [IQR 19.5-139.8]) compared to evening (50.0 cc [IQR 18.8-114.3]) or daytime (55.0 cc [17.0-126.0]), but these differences were not significant (p = 0.72).

CONCLUSION

Contrary to reports in adults, we did not find a clear association between time of day and cerebral perfusion parameters among pediatric and young adult patients.

A cross-sectional study of the impact of stigma on quality of life in hemiplegic stroke patients following suicide attempts in nursing homes

To analyze the factors affecting stigma and quality of life in hemiplegic stroke patients following suicide attempts in nursing homes and to provide a theoretical basis for developing interventions in clinical care. General demographic information, the Stigma Scale for Chronic Illness (SSCI), and the Quality of Life Scale (SF-36) were used to investigate 259 patients with hemiplegia after stroke following nursing home suicide from January to April 2024. Univariate statistical analyses were performed to assess the impact of potential determinants on quality of life. Multiple regression models and stratified analyses with smoothed curve fitting were used for further evaluation. Multiple regression modeling showed that the factors influencing the quality of life in hemiplegic stroke patients following suicide attempts in nursing homes were stigma, Age, marital status, education, type of occupation, monthly household income, and duration of illness. The level of quality of life before unadjusted variables was strongly associated with high school and college education (β = 11.9, 95% CI: 8.2-15.6; P < 0.001), (β = 13.1, 95% CI: 9.2 -16.9; P < 0.001). After adjusting for confounders such as marital status (Married, Unmarried), Age (< 30, 30-40, 40-50, > 50) (β = 8.1, 95% CI: 4 .6-11.6; P < 0.0001). (β = 9.5, 95% CI: 6.0-13.1;P < 0.0001), the results were not significantly different. Curve fitting revealed threshold nonlinear associations between intrinsic and extrinsic stigma and quality of life, with quality of life decreasing as stigma increased. Conclusion Stigma is negatively correlated with the level of quality of life in hemiplegic stroke patients following suicide attempts in nursing homes. Different demographic profiles moderated patients' quality of life levels, and effective psychological intervention strategies should be used to improve patients' quality of life.

Arterial Ischemic Stroke in Children

Arterial ischemic stroke (AIS) in children has a high mortality and life-long disability rate in surviving patients. Diagnostic delays are longer and risk factors are different compared with AIS in the adult population. Congenital heart disease, cervical arterial dissection, and intracranial arteriopathies are the main causes of AIS in children. New revascularization time windows in children require the definition of diagnostic protocols for stroke in each referral center. In this article, we discuss the neuroimaging techniques and protocols, describe the main underlying causes, and review the current treatment options for pediatric and perinatal AIS.

Magnetic resonance imaging protocols in pediatric stroke

Neuroimaging protocols play an important role in the timely evaluation and treatment of pediatric stroke and its mimics. MRI protocols for stroke in the pediatric population should be guided by the clinical scenario and neurologic examination, with consideration of age, suspected infarct type and underlying risk factors. Acute stroke diagnosis and causes in pediatric age groups can differ significantly from those in adult populations, and delay in stroke diagnosis among children is a common problem. An awareness of pediatric stroke presentations and risk factors among pediatric emergency physicians, neurologists, pediatricians, subspecialists and radiologists is critical to ensuring timely diagnosis. Given special considerations related to unique pediatric stroke risk factors and the need for sedation in some children, expert consensus guidelines for the imaging of suspected pediatric infarct have been proposed. In this article the authors review standard and rapid MRI protocols for the diagnosis of pediatric stroke, as well as the key differences between pediatric and adult stroke imaging.

Advances in the Diagnosis and Treatment of Pediatric Arterial Ischemic Stroke

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.

Neuroimaging in Pediatric Stroke

Pediatric stroke is unfortunately not a rare condition. It is associated with severe disability and mortality because of the complexity of potential clinical manifestations, and the resulting delay in seeking care and in diagnosis. Neuroimaging plays an important role in the multidisciplinary response for pediatric stroke patients. The rapid development of adult endovascular thrombectomy has created a new momentum in health professionals caring for pediatric stroke patients. Neuroimaging is critical to make decisions of identifying appropriate candidates for thrombectomy. This review article will review current neuroimaging techniques, imaging work-up strategies and special considerations in pediatric stroke. For resources limited areas, recommendation of substitute imaging approaches will be provided. Finally, promising new techniques and hypothesis-driven research protocols will be discussed.