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Introduction Disclosures and Objectives | Pediatric Stroke
Introduction Disclosures and Objectives | Pediatric Stroke
Pediatric Stroke Frequency Impact and Epidemiology | Pediatric Stroke
Pediatric Stroke Frequency Impact and Epidemiology | Pediatric Stroke
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Etiology Pediatric Stroke | Pediatric Stroke
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CASCADE Criteria - AIS | Pediatric Stroke
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Pediatric Arterial Ischemic Stroke | Pediatric Stroke
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Arterial Stroke Marfan's Syndrome | tPA | 9 | Male | Pediatric Stroke
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Wax Wane LUE Weakness and Asphasia | Steroids | 9 | Female | Pediatric Stroke
Wax Wane LUE Weakness and Asphasia | Steroids | 9 | Female | Pediatric Stroke
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Unilateral Focal Cerebral Arteriopathy | Pediatric Stroke
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Severe headaches Mild Aphasia ADD | 13 | Male | Pediatric Stroke
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Moya Moya | Pediatric Stroke
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Result - WAS - EDS Summary and AIS from Dissection | Pediatric Stroke
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University of Wisconsin Pediatric Stroke Service | Pediatric Stroke
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Summary and Questions | Pediatric Stroke
Summary and Questions | Pediatric Stroke
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going to continue on with our next presenter our next presenter will be speaking about pediatric stroke turning this dr. Beverly a guard Tina's dr. Beverly a jars Tina's received her medical degree from the University of California favor she completed her

diagnostic radiology residency at the University of California San fiscal she attended the University of Washington for her neuroradiology fellowship and the Columbia Presbyterian Medical Center at Columbia University for an

interventional neuroradiology fellowship dr. Agard kinas currently served as a professor of radiology the neurological surgery was with university wisconsin pharisees the director of neuro and Vascular service lines program director

of the neural endovascular fellowship and ho director and founder a viewer cities vascular and of animality center dr e dark United Teachers medical students residents and fellows clinically very actively in

neuroradiology anatomy magnetic strip residence nurse Susan neuro graphy and endovascular treatment please help me welcome dr. Beverly a jerkiness to the podium [Applause]

[Music] can you hear me yes first of all thank you very very much for inviting me to come and talk to you this morning and it's played to be here and it's thank you fall for getting up early this

morning to come as well take a look here oh I did also four years of general surgery at UCSF before I did radiology I enjoyed hearing about some of the history because I presented it at CDI are about 20 years ago things are gone a

long ways I've been told that you've heard a lot of stuff recently about adult stroke and all the wonderful new trials and new equipment new tools and so I'm not going to really go into that I'm going to assume that you all know

what spent Reavers are and number of devices are and all the recent new literature so we're going to talk about pediatric stroke today kind of like the next phase of development for stroke treatment and we're going to look at the

significance of pediatric stroke look at some of the ideologies just mentioned briefly the classification system that's now been adopted not for you to memorize it just know that it's there briefly go over some innovative treatments and no

series of case studies i'll show you cases for some of these entities and then just briefly show you what it takes to actually start a pediatric stroke

service stroke is really important in the pediatric population and it's one of

the top 10 causes of death and children that always surprises people because they always think of leukemia and brain tumors and all kinds of things like that which are tragic but they don't think about stroke of the majority of the

survivors and I'm going to have some cognitive or neurological dysfunction because they're young they have many years of their life ahead of them and so the cost to their families into society is enormous the risk of stroke is

actually highest in the first year of life but it can occur at any point in childhood or adolescence compared to some of the other diseases you hear more about brain tumors brain tumors are only approximately three four

hundred thousand and children flamma tori bowel disease only about 24 hundred thousand and children whereas stroke actually is much higher in pre needs at the hundred preemies per hundred thousand in neonates it's up to 40

neonates four hundred thousand and four children up to 13 children four hundred thousand are going to have a stroke so one of every 2500 births and a neonate more prominent in males and females most of them are going to be arterial hi Dan

most of the arterial and twenty of them are twenty percent of them are going to be from Venus occlusive disease or hemorrhage in children over one month of age again we're saying 13 again more often in males and females 75% of these are going to be arterial in nature so a little bit higher 25% are going to be Venus or hemorrhage and unfortunately african-americans more often than Caucasian there a higher risk

of group not to memorize this slide but

to get across the larger picture is that there are you know assert assert a third so assertive the causes are going to be cardiac in nature we have a lot more children surviving complex congenital

heart disease or invasive pediatric cardiologist doing an excellent job and so we're getting more of those children children they have sudden arrhythmia is you have on machines that we put them on ECMO LVAD for example going to have a

higher incidence of stroke a sort of these are going to be different kinds of a skill Appa these and in this category we're lumping in things like vasculitis dissection moyamoya disease transient arteriography I mean focal dare

curiosity of childhood radiation vasculopathy because a lot more kids are surviving cancer and a lot of them getting radiated and then the other third category is everything else and that includes a hefty number of

idiopathic venous sinus disease clotting disorders underlying coagulopathy sickle cell don't forget about metabolic we're not going to show any metabolic this morning but just remember that it exists and then there's some rare causes

and children you know migraine can cause stroke and children not just adults and other factors that actually becoming more important than children that you always a tribute to adults just lip ademia hypertension other causes of

stroke the Cascade classification or criteria is the new classification system that we're trying to use a pediatric stroke we do have this in the adult world and it really is beneficial in running trials and actually having a

common language with which we all communicate so in the adult world it's called toast and over 180 trials have used the toast criteria in the adult world but this doesn't translate well into the pediatric population I haven't

seen very many chain-smoker hypertensive diabetic alcoholic you know expensive a thyroid disease youngsters running around and so that so they criteria has to be a little bit different than the nomenclature has to be a little bit

different so the International pediatric stroke study group got together and by consensus came up with something that they call cascade which is those now going to be the nomenclature for studies to use in children and just a brief look

it's really not very difficult but it's going to be primarily driven on anatomic site of disease so you get to pick one category here or one category here and then you see what happens from acute to chronic presentation so you're looking

at the heart the great vessels intracranial vessels you're looking at echocardiography enlarged CT angio to help you make this plus clinical history so this will give us a common language to talk to each other about and also to

help us with trials so children actually

most the time present just like adults do eighty-five percent of non neonates are going to present with sudden onset of something sohini paris's up to eighty percent speech difficulties and a little

over of third visual field deficits in about twenty percent but why is it

that pediatric stroke doesn't get diagnosed quickly why is there still so many delays and they're still really are and that's because there's a lot of

signs and symptoms in the pediatric world that are not seeing readily in the adult world and probably the most important of that is seizure assertive children presents with a seizure as their presentation of stroke now that's

not common in the adult world but you see this in children all the time and the problem with seizure is it doesn't mean that this is a stroke mimic so mimics conceives strokes can seize how you tell which one you have headache

forty-five percent of kids complain really of this headache that's what they complain of foremost altered mental status is more common in children and adults visual field deficits are kind of hard to pick up you have a six month old

baby how can you tell if they have a field cut pre language early language children again how do you pick up a fascia when they can't really speak understandable language yet so kids get

picked up late 12 to 20 hours not

unusual on foreign oil that's a terrible thing fortunately that number is starting to drop significantly just like we saw twenty years ago in the adult population that urgency and rapidity with which we responded stroke so how do

we image kids that we think might have a stroke well using em are as though is the preferred method if we can get it no radiation plus you can pick up some of those mimics right office of the scan the problem is it's not very available a

lot of places don't have 24 7 m.r.k p'tee it also takes a long long time so conventional Mr may take 45 minutes to an hour if you have a child that has to go under general anesthesia first to get in the magnet you add on at least

another half an hour to that so you're already well into the stroke by the time you diagnose the stroke the answer to that is quick brain so we have developed does pediatric stroke screen at university wisconsin that's extremely

fast you can get a lot of imaging and i'll show you an example in under 10 minutes if you can't do an mr then CT is not a bogeyman in the pediatric world yes it is radiation yes it takes contrast but it's fast it's readily

available all over the place and it gives you a really quick good look so if you can't get an mr or there's the patient has hardware that doesn't allow them go into the magnetic field absolutely CT is the way to go here's an

example of the pediatric stroke screen and you can see that we get reasonably good images I mean this is remember it's a screen it doesn't have as much detail but look what you can get in five minutes of scanning and get DWI you can

get a t2 you can get an ADC map get a flare you get a pseudo Swan you can do a 3d pcr and from that you can generate nips of both arteries and veins and if you go on long enough you can reconstruct that at three pca into t1

images and three orthogonal planes all of that in about five to eight minutes pretty quick to use the keys then you should apply the aspect score to the non-contrast portion aspect score is the Alberta stroke program early CT score

we're using adults all the time not to make you experts but you just simply take some different levels each areas marked off you add off the areas where you see infarction and you get a score next you're subtracting from some

perfect 10 so you can see on the screen if you have eight to ten that means you have a very small stroke but you may have may have a large penumbra that Inbetweeners you have a medium-sized stroke if you're five to seven generally

we don't like to treat below six and if you're below six or zero to four you have a massive stroke and there's not much we can do to help you and all of this is generated off a non-con head CT CT perfusion still somewhat

controversial i would put mr profusion here to basically is there a penumbra to

save and i'm going to show you some young adult images because i don't really have any good CT perfusion images on my children that i've taken four

stroke but this is an example of a six defect so what you're trying to do is see the smoke a stroke is small but the amount of rain at risk to to die later it's not getting good enough blood flow is large so you want to have a big

mismatch small stroke big penumbra so in this patient she has lots of great white and then left frontal lobe you can see on the CTA there's an abrupt cutoff with a little partial promise and one of the other

vessels you can see that on the all three images CD vc BF and mean transit time it's all matched the only portion that looks really abnormal or mostly abnormal is that one small area nothing we can do to get that brain back

probably this patients going to do really well if we do nothing but give supportive care and that's what we did and she did fine this is a the opposite

extreme this patient no one's going to be able to help and this is called a

malignant pattern and malignant mismatch this is also a young man who came in with a arrhythmia I think he was 26 and he came within four hours of the observed onset of his stroke but in contrast here you have this dense artery

sign cut off but look we see vessels here but there is absolutely nothing there you don't see any visualization on the affected side and you look at his perfusion maps just this ginormous area of poor perfusion cbv down in fact the

mean transit he already has so much compromised brain that the transit time practically doesn't exist so this is a malignant transformation if you try to open the staffel up he's going to hemorrhage this is what we want to see

in both children and adults you have a nice dense artery sign in the right middle cerebral artery and abrupt cutoff on CTA and here you have a delay in transit time you have very diminished flow but the cerebral blood volume is

completely preserved that tells us we have a very small stroke we had a large portion essentially the entire right in CA territories at risk and if we open up this vessel we're going to restore flow and have salvaged spring so that's what

we're looking for in children and as well as adults how do we treat these children just pretty much like we do adults you can give intravenous TPA you can give in to arterial TPA you can do aspiration like the number system and

suck that clot out you can use stent Reavers you can do a combination of all of them can we do this safely in children they're little people what about their vessels their vessels a little too well there was a really nice

study that came out in 2015 and jay jay and is that basically looked at the vessel diameter and different ages of children and what it showed is that if you look at children and this is the age range that they used and they use looked

at both girls and boys the diameter of vessels and large vessels in ten locations 600 level measurements and then they calculate diameter based on age zero to six months in different years and what they found is that the

vessel diameters increase rapidly from zero to five but after that they increase very slowly so a five year old has about ninety-four percent the vessel diameter as a teenager or a young adult so absolutely the devices that we use in

adults can be used nicely and children so they call it the rule of five but even so large vessel even children younger than 5 some of those tools that we use in adults now we're very small and can go out into very distal small

vessels and the brains of adults of those that those stench Reavers and other devices can absolutely be used even in children under the age of five safely so size is not an issue at least

when it comes to vessels so let's look

at a few cases and these are going to be different types of pediatric stroke and the first one is going to be an arterial stroke so this is a nine-year-old in the history of Mar fans and he really doesn't just have a diagnosis of Marfan

he's already had a aortic surgery he's already had a mitral valve repair this is a nine-year-old with a full expression of Marfan syndrome and he initially presented to his parents with a sudden onset of facial week facial

weakness then he felt kind of dizzy and then he collapsed and became unconscious of course with that kind of presentation everybody thinking stroke and so he got to work fast was imaged very quickly this is his outside hospital CT scan if

you look close you can sort of see that dense artery sign and the right middle cerebral artery territory but the rest of the brain looks pretty good no big nobly no big obvious and this is his GTA showing a rough-cut off

in the right middle cerebral artery right at the bifurcation and you can see his profusion shows that he has preserved cvv the pattern that we want with diminished flow and long transit time so just like that other case this

is his angiogram showing the cut off of the middle cerebral artery because he's Mar fans because he really got expression of Mar fans I was afraid actually to use a stent rever I was afraid that I might dissect him or

injure this vessel so I did the entire thrombolysis using TPA and there you can see the microcatheter in the vessel was surrounded by some clot and I was able to reopen him just using TPA alone this is the next day this is mr showing that

he does have focal area of infarct and i think it's a little larger than they suggested but it's actually fairly small and the rest of that brain is going to recover and the best of this is pretty much teaching shine to at that point

this is him four months later he had a full total and complete neurological recovery you can see that maybe has a little bit of atrophy in that Sylvian fissure but not a whole much else the brain otherwise looks good the arteries

and veins are perfect and the profusion pattern is completely normalized so

that's what we can get if we just have a cardio and bollock source you can take down the whole vessel just like adults and this was his source he actually had

a piece of suture in his next with mitral valve that had a bunch of Claude on it so when we echoed him there's this flapping thrombus in the heart so caramelos embolism about twenty percent of course highest when you have a right

left to right shunt choir disease such as cardiomyopathy and other things in about twenty percent of kids Peyton frame and Ovalle this is a big question nobody really knows whether or not this is a risk factor or not we think it is

in certain cases but certainly there's PFOS or common in children even common in adults what does it really mean there's a study that was recently published in 2014 that looked at a meta-analysis of all the studies out

there that looked at pfoa and what they found is actually surprising and that is that there didn't seem to be a correlation between the size of pfoa or whether one was present to connote stroke or recurrent stroke so I

certainly had people with pfos that have definitely that is the source but just because of the PF oh you can't assume so this kids came off as valve here's

another case 13 year old african-american female previously

healthy she plays volleyball she fell broker fibula a couple weeks before she presented she was actually just had just finished breakfast she was getting ready for school she stood up at the kitchen table and suddenly had a massive stroke

and collapsed she went to the outside emergency room she was never verbal she had right hemiplegia at that time loss of gag reflex a few other symptoms she might had to be intubated for airway protection and she came to us with this

skin and I can tell you that all of these white things are that stroke in the cerebellum but look at the brain stem I mean it is really really bad and these are the ADC maps showing that that is absolutely true this was her MRA you

can see carotid where that where is where is that missing rakibul artery so when you cut it out you look at it specifically most of that the people excuse me that bezar artery is absolutely thrombosed and you can't see

d they don't project very well I apologize but if you can see them well you see that you see the verts coming together you see a little basler you're going going and then go on if you get up to the top where the poster cerebral

arteries from the carotid come and supply the poster cerebral system so the communicating artist keeper pca is alive this is some her angiograms you can see on the first one there's really no top of the bandler at all on the front of

the side you you see just a trickle of slow with a lot of Claude up there and then I put a microcatheter up and I'm is using this was before the days of stint Reavers i would use scent Cheevers day if i had it but I'm infusing TPA

trying to open up the clot and you can see from the entire circulation she absolutely across that poster communicating artery fills the top of the basler and the pcas so you know that you just have to get the bad we're open

the PCA it can be taken care of right from the front and this is what we end up with this is her for months later remember how bad that brain stem look this is her for months later and you can see she has a few hits there but really

we preserved a lot of this I'm sorry I can't I can't I have to do one screen and you can see that her basler is wide open and her perfusion studies have normalized and don't need this basically it's to say that she used to beat raped

and pegged in fact when she first woke up from the stroke all she could do was kick or right foot now how that how that translates out neurologically I don't really understand because it doesn't make sense but that's all she could do

she could swing her foot when she was really angry and that was it and she was traits and pigs she couldn't move anything else couldn't walk couldn't do anything fast forward about four months trach and PEG her out she feeds herself

she walked eight blocks before she gets tired she has weakness specially her left upper arm is really affected and her left leg is a little bit weak but she can walk and that's just amazing that is an absolute miraculous recovery

you and I being older we'd be sunk but children can tolerate stroke and recover from it much better than we can she was a non Sickler by the way everybody assumes she had sickle-cell she did not [Music]

so let's look at a different case this is a nine year old female with a history occasional minor headache she presented with a new and very severe headache very atypical for her she was having wax weyn symptoms with left upper extremity

weakness slurring and an aphasia and hits in Navia later we found out that she had had a very mild viral syndrome for a couple of days about a week prior to presentation so she went through emergency room they

did a head CT they didn't see anything no guns re-signed brain looks good and they decided that she had a migraine that being the catch-all term for you know people that have neurological stuff you can't explain so she was she's done

pretty well and she was going to get ready to go home they were to discharge her and she suddenly worsened so now we're about 12 hours into her from being last known well so seven hours into this she she gets worse and they decided that

this probably is a stroke not migraine or it could be my grand causing stroke or something and they call neurology and this is her mr at that time which shows some deep nuclear strokes on the DWI matched on the ADC map and you can look

at her mr angiogram and right where that big blue arrow is because i thought i might have this problem up in Yoda arrow two screens at the same time but white where that big blue arrow is is a filling defect or narrowing of that

vessel and you can see from the profusion Maps the bottom maps you can see that there's a longer transit time in that right hemisphere than in the left and this was interpreted as being a partial thrombus and in the m2 and I was

called so they called a king stroke called they called me and asked me to remove the promise or at least consider removing that after all she has a very small stroke she has a very large penumbra so yes she's well at a time but

we don't really just look at time we look at the picture too we've done patients out 18 20 hours beyond where they should be FDA sanctioned to be done and they've done well so it's not crazy to ask us this question so should we do

this just forget time to should we do it that I heard a yes in the audience I decided not to and I took a lot of heat for that but here she is two days later she's extended that stroke a little bit her perfusion is even worse for transit

times even worse and I'm people are saying well why didn't you take her look she has this partial occlusive thrombus except she didn't this isn't rhombus this actually is the earliest presentation at least from the first

couple of em ours of an artery office e and she turned out to be strongly positive for mycoplasma and this is inflammatory this is not clot now you can see two weeks later and I just skipped a couple mrs I should show you

you can see the beating of the Emile's from middle cerebral artery you see that the a1 is now almost occluded you see that the super kleiner carotid is very narrowed if I had put a stent tree her up in an inflamed vessel and pulled on

it you can rip the vessel you denuded you can rupture it you can kill people so I'm really glad that we didn't do it now look at her transit time even worse than before so she was placed with place on steroids and treated very

aggressively with fluid and I don't have a good mr on her for focal arteriography so I took this one out of a paper it just show that you can see enhancement in the wall of the vessel and people that have this entity and after steroid

treatment that enhancement or the inflammatory process goes away so that's exactly what happened to her she did actually quite well this is her one year later she's virtually back to normal she has some deficits her brain just shows a

small stroke that she had but her vessels have normalized again inflammatory process is resolved she doesn't have perfect perfusion but it's

much improved so what is this stuff what is that the FDA so basically it's a

poorly understood phenomena but it's a unilateral you focal or multifocal areas of narrowing in the blood vessels the super clinic carotid the m1 the a1 and sometimes the proximal a1m tues and a tues and you can't attribute it to

anything else it's not dissection it's not a true vasculitis and in that sense it's not a postive varicella it's typically seen can get worse over the first three months but then it stabilizes and can actually resolve

or improve in about six months and we basically be based on the diagnosis on the clinical presentation as well as the imaging so it's thought to be this probably immune-mediated inflammatory response the International pediatric

stroke study actually looked specifically at this for risk factors and the only thing that really came out statistically significant extremely positive was the history of a recent upper respiratory infection viral

illness the other thing that tended to was a trend towards being important with the age of the child so early elementary school school age children five to nine that's the peak incidence in our kid was nine here's another child with a

different problem 13 year old male has a history of a DD he complained all the time of headaches but they became more frequent more severe and progressive and then at some point he started developing numbness on one side of his body and had

developed periods of a stage a very mild aphasia he never had a bleed never had a seizure otherwise was fine this is his mr and right off the bat if you look at the enlarged pictures at the t2 you'll see all those little black dots all

those blacks little dots those are all tiny tiny multiple slow voids and if you look at this is actually a stealth study but it showed it better than the MRA did source imagers if you look at the other image you'll see too many tiny vessels

just tons of them and then if you look at the MRA nip itself you'll see that there's something missing especially on the left that vessel kind of peters out and kind of stops and this is moyamoya this child has moyamoya syndrome you can

see on the right side which is more normal side even that looks a little taper he has beginning of that those tangle of vessels silly doesn't have an a.1 to speak of the limited flow but definitely the MCA is somewhat preserved

on the left side and the AP view and the lateral view you just kind of lose the carotid completely and all you see are these multiple tiny little vessels and the thing that's really helping him out the ancestral territory are the new

collateral from the posterior circulation so this is a bootable artery injection AP and lateral and you can see a lot of the brain is particularly the entry of cerebral and also the left middle cerebral are supplied from the

vessels in the back and this is an ice floe picture of him I flow if you don't know is color coded blood flow and we apply a software program just to the angiographic images we did no more radiation no more contrast was just

taking this and looking at it using a software program and this confirms to you what you kind of knew from the grayscale images that the right mca territorial looks pretty good but on the left there's just almost no supplies the

MCA and the workhorse even though they said their project well in the bright room is really being supplied most of that perfusion from from the posterior circulation so what is moyamoya well

it's the moyamoya means puff of smoke

it's a chronic occlusive disease of really no not unknown etiology we know there are some genetic variants we know there are some diseases that predispose to that but most cases were not really certain why they have it ten percent of

these cases are familial they tend to be more aggressive and more widespread in Japan in Asia in general this is a much more common disease than here Japan the incidence is p pretty common there you get progressive stenosis of the super Klein and carotid again the m1a1 it can involve posted circulation but usually posted circulation is spared can be unilateral or bilateral and in this case you might

say this is unilateral it's really not because if you really looked at that as we said the a1 is abnormal on that side even the middle cerebral artery is it comes off that in one segments a little bit narrow and then you get all of those

torturous puff of smoke the vessels well kids that have down syndrome sickle-cell anemia and f1 activated protein C resistance and even head trauma can cause moyamoya there's a bimodal distribution so

the peaks in the first decade around age 5 and then again in the fourth Nick fourth decade around 30 for females much more commonly males are affected the United States if you look at all comers and most common patients going to be a

woman in her third or fourth decade kids frequently present with stroke headaches seizures occasionally they can have these wax wings symptoms like this kid had with you know sensory changes adults will present also with Dia or stroke but

they more often have hemorrhaged and

children so how do we fix these this is some work that we've been doing at the University of Wisconsin over the last I'd say eight or nine years maybe ten actually now that I think about it and

we recently presented our data at the double ANS meeting and dr. Benning esconder is a pediatric neurosurgeon who's my colleague and partner on this project and we've taken a traditional surgery and actually tweaked it a little

bit to get better results so if you have a moyamoya there's basically no randomized controlled study to tell you which witch treatment to do but there are three basic things you can do one is you can do a direct bypass so that's

called the EC IC bypass where you take the superficial temporal artery and you so it to the middle cerebral artery so it's a direct bypass and that's often done more in adults than in children although sometimes you do it in children

and it's a very common procedure in Japan so that's the direct approach then there's the indirect approach and there's a whole bunch of variations on a theme which are important to know except that EDS just stands for and we call it

EDS purpose because it's harder to stay afloat duro and arterioles and ngos so spending it to say EDF so EDS is the standard procedure and the traditional EDS is actually opening the door taking the superficial temporal artery and

laying it on the surface of the brain and when you do that the brain is really scarred for blood and when you do that angiogenic factors like this go crazy and you start forming all these little vessels that actually now go to supply

brain itself on the field service so that's the typical one and it works really well that's a failure rate is pretty low so if it if it does fail you have a couple options you can repeat the eds you can go to ec IC bypass and you

can do a bunch of other things like muscle flap or mental inversion things like that but and this is what it looks like a sta vessel and now you see before you do the procedure and then after you look at all the vessels of the brain has

now built from this so there's a lot of reasons why can fail which important except for one and that is in this procedure you're actually sacrificing branches of the middle meningeal artery which is a big blood vessel that

supplies that dura over the brain so this procedure when you do typical edfu sacrifice those and we decided that that didn't sound like a good idea the brain can use that you'll see Otto sometimes people will actually supply the rain

himself with the middle meningeal so characterization zamil menaggio we see that every now and then so so well what if we save all those vessels and we simply finna straight the dura more widely more broadly preserve all those

big branches do an arachnoid ille opening and allow nature to then take over what happens when we do that so we called it wide Archer of sparing because we spare the middle through an amendment in geo artery eid asked procedure so the

first three patients we did as a salvage we gave them EDF we did a conventional EDS procedure and they kept stroking so they were failures so instead of doing the traditional EDF of second time we did our wide arterial staring aghast

procedure and after we did that all stroke stopped and they stabilized and

this is an example of that this is a woman who shows that she has she presented with right hemiparesis you see a stroke in the high left hemisphere and

confirmed with Ed seaman ADC maps so we did a bilateral conventional EDS procedure in 2006 and then she kept stroking despite hydration aspirin Edith and here she comes in 2007 with Louis lower extremity paris's and another

stroke she had another stroke in 2008 and then we said okay we're going to do the wider children salvage this so in 2009 we did bilateral EDF even though she already had some of those branches compromise we did what we could and then

after that she stabilized her cognitive development and behavioural improvement and no strokes since 2009 this is that the top row is pre EDF so that you can see that there's a tremendous transit time diminished flow the middle is after

her first conventional surgery you see that we've improved her but she still has a lot of areas that are not adequately perfused and then after we did the white Archer was faring we now have essentially normalization of

perfusion so the next three patients we said well why wait until they have failed let's just do this from the beginning and there were no studies for this and we talked to the parents very carefully and the nice thing about our

procedure is it burns no bridges you can still go back and do the traditional EDS and lay that superficial temporal artery in the brain or you can go to conventional bypass if you've really got nothing to lose but if it was my kid I

start with this and so we did three children one sickle cell and two downs children with this procedure and they did phenomenally well unbelievably well so here's the pre on the top you can see that there's decreased flow and along

transit time and this is post the loss of bilateral loss of procedure and this child just has complete normalization of everything and she's like a different kid she's all sparkly she runs around the room her teacher said what did you

do to this child all of a sudden she's doing super in school gran needs blood

so all six patients had complete cessation of PIAA and strokes and five out of the six showed mr imaging evidence of normalized profusion so we

think that this technique is effective revascularisation and we actually use it now as our first line surgery not as a salvage ok let's go to something different from loyola and how we fix those

talk about dissection and I don't really have a good personal case i'm going to show you one from the literature i think this is massively under-diagnosed can be found up to twenty percent of cases it's more common and people with connective

tissue disorder is not surprising even minor trauma can cause it particularly if you have a risk factor I think most of these though we have no risk factor and no underlying connective tissue so they are truly spontaneous and most of

them or at least over half of them are inter-cranial and here's an example from from the paper that shows what they're calling a possible filling occlusion if I took one look at that that's a dissection there's a true lumen there's

a false lumen is look it doesn't look anything like clot and then one to me but but that was a possibility that that's what this was and then if you look at the axial image with the little circuit inside the circle you'll see a

bright signal and that's actually clot in the false lumen of the dissection these are treated usually conservatively if you can you know you put them on any coagulation eventually just aspirin these will usually heal spontaneously

just like they do in the neck very rarely what I want to put a stent in especially a child stenting would be reserved for if you really cannot treat them conservatively because they're going to stroke further than you need to

scan them let's spend some time on

venous disease because this is another under diagnosed and inadequately treated most of the time inadequately treated disorder and we're kind of changing how we treat treat so this is a

nine-year-old that had a tonsillectomy adenoidectomy he wasn't drinking very much and you know that you know when you get to be nine years old you don't tell your parents how much you pee or don't pee evil turns out he wasn't really

urinating for about three days it got taken several times for the hospital they would find that he was hyponatremic they would give him some fluid and then they would send him home and they did okay with that until he he really

started developing neurological signs and came to our institution with expensive thrombosis as you can see in the superior sagittal sinus straight sinus Lina Galen and very limit dead slow and the venous system by the

time he got to us he was unconscious this is a CT scans of showing high density again from the clock and this is his DWI and ADC maps on arrival now ATC maps confirm that what you see on DWI is probably stroke and what you see is

extensive high signal and the deep white matter both sides both dr. iskanders boss and my boss said don't touch this child who's you're just going to make him bleed it's all over we decided this is venous disease not arterial disease

we thought we'd rather go down fighting if we're going to lose we're going to lose by trying especially the nine-year-old we talked to the parents they said try anything so we didn't so let me ask you a question to DWI always

mean dead brain can DWI reverse both arterial and venous well this is an arterial case years after the venous one this is courtesy of Howard rally a patient that comes in with a brain stem stroke six hours into this stroke has to

be Paris if they see this on DWI and on the ADC map and they say okay this is a completed stroke we're just going to give supportive care blood pressure management heparin etc and that you know was fine until a patient like

miraculously all symptoms were gone four days later they decide to rescan and what do they see no stroke nothing nothing ot to shine through nothing and this correlates completely with hundred percent reversal of the patient's

symptoms so yes and we know from baboon experiments that we didn't publish you know 15 years ago that you can take a DWI and if you leave profuse the brain fast enough some of those gwi changes will resolve so that's really really bad

brains it hasn't actually died yet this is from his the nine-year-olds angiogram and on the left you can see that there's virtually no flow and the sinuses there's too much clot here for TPA alone and so I use a balloon and I actually do

a foggy maneuver things I did in the artery and legs when I was a surgery person I do in the brain now as a neuro and Vascular person and you can pull Claude out and in the in the straight sinus

is up here I actually only use TPA and in that location and you can see that on the right bottom right is now we've reopened those veins and he did really well this is him eight days later his clinical exam is now completely normal

three days after the procedure I walked into the picu and found and sitting up playing gameboy so he's he went from being completely comatose to wide awake on Game Boy and this is him at eight days everything is gone all signal has

reversed he's normal veins are open and this is him five years later brain is perfect sinuses are perfect and he graduated from college last year another

case this one not so so good ending this is a 15 year old girl of much desired

and much worked for only child parents went through multiple rounds of everything to have her she had bad periods were ob/gyn sucker on birth control pills even it out she started getting a headache a few weeks later and

that progressed over a week and by the time she arrived to our ed she was already unconscious you are you blew a pupil and she was herniating this is her CT scan you can see that there's absolutely no CSF around the brain stem

she actually if you were looking closely to see upward herniation of the vermis downward herniation of the tonsils and no salsa at all the brain is tight ICP is high she's got clawed all over the place and I really didn't want to take

her but she was an only child and we had nothing to lose at that point if we didn't get her out of it if she was going to die anyway so I took her and she was extremely unstable during the entire procedure she arrested twice we

resuscitated her and I just couldn't get anywhere I tried everything I'm doing balloon I'm giving her everything I gave her full system the camper nization I gave her 30 milligrams of TPA I did balloon angioplasty I fogarty her I

loaded her with rya pro gave her full loading dose of reproach she kept clotting well while I'm working but I finally after all of that sort of turned the corner and got her open to this point but it was just too little too

late and unfortunately we took her back to the ICU and she died so these can be lethal it is so important to have a high index of suspicion it's under diagnosed it accounts for up to one percent of strokes I think even more diverse

presentation headache being the most common seizures focal deficits much more common in women lots of things that can cause it but yo pathak is still a high one infection birth control pills coagulopathy inflammatory conditions and

hormonal we get pregnant women with this as well high index of suspicion do a CT mr one of these things look for that that is empty del throw sign and then Catherine geography if you think you've got something to offer the big sinuses

are the most commonly involved as you would expect but don't forget straight sinus thirty percent of cases and I've seen cortical vein involvement as well how are they going to do well if they present in a coma that's not good if

they're really really young or really really old they're going to do more poorly and if they have deep venous involvement they're more likely to have a bad outcome we used to say I'm going to go a little bit faster on some of

this that those this is the old data saying gosh and mortality rates really high can be as high as fifty percent your disability can be severe and if we view mild and we get you through with this medication than sixty-five percent

of people ought to survive it now we've got better tools just like in the last hour when you learned all about the history of our field now we're saying okay we expect 87 people percent of people to make it we expect only about

5% people to die or less we expect mild and moderate deficits and only fifty percent and severe deficits only two percent or less that's what we expect now and why is that work well the treatment is extremely high dose heparin

I know I just been working around the clock for the last few days every three to four hours and a little four-year-old girl so kind of tired but she came in looking at that 15 year old girl except was not was

not unconscious and we took her because she was vomiting and I ACPs and the most Thomas ever but the dose is high heparin you open them up a little bit and then you must slam them with heparin high and the pharmacies always come and call you

the pharmacies are very upset because you're using so much and you're off protocol but you must run them high PT keys of 80 to 100 antigen a is a point seven to one you must run it and you must be vigilant and watch it and then

if they decline or they have a look large version version you're going to go up and balloon them use state Reavers use and georgette something to get them open and treat the underlying cause american heart association in 2011 made

a recommendation that's kind of helpful except it's what we've done for the last 25 years already and that is you know give them any coagulation with heparin do and a vascular if they're declining and they don't say what kind of therapy

that has to be I'm just going to switch

to two advantages of doing mechanical therapy and I think we're going to start doing this a little bit earlier in certain patients particularly those that have a heavy cloth burden and their

otherwise high risk and the advantage of this is that it's very direct its rapid may not get all of it opens but if you can get a channel open you're going to do a better than if you have everything just thrombosed and if you stay in the

big sinuses with some of these tools you're less likely to damage something it doesn't come risk-free however don't see the numbers but if you get TPA alone your risk of hemorrhagic conversions about ten percent if you go up there

with tools yeah it's about another fifteen percent so you can have a fairly high complication rate so we don't take anybody who's stable but kids that have high club burdens and that aren't that have other really significant risk

factors we should start taking them more so high index of suspicion essential high dose heparin good hydration treat the underlying entity and consider taking people earlier to the ngos sweet if they have big clock burden high FCPS

or chronic thrombus they need any coagulation for four months even if it's a idiopathic at six to twelve months of any coagulation and most these kids that have some under other underlying problem like a

coagulopathy will need to be on medication for life and then really

quickly in about five minutes I want to show you stroke centers and Stroke teams the adult model you know we worked really hard over last decade to build

and develop stroke models and it's paid off beautifully we have primary and comprehensive stroke centers we have standardized acute care now many of you in the audience that work with us have that 30 minute timer goes off we're

going to achieve stroke to get in there and help us it's a tremendous advancement in the treatment of acute stroke and a neurological outcomes are proving that we are on the right track time is brain get it open and you're

going to have a much better neurological outcome pediatric model what model you know before the the trial I'm going to talk to you about pediatric stroke was doing what we did in adults 20 years ago slow recognition slow movement really

not a cohesive team and really no written protocols so some young

neurologists got together and decided and along with their older colleagues with things have got to change and so the NA nds funded the very first

prospective treatment trial called thrombolysis and pediatric stroke otherwise known as chips different kind of tips than the body and eventual estar thinking of and this is a phase one multicenter trial was supposed to go for

five years that was they're going to look at TPA look at pharmacokinetics and they had to be a few requirements for to be in this trial you had to have a pic you you had have neurosurgery available in case you need decompressive

craniectomy you needed urgent and imaging you needed anesthesia and you had to be able to do a pediatric NIH Stroke score and why is this trial important well there is absolutely no idea what goes to use in children

there's no there's no data out there so this is supposed to get us that data and this diagram from dr. Rifkin shows that you need to have plasminogen activated to plasmin to get Trimble Isis that's the step that has to happen and there is

a plasminogen activator inhibitor that inhibits that process well wouldn't you know that kids are different than adult so their endogenous free TPA concentration is lower than adults their plasminogen activator inhibitor

concentration is higher than adults in addition they have a larger volume distribution they have more rapid hepatic clearance so you suggest that you probably need a higher dose and children to get the same effect as a

standard dose and adults but we have no idea so we might need a higher dose in order to treat them and that was the purpose of this study it was looking for kids up to four and a half hours from onset but it got stopped by the NIH in

2013 because it was such a low enrollment and in fact just a cut to the chase there was only only one child out of all the hundreds that they screen that actually was a candidate for this pathway so what this trial really did

was it took in unorganized slow pediatric stroke services and turned them into effective machines and the in the beginning of this trial less than twenty-five percent of these centers had had a cohesive team that could respond

in the fashion the trial required and afterwards it was over eighty percent and they developed teens and strokes order sets and everything so it drove the development of primary pediatric stroke services and this slide shows

that we're just slowly going along to getting all these things until we get to 2010 and then the curves have become more vertical we had an ad hoc approach

for many years the same people got together but there was really no

cohesive nature to it so we've been working really hard over the past three years to develop a pediatric stroke service which is being implemented formally now and it's much harder to do pediatric because you need lots more

people involved so this is our one sheet saying you know who who do we think has strokes what should we do if there is a stroke and supportive care the entities that we're looking for and who to consult and why to consult and this is

our one page of protocol basically saying this is what happens when we get someone was stroking their high suspicion or moderate suspicion and then once you confirm that that stroke is confirmed and then we activate the whole

rest of the system goes just like adults

so in summary pediatric stroke is more complex than adult stroke symptomatology is more varied our curiosities are really important cause pediatric stroke as our other causes cardio ambala

dissection venous thrombosis metabolic we didnt talk about but it definitely involved theres a new classification system and nomenclature for pediatric stroke meth called cascade and pediatric stroke centers are stream of the first

of all were forming pediat primary pediatric stroke centers and because we're doing that we're streamlining and making treatment of pediatric patients more rapid and we need a higher index of suspicion we need more rapid stroke

imaging we need a faster activation of the pediatric stroke service just like we did in adults and if we do all of that our neurological outcomes in our little people with their strokes is going to be improved and they'll benefit

for the whole rest of their hopefully long lives and thank you very much [Applause] how many pediatric stroke centers are there throughout the United States at the end of the trial in 20 I don't know

what is today but the end of the trial in 2013 there were now 17 certified pediatric Primary Stroke Center and I think a lot of us are building stroke teams the amount of regulation is breathtaking if you've ever put together

an adult system you know it takes several years and they're reams and reams of paper will have to go through i'm trying to convince our group right now that we must get a nurse coordinator if we really want to go to the next

level right now i mean our biggest job is launching and most of the most places like us you have to have a full team that has ed Rapid Response pick you we have I mean it's like there's like 15 people to get notified every time a

child as a stroke as opposed to like five people every time an adult gives a stroke so a lot of places like us are aiming towards becoming primary pediatric stroke centers of our goals we status 2018 if you can probably be 20 19

but there are some truly up and running pediatric services near the questions of that precede you I think thank you i'm curious some with the UM what is your H frame for the when you talk about pediatric stroke up to adolescent 15 16

and and the different entities that you mentioned are some more common in let's say the teen age and the preteen area of the you know age and the other question is mo Roderick Strong how that's more common i suppose and children then we

think in adults like twenty percent of all strokes what is what is your experience with that i didn't talk about humoristic if i only had an hour like a two hours they could have been covered all hemorrhagic hit our

institution in most places p.s because anything under the age of 18 so 18 is the cutoff and once you're 18 and older than they are considered results and they're treated on the adult side so we recall that the big house they go to a

big house when they're 18 above they say the Children's Hospital when they're below 18 I think most Pediatrics ischaemic stroke is underdiagnosed and so I don't really know that your incidents clearly if you believe you

shows up on a scan and you see it big and dramatic the things that happen to children fewer aneurysms and children although can't have them like be true aneurysms even book a child five years of age the youngest i've ever treated as

a brain aneurysm they have a fistula they have a BM they don't tend to bleed as much as adults to bleeding julia starts often at the age of you know in the 30s you have native galen malformations could mildura lady fistula

and the vein of galen most of those children don't forget when the hemorrhage although they can neural and choroidal there's a lot of other than two entities that we're not going to talk about today because it's just lack

of time I just wanted to focus on a scenic cause of stroke in terms of what is the most common I think if yo pathak is probably the most common still we still don't know i think infectious etiologies under recognizes

under-diagnosed so you were to look at everything i would say probably the perfect storm is like the child I had in the hospital right now her grandfather has a coagulopathy he's been on khuvon in for Pease and DDT's of pts and she

was 20 she gets six of the cold comes in correctly every vein her head fly off so she has underlying coagulopathy and she just hydrated and we have the perfect storm question yeah first I want to thank you you know the passion you give

with your presentation you know it's really enjoyable and kind of palpable but I also want to ask you know in regards to nationally our people really kind of on board with the same type of protocols you presented or is it you

know you know your uniform to where we are lagging way behind the adult side but there is a true passion out there to develop pediatric stroke services and I reach when I was developing hours along with

my colleague we I reached out to Bob some children's I big sales to Seattle I reached out to Cleveland and they were so generous I mean people share the order sets they shared their protocol I'm happy to share with anybody that

wants the data that we have I can give you a list of all the people that you need and so this is kind of a grassroots effort it reminds me of 20 years ago with adults I think we have work of dedicated people that treat Chuck

pediatrics we have in the neuron adapter world we have we're developing just a pediatric subsection 2 sniffs and to all these other things and Darren Orbach in Boston Children's and I were talking and there's a whole people around the world

we're getting just the peach people I do adults too i mean i do everything from burst ninety-year-old but but you know not everybody wants to pee and so we're trying to just join you have a little log in truth now so that we can ask each

other questions show each other cases so I think this is really guilty and I think every children's hospital she you know Big Shoulders hospital needs an organized team like this and the smaller hospitals around us need to recognize

that this could be a stroke and get these kids to us as fast as possible yes sir I think I think the passion is real as the few and it's the fourth line and one last question on average monthly how many Pete's droves to you treat yeah if

you're talking about just arterial that go to the angio suite we probably get we probably take about one every three months to the enviously you're just looking at arterial if you're looking at venous occlusion we probably take maybe

two kids a year that's because we're really aggressive on the medical side I'm aunt actually living in that child rooms is wednesday you know i am there i am there I on the phone i'm checking i'm getting up in the middle of the night

second second second laughs because it is absolutely essential that you keep that child hydrated keep that heparin high and you have to no one else is going to drive it like you're going to drive it so you know thank you again hey

um in the same vein of the increased passion for theater stroke how do you increase the the heightened awareness in ed even if I mean how do you balance that with you know judicious use of imaging it's clearly not practical to

send every kid even for a 10 minute stroke MRI yeah there are places I went to two years ago to a stroke meeting and one of the guys they had an mr in there ed never Nikki room in any k to Compton it has the first time see you go

straight to the skin and they do a VW is a bed now that's the perfect world we don't live in the perfect world so if your kid comes in to have a seizure and has some transient neurological deficits and then completely normalizes that's

the kids it probably is a lower risk for stroke whereas if that kid comes in with a seizure for example and has persisted many characters that has a stroke until proven otherwise do you guys do a little bit of clinical you know work on that

and then what other illnesses that the child have is that or do they have a history of a mimic or something like this but I think we have to have a bunch of false negative we have to be aggressive that means you have to put

some resources into it that's not just for mr and see imaging that can see the angio sleep we are possible to invest in more technologists we need are technologists not to be working around the clock all

the time they need to be hostile acts is recognized that we're asking people to do this we need more of them and they have to be supported facing for our nurses this is truly a team effort not one person can do all of this in a

vacuum the other answer your question is education we are we are planning on our small strokes group which which has ed representation 50 representation pharmacy records representation we're going to go give grant around all of the

people that we think are gonna see these children and try against you know educate the residents to know our trainees as well as all the nurses and other staff what to look for but the first thing is just be suspicious and I

would much rather have you know five or six negative scans and miss that one child 10 negative scan then miss miss miss net1 childís you'll all have that window of opportunity to close this and then you've got nothing you can do yeah

thank you [Applause] [Applause]

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