Stroke in children

Etiologic Profile of Childhood Stroke from North India: Is It Different from Developed World?

OBJECTIVE

To describe the etiology of childhood arterial-ischemic stroke from a developing country and assess short-term neurologic outcome.

METHODS

Prospective observational study. Consecutive children between the age of >28 days to <12 years, admitted with the diagnosis of arterial-ischemic stroke were enrolled during the study period from January 2017 to December 2018. Short-term neurologic outcome was assessed with Pediatric Cerebral Performance Category (PCPC) scale and Pediatric Stroke Outcome Measure (PSOM).

RESULTS

We enrolled 76 children with arterial-ischemic stroke, with a median age of 24 months (interquartile range 12-69), and 43 (57%) were boys. The most common risk factor for childhood arterial-ischemic stroke was arteriopathy in 59 (77%), followed by cardiovascular disorder in 12 (16%) children. Among 59 children with arteriopathy, 32 (42%) had infection-associated arteriopathies, 10 (13%) had mineralizing angiopathy, 10 (13%) had moyamoya disease. Pediatric stroke risk factors were classified according to Pediatric Stroke Classification and CASCADE primary classification. Short-term neurologic outcome was assessed at 3 months in 62 (82%) survivors. Among stroke survivors, 33 (61%) had sensory-motor deficits, and 24 (39%) had severe neurologic disability (PCPC ≥ 4). The presence of fever, encephalopathy, low Glasgow coma score at presentation, seizures, and infection-associated arteriopathy predicted severe neurologic disability at follow-up.

CONCLUSION

The risk factors for pediatric arterial-ischemic stroke are different from developed countries in our cohort. Infection-associated arteriopathies, mineralizing angiopathy, and moyamoya disease are the most common risk factors in our cohort. Two-thirds of pediatric stroke survivors have neurologic disability at short-term follow-up.

Ischemic Stroke in a 6-Month-Old Child Presenting with Hemiplegia: A Rare Case Report

Ischemic stroke is a clinical condition resulting from a decrease in blood flow to the brain. It is rare in children, especially more rare in infants. The symptoms in the patients vary according to the age of the patient and the affected vessel. Diagnosis of pediatric stroke is not simple and requires neuroimaging reference. If the diagnosis is delayed and the treatment is not started as soon as possible, the probability of disability or death of the patient increases. In this report, we present a 6-month-old girl with hemiplegia, who was admitted to the emergency department with a complaint of not able to move her left side and who was diagnosed as ischemic stroke. Our case is the youngest ischemic stroke detected in infant period that we know of in the literature. In this case report, we aimed to remind that ischemic stroke is one of the causes of neurological symptoms occurring during infant period.

Contribution of Sickle Cell Disease to the Pediatric Stroke Burden Among Hospital Discharges of African-Americans-United States, 1997-2012

BACKGROUND

Approximately 10-20% of children with sickle cell disease (SCD) develop stroke, but few consistent national estimates of the stroke burden for children with SCD exist. The purpose of this study is to determine the proportion of diagnosed stroke among African-American pediatric discharges with and without SCD.

PROCEDURE

Records for African-Americans aged 1-18 years in the Kids' Inpatient Database (KID) 1997-2012 with ≥1 ICD-9-CM diagnosis code for stroke were included. Data were weighted to provide national estimates. A total of 2,994 stroke cases among African-American children were identified. Diagnoses co-existing with ischemic or hemorrhagic stroke were frequency ranked separately.

RESULTS

From 1997 through 2012, SCD was present in 24% of stroke discharges, with 89% being ischemic stroke. For hospital discharges of African-American children, SCD is the highest co-existing risk factor for ischemic stroke (29%). Stroke in children with SCD occurred predominantly in children aged 5-9 years, older than previously reported. The trend of stroke discharges significantly decreased for children with SCD from 1997 to 2012 for children aged 10-14 years.

CONCLUSIONS

SCD is a leading risk factor to pediatric stroke in African-American children. Reducing the number of strokes among children with SCD would have a significant impact on the rate of strokes among African-American children. Preventative intervention may be modifying initial age of presentation of stroke in children with SCD.

Hypoxia recruits intrapulmonary arteriovenous pathways in intact rats but not isolated rat lungs

Intrapulmonary arteriovenous anastomoses (IPAVS) directly connect the arterial and venous circulations in the lung, bypassing the capillary network. Here, we used solid, latex microspheres and isolated rat lung and intact, spontaneously breathing rat models to test the hypothesis that IPAVS are recruited by alveolar hypoxia. We found that hypoxia recruits IPAVS in the intact rat, but not the isolated lung. IPAVS are at least 70 μm in the rat and, interestingly, appear to be recruited when the mixed venous Po(2) falls below 22 mmHg. These data provide evidence that large-diameter, direct arteriovenous connections exist in the lung and are recruitable by hypoxia in the intact animal.

Pediatric stroke: a review

Stroke is relatively rare in children, but can lead to significant morbidity and mortality. Understanding that children with strokes present differently than adults and often present with unique risk factors will optimize outcomes in children. Despite an increased incidence of pediatric stroke, there is often a delay in diagnosis, and cases may still remain under- or misdiagnosed. Clinical presentation will vary based on the child's age, and children will have risk factors for stroke that are less common than in adults. Management strategies in children are extrapolated primarily from adult studies, but with different considerations regarding short-term anticoagulation and guarded recommendations regarding thrombolytics. Although most recommendations for management are extrapolated from adult populations, they still remain useful, in conjunction with pediatric-specific considerations.

Pediatric stroke: clinical findings and radiological approach

This paper focuses on radiological approach in pediatric stroke including both ischemic stroke (Arterial Ischemic Stroke and Cerebral Sinovenous Thrombosis) and hemorrhagic stroke. Etiopathology and main clinical findings are examined as well. Magnetic Resonance Imaging could be considered as the first-choice diagnostic exam, offering a complete diagnostic set of information both in the discrimination between ischemic/hemorrhagic stroke and in the identification of underlying causes. In addition, Magnetic Resonance vascular techniques supply further information about cerebral arterial and venous circulation. Computed Tomography, for its limits and radiation exposure, should be used only when Magnetic Resonance is not available and on unstable patients.

Diagnosis and management of pediatric arterial ischemic stroke

Pediatric stroke is among the top 10 causes of death in children and an important cause of chronic morbidity, with an incidence of 3.3/100,000 children/year. Risk factors associated with stroke in children include cardiac diseases, hematologic and vascular disorders, and infection. Clinical presentation varies depending on age, underlying cause, and stroke location. Antithrombotics and anticoagulants are used in the treatment of pediatric stroke; however, there are no established guidelines for the use of these agents in children. In this article we review the cause, pathophysiology, clinical presentation, diagnosis, acute management, secondary prevention, and outcome of children with stroke. The approach to patients with sickle cell disease and Moyamoya disease is also discussed. Up to date studies to determine the optimal acute treatment of childhood stroke and secondary prevention and risk factor modification are critically needed.

Managing stroke in children

The incidence of stroke in the pediatric population is estimated at between 2 and 3 per 100,000. Strokes are divided into ischemic or hemmorhagic categories, depending on whether the primary cause is obstruction or bleeding into the brain. Strokes may present with acute, recurrent, or evolving neurological deficits. There is a long and varied list of causes of stroke in children. The major causes of ischemic stroke are cardiac abnormalities and coagulation disorders. Cerebrovascular malformations account for the majority of hemmorhaghic strokes. The workup is guided by the initial history and imaging studies. Treatment is dependent on the specific risk factors identified, and outcome is dependent on the location and extent of the initial insult.

Childhood ischemic stroke in a nonurban population

A 10-year, retrospective review of the etiology, outcome, and complications of ischemic stroke in children from a nonurban population was conducted. Twenty-seven children were identified (14 boys, 13 girls), ages 1.25 to 17 years (mean 7.7 years). Etiologies included undetermined (22%), arterial dissection (19%), coagulopathy (15%), embolism (15%), moyamoya disease (11%), sickle cell disease (11%), isolated angiitis of the central nervous system or vasculitis (11%), or other known source (11%; two fibromuscular dysplasia, one L-asparaginase). More than one risk factor was present in five children. Seventeen (65%) children were anticoagulated, with no adverse events occurring. Nine children were anticoagulated initially with low-molecular-weight heparin. Other treatments included corticosteroids; physical, occupational, and speech therapy; and anticonvulsants for concomitant seizures. Follow-up ranged from 3 to 60 months (mean 17 months) and was as follows: 6 (22%) were normal, 9 (33%) had mild impairment, and 12 (44%) had moderate to severe deficits. There were no deaths. Neurologic complications included seizure (two), behavioral problems (two), and hemorrhagic conversion (one). In this population, the outcome from ischemic stroke was similar to that of other studies, with the majority of children demonstrating persistent neurologic deficits. Etiology could be determined for the majority of patients, with 19% having more than one risk factor.

Occurrence of intracerebral aneurysm in an HIV-infected child: a case report

A 12-year-old female diagnosed with human immunodeficiency virus infection at age 1 was admitted to our hospital with complaints of headache, left hemiparesis, and blurry vision. On admission, her CD4+ count was 97 cells/mm(3) (13%) and her viral load 44,783 ribonucleic acid copies/mL. Treatment had been initiated 3 months before admission with lopinavir/ritonavir, lamivudine, and stavudine. A computed tomographic scan and magnetic resonance imaging of the head revealed an aneurysm of the right middle cerebral artery. A head angiographic scan was consistent with intracranial arteritis. Six months after the initiation of antiretroviral therapy, her CD4+ cell count was 226 cells/mm(3) (16%) and her viral load was undetectable (less than 50 copies ribonucleic acid/mL). Magnetic resonance angiography of the head performed 15 months after the diagnosis demonstrated resolution of the aneurysm and the intracranial arteritis. This case highlights the association of human immunodeficiency virus infection with the occurrence of intracerebral aneurysms in the context of human immunodeficiency virus-vasculopathy, as well as its improvement with highly active antiretroviral therapy.