Outcome Measures in Pediatric Stroke: A Systematic Review

Review

Bryce Yale, SPT¹, Laura Greiss Hess, PhD, OTR/L², Micah Mar, SPT¹, Alejandra Roque, PT, DPT³, Dana Jacobs, PT,¹, Janice Brown, OTS², Jordan Ng², OTS, Reilly Todd², OTS, Alyssa Vo, OTS², *Kathryn C. Nesbit, PT, DPT, DSc²

University of California San Francisco/San Francisco State University Graduate Program in Physical Therapy
1600 Holloway Ave. San Francisco CA 94132
Dominican University of California, Department of Occupational Therapy
50 Acacia Ave
San Rafael, CA 94901-2298
NAPA Center Inc.
Los Angeles, CA
8371 La Villa Street Downey CA 90241

Corresponding Author

* Corresponding Author

Any redistribution or reproduction of part or all of the contents in any form is prohibited other than the following:

you may print or download to a local hard disk extracts for your personal and non-commercial use only
you may copy the content to individual third parties for their personal use, but only if you acknowledge the website as the source of the material

You may not, except with our express written permission, distribute or commercially exploit the content. Nor may you transmit it or store it in any other website or other form of electronic retrieval system.

Abstract

Pediatric stroke has a significant impact on children and families. Outcome measures are essential to guide clinical management and inform research priorities, yet these instruments are highly varied in scope and application. Because pediatric stroke care and research is evolving, there is a need for a current review of pediatric stroke outcome measures. The purpose of this study was to systematically review the current literature for pediatric outcome measures, describe the studies using pediatric outcome measures, and describe the outcome measure characteristics.

From an initial search of 1625 articles with duplicates removed, 116 articles met inclusion criteria. In those 116 articles, 95 distinct outcome measures were identified. Our review noted the most used outcome measures focused on deficits of the child whereas there was a paucity of outcomes used that included patient and family perspectives, recovery in natural contexts (e.g., home, school, community), and inadequate representation executive function and quality of life. We also found a lack of reliable and valid outcomes for the pediatric hemorrhagic stroke population, and a limited amount of outcomes that measure recovery over time.

The findings in this systematic review support recommendations for future development and use of pediatric stroke outcome measures, particularly for pediatric hemorrhagic stroke, that better capture the impacts to child and family life and contextually meaningful aspects of recovery over time.

Introduction

Pediatric stroke, despite its reduced incidence when compared to many other childhood conditions, is a major cause of lifelong neurological disability and remains one of the top ten causes of death in childhood.^1,2 The pediatric ischemic stroke incidence rate is 2.7 per 100,000 and the hemorrhagic incident rate is 1.7 per 100,000.³ While the incidence of hemorrhagic stroke is less than ischemic stroke, death rate, and morbidity as measured by Disability-Adjusted Life Years (DALYs) were reported to be 6-7 times higher.⁴ Despite advances in the treatment of both ischemic and hemorrhagic stroke, 1 of 10 children with pediatric stroke have a recurrence within 5 years.²

Recovery from pediatric stroke is assessed by outcome measures that vary in their scope, timing, use, and domain. Based on the International Classification of Functioning, Disability and Health (ICF) model,⁵ outcome measures may assess difficulties with body structure and function (impairments), difficulties executing tasks (activity limitations) and difficulties with carrying out life roles in the home, school, or community (participation restrictions). Some outcome measures are patient-centered, including patient perspectives, preferences, and values.⁶ Others are family-centered, affording the family the opportunity to self-report and/or collaborate with the person administering the assessment.⁷ Outcome measures can be psychometrically reliable and valid for specific purposes: discriminative (a measurement at a one point in time), evaluative (repeated to show progress over time), or predictive (associated with a future condition).⁸ Outcome measures are often shown to be reliable and/or valid for specific populations. Timing of outcome measures can vary from administration early in recovery to long-term assessment. Malone and Felling9 noted that the variability of outcome measure type and timing in pediatric stroke recovery contributes to the difficulty making comparisons across studies.

A robust battery and a clear understanding of the application of outcome measures essential for clinical care and ongoing research. Current literature notes the need for outcome measures to capture the nuances of pediatric stroke recovery based on injury to the developing brain, rather than reliance on assumptions based on adult stroke.^9,10 Additionally, current literature noted the importance of patient- and family-centered outcomes in providing meaningful, contextually relevant perspectives on long-term implications of disability from pediatric stroke.^11,12 In 2012, Englemann and Jordan completed a systematic review of outcome measures utilized in pediatric stroke studies and identified 36 studies using standardized measures, with 38 unique outcome measures noted.¹⁰ Importantly, Porcari, et al¹³ noted that the lack of pediatric stroke specific outcome measures made it difficult to determine the effectiveness of immediate and long-term interventions.

Pediatric stroke has a significant impact on children and families while outcome measures guide clinical management, rehabilitation and inform research priorities. Because pediatric stroke care and research is evolving, there is a need for a current review of pediatric stroke outcome measures for scope, application, and timing. It is essential to examine the characteristics of the outcome measures, including those that capture the perspectives and experiences in real-life contexts of the children and families.

The purpose of this study was to systematically review the current literature for pediatric outcome measures, describe the studies using pediatric outcome measures, and describe the outcome measures characteristics. A clear understanding of the has important implications for the direction of current efforts to develop pediatric stroke registries¹⁴ and research protocols, especially for the less-studied pediatric hemorrhagic stroke population. The specific aims of this study were to examine the literature for (1) type of study and level of evidence, (2) timing of outcome measure administration post-stroke, (3) number of outcome measures used in each study (4) and the number of times an outcome measure was used across studies. Further aims included analyses of the outcomes measures found in the literature themselves and included: (1) ICF levels (body structure and function, activity, participation), (2) domains (motor, cognitive, quality of life, social-emotional, executive function), (3) contexts (home, school, community), (4) perspectives of patient and family, (5) type (discriminative, evaluative, predictive), and (6) reliability and validity for pediatric stroke.

Methods

Study Design
This systematic review had the following inclusion criteria: prognostic or intervention study articles from 2000-2021, population n > 3, population age > 28 days through 18 years, population diagnosis of ischemic and/or hemorrhagic stroke, study included named functional outcome measures, and article is full text in a peer-reviewed journal. Studies were excluded if they were diagnostic or cost-effectiveness studies as well as if the study population was perinatal, neonatal, adult, or post-trauma. This systematic review was determined to be exempt by the institutional review board.

Search terms
Search terms included: pediatric stroke, pediatric ischemic stroke, pediatric hemorrhagic stroke, pediatric stroke outcome measures (including alternate spelling of all terms).

Data Collection
Initial electronic searches of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Elton B. Stephens Company (EBSCO), Google Scholar, and Cochrane Library were performed in September 2021 with the final search on June 15, 2022.

Data Analysis
After duplicates were removed from the initial search list, records were screened by title and abstract by two authors and excluded by relevance. Remaining records were sought for retrieval, and full text articles were assessed by two authors for eligibility based on the inclusion criteria. If there were any discrepancies related to eligibility criteria, a third author was included to reach a consensus. The study type and strength of evidence was reviewed by two authors.

Figure 1 is the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram.¹⁵ Outcome measures named in the studies were then identified. Each outcome was reviewed by two authors. If there were any discrepancies related to the outcome characteristics, a third author was included to reach a consensus. The outcome measure characteristics were determined through a variety of resources such as the outcome measure website, available outcome measure protocols, outcome measure databases, and information in the included article itself. Descriptive statistics (frequencies) were used to examine the article and outcome measure characteristics. Post-analysis weighting based on the frequency of the use of the outcome measure in the study articles was used to report on the weighted outcome measure characteristics.

Results

Articles, levels of evidence, and time of study
The initial search returned 1625 articles once duplicates were removed. After assessment for inclusion criteria, 116 articles were included in the review^{13, 16-130} Reasons for exclusion included inability to access articles, study type, lack of outcome measures, study population characteristics, and number of study participants (PRISMA flow diagram, Figure 1).¹⁵ From the 116 articles detailed in Appendix 1, 95 unique outcome measures were identified. Appendix 2 is the PRISMA checklist.¹⁵

Of the 116 included studies, 91 were prognostic studies looking at factors which influence outcomes in the pediatric stroke population (78.5%). Most of these were Level 2B retrospective cohort studies (59.3%), and less than half (40.7%) were prognostic case series or cross-sectional studies (Level 4).¹³¹ Only 21.6% (n=25) were intervention studies looking at the effectiveness of treatment interventions in the pediatric stroke population. More than half of the intervention studies were Level 4 case-series or cross-sectional studies (61.9%). ¹³¹ Other intervention studies (52.4%) were Level 2B individual longitudinal cohort studies with a control group and one Level 1B randomized control trial (4.8%).¹³¹ Overall, most prognostic and intervention studies were Level 2B with only one higher level (1B) study, and many studies were Level 4.¹³¹ Of the 116 articles, 91.4% of the studies were set in Upper-Income Countries, 6.0% were set in Upper-Middle Income Countries, and 5.2% were set in Lower- and Middle-Income Countries. Four studies included centers in countries with two different income levels. Appendix 1 contains details of the levels of evidence and countries represented by each study.

Time the outcome measures were administered relative to the stroke
Our analysis revealed a wide range of outcome measure administration timing relative to the time of the stroke. Outcome measure administration timing ranged from time of injury to 11.5 years post-stroke. The mean was 2.4 years post-stroke (SD=2.9) (median and mode = 1-year post-stroke). Frequency of outcome administration timing was most often once, with a range of one to five times, and an average of 1.2 times (SD=0.8). In general, outcomes were measured post-acutely, most at one year, and at one time during recovery. Figure 2 is a summary of the age ranges and percentage of outcomes administered at that age (using n=133 outcomes noted in the articles with some studies administering outcomes more than once and some studies not clearly indicating the timing).

School function measured in the studies
Approximately a third (31.0%) of the 116 studies included a measure related to school. The school measure characteristics included a range of factors including school function or questions about school attendance, grades, type of school, or type of support at school (31.0%, n=36). In the 36 articles that included school function, 25 of them (69.4%) used an outcome measure, while 11 used less standardized questionnaires or surveys.

Number of outcomes used in each study
Within the 116 articles, our results showed a range of the number of outcome measures used from 1 to 15 unique measures. The mean number of outcome measures used was 3.0 (SD = 2.7) (median = 2, mode = 1).

Frequency of outcome use across studies
The most frequently used outcome measures were the Pediatric Stroke Outcome Measure (PSOM) (50 times) and the Modified Rankin Scale (mRS) (45 times). Both the PSOM and the mRS were used 48.0% more than the next most frequently used outcome measure, the Pediatric National Institutes of Health Stroke Severity Scale (PedNIHSS) (27 times). On average, each outcome measure was used 3.8 times (median = 2, mode = 1). Of the 95 outcome measures, only 33 were used more than twice, and only 7 were used more than 10 times.
Table 1 includes names and characteristics of the top 10 most frequently used outcome measures.

International Classification of Functioning, Disability, and Health (ICF) levels of all outcome measures
Our analyses of outcome measure characteristics included an examination of ICF levels. ICF activity level was more frequently when compared to body structure and function and participation (61.1%, 46.3%, and 45.3% unweighted respectively). When weighting the outcome measures based on their frequency of use, activity level measures were used about three quarters of the time (78.0% weighted), body structure and function measures a little over half the time (60.0% weighted) and participation level measures about a quarter of the time (28.9% weighted). Figure 3 includes the comparison between the weighted and unweighted frequencies of these ICF level characteristics for all outcome measures. Appendix 3 is a table of the details of the ICF levels of all outcome measures.

Domains of all outcome measures
Our analyses of outcome measure characteristics included an examination of domains – cognitive, motor, and social domains were most frequently measured (48.4%, 44.2%, and 28.4% unweighted respectively). The least frequently measured domains were executive function and quality of life (5.3% and 15.8% unweighted respectively). When weighted based on frequency of use, cognitive, motor, and language domains were most frequently measured (74.1%, 63.4%, and 49.9% weighted respectively). With weighting also, the least frequently measured domains were executive function and quality of life (5.5% and 27.6% weighted respectively). Figure 3 includes the comparison between the weighted and unweighted frequencies of these domain characteristics for all outcome measures. Appendix 3 is a table of the details of the domains of all outcome measures.

Context of all outcome measures
We then analyzed the contexts of the outcome measures. About a third of the outcomes measured home function (30.5% unweighted), about a quarter of the outcomes measured school function (24.2% unweighted), and about a third of the outcomes measured community function (35.8% unweighted). Note, some measures included both home and community function. When weighting the outcome measures based on their frequency of use, less than a quarter of the outcomes measured home (18.7% weighted), school (16.5% weighted) and community (23.1% weighted) function. Figure 3 includes the comparison between the weighted and unweighted frequencies of these context characteristics for all outcome measures. Appendix 3 is a table of the context details of all outcome measures.

Patient and Family Perspectives of all outcome measures
We analyzed whether the patient or family perspectives were included in the outcome measure through a patient or family survey element (e.g., experience, preferences, rankings, goals, etc.), Approximately a quarter of the outcome measures include direct input from the patient perspective (27.4% unweighted). However, when weighted based on frequency of the use of the outcome measures, outcome measures included direct input from the patient perspective less than a quarter of the time (14.3% weighted). Direct input from family perspectives were included in slightly less than a quarter of the outcome measures (22.1% unweighted). This percentage stayed close to the same when weighted based on the frequency of the use of the outcome measures (20.7% weighted). Figure 3 includes the comparison between the weighted and unweighted frequencies of these perspective characteristics for all outcome measures. Appendix 3 is a table of the details of the perspectives of all outcome measures.

Type of all outcome measures
When the type of outcome measure was considered, all outcome measures (n=95) were discriminative (100.0%) providing an assessment of the current functioning at a single point in time. Approximately a quarter (25.3%) of the measures were evaluative, and a smaller percentage were predictive (14.7%). With weighting based on frequency of use, approximately a quarter of the measures were evaluative (27.8%); however, over a third were predictive (35.5%).

Reliability and validity for pediatric stroke across all outcome measures
Only 6 outcome measures had some reliability and validity for the pediatric ischemic stroke population. No outcome measures had reliability and validity specifically for the pediatric hemorrhagic stroke population. With weighting based on frequency of outcome use, a measure with reliability and validity for pediatric ischemic stroke was used approximately a quarter of the time (24.5%). In contrast, a measure with reliability and validity for pediatric hemorrhagic stroke was used 0.0% of the time.

Most frequently used outcome measures summary
Table 1 is a summary of the 16 most frequently used outcome measures in the 116 study articles (outcomes that were used 5 or more times) and their characteristics weighted based on their frequency. Appendix 4 includes details about these outcome measures. Figure 4 includes the comparison between the weighted and unweighted frequencies of the characteristics for the 16 most frequently used outcome measures. In summary, activity ICF level was included most frequently in the outcome measures, and participation ICF level least frequently. Motor and cognitive domains were most frequently represented while executive function and quality of life were least frequently represented. The contexts of home, school, and community were infrequently included with school function being the context included least frequently. Patient and family perspectives were also included infrequently in these 16 most frequently used outcome measures. The age range for the 16 most frequently used outcome measures was 0-90 years, with the most common age range of 2-17 or 18 years. For several outcome measures, the condition (ischemic stroke) was specified rather than a specific age.

Discussion

The results of this systematic review revealed important information about the use of pediatric stroke outcome measures by describing the frequency, application and characteristics of the outcome measures used. Outcome measures inform the clinical management and research of pediatric stroke care; therefore, how often they are employed, what they measure, and how they measure it have implications for the recovery journeys of children and families. In summary (Figure 5):

Ninety-five distinct outcome measures were identified.
All outcomes were discriminative, some were evaluative, and few were predictive.
Few outcome measures had some reliability and validity for pediatric ischemic stroke, but none had reliability and validity for pediatric hemorrhagic stroke.
Most outcomes were administered post-acutely at one year, and at one point in time.
Most studies used one outcome measure; however, there was a wide range in the number of outcome measures used.
On average, each outcome measure was used 3-4 times across the 116 studies; however, most were used only once, and only a few were used more than 10 times.
From the perspective of ICF levels, the activity level was most represented in the outcome measures, and the participation level the least represented.
Motor, cognitive, social and language domains were most frequently measured and executive function and quality of life were least frequently measured.
Few outcome measures related to home, community, or school function.
Few outcome measures included perspectives from the patient or family.
When the characteristics of the outcome measures were weighted based on the frequency of use within the study articles, the paucity of participation level, real-life contexts (home, school, community), and both patient- and family-centered characteristics was noteworthy.

Our results revealed an increase in the number of studies using pediatric stroke outcome measures as well as the number of distinct outcome measures used when compared to previous literature.¹⁰ For example, in 2012, Engleman and Jordan¹⁰ identified only 36 studies and 38 unique outcome measures compared to our finding of 116 included articles and 95 outcome measures. These trends suggest an increased awareness of the need for specific pediatric stroke outcomes. The Pediatric Stroke Outcome Measure (PSOM) was the most frequently used outcome measure identified in our study and this outcome was very new at the time of the Engelman and Jordan review.¹⁰ However, because the PSOM and many of the top 10 most frequently used outcomes do not include home, school, or community function, and do not include patient and family perspectives, meaningful information from outcome measures about the real-life experiences during stroke recovery is lacking.

This systematic review revealed that pediatric stroke outcomes less often include contextual and functional areas. Specifically, deficiencies in outcome measures for pediatric stroke were the limited opportunity for inclusion of patient and family perspectives, the infrequent consideration of recovery in a real-life context (home, school, community), and inadequate representation and inclusion of all domains important to stroke recovery (executive function, quality of life). We also found a lack of reliable and valid outcomes for the pediatric hemorrhagic stroke population, and limited amount of longitudinal outcome measurement. These gaps illuminate a skewing of outcome measurement data being more deficit focused and not broadly inclusive of child and family centered care within meaningful, daily contexts. Therefore, the underutilized types of outcome measures are critically important.

The first area of shortcoming is including patient and family perspective in the outcome. Our efforts to provide patient- and family-centered care are hindered by a lack of use of measures that include patient and family perspectives and on outcomes that focus on the experiences of children and their families as they return to life at home, school, and in the community. Mangin, et al.⁶ noted that the scarcity of tools for identifying patient priorities was a barrier to shared decision making. We found that despite the premise that promoting patient-centered care can optimize health outcomes, few outcome measures encourage patient collaboration. Clay and Parsh7 noted that “a patient’s health care decisions should be contextualized in terms of a patient’s broader life experiences” including the role of family members (p.40). McKevitt, et al.¹³² reported a variety of parent experiences based on the child’s needs and family situation, with a theme in their work being the impact of the child’s stroke on the parent as well as the family’s well-being. Unfortunately, as our results indicate, the family perspectives are often overlooked and not commonly included in chosen outcome measures.

The second area of shortcoming is in gathering information about recovery in a real-life context. The current literature highlighted the importance of understanding the needs of children post-stroke as they return to school. Hawks, et al.¹⁶⁹ described educational placement of following hemorrhagic stroke and noted that although almost all children were able to attend school post-stroke, most children required educational modifications. Gordon, et al.¹⁰ reported that over two thirds of families and children reported unmet needs post- stroke; over half reported difficulties in school-related activities and over one third had difficulties in leisure activities and social relationships. The American Heart Association/American Stroke Association Scientific Statement on stroke management in neonates and children noted school-based needs in this population.134 Again, unfortunately, our results revealed limited consideration of real-life contexts employed in the frequently used outcome measures.

The third area of shortcoming is in capturing domains important to stroke recovery. The literature suggests the importance of executive function and quality of life for children with disabilities.^135,136 and these domains were infrequently measured by current outcome measures. The fourth area of shortcoming is the lack of reliable and valid outcome measures for hemorrhagic stroke in the pediatric stroke population – a population with a high mortality and morbidity burden. Lastly, the fifth area of shortcoming is the lack of outcome measures used for longitudinal studies. Given the uncertain trajectory of pediatric stroke recovery on the developing brain as noted by Porcari, et al.¹³ and Malone and Felling,⁹ it is important for outcome measures to inform care management over time, not only with a focus on the immediate post-acute phase of recovery. Golomb and Lo,¹³⁷ in their comment on the longitudinal study by Goegel Simonetti, et al.,⁶⁰ noted that “Parents want to know if their children will be able to finish high school, attend university, hold a job, live independently and start families of their own.” (p.1917). We found most outcome measures are used to examine the patient’s condition at a single point in time (discriminative measures), only some were used to monitor progress over time (evaluative), and even fewer were designed to predict how a patient’s current function might indicate a level of disability or condition in the future (predictive).

Limitations
Information about the outcome measures used in the studies in this systematic review was limited to what was available on outcome measure websites, available outcome measure protocols, outcome measure databases, and information in the included study article itself. We did not complete an extensive literature review and critique of each outcome measure beyond our inclusion / exclusion criteria. In addition, several studies used only parts of each outcome measure adding another limitation to this study’s interpretation. Although articles and outcome measures were reviewed by at least two authors, and if needed, a third author was used to resolve any discrepancies, the results may be influenced by a small group of reviewers. Outcomes in these studies represented those used in a research context and may differ from outcomes used in a clinical context.

Of note, we have examined quantitative measurement of recovery in real-life contexts and of patient and family perspectives. However, in clinical practice and qualitative research methodologies, information about real-life, as well as personal accounts of lived experiences from patients and families are often gathered through interviews and / or added to comment sections of outcome measures. Therefore, there are opportunities to expand current research to include more examination of qualitative data.

Implications and directions for future research
The findings in this systematic review support recommendations for future development and use of outcome measures for pediatric stroke, particularly for pediatric hemorrhagic stroke, that better capture meaningful aspects of recovery over time. Outcome measures with reliability and validity specifically for the pediatric hemorrhagic stroke population are needed. Development and use of outcome measures that include contextual elements of the patient’s recovery such as the home, school, and community as well as domains of executive function and quality of life are important. In addition, outcome measures that include patient and family perspectives would promote shared decision making, collaboration, and engagement in care. Clinicians and researchers would additionally benefit from resources to guide choosing and utilizing outcome measures beyond the medical model.

Conclusion
This study highlights the increasing use of outcome measures in a growing body of pediatric stroke research. With advancements in collaborative, interdisciplinary team pediatric stroke management and research, outcome measures are critical for guiding care and afford an opportunity to engage children and families in shared decision making. The lack of reliable and valid measures for pediatric hemorrhagic stroke is striking and will hopefully, in the future, follow the recent progress in development of outcome measures for pediatric ischemic stroke. Relevance of the outcomes used in pediatric stroke management to real-life contexts and consideration of patient and family perspectives are paramount to making health measures meaningful to children and their families.

Acknowledgements
The authors would like to acknowledge the multidisciplinary team at the University of California’s American Heart Association Bugher Center of Excellence in Pediatric Hemorrhagic Stroke.

References

1. Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Mortality 1999-2020. Published 2021. Accessed September 4, 2022. http://wonder.cdc.gov/ucd-icd10.html

2. Virani SS, Alonso A, Aparico HJ, et al. Heart disease and stroke statistics – 2021 update. Circulation. 2021, 143 (8): e254-e743. https://doi.org/10.1161/CIR.0000000000000950

3. Lehman LL, Khoury JC, Taylor JM, et al. Pediatric stroke rates over 17 years: report from a population-based study. J Child Neurol. 2018;33(7):463-467. doi:10.1177/0883073818767039

4. Kirshnamurthi RV, DeVeber G, Feign VL, et al. Stroke prevalence, mortality and disability-adjusted life years in children and youth aged 0-10 years: data from the Global and Regional Burden of Stroke 2013. Neuroepidemiology. 2015, 45: 177-189. doi: 10.1159/000441087.

5. World Health Organization. International Classification of Functioning, Disability and Health. Published 2022. Accessed September 4, 2022. https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health

6. Mangin D,Stephen G, Bismah V, et al. Making patient values visible in healthcare: a systematic review of tools to assess patient treatment priorities and preferences in the context of multimorbidity. BMJ Open 2016;6:e010903. doi:10.1136/bmjopen-2015-010903.

7. Clay AM, Parsh B. Patient- and family-centered care: it’s not just for pediatrics anymore. AMA J Ethics. 2016;18(1):40-44. doi: 10.1001/journalofethics.2016.18.1.medu3-1601.

8. Kirshner B, Guyatt G. A methodological framework for assessing health indices. J Chronic Dis. 1985;38(1):27-36. doi: 10.1016/0021-9681(85)90005-0.

9. Malone LA, Felling R. Pediatric stroke: unique implications of the immature brain on recovery. Pediatr Neurol. 2020; 102:3-9. https://doi.org/10.1016/j.pediatrneurol.2019.06.016

10. Englemann, KA, Jordan LC. Outcome measures utilized in pediatric stroke studies: a systematic review. Arch Neurol. 2012. 69(1): 23–27. doi:10.1001/archneurol.2011.1015.

11. Anderson V, Gomes A, Greenham M et al. Social competence following pediatric stroke: contributions of brain insult and family environment. Soc Neurosci. 2014;9(5):471-83. doi: 10.1080/17470919.2014.932308.

12. Galvin J, Randall M, Hewish S, Rice J, MacKay MT. Family-centred outcome measurement following paediatric stroke. Aust Occup Ther J. 2010. 57(3):152-8. doi: 10.1111/j.1440-1630.2010.00853.x.

13. Porcari GS, Beslow LA, Ichord RN, Licht DJ, Kleinman JT, Jordan LC. Neurologic outcome predictors in pediatric intracerebral hemorrhage: a prospective study. Stroke. 2018;49(7):1755-1758. doi:10.1161/strokeaha.118.021845

14. International Pediatric Stroke Organization. International Pediatric Stroke Study. Published 2022. Accessed September 4, 2022. https://internationalpediatricstroke.org/ipss-research/

15. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71
010903.

16. Allman C, Scott RB. Neuropsychological sequelae following pediatric stroke: a nonlinear model of age at lesion effects. Child Neuropsychol. 2013;19(1):97-107. doi:10.1080/09297049.2011.639756.

17. Amlie-Lefond C, Shaw DWW, Cooper A, et al. Risk of intracranial hemorrhage following intravenous tpa (tissue-type plasminogen activator) for acute stroke is low in children. Stroke. 2020;51(2):542-548. doi:10.1161/strokeaha.119.027225.

18. Anderson V, Gomes A, Greenham M, et al. Social competence following pediatric stroke: contributions of brain insult and family environment. Soc Neurosci. 2014;9(5):471-83. doi:10.1080/17470919.2014.932308.

19. Andrade A, Bigi S, Laughlin S, et al. Association between prolonged seizures and malignant middle cerebral artery infarction in children with acute ischemic stroke. Pediatr Neurol. 2016;64:44-51. doi:10.1016/j.pediatrneurol.2016.08.015.

20. Appavu B, Foldes S, Burrows BT, et al. Multimodal assessment of cerebral autoregulation and autonomic function after pediatric cerebral arteriovenous malformation rupture. Neurocrit Care. Apr 2021;34(2):537-546. doi:10.1007/s12028-020-01058-3.

21. Aprasidze T, Tatishvili N, Shatirishvili T, Lomidze G. Predictors of neurological outcome of arterial ischemic stroke in children. Pediatr Neurol. 2021;19(3):161-165. doi:10.1055/s-0040-1701204.

22. Aurangzeb S, Noman MA, Azam M. Clinical features, etiological factors, neurological imaging and outcome in children with ischemic stroke. PJNS. 2010;14(1):35-43.

23. Bal J, Milosevich E, Rennie A, et al. Management of haemorrhagic stroke secondary to arteriovenous malformations in childhood. Childs Nerv Syst. 2021;37(4):1255-1265. doi:10.1007/s00381-020-04976-x.

24. Bartha-Doering L, Gleiss A, Knaus S, Schmook MT, Seidl R. Influence of socioeconomic status on cognitive outcome after childhood arterial ischemic stroke. Dev Med Child Neurol. 2021;63(4):465-471. doi:10.1111/dmcn.14779.

25. Bartha-Doering L, Novak A, Kollndorfer K, et al. Atypical language representation is unfavorable for language abilities following childhood stroke. Eur J Paediatr Neurol. 2019;23(1):102-116. doi:10.1016/j.ejpn.2018.09.007.

26. Beslow LA, Licht DJ, Smith SE, et al. Predictors of outcome in childhood intracerebral hemorrhage: a prospective consecutive cohort study. Stroke. 2010;41(2):313-8. doi:10.1161/strokeaha.109.56807.

27. Beslow LA, Smith SE, Vossough A, et al. Hemorrhagic transformation of childhood arterial ischemic stroke. Stroke. Apr 2011;42(4):941-6. doi:10.1161/strokeaha.110.604199.

28. Bhatti A, Huded V, Vyas D, et al. Mechanical Thrombectomy Using Retrievable Stents in Pediatric Acute Ischemic Stroke. Indian Pediatr. 2019;56(7):571-575.

29. Bhogal P, Hellstern V, AlMatter M, et al. Mechanical thrombectomy in children and adolescents: report of five cases and literature review. Stroke Vasc Neurol. 2018;3(4):245-252. doi:10.1136/svn-2018-000181.

30. Bigi S, Dulcey A, Gralla J, et al. Feasibility, safety, and outcome of recanalization treatment in childhood stroke. Ann Neurol. 2018;83(6):1125-1132. doi:10.1002/ana.25242.

31. Bigi S, Fischer U, Wehrli E, et al. Acute ischemic stroke in children versus young adults. Ann Neurol. 2011;70(2):245-54. doi:10.1002/ana.22427.

32. Blackburn E, D’Arco F, Devito A, et al. Predictors of motor outcome after childhood arterial ischemic stroke. Dev Med Child Neurol. 2021;63(10):1171-1179. doi:10.1111/dmcn.14914.

33. Bodey C, Goddard T, Patankar T, et al. Experience of mechanical thrombectomy for paediatric arterial ischaemic stroke. Eur J Paediatr Neurol. 2014;18(6):730-5. doi:10.1016/j.ejpn.2014.07.006.

34. Brush LN, Monagle PT, Mackay MT, Gordon AL. Hypertension at time of diagnosis and long-term outcome after childhood ischemic stroke. Neurology. 2013;80(13):1225-30. doi:10.1212/WNL.0b013e3182896ffb.

35. Carey S, Wrogemann J, Booth FA, Rafay MF. Epidemiology, Clinical Presentation, and Prognosis of Posterior Circulation Ischemic Stroke in Children. Pediatr Neurol. 2017;74:41-50. doi:10.1016/j.pediatrneurol.2017.05.007.

36. Champigny CM, Deotto A, Westmacott R, Dlamini N, Desrocher M. Academic outcome in pediatric ischemic stroke. Child Neuropsychol. 2020;26(6):817-833. doi:10.1080/09297049.2020.1712346.

37. Christerson S, Strömberg B. Stroke in Swedish children II: long-term outcome. Acta Paediatr. 2010;99(11):1650-6. doi:10.1111/j.1651-2227.2010.01948.x.

38. Cnossen MH, Aarsen FK, Akker S, et al. Paediatric arterial ischaemic stroke: functional outcome and risk factors. Dev Med Child Neurol. 2010;52(4):394-9. doi:10.1111/j.1469-8749.2009.03580.x.

39. Cooper AN, Anderson V, Greenham M, et al. Motor function daily living skills 5 years after paediatric arterial ischaemic stroke: a prospective longitudinal study. Dev Med Child Neurol. 2019;61(2):161-167. doi:10.1111/dmcn.13915.

40. Cooper AN, Anderson V, Hearps S, et al. Trajectories of motor recovery in the first year after pediatric arterial ischemic stroke. Pediatrics. 2017;140(2). doi:10.1542/peds.2016-3870.

41. Darteyre S, Chabrier S, Presles E, et al. Lack of progressive arteriopathy and stroke recurrence among children with cryptogenic stroke. Neurology. 2012;79(24):2342-8; discussion 2346. doi:10.1212/WNL.0b013e318278b629.

42. Deotto A, Westmacott R, Fuentes A, deVeber G, Desrocher M. Does stroke impair academic achievement in children? The role of metacognition in math and spelling outcomes following pediatric stroke. J Clin Exp Neuropsychol. 2019;41(3):257-269. doi:10.1080/13803395.2018.1533528.

43. deVeber GA, MacGregor D, Curtis R, Mayank S. Neurologic outcome in survivors of childhood arterial ischemic stroke and sinovenous thrombosis. J Child Neurol. 2000;15(5):316-24. doi:10.1177/088307380001500508.

44. Dlamini N, Yau I, Westmacott R, et al. Cerebrovascular reactivity and intellectual outcome in childhood stroke with transient cerebral arteriopathy. Pediatr Neurol. 2017;69:71-78. doi:10.1016/j.pediatrneurol.2017.01.001.

45. Domi T, Edgell DS, McCrindle BW, et al. Frequency, predictors, and neurologic outcomes of vaso-occlusive strokes associated with cardiac surgery in children. Pediatrics. 2008;122(6):1292-8. doi:10.1542/peds.2007-1459.

46. Duan L, Bao XY, Yang WZ, et al. Moyamoya disease in China: its clinical features and outcomes. Stroke. 2012;43(1):56-60. doi:10.1161/strokeaha.111.621300.

47. Elbers J, deVeber G, Pontigon AM, Moharir M. Long-term outcomes of pediatric ischemic stroke in adulthood. J Child Neurol. 2014;29(6):782-8. doi:10.1177/0883073813484358.

48. Eve M, O’Keeffe F, Jhuty S, Ganesan V, Brown G, Murphy T. Computerized working-memory training for children following arterial ischemic stroke: A pilot study with long-term follow-up. Appl Neuropsychol: Child. 2016;5(4):273-282. doi:10.1080/21622965.2015.1055563.

49. Everts R, Pavlovic J, Kaufmann F, et al. Cognitive functioning, behavior, and quality of life after stroke in childhood. Child Neuropsychol. 2008;14(4):323-38. doi:10.1080/09297040701792383.

50. Felling RJ, Hassanein SMA, Armstrong J, et al. Treatment and outcome of childhood cerebral sinovenous thrombosis. Neurol Clin Pract. 2020;10(3):232-244. doi:10.1212/cpj.0000000000000720.

51. Friefeld SJ, Westmacott R, Macgregor D, Deveber GA. Predictors of quality of life in pediatric survivors of arterial ischemic stroke and cerebral sinovenous thrombosis. J Child Neurol. 2011;26(9):1186-92. doi:10.1177/0883073811408609.

52. Friefeld S, Yeboah O, Jones JE, deVeber G. Health-related quality of life and its relationship to neurological outcome in child survivors of stroke. CNS Spectr. 2004;9(6):465-75. doi:10.1017/s1092852900009500.

53. Fuentes A, Westmacott R, Deotto A, deVeber G, Desrocher M. Working memory outcomes following unilateral arterial ischemic stroke in childhood. Child Neuropsychol. 2017;23(7):803-821. doi:10.1080/09297049.2016.1205008.

54. Gadgil N, Lam S, Pyarali M, Paldino M, Pan IW, Dauser RC. Indirect revascularization with the dural inversion technique for pediatric moyamoya disease: 20-year experience. J Neurosurg Pediatr. 2018;22(5):541-549. doi:10.3171/2018.5.Peds18163.

55. Galvin J, Hewish S, Rice J, Mackay MT. Functional outcome following paediatric stroke. Dev Neurorehabil. 2011;14(2):67-71. doi:10.3109/17518423.2010.547241.

56. Ganesan V. Outcome and rehabilitation after childhood stroke. Handb Clin Neurol. 2013;112:1079-83. doi:10.1016/b978-0-444-52910-7.00025-8.

57. Gatti JR, Torriente AG, Sun LR. Clinical presentation and stroke incidence differ by Moyamoya etiology. J Child Neurol. Mar 2021;36(4):272-280. doi:10.1177/0883073820967160.

58. Gerzson L, Ranzan J, Almeida C, Riesgo R. O impacto do acidente vascular cerebral na qualidade de vida de crianças e adolescentes. Fisioterapia e Pesquisa. 2018;25:241-250. doi:10.1590/1809-2950/17007025032018.

59. Ghotra SK, Johnson JA, Qiu W, Newton AS, Rasmussen C, Yager JY. Health-related quality of life and its determinants in paediatric arterial ischaemic stroke survivors. Arch Dis Child. 2018;103(10):930-936. doi:10.1136/archdischild-2017-313334.

60. Goeggel Simonetti B, Cavelti A, Arnold M, et al. Long-term outcome after arterial ischemic stroke in children and young adults. Neurology. 2015;84(19):1941-7. doi:10.1212/wnl.0000000000001555.

61. Goldenberg NAMDP, Jenkins SBA, Jack JBA, et al. Arteriopathy, d-dimer, and risk of poor neurologic outcome in childhood-onset arterial ischemic stroke. J Pediatr. 2013;162(5):1041-1046.e1. doi:10.1016/j.jpeds.2012.11.035.

62. Gordon A, Connelly A, Neville B, et al. Modified constraint-induced movement therapy after childhood stroke. Dev Med Child Neurol. 2007;49(1):23-7. doi:10.1111/j.1469-8749.2007.0072a.x.

63. Goren O, Hendrix P, Peled A, et al. Encephaloduroarteriosynangiosis with dural inversion for moyamoya disease in a pediatric and adult population-a single-center 20-year experience. World Neurosurg. 2021;149:e16-e21. doi:10.1016/j.wneu.2021.02.102.

64. Greenham M, Anderson V, Cooper A, et al. Early predictors of psychosocial functioning 5 years after paediatric stroke. Dev Med Child Neurol. 2017;59(10):1034-1041. doi:10.1111/dmcn.13519.

65. Greenham M, Anderson V, Hearps S, et al. Psychosocial function in the first year after childhood stroke. Dev Med Child Neurol. 2017;59(10):1027-1033. doi:10.1111/dmcn.13387.

66. Grelli KN, Gindville MC, Walker CH, Jordan LC. Association of blood pressure, blood glucose, and temperature with neurological outcome after childhood stroke. JAMA Neurology. 2016;73(7):829-835. doi:10.1001/jamaneurol.2016.0992.

67. Harrar DB, Salussolia CL, Vittner P, et al. Stroke After cardiac catheterization in children. Pediatr Neurol. 2019;100:42-48. doi:10.1016/j.pediatrneurol.2019.07.005.

68. Hartman AL, Lunney KM, Serena JE. Pediatric stroke: do clinical factors predict delays in presentation? J Pediatr. 2009;154(5):727-732. doi:10.1016/j.jpeds.2008.11.011.

69. Hawks C, Jordan LC, Gindville M, Ichord RN, Licht DJ, Beslow LA. Educational placement after pediatric intracerebral hemorrhage. Pediatr Neurol. 2016;61:46-50. doi:10.1016/j.pediatrneurol.2016.05.004.

70. Hetherington R, Tuff L, Anderson P, Miles B, deVeber G. Short-term intellectual outcome after arterial ischemic stroke and sinovenous thrombosis in childhood and infancy. J Child Neurol. 2005;20(7):553-9. doi:10.1177/08830738050200070201.

71. Jiang B, Hills NK, Forsyth R, et al. Imaging predictors of neurologic outcome after pediatric arterial ischemic stroke. Stroke. 2021;52(1):152-161. doi:10.1161/strokeaha.120.030965.

72. Jordan LC, Hills NK, Fox CK, et al. Socioeconomic determinants of outcome after childhood arterial ischemic stroke. Neurology. 2018;91(6):e509-e516. doi:10.1212/wnl.0000000000005946.

73. Jordan LC, Ichord RN, Reinhartz O, et al. Neurological complications and outcomes in the Berlin Heart EXCOR® pediatric investigational device exemption trial. J Am Heart Assoc. 2015;4(1):e001429. doi:10.1161/jaha.114.001429.

74. Kalita J, Goyal G, Misra UK. Experience of pediatric stroke from a tertiary medical center in North India. J Neurol Sci. 2013;325(1-2):67-73. doi:10.1016/j.jns.2012.11.020.

75. Khan N, Achrol AS, Guzman R, et al. Sex differences in clinical presentation and treatment outcomes in Moyamoya disease. Neurosurgery. 2012;71(3):587-93. doi:10.1227/NEU.0b013e3182600b3c.

76. Kirton A, Chen R, Friefeld S, Gunraj C, Pontigon AM, Deveber G. Contralesional repetitive transcranial magnetic stimulation for chronic hemiparesis in subcortical paediatric stroke: a randomised trial. Lancet Neurol. 2008;7(6):507-13. doi:10.1016/s1474-4422(08)70096-6.

77. Kirton A, Crone M, Benseler S, et al. Fibromuscular dysplasia and childhood stroke. Brain. 2013;136(Pt 6):1846-56. doi:10.1093/brain/awt111.

78. Kornfeld S, Studer M, Winkelbeiner S, Regényi M, Boltshauser E, Steinlin M. Quality of life after paediatric ischaemic stroke. Dev Med Child Neurol. 2017;59(1):45-51. doi:10.1111/dmcn.13295.

79. Lagman-Bartolome AM, Pontigon AM, Moharir M, et al. Basilar artery strokes in children: good outcomes with conservative medical treatment. Dev Med Child Neurol. 2013;55(5):434-9. doi:10.1111/dmcn.12092.

80. Ledochowski J, Desrocher M, Williams T, Dlamini N, Westmacott R. Mental health outcomes in children with acquired dystonia after basal ganglia stroke and associations with cognitive and motor outcomes. Child Neuropsychol. 2020;26(5):691-710. doi:10.1080/09297049.2020.1721453.

81. Leistner R, Everts R, Federspiel A, et al. Cerebral blood flow imbalance is associated with motor outcome after pediatric arterial ischemic stroke. PLoS One. 2019;14(10):e0223584. doi:10.1371/journal.pone.0223584.

82. Liu P, Han C, Li D-S, Lv X-L, Li Y-X, Duan L. Hemorrhagic Moyamoya disease in children: clinical, angiographic features, and long-term surgical outcome. Stroke (1970). 2016;47(1):240-243. doi:10.1161/STROKEAHA.115.010512.

83. Lo WD, Hajek C, Pappa C, Wang W, Zumberge N. Outcomes in children with hemorrhagic stroke. JAMA Neurology. 2013;70(1):66-71. doi:10.1001/jamaneurol.2013.577.

84. Lopez-Espejo M, Hernandez-Chavez M, Huete I. Risk factors for in-hospital and follow-up mortality after childhood arterial ischemic stroke. J Neurol. 2019;266(6):1526-1532. doi:10.1007/s00415-019-09293-1.

85. Macdonald-Laurs E, Wenderoth J, Cardamone M, Sampaio H, Andrews PI. Endovascular clot retrieval for acute ischaemic stroke due to basilar artery occlusion in childhood. Dev Med Child Neurol. 2020;62(10):1221-1223. doi:10.1111/dmcn.14449.

86. Mah S, deVeber G, Wei XC, Liapounova N, Kirton A. Cerebellar atrophy in childhood arterial ischemic stroke: acute diffusion MRI biomarkers. Stroke. 2013;44(9):2468-74. doi:10.1161/strokeaha.111.000744.

87. Mallick AA, Ganesan V, Kirkham FJ, et al. Outcome and recurrence 1 year after pediatric arterial ischemic stroke in a population-based cohort. Ann Neurol. 2016;79(5):784-793. doi:10.1002/ana.24626.

88. McCrea N, Saunders D, Bagkeris E, Chitre M, Ganesan V. Diagnosis of vertebral artery dissection in childhood posterior circulation arterial ischaemic stroke. Dev Med Child Neurol. 2016;58(1):63-69. doi: https://doi.org/10.1111/dmcn.12945.

89. Meyer PG, Orliaguet GA, Zerah M, et al. Emergency management of deeply comatose children with acute rupture of cerebral arteriovenous malformations. Can J Anaesth. 2000;47(8):758-66. doi:10.1007/bf03019478.

90. Misra UK, Kalita J, Kumar M, Neyaz Z. Hypovolemia due to cerebral salt wasting may contribute to stroke in tuberculous meningitis. Qjm. 2018;111(7):455-460. doi:10.1093/qjmed/hcy072.

91. Nerva JD, Kim LJ, Barber J, et al. Outcomes of multimodality therapy in pediatric patients with ruptured and unruptured brain arteriovenous malformations. Neurosurgery. 2016;78(5):695-707. doi:10.1227/neu.0000000000001076.

92. O’Keeffe F, Liégeois F, Eve M, Ganesan V, King J, Murphy T. Neuropsychological and neurobehavioral outcome following childhood arterial ischemic stroke: attention deficits, emotional dysregulation, and executive dysfunction. Child neuropsychol. 2014;20(5):557-582. doi:10.1080/09297049.2013.832740.

93. O’Keeffe F, Ganesan V, King J, Murphy T. Quality-of-life and psychosocial outcome following childhood arterial ischaemic stroke. Brain Inj. 2012;26(9):1072-1083. doi:10.3109/02699052.2012.661117.

94. Pandey AS, Hill E, Al-Holou WN, et al. Management of pediatric craniocervical arterial dissections. Childs Nerv Syst. 2015;31(1):101-7. doi:10.1007/s00381-014-2547-8.

95. Parra-Fariñas C, Dmytriw AA, Delgado-Álvarez I, et al. Primary endovascular treatment for acute ischemic stroke in teenage patients: a short case series. Neuroradiology. 2020;62(7):851-860. doi:10.1007/s00234-020-02421-z.

96. Per H, Unal E, Poyrazoglu HG, et al. Childhood stroke: results of 130 children from a reference center in Central Anatolia, Turkey. Pediatr Neurol. 2014;50(6):595-600. doi:10.1016/j.pediatrneurol.2013.12.023.

97. Piastra M, De Luca D, Genovese O, et al. Clinical outcomes and prognostic factors for spontaneous intracerebral hemorrhage in pediatric ICU: A 12-Year Experience. J Intensive Care Med. 2019;34(11-12):1003-1009. doi:10.1177/0885066617726049.

98. Press CA, Lindsay A, Stence NV, Fenton LZ, Bernard TJ, Mirsky DM. Cavernous sinus thrombosis in children: imaging characteristics and clinical outcomes. Stroke (00392499). 2015;46(9):2657-2660. doi:10.1161/STROKEAHA.115.009437.

99. Ramaswamy V, Mehta V, Bauman M, Richer L, Massicotte P, Yager JY. Decompressive hemicraniectomy in children with severe ischemic stroke and life-threatening cerebral edema. J Child Neurol. 2008;23(8):889-94. doi:10.1177/0883073808314960.

100. Rambaud T, Legris N, Bejot Y, et al. Acute ischemic stroke in adolescents. Neurology. 2020;94(2):e158-e169. doi:10.1212/wnl.0000000000008783.

101. Ravindra VM, Alexander M, Taussky P, et al. Endovascular thrombectomy for pediatric acute ischemic stroke: a multi-institutional experience of technical and clinical outcomes. Neurosurgery. 2020;88(1):46-54. doi:10.1093/neuros/nyaa312.

102. Ryan NP, Greenham M, Gordon AL, et al. Social cognitive dysfunction following pediatric arterial ischemic stroke: evidence from a prospective cohort study. Stroke. 2021;52(5):1609-1617. doi:10.1161/strokeaha.120.032955.

103. Savolainen M, Mustanoja S, Pekkola J, et al. Moyamoya angiopathy: long-term follow-up study in a Finnish population. J Neurol. 2019/03/01 2019;266(3):574-581. doi:10.1007/s00415-018-9154-7.

104. Shah S, Murthy SB, Whitehead WE, Jea A, Nassif LM. Decompressive hemicraniectomy in pediatric patients with malignant middle cerebral artery infarction: case series and review of the literature. World Neurosurg. 2013;80(1-2):126-33. doi:10.1016/j.wneu.2013.06.001.

105. Shoirah H, Shallwani H, Siddiqui AH, et al. Endovascular thrombectomy in pediatric patients with large vessel occlusion. J Neurointerv Surg. 2019;11(7):729-732. doi:10.1136/neurintsurg-2018-014320.

106. Signorelli F, Gory B, Pelissou-Guyotat I, et al. Ruptured brain arteriovenous malformations associated with aneurysms: safety and efficacy of selective embolization in the acute phase of hemorrhage. Neuroradiology. 2014/09/01 2014;56(9):763-769. doi:10.1007/s00234-014-1395-2.

107. Simma B, Martin G, Müller T, Huemer M. Risk factors for pediatric stroke: consequences for therapy and quality of life. Pediatr Neurol. 2007;37(2):121-6. doi:10.1016/j.pediatrneurol.2007.04.005.

108. Smith SE, Kirkham FJ, Deveber G, et al. Outcome following decompressive craniectomy for malignant middle cerebral artery infarction in children. Dev Med Child Neurol. 2011;53(1):29-33. doi:10.1111/j.1469-8749.2010.03775.x.

109. Sood A, Suthar R, Sahu JK, et al. Etiologic profile of childhood stroke from north India: is it different from developed world? J Child Neurol. Jul 2021;36(8):655-663. doi:10.1177/0883073821991291.

110. Sporns PB, Psychogios MN, Straeter R, et al. Clinical diffusion mismatch to select pediatric patients for embolectomy 6 to 24 hours after stroke: an analysis of the Save ChildS study. Neurology. 2021;96(3):e343-e351. doi:10.1212/wnl.0000000000011107.

111. Sporns PB, Straeter R, Minnerup J, et al. Does device selection impact recanalization rate and neurological outcome?: An Analysis of the Save ChildS Study. Stroke. 2020;51(4):1182-1189. doi:10.1161/strokeaha.119.028221.

112. Sporns PB, Sträter R, Minnerup J, et al. Feasibility, safety, and outcome of endovascular recanalization in childhood stroke: the Save ChildS study. JAMA Neurol. 2020;77(1):25-34. doi:10.1001/jamaneurol.2019.3403.

113. Stein KP, Huetter BO, Goericke S, et al. Cerebral arterio-venous malformations in the paediatric population: Angiographic characteristics, multimodal treatment strategies and outcome. Clin Neurol Neurosurg. 2018;164:164-168. doi:10.1016/j.clineuro.2017.12.006.

114. Steiner L, Homan S, Everts R, et al. Functional connectivity and upper limb function in patients after pediatric arterial ischemic stroke with contralateral corticospinal tract wiring. Sci Rep. 2021;11(1):5490. doi:10.1038/s41598-021-84671-2.

115. Steinlin M, Bigi S, Stojanovski B, et al. Focal cerebral arteriopathy: do steroids improve outcome? Stroke. 2017;48(9):2375-2382. doi:10.1161/strokeaha.117.016818.

116. Studer M, Boltshauser E, Capone Mori A, et al. Factors affecting cognitive outcome in early pediatric stroke. Neurology. 2014;82(9):784-92. doi:10.1212/wnl.0000000000000162.

117. Tabone L, Mediamolle N, Bellesme C, et al. Regional pediatric acute stroke protocol: initial experience during 3 years and 13 recanalization treatments in children. Stroke. 2017;48(8):2278-2281. doi:10.1161/strokeaha.117.016591.

118. Tatum J, Farid H, Cooke D, et al. Mechanical embolectomy for treatment of large vessel acute ischemic stroke in children. J Neurointerv Surg. 2013;5(2):128-34. doi:10.1136/neurintsurg-2011-010100.

119. Tho-Calvi SC, Thompson D, Saunders D, et al. Clinical features, course, and outcomes of a UK cohort of pediatric moyamoya. Neurology. 2018;90(9):e763-e770. doi:10.1212/wnl.0000000000005026.

120. Ullah S, Bin Ayaz S, Zaheer Qureshi A, Samir Tantawy S, Fe Flandez M. Characteristics and functional outcomes of pediatric stroke survivors at a rehabilitation unit in Saudi Arabia. J Clin Neurosci. 2020;81:403-408. doi:10.1016/j.jocn.2020.10.014.

121. van Es A, Hunfeld MAW, van den Wijngaard I, et al. Endovascular treatment for acute ischemic stroke in children. Stroke. 2021;52(3):781-788.:doi:10.1161/STROKEAHA.120.030210.

122. van Essen MJ, Han KS, Lo RTH, Woerdeman P, van der Zwan A, van Doormaal TPC. Functional and educational outcomes after treatment for intracranial arteriovenous malformations in children. Acta neurochirurgica. 2018;160(11):2199-2205. doi:10.1007/s00701-018-3665-y.

123. Vázquez López M, de Castro de Castro P, Barredo Valderrama E, et al. Outcome of arterial ischemic stroke in children with heart disease. Eur J Paediatr Neurol. 2017;21(5):730-737. doi:10.1016/j.ejpn.2017.05.007.

124. Westmacott R, McDonald KP, Roberts SD, et al. Predictors of cognitive and academic outcome following childhood subcortical stroke. Dev Neuropsychol. 2018;43(8):708-728. doi:10.1080/87565641.2018.1522538.

125. Westmacott R, Askalan R, MacGregor D, Anderson P, de Veber G. Cognitive outcome following unilateral arterial ischaemic stroke in childhood: effects of age at stroke and lesion location. Dev Med Child Neuro. 2010;52(4):386-393.
doi:https://doi.org/10.1111/j.1469-8749.2009.03403.x

126. Westmacott R, McDonald KP, deVeber G, et al. Neurocognitive outcomes in children with unilateral basal ganglia arterial ischemic stroke and secondary hemidystonia. Child Neuropsychol. 2018;24(7):923-937. doi:10.1080/09297049.2017.1353073.

127. Yilmaz EY, Pritz MB, Bruno A, Lopez-Yunez A, Biller J. Moyamoya: Indiana University Medical Center experience. Arch Neurol. 2001;58(8):1274-8. doi:10.1001/archneur.58.8.1274.

128. Yvon E, Lamotte D, Tiberghien A, et al. Long-term motor, functional, and academic outcome following childhood ischemic and hemorrhagic stroke: a large rehabilitation center-based retrospective study. Dev Neurorehabil. 2018;21(2):83-90. doi:10.1080/17518423.2016.1247923.

129. Zanaty M, Chalouhi N, Starke RM, et al. Endovascular stroke intervention in the very young. Clin Neurol Neurosurg. 2014;127:15-18. doi:10.1016/j.clineuro.2014.09.022.

130. Ziesmann MT, Nash M, Booth FA, Rafay MF. Cardioembolic stroke in children: a clinical presentation and outcome study. Pediatr Neurol. 2014;51(4):494-502. doi:10.1016/j.pediatrneurol.2014.06.013.

131. Jewell, D. Guide to Evidence-Based Physical Therapist Practice. 2nd ed. Jones & Bartlett Learning; 2011.

132. McKevitt C, Topor M, Panton A, et al. Seeking normality: parents’ experiences of childhood stroke. Child Care Health Dev. 2019;45(1):89-95. doi: 10.1111/cch.12622.

133. Gordon AL, Nguyen L, Panton A, et al. Self-reported needs after pediatric stroke. Eur J Paediatr Neurol. 2018 Sep;22(5):791-796. doi: 10.1016/j.ejpn.2018.06.003.

134. Ferriero DM, Fullerton HJ, Bernard TJ, et al. American Heart Association Stroke Council and Council on Cardiovascular and Stroke Nursing. Management of stroke in neonates and children: a scientific statement from the American Heart Association/American Stroke Association. Stroke. 2019;50(3):e51-e96. doi: 10.1161/STR.0000000000000183.

135. Bhopti A, Brown T, Lentin P. Opportunities for participation, inclusion and recreation in school-aged children with disability influences parent occupations and family quality of life: A mixed-methods study. Br J Occup Ther. 2020;83(4):204-214. doi:10.1177/0308022619883480.

136. Long B, Spencer-Smith MM, Jacobs R, et al. Executive function following child stroke: the impact of lesion location. J Child Neurol. 2011 Mar;26(3):279-87. doi: 10.1177/0883073810380049.

137. Golomb MR, Lo W. Do children recover better from arterial ischemic stroke than young adults? Neurology. 2015;84(19):1916-7. doi: 10.1212/WNL.000000000000157