Potential of neuroimaging methods in assessing the time stages of development of ischemic stroke in children

Purpose of the study. To analyze the data of computed tomography (СТ) and magnetic resonance imaging (MRI) in children with ischemic stroke at different time stages of the pathological process and determine the significance of the results obtained.

Materials and methods. The study is based on the analysis of the examination results of 105 children (aged from 29 days to 18 years) with clinical manifestations of stroke, who underwent CT in 48 cases and MRI in 101 cases, of which a combination was in 44 cases. In statistical comparison of the characteristics of the MRI signal of the focus of ischemic cerebrovascular accident (iCVA) in T2-WI and FLAIR modes, the McNemar criterion was used. In descriptive statistics, the definition of the median (Me) was used, and in qualitative data – the definition of absolute and relative frequencies with an indication of the 95% confidence interval (CI).

Research results. CT allows to detect focal lesion in ischemic stroke at the initial stages of its development in 62.5% of cases, but does not provide the opportunity to differentiate the stage, unlike MRI, which allows to determine the hyperacute, acute, early and late subacute stages. Due to the poorly distinguishable characteristics of the MRI signal from the focus of ischemic stroke on T2-WI, T1-WI, FLAIR and DWI (b = 1000) in combination with the ADC map in the acute and early subacute stages, it is necessary to analyze perifocal changes in the focus of cerebral ischemia. It was found that in the acute and early subacute stages, the T2-WI and FLAIR modes can be interchangeable, since they have the same characteristics of the MR signal of the focal change in this time interval.

Discussion. The conducted study demonstrated the capabilities of CT and MRI in children with iCVA in identifying and determining the time stages of the pathological process development. MRI semiotics of the iCVA focus at the stage of the first 21 days from the moment of development of neurological symptoms were determined. A diagnostic MRI sign was established that allows differentiating the acute with the early subacute stage, as well as the modes in MRI examination necessary to establish the time from the moment of occurrence of neurological symptoms. Differences in MRI semiotics of iCVA in children and adults were revealed, which can occur as a result of physiological features of the child's brain, causing the course of the pathological process.

Conclusions. Neuroimaging using CT and MRI methods is mandatory in children with a clinical picture of cerebrovascular accident. The absence of focal lesions in the brain tissue on CT images with persistent or increasing neurological symptoms creates the need for MRI. The use of CT makes it possible to determine focal lesions in the brain tissue, but does not allow assessing the time limits for the development of ischemic stroke, unlike MRI, which, based on a combined analysis of different scanning modes and assessment of the peripheral parts of the focal lesion, allows differentiating the stages of ischemic stroke.

1. Volodin N.N., Vykhristyuk O.F., Gorbunov A.V. et al. Computer and magnetic resonance imaging in the diagnosis of acute cerebrovascular accident in children / Best practices of radiation and instrumental diagnostics [recommendation method]. M., 2019. 42 p. ISSN 2618-7124 (In Russian)

2. Shchederkina I.O., Koltunov I.E., Livshits M.I. Stroke and cerebrovascular pathology in children and adolescents. Guide for doctors / Ed. I.O. Shchederkina. M.: GEOTAR-Media, 2022: 13–45. (In Russian)

3. Shchederkina I.O., Zavadenko N.N., Koltunov I.E. Stroke in children and adolescents: formation of a pediatric register. Zhurnal Nevrologii i Psikhiatrii imeni S.S. Korsakova = Korsakov Neurology and Psychiatry Journal. 2016; 116 (9): 24–29. http://doi.org/10.17116/jnevro20161169124-29 (In Russian)

4. Mallick A.A., Ganesan V., Kirkham F.J. et al. Childhood arterial ischaemic stroke incidence, presenting features, and risk factors: a prospective population-based study. Lancet Neurol. 2014; 13 (1): 35–43. http://doi.org/10.1016/S1474-4422(13)70290-4

5. Petryaykina E.E., Shchederkina I.O., Vitkovskaya I.P. et al. Primary pediatric stroke center based in a multidisciplinary pediatric hospital. New reality in pediatrics. Health of the Metropolis. 2020; 1 (1): 15–30. https://doi.org/10.47619/2713-2617.zm.2020.v1i1;15-30 (In Russian)

6. Ladner T.R., Mahdi J., Gindville M.C. et al. Pediatric acute stroke protocol activation in a children’s hospital emergency department. Stroke. 2015; 46: 2328–2331. https://doi.org/10.1161/STROKEAHA.115.009961

7. McGlennan C., Ganesan V. Delays in investigation and management of acute arterial ischaemic stroke in children. Dev. Med. Child. Neurol. 2008; 50: 537–540. https://doi.org/10.1111/j.1469-8749.2008.03012.x

8. Mirsky D.M., Beslow L.A., Amlie-Lefond C. et al.; International Paediatric Stroke Study Neuroimaging Consortium and the Paediatric Stroke Neuroimaging Consortium. Pathways for Neuroimaging of Childhood Stroke. Pediatr. Neurol. 2017; 69: 11–23. https://doi.org/10.1016/j.pediatrneurol.2016.12.004

9. Perez F.A., Oesch G., Amlie-Lefond C.M. MRI Vessel Wall Enhancement and Other Imaging Biomarkers in Pediatric Focal Cerebral Arteriopathy-Inflammatory Subtype. Stroke. 2020; 51 (3): 853–859. https://doi.org/10.1161/STROKEAHA.119.027917

10. Mazaev A.P., Molodtsov M.S., Shchelykalina S.P. Magnetic resonance angiography in children with ischemic stroke. Pediatric Diseases of the Heart and Blood Vessels. 2023; 1 (20): 23–32. https://doi.org/10.24022/1810-0686-2023-20-1-23-32 (In Russian)

11. Rivkin M.J., deVeber G., Ichord R.N. et al. Thrombolysis in pediatric stroke study. Stroke. 2015; 46 (3): 880–885. https://doi.org/10.1161/STROKEAHA.114.008210

12. Shchederkina I.O., Larina L.E., Vlasova A.V. et al. Possibilities of reperfusion therapy for ischemic stroke in pediatrics: thrombolysis protocol in children at the primary pediatric stroke center. Moscow Medicine. 2020; 3 (37): 20–31. (In Russian)

13. Gonzalez R.G. et al. Acute ischemic stroke: imaging and intervention. Second edition. Springer, New York, 2011.

14. Merino JG, Warach S. Imaging of acute stroke. Nat. Rev. Neurol. 2010; 6 (10): 560–571. https://doi.org/10.1038/nrneurol.2010.129

15. Allen L.M., Hasso A.N., Handwerker J., Farid H. Sequence-specific MR imaging findings that are useful in dating ischemic stroke. Radiographics. 2012; 32: 1285–1297. https://doi.org/10.1148/rg.325115760

16. Wouters A., Lemmens R., Dupont P., Thijs V. Wake-up stroke and stroke of unknown onset: a critical review. Front. Neurol. 2014; 5: 153. https://doi.org/10.3389/fneur.2014.00153

17. Donahue M.J., Dlamini N., Bhatia A., Jordan L.C. Neuroimaging Advances in Pediatric Stroke. Stroke. 2019; 50 (2): 240–248. https://doi.org/10.1161/STROKEAHA.118.020478

18. Lee S., Jiang B., Heit J.J. et al. Cerebral Perfusion in Pediatric Stroke: Children Are Not Little Adults. Top Magn. Reson. Imaging. 2021; 30 (5): 245–252. https://doi.org/10.1097/RMR.0000000000000275

19. Pluncevic Gligoroska J., Gontarev S., Dejanova B. et al. Red Blood Cell Variables in Children and Adolescents regarding the Age and Sex. Iran J. Public Hlth. 2019; 48 (4): 704–712. PMID: 31110981

20. Sinha R, Ramji S. Neurovascular disorders in children: an updated practical guide. Transl. Pediatr. 2021; 10 (4): 1100–1116. https://doi.org/10.21037/tp-20-205

21. Shchederkina I.O., Vitkovskaya I.P., Koltunov I.E. et al. Stroke in children. Formation of the pediatric register: international and regional experience. Russian Journal of Child Neurology. 2018; 13 (1): 7–19. https://doi.org/10.17650/2073-8803-2018-13-1-7-19 (In Russian)

22. Mazaev A.P., Molodtsov M.S. Possibilities of magnetic resonance imaging in the diagnosis of ischemic stroke in children. Medical Visualization. 2023; 27 (3): 130–140. https://doi.org/10.24835/1607-0763-1280 (In Russian)

23. Goldman-Yassen A.E., Dehkharghani S. Neuroimaging in Pediatric Stroke and Cerebrovascular Disease. Stroke. Dehkharghani S (Editor). Exon Publications, Brisbane, Australia. ISBN:978-0-6450017-6-1. https://doi.org/10.36255/exonpublications.stroke.2021

24. Mastrangelo M., Giordo L., Ricciardi G. et al. Acute ischemic stroke in childhood: a comprehensive review. Eur. J. Pediatr. 2022; 181 (1): 45–58. http://doi.org/10.1007/s00431-021-04212-x

25. Polan R.M., Poretti A., Huisman T.A., Bosemani T. Susceptibility-weighted imaging in pediatric arterial ischemic stroke: a valuable alternative for the noninvasive evaluation of altered cerebral hemodynamics. Am. J. Neuroradiol. 2015; 36 (4): 783–788. http://doi.org/10.3174/ajnr.A4187

26. Tong E., Hou Q., Fiebach J.B., Wintermark M. The role of imaging in acute ischemic stroke. Neurosurg. Focus. 2014; 36 (1): E3. http://doi.org/10.3171/2013.10.FOCUS13396

27. Bachtiar N.A., Murtala B., Muis M. et al. Non-Contrast MRI Sequences for Ischemic Stroke: A Concise Overview for Clinical Radiologists. Vasc. Hlth Risk Manag. 2024; 20: 521–531. http://doi.org/10.2147/VHRM.S474143