Arterial ischemic stroke risk factors: The international pediatric stroke study

Multiple presence of prothrombotic risk factors in Croatian children with arterial ischemic stroke and transient ischemic attack

Aim

To determine the frequency of inherited and acquired prothrombotic risk factors in children with arterial ischemic stroke (AIS) and transient ischemic attacks (TIA) in Croatia.

Methods

We investigated 14 prothrombotic risk factors using blood samples from 124 children with AIS or TIA and 42 healthy children. Prothrombotic risk factors were classified into five groups: natural coagulation inhibitors (antithrombin, protein C, protein S), blood coagulation factors (FV Leiden and FII 20210), homocysteine, lipid and lipoprotein profile (lipoprotein (a), triglycerides, total, high- and low-density lipoprotein), and antiphospholipid antibodies (lupus anticoagulant, anticardiolipin, and antiphosphatidylserine antibodies).

Results

The most common prothrombotic risk factor was elevated lipoprotein (a), which was identified in about 31% of patients and in 24% of controls. Natural coagulation inhibitors were decreased in about 19% of patients, but not in controls. Pathological values of homocysteine, blood coagulation factor polymorphisms, and antiphospholipid antibodies were found in similar frequencies in all groups. Fourteen children with AIS and TIA (11.3%) and no children from the control group had three or more investigated risk factors.

Conclusion

The presence of multiple prothrombotic risk factors in children with cerebrovascular disorder suggests that a combination of risk factors rather than individual risk factors could contribute to cerebrovascular disorders in children.

Thrombolysis for children with acute ischemic stroke: a perspective from the kids' inpatient database

BACKGROUND

Thrombolysis for acute ischemic stroke (AIS) in children is yet to be proven efficacious, and there is limited information about its safety in large pediatric samples. Here we evaluate the safety outcomes associated with thrombolysis in children as well as the trend of hospital utilization over the past decade in the United States.

METHODS

A cohort of children with acute ischemic stroke was identified from the Kids' Inpatient Database for the years 1998-2009. Acute ischemic stroke was identified by the International Classification of Diseases-9 clinical classification software codes (109 and 110). Multivariate logistic regression analyses were used to assess covariates associated with outcomes of hospital mortality and intracerebral hemorrhage. The Cochran-Armitage test was employed for linear trend of discrete variables.

RESULTS

In this analysis, 9257 children were admitted with the diagnosis of acute ischemic stroke; only 67 (0.7%) received thrombolysis. Thrombolysis-treated children were older than the rest of the cohort (13.1 ± 7.3 vs 8.18 ± 7.5; P < 0.0001) and they had a longer hospital stay (median 11 vs 6 days; P < 0.0001). Gender, race, and family income approximated by postal code were similar among the treated and untreated children. Unadjusted analysis showed higher hospital mortality (10.45% vs 6.14%; P = 0.06) and intracerebral hemorrhage (2.99% vs 0.77%; P = 0.08) in the thrombolysis group. Adjusted analysis showed that intracerebral hemorrhage is predictive of a higher hospital mortality (odds ratio 3.43; 95% confidence interval 1.89-6.22), whereas thrombolysis was not (odds ratio 1.78; 95% confidence interval 0.86-3.64). The overall rate of thrombolysis per 3 years intervals had increased from 5.2 to 9.7 per 1000 children with acute ischemic stroke (P = 0.02). This increase was mainly seen in non-children hospitals (P = 0.01).

CONCLUSION

Thrombolysis for acute ischemic stroke is infrequently used in children. There is a trend toward higher risks of intracerebral hemorrhage and hospital mortality, although these risks are as low as those reported in adult population. The hospitals' utilization of thrombolysis in children has increased during the study period.

Review of lipid and lipoprotein(a) abnormalities in childhood arterial ischemic stroke

National organizations recommend cholesterol screening in children to prevent vascular disease in adulthood. There are currently no recommendations for cholesterol and lipoprotein (a) testing in children who experience an arterial ischemic stroke. While dyslipidemia and elevated lipoprotein (a) are associated with ischemic stroke in adults, the role of atherosclerotic risk factors in childhood arterial ischemic stroke is not known. A review of the literature was performed from 1966 to April 2012 to evaluate the association between childhood arterial ischemic stroke and dyslipidemia or elevated lipoprotein (a). Of 239 citations, there were 16 original observational studies in children (with or without neonates) with imaging-confirmed arterial ischemic stroke and data on cholesterol or lipoprotein (a) values. Three pairs of studies reported overlapping subjects, and two were eliminated. Among 14 studies, there were data on cholesterol in 7 and lipoprotein (a) in 10. After stroke, testing was performed at >three-months in nine studies, at ≤three-months in four studies, and not specified in one study. There were five case-control studies: four compared elevated lipoprotein (a) and one compared abnormal cholesterol in children with arterial ischemic stroke to controls. A consistent positive association between elevated lipoprotein (a) and stroke was found [Mantel-Haenszel OR 4·24 (2·94-6·11)]. There was no association in one study on total cholesterol, and a positive association in one study on triglycerides. The literature suggests that elevated lipoprotein (a) may be more likely in children with arterial ischemic stroke than in control children. The absence of confirmatory study on dyslipidemia should be addressed with future research.

Mycoplasma pneumoniae associated stroke in a 3-year-old girl

Infectious diseases precede a significant proportion of acute ischemic strokes in children. Here, we report a case of acute ischemic stroke in a 3-year-old girl with a Mycoplasma pneumonia-associated respiratory tract infection. She developed an acquired prothrombotic state of protein S deficiency and had increased fibrinogen and fibrinogen degradation product levels and increased titer of antinuclear antibodies. However, these conditions were completely alleviated at the 1-month follow-up examination. Infection with M. pneumoniae may cause a transient prothrombotic state that can potentially cause a thrombus.

Safe use of alteplase in a 10 months old infant with cardio-embolic stroke

The knowledge about safety and efficacy of thrombolysis in paediatric stroke is limited, especially for very young children. We present an infant with cardioembolic stroke treated with alteplase. He had hypoplastic left heart syndrome since birth. He underwent Norwood operation, followed by bidirectional cavopulmonary anastomosis at 3 months. On aspirin therapy he was well until heart failure developed at the age of 9 months with 2 thrombi in the right ventricle. During the course of enoxaparin therapy sudden acute left-sided haemiplegia occurred. The emergency brain CT scan was normal. Informed consent was obtained from parents after explaining the alteplase treatment protocol and possible complications. Alteplase was administered i.v. according to standard adult stroke regimen. A control CT scan obtained 24 h later was negative for intracranial haemorrhage but the hypodense area in insula, internal capsule and subcortical area of the right parietal region were indicative of ischaemic stroke. Anticoagulation therapy was continued. He recovered hand functions after 5 days and full repertoire of movements on his left side 3 weeks later. A neurological examination performed 2 months after indicated mild residual haemiparesis and a modified Rankin scale score of 1. Three months later, the patient died of progressive heart failure. An international multicentre prospective trial is ongoing to investigate the safety and appropriate dose of alteplase for paediatric ages 2-17 years. The aim of this paper is to report safe use of alteplase even in a very young child.

Recognition and management of stroke in young adults and adolescents

Approximately 15% of all ischemic strokes (IS) occur in young adults and adolescents. To date, only limited prior public health and research efforts have specifically addressed stroke in the young. Early diagnosis remains challenging because of the lack of awareness and the relative infrequency of stroke compared with stroke mimics. Moreover, the causes of IS in the young are heterogeneous and can be relatively uncommon, resulting in uncertainties about diagnostic evaluation and cause-specific management. Emerging data have raised public health concerns about the increasing prevalence of traditional vascular risk factors in young individuals, and their potential role in increasing the risk of IS, stroke recurrence, and poststroke mortality. These issues make it important to formulate and enact strategies to increase both awareness and access to resources for young stroke patients, their caregivers and families, and health care professionals. The American Academy of Neurology recently convened an expert panel to develop a consensus document concerning the recognition, evaluation, and management of IS in young adults and adolescents. The report of the consensus panel is presented herein.

[Current management of post-varicella stroke in children: a literature review]

Among infectious factors, varicella-zoster virus (VZV) is a leading cause of central nervous system vasculopathy and stroke in childhood. Not only have viral markers been detected in the cerebrospinal fluid of affected patients, but also direct evidence of viral particles in the wall of cerebral arteries has been demonstrated in rare pathological specimens. This certainly reflects a localized infectious process likely associated with variable indirect inflammatory responses. Yet the usefulness in this setting of a lumbar puncture as well as of subsequent targeted antiviral and/or anti-inflammatory therapies is uncertain. Indeed, in the majority of cases, the so-called post-varicella angiopathy has a monophasic evolution with spontaneous resolution or stabilization, explaining diverging diagnostic and treatment approaches. In this paper, we have addressed this problematic area by reviewing 26 published cases from the year 2000 and three unpublished cases. Post-varicella stroke is typically associated with angiopathy most often involving the initial portion of the middle cerebral artery, causing a basal ganglia stroke. It tends to occur in young immunocompetent children. Thrombophilia work-up is in general negative. Lumbar puncture was performed in 17 out of 29 cases. Viral markers were examined in 14 cases, but were positive in only eight cases. Antiviral therapy was administrated in 11 children. In this small retrospective study, the treated children's vasculopathy did not progress more favorably nor was there a better outcome compared with untreated subjects.

Therapy in pediatric stroke

The aim of this review is to summarize the existing literature on therapy and management of cerebrovascular insults in children and adolescents. As data sources, studies were identified by MEDLINE, PubMed, Cochrane Library, and relevant bibliographies for the topic "pediatric stroke." We also reviewed guidelines for "stroke in adults." As a result, pediatric stroke is underestimated. The annual incidence for all stroke entities (cerebral venous thrombosis and hemorrhagic and arterial ischemic stroke) is as high as for pediatric brain tumors, 3-15/100.000 children per year. A distinct etiology can be determined only in a minority of them. Underlying risk factors are multiple, mainly vasculopathies, congential heart diseases, coagulopathies, lipometabolic disorders, and sickle cell anemia. Current recommendations for therapy are based on adult studies, are preliminary, and discussed controversially. Antithrombotic therapy is uniformly recommended for the acute stage of pediatric stroke; no consensus exists on antiplatelet therapy with acetylsalicylic acid (ASA, aspirin) (5 mg/d), with ultra-fractionated or low-molecular-weight heparin. Thrombolysis using recombinant tissue plasminogen activator is not advised, despite the fact that current practice takes a different approach. None of the guidelines specify the duration of ASA for secondary prevention. Additional supportive therapy measures are osmotherapy and decompressive craniectomy. Oxygen in the absence of hypoxemia, intensive insulin therapy, antiepileptic drugs in the absence of clinical or electrographic seizures, corticosteroids, and GP-IIb/IIIa-receptor antagonists should not be used outside clinical trials. In conclusions, current therapeutic guidelines for pediatric stoke are still based on consensus and expert and society opinions and differ between countries. Consensus prevails on the need for acute anticoagulation using either antiplatelets or heparin. Long-term treatment with acetylsalicylic acid in all or only high-risk patients and for how long remains the subject of debate. Lifelong secondary prevention has never been investigated in children or adults. All guidelines agree that there is no indication for thrombolysis in children outside clinical trials, although clinical practice in large centers differs.

How commonly do children with complex cerebral arteriopathy have renovascular disease?

AIM

To describe the frequency of renovascular abnormalities and hypertension in an opportunistic cohort of children with complex cerebrovascular disease from a single tertiary/quaternary referral centre.

METHOD

This was a retrospective case note and imaging review of children who had had cerebral and renal angiography, with a diagnosis of moyamoya or other occlusive cerebrovascular disease (OCVD). Hypertension was defined as at least three systolic blood pressure readings of the 95th centile or above.

RESULTS

Of 34 children (12 males, 22 females; median age 5y 11mo, range 2mo-15y 3mo; 20 with moyamoya, 14 with OCVD), primary presentation was neurological in 29 (arterial ischaemic stroke, transient ischaemic attack, or headache) and with hypertension in five. Renovascular abnormalities were identified in 17, of whom 10 had main renal artery stenosis. Renovascular involvement was not predictable according to arteriopathy diagnosis. Blood pressure was rarely plotted on centile charts. Using the 50th height centile for blood pressure, and based on a median of five systolic blood pressure readings per patient, 20 out of 34 met the definition for hypertension (15/29 patients with primary neurological presentation).

INTERPRETATION

Renovascular abnormalities were common in this group of children with complex cerebrovascular disease. Blood pressure was frequently abnormal but rarely measured and infrequently plotted on centile charts. Neurologists should be alert to potential systemic vascular involvement and its sequelae in children with complex cerebrovascular disease.

Clinical features and risk factors of cerebral infarction after mild head trauma under 18 months of age

Mild head trauma can cause cerebral infarction in children younger than 18 months of age, yet the pathogenesis, clinical characteristics, and risk factors are not fully understood. Data of 16 cases between August 2008 and September 2011, including clinical manifestations and imaging and laboratory findings were collected and analyzed. All patients had the history of mild head trauma. The median age of the cohort was 13.5 months (range 6 months to 18 months). All children developed neurologic symptoms and signs within 72 hours after trauma, 62.5% (10/16) within 30 minutes. The first symptoms included hemiparesis (9/16), facial paresis (4/16), and convulsion (6/16). Overall, 93.75% (15/16) of the lesions were in the basal ganglia region. Two risk factors were identified, basal ganglia calcification in 10 and cytomegalovirus infection in eight. After conservative therapy, the neurologic deficits recovered to some extent. Cerebral infarction after mild head trauma in children younger than 18 months of age may take place, especially under the circumstances of basal ganglia calcification or cytomegalovirus infection.

Recent trauma and acute infection as risk factors for childhood arterial ischemic stroke

OBJECTIVE

Trauma and acute infection have been associated with stroke in adults, and are prevalent exposures in children. We hypothesized that these environmental factors are independently associated with childhood arterial ischemic stroke (AIS).

METHODS

In a case-control study nested within a cohort of 2.5 million children (≤19 years old) enrolled in an integrated health care plan (1993-2007), childhood AIS cases (n = 126) were identified from electronic records and confirmed through chart review. Age- and facility-matched controls (n = 378) were randomly selected from the cohort. Exposures were determined from review of medical records prior to the stroke diagnosis, or the same date for the paired controls; time windows were defined a priori.

RESULTS

A medical encounter for head or neck trauma within the prior 12 weeks was an independent risk factor for childhood AIS (odds ratio [OR], 7.5; 95% confidence interval [CI], 2.9-19.3), present in 12% of cases (1.6% of controls). Median time from trauma to stroke was 0.5 days (interquartile range, 0-2 days); post hoc redefinition of trauma exposure (prior 1 week) was more strongly associated with AIS: OR, 39; 95% CI, 5.1-298. A medical encounter for a minor acute infection (prior 4 weeks) was also an independent risk factor (OR, 4.6; 95% CI, 2.6-8.2), present in 33% of cases (13% of controls). No single infection type predominated. Only 2 cases had exposure to trauma and infection.

INTERPRETATION

Trauma and acute infection are common independent risk factors for childhood AIS, and may be targets for stroke prevention strategies.

Mechanisms of pediatric cerebral arteriopathy: an inflammatory debate

Arteriopathy is the leading cause of childhood arterial ischemic stroke, but its mechanisms are poorly understood. This review explores the possible role of inflammatory mechanisms and evidence for inflammatory pathophysiology in specific pediatric cerebral arteriopathies. Pathologically proven small-vessel central nervous system vasculitis provides a definitive inflammatory model where available treatments are likely improving outcomes. In contrast, a common large-vessel arteriopathy presents many features suggestive of inflammation, but definitive proof remains elusive. Recent advances and future research directions, including biomarker, neuroimaging, and pathologic approaches and how they might address these important clinical questions, are discussed.

International Paediatric Stroke Study: stroke associated with cardiac disorders

BACKGROUND AND HYPOTHESIS

The aetiologies of arterial ischaemic stroke in children are diverse and often multifactorial. A large proportion occurs in children with cardiac disorders. We hypothesized that the clinical and radiographic features of children with arterial ischaemic stroke attributed to cardiac disorders would differ from those with other causes.

METHODS

Using the large population collected in the prospective International Paediatric Stroke Study, we analysed the characteristics, clinical presentations, imaging findings, and early outcomes of children with and without cardiac disorders.

RESULTS

Aetiological data were available for 667 children with arterial ischaemic stroke (ages 29 days to 19 years). Cardiac disorders were indentified in 204/667 (30.6%), congenital defects in 121/204 (59.3%), acquired in 40/204 (19.6%), and isolated patent foramen ovale in 31/204 (15.2%). Compared to other children with stroke, those with cardiac disorders were younger (median age 3.1 vs. 6.5 years; P < 0.001) and less likely to present with headache (25.6% vs. 44.6%; P < 0.001), but were similar in terms of gender and presentation with focal deficits, seizures, or recent infection. Analysis of imaging data identified significant differences (P = 0.005) in the vascular distribution (anterior vs. posterior circulation or both) between groups. Bilateral strokes and haemorrhagic conversion were more prevalent in the cardiac disorders group.

CONCLUSIONS

Cardiac disorders were identified in almost one-third of children with arterial ischaemic stroke. They had similar clinical presentations to those without cardiac disorders but differed in age and headache prevalence. Children with cardiac disorders more frequently had a 'cardioembolic stroke pattern' with a higher prevalence of bilateral strokes in both the anterior and posterior circulations, and a greater tendency to haemorrhagic transformation.

Genetic deletion of CD36 enhances injury after acute neonatal stroke

OBJECTIVE

The scavenger receptor CD36 is injurious in acute experimental focal stroke and neurodegenerative diseases in the adult. We investigated the effects of genetic deletion of CD36 (CD36ko) on acute injury, and oxidative and inflammatory signaling after neonatal stroke.

METHODS

Postnatal day 9 CD36ko and wild-type (WT) mice were subjected to a transient middle cerebral artery occlusion (MCAO). Injury, phagocytosis of dying cells, and CD36 inflammatory signaling were determined.

RESULTS

While the volume of tissue at risk by diffusion-weighted magnetic resonance imaging during MCAO was similar in neonatal CD36ko and WT mice, by 24 hours after reperfusion, injury was more severe in CD36ko and was associated with increased caspase-3 cleavage and reduced engulfment of neurons expressing cleaved caspase-3 by activated microglia. No significant superoxide generation was observed in activated microglia in injured WT, whereas increased superoxide production in vessels and nuclear factor (NF)-κB activation induced by MCAO were unaffected by lack of CD36. Lyn expression was higher in injured CD36ko, and cell type-specific patterns of Lyn expression were altered; Lyn was expressed in endothelial cells and microglia in WT but predominantly in dying neurons in CD36ko.

INTERPRETATION

Lack of CD36 results in poorer short-term outcome from neonatal focal stroke due to lack of attenuation of NF-κB-mediated inflammation and diminished removal of apoptotic neuronal debris. Although inhibition of CD36 does not seem to be a good therapeutic target for protection after acute neonatal stroke, as it is after adult stroke, seeking better understanding of CD36 signaling in particular cell populations may reveal important therapeutic targets for neonatal stroke.

Inherited prothrombotic risk factors in children with first ischemic stroke

Stroke in children is a heterogeneous disorder. Over 100 risk factors for stroke have been reported and genetic predisposition to stroke has been established. The most frequently reported risk factors are congenital heart malformations, hemolytic anemias, collagen vascular diseases, some rare inborn metabolic disorders, trauma, infection and thrombophilia. The aim of this article is to provide an overview of investigated inherited prothrombotic risk factors in children with first ischemic stroke. Various prothrombotic risk factors have been investigated in pediatric stroke including elevated homocysteine and lipoprotein (a), antithrombin, protein C and protein S deficiency, Factor V Leiden, Factor II G20210A and plasminogen activator inhibitor-1 4G/5G polymorphism. Despite similar criteria for inclusion of different studies in meta-analyses investigating first ischemic stroke in children, the obtained results were not consistent for all prothrombotic risk factors. The discrepancies found could be explained by methodological issues like different sample sizes, patient populations included and lack of controls. In order to provide the necessary power for randomized control trials, multi-center, multi-national approaches like International Pediatric Stroke Study have been initiated with the aim to describe risk factors for childhood stroke and explore their relationship with presentation, age, geography, and infarct characteristics. Although it is evident from numerous studies that the frequency of inherited prothrombotic factors is increased in pediatric stroke, single thrombophilia does not fully explain stroke in a child as it represents only a mild risk factor. Further studies are needed, as improved understanding of underlying mechanisms will improve primary and secondary prevention of childhood stroke.

Endothelial injury in childhood stroke with cerebral arteriopathy: a cross-sectional study

OBJECTIVE

Circulating endothelial cells (CECs) and microparticles (MPs) have been reported to reflect endothelial injury, cellular activation, and MP-mediated thrombin generation. We tested the hypothesis that these indices differ between children with cerebral arteriopathy and arterial ischemic stroke (AIS) recurrence, and those with a single event.

METHODS

This was a single-center cross-sectional study of 46 children with AIS and cerebral arteriopathy matched with pediatric controls. AIS recurrence was defined as new acute neurologic deficit with radiologic evidence of further cerebral infarction. CECs and MPs were identified with immunomagnetic bead extraction and flow cytometry, respectively. MP function as assessed by thrombin generation was determined using a fluorogenic assay.

RESULTS

Ten children had AIS recurrence while 36 had a single AIS event. CECs were raised in children with recurrent AIS, compared to those with no recurrence (p = 0.0001), and in controls (p = 0.0001). Total circulating annexin V+ MPs were significantly greater in children with recurrence than in those with no recurrence (p = 0.0020). These MPs were of endothelial or platelet origin, and a subpopulation expressed tissue factor. Finally, MP-mediated thrombin generation was enhanced in children with recurrent AIS compared to those with no recurrence (p = 0.0001), providing a link between inflammation, endothelial injury, and increased thrombotic tendency.

CONCLUSION

Despite the wide spectrum of clinical and radiologic presentation of childhood AIS, indices of endothelial injury and cellular activation are different in patients with single and recurrent events. This novel approach has potential for furthering understanding of AIS pathophysiology and prognosis.

A successful treatment of arterial ischemic stroke with stent insertion in a child with congenital heart disease

INTRODUCTION

Diagnosis of arterial ischemic stroke in pediatric patients is often delayed due to the uncertainty and variability of clinical symptoms. Early diagnosis of arterial ischemic stroke can bring a favorable prognosis with prompt thrombolytic therapy or stent insertion, via transfemoral cerebral arteriogram. Acute thrombolytic therapy is rarely attempted in children because of the delayed diagnosis.

PATIENT AND METHOD

We report a case of a 4-year-old girl with complex heart disease who was presented with arterial ischemic stroke at the right distal internal carotid artery and successfully treated by stent insertion in which repeated thrombolysis or ballooning had failed.

RESULT

Left hemiparesis was nearly recovered 6 days after the stent insertion. The mean flow velocity of the right middle cerebral artery has slightly improved compared to that of the initial study. She has been followed-up for 6 months in the outpatient clinic without neurologic sequelae.

CONCLUSION

This case suggests that intracranial stent insertion may be a safe and an effective modality in young children, when the thrombolytic therapy or ballooning is inapplicable. Additionally, transcranial Doppler ultrasonography is useful to monitor the cerebral blood flow after stent insertion in children.

Stroke recurrence in children with congenital heart disease

OBJECTIVE

Pediatric arterial ischemic stroke (AIS) carries an important morbidity and mortality burden. Congenital heart disease (CHD) is among the most important risk factors for pediatric AIS. Data on stroke recurrence in childhood CHD are lacking, resulting in uncertainty regarding optimal strategies for preventing recurrence.

METHODS

In the Canadian Pediatric Ischemic Stroke Registry-Toronto site, we identified children (birth to 18 years) with CHD diagnosed with AIS during 1992-2008. Data were abstracted from both stroke and cardiac surgery databases. Time-dependent outcomes (death and recurrent stroke) following sentinel stroke were parametrically modeled in competing risk analysis. Factors predicting stroke recurrence in parametric survival models were sought in parametric survival model analyses using backward variable selection of variables.

RESULTS

A total of 135 patients (19 with recurrence, 116 without recurrence) were studied. In competing risk analysis, 10 years following sentinel stoke, 27% had experienced a stroke recurrence, 26% had died, and 47% were alive and free from recurrence. Stroke recurrence risk decreased over time from sentinel stroke. Approximately 50% of patients were receiving anticoagulation at recurrence. Significant factors associated with recurrence included the presence of a mechanical valve, prothrombotic condition, and an acute infection at the time of sentinel stroke. Hazard of mortality after recurrence was similar to mortality after sentinel stroke (hazard ratio, 1.3; p = 0.75).

INTERPRETATION

Stroke recurrence was relatively common in neonates and children with CHD. Identified groups of patients at increased risk may require more aggressive secondary prophylaxis, especially in the early poststroke period.

Imaging findings and cerebral perfusion in arterial ischemic stroke due to transient cerebral arteriopathy in children

We report the case of a 4-year-old female child who developed an arterial ischemic stroke in the left middle cerebral artery territory, due to a proximal stenosis of the supraclinoid internal carotid artery, most probably related to transient cerebral arteriopathy of childhood. Computed tomography scan, magnetic resonance imaging, perfusion magnetic resonance and magnetic resonance angiography are presented, as well as follow-up by magnetic resonance and magnetic resonance angiography exams. Changes in cerebral perfusion and diffusion-perfusion mismatch call attention. As far as we know, this is the first report of magnetic resonance perfusion findings in transient cerebral arteriopathy.

Sibling cases of moyamoya disease having homozygous and heterozygous c.14576G>A variant in RNF213 showed varying clinical course and severity

Moyamoya disease (MMD) is a rare cerebrovascular disease characterized by progressive occlusion of the terminal portion of the internal carotid arteries and their branches. A genetic background was under speculation, because of the high incidence of familial occurrence. Sibling cases usually exhibit a similar clinical course. Recently, RNF213 was identified as the first MMD susceptibility gene. The c.14576G>A variant of RNF213 significantly increases the MMD risk, with an odds ratio of 190.8. Furthermore, there is a strong association between clinical phenotype and the dosage of this variant. The present study described sibling MMD cases having homozygous and heterozygous c.14576G>A variant in RNF213, as well as different clinical course and disease severity. The homozygote of c.14576G>A variant showed an early onset age and rapid disease progress, which resulted in significant neurological deficits with severe and wide distribution of vasculopathy. In contrast, the heterozygote of the variant showed a relatively late-onset age and mild clinical course without irreversible brain lesions with limited distribution of vasculopathy. This is the first report of sibling MMD cases with different doses of the RNF213 variant, showing its genetic impact on clinical phenotype even in members with similar genetic background.

Decompressive hemicraniectomy for ischemic stroke in the pediatric population

Adult patients with space-occupying hemispheric infarctions have a poor prognosis, with an associated fatality rate of 80%. Decompressive hemicraniectomy (DH) has been studied as a treatment option for patients with malignant cerebral infarction refractory to maximal medical therapy, with reasonable outcomes demonstrated in the adult population if the patient is decompressed within 48 h. However, there are no randomized controlled trials in the pediatric literature to make the same claims. In this study, we evaluated the current literature in regards to DH following malignant stroke in the pediatric population. We found that excellent recovery, with an acceptable quality of life, is possible, particularly in the pediatric patient. Our cohort suggests that pediatric intervention beyond the 48-h time interval may still lead to positive outcomes, unlike adult patients. Regardless, randomized controlled trials are needed to determine optimal timing of intervention following symptom onset, as well as to identify predictors for positive outcome in the pediatric population.

Inherited thrombophilia in pediatric ischemic stroke: an Egyptian study

Pediatric stroke is relatively uncommon, with often subtle clinical presentations. Numerous predisposing risk factors can be both inherited and acquired, including cardiac disease, vascular abnormalities, infectious diseases, collagen tissue diseases, inborn errors of metabolism, anticardiolipin antibody, lupus anticoagulant, deficiencies of protein C, protein S, antithrombin, or plasminogen, and prothrombotic mutations. We explored risk factors, clinical features, and neuroimaging among Egyptian children with ischemic stroke, and estimated the prevalence of inherited thrombophilia. We included 20 children with ischemic stroke, recruited from the Pediatric Neurology Outpatient Clinic (Ain Shams University). Basic clinical evaluations for stroke and genotyping for factor V 1691 G-A (factor V Leiden), prothrombin 20210 G-A mutations, and methylenetetrahydrofolate reductase 677 C-T polymorphisms were performed using real-time polymerase chain reaction, with fluorescent melting curve detection analysis. Ten patients (50%) manifested methylenetetrahydrofolate reductase polymorphisms (six homozygotes and four heterozygotes). Heterozygous factor V Leiden was present in five (25%), whereas prothrombin mutation was present in only one (5%). Five patients (25%) manifested combined prothrombotic abnormalities. Thirteen demonstrated evidence of inherited thrombophilic disorder; 25% manifested more than one mutation. For appropriate risk assessment, even in the presence of overt acquired thrombotic risk factors, physicians should request complete thrombophilia screening for patients with stroke.

The course of unilateral intracranial arteriopathy in young adults with arterial ischemic stroke

BACKGROUND AND PURPOSE

Unilateral intracranial focal nonprogressive arteriopathy is often found in children with arterial ischemic stroke. We aimed to investigate the course of unilateral intracranial arteriopathy in young adults.

METHODS

We searched the Utrecht Stroke Database for patients between 16 and 50 years of age diagnosed with anterior circulation arterial ischemic stroke and a nonatherosclerotic, unilateral intracranial large-artery arteriopathy between 1991 and 2005. We assessed clinical features, potential causes, risk factors, extent of infarction and arteriopathy at presentation, long-term angiographic course, and clinical outcome.

RESULTS

Of 356 patients with anterior circulation arterial ischemic stroke, 17 (5%) had a documented unilateral intracranial arteriopathy, of whom 14 could be included for follow-up investigations (median age, 34 years; range, 27-49 years). Median duration of follow-up was 8.8 years (range, 1.7-12.8 years). In 11 patients, onset of symptoms was not abrupt. The arteriopathy normalized completely in 5 and improved in 3 patients; in none of the patients did the arteriopathy worsen. Two of 14 patients had recurrent symptoms. Ten patients (71%) had a good outcome (modified Rankin Scale score≤2).

CONCLUSIONS

In young adults, arterial ischemic stroke is rarely caused by a unilateral intracranial arteriopathy. Similar to children, onset of symptoms in young adults is often not abrupt and the arteriopathy may improve over time. Late recurrences were rare. Possibly, a monophasic inflammatory process, as has been suggested for childhood intracranial focal nonprogressive arteriopathies, also occurs in young adults.

Risk factors and clinical outcomes of childhood ischemic stroke in a single Korean tertiary care center

A 10-year, retrospective review of the risk factors and clinical outcome of childhood ischemic stroke treated in a single tertiary care center was conducted. Sixty-two children were identified (33 boys and 29 girls), ages 1 month to 17 years. Risk factors included vasculopathy (35.5%), cardiac disease (17.4%), metabolic disorder (14.5%), infection (14.5%), and coagulopathy (1.6%). Nine patients (14.5%) had no identifiable cause of stroke and 1 patient had 2 risk factors. Hemiplegia (69.3%) and seizures (32.3%) were the most common presenting features, and seizures were significantly more frequent in children <12 months of age than in older children (71.4% vs 20.8%, P = .001). Recurrence of stroke occurred in 55.6% of patients with metabolic disorder, 33.3% of those with cardiac disease, and 19.0% of those with vasculopathy. Vasculopathy including moyamoya disease was the most important risk factor for ischemic stroke in Korea, and their prognosis were varied with the etiology of stroke.

Towards a consensus-based classification of childhood arterial ischemic stroke

BACKGROUND AND PURPOSE

The implementation of uniform nomenclature and classification in adult arterial ischemic stroke (AIS) has been critical for defining outcomes and recurrence risks according to etiology and in developing risk-stratified treatments. In contrast, current classification and nomenclature in childhood AIS are often overlapping or contradictory. Our purpose was to develop a comprehensive consensus-based classification system for childhood AIS.

METHODS

Using a modified-Delphi method, members of the International Pediatric Stroke Study (IPSS) developed the Childhood AIS Standardized Classification And Diagnostic Evaluation (CASCADE) criteria. Two groups of pediatric stroke specialists from the IPSS classified 7 test cases using 2 methods each: (1) classification typical of the individual clinician's current clinical practice; and (2) classification based on the CASCADE criteria. Group 1 underwent in-person training in the utilization of the CASCADE criteria. Group 2 classified the same cases via an online survey, including definitions but without training. Inter-rater reliability (IRR) was assessed via multi-rater unweighted κ-statistic.

RESULTS

In Group 1 (with training), IRR was improved using CASCADE criteria (κ=0.78, 95% CI=[0.49, 0.94]), compared with typical clinical practice (κ=0.40, 95% CI=[0.11, 0.60]). In Group 2 (without training), IRR was lower than among trained raters (κ=0.61, 95% CI=[0.29, 0.77]), but higher than current practice (κ=0.23, 95% CI=[0.03, 0.36]).

CONCLUSIONS

A new, consensus-based classification system for childhood AIS, the CASCADE criteria, can be used to classify cases with good IRR. These preliminary findings suggest that the CASCADE criteria may be particularity useful in the setting of prospective multicenter studies in childhood-onset AIS, where standardized training of investigators is feasible.

Intracranial dissection mimicking transient cerebral arteriopathy in childhood arterial ischemic stroke

Transient cerebral arteriopathy is a frequent cause of childhood arterial ischemic stroke. Differentiating this condition from intracranial carotid artery dissection is challenging but important for initial treatment. We describe 4 cases from the International Pediatric Stroke Study of intracranial carotid artery dissection, initially misdiagnosed as transient cerebral arteriopathy. Presentations were abrupt, with focal neurological deficits in 4, preceding headache in 3, and minor trauma in 1. Infarcts involved the anterior circulation, and magnetic resonance angiography showed unilateral arterial stenosis/occlusion. None had evidence of dissection. All received anticoagulation or thrombolysis. Three died from refractory intracranial hypertension. Intracranial carotid artery dissection was confirmed postmortem (n = 3) and on dedicated MR wall imaging showing intramural hematoma (n = 1). In differentiating transient cerebral arteriopathy from intracranial carotid artery dissection, routine magnetic resonance angiography is unreliable and adjunctive conventional angiography, gadolinium magnetic resonance angiography, or dedicated MRI wall imaging should be considered.

Childhood hemorrhagic stroke: an important but understudied problem

Hemorrhagic stroke in children occurs more frequently than is commonly appreciated. There are important differences in the factors associated with hemorrhagic stroke in children when compared with adults. These differences likely play a role in the different outcomes, which tend to worsen with age. In this review, we describe the estimated frequency, clinical presentation, acute management of hemorrhagic stroke, and an overview of rehabilitation techniques. We identify key topics for future basic and clinical research. Findings from future studies will help improve our ability to optimize treatment for and long-term rehabilitation of these patients.