United Kingdom

**Abstract authors:**

Stuart Fraser¹, Wilmot Bonnet², Michael Dowling², Sam Russo¹, Beth Anne Cavanaugh¹

¹Division of Child and Adolescent Neurology, ²Division of Child Neurology

**Abstract body:**

Objective: To describe patterns of ischemic infarction in cases of acute hydrocephalus. Methods: Authors identified recent cases from their institutions and shared clinical descriptors. Brief case reports and imaging findings are described below. Case 1: A 12 month old with dandy walker malformation and ventriculoperitoneal shunt presented for new onset seizures and altered mental status. Magnetic resonance imaging demonstrated worsening hydrocephalus and the patient went to the operating room for emergent shunt revision. Post-operative MRI the following day demonstrated watershed, posterior cerebral artery, and cerebellar infarctions (Figure 1) Case 2: A 16 year old male with a history of ventriculoperitoneal shunt and epilepsy presented in status epilepticus. MRI confirmed shunt failure and the patient was emergently taken to OR for hydrocephalus. He had delayed recovery after shunt revision, and MRI demonstrated posterior cerebral artery and cerebellar infarctions (Figure 2) Case 3: A 2 year old male with achondroplasia developed sudden onset confusion and lethargy. Emergent magnetic resonance imaging demonstrated acute hydrocephalus, as well as infarction in the occipital lobe and cerebellar hemispheres. After ventriculoperitoneal shunt placement, he had no further infarction (Figure 3). Conclusion: Acute hydrocephalus, associated with increased intracranial pressure, is associated with posterior cerebral artery and cerebellar infarction. The exact mechanism of infarction is unclear. We propose posterior cerebral artery infarctions may be mediated from tentorium cerebelli impinging on the posterior cerebral arteries. Cerebellar infarcts may also be mediated by a similar mechanism.

IPSO 2023

Patterns of Infarction in Acute Hydrocephalus

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poster

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/). 

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. 



**Abstract authors:**

Abhijit Das¹, Alex Ankar¹, Alyssa Runco¹, Kristen Fisher¹, Sarah Risen¹, Daniel Davila Williams¹

¹Baylor College of Medicine

**Abstract body:**

Spinal cord infarction is difficult to diagnose in pediatrics, especially given symptomatic overlap with demyelinating/neuroinflammatory disease and its low incidence. Typical presentations involve acute, progressive loss of function at corresponding spinal levels, though autonomic symptoms are not well described in children. Here, we describe a pediatric patient presenting with neurogenic shock due to acute traumatic spinal cord infarction attributed to fibrocartilaginous emboli (FCE). A 10-year-old female presented after being found on the floor. She recalled a neck hyperextension-hyperflexion event while cheerleading the night prior. Hours later, she developed bilateral hand weakness and paresthesias in all extremities. In the morning, she fell when walking and could not get up. Initial vitals revealed hypothermia, normocardia, and hypotension requiring vasoactives. Head CT was normal. She was admitted to ICU for presumed urosepsis given pyuria. Neurologic exam was notable for intact mentation and sensation, 0/5 distal upper extremity (UE) strength in all modalities, UE areflexia, 3/5 proximal UE strength, and 4/5 lower extremity strength with intact reflexes. Spinal MRI revealed traumatic disc protrusion at C3-C4 and C4-C5 with associated edema; DWI showed diffusion restriction from C3-C7 suggestive of acute infarct from FCE. CSF evaluation was unrevealing for neuro-inflammation. She was later discharged to inpatient rehab. The incidence of neurogenic shock in cervical spinal cord injury has been reported at 29%, though it is unclear if incidence is higher among patients with cord ischemia. In the acute setting, other differentials, such as acute flaccid myelitis or transverse myelitis, can also present with vital signs that may be interpreted as dysautonomia rather than neurogenic shock. In patients presenting with acute, progressive myelopathy coupled with severe autonomic instability, it is imperative to consider ischemic injury in the differential diagnosis.

Traumatic Pediatric Spinal Cord Stroke Presenting with Acute Spinal Shock

**Abstract authors:**

Mahesh Chikkannaiah¹, Sarah Yu², Laura Fonseca¹, Ajay Goenka³, Gogi Kumar¹

¹Dayton Children's Hospital, ²Wright State University, ³Eternal Hospital

**Abstract body:**

Abstract Objective We report a 11-month-old under immunized girl from the United States with ischemic stroke associated with inflammatory focal cerebral arteriopathy secondary to tuberculous meningitis. Methods Diagnosis was based upon the head CT, brain MRI, and magnetic resonance angiography (MRA) of the head and neck, CSF evaluation, TB blood and skin test, and gastric aspirate culture. Results Patient presented to the local emergency department (ED) for left arm and leg weakness. Laboratory work was significant for hyponatremia. Head CT demonstrated an area of attenuation in the right basal ganglia and caudate nucleus, and a focus of gray and white matter differentiation loss in the right frontal cortex. MRI brain showed a right middle cerebral artery stroke. CSF evaluation showed pleocytosis with hypoglycorrhachia and elevated protein. Further testing showed mediastinal and hilar lymphadenopathy and additional history included exposure to a grandparent with active tuberculosis. Discussion This case emphasizes the importance of childhood vaccinations and considering CSF evaluation, which is usually not considered as part of routine pediatric stroke work up. With increasing international travel and global immigration, clinicians even in the non-endemic countries should consider tuberculosis in their differential diagnosis.

Pediatric stroke associated with inflammatory focal cerebral arteriopathy secondary to tuberculous meningitis in the United States

**Abstract authors:**

Melissa Fleming¹

¹Children's National Hospital

**Abstract body:**

Intro: Movement disorders following stroke are a rare but known phenomenon. Presentations includes chorea, dystonia, tremor, ballism, and parkinsonism. They can occur acutely or delayed; they can be transient or persistent. The basal ganglia are frequently involved. Presented here is a case of hemichorea following thrombectomy. Case: The patient is a 16-year-old male who presented to our ED with classic signs of left MCA stroke: acute right hemiparesis, facial droop, and aphasia. Imaging demonstrated thrombus at the left ICA terminus. He received TPA and was briefly transferred to an outside hospital for thrombectomy. He returned to our hospital the next day for ongoing management with a very different exam. His facial droop and aphasia were resolved, with only slight weakness in the right arm and leg. However, he had new involuntary movements on the right side, described as chorea. Seizure was ruled out with negative EEG. Repeat imaging showed left MCA territory infarct with some residual clot within the left MCA but improved flow. His hemichorea was thought to be the result of basal ganglia involvement of stroke. He was started on tetrabenazine for management. Discussion: Hemichorea following stroke is a rare finding, estimated at 1% based on literature review. Notably, these studies were in adults; prevalence among pediatric and adolescent stroke survivors could not be found. Imaging typically demonstrates basal ganglia involvement though other involved structures include the thalamus, subthalamic nuclei, and cortex. Chorea after ischemic stroke tends to present quickly, within hours. It is noteworthy that our patient initially presented with hemiparesis, but, following thrombectomy, had quick return of strength but acute hemichorea. Pharmacologic therapy options include antipsychotics, benzodiazepines, antiepileptics, and tetrabenazine. Improvement or resolution of chorea within 6 weeks is reported in most patients, though some will have persistent symptoms.

Acute hemichorea following thrombectomy for left MCA stroke in an adolescent male

**Abstract authors:**

Julie Meadows¹, Edward Smith¹, Laura Lehman²

¹Boston Children's Hospital, ²Attending

**Abstract body:**

Introduction: Children with moyamoya and their parents experience significant stress around the time of diagnosis. There are not many studies that examine the extent of the symptoms including clinical concerns for anxiety and depression around time of diagnosis. Hypothesis: Children with moyamoya and their parents will have higher rates of anxiety and depression on standardized questionnaires than the general population. Methods: We enrolled parents of children with moyamoya as well as the child if child was 6 years of age or older prior to revascularization surgery. At time of enrollment parents and child filled out standardized questionnaires on symptom of anxiety and depression. Parents filled out Beck's Depression Inventory (BDI) and Beck's Anxiety Inventory (BAI). Children filled out the Behavioral Assessment System for Children 3rd edition (BASC-3). Results: A total of 22 children with moyamoya enrolled in our study, some children were less than 6 years old so we did not collect emotional outcomes on them. Children's age ranged from 13 months to 18 years old with 14 females (63%). In our cohort of children with moyamoya 12 children, 17 mothers, and 12 fathers filled out questionnaires. Four fathers (33%) and 4 mothers (24%) had clinical concern for depression. We did not have any mothers or fathers with clinical concern for anxiety. However, 4 children (33%) had clinical concern for anxiety and 3 children (25%) had clinical concern for depression. Conclusion: Compared to the general population children with moyamoya have higher rates of depression and anxiety while their parents have higher rates of depression. Further research is needed to determine if symptoms improve post-revascularization surgery.

Depression and Anxiety in Children and their Parents Following Diagnosis of Moyamoya

**Abstract authors:**

Kathryn (Casey) Nesbit¹, Bryce Yale², Laura Hess³, Micah Mar², Alejandra Roque⁴, Dana Jacobs², Janice Brown³, Jordan Ng³, Reilly Todd³, Alyssa Vo³

¹Assistant Professor, ²UCSF/SFSU Graduate Program in Physical Therapy, ³Dominican University of California, ⁴NAPA Center, Inc

**Abstract body:**

Pediatric stroke has a significant impact on children and families. Outcome measures are essential to guide clinical management and inform research priorities, yet these instruments are highly varied in scope and application. Because pediatric stroke care and research is evolving, there is a need for a current review of pediatric stroke outcome measures. The purpose of this study was to systematically review the current literature for pediatric outcome measures, describe the studies using pediatric outcome measures, and describe the outcome measure characteristics. From an initial search of 1625 articles with duplicates removed, 116 articles met inclusion criteria. In those 116 articles, 95 distinct outcome measures were identified. Our review noted the most used outcome measures focused on deficits of the child whereas there was a paucity of outcomes used that included patient and family perspectives, recovery in natural contexts (e.g., home, school, community), and inadequate representation executive function and quality of life. We also found a lack of reliable and valid outcomes for the pediatric hemorrhagic stroke population, and a limited number of outcomes that measure recovery over time. The findings in this systematic review support recommendations for future development and use of pediatric stroke outcome measures, particularly for pediatric hemorrhagic stroke, that better capture the impacts to child and family life and contextually meaningful aspects of recovery over time.

Outcome Measures in Pediatric Stroke: A Systematic Review

**Abstract authors:**

Claire Champigny¹, Samantha Feldman¹, Nataly Beribisky², Mary Desrocher², Tamiko Isaacs², Pradeep Krishnan¹, Georges Monette², Nomazulu Dlamini¹, Peter Dirks¹, Robyn Westmacott¹

¹the Hospital for Sick Children, ²York University

**Abstract body:**

Objective: This prospective clinical study examined the impact of eight predictors on neurocognitive outcomes following pediatric stroke across a range of domains (e.g., processing speed, working memory, executive functions). Predictors included: age at stroke, stroke type (arterial ischemic vs. hemorrhagic), lesion size relative to total brain volume, lesion location and structures involved, time since stroke, neurologic severity, presence of seizure disorder post-stroke, and socioeconomic status (i.e., household income). Method: Youth with a history of stroke (n=92) underwent neuropsychological testing. Their caregivers completed a standardized parent report. Hospital records provided medical history. Spline regressions, likelihood ratio tests, one-way analysis of variance, Welch's t-tests, and simple linear regressions examined associations between predictors and outcome measures. Results: Larger lesions and lower household income were significantly associated with worse neurocognitive outcomes across most domains. Ischemic stroke was associated with worse outcome in attention and executive functions compared to hemorrhagic stroke. Participants with a seizure disorder had more severe executive functioning impairments than participants without seizures. Youth with cortical-subcortical lesions scored lower on a few measures than youth with cortical or subcortical lesions. Neurologic severity predicted scores on few measures. No significant differences were found based on age at stroke, time since stroke, lesion laterality, or supra- versus infratentorial lesion. Conclusions: Lesion size and household income predict neurocognitive outcome following pediatric stroke. Findings should inform clinical practice through enhanced appraisals of prognosis, tailored psychoeducation for families, and the development of services and interventions aimed at fostering optimal development for youth with stroke.

Lesion size and household income predict neurocognitive outcome following pediatric stroke

**Abstract authors:**

Justine Ledochowski¹, Mahmoud Slim¹, Mary Desrocher², Robyn Westmacott¹, Nomazulu Dlamini¹

¹The Hospital for Sick Children, ²York University

**Abstract body:**

Motor impairments are one of the most common adverse outcomes after pediatric arterial ischemic stroke (AIS) yet knowledge of the relationship with intellectual abilities is limited. We hypothesized that motor functioning in early post-AIS recovery would be associated with intellectual functioning. Participants were 64 children, 34 childhood AIS (Mage= 11.90[2.38]); 30 perinatal AIS (Mage= 8.75[2.22]), from the Children's Stroke Program at SickKids Hospital. Motor functioning was assessed with the Pediatric Stroke Outcome Measure sensorimotor subscale at two timepoints, Time 1: early recovery (childhood: 30 days post-stroke to 1 year; perinatal: 2-5 years of age) and Time 2: closest to neuropsychological testing. Intellectual abilities were measured using the Wechsler Intelligence Scale for Children 4th or 5th edition. Motor functioning at Time 1 was associated with processing speed (r= -.391, p= .036) in the perinatal group and with intellectual functioning (r= -.414, p= .018) verbal abilities (r= -.444, p= .011), working memory (r= .393, p= .026), and processing speed (r= -.351, p= .042) in the childhood group. There were no associations between Time 2 motor functioning and intellectual abilities in the perinatal group, and only with processing speed (r= -.525, p= .002) in the childhood group. When motor functioning was dichotomized (no/mild vs. moderate/severe), at Time 1 children with perinatal AIS and moderate/severe deficit had significantly lower perceptual reasoning (t[28]= 2.15, p= .040) and children in the childhood group with moderate/severe deficit had significantly lower perceptual reasoning (t[32]= 2.35, p= .025) and processing speed (t[32]= 2.14, p= 0.41). No differences were found at Time 2. Associations between motor functioning during early stroke recovery and intellectual abilities may be related to neuroplastic changes post-injury, affecting subsequent development of intellectual abilities through hierarchical maturational processes.

Associations Between Motor Functioning and Intellectual Abilities in Pediatric Arterial Ischemic Stroke

**Abstract authors:**

Nicolas Serratrice¹, Andrea Bartoli¹, Kristof Egervari¹, Anne-Laure Rougemont-Pidoux¹, Eugénie Barras¹, Joël Fluss¹

¹HUG

**Abstract body:**

Introduction: Malignant neonatal arterial ischemic stroke concomitant with large vessel occlusion are rare and potentially life-threatening. Their origin is still controversial and very few cases reported in the literature. Case: The neonate was born full-term following an uneventful pregnancy without obstetrical maneuvers. Mild transient distress was noted at birth. Due to increasing lethargy, hypotonia and possible subtle seizures on day 2 of life, MRI was promptly conducted and showed an extensive left malignant hemispheric infarct with mass effect, left uncal herniation, right MCA infarct as well significant brainstem wallerian degeneration well visible on DWI and T2 sequences. Besides the ischemic lesions, the MRI angiography showed a complete occlusion of the left ICA, due a thrombus extending into the left MCA. Echocardiography demonstrated a PFO, normal anatomical structures, no intracardiac thrombus. The child rapidly deteriorated and was transferred to the NICU for reanimation. Given the very poor prognosis, and after multidisciplinary consensus as well as family approval, withdrawal of care was decided, and comfort measures initiated. The child died in parents' arms on day 3. Prothrombotic work-up was negative. On autopsy, thrombi were identified in the portal vein, the left iliac artery, the left MCA, and the left SCA. Large bilateral cerebral infarcts related mainly to the MCA territories were confirmed. A high grade fetal malperfusion syndrome with multiple thrombi within chorionic vessels was seen on placenta examination. Based on the various findings, it appears very likely that the severely abnormal placenta was the source of multiple thromboembolic stroke. Discussion: This case adds not only evidence of the presumed pathogenesis of perinatal arterial ischemic stroke, but also highlights the potential dramatic outcome of such situation, in particular when persistent occlusion of major neonatal cerebral vessel is still present on early imaging.

Fatal malignant neonatal arterial ischemic stroke with internal carotid occlusion: a pathological and clinic-radiological case study

**Abstract authors:**

Trish Domi¹, Darcy Fehlings², Pradeep Krishnan¹, Mahohar Shroff¹, Matylda Machnowska³, Amanda Robertson¹, Gabrielle deVeber¹, on behalf of the CP-NET Group⁴

¹Hospital for Sick Children, ²Holland Bloorview Rehabilitation Hospital, ³Sunnybrooke Health Sciences Center, ⁴Holland Bloorview Rehabiliation Center

**Abstract body:**

Objective: We sought to determine risk factors for hemiplegic cerebral palsy (HCP) associated with perinatal arterial ischemic stroke (AIS) or periventricular venous infarction (PVI). Methods: We studied children with hemiplegic cerebral palsy (HCP) enrolled at nine rehabilitation centres across Ontario. We compared children with underlying AIS or PVI on clinically acquired brain imaging. In addition, we analyzed prenatal (maternal, prenatal/gestational) and perinatal (obstetrical, neonatal) characteristics collected from birth records and standardized parent interviews. Results: The 144 children with HCP (62% male) included 95 with AIS and 49 with PVI. On multivariate analysis, children with PVI had increased rates of maternal fertility treatment (OR=4.7;95%CI=1.0-28.7;p=0.0379) and decreased rates of neonatal seizures (OR=0.03;95%CI=0.0002-0.255;p=0.0001), systemic blood clots (OR=0.082;95%CI=0.0006-0.795;p=0.0278) and emergency cesarian section (OR=0.3;95%CI=0.093-0.896). Preterm delivery rates were similar for AIS and PVI. Conclusion: We determined novel risk factors differentiating the two most typical forms of focal ischemic brain injury in children with hemiplegic CP. These include fertility treatments, mode of delivery, neonatal seizures and systemic blood clots. These findings provide direction for further research exploring causal pathways of focal brain injury and cerebral palsy.

Risk factors for Hemiplegic Cerebral Palsy due to Arterial Ischemic Stroke or Periventricular Venous Infarction

**Abstract authors:**

Moran Hausman-Kedem¹, Stephanie Libzon¹, Aviva Fattal-Valevski², Gustavo Malinger³, Shlomi Constantini², Nina Kreiden², Jonathan Roth², Liat Ben Sira², Shelly Shiran²

¹Tel Aviv Sourasky Medical Center, ²Dana Children's Hospital, Tel Aviv Sourasky Medical Center, ³Lis Maternity Hospital, Tel Aviv Sourasky Medical Center

**Abstract body:**

OBJECTIVE: to characterize clinical, neuroimaging data and etiology of spontaneous perinatal intracranial hemorrhage (spICH) in non-preterm. METHODS: a prospective, single-center study of 102 consecutive cases with spICH identified in the fetal/neonatal period between 2014-2022. RESULTS: Fifty-nine cases (58%) were diagnosed antenatally (termination of pregnancy-n=22). Intraventricular hemorrhage (IVH) was the most common hemorrhage type (73%), followed by periventricular hemorrhagic venous infarction (PVHI) (54%), parenchymal (13%), subdural (12%) and subpial (10%) hemorrhage. IVH was more commonly diagnosed prenatally (p=0.003), whereas subpial hemorrhage was exclusively diagnosed postnataly (p<0.001). Of the 73 born neonates, those with prenatal diagnosis were less likely to show symptoms in the perinatal period (p=0.005). There was no difference between prenatal versus postnatal cases or between types of hemorrhage in terms of maternal age, parity status, and mode of delivery. Intrauterine growth retardation was associated with parenchymal hemorrhage (p=0.039). Germinal matrix was the most common origin of hemorrhage (48%) and was more common in the prenatal group (65% vs. 28%, p<0.001), followed by choroid plexus (46%), hemorrhagic transformation of venous infarction (8%), bleeding diathesis (3%), vascular malformation (2%) and congenital tumor (1%). A family history of thrombophilia or coagulopathy was associated with subpial hemorrhage (p=0.033), and post-natal IVH (p=0.009). Genetic workup was performed in 42%, yielded a diagnosis in 35% of them, mostly with antenatal bleeding (p=0.003), and was associated with prenatal PVHI (p=0.029). Conclusion: Patterns of hemorrhage, as well as mechanisms, were different between the prenatal and postnatal cases, suggesting different disease mechanisms. Coagulopathy may contribute to spICH presenting in the postnatal period, whereas genetic factors play a major role in prenatal ICH.

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