Michaela Waak

Pediatric intracerebral hemorrhage (pICH) is a rare but serious neurologic emergency associated with significant morbidity. Although pICH accounts for nearly half of all pediatric strokes, it remains understudied, and dedicated evidence‐based management guidelines are lacking. To address this gap, the International Pediatric Stroke Organization convened a multidisciplinary international working group in 2020 to develop a comprehensive, consensus‐based framework for the acute evaluation and management of pICH in children aged 28 days to 18 years. The working group included child neurologists, neurointensivists, neurosurgeons, neuroradiologists, and neurointerventionalists. Subgroups conducted systematic literature reviews and formulated key clinical questions. A modified Delphi process was used to derive consensus statements across 6 domains: prehospital and emergency care, diagnostic imaging and workup, neurocritical care and medical management, neurosurgical and neurointerventional approaches, and identification of knowledge gaps. Through rounds of structured review and voting, 21 consensus statements were developed and approved. The process was endorsed by multiple professional societies. This represents the first international, multidisciplinary, multisociety consensus statement focused on the acute management of pICH in children. It provides structured, expert‐driven guidance to inform clinical decision‐making, reduce practice variability, and highlight areas for future research. These consensus statements aim to support clinicians worldwide in improving outcomes for children with pICH.

Pediatric hemorrhagic stroke can lead to significant neurologic, cognitive, and behavioral morbidities that often emerge over time and can impede long‐term academic, vocational, and socioemotional function. While many of the existing data stem from studies in arterial ischemic stroke, functional outcomes in hemorrhagic stroke, and particularly pediatric intracerebral hemorrhage, remain largely understudied. Extrapolating findings from ischemic stroke can be challenging, as there are notable differences in care and potentially in outcomes for hemorrhagic stroke. The primary goal of this consensus statement by a multidisciplinary group of stroke experts is to provide a review of the current literature on neurologic, cognitive, behavioral, and socioemotional outcomes after hemorrhagic stroke. Neurologically, children with pediatric intracerebral hemorrhage often experience motor deficits, including hemiparesis and coordination issues, as well as cognitive impairments affecting attention, memory, and executive function. Behavioral and emotional problems, such as depression, and social difficulties can also occur. Data on academic attainment are also presented, along with considerations regarding long‐term outcomes and the transition to adulthood. We further examine a variety of key determinants predicting outcomes, including medical, demographic, familial, and socioeconomic factors, as well as current research on rehabilitation, with an emphasis on gold‐standard guidelines for clinical interventions. Given the complexity of outcome measurement in pediatric hemorrhagic stroke and the lack of uniform tools for assessing outcomes across diverse populations, we propose guiding principles for outcome measurement, along with examples of domain‐specific tools. Finally, we discuss the limitations of the current literature and outline goals for future clinical practice and research.

Tenecteplase is replacing alteplase as the fibrinolytic agent of choice for the acute management of ischemic stroke in many adult stroke centers due to practical and pharmacokinetic advantages in the setting of similar outcomes. Although thrombolytic use is increasing for acute childhood stroke, there is very limited experience with tenecteplase in children for any indication, and importantly, there are no data on safety, dosing, or efficacy of tenecteplase for childhood stroke. Changes in fibrinolytic capacity over childhood, pediatric pharmacological considerations such as age-specific differences in drug clearance and volume of distribution, and practical aspects of drug delivery such as availability in children’s hospitals may impact decisions about transitioning from alteplase to tenecteplase for acute pediatric stroke treatment. Pediatric and adult neurologists should prepare institution-specific guidelines and organize prospective data collection.

Major advances in pediatric intensive care (PICU) have led to increased child survival. However, the long-term outcomes among these children following PICU discharge are a concern. Most children admitted to PICU are under five years of age, and the stressors of critical illness and necessary interventions can affect their ability to meet crucial developmental milestones. Understanding the neuroscience of brain development and vulnerability can inform PICU clinicians of new ways to enhance and support the care of these most vulnerable children and families. This review paper first explores the evidence-based neuroscience principles of brain development and vulnerability and the impact of illness and care on children’s brains and ultimately wellbeing. Implications for clinical practice and training are further discussed to help optimize brain health in children who are experiencing and surviving a critical illness or injury.

Introduction Approximately 20%–40% of comatose children with risk factors in intensive care have electrographic-only seizures; these go unrecognised due to the absence of continuous electroencephalography (EEG) monitoring (cEEG). Utility of cEEG with high-quality assessment is currently limited due to high-resource requirements. New software analysis tools are available to facilitate bedside cEEG assessment using quantitative EEG (QEEG) trends. The primary aim of this study is to describe accuracy of interpretation of QEEG trends by paediatric intensive care unit (PICU) nurses compared with cEEG assessment by neurologist (standard clinical care) in children at risk of seizures and status epilepticus utilising diagnostic test statistics. The secondary aims are to determine time to seizure detection for QEEG users compared with standard clinical care and describe impact of confounders on accuracy of seizure detection. Methods and analysis This will be a single-centre, prospective observational cohort study evaluating a paediatric QEEG programme utilising the full 19 electrode set. The setting will be a 36-bed quaternary PICU with medical, cardiac and general surgical cases. cEEG studies in PICU patients identified as ‘at risk of seizures’ will be analysed. Trained bedside clinical nurses will interpret the QEEG. Seizure events will be marked as seizures if >3 QEEG criteria occur. Post-hoc dedicated neurologists, who remain blinded to the QEEG analysis, will interpret the cEEG. Determination of standard test characteristics will assess the primary hypothesis. To calculate 95% (CIs) around the sensitivity and specificity estimates with a CI width of 10%, the sample size needed for sensitivity is 80 patients assuming each EEG will have approximately 9 to 18 1-hour epochs. Ethics and dissemination The study has received approval by the Children’s Health Queensland Human Research Ethics Committee (HREC/19/QCHQ/58145). Results will be made available to the funders, critical care survivors and their caregivers, the relevant societies, and other researchers. Trial registration number Australian New Zealand Clinical Trials Registry (ANZCTR) 12621001471875.