Post-varicella arterial ischemic stroke in children and neurocognitive performance: a 4-year follow-up study

No clear relationship between circadian rhythm and cerebral perfusion parameters in pediatric and early adult populations

BACKGROUND

Recent literature suggests circadian rhythm influences cerebral perfusion parameters in adults experiencing an acute large vessel occlusion, but this has never been investigated in the pediatric and young adult populations.

METHODS

We queried the United States RAPID Insights database (10/05/2018-09/29/2023) for unique patients between 2 and 25 years with computed tomography perfusion (CTP). Included scans had a minimum ischemic core volume (rCBF <30 %) of >0 cc and a Tmax volume of >0 cc. Intracerebral hemorrhage cases were excluded. Anterior circulation large vessel occlusion cases were segregated and reported separately. Imaging time was subdivided into three epochs: Night (23:00 h-06:59 h), Day (07:00 h-14:59 h), and Evening (15:00 h-22:59 h). Age was analyzed by pre-defined strata: 2-5, 6-11, 12-18, and 19-25 years. Perfusion parameters were stratified by age and time epochs. We used non-parametric testing for variables with non-normal distributions.

RESULTS

We included 2415 CTP scans, with 307 identified as LVO. There were 637 patients 18 or younger, with 85 LVOs. In the overall cohort, LVOs had higher penumbral volumes (75.0 cc [25.0-156.0] vs 26.0 cc [8.0-78.0], p < 0.0001) and mismatch volumes (54.0 cc [18.0-120.0] vs 21.0 cc [7.0-62.0], p < 0.0001). In the LVO subgroup, there was a trend towards higher mismatch volumes at night (58.0 cc [IQR 19.5-139.8]) compared to evening (50.0 cc [IQR 18.8-114.3]) or daytime (55.0 cc [17.0-126.0]), but these differences were not significant (p = 0.72).

CONCLUSION

Contrary to reports in adults, we did not find a clear association between time of day and cerebral perfusion parameters among pediatric and young adult patients.

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.