Health-related quality of life and its determinants in paediatric arterial ischaemic stroke survivors

Looking beyond body structure and function: a scoping review of non-impairment impacts of stroke on adolescents

BACKGROUND

Much of the childhood stroke literature has not distinguished impacts for adolescents from those of younger children. Research has also focused on body impairments. With adolescence being a unique period, this scoping review aimed to identify the impacts of childhood stroke on activity, participation, and quality of life for adolescents 13-18 years, and identify how these impacts were determined.

METHOD

This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Data pertaining to non-impairment impacts of childhood stroke for adolescents, participant and study characteristics, and measurement instruments were extracted.

RESULTS

Following screening, 79 articles were included, and 33 measurement instruments identified. Only 6 studies reported separate data for adolescents, identifying difficulties with daily activities, social and academic impacts, and reduced quality of life. Impacts of post-stroke communication difficulties on daily activities and schooling were also noted. Measurement instruments developed specifically for adolescents with stroke are lacking.

INTERPRETATION

The review identified limited research reporting non-impairment impacts of childhood stroke for adolescents. Further research specific to this population and the development of measurement instruments for adolescents who have experienced childhood stroke is required to support future research and clinicians working with this population.

Parent-reported health outcomes at preschool age in preterm survivors: a population-based cohort study

OBJECTIVE

Literature on health status (HS) and health-related quality of life of preterm survivors at preschool age is sparse. Further, little is known about the relationship between parent-reported HS outcomes and standardised neurodevelopmental outcomes measured in preterm survivors at preschool age. Our objective was to evaluate parent-reported child HS outcomes and their relationship to neurodevelopmental outcomes at 36 months of age in very preterm survivors.

DESIGN

Prospective population-based cohort study.

SETTING

Perinatal follow-up programme.

PATIENTS

Infants <31 weeks' gestational age born from 2014 to 2016.

OUTCOME MEASURES

Parents completed the Health Status Classification System for Pre-School Children questionnaire at 36 months. At the same age, neurodevelopmental assessments were completed to determine neurodevelopmental impairment (NDI). NDI was categorised as none, 'mild' or 'significant' (moderate or severe cerebral palsy, Bayley Scales of Infant and Toddler Development - Third Edition <70, blind or required hearing aid).

RESULTS

Of 118 children, 87 (73.7%) parents reported their child had an HS concern (mild: 61 (51%); moderate: 16 (13.6%); and severe: 10 (8.5%)). Mild and significant NDIs were observed in 17 (14.4%) and 14 (11.9%) children, respectively. For the 14 (12%) children with significant NDI, 7 (50.0%) parents reported severe and 4 (28.6%) reported moderate concerns. Conversely, for 26 (22%) children with parent-reported moderate to severe concerns, 11 (42.3%) met the criteria for significant NDI. There was a moderate positive correlation between parental concern and NDI status (Spearman correlation=0.46, p<0.0001).

CONCLUSIONS

Parental HS concerns only moderately correlated with the NDI status. Of the 12% of children with significant NDI, only half of the parents reported severe HS concerns.

Emotional and social functioning after stroke in childhood: a systematic review

PURPOSE

To provide an overview of the effects of pediatric stroke on emotional and social functioning in childhood.

METHODS

A literature review was completed in accordance with the Preferred Reporting Items for Systematic Reviews. A systematic search of studies on internalizing problems and social functioning after pediatric stroke in PsycInfo, PsycArticles, and PubMed databases was conducted from inception to November 2021. A total of 583 studies were identified, and 32 met the inclusion criteria.

RESULTS

The review suggests that children after stroke are at risk of developing internalizing problems and a wide range of social difficulties. Internalizing problems are often associated with environmental factors such as family functioning and parents' mental health. In addition, a higher risk of developing psychosocial problems is associated with lower cognitive functioning and severe neurological impairment.

CONCLUSIONS

The assessment of psychological well-being and social functioning after pediatric stroke is helpful to provide adequate support to children and their families. Future studies are needed to better investigate these domains and to develop adequate methodologies for specific interventions.Implication for rehabilitationThis paper reviews research concerning emotional and social functioning following pediatric stroke in order to provide helpful information to clinicians and families and to improve rehabilitation pathways.Emotional and social functioning should be addressed during post-stroke evaluation and follow-up, even when physical and cognitive recovery is progressing well.Care in pediatric stroke should include volitional treatment and address emotional and social issues.

Socioeconomic status and health-related quality of life after stroke: a systematic review and meta-analysis

BACKGROUND

Socioeconomic status (SES) is associated with stroke occurrence and survival following stroke but its association with health-related quality of life (HRQoL) following stroke remains uncertain. We performed a systematic review and meta-analysis to examine the association between SES and HRQoL after stroke.

METHODS

PubMed, SCOPUS, EMBASE, and Web of Science were searched to identify relevant cohort and case-control studies between January 2000 and May 2022. Two authors screened titles, abstracts and full text articles. One author extracted data from all included studies. Meta-analyses were performed for studies with comparable measurements of SES and HRQoL. Random effects models were used to estimate pooled summary standardised mean differences in HRQoL by SES.

RESULTS

Out of 1,876 citations, 39 studies incorporated measurement of overall HRQoL following stroke and were included in the systematic review, with 17 studies included in the meta-analyses. Overall, reports including education, income, occupation and work status effects on HRQoL after stroke were inconsistent among all included 39 studies. In the global meta-analysis of 17 studies, HRQoL among survivors of stroke was lower in the low SES group than in the high SES group (standardised mean difference (SMD) -0.36, 95% CI -0.52, -0.20, p < 0.0001). When using education and income indicators separately, summary effects were similar to those of the global analysis (low versus high education SMD -0.38, 95% CI -0.57, -0.18, p < 0.0001; low versus high income SMD -0.39, 95% CI -0.59, -0.19, p < 0.0001).

CONCLUSIONS

Across all SES indicators, people with stroke who have lower SES have poorer overall HRQoL than those with higher SES. Accessibility and affordability of poststroke support services should be taken into consideration when planning and delivering services to people with low SES.

Area-level and individual-level socio-economic differences in health-related quality of life trajectories: Results from a 10-year longitudinal stroke study

BACKGROUND

We examined area-level (aSES) and individual-level (iSES) socio-economic status on trajectories of HRQoL to 10 years following stroke.

METHODS

Participants with strokes between 1/5/1996 and 30/4/1999 completed the Assessment of Quality of Life instrument (AQoL, range: -0.04 [worse than death] to 0 [death] to 1 [full health]) at ≥one of 3month, 6-month, 1-year, 2-year, 3-year, 4-year, 5-year, 7-year and 10-year interviews after stroke. Sociodemographic and health information were collected at baseline. We derived aSES from postcode using the Australian Socio-Economic Indexes For Area (2006) (categories: high, medium, low), and iSES from lifetime occupation (categories: non-manual, manual). Multivariable linear mixed effects modelling was used to estimate trajectories of HRQoL over 10 years, by aSES and iSES, adjusting for age, sex, cardiovascular disease, smoking, diabetes, stroke severity, stroke type, and the time influence on age and health conditions.

RESULTS

Of 1,686 participants enrolled, we excluded 239 with 'possible' stroke and 284 with missing iSES. Among the remaining 1,163 participants, 1,123 (96.6%) had AQoL assessed at ≥3 timepoints. In multivariable analysis, over time, people in the medium aSES group had mean 0.02 (95% CI -0.06, 0.02) greater reduction in AQoL score, and people in the low aSES group had mean 0.04 (95% CI, -0.07, -0.001) greater reduction, than those in the high aSES group. Manual workers had an average 0.04 (95% CI, -0.07, -0.01) greater reduction in AQoL score over time than non-manual workers.

CONCLUSIONS

Over time, HRQoL declines in all people with stroke, declining most rapidly in lower SES groups.

Roadmap for the Assessment and Management of Outcomes in Pediatric Stroke

Neurological morbidity is common after pediatric stroke, with moderate to severe deficits that can significantly impact education and social function. Care and recovery occur in phases distinguished by the time interval after stroke onset. These phases include the hyperacute and acute periods in which the focus is on cerebral reperfusion and prevention of neurological deterioration, followed by the subacute and chronic phases in which the focus is on secondary stroke prevention and mitigation of disability through rehabilitation, adaptation, and reintegration into the community. In this article, a multidisciplinary group of pediatric stroke experts review the stages of recovery after pediatric stroke with an emphasis on critical assessment time points. Our goal is to encourage increased standardization of outcome assessment to facilitate future clinical trials comparing various treatment and intervention options and advance optimized care for children with stroke.

Arteriell ischämischer Schlaganfall im Kindes- und Jugendalter

Der arteriell ischämische Schlaganfall im Kindes- und Jugendalter gehört zu den zeitkritischsten pädiatrischen Notfällen, wird aber häufig erst mit prognostisch relevanter Zeitverzögerung diagnostiziert. Gründe sind geringe „Awareness“, die zuweilen unspezifische klinische Präsentation mit einer Breite an kritischen Differenzialdiagnosen und in der Fläche noch wenig verzahnte Akutversorgungsstrukturen. Die beim Erwachsenen etablierten Revaskularisationsstrategien zeigen auch beim Kind mögliche, z. T. spektakuläre Erfolge. Diese sind daher nach Möglichkeit auch betroffenen Kindern zur Verfügung zu stellen, auch wenn hier derzeit keine annähernd vergleichbare Evidenz vorliegt. Postakut ist die ätiologische Aufarbeitung aufgrund zu bedenkender Risikofaktoren komplex, muss aber das individuelle Risikoprofil mit Sekundärprophylaxe, Rezidivrisiko und Outcome präzise identifizieren. Die Langzeitbetreuung im multiprofessionellen, interdisziplinären Team muss die bio-psycho-sozialen Aspekte des Kindes in seiner jeweiligen Entwicklungsphase berücksichtigen.

Notfall-Neuropädiatrie – Der arteriell ischämische Schlaganfall als einer der zeitkritischsten Notfälle bei Kindern und Jugendlichen

Der arteriell ischämische Schlaganfall im Kindes- und Jugendalter gehört zu den zeitkritischsten Notfällen in der Pädiatrie. Dennoch wird er häufig mit einer oft prognostisch relevanten Zeitverzögerung diagnostiziert. Gründe dafür liegen neben der geringen Awareness auch in der zuweilen unspezifischen klinischen Präsentation mit einer herausfordernden Breite kritischer Differenzialdiagnosen sowie in der Fläche noch wenig verzahnter Akutversorgungsstrukturen. Gleichwohl zeigen grundsätzlich die beim Erwachsenen etablierten Revaskularisationsstrategien auch beim Kind ihre möglichen, zum Teil spektakulären Erfolge. Es gilt also, diese nach Möglichkeit auch den betroffenen Kindern zur Verfügung zu stellen, auch wenn hier derzeit ein nicht annähernd vergleichbarer Grad an Evidenz erreicht ist. Postakut ist die ätiologische Aufarbeitung durch die größere Bandbreite zu bedenkender Risikofaktoren besonders komplex, muss aber in der Lage sein, das individuelle Risikoprofil mit Sekundärprophylaxe, Rezidivrisiko und Outcome präzise zu identifizieren. Die Langzeitbetreuung im multiprofessionellen, interdisziplinären Team muss die biopsychosozialen Aspekte des Kindes in seiner jeweiligen Entwicklungsphase berücksichtigen und damit eine bestmögliche Integration des Kindes in sein soziales und schulisches, später berufliches Umfeld realisieren.

Parent-reported health status of preterm survivors in a Canadian cohort

OBJECTIVES

Health status (HS)/ health-related quality of life measures, completed by self or proxy, are important outcome indicators. Most HS literature on children born preterm includes adolescents and adults with limited data at preschool age. This study aimed to describe parent-reported HS in a large national cohort of extreme preterm children at preschool age and to identify clinical and sociodemographic variables associated with HS.

METHODS

Infants born before 29 weeks' gestation between 2009 and 2011 were enrolled in a prospective longitudinal national cohort study through the Canadian Neonatal Network (CNN) and the Canadian Neonatal Follow-Up Network (CNFUN). HS, at 36 months' corrected age (CA), was measured with the Health Status Classification System for Pre-School Children tool completed by parents. Information about HS predictors was extracted from the CNN and CNFUN databases.

RESULTS

Of 811 children included, there were 79, 309 and 423 participants in 23-24, 25-26 and 27-28 weeks' gestational age groups, respectively. At 36 months' CA, 78% had a parent-reported health concern, mild in >50% and severe in 7%. Most affected HS attributes were speech (52.1%) and self-care (41.4%). Independent predictors of HS included substance use during pregnancy, infant male sex, Score for Neonatal Acute Physiology-II, bronchopulmonary dysplasia, severe retinopathy of prematurity, caregiver employment and single caregiver.

CONCLUSION

Most parents expressed no or mild health concerns for their children at 36 months' CA. Factors associated with health concerns included initial severity of illness, complications of prematurity and social factors.

Childhood Stroke: Long-Term Outcomes and Health-Related Quality of Life with a Special Focus on the Development of Epilepsy

BACKGROUND

Childhood stroke is rare and can predispose to post-stroke epilepsy. The purpose of this study was to evaluate long-term quality of life (QoL) in patients with childhood stroke, focusing on epileptic aspects.

METHOD

This involves a retrospective study of 98 patients with childhood stroke (pre- and neonatal strokes excluded), who had been inpatients between 1986 and 2003 for early rehabilitation. Data were obtained via interviews using a standardized questionnaire: QoL evaluation with KINDL, functional outcome with Barthel Index, and motor handicaps-assessment with modified Rankin Score.

RESULTS

Forty-nine of 98 patients (31 males, mean follow-up 16 years, range 8-25 years) were included. Six patients passed away (three of sudden unexpected death in epilepsy). At least one epileptic seizure occurred in 27/49 patients (occurrence: 2 days-13 years.; mean 3.3 years.). Epilepsy manifested in 19/49 patients. No correlation was found between the development of epilepsy and the location or etiology of the stroke. The presence of functional independence was significantly higher in seizure-free patients and in patients without epilepsy. For the external assessment (filled in for the patient by the parent/caregiver), there was no significant difference in QoL in patients with and without epilepsy; however, in the in-person KINDL questionnaire a significantly lower QoL was noted in epilepsy patients compared with patients without epilepsy.

CONCLUSION

One important finding in our study is that in the long-term course 39% of patients developed epilepsy after a childhood stroke. It occurred as late as 13 years after the acute episode and affected the QoL especially in cognitively less handicapped patients.

Lipoprotein-Associated Phospholipase A2 is Linked with Poor Cardio-Metabolic Profile in Patients with Ischemic Stroke: A Study of Effects of Statins

Objectives

The objective of the study is to investigate the effects of statins on the lipoprotein-associated phospholipase A2 (Lp-PLA2) mass in patients with ischemic stroke.

Materials and Methods

A total number of 59 patient ages 43-69 years with cerebral stroke compared to 39 healthy controls that matching the age and body weight. The patients were divided into 32 patients on statins therapy assigned as statins users and 27 patients, not on statins therapy assigned as nonstatins users. Anthropometric and biochemical measurements were done including lipid profile and inflammatory biomarkers.

Results

Stroke patients on statins therapy showed a comparable low of Lp-PLA (29.82 ± 3.19 IU/mL) to nonstatins user stroke patients (15.58 ± 5.73 IU/mL). Lp-PLA2 mass levels were positively correlated with body mass index, blood pressure changes, total cholesterol, triglyceride, and very low-density lipoprotein and stroke risk (SR) percentage.

Conclusions

Patients on statins with ischemic stroke had low levels of Lp-PLA2 mass levels compared to nonstatins user with ischemic stroke. Lp-PLA2 mass levels were higher in men than women and correlated with lipid profile and SR in patients with ischemic stroke.

Language and cognitive outcomes after childhood stroke: Theoretical implications for hemispheric specialization

The purpose of this study was to investigate language and cognitive outcomes following severe childhood stroke, and the role of age at stroke according to lesion lateralization. We retrospectively included children consecutively admitted to a physical medicine and rehabilitation department between 1992 and 2015 following childhood stroke (age at stroke 1 month to15 years). Data collection included demographic and clinical information, results of cognitive assessments on the Wechsler Intelligence scales, detailed language assessments by speech and language therapists, and long-term academic outcome. Overall, 184 children (52% boys; mean age at assessment = 8.5 years, range .7-15.4 years) were hospitalized following ischemic (n = 79) or hemorrhagic (n = 105) stroke. After a median time since stroke of 4 months (n = 135), mean Full-Scale, Verbal, and Performance Intellectual Quotient (FSIQ, VIQ and PIQ) were 85 (SD = 19), 93 (SD = 22), and 85 (SD = 20), respectively. In language tests (n = 130) assessing lexical and syntactic expression and comprehension, 26%-53% of the children exhibited impairments (scores <2SD). After a median follow-up of 40 months, only 27% of the children were following a normal curriculum without adaptations or delay, and 27% were attending special education programs. School situation was strongly associated with language and FSIQ scores. Language and verbal IQ scores were significantly lower (p < .01) among patients with lesions in the left hemisphere as opposed to the right. After a left hemisphere lesion, language skills were not associated with age at stroke, but for right hemisphere lesions, language was more impaired among children who were younger at stroke onset. PIQ tended to correlate positively with age at stroke in left hemisphere lesions (poorer PIQ in early lesions) and negatively for right hemisphere lesions (poorer PIQ in late lesions). These findings, discussed in the light of the brain vulnerability and plasticity hypotheses, are in favor of a developmental view of hemispheric specialization.