The 7th edition of the Canadian Stroke Best Practice Recommendations (CSBPR) is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners, and intended to drive healthcare excellence, improved outcomes and more integrated health systems. This edition includes a new module on the management of cerebral venous thrombosis (CVT). Cerebral venous thrombosis is defined as thrombosis of the veins of the brain, including the dural venous sinuses and/or cortical or deep veins. Cerebral venous thrombosis is a rare but potentially life-threatening type of stroke, representing 0.5–1.0% of all stroke admissions. The reported rates of CVT are approximately 10–20 per million and appear to be increasing over time. The risk of CVT is higher in women and often associated with oral contraceptive use and with pregnancy and the puerperium. This guideline addresses care for adult individuals who present to the healthcare system with current or recent symptoms of CVT. The recommendations cover the continuum of care from diagnosis and initial clinical assessment of symptomatic CVT, to acute treatment of symptomatic CVT, post-acute management, person-centered care, special considerations in the long-term management of CVT, including pregnancy and considerations related to CVT in special circumstances such as trauma and vaccination. This module also includes supporting materials such as implementation resources to facilitate the adoption of evidence into practice and performance measures to enable monitoring of uptake and effectiveness of recommendations.

In this brief communication, we discuss the current landscape and unmet needs of pediatric to adult transition care in neurology. Optimizing transition care is a priority for patients, families, and providers with growing discussion in neurology. We also introduce the activities of the University of Toronto Pediatric-Adult Transition Working Group – a collaborative interdivisional and inter-subspeciality group of faculty, advanced-practice providers, trainees, and patient-family advisors pursuing collaboration with patients, families, and universities from across Canada. We envision that these efforts will result in a national neurology transition strategy that will inform designation of health authority attention and funding.

Background: Clinical outcomes following childhood arterial ischaemic stroke (AIS) depend on age at the time of stroke, infarct size and location. However, other important variables including health inequity and stroke onset to arrival times remain inadequately addressed. This study reported trends in health inequity and stroke onset to arrival times along with proximity to a stroke centre in Canada. Methods: Childhood AIS patients (N=234) with stroke onset between 2004-2019 at a Level 2 (comprehensive) stroke centre were included. Measures of material deprivation included household income, education, single-parent families, and housing quality. Patients were stratified into 3 cohorts (by date of stroke onset) and postal codes were categorized as minimal, moderate, or most deprived neighbourhoods. Results: Over the 16-year period, an increasing number of patients arrived from the most deprived neighbourhoods. Although, there was no significant association between material deprivation and stroke onset to arrival time, an increasing number of patients presented within 6 hours of stroke onset (χ2 = 13.8, p = 0.008). Furthermore, most patients arrived from urban neighbourhoods. Conclusions: The faster stroke onset to arrival trend is encouraging, however, material deprivation trends are concerning. Thus, future studies exploring post-stroke outcomes should consider material deprivation, stroke onset to arrival times, and geographical proximity.

Background: Studies evaluating long-term neurologic outcomes following NAIS are scanty. We aimed to study the emergence pattern of neurologic deficits following NAIS. Methods: Neonates diagnosed with AIS were prospectively enrolled and outcomes were evaluated using the validated Pediatric Stroke Outcome Measure-Severity Classification Scheme. Neurologic outcomes were classified as normal/mild, moderate or severe. Trend analysis was conducted using Cochran-Armitage test. Results: A total of 126 neonates (59% males) were followed for a median of 5.2 years (IQR:3.4-6.4 years). The proportion of children classified as normal/mild declined from 94% to 76% >5 years post-stroke (p<0.01). Moderate and severe outcomes increased from 5% to 15% and 1% to 8% (p=0.01), respectively. Sensorimotor, language and cognitive deficits emerged in 16%, 14%, and 17% of enrolled neonates, respectively. Of those who had normal/mild outcomes at baseline, 83 remained stable throughout the study. Improvement in neurologic outcomes was seen in 8 children. Thirty-five neonates had emerging deficits at one point during follow-up. Congenital heart disease predicted the emergence of deficits (odds ratio=3.3, 95% confidence interval:1.01-10.5). Conclusions: Emerging deficits following NAIS are not uncommon and can equally manifest in sensorimotor, language or cognitive domains. Thus, long-term follow-up and close monitoring of outcomes following NAIS is crucial.

Background: Neonatal cerebral sinovenous thrombosis (CSVT) can lead to severe brain injury and long-term neurodevelopmental impairments. Previous studies of neonatal CSVT have mainly included term infants. In this study, we examined the clinical and radiological features, treatment and outcome of CSVT in preterm infants. Methods: This was a retrospective cohort study of preterm infants born <37 weeks with radiologically confirmed CSVT. All MRI/MRV and CT/CTV scans were re-reviewed. Clinical and radiological data were analysed using descriptive statistics, ANOVA and chi-square tests. Results: A total of 26 preterm infants with CSVT were included. Of these, 65% were late preterm, 27% very preterm and 8% extreme preterm. Most were symptomatic (seizures 50%, abnormal exam 50%). Radiological features included transverse sinus (85%) and sagittal sinus thrombosis (42%), intraventricular hemorrhage (42%) and venous infarction (19%). Most preterm infants with CSVT (69%) were treated with anticoagulation. Anticoagulation was not associated with new or worsening intracranial hemorrhage. Outcome at follow-up ranged from no impairment (39%), mild impairment (19%), severe impairment (19%) and death (23%). Conclusions: Preterm infants with CSVT are often symptomatic and present with a distinct pattern of brain injury. Anticoagulation treatment of preterm CSVT appeared to be safe. Further studies and treatment guidelines for preterm CSVT are needed.

Background: Approximately 1,000 children present with AIS annually in North America. Most suffer from long-term disability. Childhood AIS is diagnosed after a median of 23 hours post-symptom onset, limiting thrombolytic treatment options that may improve outcomes. Pediatric stroke protocols decrease time to diagnosis. AIS treatment is not uniform across Canada, nor are pediatric stroke protocols standardized. Methods: We contacted neurologists at all 16 Canadian pediatric hospitals regarding their AIS management. Results: Response rate was 100%. Seven centers have an AIS protocol and two have a protocol under development. Seven centers do not have a protocol – two redirect patients to adult neurology, and five use a case-by-case approach for management. Analysis of the seven AIS protocols reveals differences: 1) IV-tPA dosage: age-dependent 0.75-0.9 mg/kg (n=1) versus age-independent 0.9 mg/kg (n=6), with maximum doses 75 mg (n=1) or 90 mg (n=6); 2) IV-tPA lower age cut-off: 2 years (n=4) versus 3, 4 or 10 years (n=1); 3) IV-tPA exclusion criteria: PedNIHSS score <4 (n=3), <5 (n=1), or <6 (n=3); 4) Pre-treatment neuroimaging: CT (n=3) versus MRI (n=4); 5) Intra-arterial tPA use (n=3). Conclusions: The seven Canadian pediatric AIS protocols show prominent differences. We plan a teleconference discussing a Canadian pediatric AIS consensus approach.