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 Key Words: childhood Ⅲ ischemic stroke Ⅲ outcome Ⅲ stroke scale Ⅲ validation I schemic stroke affects 1.2 to 7.9 per 100 000 children aged 1 month to 18 years annually in Europe and North America and ranks among the top 10 causes of death. 1,2 Long-term motor and cognitive deficits interfering with activities of daily life and academic attainment affect 40% to 60% of survivors. 3 There are no proven strategies for acute management or prevention of childhood stroke other than blood transfusion for children with sickle cell anemia. Progress in defining factors that determine outcome and designing clinical trials are hindered by the lack of a validated and reliable clinical stroke scale. Previously published cohort studies of acute clinical presentation or long-term outcome in childhood stroke have not used standardized, validated, and reliable measures of clinical stroke severity at stroke onset. The National Institutes of Health Stroke Scale (NIHSS) is a quantitative measure of stroke-related acute neurological deficit, which has proven intra-and interrater reliability (IRR) and predictive validity for outcome among adults. 4 -6 Neurological examination of children requires adjustment according to the maturation of the child's neurological and cognitive function and ability to comprehend instructions. The objective of this study was to evaluate IRR of a pediatric modification of the NIHSS, the Pediatric NIHSS (PedNIHSS), administered by child neurologists in children with ac...

Background and Purpose 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 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 (R2=0.76). Interrater reliability for the total scores was “excellent” (intraclass correlation coefficient of 0.95, 95% confidence interval 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.

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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 PARTICIPANTSProspective observational cohort study at 3 tertiary care pediatric hospitals. Children (Ն37 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 RELEVANCEHematoma 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.

Objective Direct costs for children who had stroke are similar to those for adults. There is no information regarding the out-of-pocket costs families encounter. We described the out-of-pocket costs families encountered in the first year after a child’s ischemic stroke. Methods 22 subjects were prospectively recruited at four centers in the US and Canada in 2008 and 2009 as part of the “Validation of the Pediatric NIH Stroke Scale” study; families’ indirect costs were tracked for one year. Every three months, parents reported hours they did not work, non-reimbursed costs for medical visits or other health care, and mileage. They provided estimates of annual income. We calculated total out-of-pocket costs in US dollars and reported costs as a proportion of annual income. Results Total median out-of-pocket cost for the year following an ischemic stroke was $4354 (range 0–$28,666; interquartile range $1,008–$8,245). Out-of-pocket costs were greatest in the first three months after the incident stroke, with the largest proportion due to lost wages, followed by transportation and non-reimbursed healthcare. For the entire year median costs represented 6.8% (range 0–81.9%; interquartile range 2.7–17.2%) of annual income. Conclusions Out-of-pocket expenses are significant following a child’s ischemic stroke. The median costs are noteworthy given that the median American household had cash savings of $3,860 at the time of the study. These results with previous reports of direct costs give a more complete view of the overall costs to families and society. Childhood stroke creates an under-recognized cost to society because of decreased parental productivity.

Background and Purpose The ICH Score is the most commonly used clinical grading scale for outcome prediction after adult intracerebral hemorrhage (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 2007-2012 at three 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 (ROC) curves. Results The pediatric ICH score components include ICH volume >2-3.99% 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 0-5. 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 of ≥1 predicted moderate disability or worse with a sensitivity of 75% [95% confidence interval (CI): 59-87%] and a specificity of 70% (95% CI: 46-88%). A pediatric ICH score of ≥2 predicted severe disability or death with a sensitivity and specificity of 90% (95% CI: 55-99%) and 68% (95% CI: 53-80%). The area under the ROC 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.

Background and Objectives: We aimed to define the incidence of acute symptomatic seizures and of remote symptomatic seizures and epilepsy after spontaneous pediatric intracerebral hemorrhage (ICH). Methods: Pediatric patients with spontaneous ICH presenting between 2007 and 2012 at three tertiary care centers were prospectively identified. Acute symptomatic seizures were defined as seizures occurring from presentation to 7 days after ICH. Survival analysis was used to assess development of a first remote symptomatic seizure and epilepsy (2 or more unprovoked seizures >7 days after ICH). Log-rank tests were used to examine putative risk factors for development of remote symptomatic seizures and epilepsy. Results: Seventy-three pediatric subjects with spontaneous ICH were identified, including 20 perinatal (≥37 weeks gestation to 28 days) and 53 childhood subjects (>28 days to <18 years). Acute symptomatic seizures occurred in 12 (60%) perinatal and 23 (43%) childhood subjects, p=.29, Fisher’s exact. Median age of childhood subjects with acute symptomatic seizures was younger than those without (2.2 versus 10.8 years, p=.006, rank-sum). Electrographic-only seizures occurred in 28% of 32 subjects who had continuous EEG monitoring. Follow-up was not different between perinatal and childhood subjects (median 371 versus 340 days), p=.68, rank-sum. One and two-year remote symptomatic seizure-free survival were 82% (95% CI 68-91%) and 67% (95% CI 46-82%). One and two-year epilepsy-free survival were 96% (95% CI 83-99%) and 87% (95% CI 65-95%). Elevated intracranial pressure (ICP) requiring urgent intervention was a risk factor for remote symptomatic seizures and epilepsy (p=.024 and p=.037, log-rank test). Conclusions: Acute symptomatic seizures are common in both perinatal and childhood ICH. Continuous EEG monitoring may identify electrographic-only seizures in some subjects. By two-years after ICH it is estimated that about one-third of patients will have a single remote symptomatic seizures and that about 13% will develop epilepsy. Elevated ICP requiring intervention is a risk factor for 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.