**10. Focus on pediatric stroke**

Pediatric stroke is classified into infant and childhood stroke. Infant (neonatal or perinatal) stroke is defined as occurring between 28 weeks gestation and 28 days of postnatal age. The incidence is estimated as one in every four thousand live birth per year in the United Sates81. Ischemic stroke is twice as common as hemorrhagic stroke. According to a retrospective review, the most common discharge diagnoses conjunction with neonatal stroke included infection, cardiac disorders, and blood disorders. Less than 5% was associated with birth asphyxia81.

Abnormal muscle tone leads to abnormal positioning and abnormal movement pattern, and vice versa. To break this vicious cycle, comprehensive rehabilitation should include muscle tone management, proper bracing and positioning, and stimulation control. Repetitive task training is a commonly used in current rehabilitation therapy, but a literature review

Constraint-induced movement therapy (CIMT or CIT) was introduced with a hypothesis of forceful usage of paralytic arm facilitate neuroplasticity of the brain, which in turn leads to recovery of the arm motor function64. There are many supportive reports to its effectiveness65, 66, however, there is a lack of large randomized controlled study67. CIMT is indicated for subjects who have no significant spasticity and some strength of the paralyzed

Development in neruoscience and computer technology provides novel ideas to overcome the limitation of traditional rehabilitation for stroke. Originally, robotic treatment was introduced to alleviate the labor-intensive aspects of physical therapy by preinstalled programs to perform a goal-directed movement autonoumously or semi-autonomously69. It induces movement of paralyzed limbs by activation of the motor cortex of the side of the lesion and the movement of the limb also activates the motor cortex in a positive feedback. Most of devices are designed to lead task-oriented movement by intensive repetitive patterns. Functional brain MRI studies of robotic treatments, demonstrated an increased activation of the sensorimotor cortex during grasping tasks greater than non-practiced tasks70. However, the effectiveness of robotic treatment is still in question71-73. It is likely effective for shoulder and elbow function recovery, but may lack effectiveness of hand

EEG/MEG-based motor imagery brain-computer interface utilizes neuronal activities of the motor cortex of lesion side while performing motor imagery74, 75. Currently combined brain-

Virtual reality training, although needs further study, appears to be effective in

Generally, poor prognostic factors include prolonged flaccidity of paralyzed limb, right hemisphere lesion with hemi-neglect, cognitive impairment, old age (>74 years), anterior circulation, and large lesion size. Also spouse at home, hypothermia at acute phase, and

Pediatric stroke is classified into infant and childhood stroke. Infant (neonatal or perinatal) stroke is defined as occurring between 28 weeks gestation and 28 days of postnatal age. The incidence is estimated as one in every four thousand live birth per year in the United Sates81. Ischemic stroke is twice as common as hemorrhagic stroke. According to a retrospective review, the most common discharge diagnoses conjunction with neonatal stroke included infection, cardiac disorders, and blood disorders. Less than 5% was associated with birth

reported it is not effective in upper extremity motor function63.

upper extremity. It is not effective in acute phase of stroke68.

computer interface with robotic feedback technique is being tried76.

function improvement.

**9. Prognostic factors** 

asphyxia81.

improvement of motor function77, 78.

**10. Focus on pediatric stroke** 

absent co-morbidities are good predictors79, 80.

Childhood stroke is defined as occurring between 30 days of postnatal age and 18 years old. The incidence is reported 2-3/100,000 per year in US81, 2.7/100,000 in Canada (ischemic stroke only)82, and 13/100,000 in France83. Its mortality rate is reported 7-28% and higher in males than females and in blacks than white, respectively. Stroke is less common in children than in adults, but is one of the top ten causes of death in children in the US. It results in one of the leading causes of disability in young generations. The pathophysiology of childhood stroke is same as adults, but underlying premorbidities or etiologies are different. Most of adult stroke patients have pre-existing medical conditions, such as hypertension, diabetes mellitus, hyperlipidemia, arteriosclerosis, heart disease, or obesity, but in contrast one third of child stroke patients do not have any evident pre-existing medical conditions. In childhood stroke, congenital heart disease is the most common known etiology (about 30%), and sickle cell disease is the leading cause of stroke in African American ethnic group. Arteriovenous malformation is the leading cause of hemorrhagic stroke in childhood. Various coagulation disorders-factor V Leiden and prothrombin mutation, protein C and S deficiency, anti-phospholipid antibody, and inherited coagulation abnormalities and arterial vasculitis are related to pediatric strokes. Venous stroke is not uncommon in children. Venous:arterial stroke ratio is 1:4-6 in non-hemorrhagic stroke84. Venous stroke develops, when cerebral venous drainage to the internal jugular veins is significantly obstructed by thrombosis in the cerebral venous sinus (sinus venous thrombosis). The obstructed venous drainage consequently impedes arterial supply to the brain. Progressive insufficient arterial supply to the brain eventually leads to ischemia. Because of this slow process, compared with arterial stroke, clinical symptoms and signs progress slowly in venous stroke. High risks of sinus venous thrombosis are head and neck infection (meningitis, mastoiditis), dehydration, coagulation disorder, and perinatal complications. The outcome of a venous stroke is excellent.

The ratio of hemorrhagic to nonhemorrhagic stroke in childhood stroke is about 5:3 in the US85 . It is understood that the incidence of homorrhagic stroke is higher than adult, but it is similar to a recent stroke registry data3. Diagnostic interventions of pediatric stroke are similar to those of adult stroke. In addition, hematologic and metabolic work up for coagulopathy is important. It is not easy to recognize neonatal stroke because of limited clinical presentations. It is partially plausible to explain that patients with hemiplegic cerebral palsy might have unrecognized neonatal stroke. It is supported by the fact that patients with hemiplegic cerebral palsy showed elevated antiphospholipid and/or factor V Leiden mutation than normal control86-87. Patients with sickle cell disease has 200-400 times high risk and 50% of recurrence risk by three years.

In order to prevent stroke recurrence, aspirin is recommended for high risk of stroke patients in both adult and children. Apirin used for stroke prophylaxis does not complicate Reye's syndrome in children. Regular brain MRA is suggested to patient with hemorrhagic stroke secondary to aneurysm.

Since human cerebral hemispheres are already specialized at an early stage of development, pediatric stroke patients also demonstrate adult pattern of side specificity for brain lesions88- 89. Therefore clinical features are side specific and similar to adult stroke.

Outcomes vary among studies because of differences in population characteristics, stroke type, duration of follow-up, and outcomes measurement tools. Long-term outcome study

Stroke Rehabilitation 31

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showed complete recovery rate without residual impairment in 14% of patients with nonhemorrhagic stroke90 and 25% in hemorrhagic stroke91, respectively. In adult strokes, hemorrhagic stroke has higher mortality (23%) than non-hemorrhagic stroke91.

In the long-term, cognitive impairment is significant in childhood stroke, and IQ (Intellectual Quotation) ranges widely and is lower than average90, 92, 93. As imagined, VIQ (Verbal IQ) is higher than PIQ (Performance IQ) in children with right hemisphere lesion, and PIQ is higher than VIQ in left hemisphere lesion90, 93. In spite of cognitive impairment, most of children return to mainstream school with/without support57, 90. Regardless of residual impairments and disabilities, they feel healthy and happy as normal children would94.

General survival rate of pediatric stroke is better than adults95, 96. 5 year survival rate is 85%, and residual neurological deficits of 75% (hemiparesis, epilepsy, learning disabilities, visual field deficits, mental retardation)97. Idiopathic stroke have better prognosis than stroke associated with cardiac disease98. It is controversial but generally age is also an important prognostic factor98. The functional outcome of childhood stroke is more favorable than that of adult one. However, it is reported that infant stroke has poorer outcome than childhood stroke.

Poor outcome predictors are multiple cortical dysfunction, initial symptoms with altered level of consciousness with/without seizure, middle cerebral artery lesion, infant age onset, persistence of hemiparesis 1 month after stroke, and bilateral hemisphere lesions57,90, 93,99, 100.

School re-entry is the final rehabilitation goal for children with stroke. A neuropsychological test including IQ indicates the details of the cognitive impairments. Based on the test results, school re-entry might be planned. Depending on medical conditions and the test results, home bound education, part time student, full time student, or classroom modification might be advised.
