Pediatric stroke among Hong Kong Chinese subjects

Be aware of childhood stroke: Proceedings from EPNS Webinar

Childhood arterial ischaemic stroke (AIS) is a significant health concern with increasing incidence. This review aims to provide an overview of the current understanding of childhood AIS. The incidence of childhood AIS is on the rise especially in developing countries, likely due to improved awareness and diagnostic capabilities. Aetiology of childhood AIS is multifactorial, with both modifiable risk factors and genetic predisposition playing important roles. Identifying and addressing these risk factors, such as infection, sickle cell disease, and congenital heart defects, is essential in prevention and management. Identifying underlying conditions through genetic testing is important for appropriate management and long-term prognosis. Clinically, distinguishing stroke from stroke mimics can be challenging. Awareness of important stroke mimics, including migraines, seizures, and metabolic disorders, is crucial to avoid misdiagnosis and ensure appropriate treatment. The diagnostic approach to childhood AIS involves a comprehensive "chain of care," including initial assessment, neuroimaging, and laboratory investigations. National guidelines play a pivotal role in standardizing and streamlining the diagnostic process, ensuring prompt and accurate management. Early intervention is critical in the management of childhood AIS. Due to the critical time window, the question if mechanical thrombectomy is feasible and beneficial should be addressed as fast as possible. Early initiation of antiplatelet or anticoagulation therapy and, in select cases, thrombolysis can help restore blood flow and minimize long-term neurological damage. Additionally, rehabilitation should start as soon as possible to optimize recovery and improve functional outcomes. In conclusion, childhood AIS is a growing concern. Understanding the increasing incidence, age distribution, risk factors, clinical presentation, diagnostic approach, and management strategies is crucial for optimized management of these patients.

Review of Noninvasive Neuromonitoring Modalities in Children II: EEG, qEEG

Critically ill children with acute neurologic dysfunction are at risk for a variety of complications that can be detected by noninvasive bedside neuromonitoring. Continuous electroencephalography (cEEG) is the most widely available and utilized form of neuromonitoring in the pediatric intensive care unit. In this article, we review the role of cEEG and the emerging role of quantitative EEG (qEEG) in this patient population. cEEG has long been established as the gold standard for detecting seizures in critically ill children and assessing treatment response, and its role in background assessment and neuroprognostication after brain injury is also discussed. We explore the emerging utility of both cEEG and qEEG as biomarkers of degree of cerebral dysfunction after specific injuries and their ability to detect both neurologic deterioration and improvement.

Cases of acute hemiparesis in childhood

INTRODUCTION

Acute hemiparesis is an emergency of various etiologies and possible fatal outcome.

Pediatric Stroke: A Review of Common Etiologies and Management Strategies

Pediatric stroke is an important cause of mortality and morbidity in children. There is a paucity of clinical trials pertaining to pediatric stroke management, and solidified universal guidelines are not established for children the way they are for the adult population. Diagnosis of pediatric stroke can be challenging, and it is often delayed or mischaracterized, which can result in worse outcomes. Understanding risks and appropriate therapy is paramount to improving care.

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.

Childhood stroke

Stroke is an important cause of neurological morbidity in children; most survivors have permanent neurological deficits that affect the remainder of their life. Stroke in childhood, the focus of this Primer, is distinguished from perinatal stroke, defined as stroke before 29 days of age, because of its unique pathogenesis reflecting the maternal-fetal unit. Although approximately 15% of strokes in adults are haemorrhagic, half of incident strokes in children are haemorrhagic and half are ischaemic. The causes of childhood stroke are distinct from those in adults. Urgent brain imaging is essential to confirm the stroke diagnosis and guide decisions about hyperacute therapies. Secondary stroke prevention strongly depends on the underlying aetiology. While the past decade has seen substantial advances in paediatric stroke research, the quality of evidence for interventions, such as the rapid reperfusion therapies that have revolutionized arterial ischaemic stroke care in adults, remains low. Substantial time delays in diagnosis and treatment continue to challenge best possible care. Effective primary stroke prevention strategies in children with sickle cell disease represent a major success, yet barriers to implementation persist. The multidisciplinary members of the International Pediatric Stroke Organization are coordinating global efforts to tackle these challenges and improve the outcomes in children with cerebrovascular disease.

Contrast-enhanced ultrasound of the pediatric brain

Brain contrast-enhanced ultrasound (CEUS) is an emerging application that can complement gray-scale US and yield additional insights into cerebral flow dynamics. CEUS uses intravenous injection of ultrasound contrast agents (UCAs) to highlight tissue perfusion and thus more clearly delineate cerebral pathologies including stroke, hypoxic-ischemic injury and focal lesions such as tumors and vascular malformations. It can be applied not only in infants with open fontanelles but also in older children and adults via a transtemporal window or surgically created acoustic window. Advancements in CEUS technology and post-processing methods for quantitative analysis of UCA kinetics further elucidate cerebral microcirculation. In this review article we discuss the CEUS examination protocol for brain imaging in children, current clinical applications and future directions for research and clinical uses of brain CEUS.

Pediatric Acute Ischemic Stroke by Age-Group: A Systematic Review and Meta-Analysis of Published Studies and Hospitalization Records

BACKGROUND

Although stroke is rare among the pediatric population, it is nevertheless associated with serious or life-threatening consequences. The etiologic factors of acute ischemic stroke (AIS) are likely to vary over the course of childhood development. The incidence rates of AIS, not previously systematically examined by pediatric age subgroup, could guide studies of its etiology.

OBJECTIVE

The aim of this study is to evaluate the incidence rate of AIS by age-group in the pediatric population (aged 0-17/18 years) and identify any common trends or sources of variability across different countries.

METHODS

Rates of pediatric AIS were collated from a systematic literature review of published studies globally (1983-2020) and hospitalization records from Europe and the USA (2015-2018). Records that were included in the analysis reported the code or description used for AIS diagnosis and age-specific data for children aged 0-17/18 years. AIS incidence rates were summarized by age-group, data source, country, and geographic region. A meta-analysis was conducted to assess the heterogeneity of AIS rates in neonates.

RESULTS

The pooled AIS incidence rate was 5.6 per 100,000 children across all records. When only records reporting the AIS incidence rates for children across the full age range (0-17/18 years) were analyzed, the pooled AIS incidence rate was 4.6 per 100,000 children and ranged from 7.0 per 100,000 (Germany) to 1.3 per 100,000 (Denmark). The highest pooled rates were observed in the 0-28-day age-group (24.6 per 100,000 live births), declining to the lowest rates in the 5-9-year age-group, and rising again in the 10-17/18-year age-group. AIS rates were the most heterogeneous in the 0-28-day age-group and across European countries. Significantly higher AIS rates in neonates were observed from hospital databases (35.9 per 100,000) than in the literature (19.4 per 100,000). AIS rates may be underestimated as pediatric AIS events are rare and challenging to diagnose, and limited age-specific data are available.

CONCLUSIONS

Incidence rates of pediatric AIS by age-groups followed a consistent overall pattern of a reverse J-shaped curve, with the highest rates in neonates, across predominantly European and North American countries. Further research is warranted to examine if this pattern is observed in other geographic regions and to identify AIS risk factors specific to different phases of childhood development.

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.

Early Deaths after Arterial Ischemic Stroke in Pediatric Patients: Incidence and Risk Factors

In developed countries, cerebrovascular diseases are among the 10 most common causes of death in both the pediatric and adult population. The prevalence of fatal outcomes following arterial ischemic stroke (AIS) in various groups of pediatric patients ranges from 1% to almost 32%. However, a constant improvement in stroke mortality among children has been observed. The extent of the decline differs among studies (from nearly tenfold to twofold decline), as it depends on the study population. While a portion of this variability might be explained by factors such as health care access, population age, diseases related to ethnicity, and different etiologies of stroke in studied populations, the understanding of such differences is still insufficient. Risk factors for death in the early stages of the disease are poorly understood and are usually based on the clinical presentations of relatively small groups of pediatric patients. Familiarity with these factors may be of significant importance for prognosis, but also for the early selection of patients requiring careful supervision. The present study aimed to analyze and discuss the current literature data on the incidence of early death and risk factors for early death in children suffering from stroke.

Hypertension and childhood stroke

Cerebrovascular disease (stroke) is one of the ten leading causes of death in children and adolescents. Multiple etiologies, from arteriopathies to prothrombic states, can cause stroke in youth. In adult stroke, hypertension has been shown to be the single most important modifiable risk factor. Although hypertension has not been strongly identified as a risk factor in childhood stroke to date, there is preliminary evidence that suggests that hypertension may also be associated with stroke in children. In this review, we summarize the literature that may link hypertension to stroke in the young. We have identified a series of barriers and limitations in the fields of pediatric hypertension and pediatric neurology that might explain why hypertension has been overlooked in childhood stroke. We suggest that hypertension may be a relevant risk factor that, alone or in combination with other multiple factors, contributes to the development of stroke in children. Currently, there are no consensus guidelines for the management of post-stroke hypertension in children. Thus, we recommend that blood pressure be assessed carefully in every child presenting with acute stroke in order to better understand the effects of hypertension in the development and the outcome of childhood stroke. We suggest a treatment algorithm to help practitioners manage hypertension after a stroke.

Intracerebral Nontraumatic Hemorrhagic Stroke in Children: Case Series and Literature Review

Pediatric stroke is an event caused by disturbance of cerebral circulation that occurs in individuals between 28 days and 18 years of age. Although an uncommon event, pediatric stroke still carries significant morbidity and mortality. Unlike adults, causes of pediatric stroke are various and include vascular, infectious, hematologic, neoplastic, and toxic etiologies. Clinical presentation of nontraumatic intracerebral hemorrhages in older children is similar to adults, however in neonates and infants signs and symptoms can be more subtle, especially with smaller hemorrhages. Management of nontraumatic intracerebral hemorrhage consists of stabilizing the patient, management of the hemorrhage itself, and reduction of the rebleeding risk. Even so, when child reaches a medical care, morbidity and mortality rates are still high. We described a case series of pediatric patients with intracerebral nontraumatic hemorrhagic stroke from different etiologies. Although increasingly recognized, such situations are still poorly described in children and our report offers a good overview on this topic.

Unusual presentation of brain abscess in a 23-month-old infant

BACKGROUD

Pediatric brain abscesses usually occur as a consequence of predisposing conditions, such as ENT (ear, nose, and throat) infection and physical damage. But there are still a number of cryptogenic infection cases.

METHODS

We present an unusual cryptogenic infection case of multiple and multiloculated brain abscess in an infant, which was in the absence of ENT infection, meningitis, trauma, prior surgery, cyanotic heart disease, or immune defect. The child has no specific symptoms but keeping apathic and days of diarrhea. Deduced from clinical presentation and this case's DWI-MRI features, the onset of infection is hematogenous route, and the diarrhea could be the possible inducement. The child was successfully treated by surgical excision of big lesions and an 8-week total course of intravenous antibiotics. At the end of the 1-year follow-up period, the infant is well at both of physical and mental health.

CONCLUSION

The interest of this case is the silent clinical presentation and the possibly rare precipitating factor. To a certain extent, the variation trend of blood C-reactive protein level could predict the clinical effect of antibiotics in brain abscess case.

Intensive treadmill training promotes cognitive recovery after cerebral ischemia-reperfusion in juvenile rats

Rehabilitation training is routine for children who experience stroke, but its protective mechanism remains unclear. To study the effect of treadmill training intensity on hippocampal synaptic plasticity after cerebral ischemia, a model of middle cerebral artery occlusion (MCAO)/reperfusion was established in young rats to simulate childhood ischemic stroke. The rats were randomly allocated into five groups: sham operation, MCAO, low-intensity exercise and MCAO (5 m/min), medium-intensity exercise and MCAO (10 m/min), and high-intensity exercise and MCAO (15 m/min). Intervention was continued for 14 days, and a series of experimental tests were conducted. After MCAO, the juvenile rats exhibited a series of morphological and functional alterations, including changes in their neurobehavior and cerebral infarct volumes. Compared with control rats, MCAO rats had a longer escape latency and crossed fewer platforms in the water maze test and exhibited decreased hippocampal neuron density and Synapsin I and PSD95 expression. Furthermore, MCAO rats exhibited synapse morphology changes and abnormal serum levels of lactic acid and corticosterone. Treadmill training effectively reduced the neurobehavioral scores and cerebral infarction volumes, with medium-intensity training showing the best effect. Treadmill training shortened the escape latency, increased the number of platform crossings, and improved the spatial cognitive abilities of the rats, with the medium intensity training having the best effect on spatial learning/memory efficiency. Treadmill training increased the neuron density in the hippocampus, with the medium-intensity training resulting in the highest density. Treadmill training had a positive effect on the expression of Synapsin I and PSD95, with the medium-intensity training showing the strongest effect. Treadmill training improved the sub-microstructure synapse morphology, with the medium-intensity training demonstrating the best effect. Treadmill training increased the plasma levels of lactic acid and corticosterone, with the high-intensity training having the most obvious effect. Treadmill training can provide neuroprotection by promoting hippocampal synaptic plasticity, with medium-intensity training showing the most optimal effects.

Revascularisation surgery for paediatric moyamoya disease: The Singapore experience

Moyamoya disease (MMD) is characterized by the spontaneous occlusion of the distal internal carotid arteries and resultant neo-angiogenesis of fragile collateral blood vessels. Direct and indirect revascularization surgeries have shown to effectively reduce stroke risks in paediatric MMD, whereby the latter is a more utilised technique in children. This study was undertaken to determine the outcomes of revascularization in Singapore's multi-ethnic, Southeast Asian paediatric population. This is an ethics-approved study conducted in Singapore's 2 tertiary children hospital units: KK Women's and Children's Hospital and National University Hospital. Sixteen patients with a diagnosis of ischaemic-type MMD are recruited between 01 January 2002 to 31 January 2019; and a total of 24 surgeries are undertaken (24 cerebral hemispheres). There are 2 cases of stroke within 30 days post-surgery. However, no stroke recurrence is observed beyond 30 days after surgery in all patients. Four patients reported recurrent transient ischaemic attack symptoms in the follow-up period ranging from 3 months to 12 years. Data analyses show a statistically significant improvement in modified Rankin's Scale (mMRS) in post-operative patients from baseline to discharge, and at 3 months after surgery. Our study also observes that predictors of recurrent ischaemic events include higher pre-operative MRS, Suzuki stage and perioperative infarction. To the authors' knowledge, this is the first study to date reporting the outcomes of revascularisation in a paediatric Southeast Asian cohort.

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.

Cardiovascular and Hematological Risk Factors and Mortality Risk in Pediatric Arterial Ischemic Stroke: Analysis Report From Hospitals in the United States

Objective We aimed to analyze the differences in demographics, comorbidities, and the risk of in-hospital mortality in pediatric arterial ischemic stroke (PAIS) inpatient population by hematological (HEM) and cardiovascular (CV) risk factors. Methods A total of 4,036 inpatients (1-18 years of age) from the Nationwide Inpatient Sample (NIS) with a primary diagnosis of PAIS were included. Descriptive statistics, linear-by-linear association test, and logistic regression models were utilized to analyze differences in demographics, comorbidities, and their impact on mortality in PAIS inpatients by CV and HEM risk factors. Results The cumulative in-hospital mortality rate in the entire PAIS inpatient cohort was 3.6%. The mortality rate was higher in the CV cohort (57.4%) as compared to the HEM cohort (29.7%). When compared with the cohort with no risk factors, HEM and CV were associated with four times (95% CI: 2.36-8.03) and seven (95% CI: 4.03-12.61) times higher odds for in-hospital mortality respectively. CV risk factors like cardiomyopathy and diabetes, and HEM risk factors like blood disorders, coagulation disorders, and deficiency anemias were associated with a significantly increased risk of in-hospital mortality. Conclusion The in-hospital mortality risk in PAIS patients was increased by 613% by CV risk factors and by 336% by HEM risk factors. Early identification and effective management of associated CV and HEM risk factors in the PAIS patient population can pave the way for increased survival and improved clinical outcomes.

Characteristics of Acute Nystagmus in the Pediatric Emergency Department

OBJECTIVES

Acute nystagmus (AN) is an uncommon neurologic sign in children presenting to pediatric emergency departments. We described the epidemiology, clinical features, and underlying causes of AN in a large cohort of children, aiming at identifying features associated with higher risk of severe underlying urgent conditions (UCs).

METHODS

Clinical records of all patients aged 0 to 18 years presenting for AN to the pediatric emergency departments of 9 Italian hospitals in an 8-year period were retrospectively reviewed. Clinical and demographic features and the underlying causes were analyzed. A logistic regression model was applied to detect predictive variables associated with a higher risk of UCs.

RESULTS

A total of 206 patients with AN were included (male-to-female ratio: 1.01; mean age: 8 years 11 months). The most frequently associated symptoms were headache (43.2%) and vertigo (42.2%). Ataxia (17.5%) and strabismus (13.1%) were the most common neurologic signs. Migraine (25.7%) and vestibular disorders (14.1%) were the most common causes of AN. Idiopathic infantile nystagmus was the most common cause in infants <1 year of age. UCs accounted for 18.9% of all cases, mostly represented by brain tumors (8.3%). Accordant with the logistic model, cranial nerve deficits, ataxia, or strabismus were strongly associated with an underlying UC. Presence of vertigo or attribution of a nonurgent triage code was associated with a reduced risk of UCs.

CONCLUSIONS

AN should be considered an alarming finding in children given the risk of severe UCs. Cranial nerve palsy, ataxia, and strabismus should be considered red flags during the assessment of a child with AN.

Mechanical thrombectomy for a 12-year-old boy with acute ischemic stroke: A case report

RATIONALE

Acute ischemic stroke (AIS) is one of the most severe diseases that endanger human health. It is very common among middle-aged and elderly people, but it is rare in children. The treatment varies among children and adults, since the cause for AIS in children differs from that in adults. In adults with AIS, endovascular therapy has been recommended, but guidelines for endovascular therapy in children with AIS have not been established yet. In China, few relevant evidence is present so far in clinical research of mechanical thrombectomy in the treatment for children with AIS.

PATIENT CONCERNS

A 12-year-old boy without any special physical collision and trauma was admitted to emergency department of Changsha central hospital due to hemiplegia of left limbs for 3 hours.

DIAGNOSES

He was diagnosed with AIS after magnetic resonance imaging (MRI) examination and magnetic resonance angiography (MRA) examination. Cerebral infarction in the right parietal, temporal, insular, and frontal lobes was revealed by the MRI test. The MRA test detected occlusions in right internal carotid artery, A1 segment of right anterior cerebral artery, right middle cerebral artery, and distal branch.

INTERVENTIONS

Mechanic thrombectomy and antiplatelet aggregation therapy with clopidogrel helped the patient to recover, along with active rehabilitation training.

OUTCOMES

A significant improvement in muscle strength of his left limbs was proved. He walked by himself and had 2 of Modified Rankin Scale (MRS). At 1-year follow-up visit, he recovered well except feeling a bit pain of left lower limb when walking, with finally MRS of 1.

CONCLUSIONS

Mechanical thrombectomy can be performed safely for children with AIS, but needs a further research with large samples.

Neonatal thrombosis

Neonatal thromboembolism in pediatric patients is a rare but life-threatening condition mainly caused by combinations of at least 2 prothrombotic triggering risk factors such as the central venous lines, septic condition, and prematurity. Other risk factors include asphyxia, dehydration, liver dysfunction, inflammation, and maternal condition. Neonatal hemostatic system is different from one of the older children and adults. Coagulation proteins do not cross the placenta but are synthesized in the fetus from an early stage. In the term neonate, concentrations of several procoagulant proteins, particularly the vitamin K dependent and contact factors are reduced when compared with adults. Conversely, levels of antithrombin, heparin cofactor II and protein C and S are low at birth and fibrinolysis system is characterized by the decreased level of plasminogen and alpha-1-antiplasmin, increased tissue plasminogen activator. These features all tend to be gestational dependent and are more present in the preterm infant. Primarily in this context neonates appear to be at a higher risk of thrombosis than older children. Thrombotic complications reach their peak in the group of children born at 22-27 weeks. The role of inherited thrombophilic risk factors in neonatal VTE development is poorly defined. The presence of inherited and acquired thrombophilia in mother and newborn is also responsible for the development of thrombosis in neonates and should be considered. Thrombophilia in the mother can lead to increased coagulation potential and prethrombotic conditions during pregnancy, causing thrombotic vasculopathy at the placental level. The benefit of identifying thrombophilia in the sick preterm newborns who are in the group of risk for development of thrombotic complications may facilitate the thromboprophylaxis. Further research regarding assessment of risk factors, diagnostics and treatment strategy is required.

Fractional Flow on TOF-MRA as a Measure of Stroke Risk in Children with Intracranial Arterial Stenosis

BACKGROUND AND PURPOSE

Conventional angiography is the criterion standard for measuring intracranial arterial stenosis. We evaluated signal intensity ratios from TOF-MRA as a measure of intracranial stenosis and infarct risk in pediatric stroke.

MATERIALS AND METHODS

A retrospective study was undertaken in children with intracranial arterial stenosis, who had TOF-MRA and conventional angiography performed within 6 months. Arterial diameters were measured for percentage stenosis. ROI analysis on TOF-MRA measured signal intensity in pre- and poststenotic segments, with post-/pre-signal intensity ratios calculated. The Pearson correlation was used to compare percentage stenosis on MRA with conventional angiography and signal intensity ratios with percentage stenosis; the point-biserial correlation was used for infarcts compared with percentage stenosis and signal intensity ratios. Sensitivity, specificity, and positive and negative predictive values were calculated for determining severe (≥70%) stenosis from MRA and signal intensity ratios against the criterion standard conventional angiography. P < .05 was considered statistically significant.

RESULTS

Seventy stenotic segments were found in 48 studies in 41 children (median age, 11.0 years; range, 5 months to 17.0 years; male/female ratio, 22:19): 20/41 (48.8%) bilateral, 11/41 (26.8%) right, and 10/41 (24.4%) left, with the most common site being the proximal middle cerebral artery (22/70, 31%). Moyamoya disease accounted for 27/41 (65.9%). Signal intensity ratios and conventional angiography stenosis showed a moderate negative correlation (R = -0.54, P < .001). Receiver operating characteristic statistics showed an area under the curve of 0.86 for using post-/pre-signal intensity ratios to determine severe (≥70%) carotid stenosis, yielding a threshold of 1.00. Sensitivity, specificity, and positive and negative predictive values for severe stenosis were the following-MRA: 42.8%, 58.8%, 30.0%, and 71.4%; signal intensity ratio >1.00: 97.1%, 77.8%, 71.7%, and 97.4%; combination: 75.5%, 100%, 100%, and 76.8%, respectively. Signal intensity ratios decreased with increasing grade of stenosis (none/mild-moderate/severe/complete, P < .001) and were less when associated with infarcts (0.81 ± 0.52 for arteries associated with downstream infarcts versus 1.31 ± 0.55 for arteries without associated infarcts, P < .001).

CONCLUSIONS

Signal intensity ratios from TOF-MRA can serve as a noninvasive measure of intracranial arterial stenosis and allow identification of high-risk lesions in pediatric stroke.

Treadmill exercise improves neurological function by inhibiting autophagy and the binding of HMGB1 to Beclin1 in MCAO juvenile rats

AIMS

Treadmill exercise is a beneficial treatment following childhood stroke. Thus, studies focusing on the neuroprotective mechanism of exercise training during postischemic treatment in children with ischemic stroke are urgently needed. We evaluated the effects of treadmill exercise on autophagy after cerebral ischemia in young rats.

MAIN METHODS

Rats (23-25 days old) underwent cerebral ischemia-reperfusion (CI/R) surgery. The experimental animals were divided into 5 groups, and some groups received either treadmill exercise, a rapamycin (RAPA) injection or combination therapy for 3 or 7 days. We performed a series of experimental tests including neurological scoring, hematoxylin-eosin staining (H&E), Nissl staining, triphenyl tetrazolium chloride (TTC) staining, Western blot analysis (WB), immunofluorescence (IF), enzyme-linked immunosorbent assay (ELISA), transmission electron microscopy (TEM) and Terminal deoxynucleotidyl transferase-mediated dUTP-digoxigenin nick end labeling (TUNEL) fluorescence.

KEY FINDINGS

The experimental data indicated that treadmill exercise inhibited autophagy in the ischemic penumbra, inhibited high mobility group box 1 (HMGB1) translocation and binding to Beclin1, reduced apoptosis, reduced infarct volumes, and aided in functional recovery. However, RAPA promoted the opposite effects of treadmill exercise.

SIGNIFICANCE

We found that treadmill exercise improves the neurological deficits induced by CI/R by inhibiting autophagy and HMGB1 binding to Beclin1.

Stroke risks in women with dysmenorrhea by age and stroke subtype

BACKGROUND

Dysmenorrhea and stroke are health problems affecting women worldwide in their day-to-day lives; however, there is limited knowledge of the stroke risk in women with dysmenorrhea, and there have been no studies assessing the specific distribution of stroke subtypes. This case-control study assessed stroke subtypes by age and the role of comorbidities in women with dysmenorrhea.

METHODS AND FINDINGS

Data obtained between 1997 and 2013 from Taiwan's health insurance database identified 514 stroke cases and 31,201 non-stroke controls in women with dysmenorrhea aged 15-49 years. Proportional distributions of subtypes and odds ratios (ORs) of stroke associated with comorbidities by age and subtype were measured. We found that the stroke risk in dysmenorrheal patients increased with age, and that hypertension was nine-fold more prevalent in the stroke cases than in the controls and was associated with an adjusted OR of 4.53 (95% confidence interval (CI) = 3.46-5.92) for all stroke cases. Moreover, the proportion of hemorrhagic stroke was greater than that of ischemic stroke in younger dysmenorrheal patients between 15-24 years old (50.5% vs. 11.4%), whereas this was reversed in those aged 30-49 years old (16.1% vs. 21.0%). Overall, 25.3% of the stroke cases consisted of transient cerebral ischemia and 31.3% were other acute but ill-defined cerebrovascular diseases, in which the prevalence increased with age for both types of strokes. Hypertension was the comorbidity with the highest OR associated with each subtype stroke; diabetes, hyperlipidemia, arrhythmia, and thyroid disease were also comorbidities that were significantly associated with ill-defined cerebrovascular diseases.

CONCLUSIONS

The stroke type varies by age in dysmenorrheal patients, and hypertension is the most important comorbidity associated with all types of stroke; therefore, more attention for stroke prevention must be paid to women with dysmenorrhea, particularly when combined with comorbidities.

PEXO - A Pediatric Whole Hand Exoskeleton for Grasping Assistance in Task-Oriented Training

Children with hand motor impairment due to cerebral palsy, traumatic brain injury, or pediatric stroke are considerably affected in their independence, development, and quality of life. Treatment conventionally includes task-oriented training in occupational therapy. While dose and intensity of hand therapy can be promoted through technology, these approaches are mostly limited to large stationary robotic devices for non-task-oriented training, or passive wearable devices for children with mild impairments. Here we present PEXO, a fully wearable actuated pediatric hand exoskeleton to cover the special needs of children (6 to 12 years of age) with strong impairments in hand function. Through three degrees of freedom, PEXO provides assistance in various grasp types needed for the execution of functional tasks. It is lightweight, water proof, and inherently interacts safely with the user. It meets mechanical requirements such as force, fast closing movement, and battery lifetime derived from literature and discussions with clinicians. Appealing appearance, user-friendly design, and intuitive control with visual feedback of forearm muscle activity should keep the user motivated during training in the clinic or at home. A pilot test with a 6-years old child with stroke showed that PEXO can provide assistance in grasping various objects weighing up to 0.5 kg. These are promising first results on the way to make hand exoskeletons accessible for children with neuromotor disorders.

Short-term neurological outcomes in ischemic and hemorrhagic pediatric stroke

BACKGROUND

The aim of this study was to retrospectively assess short-term neurological outcomes in pediatric stroke with regard to patient characteristics.

METHODS

Children aged 28 days-18 years with arterial ischemic stroke (AIS), cerebral sinovenous thrombosis (CSVT), and hemorrhagic stroke (HS) between 2007 and 2013 were evaluated. Neurological findings in the first 3 months were accepted as short-term prognosis, and modified Rankin scale was used.

RESULTS

A total of 33 patients (62%) with AIS, 12 (23%) with HS, and eight (15%) with CSVT were included. Moya moya syndrome was the most common new diagnosis in AIS. Stroke recurred in five (15%); and one AIS patient with posterior circulation infarct died (3%). Prognosis in AIS was favorable for 20 patients (61%) and poor for 13 patients (39%). Forty-two percent of HS were of vascular origin. Seven patients (70%) with HS had good prognosis and three (30%) had poor prognosis with no death. Homocysteine-related hypercoagulability was most frequently noted in the etiology of CSVT. Synchronous systemic thrombosis was observed in three CSVT patients (37.5%) and death occurred in two (25%). Prognosis was evaluated as favorable for three CSVT patients (37.5%) and poor for five (62.5%). For thrombophilia, thrombosis panel was performed fully in 83% of AIS and CSVT patients.

CONCLUSIONS

Pediatric stroke is associated with a poor prognosis in a substantial number of patients in the short term, with CSVT having the worst prognosis. Detailed patient characteristics are listed not only for ischemic but also for hemorrhagic stroke; and a full thrombosis panel was achieved for most ischemic stroke patients.

Childhood arterial ischemic stroke in Senegal (West Africa)

Etiological factors of childhood ischemic stroke depend on the epidemiological context. The purpose of this study was to determine the risk factors, the clinical and radiologic features, and the outcome of arterial ischemic stroke in a case series of Senegalese children. We carried out a retrospective registry-based study on arterial ischemic stroke in children hospitalized in the neurology department of Fann Teaching Hospital and Albert Royer Children's Hospital, from January 2005 to December 2015. We enrolled 116 cases with an age range from 2 months to 18 years. The mean age at stroke occurrence was 71.5 months. The most common manifestations were hemiparesis (84%), aphasia (19%), and partial motor seizures (10%). The middle cerebral artery was the most affected (81%). Risk factors were predominantly sickle cell disease (38%), embolic heart disease (9%), and anemia (3%). Twenty-eight percent of patients were lost to follow-up, 62% had neurological impairments, and 4% died. Secondary prevention was based on antithrombotic agents. Prevention must be prioritized and public health actions need to focus on sickle cell disease, rheumatismal disease, anemia, and related disorders. It will be necessary to set up policies that fight against consanguineous marriage, endemic infections, and argue for better nutrition.

Risk Factors of Pediatric Arterial Ischemic Stroke; A Regional Survey

Background:

Considering that better understanding of the underlying mechanisms and risk factors of arterial ischemic stroke (AIS) would be helpful for better management of stroke and its outcome in children as well as preventing or reducing the occurrence of its related potential disabilities, the aim of this study was to investigate the most common risk factors and causes of AIS in patients referred to the referral hospitals in Tehran and Isfahan cities of Iran.

Methods:

In this study, medical files of all pediatric patients admitted to the Mofid and Imam Hossein children's hospitals with the diagnosis of AIS from 2001 to 2011 and 2011 to 2016, respectively, were evaluated. Identified risk factors of AIS were categorized as arteriopathies, cardiac disorders (CDs), infection, acute head-and-neck disorders, acute systemic conditions, chronic systemic conditions, prothrombotic states, chronic head-and-neck disorders, atherosclerosis-related RFs, and others.

Results:

In this study, 61 patients were evaluated. Mean (standard deviation) age of the patients was 5.1 (3.9) years. About 62.3% of the patients were boys while 37.7% were girls (P < 0.01). A total of 36 patients (59%) had at least one risk factor for AIS. About 40.9% of patients had undetermined risk factors. CDs (21.31%) and vascular disease (21.31%) were the most common risk factors of AIS in the studied children. Nearly 11.5% of the patients had moyamoya vascular disease (MMD).

Conclusion:

The findings of our study indicated that the most common risk factors for AIS in the two studied regions are congenital heart and vascular diseases. The results of the current study could be used for planning more preventive strategies in patients suffering from the mentioned diseases. In addition, the obtained data could be used for conducting targeted education and management of high-risk patients.

Epidemiology, risk factors and characteristics of pediatric stroke: a nationwide population-based study

BACKGROUND

Stroke, classically characterized as an acute acquired neurological deficit, is an important leading cause of death and chronic morbidity in children.

AIMS

This study reported the period prevalence, incidence and risk factors of pediatric stroke in Taiwan.

METHODS AND PROCEDURES

All Taiwan inhabitants aged 1 month to 18 years registered in the National Health Insurance Research Database between 2010 and 2011 were enrolled in this study. Factors including age, sex, location and household income levels were collected. Incidence, period prevalence, mortality rate and the possible risks were completely evaluated. Outcomes and results: Hemorrhagic stroke has a significantly higher mortality rate than ischemic stroke (27.6% vs. 10.2%, P<0.05). Risk factors or underlying diseases for stroke were identified in 77.8% of the patients and 16.2% had more than one risk factor. The most common risk factors were vascular diseases (26.3%), infection (14.0%) and cardiac disorders (9.1%).

CONCLUSIONS AND IMPLICATIONS

Infants younger than 2 years, boys and children in lower socioeconomic status have a significantly higher risk of stroke. Hemorrhagic stroke has a significantly higher mortality rate than ischemic stroke. More than half of the children with stroke had underlying diseases and the causes of hemorrhagic stroke are significantly different from ischemic stroke.

Affiliate stigma and its association with quality of life among caregivers of relatives with mental illness in Singapore

Affiliated stigma often refers to internalized stigma among family members of stigmatized individuals. This study aimed to investigate the relationship between affiliate stigma and quality of life (QOL) among primary caregivers of individuals with mental illness undergoing treatment at the Institute of Mental Health, Singapore. Three hundred and fifty caregivers were recruited for the study. The World Health Organization Quality of Life questionnaire (WHOQOL-BREF) and Family Stigma Scale (FSS) were administered to the primary caregivers of patients with mental illness. Multiple linear regression analyses were conducted to investigate the association of affiliate stigma with QOL. A high proportion of caregivers of individuals with mental illness experience affiliate stigma in Singapore. All four QOL domains were significantly associated with affiliate stigma. These findings entail that it is imperative to improve public's perception of those with mental illness to reduce stigmatization and thus improve caregiver's QOL.

Refractory Mycoplasma pneumoniae pneumonia with concomitant acute cerebral infarction in a child: A case report and literature review

RATIONALE

Mycoplasma pneumoniae pneumonia, a common cause of community-acquired pneumonia in children, is rarely complicated with acute cerebral infarction.

PATIENT CONCERNS

We present a 7-year-old boy with severe M pneumoniae pneumonia who developed impaired consciousness, aphasia, and reduced limb muscle power 7 days postadmission.

DIAGNOSES

Mycoplasma pneumoniae pneumonia with concomitant acute cerebral infarction.

INTERVENTIONS

The patient recovered with aggressive antibiotic therapy, antiinflammation therapy with methylprednisolone, and gamma immunoglobulin and anticoagulation therapy with aspirin and low molecular weight heparin along with rehabilitation training.

OUTCOMES

At 8 days postadmission, his consciousness was improved and at the 6-month follow-up visit, his muscle power of bilateral upper and lower limbs was normal except still poor right handgrip power.

LESSONS

Stroke or cerebral infarction should be considered and promptly managed in rare cases of M pneumoniae pneumonia with neurologic manifestations.

Stroke and Hypertension in Children and Adolescents

Hypertension is the single most important modifiable risk factor for adult stroke. Stroke mortality has significantly decreased over the last 5 decades; this decline has been mainly associated to improved blood pressure control. Though much less prevalent than in adults, stroke is an increasingly recognized cause of morbidity and mortality in children. Although hypertension has not been strongly identified as a risk factor in childhood stroke yet, there is preliminary evidence that suggests that elevated blood pressure may be associated with stroke in children. This review summarizes the literature that may link elevated blood pressure to the development of childhood ischemic and hemorrhagic stroke. The authors suggest that elevated blood pressure may be a significant risk factor that, alone or in combination with other multiple risk factors, leads to the development of stroke in childhood. It is therefore recommend that blood pressure be measured and assessed carefully in every child presenting with acute stroke.

[Epidemiology of strokes in pediatry]

Incidence of perinatal arterial stroke (ischemic stroke, intracerebral hemorrhage and subarachnoid hemorrhage) occurring between 20 weeks of gestation and postnatal day 28 ranges between 20 and 65 cases per 100,000 living births. In children aged 29 days to 18 years old, the total incidence is 1.3 to 4.3 for 100,000 per year. In France, almost 450 children are hospitalized for a stroke each year, among them approximately half have an intracerebral hemorrhage.

Clinico-etiological profile of childhood stroke in a Tertiary Care Hospital in Eastern India

Background:

The clinical pattern and etiology of stroke may vary over time or with geographical location. In Asian countries, specific etiology and outcome of childhood stroke have been rarely reported.

Objective:

To determine the clinical and etiological pattern of childhood stroke and their outcome in a Tertiary Care Center.

Materials and Methods:

This study was conducted in a Tertiary Care Hospital of Kolkata over a period of 3 years. All children from 6 months to 12 years, diagnosed as childhood stroke by radio-imaging were included in our study. Children presenting with paraplegia/paraparesis were excluded. Etiologies were determined on the basis of clinical examination, related blood investigations and radio-imaging findings. Data gathered from the stroke patients were entered into a preformed proforma and appropriate statistical analyses were done.

Result:

Most commonly found clinical presentation was hemiparesis (70.6%). Next in place was a seizure (61.8%) and alteration of consciousness (58.8%). The most common etiology of childhood stroke in our hospital was found to be an intracranial infection (41.2%), followed by vascular etiology. Stroke was ischemic in nature in 91.2% of cases. Among the clinical features, vomiting, alteration of sensorium, and fever were significantly (P < 0.01) more in infectious cases of stroke, but hemiparesis was significantly (P < 0.05) more common in noninfectious etiology. Most of the cases of noninfectious etiology (95%) completely recovered without any persistent neurodeficit or mortality.

Conclusion:

Intracranial infection is the commonest etiology of stroke in pediatric patients presenting at our hospital. Commonest type is an ischemic stroke. The most of the patients completely recovered from the acute neurological insult after proper and timely management.

Post-stroke epilepsy in Polish paediatric patients

AIM

The aim of this study was to characterize a group of children with early and late remote seizures, which occurred after arterial ischaemic stroke (AIS), and to find predictors of post-stroke seizures.

METHOD

The study group, recruited in the Department of Neuropediatrics (Medical University of Silesia, Katowice, Poland), comprised 78 individuals (range 1-18y) who had suffered a stroke: 13 participants had early seizures, occurring up to 7 days after AIS, seven participants had late remote seizures, occurring more than 7 days after AIS, and 58 participants had no seizures.

RESULTS

Post-stroke epilepsy occurred in 10 patients having post-stroke seizures. Participants affected by late remote seizures were younger, on average, than participants unaffected by seizures. The frequencies of total anterior circulation infarct (TACI) stroke subtype and focal cerebral arteriopathy (FCA) were significantly higher in the late seizure subgroup than in the subgroup without seizures (71% vs 26%, p=0.014, OR 7.17, and 100% vs 51%, p=0.015 respectively). Multivariable Cox analysis showed that age at time of stroke (p=0.027), FCA (p=0.010), and the number of infarct foci (p<0.001) were significant predictors of post-stroke seizures.

INTERPRETATION

Age at time of stroke, presence of FCA, and number of infarct foci are predictors of post-stroke seizures in Polish paediatric patients.

Retracted: Post-stroke epilepsy in Polish paediatric patients

The above article, published online on 5 October 2013 in Wiley Online Library Early View (http://onlinelibrary.wiley.com/), has been retracted by agreement between the authors, the journal Editor in Chief, Dr Peter Baxter, and John Wiley & Sons Ltd. The retraction has been agreed due to several errors in the statistics. These errors make interpretation of the data difficult and the validity of the conclusions questionable.

Risk factors and imaging characteristics of childhood stroke in china

There are scarce reports of childhood stroke from China. Our objective was to describe the clinical spectrum, risk factors, and imaging characteristics of childhood stroke in China. Using a hospital discharge database, children with stroke who were first admitted from 2002 to 2011 were retrospectively enrolled. We identified 478 first admissions with childhood stroke, including 229 cases of ischemic stroke and 249 hemorrhagic stroke. Boys accounted for more than 60% in all stroke types (62.2% for ischemic stroke, intracerebral hemorrhage for 66.2%). The leading cause was moyamoya for ischemic stroke and arteriovenous malformations for intracerebral hemorrhage. Hemiplegia and headache were the most common presenting features. Internal carotid artery and middle cerebral artery were the most involved arteries according to imaging examination in the ischemic stroke. A total of 8 patients died of intracerebral hemorrhage. The prevalence of hemorrhagic stroke was more than that of ischemic stroke. As Western countries, arteriopathy was the most common cause of childhood stroke.

Current concepts in pediatric stroke

Stroke is a relatively rare but rather significant cause of short- and long-term morbidity and mortality in children. It can be divided into three categories: arterial ischemic stroke (AIS), hemorrhagic stroke (HS) and cerebral sinovenous thrombosis (CSVT). This review focuses on AIS. The etiologies of pediatric AIS are diverse and different from those in adult stroke, chief among these being congenital heart disease, vasculopathies, hematological disorders and prothrombotic states. Additional factors might be related to the age group, ethnicity and geographic factors. Early recognition enables initiation of prompt therapy thereby reducing risk of further recurrence and complications.

Therapeutic benefits and side effects of Azathioprine and Aspirin in treatment of childhood primary arterial stroke

BACKGROUND

Childhood primary angiitis of central nervous system (cPACNS) is rare idiopathic vasculitis most frequently in adults. Children with this disorder can present with a range of neurological symptoms and signs including decreased consciousness, seizures, hemiparesis, cranial nerve deficits, and cognitive deficits. Delayed diagnosis and treatment may compromise the outcome. Therapeutic modalities including Anti-Platelet agents, Corticosteroids, Azathioprine, Cyclophosphamide and other Immunomodulatory agents have been used with variable success.

PURPOSE

We wanted to study a cohort of children with childhood primary angiitis of Central Nervous System (cPACNS); and evaluate efficacy and safety of their management.

METHODS

Current study is an observational cohort study that included 68 patients admitted with acute ischemic strokes (AIS) within 14 days of symptoms onset at Department of Neurosciences at Children's Hospital, Lahore, Pakistan from January 2009 to December 2010 with an age ≤16 years. They were subjected to physical examination laboratory and neuroimaging evaluation. They received pulses of intravenous steroids and/or Immunoglobulins for 4 weeks with maintenance dose of Azathioprine and low dose Aspirin for 24 months and kept on follow for 2 years.

RESULTS

Sixty eight patients were included; 42 (62.76%) boys and 26 (38.23%) girls whose mean age was 8.5 ± 3.5 years. Presenting symptoms and signs included fever (20%), headache (64%), disturbed consciousness (30%), seizures 55%, hemiparesis (60%), and motor deficit (70%). Neuroimaging studies revealed ischemic strokes in 50 patients (73.5%), hemorrhagic strokes in 10 (14.7%) and ischemic-hemorrhagic lesions in 8 (11.8%). Males with, deep coma and raised intracranial pressure were poor prognostic signs. Mortality was encountered in 12 patients (17.64%) with normal outcome in 11 (16.17%), minor disabilities in 14 (20.59%), moderate disabilities in 11 (16.17%) and severe disabilities in 20 (29.41%).

CONCLUSIONS

Characteristic features of cPACNS on presentation may predict later progression and outcome, identify high-risk patients which may guide selection of patients for immunosuppressive therapy. Further studies are required to substantiate our findings regarding immunosuppressive therapy for such patients.

The role of genetic risk factors in arterial ischemic stroke in pediatric and adult patients: a critical review

The incidence of arterial ischemic stroke (AIS) in childhood (about 2-13 per 100,000 children a year) is much lower than the incidence in the adult population. Still, adverse outcomes of acute brain ischemia in childhood include death (10% of AIS children), neurological sequel, epileptic seizures (over 50%) and recurrence (over 20%). The knowledge of childhood stroke etiopathogenesis is still insufficient and the diagnostic and therapeutic procedures--controversial. Risk factors for childhood stroke differ from those observed in adults due to differing exposure to external risk factors. The most frequently reported risk factors for pediatric ischemic stroke are cerebral arteriopathies and vascular malformations, cardiac diseases, infections, traumas and metabolic diseases. Because of its multifactorial etiology pediatric AIS probably has a multigenic inheritance pattern. The genetic susceptibility to AIS may be determined by specific polymorphic variants encoding markers of hemostasis regulation and they are some of the most important targets in searching for genetic determinants in pediatric AIS. The authors have reviewed the recent literature on risk factors of childhood ischemic stroke with the focus on genetic factors like polymorphisms of genes encoding coagulation factors II, V, VII and XIII, MTHFR, fibrinogen beta, and compared them with the results performed in adult patients.

Arterial ischemic stroke and hemorrhagic stroke in Chinese children: a retrospective analysis

To study the characteristics of pediatric arterial ischemic stroke (AIS) and hemorrhagic stroke (HS) in southwest of China, and analyze the etiology and risk factor. This study retrospectively reviewed the records of all patients in both department of neurology and department of neurosurgery in Children's hospital of Chongqing medical university from January 2003 to March 2011, and patients were eligible for analysis if they had been diagnosed with AIS or HS. And SPSS 17.0 software was used for statistical analysis. The χ(2) test was used to exam relationships between stroke types and sex, age, and that between neuroradiological images and sex. 119 Boys (70.4%) and 50 girls (29.6%) were included. In these cases, HS accounted for the majority of the cases (n=109, 64.1%), and vitamin K deficiency was a major etiology in 65 out of 109 HS (59.6%), most of which occurred in breastfeeding infants (87.7%) and those who received no vitamin K after birth. AIS accounted for 35.3% of the cases, and minor head injury associated stroke (40.0%) was more common than vasculopathy associated stroke (16.6%) and other kinds of stroke. HS in children is more common than AIS. Vitamin K deficiency was a major etiology in these young infants who experienced HS, and many cases of AIS were associated with minor head injury.

Treatment of arterial ischemic stroke in children

Stroke is a rare but increasingly recognized disorder in children. Current therapies for arterial ischemic stroke include thrombolytic, antithrombotic and antiplatelet agents, blood transfusion and surgery. Adult studies, pediatric case studies and expert opinion form the basis for these treatment strategies. Thrombolytic agents are increasingly used but, as in adults, the majority of arterial ischemic strokes in children are treated with antiplatelet and antithrombotic agents. Sickle-cell patients, a distinct subset of the pediatric stroke population, are treated primarily with transfusion therapy. Pediatric arterial ischemic stroke studies are needed to determine the most appropriate course of treatment. An international study is currently in progress to formally study the incidence, risk factors, treatment strategies and outcomes of stroke in children.