Heather J. Fullerton

Background and ObjectivesCardiac abnormalities are among the most common and complex risk factors of pediatric acute ischemic stroke (AIS). Although endovascular treatment (EVT) is increasingly use...

Stroke is less common in children than in adults, yet equally devastating. Nevertheless, children with symptoms of acute stroke commonly present to community hospitals or adult stroke centers where experience and institutional protocols for pediatric stroke diagnosis and management may be limited. Despite advances in pediatric stroke awareness and the implementation of stroke pathways in many children’s hospitals, significant gaps remain in the timely recognition, diagnosis, and management of pediatric stroke. A key contributing factor is the lack of system-level infrastructure to guide pediatric acute stroke care. This special report examines the challenges and barriers to achieving Pediatric Stroke Readiness at a national level in the United States and presents 5 engagement case studies highlighting efforts to establish processes and networks for pediatric stroke management across diverse care settings. The cases emphasize the development and implementation of systems of care in which pediatric stroke centers collaborate with first responders, community hospitals, and adult stroke centers to improve the delivery of acute stroke care for children. The strategies underscore different engagement approaches and identify opportunities for future research and quality improvement. These case studies also illustrate educational materials and clinical pathways that may serve as resources for others pursuing similar initiatives.

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.

BACKGROUND: Acute respiratory infection transiently increases risk for childhood arterial ischemic stroke (AIS). We hypothesize that this paradox of a common exposure linked to a rare outcome could be explained by either (1) the infection hypothesis: unusual or multiple pathogens or (2) the host response hypothesis: heterogeneity in the inflammatory response to infection. We leverage metagenomic next-generation sequencing (mNGS), a comprehensive microbial detection tool, to test the first hypothesis. METHODS: The VIPS II study (Vascular Effects of Infection in Pediatric Stroke II) prospectively enrolled children with AIS at 22 international sites over 5 years (December 2016 to January 2022). Sites measured prestroke clinical infection via standardized parental interviews and chart abstraction. To assess more broadly the background spectrum of pathogens, a central research laboratory performed mNGS on plasma and oropharyngeal swabs collected within 72 hours of stroke. mNGS was also performed on biological samples from stroke-free children (June 2017 to January 2022), both without (well) and with (ill) documentation of clinical infection. RESULTS: VIPS II enrolled 205 patients with AIS, 95 stroke-free well children, and 47 stroke-free ill children. Clinical infection, most commonly upper respiratory tract infection, was detected in 81 of 205 (40%) of patients. Both plasma and oropharyngeal swab mNGS data were available for 190 of 205 patients with AIS, 91 of 95 stroke-free well children, and 27 of 47 stroke-free ill children. mNGS detected viruses in 27 of 190 (14%) patients with AIS, 9 of 91 stroke-free well children (10%), and 9 of 27 (33%) stroke-free ill children. Most were common upper respiratory viruses. Coinfections were rare. Similar viruses were found in patients with AIS and stroke-free children. CONCLUSIONS: mNGS detected a variety of common childhood viruses in both patients with AIS and stroke-free children, suggesting that the type of infection does not explain AIS susceptibility. Rather, the alternative hypothesis regarding an unusual host immune response to common infections in the pathogenicity of AIS should be further explored.

BACKGROUND: The most common cause of arterial ischemic stroke in healthy children, focal cerebral arteriopathy (FCA), can progress rapidly over days with worsening brain injury. A 2017 retrospective Swiss study of corticosteroid treatment for FCA changed practice. To assess its impact, we compared the FCA cohorts from the 2 VIPS (Vascular Effects of Infection in Pediatric Stroke) prospective cohort studies. METHODS: The VIPS II study prospectively enrolled 205 children (29 days to 18 years) with arterial ischemic stroke at 22 centers, December 2016 to January 2022. The local team measured 12-month outcomes using the pediatric stroke outcome measure. A neuroradiologist and pediatric vascular neurologist independently reviewed all clinically obtained imaging and clinical data to classify the cause of arterial ischemic stroke. The neuroradiologist measured the FCA Severity Score on vascular imaging performed at any time poststroke. We compared the VIPS II FCA cohort to the previously published FCA cohort from VIPS I (2010–2014; 37 centers). RESULTS: Of 75 children with definite arteriopathy enrolled in VIPS II, 32 (43%) had FCA, compared with 41 of 127 (32%) of definite arteriopathy cases in VIPS I. The median age was 11.3 years (56% male) in VIPS I and 11.4 years (55%) in VIPS II. Treatment with intravenous corticosteroids increased from 2 of 41 (5%) of FCA patients in VIPS I to 18 of 32 (56%) in VIPS II. The VIPS II FCA cases were more severe at baseline (median FCA Severity Score 6 versus 4; P =0.006). There were no significant differences in either the change in FCA Severity Score (baseline to maximum) or the 12-month neurological outcomes. CONCLUSIONS: Treatment of FCA with corticosteroids increased dramatically between the VIPS I and VIPS II studies. VIPS II cases were more severe at baseline, but we observed no significant difference in disease progression or neurological outcomes. Given the low level of evidence supporting corticosteroid therapy, pediatric stroke centers should enroll FCA patients into ongoing FCA corticosteroid treatment trials. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifiers: NCT04873583 and NCT06040255.