An atypical case of post-varicella stroke in a child presenting with hemichorea followed by late-onset inflammatory focal cerebral arteriopathy

Association between SARS-CoV-2 Seropositivity and Severity of Out-of-Hospital Acute Ischemic Stroke Following Asymptomatic/Mild COVID-19 in Children

Objective This article investigates the frequency of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seropositivity and its association with the severity of new-onset acute ischemic stroke (AIS) among previously healthy children with asymptomatic/mild coronavirus disease 2019 (COVID-19).

Methods A case–control study that included children < 18 years with out-of-hospital AIS of undetermined etiology and a control group of healthy children. Exclusion criteria were current respiratory symptoms, previous COVID-19 diagnosis, prior COVID-19 vaccination, active SARS-CoV-2 infection, history of hospital admission in the last 6 months, and having a stroke predisposition. We screened children for SARS-CoV-2 immunoglobulin G antibodies using enzyme-linked immunosorbent assay. The severity of stroke was evaluated using the Pediatric National Institutes of Health Stroke Scale (PedNIHSS).

Results The current study included 25 children (15 males and 10 females; median age 24 months) with out-of-hospital AIS and 25 healthy controls (11 males and 14 females; median age 24 months). SARS-CoV-2 seropositivity was detected in 15 (60%) of AIS children and 11 (44%) among controls (p = 0.258). Compared with seronegative AIS children, those seropositive for SARS-CoV-2 had higher PedNIHSS scores (median 19 vs. 8.5; p = 0.001), pediatric intensive care unit admission (93.3% vs. 40%; p = 0.007), need for mechanical ventilation (53.3% vs. 10%; p = 0.040), and D-dimer levels (median 3.5 vs. 1.75 μg/mL; p < 0.001).

Conclusion SARS-CoV-2 seropositivity may be associated with more severe AIS affecting previously healthy children during the postacute phase of asymptomatic/mildly symptomatic COVID-19.

Ischemic stroke on SARS-CoV2 vasculitis in a healthy young girl

Background and Aims

In France, we noted the fifth wave of SARS-CoV2 pandemic, characterized by presence of Omicron variant. This variant is very contagious, but less often aggressive, especially in pediatric population.

Methods

We report a case of a 10-year-old girl, previously healthy, not yet vaccinated for SARS-CoV2, presented to our emergency department for left hemiparesis associated with headache and vomiting, without any signs of respiratory tract infection.

Results

Cerebral CT and MRI showed an ischemic stroke of right sylvian artery. Magnetic resonance angiography performed upon resurgence of new symptoms was in favor of vasculitis on the right internal carotid and right sylvian artery. PCR SARS-CoV2 was positive for Omicron variant. She fully recovered after few days and was treated with acetylsalicylic acid and intravenous corticosteroids.

Conclusion

We report this case to raise awareness on the possible complications related to SARS-CoV2 infection and we highly recommend vaccination in this age group.

Expanding the clinical and neuroimaging features of post-varicella arteriopathy of childhood

OBJECTIVE

Post-varicella arterial ischemic stroke (AIS) is considered an uncommon cause of pediatric stroke that is considered a self-limiting, monophasic disease. However, in a subset of patients, disease recurs; the prevalence of vasculopathy or AIS recurrence, severity of clinical outcomes, and standardized therapies have not been well characterized. Herein, we determined the clinical-neuroradiological features, long-term evolution, and relationship between acute phase treatment and vasculopathy recurrence in a pediatric population with post-varicella AIS.

METHODS

Clinical, laboratory, and neuroradiological features of 22 children with post-varicella AIS between 2010 and 2019 (16 males, mean age at stroke 4 years, range 1.7-10) were reviewed. Statistical analyses were performed using χ² and Fisher exact tests.

RESULTS

Of the 22 cases, mean time from varicella to stroke was 4.5 months with 3 cases presenting more than 12 months after rash; 21 (95%) were not vaccinated for varicella; 3 (13.6%) had posterior circulation involvement; and 5 (22.7%) had AIS or vasculopathy recurrence, of which 4 recurred 6.1 months to 2.8 years after initial clinical onset. Recurrence was associated with lack of antiviral treatment during the first episode (p = 0.02).

CONCLUSIONS

Post-varicella AIS can occur months after rash making diagnosis challenging. Because recurrent vasculopathy was seen predominantly in cases not treated with antiviral therapy during initial presentation, it is important to rapidly diagnose post-varicella AIS through clinical criteria and/or virological testing then treat with antivirals to prevent recurrence.