Pediatric stroke among Hong Kong Chinese subjects

The importance of cerebral aneurysms in childhood hemorrhagic stroke: a population-based study

BACKGROUND AND PURPOSE

Prior population-based studies of pediatric hemorrhagic stroke (HS) had too few incident cases to assess predictors of cerebral aneurysms, a HS etiology that requires urgent intervention.

METHODS

We performed a retrospective cohort study of HS (intracerebral, subarachnoid [SAH], and intraventricular hemorrhage) using the population of all children <20 years of age enrolled in a large Northern Californian healthcare plan (January 1993 to December 2003). Cases were identified through electronic searches and confirmed through independent chart review by 2 neurologists with adjudication by a third; traumatic hemorrhages were excluded. Logistic regression was used to examine potential predictors of underlying aneurysm.

RESULTS

Within a cohort of 2.3 million children followed for a mean of 3.5 years, we identified 116 cases of spontaneous HS (overall incidence, 1.4 per 100000 person-years). Cerebral aneurysms were identified in 15 (13%) of HS cases. Among 21 children with pure SAH, 57% were found to have an underlying aneurysm compared with only 2% of 58 children with pure intracerebral hemorrhage and 5% of 37 children with a mixed pattern of hemorrhage (intracerebral hemorrhage and SAH). Independent predictors of an underlying aneurysm included pure SAH (OR, 76; 95% CI, 9 to 657; P<0.001) and late adolescent age (15 to 19 years versus younger age groups; OR, 6.4; 95% CI, 1.0 to 40; P=0.047).

CONCLUSIONS

Cerebral aneurysms cause the majority of spontaneous SAH in children and account for more than 10% of childhood HS overall. Children, and particularly teenagers, presenting with spontaneous SAH should be promptly evaluated with cerebrovascular imaging.

Antithrombotic therapy in neonates and children: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)

This chapter about antithrombotic therapy in neonates and children is part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs, and Grade 2 suggests that individual patient values may lead to different choices (for a full understanding of the grading, see Guyatt et al in this supplement, pages 123S-131S). In this chapter, many recommendations are based on extrapolation of adult data, and the reader is referred to the appropriate chapters relating to guidelines for adult populations. Within this chapter, the majority of recommendations are separate for neonates and children, reflecting the significant differences in epidemiology of thrombosis and safety and efficacy of therapy in these two populations. Among the key recommendations in this chapter are the following: In children with first episode of venous thromboembolism (VTE), we recommend anticoagulant therapy with either unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) [Grade 1B]. Dosing of IV UFH should prolong the activated partial thromboplastin time (aPTT) to a range that corresponds to an anti-factor Xa assay (anti-FXa) level of 0.35 to 0.7 U/mL, whereas LMWH should achieve an anti-FXa level of 0.5 to 1.0 U/mL 4 h after an injection for twice-daily dosing. In neonates with first VTE, we suggest either anticoagulation or supportive care with radiologic monitoring and subsequent anticoagulation if extension of the thrombosis occurs during supportive care (Grade 2C). We recommend against the use of routine systemic thromboprophylaxis for children with central venous lines (Grade 1B). For children with cerebral sinovenous thrombosis (CSVT) without significant intracranial hemorrhage (ICH), we recommend anticoagulation initially with UFH, or LMWH and subsequently with LMWH or vitamin K antagonists (VKAs) for a minimum of 3 months (Grade 1B). For children with non-sickle-cell disease-related acute arterial ischemic stroke (AIS), we recommend UFH or LMWH or aspirin (1 to 5 mg/kg/d) as initial therapy until dissection and embolic causes have been excluded (Grade 1B). For neonates with a first AIS, in the absence of a documented ongoing cardioembolic source, we recommend against anticoagulation or aspirin therapy (Grade 1B).

Arterial ischemic stroke: experience in Chinese children

The aim of this study was to review cases of pediatric arterial ischemic stroke among Chinese subjects and thereby evaluate risk factors, clinical and neuroimaging features, and treatment, to establish a reasonable guideline for assessment and management of the disease. Between 1996 and 2006, 157 children (male:female ratio, 1.4:1) with arterial ischemic stroke were identified at Beijing Children's Hospital. The median age at stroke was 32 months (range, 4-192). Among patients with determined etiology, infections (12.1%), moyamoya disease (12.1%), and trauma (10.8%) were the most common. In 51 patients, there were no obvious risk factors (32.5%). Hemiplegia was the most common presenting feature (81.5%). The region of left middle cerebral artery was most frequently affected (36.3%), followed by the right middle cerebral artery (29.9%). Of the 157 patients, 56 were treated by intravenous thrombolytic agents (35.7%), all but one of them successfully (the one exception involving hemorrhagic complication). Randomized controlled trials are needed to establish primary prevention, acute treatment, and secondary prevention of pediatric ischemic stroke.

More hemorrhagic and severe events cause higher hospitalization care cost for childhood stroke in Taiwan

OBJECTIVE

Rarely has childhood stroke been compared with adult stroke for incidence or cost. This population study compared the stroke incidence and the associated hospitalization care costs between children and adults in Taiwan.

STUDY DESIGN

We used reimbursement claims data from the National Health Insurance program to identify stroke diagnoses in 1997 to 2003. The inpatient costs of both the first admission and recurrent stroke from 1979 childhood cases and 365,169 adult cases were compared by age and stroke subtype, excluding those less than 1 month of age.

RESULTS

The mean inpatient costs were higher for patients <10 and 10 to 19 years of age ($3565 per case) compared with adult cases ($1933), including both first and recurrent hospitalizations, and they were higher for the recurrent cases. Patients <10 years old had the highest proportional incidence of hemorrhage events (71.4%), followed by patients in the 10- to 19-year-old group (61.4%), and the lowest for adults (21.3%). Hemorrhagic events incurred 2 to 12 times higher cost than other types of stroke.

CONCLUSIONS

The hospitalization care costs for stroke are higher for children than for adults because of a greater proportion of hemorrhagic cases among children.

Risk factors and outcomes of childhood ischemic stroke in Taiwan

In this retrospective study, we reviewed the charts and collected clinical and radiographic data on children (age range, 1 month to 18 years) with symptoms and radiographic confirmation of ischemic stroke for the period of January 1996 to July 2006. Ninety-four children were enrolled. Eighty-eight had arterial ischemic stroke and six had sinovenous thrombosis. Twenty-nine percent of the children had seizures. Twenty-six percent had diffuse neurological signs and 76% had focal neurological signs. Risk factors included vascular disease (33%), infection (27%), metabolic disorders (18%), trauma (11%), prothrombotic states (13%), cardiac disease (10%), and mitochondrial disease (6%). Ten percent (n=9) had no identifiable cause. Twenty-two percent of the children had more than one risk factor. Anterior territory (70%) was more involved than posterior territory (18%) in arterial ischemic stroke. Unilateral infarctions were more common on the left side (51%) than on the right (24.5%). Neurological deficits were present in 45% (n=34/75) of the children; the most frequent deficit was motor impairment (24%). Seven children (9%) died in the acute stage. There were 12 children (16%) who had recurrent stroke and 8 children (8/12) who had underlying vascular disease. The vascular disease included moyamoya disease (5), CNS lupus (1) and ill-defined vasculopathy (2). The etiology pattern in Taiwan was different from that in Western countries. Vascular disease was a significant risk factor for recurrence in childhood ischemic stroke.

Ischemic stroke in a child mistaken as functional disorder

Stroke is a rare but increasingly recognized disorder in children. Lack of published clinical trials and experience in most institutions has resulted in significant challenges for clinicians who manage children with stroke. We report a case of 16-year-old male child who was presented with history of sudden onset of weakness 2 months back and before he could consult the physician, the weakness improved significantly and a misdiagnosis of functional disorder was made at a peripheral hospital. Children with stroke may have subtle manifestations and to make an early diagnosis of stroke in children there is need of awareness about this entity in children.

Risk factors for pediatric stroke: consequences for therapy and quality of life

A retrospective population-based study was conducted to calculate incidence of pediatric stroke, detect risk factors, determine long term outcome and to optimize therapy. Patients (age: >1 month and <19 years) with stroke in Vorarlberg, Austria, from 1984-2005 were investigated. Outcome was evaluated in terms of neurological deficits, neuropsychological measures, and quality of life. Consequences on therapy were established according to current guidelines. Twenty-two children, median age 6 years (range, 0.9-14) years, 16 ischemic and 6 hemorrhagic stroke, correspond to an incidence of 1.96 and 0.74/100.000 child-years, respectively. No child died; one had a recurrent stroke. Twenty children (12 boys) were included after a median time of 3.7 years (range, 0.4-18). Risk factors were vasculopathy (17/20; 85%), lipometabolic disorders (17/20; 85%), and prothrombotic abnormality (10/20; 50%). Three children had no risk factor; four children had a reduced quality of life. The study led to therapeutic consequences in 13 of 20 children (65%): aspirin (5/20; 25%), folic acid in (3/20; 15%), and rehabilitative therapy (9/20; 45%). Most children with pediatric stroke have more than one risk factor, mainly vasculopathies or elevation of lipoprotein(a). Overall outcome is determined solely by neurological deficits and is positively influenced by good quality of life.

Peripheral retinal neovascularization and retinal detachment in turner syndrome

BACKGROUND

Peripheral retinal neovascularization occurs in many diseases, including sickle-cell disease, Eales disease, and sarcoidosis. To our knowledge, combined retinal detachment with peripheral retinal neovascularization has not been reported in the literature.

METHODS

We examined a 14-year-old girl with Turner syndrome. Total rhegmatogenous retinal detachment and tractional retinal detachment were found in the left eye, and peripheral avascular zone with neovascularization was found in both eyes. The retinal detachment was treated with an encircling scleral buckle. Subsequent retinal photocoagulation over the avascular zones of both eyes was performed.

RESULTS

Retinal neovascularizations regressed, and the retinal detachment reattached after treatment.

CONCLUSIONS

Retinal neovascularization, rhegmatogenous retinal detachment, and tractional retinal detachment can be ocular findings associated with Turner syndrome. Retinal photocoagulation over the avascular zone is a possible treatment for neovascularization.

Acute midbrain infarction in a child with intracranial carotid artery hypoplasia and aberrant cerebral vasculature: a case report

Strokes identified in older children typically present with sudden hemiparesis, frequent association with seizures, and occasional accompaniment of hemisensory signs or visual field defects. In this case of a left cerebral peduncle infarction, initially the patient was not found with evident right-side hemiparesis but with right-side paresthesia and mild worsening of her underlying left-side weakness, including weakness of left facial expression and left ptosis. Her right limbs became gradually weaker in the first 2 days. These bizarre clinical presentations, the mild worsening of the underlying left-side weakness, and the delayed presentation of right-side hemiparesis added to the difficulty of making a diagnosis and of the initial localization. In addition, the magnetic resonance angiography incidentally found an abnormal vessel, which was additional and serpiginous to the right posterior fossa. The right internal carotid artery was markedly smaller than the left one, and a defect was seen around the area of the presumed distal right internal carotid artery. The abnormal cerebral vasculature might be the cause of the unique clinical presentation and might be the contributing factor to the recurrence of her stroke. In conclusion, the authors report a special case of recurrent stroke on the basis of aberrant cerebral vasculature.

AE. Hemorrhagic stroke in children

Hemorrhagic stroke accounts for approximately half of stroke in childhood. Unlike arterial ischemic stroke, there are no consensus guidelines to assist in the evaluation and treatment of these children. This article reviews the literature on the evaluation, treatment, etiology, and neurologic outcome of hemorrhagic stroke in children. Important differences between pediatric and adult hemorrhage are highlighted, as treatment guidelines for adults may not be applicable in all cases. Required future research and potential therapies are also discussed.

Homocysteine, MTHFR C677 T, vitamin B12, and folate levels in Thai children with ischemic stroke: a case-control study

Hyperhomocysteinemia has been identified as a risk factor for venous and arterial thrombosis especially in adult populations. Twenty-eight patients with an initial diagnosis of ischemic stroke and 100 controls, aged <or=18 years, were enrolled in this study. The mean plasma total homocysteine (tHcy) levels in patients and controls were significantly different with values of 8.7+/-3.6 and 7.5+/-2.4 micromol/L, respectively (P=0.01). The plasma tHcy at the 95th percentile was 11.5 micromol/L and patients whose plasma tHcy was above the 95th percentile had an odds ratio of 8.2 (95% confidence interval 1.4-47.2, P=0.02) for developing ischemic stroke. The genetic and acquired factors that could have affected plasma tHcy levels were studied and no differences were found between patients and controls. Factors that were investigated were vitamin B12, red blood cell folate, and serum folate levels as well as methylenetetrahydrofolate reductase C677T polymorphism. It is of note, however, that subjects whose plasma tHcy was above the 95th percentile had significantly lower serum folate levels (P=0.02).

Recurrent hemiparesis due to anterior mitral leaflet myxomas

Strokes, cardiac or noncardiac, generally affect the elderly and only occasionally occur in children. A tendency to stroke occurs in cyanotic congenital heart disease; however, this report describes two female patients, aged 6 years and 4 years, who had no cyanotic disease. The first patient was admitted to the hospital after the first stroke but suffered a second one after admission. Her initial cardiac examination was normal. The other patient was admitted after a second right-sided hemiparesis. A mild pansystolic ejection murmur was observed at the lower left sternal border on auscultation; slight late diastolic murmurs with opening snap were found in the mitral valve area, and the second heart sound was increased. Transthoracic echocardiography revealed a mass in the anterior mitral valve in both patients. These masses were completely removed surgically and pathology revealed myxomas. Hemiparesis completely resolved after surgical and medical treatment. The clinical manifestations of cardiac tumors primarily depend on their number, size, location, and histology. Strokes and anterior mitral valve masses are extremely rare in children. In the two cases reported here, anterior mitral valve myxomas caused systemic embolization as a result of their location. Echocardiography should be performed early in patients presenting with recurrent strokes to exclude such pathology.

Cerebrovascular disorders in childhood: etiology, clinical presentation, and neuroimaging findings in a case series study

OBJECTIVE: To describe the main etiologies, neurological manifestations and neuro-imaging findings among children with sequelae of cerebrovascular disorders. METHOD: Case series study of children whose diagnosis was stroke sequelae. Variables studied were age at the time of first episode, number of episodes, etiology, motor deficits, epilepsy, and effected vascular territory. RESULTS: Twenty three patients were studied. Average age at first episode was 6.91 (±2.08) years. Fourteen patients were female. The number of stroke events per patient ranged from one to five. The most frequent etiologies were heart disease and sickle cell anemia. The most frequent neurological deficit was right hemiparesis. Nine patients experienced seizures. The left middle cerebral artery was the most affected vascular area. CONCLUSION: Our findings are similar to those described in the literature. Despite a careful investigation, some causes of stroke remain unidentified.

Mutations and polymorphisms in genes affecting hemostasis proteins and homocysteine metabolism in children with arterial ischemic stroke

BACKGROUND

The pathogenesis of thrombosis in childhood seems to be multifactorial implicating genetic and environmental factors.

AIM

To compare the distributions of mutations/polymorphisms in genes affecting hemostasis (factor V Leiden - FVL, FV H1298R-FVR2, FII 20210A, b-Fib 455G>A, FXIII V34L, PAI-1 4G, HPA-1b) or homocysteine metabolism (MTHFR C677T, MTHFR A1298C) among 90 children with arterial ischemic stroke (AIS) and 103 controls, and to associate the carriage of these mutations/polymorphisms with their corresponding proteins in children with AIS.

RESULTS

AIS was more frequent in boys (p < 0.01). No studied mutation/polymorphism was found to be a risk factor for AIS, except for FVL [odds ratio 4.2 (95% CI 1.5-12.1)], the presence of which was even higher in 31 children with congenital AIS [odds ratio 6.82 (95% CI 2.0-22.8)]. FVL carriers had an odds ratio of 5.76 (95% CI 1.6-6.4) when FVR2 was absent. In thrombosed children, activated protein C resistance, prothrombin and fibrinogen levels were higher in the presence of FVL, FII20210A or b-Fib 455G-->A, respectively. Double heterozygotes in both MTHFR C677T and A1298T or homozygotes in one had significantly elevated homocysteine levels.

CONCLUSION

Except for FVL, no definite conclusion could be reached regarding the involvement of the studied mutations/polymorphisms in childhood AIS.

Treatment and prevention of cerebrovascular disorders in children

Cerebrovascular disorders are an important cause of mortality and chronic morbidity in children. Ischemic stroke is more common than cerebral venous thrombosis and hemorrhagic stroke in children. Several medical disorders have been associated with stroke in children, and a thorough evaluation of underlying causes is needed to determine the best treatment and prevention strategy. The treatment and prevention of stroke in children is not well studied, and current recommendations are based on adult studies, nonrandomized trials, or expert opinion. Children with stroke require immediate, special attention and if possible should be stabilized and transferred to an institution that can offer pediatric neurovascular expertise and care. All children with stroke should be referred to or have their care managed by a pediatric neurologist. The treatment of stroke in adults is well studied, and when applicable this evidence should be considered in the treatment of children with stroke. Data from animal and adult stroke studies have demonstrated a benefit for the aggressive treatment of infection, fever, blood pressure, hypo/hyperglycemia, intracranial pressure, and seizures, and should be applied to children with stroke. The use of thrombolytic, antithrombotic, and antiplatelet therapies is based on adult studies, cohort studies, and/or expert opinion. Two consensus guidelines regarding the treatment of arterial ischemic stroke and cerebral venous thrombosis were recently published and recommend the use of anticoagulants or antiplatelet agents in the acute setting, depending on the underlying cause of stroke. The evidence for the primary prevention of stroke in children is restricted to sickle cell disease (SCD) and derived from the Stroke Prevention in Sickle Cell Study Project studies. Long-term chronic transfusion therapy to maintain hemoglobin S levels below 30% is indicated in children with SCD and intracranial stenosis. It has also been recently determined that chronic transfusion therapy should not be stopped in children with SCD and an increased risk for stroke. The recurrence rate of arterial ischemic stroke (AIS) in children ranges from 6% to 30% and is highest among children with recurrent transient ischemic attack, cardiac disease, arteriopathies, and metabolic and coagulation abnormalities. Recommendations for secondary prevention are based on adult studies and the underlying pathophysiology of the stroke. Antiplatelet therapy (aspirin 1-5 mg/kg/day) is recommended in most children with a history of AIS. Although there is minimal evidence to support its use in children, anticoagulation may be indicated in AIS associated with extracranial arterial dissection, prothrombotic disorders, cardiac disease, severe intracranial stenosis, and recurrent AIS while on antiplatelet therapy.

Is It Time for a Large, Collaborative Study of Pediatric Stroke?

Background and Purpose— A 2002 report from the National Institute of Neurological Disorders and Stroke cited the critical importance of more childhood stroke studies. We present the incidence rate of pediatric stroke from a biethnic community-based project and calculate the population size required for future prospective studies of pediatric stroke.

Methods— This work is part of the Brain Attack Surveillance in Corpus Christi (BASIC) project. The community of 325 000 is located in southeast Texas and is composed of approximately equal numbers of Mexican Americans (MAs) and non-Hispanic whites (NHWs). Discharge diagnosis codes from all hospitals in the county were used to identify cases of childhood stroke (age >1 month and <20 years) in 2002 and 2003, and stroke cases were validated by source document review. On the basis of the incidence rates, the population size required to complete a case-control study to examine risk factors for pediatric stroke was calculated.

Results— Eight cases of pediatric stroke were identified, yielding an annual incidence rate of 4.3 per 100 000 (95% CI, 1.9 to 8.5). There were 5 cases of intracerebral hemorrhage, 1 subarachnoid hemorrhage, 1 ischemic stroke, and 1 transient ischemic attack. All of the events occurred in MAs. Depending on the prevalence of the risk factors of interest, future studies of pediatric stroke would have to draw from a population of up to 59 million children to complete a case-control study within 4 years.

Conclusions— Given the rarity of pediatric stroke, future studies will require multicenter efforts and possibly a national surveillance system.