Background: Perinatal hemorrhagic stroke in late preterm and term neonates is understudied. We describe two-month and two-year neurological outcomes in a prospective cohort. Methods: Neonates >= 36 weeks' gestation with spontaneous hemorrhagic stroke (parenchymal and intraventricular) presenting at age <= 28 days were enrolled between March 2007 and May 2015 at three tertiary pediatric centers. Hemorrhagic transformation of arterial ischemic stroke or cerebral sinovenous thrombosis was excluded. The Pediatric Stroke Outcome Measure (PSOM) assessed outcomes. Wilcoxon signed-rank tests evaluated change over time. Results: Twenty-six neonates were included (median age: 1 day, interquartile range [IQR] 0 to 16; median gestational age: 38.3 weeks, IQR 37.0 to 39.0). Hemorrhage was isolated intraventricular in seven (27%), isolated intraparenchymal in six (23%), and a combination in 10 (39%). Three neonates (12%) died during hospitalization; one died later due to cardiac disease. Among 22 survivors, outcomes were assessed at a median of 2.1 months (IQR 1.7 to 3.3) in 96% and 1.9 years (IQR 1.3 to 2.0) in 73%. Median PSOM scores were 0.0 (IQR 0.0 to 1.0) and 0.25 (IQR 0.0 to 1.3), respectively. At two years, 45% of patients had no or nonimpairing deficits (PSOM <1.0), 30% had mild deficits (PSOM 1.0 to 2.0), and 5% had moderate deficits (PSOM 2.5 to 4.5). Over time, 31% worsened and 6% improved. Although total PSOM scores did not change significantly (P = 0.08), language subscores worsened (P = 0.009). No child developed epilepsy. Conclusions: Perinatal hemorrhagic stroke survivors had favorable outcomes in early childhood; at two years moderate to severe deficits occurred in 5%. Language deficits may emerge over time, warranting close follow-up. (C) 2019 Elsevier Inc. All rights reserved.

Objectives:To determine incidence rates and risk factors of remote seizure after perinatal arterial ischemic stroke.Methods:We retrospectively identified a population-based cohort of children with perinatal arterial ischemic stroke (presenting acutely or in a delayed fashion) from a large Northern Californian integrated health care system. We determined incidence and predictors of a remote seizure (unprovoked seizure after neonatal period, defined as 28 days of life) by survival analyses, and measured epilepsy severity in those with active epilepsy (1 remote seizure and maintenance anticonvulsant treatment) at last follow-up.Results:Among 87 children with perinatal stroke, 40 (46%) had a seizure in the neonatal period. During a median follow-up of 7.1 years (interquartile range 3.2-10.5), 37 children had 1 remote seizure. Remote seizure risk was highest during the first year of life, with a 20% (95% confidence interval [CI] 13%-30%) cumulative incidence by 1 year of age, 46% (CI 35%-58%) by 5 years, and 54% (CI 41%-67%) by 10 years. Neonatal seizures increased the risk of a remote seizure (hazard ratio 2.8, CI 1.3-5.8). Children with neonatal seizures had a 69% (CI 48%-87%) cumulative incidence of remote seizure by age 10 years. Among the 24 children with active epilepsy at last follow-up, 8 (33%) were having monthly seizures despite an anticonvulsant and 7 (29%) were on more than one anticonvulsant.Conclusions:Remote seizures and epilepsy, including medically refractory epilepsy, are common after perinatal stroke. Neonatal seizures are associated with nearly 3-fold increased remote seizure risk.

BACKGROUND:Perinatal and childhood stroke result in neurological impairment in the majority of survivors, but less is known about patient and parent perception of function following stroke in children. Our aim was to characterize parent-proxy and child-reported health status in children following unilateral arterial ischemic stroke or intraparenchymal hemorrhage.METHODS:Fifty-nine children 2-18 years (30 girls, 29 boys) with unilateral arterial ischemic stroke or spontaneous intraparenchymal hemorrhage at least 6 months before evaluation were enrolled from a single center. The PedsQL version 4.0 Generic Short Form and PedsQL version 3.0 Cerebral Palsy Module were administered to childhood stroke subjects and parents. Generic PedsQL Inventory scores were compared between children with stroke and published data from healthy children. Reported health status scores for children with varying degrees of hemiparesis were compared.RESULTS:Children with stroke had lower reported health status scores on the Generic PedsQL Inventory than healthy children. Children with moderate-severe hemiparesis had worse scores than children without hemiparesis on several measures of the Cerebral Palsy Module as reported by both parents and children. The parents of children with epilepsy reported worse scores on several measures compared with children without epilepsy, and the parent scores were lower on several measures for children with lower intelligence quotients. Agreement between parent and child scores was better on the Cerebral Palsy Module than on the Generic Inventory.CONCLUSIONS:Children with stroke have worse reported health status than healthy controls. Degree of hemiparesis, epilepsy, and lower intelligence quotient affect reported health status on some measures. Agreement between parent-proxy and child scores ranges from slight to good which suggests that both provide useful information.

IMPORTANCE:Hematoma expansion is the only modifiable predictor of outcome in adult intracerebral hemorrhage; however, the frequency and clinical significance of hematoma expansion after childhood intracerebral hemorrhage are unknown. OBJECTIVE:To assess the frequency and extent of hematoma expansion in children with nontraumatic intracerebral hemorrhage. DESIGN, SETTING, AND PARTICIPANTS:Prospective observational cohort study at 3 tertiary care pediatric hospitals. Children (≥ 37 weeks' gestation to 18 years) with nontraumatic intracerebral hemorrhage were enrolled in a study from 2007 to 2012 focused on predictors of outcome. For this planned substudy of hematoma expansion, neonates 28 days or younger and participants with isolated intraventricular hemorrhage were excluded. Children with 2 head computed tomography (CT) scans within 48 hours were evaluated for hematoma expansion and were compared with children with only 1 head CT scan. Consent for the primary cohort was obtained from 73 of 87 eligible participants (84%); 41 of 73 children enrolled in the primary cohort met all inclusion/exclusion criteria for this substudy, in whom 22 had 2 head CT scans obtained within 48 hours that could be evaluated for hematoma expansion. Within our substudy cohort, 21 of 41 (51%) were male, 25 of 41 (61%) were white, 16 of 41 (39%) were black, and median age was 7.7 years (interquartile range, 2.0-13.4 years). MAIN OUTCOME AND MEASURE:Primary outcome was prevalence of hematoma expansion. RESULTS:Of 73 children, 41 (56%) met inclusion criteria, and 22 (30%) had 2 head CT scans to evaluate expansion. Among these 22 children, median time from symptom onset to first CT was 2 hours (interquartile range, 1.3-6.5 hours). Median baseline hemorrhage volume was 19.5 mL, 1.6% of brain volume. Hematoma expansion occurred in 7 of 22 (32%). Median expansion was 4 mL (interquartile range, 1-11 mL). Three children had significant (>33%) expansion; 2 required urgent hematoma evacuation. Expansion was not associated with poorer outcome. Compared with children with only 1 head CT scan within 48 hours, children with 2 head CT scans had larger baseline hemorrhage volumes (P = .05) and were more likely to receive treatment for elevated intracranial pressure (P < .001). CONCLUSIONS AND RELEVANCE:Hematoma expansion occurs in children with intracerebral hemorrhage and may require urgent treatment. Repeat CT should be considered in children with either large hemorrhage or increased intracranial pressure.

Background and Purpose— The intracerebral hemorrhage (ICH) score is the most commonly used clinical grading scale for outcome prediction after adult ICH. We created a similar scale in children to inform clinical care and assist in clinical research. Methods— Children, full-term newborns to 18 years, with spontaneous ICH were prospectively enrolled from 2007 to 2012 at 3 centers. The pediatric ICH score was created by identifying factors associated with poor outcome. The score’s ability to detect moderate disability or worse and severe disability or death was examined with sensitivity, specificity, and area under the receiver operating characteristic curve. Results— The pediatric ICH score components include ICH volume >2% to 3.99% of total brain volume (TBV): 1 point; ICH volume ≥4% TBV: 2 points; acute hydrocephalus: 1 point; herniation: 1 point; and infratentorial location: 1 point. The score ranges from 0 to 5. At 3-month follow-up of 60 children, 10 were severely disabled or dead, 30 had moderate disability, and 20 had good recovery. A pediatric ICH score ≥1 predicted moderate disability or worse with a sensitivity of 75% (95% confidence interval [CI], 59% to 87%) and a specificity of 70% (95% CI, 46% to 88%). A pediatric ICH score ≥2 predicted severe disability or death with a sensitivity and specificity of 90% (95% CI, 55% to 99%) and 68% (95% CI, 53% to 80%), respectively. The area under the receiver operating characteristic curve for classifying outcome as severe disability or death was 0.88 (95% CI, 0.78–0.97). Conclusions— The pediatric ICH score is a simple clinical grading scale that may ultimately be used for risk stratification, clinical care, and research.

Objective Few data regarding causes and outcomes of haemorrhagic stroke (HS) in term neonates are available. We characterised risk factors, mechanism and short-term outcomes in term and late preterm neonates with acute HS.Design Prospective cohort.Setting Single-centre tertiary care stroke registry.Subjects Term and late preterm neonates (>= 34 weeks gestation), born 2004-2010, with acute HS <= 28 days of life were identified, and clinical information was abstracted. Short-term outcomes were assessed via standardised neurological exam and rated using the Paediatric Stroke Outcome Measure (PSOM).Results Among 42 neonates, median gestational age was 39.7 weeks (IQR 38-40.7 weeks). Diagnosis occurred at a median of 1 day (IQR 0-7 days) after delivery. Twenty-seven (64%) had intraparenchymal and intraventricular haemorrhage. Mechanism was haemorrhagic transformation of venous or arterial infarction in 22 (53%). Major risk factors included congenital heart disease (CHD), fetal distress and haemostatic abnormalities. Common presentations included seizure, apnoea, and poor feeding or vomiting. Acute hydrocephalus was common. Mortality was 12%. Follow-up occurred in 36/37 survivors at a median of 1 year (IQR 0.5-2.0 years). Among 17/36 survivors evaluated in stroke clinic, 47% demonstrated neurologic deficits. Deficits were mild (PSOM 0.5-1.5) in 9/36 (25%), and moderate-to-severe (PSOM >= 2.0) in 8/36 (22%).Conclusions In our cohort with acute HS, most presented with seizures, apnoea and/or poor feeding. Fetal distress and CHD were common. Nearly two-thirds had intraparenchymal with intraventricular haemorrhage. Over half were due to haemorrhagic transformation of infarction. Short-term neurologic deficits were present in 47% of survivors.

IMPORTANCESeizures are believed to be common presenting symptoms in neonates and children with spontaneous intracerebral hemorrhage (ICH). However, few data are available on the epidemiology of acute symptomatic seizures or the risk for later epilepsy.OBJECTIVETo define the incidence of and explore risk factors for seizures and epilepsy in children with spontaneous ICH. Our a priori hypotheses were that younger age at presentation, cortical involvement of ICH, acute symptomatic seizures after presentation, ICH due to vascular malformation, and elevated intracranial pressure requiring urgent intervention would predict remote symptomatic seizures and epilepsy.DESIGNProspective cohort study conducted between March 1, 2007, and January 1, 2012.SETTINGThree tertiary care pediatric hospitals.PARTICIPANTSSeventy-three pediatric subjects with spontaneous ICH including 20 perinatal (≥37 weeks' gestation to 28 days) and 53 childhood subjects (>28 days to <18 years at presentation).MAIN OUTCOME MEASURESAcute symptomatic seizures (clinically evident and electrographic-only seizures within 7 days), remote symptomatic seizures, and epilepsy.RESULTSAcute symptomatic seizures occurred in 35 subjects (48%). Acute symptomatic seizures as a presenting symptom of ICH occurred in 12 perinatal (60%) and 19 childhood (36%) subjects (P = .07). Acute symptomatic seizures after presentation occurred in 7 children. Electrographic-only seizures were present in 9 of 32 subjects (28%) with continuous electroencephalogram monitoring. One-year and 2-year remote symptomatic seizure-free survival rates were 82% (95% CI, 68-90) and 67% (95% CI, 46-82), respectively. One-year and 2-year epilepsy-free survival rates were 96% (95% CI, 83-99) and 87% (95% CI, 65-95), respectively. Elevated intracranial pressure requiring acute intervention was a risk factor for seizures after presentation (P = .01; Fisher exact test), remote symptomatic seizures, and epilepsy (P = .03, and P = .04, respectively; log-rank test).CONCLUSIONS AND RELEVANCEPresenting seizures are common in perinatal and childhood ICH. Continuous electroencephalography may detect electrographic seizures in some subjects. Single remote symptomatic seizures occur in many, and development of epilepsy is estimated to occur in 13% of patients at 2 years. Elevated intracranial pressure requiring acute intervention is a risk factor for acute seizures after presentation, remote symptomatic seizures, and epilepsy.

Background and Objectives: The role of patent foramen ovale (PFO) in childhood arterial ischemic stroke (AIS) is poorly understood. We aimed to define the prevalence of PFO in children with first AIS, and its relationship to recurrence. Methods: Subjects (>28 days to <18 years) with AIS between 2006-2012 were identified from a single-center consecutive prospective cohort study. Subjects were excluded with diagnoses of congenital or acquired heart disease, moyamoya, meningitis, brain tumor, surgery of the head or neck, endovascular procedures, metabolic disorder, or hemoglobinopathy. Charts were abstracted for clinical and radiologic features, echocardiogram, and thrombophilia evaluations. Recurrent events included 1) stroke, defined as a new focal deficit with new infarction on imaging, or 2) transient ischemic event (TIA). Incidence of recurrence in children with PFO was compared to those without PFO by survival analysis. Data are given as median (range). Results: Forty-four subjects met eligibility criteria, median age 5.8 years (0.1-17), 77% male. Echocardiogram was obtained in 42 (95%), and disclosed a PFO in 7/42 (17%), of which other stroke risk factors were present in 5. In the entire cohort, primary stroke risk factors other than PFO included cervical arterial dissection (8), intracranial focal cerebral arteriopathy (8), thrombophilia (10), CNS vasculitis (1), other (4), none (11). All subjects received antithrombotic treatment for stroke prevention, and 2 underwent endovascular PFO device closure. Follow-up was available in all subjects at median of 25 months (4-71). Incidence rate of recurrent stroke or TIA was 8/1000 - person-months, and was similar in both groups, affecting 1/7 subjects with PFO at 0.3 months, and in 6/37 subjects without PFO at median of 2.8 months (0.3-36) after first stroke. Conclusions: PFO is present in a small proportion of children with first AIS, often with other risk factors. Recurrence in children with PFO in this small cohort was similar to those without PFO. Outcomes may have been influenced by other stroke risk factors, and secondary stroke preventive treatments including PFO closure and antithrombotic treatment. The role of PFO in initial and recurrent stroke remains uncertain, and deserves further study.

Background and Purpose: Stroke affects 2-13/100,000 children annually and ranks among the top ten causes of childhood death with long-term deficits in 40-60% of survivors. Parents report behavioral changes, such as short temper, irritability, or symptoms of depression. Using data collected in the multicenter study to validate the Pediatric NIH Stroke Scale, we report the prevalence and factors associated with emotional changes and depression following childhood stroke. Methods: Children 2-18 years old with arterial ischemic stroke were prospectively enrolled over 34 months at 15 sites with daily PedNIH Stroke Scale examination. Outcomes were assessed by Pediatric Stroke Outcome Measure (PSOM) at 3 and 12 months. Parents reported the presence or absence of emotional changes or depression. Hemispheric localization and vascular distribution was determined by MRI. Associations were evaluated by logistic regression. Results: 105 children were enrolled (mean age 10.4y, 63% male). Emotional changes were reported in 39/93 (42%) at 3m and 28/78 (36%) at 12m. Depressive symptoms were reported in 13/93 (14%) and 11/80 (14%) at 3 and 12m, respectively. Among those with data at both timepoints, emotional changes present at 3m resolved at 12m for 9/30 (30%) and 6/41 (15%) of those initially without changes at 3m, developed emotional changes at 12m. Symptoms of depression resolved at 12m in 7/12 (58%) with symptoms at 3m, while 5/60 (8.3%) of those without symptoms at 3m reported depressive symptoms at 12m. In multivariate analyses, only PSOM, and not gender, hemispheric lateralization, vascular distribution, or PedNIHSS were predictive of emotional changes or depressive symptoms. Conclusions: Behavioral changes affect a large proportion of children after stroke. In multivariate analysis, parent-reported emotional changes and depression correlated with physician scored severity (PSOM). Behavioral assessment of pediatric stroke survivors and parental education is needed as children encounter emotional struggles in recovery. These potentially treatable behavioral changes could impede therapy and inhibit maximal recovery.

Objective: Hematoma expansion and its predictors like the “spot sign” are important research areas in adults with primary (hypertensive) intracerebral hemorrhage (ICH), but are rarely studied in secondary ICH. At one center, in adults with ICH due to brain arteriovenous malformation (AVM), aneurysm, or tumor, significant hematoma expansion (>33%) occurred in 6/30 (20%) within 24 hours. In children, the frequency of hematoma expansion and the appropriate timing of follow-up neuroimaging are unknown. We assessed the frequency and extent of hematoma expansion in children with non-traumatic ICH. Methods: From 2007 to 2012, 73 children with spontaneous ICH were enrolled in a three-center prospective study (≥37 weeks gestation-17 years). Inclusion for this sub-study: 2 head CTs obtained for clinical indications within 48 hours after presentation with ICH (28 children). Exclusion: Surgical evacuation of hematoma before 2 nd CT was obtained (2 children), IVH only (7 children), neonates <29 days old (20 children). Hematoma volume was assessed via manual volumetric analysis. Results: Of 73 children, 25 (34%) met all inclusion and exclusion criteria. Median age was 9.0 years, interquartile range (IQR) 2.1-14.1. Median time from symptom onset to first CT was 9.4 hours (IQR 4.5-20). ICH was due to coagulopathy or vascular cause in 22/25 children (88%). Median baseline ICH volume was 22.2mL (range 2-86mL). Hematoma expansion occurred in 7/25 (28%) with 2 head CTs. Median ICH volume expansion was 4mL (range 0.1-12mL), 32% (range 2-58%) of baseline ICH volume. Three had significant (>33%) expansion; all had coagulopathy or vascular etiologies of ICH. As expected, children with 2 head CTs had larger baseline ICH volumes (p=0.05) and were more likely to receive treatment for elevated intracranial pressure (ICP) (p=0.001) compared to children with ICH who had fewer than 2 head CTs within 48 hours. Conclusion: Hematoma expansion occurred in 28% of children with clinical concern for hematoma growth and was >33% in 12%. Repeat CT should be considered in those with large ICH and increased ICP. Head CTs were not obtained at prescribed time intervals; research CTs without clear benefit are not feasible in children.

Numbers are conceptualized spatially along a horizontal mental line. This view is supported by mounting evidence from healthy adults and patients with unilateral spatial neglect. Little is known about children's representation of numbers with respect to space. This study investigated elementary school children's directional biases in physical and numerical space to better understand the relation between space and number. We also examined the nature of spatial organization in numerical space. In two separate tasks, children (n = 57) were asked to bisect a physical line and verbally estimate the midpoint of number pairs. In general, results indicated leftward biases in both tasks, but the degree of deviation did not correlate between the tasks. In the number bisection task, leftward bias (underestimating the midpoint) increased as a function of numerical magnitude and interval between number pairs. In contrast, a rightward deviation was found for smaller number pairs. These findings suggest that different underlying spatial attentional mechanisms might be directed in physical and numerical space in young school children, which would be integrated in adulthood.

Visual search plays an important role in guiding behavior. Children have more difficulty performing conjunction search tasks than adults. The present research evaluates whether developmental differences in children's ability to organize serial visual search (i.e., search organization skills) contribute to performance limitations in a typical conjunction search task. We evaluated 134 children between the ages of 2 and 17 on separate tasks measuring search for targets defined by a conjunction of features or by distinct features. Our results demonstrated that children organize their visual search better as they get older. As children's skills at organizing visual search improve they become more accurate at locating targets with conjunction of features amongst distractors, but not for targets with distinct features. Developmental limitations in children's abilities to organize their visual search of the environment are an important component of poor conjunction search in young children. In addition, our findings provide preliminary evidence that, like other visuospatial tasks, exposure to reading may influence children's spatial orientation to the visual environment when performing a visual search.

Background and Purpose— The Pediatric National Institutes of Health Stroke Scale (PedNIHSS), an adaptation of the adult National Institutes of Health Stroke Scale, is a quantitative measure of stroke severity shown to be reliable when scored prospectively. The ability to calculate the PedNIHSS score retrospectively would be invaluable in the conduct of observational pediatric stroke studies. The study objective was to assess the concurrent validity and reliability of estimating the PedNIHSS score retrospectively from medical records. Methods— Neurological examinations from medical records of 75 children enrolled in a prospective PedNIHSS validation study were photocopied. Four neurologists of varying training levels blinded to the prospective PedNIHSS scores reviewed the records and retrospectively assigned PedNIHSS scores. Retrospective scores were compared among raters and to the prospective scores. Results— Total retrospective PedNIHSS scores correlated highly with total prospective scores ( R 2 =0.76). Interrater reliability for the total scores was “excellent” (intraclass correlation coefficient, 0.95; 95% CI, 0.94–0.97). Interrater reliability for individual test items was “substantial” or “excellent” for 14 of 15 items. Conclusions— The PedNIHSS score can be scored retrospectively from medical records with a high degree of concurrent validity and reliability. This tool can be used to improve the quality of retrospective pediatric stroke studies.

Background: Stroke is an important cause of death and disability among children. Clinical trials for childhood stroke will require a valid acute clinical stroke scale. We evaluated predictive validity of a pediatric adaptation of the NIH Stroke Scale, (PedNIHSS). Methods: The PedNIHSS was developed by modifying the adult NIHSS for administration in children. Children 2-18 yrs with acute arterial ischemic stroke were enrolled in a prospective cohort study from 15 North American sites Jan 2007-Oct 2009. Examiners were child neurologists experienced in pediatric stroke, certified in the NIHSS and trained in using the PedNIHSS. Each subject was examined daily for 7 days or until discharge. Outcome at 3 and 12 months was assessed with the Pediatric Stroke Outcome Measure (PSOM). Associations were evaluated using Pearson rank correlation and simple linear regression. Data are mean±SD or median(IQR). Results: Among 112 children enrolled, mean age was 10.3±5.3 yr, 60% were male. Stroke mechanism was vasculopathy in 32%, cardioembolic in 30%, other in 17%, and unknown in 21%. Infarcts were in the anterior circulation in 66%, posterior circulation in 26%, both in 8%. Median time from symptom onset to initial PedNIHSS exam was 28 hrs (IQR 18-53). Median initial PedNIHSS score was 6 (IQR 3-13) and maximum 7 (IQR 3-14). Three (3%) children died, and were excluded from further analysis. Outcome data was available in 102(90%) at 3 months and 81(72%) at 12 months. Median PSOM was 1.0 (IQR 0.5-2.5) at 3 months, and 1.0 (IQR 0-2.5) at 12 months. Outcome at 12 months was good (PSOM 0-0.5) in 32/81(40%), moderate (PSOM 1.0-2.0) in 27/81(33%), and severely impaired (PSOM>2.0) in 22/81 (27%). Initial PedNIHSS score significantly predicted global deficits on PSOM at 3 (Adj R 2 =0.32, p<.0001) and 12 months (Adj R 2 =0.26, p<.0001). Maximum PedNIHSS score also significantly predicted PSOM at 3 (Adj R 2 =0.41, P<.0001) and 12 months (Adj R 2 =0.36, P<.0001).( Fig ). Conclusion: Initial stroke severity in children measured by the PedNIHSS is predictive of 3- and 12-month outcome.

Background and Objectives: The Pediatric National Institutes of Health Stroke Scale (PedNIHSS), an adaptation of the adult NIH Stroke Scale, is a quantitative measure of stroke severity shown to be reliable when scored prospectively. The ability to calculate the PedNIHSS score retrospectively would be invaluable in the conduct of retrospective pediatric stroke studies. To this end, the objective of this study was to assess the validity and reliability of calculating the PedNIHSS score retrospectively from medical records. Methods: Neurological examinations documented in medical records of 75 children from 9 institutions were deidentified and photocopied. All subjects had been previously enrolled in a prospective PedNIHSS validation study. Four neurologists of varying clinical training levels were given detailed instructions on how to translate the neurological examination into a PedNIHSS score. If an item was not recorded in the medical record, it was scored as 0 (normal) as was done in past adult studies. The raters were blinded to the PedNIHSS scores derived from the prospective study, reviewed the documented neurological examinations, and retrospectively assigned the PedNIHSS score. Each rater scored the 75 patients' examinations in the same order. Retrospective scores were compared among raters and to the prospectively measured scores. Results: The mean prospective total PedNIHSS score for the 75 subjects was 8.2 (SD 7) with median 6 (IQR 3-12).The mean total retrospective PedNIHSS score was 7.6 (SD 7) with median 5 (IQR 3-11). The mean and median total prospective and retrospective PedNIHSS scores were not significantly different (p= 0.49 Student's t-test; p=0.37 Wilcoxon rank-sum). Total retrospective PedNIHSS scores correlated highly with prospectively assigned total scores (R 2 0.76, p<0.001). Eighty-nine percent of retrospective total scores were within 5 points of the prospectively scored totals. Using a pre-determined threshold PedNIHSS score ≤5, the sensitivity of retrospective assessment was 87% (95% CI: 81-92%) and the specificity was 81% (95%CI: 74-87%). Interrater reliability for the total retrospective scores among the four raters assessed with the intraclass correlation coefficient was 0.95 (95% CI: 0.94-0.97). Interrater reliability for the 15 item scores that comprise the total PedNIHSS score, assessed with weighted κ, ranged from 0.47 to 0.93. Interrater reliability for all but one item was “substantial” or “excellent.” Conclusions: The PedNIHSS score can be assessed retrospectively from medical records with a high degree of validity and reliability. This tool, a stroke severity measure, can be used to improve the quality of retrospective pediatric stroke studies.

Background and Purpose— The purposes of this study were to determine the incidence of neurovascular events as late complications in pediatric patients with brain tumor and to evaluate radiation as a risk factor. Methods— Patients were ascertained using the tumor database of a pediatric tertiary care center. Included patients had a primary brain tumor, age birth to 21 years, initial treatment January 1, 1993, to December 31, 2002, and at least 2 visits with neuro-oncology. Radiation exposure included: whole brain, whole brain plus a focal boost, or focal brain. The primary outcome was stroke or transient ischemic attack. Results— Of 431 subjects, 14 had 19 events of stroke or transient ischemic attack over a median follow-up of 6.3 years. The incidence rate was 548/100 000 person-years. Overall, 61.5% of subjects received radiation, including 13 of 14 subjects with events. Median time from first radiation to first event was 4.9 years. The stroke/transient ischemic attack hazard ratio for any brain irradiation was 8.0 (95% CI, 1.05–62; P=0.045); for the circle of Willis, radiation was 9.0 (95% CI, 1.2–70; P=0.035); and for focal noncircle of Willis, radiation was 3.4 (95% CI, 0.21–55; P=0.38). Conclusions— The incidence of neurovascular events in this population is 100-fold higher than in the general pediatric population and cranial irradiation is an important risk factor. By defining the incidence of this late effect, physicians are better able to counsel parents regarding treatment, monitor patients at risk, and target a population for primary stroke prevention in future studies.

Background and Purpose— Stroke is an important cause of death and disability among children. Clinical trials for childhood stroke require a valid and reliable acute clinical stroke scale. We evaluated interrater reliability (IRR) of a pediatric adaptation of the National Institutes of Health Stroke Scale. Methods— The pediatric adaptation of the National Institutes of Health Stroke Scale was developed by pediatric and adult stroke experts by modifying each item of the adult National Institutes of Health Stroke Scale for children, retaining all examination items and scoring ranges of the National Institutes of Health Stroke Scale. Children 2 to 18 years of age with acute arterial ischemic stroke were enrolled in a prospective cohort study from 15 North American sites from January 2007 to October 2009. Examiners were child neurologists certified in the adult National Institutes of Health Stroke Scale. Each subject was examined daily for 7 days or until discharge. A subset of patients at 3 sites was scored simultaneously and independently by 2 study neurologists. Results— IRR testing was performed in 25 of 113 a median of 3 days (interquartile range, 2 to 4 days) after symptom onset. Patient demographics, total initial pediatric adaptation of the National Institutes of Health Stroke Scale scores, risk factors, and infarct characteristics in the IRR subset were similar to the non-IRR subset. The 2 raters' total scores were identical in 60% and within 1 point in 84%. IRR was excellent as measured by concordance correlation coefficient of 0.97 (95% CI, 0.94 to 0.99); intraclass correlation coefficient of 0.99 (95% CI, 0.97 to 0.99); precision measured by Pearson ρ of 0.97; and accuracy measured by the bias correction factor of 1.0. Conclusions— There was excellent IRR of the pediatric adaptation of the National Institutes of Health Stroke Scale in a multicenter prospective cohort performed by trained child neurologists.