Inherited thrombophilia in childhood arterial stroke: data from Lebanon

Thrombophilia screening in the routine clinical care of children with arterial ischemic stroke

BACKGROUND

Current guidelines recommend thrombophilia evaluation in childhood arterial ischemic stroke, but the impact of screening on management is unknown. The objective of the current study is to report the incidence of thrombophilia identified as part of routine clinical care in the context of available literature reports, and to describe the impact of a diagnosis of thrombophilia on patient management.

METHODS

We conducted a single-institution retrospective chart review for all children with arterial ischemic stroke occurring between January 1, 2009 and January 1, 2021. We collected thrombophilia screening results, stroke etiology, and management. We also reviewed the literature of thrombophilia testing in childhood arterial ischemic stroke published prior to June 30, 2022. Meta-analysis methods were used to assess prevalence rates.

RESULTS

Among children with thrombophilia testing performed, 5% (six of 122 patients) were factor V Leiden heterozygous, 1% (one of 102 patients) were prothrombin gene mutation heterozygous, 1% (one of 122) had protein S deficiency, 20% (23/116 patients) had elevated lipoprotein(a), 3% (three of 110 patients) had elevated homocysteine levels, and 9% (10/112) had elevated antiphospholipid antibodies, only two of whom had persistently elevated levels. There was no change in stroke therapy due to these results. Literature review revealed a wide range of prevalence for most thrombophilia traits, with high cross-study heterogeneity in most cases.

CONCLUSIONS

The rates of thrombophilia in our cohort were consistent with that expected in the general population. The identification of thrombophilia did not alter stroke care. However, some of the results were actionable, prompting evaluation for lipid disorders and patient-specific counseling on cardiovascular risk and risk for venous thrombosis.

Diagnosis of Pediatric Stroke in Resource Limited Settings

Global awareness of stroke as a significant cause of neurologic sequelae and death in children has increased over the years as more data in this field becomes available. However, most published literature on pediatric stroke have limited geographic representation. Data on childhood stroke from developing countries remains limited. Thus, this paper reviewed geographic/ethnic differences in pediatric stroke risk factors highlighting those reported in low- and middle-income countries, and proposes a childhood arterial ischemic stroke diagnostic algorithm for resource limited settings. Stroke risk factors include cardiac disorders, infectious diseases, cerebral arteriopathies, hematologic disorders, inflammatory diseases, thrombophilia and genetic conditions. Infection of the central nervous system particularly tuberculous meningitis, is a leading cause of pediatric arterial ischemic stroke in developing countries. Stroke should be considered in children with acute focal neurologic deficit especially in the presence of aforementioned risk factors. Cranial magnetic resonance imaging with angiography is the neuroimaging modality of choice but if unavailable, cranial computed tomography with angiography may be performed as an alternative. If both are not available, transcranial doppler together with neurologic exam may be used to screen children for arterial ischemic stroke. Etiological diagnosis follows with the aid of appropriate laboratory tests that are available in each level of care. International collaborative research on stroke risk factors that are prevalent in low and middle income countries will provide information for drafting of stroke care guidelines that are universal yet inclusive taking into consideration regional differences in available resources with the goal of reducing global stroke burden.

Does the Occurrence of Particular Symptoms and Outcomes of Arterial Ischemic Stroke Depend on Sex in Pediatric Patients?-A Pilot Study

Arterial ischemic stroke (AIS) in childhood is reported to occur more frequently in boys, which may lead to the assumption that the prevalence of post-stroke deficits is sex related. The present study aimed to evaluate sex-related differences in functional outcomes (hemiparesis, seizures, aphasia, and motor disturbances other than hemiparesis) in pediatric patients with AIS. A total of 89 children (52 boys and 37 girls; mean age at stroke onset: 8.4 ± 5.6 years) were evaluated retrospectively based on data from medical records. The patients were divided into subgroups according to age (i.e., infants and toddlers, children, and adolescents), stroke subtype (i.e., lacunar anterior circulation infarct (LACI), total anterior circulation infarct (TACI), partial anterior circulation infarct (PACI), posterior circulation infarct (POCI)) and stroke location (i.e., anterior stroke, posterior stroke). Significant differences in the prevalence of stroke subtypes between girls and boys were observed (p = 0.034). POCI stroke were found to be more frequent in boys than in girls (OR = 8.57 95%CI 1.05–70.23, p = 0.023). Males predominated in the total group and in all analyzed age subgroups. The proportions of boys within the subgroups according to stroke subtype were extremely high for the POCI and TACI stroke subgroups. On the other hand, girls predominated in the LACI stroke subgroup. Frequency of central type facial nerve palsy and other symptoms of AIS were found to significantly differ between male subgroups according to stroke subtype (p = 0.050 and p < 0.001, respectively), as well as between children with anterior stroke and those with posterior stroke (p = 0.059 and p < 0.001, respectively). Post-stroke seizures appeared significantly more commonly in girls with TACI and POCI stroke than in girls with LACI and PACI stroke (p = 0.022). In turn, the prevalence of post-stroke hemiparesis differed between stroke subtypes in boys (p = 0.026). In conclusion, sex may have an impact in predisposing to a certain type of AIS in the patient. Post-stroke seizure may be related to stroke subtype in girls and hemiparesis in boys. However, further studies are needed to confirm the results.

Risk Factors for Recurrent Arterial Ischemic Stroke in Children and Young Adults

Arterial ischemic stroke (AIS) experienced at a young age is undoubtedly a serious medical problem. AIS very rarely occurs at a developmental age, whereas in young adults, it occurs with a higher frequency. The etiologic mechanisms of AIS occurring in childhood and adulthood differ. However, for both age populations, neurological consequences of AIS, including post-stroke seizures, motor disability, and recurrence of the disease, are connected to many years of care, rehabilitation, and treatment. Recurrent stroke was observed to increase the risk of patients' mortality. One of the confirmed risk factors for recurrent stroke in children is the presence of vasculopathies, especially Moyamoya disease and syndrome, and focal cerebral arteriopathy of childhood (FCA). FCA causes a 5-fold increase in the risk of recurrent stroke in comparison with idiopathic AIS. In turn, young adults with recurrent stroke were found to more often suffer from hypertension, diabetes mellitus, or peripheral artery disease than young patients with first-ever stroke. Some reports also indicate relationships between specific genetic polymorphisms and AIS recurrence in both age groups. The aim of the present literature review was to discuss available data regarding the risk factors for recurrent AIS in children and young adults.

Association Between the 20210G>A Prothrombin Gene Polymorphism and Arterial Ischemic Stroke in Children and Young Adults-Two Meta-analyses of 3586 Cases and 6440 Control Subjects in Total

BACKGROUND

Previous data have shown that the 20210G>A polymorphism of the Factor II gene is related to an increased prothrombin level, which may in turn lead to a procoagulant state. The heterogeneous and multifactorial character of arterial ischemic stroke often results in contradictory reports describing the association between the 20210G>A polymorphism and arterial ischemic stroke in different populations. We performed a meta-analysis of available data addressing the relation between the FII 20210G>A polymorphism and arterial ischemic stroke, both in young adults and children.

METHODS

We searched PubMed using appropriate keywords. The inclusion criteria for the study were as follows: case-control study, study population consisting of children, study population consisting of young adults, arterial ischemic stroke confirmed by magnetic resonance imaging or computed tomography, and English language. The exclusion criteria included lack of genotype or allele frequencies, study design other than a case-control study, outcome definition other than arterial ischemic stroke, and previously overlapped patient groups. Finally, 30 case-control studies (14 in children and 16 in young adults) were included. Statistical analyses were conducted using R software. Heterogeneity between the studies was evaluated using the Dersimonian and Laird's Q test. In the case of significant between-studies heterogeneity, the pooled odds ratio was estimated with a random-effects model, otherwise a fixed-effects model was used.

RESULTS

The pooled analysis showed that carriers of 20210A allele (GA+AA genotypes) of the prothrombin gene are more common in arterial ischemic stroke patients, both in children and young adults, than in control subjects (P = 0.006; odds ratio, 1.83; 95% confidence interval, 1.19 to 2.80 and P = 0.001; odds ratio, 1.69; 95% confidence interval, 1.25 to 2.28, respectively).

CONCLUSIONS

The results of the present meta-analysis have proven that the FII 20210G>A polymorphism is associated with arterial ischemic stroke in both pediatric and young adult patients.

Clinical presentation, etiology, and outcome of stroke in children: A hospital-based study

AIM

To describe clinical presentations, etiologies, and outcomes of stroke in Jordanian children.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of children diagnosed with ischemic stroke who presented to our clinic from January 2001 to June 2014. Patients with onset of stroke in the neonatal period were excluded.

RESULTS

Twenty-four children (12 boys and 12 girls, with a male to female ratio of 1:1) were included in this study. The follow-up period ranged from 1 month to 9 years. Age at onset of the first stroke ranged from 1 month to 13 years. The most common initial clinical presentation was hemiparesis (58.3%). A known etiology was identified in 58.3% of patients. The most common etiologies were metabolic disorders, such as mitochondrial encephalopathy lactic acidosis and stroke (MELAS) and homocystinuria (25%), cardiac disorders (17%), and coagulopathy, such as a homozygous mutation in the MTHFR gene and a factor V Leiden mutation (17%). Recurrence of both clinical and silent strokes occurred in 46% of patients, residual motor weakness occurred in 58.3%, and residual epilepsy occurred in 29.2%.

CONCLUSION

Metabolic disorders, cardiac disorders, and coagulopathy are the causes of strokes in Jordanian children. Our results emphasized the importance of inherited disorders in Jordan.

Interactions between age, sex, and hormones in experimental ischemic stroke

Age, sex, and gonadal hormones have profound effects on ischemic stroke outcomes, although how these factors impact basic stroke pathophysiology remains unclear. There is a plethora of inconsistent data reported throughout the literature, primarily due to differences in the species examined, the timing and methods used to evaluate injury, the models used, and confusion regarding differences in stroke incidence as seen in clinical populations vs. effects on acute neuroprotection or neurorepair in experimental stroke models. Sex and gonadal hormone exposure have considerable independent impact on stroke outcome, but these factors also interact with each other, and the contribution of each differs throughout the lifespan. The contribution of sex and hormones to experimental stroke will be the focus of this review. Recent advances and our current understanding of age, sex, and hormone interactions in ischemic stroke with a focus on inflammation will be discussed.

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.