Inherited prothrombotic risk factors in children with first ischemic stroke

Risk factors for pediatric ischemic stroke and intracranial hemorrhage: A national electronic health record based study

Background

Stroke is an important cause of morbidity in pediatrics. Large studies are needed to better understand the epidemiology, pathogenesis and risk factors associated with pediatric stroke. Large administrative datasets can provide information on risk factors in perinatal and childhood stroke at low cost. The aim of this hypothesis-generating study was to use a large administrative dataset to assess for prevalence and odds-ratios of rare exposures associated with pediatric stroke.

Methods

The data for patients aged 0-18 with a diagnosis of either ischemic stroke or intracranial hemorrhage were extracted from the Cerner Health Facts EMR Database from 2000 to 2018. Prevalence of various possible risk factors for pediatric and adult stroke was assessed using ICD 9 and 10 codes. Odds ratios were calculated using a control group of patients without stroke.

Results

10,688 children were identified with stroke. 6339 (59 %) were ischemic and 4349 (41 %) were hemorrhagic. The most frequently identified risk factors for ischemic stroke across age groups were hypertension (29-44 %), trauma (19-33 %), and malignancy (11-24 %). The most common risk factors seen with hemorrhagic stroke were trauma (32-64 %), malignancy (5-19 %) and arrhythmia (9-12 %). Odds ratios across all age groups for dyslipidemia (17-64), hypertension (20-63), and tobacco exposure (3-59) were high in the ischemic stroke cohort.

Conclusion

This is the largest retrospective study of pediatric stroke of its kind from hospitals across the US in both academic and non-academic clinical settings. Much of our data was consistent with prior studies. ICD codes for tobacco exposure, hyperlipidemia, diabetes, and hypertension all had high odds ratios for stroke in children, which suggest a relationship between these conditions and pediatric stroke. However, ascertainment bias is a major concern with electronic health record-based studies. More focused study is needed into the role of these exposures into the pathogenesis of pediatric stroke.

Inherited Thrombophilia Associated With Ischemic Pediatric Stroke in Parent-Child Pairs

BACKGROUND

We aimed to examine inherited thrombophilia frequencies by extending genetic profile to previously rarely or not investigated polymorphisms in children with ischemic pediatric stroke (IPS) and their parents.

METHODS

The study included 33 children: 23 with perinatal arterial ischemic stroke (PAIS), eight with childhood arterial ischemic stroke (CAIS), and two with sinovenous thrombosis and their parents (33 mother-child, 12 father-child, and 12 mother-father-child pairs). Genotyping of FV-Leiden, FV-H1299R, FII-G20210A, β-fibrinogen-455G>A, FXIII-A-Val34Leu, PAI-1(4G/5G), HPA-1, MTHFR-C677T, MTHFR-A1298C, ACE(I/D), and APOE(ε2-4) was performed using CVD Strip assay (ViennaLab, Austria).

RESULTS

At least one and up to seven simultaneously present polymorphisms were observed in all children with IPS, mothers, and fathers. More than five simultaneously present polymorphisms were identified threefold more frequently in children with IPS (10 of 33; 30%) compared with the child control group (17 of 150; 11%), yielding a statistically significant difference between the two groups (odds ratio [OR] = 3.40; 95% confidence interval [CI] = 1.39 to 8.35; P = 0.012). Stronger association was revealed for PAIS (OR = 4.17; 95% CI = 1.55 to 11.29; P = 0.008) and CAIS subgroups (OR = 7.82; 95% CI = 1.79 to 34.20; P = 0.012). Complete match of polymorphisms was not identified in any parent-child pair. A partial match (one to four mutual polymorphisms) was found in 11 of 12 parent-child pairs where until three mutual polymorphisms was present in 11 of 12 (91.7%) father-child compared with 21 of 33 (63.6%) mother-child pairs.

CONCLUSIONS

According to obtained results the simultaneous presence of more than five polymorphisms is associated with a higher risk for IPS occurrence, suggesting the risk enhancement for PAIS in the presence of pregnancy complications or for CAIS in conjunction with maternal comorbidity and positive family history. The presence of up to three mutual polymorphisms more frequently in father-child than mother-child pairs suggests significant paternal contribution of inherited thrombophilia to increased risk of IPS.

Risk factors in childhood arterial ischaemic stroke: Findings from a population-based study in Germany

OBJECTIVE

Acute treatment of childhood arterial ischaemic stroke and prevention strategies for recurrent stroke episodes depend strongly on each child's individual risk profile. The aim of this study is to characterize risk factors for childhood stroke, their occurrence in isolation or combination, and to identify possible common risk factor patterns.

METHODS

This population-based study was conducted via ESPED, a surveillance unit for rare paediatric diseases in Germany. Children aged >28days and <18 years with an acute arterial ischaemic stroke occurring between January 2015 and December 2016 were included.

RESULTS

Among 99 reported children with arterial ischaemic stroke, 56 children were male. Male predominance was significant in adolescents from 12 years old onward. Arterial ischaemic stroke was more common in very young children <2 years of age and in adolescence. No risk factor was identified in 27 children. Hypercoagulable states (29%), cardiac disorders (24%), and arteriopathies (21%) were the most common risk factors. Some risk factor categories were more likely to be identified in isolation (i.e. cardiac disorders, prothrombotic abnormalities and chronic head and neck disorders) than others. The number of risk factors (n = 0-4) per patient and risk factor categories did not differ by age.

CONCLUSION

Although we could not identify common patterns of risk factor combinations, several risk factors occurred more likely in isolation than others. Further research should focus on the impact of isolated presumed childhood stroke risk factors like certain prothrombotic abnormalities, migraine or a patent foramen ovale. With regard to different age groups, stroke mechanisms in male adolescents require particular attention.

Is the 1298A>C polymorphism in the MTHFR gene a risk factor for arterial ischaemic stroke in children? The results of meta-analysis

An elevated level of homocysteine is a risk factor for vascular diseases, brain atrophy and several other disorders. The 1298A>C polymorphism (rs1801131) leads to mildly decreased MTHFR activity. Previously, it was observed that the MTHFR 1298A>C polymorphism in combined analysis with the MTHFR 677C>T polymorphism increases homocysteine levels. However, conflicting results on its relation to ischaemic stroke in children can be found. We conducted a meta-analysis to analyse possible connections between the MTHFR 1298A>C polymorphism and ischaemic stroke in paediatric patients. We identified available data published before December 2016 using appropriate keywords and searching PubMed as well as the references cited in the found articles. Eight case-control studies were included in the meta-analysis (426 children with stroke and 778 controls). Statistical analyses were made using R and Comprehensive Meta-Analysis softwares to investigate the impact of polymorphism in four models: dominant, recessive, additive and allelic. No publication bias was observed in the meta-analysis. We demonstrated no relationship between the 1298A>C polymorphism and ischaemic stroke in children in the case of recessive, additive and allelic models. However, the results of the dominant model analysis should be treated with caution due to the sensitivity analysis results. After omitting one of the included study, we observed a significant association between the carriers of the MTHFR C allele (cases with AC + CC genotypes) and ischaemic stroke in children (OR 1.35 95% CI 1.02-1.79, p = 0.035 in a fixed effects model). In conclusion, the 1298A>C polymorphism in the MTHFR gene is not a risk factor for ischaemic stroke in paediatric patients.

Cilioretinal artery: Vasculogenesis might be promoted by plasminogen activator inhibitor-1 5G allele

BACKGROUND

Cilioretinal arteries (CAs) represent enlargements of microscopic and early established collaterals formed via vasculogenesis between choroidal and retinal circulations. We aimed to investigate whether genetic tendency to thrombosis due to well-known gene polymorphisms may induce CA vasculogenesis in embryonic life.

METHODS

We assessed plasminogen activator inhibitor-1 (PAI-1) 4G/5G, methylenetetrahydrofolatereductase (MTHFR), FACTOR V LEIDEN and PROTHROMBIN gene polymorphisms on 130 patients [82/48 females/males; Median age: 57 (18-84) with visible CAs and 100 (64/36: female/male; Median age: 55 (19-90)] without visible CAs.

RESULTS

Using multiple logistic regression models, we found PAI-1 4G/5G; MTHFR (C677T and A1298C) polymorphisms to have significant effects on the probability of visible CAs, that having at least one 5G allele would increase the odds of having visible cilioretinal artery by 98.4% [Odds ratio: 1984 (95% CI: 1.320-3.000, p = 0.001)], and having at least one MTHFR C677T or A1298C allele would decrease the odds of having visible CAs by approximately 38% (OR = 0.618, 95% CI: 0.394-0.961, p = 0.035) or 44% (OR = 0.558, 95% CI: 0.354-0.871, p = 0.011), respectively.

CONCLUSIONS

This is the first study to test the existence of significant association between presence of enlarged and visible CAs and genetic factors predisposing to thrombosis, according to the literature. Here we suggest that not only the lack of genetic predisposition to thrombosis by MTHFR gene polymorphisms, but also the PAI-1 5G allele might promote vasculogenesis of CAs.

Association of Polymorphisms in Coagulation Factor Genes and Enzymes of Homocysteine Metabolism With Arterial Ischemic Stroke in Children

Despite the identification of a wide range of inherited and acquired risk factors for arterial ischemic stroke (AIS) in children, genetic risk factors are incompletely characterized and may vary among different populations. We investigated the role of individual and combined inherited prothrombotic and intermediate-risk factors in 73 children with perinatal (n = 35) and childhood AIS (n = 38) and 100 age- and sex-matched controls. Ten polymorphisms in 8 candidate genes encoding coagulation and fibrinolytic proteins (factor V [FV] Leiden, FV HR2, factor II [FII] G20210A, β-fibrinogen [β-FBG]-455G>A, factor XIII [FXIII]-A p.Val34Leu, plasminogen activator inhibitor 1 4G/5G), homocysteine metabolism (methylenetetrahydrofolate reductase [MTHFR] C677T, MTHFR A1298C), and intermediate-risk factors (angiotensin-converting enzyme I/D, apoE ∊2-4) were detected using a multilocus genotyping assay. Allele-specific polymerase chain reaction was used for the determination of human platelet alloantigens (HPA-1, HPA-2, HPA-3, and HPA-5). Factor V Leiden was associated with an increased risk of AIS (odds ratio [OR]: 4.72, 95% confidence interval [CI]: 1.22-18.27) and perinatal AIS (OR: 8.29, 95% CI: 1.95-35.24). Human platelet antigen-3b allele carriers had a 2-fold lower risk of AIS (OR: 0.51, 95% CI: 0.26-0.98) and perinatal AIS (OR: 0.40, 95% CI: 0.18-0.92). A 2.21-fold increased risk of childhood AIS (95% CI: 1.03-4.73) was identified in FXIII-A Leu34 allele carriers. Combined FV Leiden/FV HR2, FV Leiden/MTHFR A1298C, FV Leiden/MTHFR C677T/MTHFR A1298C, and FV Leiden/FV HR2/MTHFR A1298C heterozygosity was identified in children with AIS but not in controls, which revealed a statistically significant difference. This case-control study shows that besides already documented association between FV Leiden and AIS, other previously unreported polymorphisms (FXIII-A p.Val34Leu, HPA-3) and several genotype combinations that always include heterozygous FV Leiden can be related to AIS in Croatian population.

Paediatric arterial ischemic stroke: acute management, recent advances and remaining issues

Stroke is a rare disease in childhood with an estimated incidence of 1-6/100.000. It has an increasingly recognised impact on child mortality along with its outcomes and effects on quality of life of patients and their families. Clinical presentation and risk factors of paediatric stroke are different to those of adults therefore it can be considered as an independent nosological entity. The relative rarity, the age-related peculiarities and the variety of manifested symptoms makes the diagnosis of paediatric stroke extremely difficult and often delayed. History and clinical examination should investigate underlying diseases or predisposing factors and should take into account the potential territoriality of neurological deficits and the spectrum of differential diagnosis of acute neurological accidents in childhood. Neuroimaging (in particular diffusion weighted magnetic resonance) is the keystone for diagnosis of paediatric stroke and other investigations might be considered according to the clinical condition. Despite substantial advances in paediatric stroke research and clinical care, many unanswered questions remain concerning both its acute treatment and its secondary prevention and rehabilitation so that treatment recommendations are mainly extrapolated from studies on adult population. We have tried to summarize the pathophysiological and clinical characteristics of arterial ischemic stroke in children and the most recent international guidelines and practical directions on how to recognise and manage it in paediatric emergency.

Cerebral infarction and femoral venous thrombosis detected in a patient with diabetic ketoacidosis and heterozygous factor V Leiden G1691A and PAI-1 4G/5G mutations

Cerebral infarction is one of the serious neurological complications of diabetic ketoacidosis (DKA). Especially in patients who are genetically prone to thrombosis, cerebral infarction may develop due to inflammation, dehydration, and hyperviscocity secondary to DKA. A 6-year-old child with DKA is diagnosed with cerebral infarction after respiratory insufficiency, convulsion, and altered level of consciousness. Femoral and external iliac venous thrombosis also developed in a few hours after central femoral catheter had been inserted. Heterozygous type of factor V Leiden and PAI-14G/5G mutation were detected. In patients with DKA, cerebral infarction may be suspected other than cerebral edema when altered level of consciousness, convulsion, and respiratory insufficiency develop and once cerebral infarction occurs the patients should also be evaluated for factor V Leiden and PAI-14G/5G mutation analysis in addition to the other prothrombotic risk factors.

Systematic review: hereditary thrombophilia associated to pediatric strokes and cerebral palsy

OBJECTIVES

This review aimed to organize and consolidate the latest knowledge about mutations and genetic polymorphisms related to hereditary thrombophilia and their potential association with pediatric stroke and cerebral palsy (CP).

SOURCES

Scientific articles published from 1993 to 2013, written in Portuguese, English, French, and Spanish, were selected and reviewed. The publications were searched in electronic databases, and also in the collections of local libraries. The terms "hereditary thrombophilia", "polymorphisms", "mutation", "pediatric strokes", and "cerebral palsy" were used for the research.

SUMMARY OF THE FINDINGS

The search in databases and in the bibliographic references retrieved 75 articles for inclusion in this review. Studies that investigated hereditary thrombophilias and their associations to CP and arterial and venous pediatric stroke presented contradictory results. The meta-analysis and case-control studies that showed positive results for this association described only slightly increased relative risks and sometimes had questionable conclusions. The association of two or more hereditary thrombophilias, or the association between thrombophilia and other specific clinical risk factors, suggest a higher risk of CP and pediatric stroke than isolated hereditary thrombophilia.

CONCLUSIONS

Larger, multicenter studies should be developed in order to elucidate the role of mutations leading to hereditary thrombophilia and the development of CP and pediatric stroke. The complex and multifactorial etiology of CP and stroke makes this an arduous and difficult task; however, the benefits generated by these studies are immeasurable.

The role of biochemical risk factors in the etiology of AIS in children and adults

Stroke is an abrupt onset of both focal and global neurological deficits secondary to a vascular event lasting more than 24 h and with a vascular background as its only cause. It can be triggered by a rupture of a blood vessel, aneurysm (hemorrhagic stroke, HS), thrombosis or embolisms (ischemic stroke, IS). In developed countries, it is the third most common cause of death in the adult population. Stroke in children is a rare disorder with a reported frequency of about 3 cases per 100,000 children per year. The history of acute brain ischemia is burdened with neurological complications such as motor impairment, speech impairment and intellectual delay. Moreover, in children after AIS seizures and epilepsy are also quite common. Stroke is a heterogeneous disorder; its risk factors in adults are well known, however, in pediatrics, in more than 20% cases, the cause of stroke is impossible to determine. Due to the fact that stroke usually arises as a consequence of the cerebral thrombosis, many of the mechanisms responsible for its occurrence can be considered as risk factors. We have reviewed the recent case-control studies conducted on pediatric patients regarding biochemical risk factors such as elevated levels of homocysteine, fibrinogen, protein C, protein S, antithrombin III, lipoprotein(a), cholesterol and its fractions, and compared them with the results obtained from adult patients.

Inherited, congenital and acquired disorders by hemostasis (vascular, platelet & plasmatic phases) with repercussions in the therapeutic oral sphere

The hemostasis alterations, either congenital or hereditary origin, and acquired, are circumstances that hinder oral care to patients who suffer them and also generates in the professional who has to attend, high stress. Bleeding control once established and dental treatment planning, both in the aspect of preparation, as the realization of the odonto-stomatological therapeutic, has suffered updates that do need to remember certain aspects of the care of these patients. But we must not forget that the hematologist or internist who controls the patient's medical condition, is a cornerstone for the planning and implementation of treatment plans. We must also remember that, in certain circumstances, treatment should be performed in a hospital setting. In this review, we aim to provide the odonto-stomatologist guidance on how to address the problem and provide simple and updated guidelines to apply in the treatment of these people.

Association between hypoxia and perinatal arterial ischemic stroke: a meta-analysis

BACKGROUND

Perinatal arterial ischemic stroke (AIS) occurs in an estimated 17 to 93 per 100000 live births, yet the etiology is poorly understood. Although investigators have implicated hypoxia as a potential cause of AIS, the role of hypoxia in AIS remains controversial. The aim of this study was to estimate the association between perinatal hypoxia factors and perinatal arterial ischemic stroke through a meta-analysis of published observational studies.

PATIENTS AND METHODS

A systematic search of electronically available studies published through July 2013 was conducted. Publication bias and heterogeneity across studies were evaluated and summary odds ratios (ORs) and 95% confidence intervals (CIs) were calculated with fixed-effects or random-effects models.

RESULTS

A total of 8 studies describing the association between perinatal hypoxia factors and neonatal arterial ischemic stroke (AIS) met inclusion criteria, and 550 newborns with AIS were enrolled. The associations were found for AIS: preeclampsia (OR 2.14; 95% CI, 1.25 to 3.66), ventouse delivery (OR 2.23; 95% CI, 1.26 to 3.97), fetal heart rate abnormalities (OR 6.30; 95% CI, 3.84 to 10.34), reduced fetal movement (OR 5.35; 95% CI, 2.17 to 13.23), meconium-stained liquor (OR 3.05; 95% CI, 2.02 to 4.60), low Apgar score (OR 5.77; 95% CI, 1.66 to 20.04) and resuscitation at birth (OR 4.59; 95% CI, 3.23 to 6.52). Our data did not show any significant change of the mean risk estimate for oxytocin induction (OR 1.33; 95% CI, 0.84 to 2.11) and low arterial umbilical cord ph (OR 4.63; 95% CI 2.14 to 9.98).

CONCLUSIONS

There is a significant association between perinatal hypoxia factors and AIS. The result indicates that perinatal hypoxia maybe one of causes of AIS. Large scale prospective clinical studies are still warranted.

Hypercoagulability in a newborn with concomitant homozygous factor V Leiden and severe homozygous protein C deficiency type 1

This is a case report of a female newborn presented with skin necrotic lesions 1 week after delivery. Laboratory investigations revealed severe homozygous protein C deficiency associated with homozygous factor V Leiden, although her pregnancy and perinatal periods were otherwise uneventful, with negative family history of thrombotic or bleeding disorders. Patient stabilization was established by supportive measures and long-term administration of fresh frozen plasma and warfarin.