By Bin Jiang and Warren Lo.
Due to the complexity of the outcome in pediatric AIS, many efforts have been conducted to uncover the potential role of clinical and imaging variables in outcome prediction. The infarct volume, age at onset, hemorrhagic transformation, social-economic status, underlying disorders, post-stroke epilepsy and treatment approaches have been discussed in previously published articles. We were motivated to perform a secondary analysis of the VIPS dataset to assess the potential relationship between imaging characteristics and outcome. VIPS was at the time the largest, prospectively collected pediatric stroke dataset with central review of all the brain images, as well as one-year outcomes.
In our initial analysis, we found that infarction involving certain locations: The insular ribbon represented a risk factor, but only before the age of 2. The uncinate fasciculus, and angular gyrus serve important functions in connecting or receiving input from other regions. The angular gyrus is a key structure of the Default Mode Network (DMN), a large-scale network of brain regions showing highly correlated levels of functional activity characterized by high levels of “hubness.” Functional recovery after acquired brain injury depends in part on the ability to restore functional connectivity despite disrupted structural connectivity (i.e., re-routing of functional activity via alternate anatomical pathways) and hub integrity is essential to this. The arcuate fasciculus (connecting Broca and Wernicke areas) is traditionally associated with aphasia, the uncinate fasciculus (connecting limbic system structures in the temporal lobe to orbito-frontal cortex) in the dominant hemisphere has also been implicated in the “ventral stream” language network. Uncinate fasciculus disruption in early childhood has been associated with a range of developmental disorders.
However, when these locations were adjusted for infarct volume, they were no longer significantly associated with outcome. We tested the correlation of infarct volume with outcome and concluded that a larger infarct volume at the time stroke onset were significantly associated with poorer outcomes, however with modest odds ratios. Our results generate the intriguing hypothesis that it may not just be infarct volume, but rather what networks are impaired. So, are we ready to look at an MRI and make a prediction about how a child will do? Yes, but only to a limited degree. In children there are other factors, perhaps network connections, that are likely to influence outcomes.
Links to Relevant Scientific Publications:
VIPS paper on pediatric AIS outcome prediction
- Imaging Predictors of Neurologic Outcome After Pediatric Arterial Ischemic Stroke
- Socioeconomic determinants of outcome after childhood arterial ischemic stroke
Recent papers on pediatric AIS outcome prediction (2020~2021)
- Predicting Recovery and Outcome after Pediatric Stroke: Results from the International Pediatric Stroke Study
- Endovascular treatment of pediatric ischemic stroke: A single center experience and review of the literature
- Determinants of neurological outcome in neonates with congenital heart disease following heart surgery
- Validation of the focal cerebral arteriopathy severity score (FCASS) in a Swiss cohort: Correlation with infarct volume and outcome
Papers on neuro-networks
- The organization of the human cerebral cortex estimated by intrinsic functional connectivity
- Complex network measures of brain connectivity: uses and interpretations
- Modeling the impact of lesions in the human brain
- Perisylvian language networks of the human brain
- A contemporary framework of language processing in the human brain in the context of preoperative and intraoperative language mapping
- What is the role of the uncinate fasciculus? Surgical removal and proper name retrieval
- Is the left uncinate fasciculus essential for language? A cerebral stimulation study
- Development of the uncinate fasciculus: Implications for theory and developmental disorders
- Development and aging of the healthy human brain uncinate fasciculus across the lifespan using diffusion tensor tractography
- Establishing, versus maintaining, brain function: a neuro-computational model of cortical reorganization after injury to the immature brain
Bin Jiang, MD, Ph.D.
Stanford University School of Medicine
Warren Lo, MD
Nationwide Children's Hospital
Warren Lo, MD, is a pediatric neurologist at The Ohio State University and Nationwide Children’s Hospital. He has been a member of the International Pediatric Stroke Study (IPSS) since 2006.
