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Editorial: Pediatric structural cerebrovascular disease, interventions, hemodynamics, and pathophysiology.

DOI:10.1097/MOP.0000000000000288 There is much that has been written about the importance of childhood arterial ischemic stroke (AIS) as a cause of long-term morbidity and substantial health, economic, and personal costs. The crude incidence of childhood AIS in a population denominator of 5.99 million children was recently found to be 1.60 per 100 000 child population, per year (95% confidence interval 1.30–1.96) [1]. Almost onethird of such children have an arteriopathy, perhaps related to infection [1,2]. However, the unfortunate reality is that in contrast to current practices in adult stroke therapy, there is no thrombolytic or other specific treatment for AIS in children. The promising Thrombolysis in Pediatric Stroke study of tissue-type plasminogen activator was closed by the sponsor (US National Institute of Neurological Disorders and Stroke) because of a lack of eligible patients [3,4]. Surprisingly, only one case out of 93 screened in 14 sites was enrolled into the study, which ran for 20 months (20 April 2012 to 21 December 2013) [4]. There are many lessons to be learnt from the Thrombolysis in Pediatric Stroke study, and perhaps the priorities now for the physician, are pediatric and neurology community at large are better system-wide approaches. At least, there should be a renewed emphasis on the elements of our healthcare organization that would better enable earlier stroke recognition, diagnosis, and emergency transfer to specialist centers. It is in this context – absence of medical interventions for pediatric AIS – that we focus on pediatric structural cerebrovascular disease in this issue of Current Opinion in Pediatrics, lest we forget that there are children with AIS who do benefit from interventions. For example, Moyamoya – although rare – is a significant source of AIS and other patterns of cerebral ischemic injury in children after the first year of life, and there are viable surgical interventions that will limit neuropathology [5]. Therefore, we start with an article by Smith (pp. 706–711) who sets the scene with a contemporary clinical landscape for symptomatic and asymptomatic Moyamoya, and cerebral arteriovenous malformations. The author reviews recent advances in