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

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.

Epidemiology of Moyamoya Angiopathy in Eastern India

Introduction

Moyamoya angiopathy (MMA) is a chronic, progressive intracranial vasculopathy with variation in prevalence and clinical manifestations across different populations. This study was aimed to estimate the frequency of MMA as an etiology of stroke and its epidemiological features in the largest cohort of MMA patients in India.

Method

A single-centered cross-sectional observational study over a period of 5 years (2016–2021) was undertaken among consecutive stroke and transient ischemic attack (TIA) patients to look for the presence of MMA angiographically. Each patient with angiographically proven MMA was further evaluated for demographic, clinical, and radiological characteristics.

Results

Among 10,250 consecutive stroke and TIA patients (ischemic = 78%, hemorrhagic = 22%), frequency of MMA was 1.56% (n = 160); 15.3% among children. Female preponderance (Male:Female = 1:1.4) was noted among 160 MMA patients, with bimodal age distribution, first peak at 3–8 years, and a shorter second peak at 41–47 years. Childhood-onset MMA was seen in 75 (46.9%) with commonest initial neurological symptom of fixed-motor-weakness (44.0%), followed by TIA (26.7%); while 85 (53.1%) had adult-onset MMA with fixed-motor-weakness (50.6%) followed by headache (24.7%) as the predominant initial neurological symptom; seizure significantly higher in children (p < 0.001) and headache in adults (p = 0.012). Transient and fixed neurological manifestations constituted 87.5 and 69.4% respectively, of symptoms throughout the disease course. Cerebral infarction (45.0%) and TIA (21.9%) were the commonest types of MMA. On brain imaging, infarction was noted in 80.6%, hemorrhage in 11.3%, significantly higher among adults (p < 0.001). Cortical infarct and Gyral pattern were commoner in children (p = 0.004), subcortical infarcts in adults (p = 0.018). Frequent Suzuki staging observed was stage 4 (31.3%), followed by stage 3 (30.0%). Involvement of posterior circulation was detected in 55.6%, brain atrophy at the time of diagnosis was seen in 65.0%.

Conclusion

MMA is an important etiological consideration in patients with stroke, especially in children. It can present with a myriad of transient neurological symptoms, frequently overlooked, leading to delayed diagnosis, and contributing to socio-economic burden. Indian MMA showed aberrations in its gender predisposition, age distribution, frequency of familial cases, disease manifestation, and type of stroke, in comparison to its Japanese and Caucasian counterparts pointing to the inter- and intra-continent differences of MMA phenotype. Future development of the Indian MMA national registry is of essence.

Arterial Ischemic Stroke-Peculiarities of Clinical Presentation and Risk Factors in Indian Children

There are not enough recent studies on arterial ischemic stroke (AIS) in Indian children. We retrospectively reviewed data on 95 children (69 boys), aged 3 months to 17 years, with AIS. Focal signs were noted in 84 (88%) with hemiparesis in 72 (76%). Diffuse signs were present in 33 (35%) with fever in 22 (23%), altered mental status in 20 (21%), and headache in 12 (13%). Seizures occurred in 29 (31%) children. Arteriopathy was observed in 57 (60%) children with mineralizing lenticulostriate vasculopathy (mLSV) in 22 (23%) being the most common, followed by moyamoya in 14 (15%), arterial dissection in 9 (10%), and focal cerebral arteriopathy (FCA) in 8 (8%). Preceding head/neck trauma was present in 27 (28%) children: 23 had minor head trauma (MHT), 3 neck trauma, and 1 unspecified. Other common risk factors (RFs) were iron deficiency in 10 children, homocysteinemia in 8 children, and tuberculous meningitis in 5 children. Complete or nearly complete recovery occurred in 42 (44%). Nine children developed epilepsy and five cognitive and language disability. Stroke recurrences occurred in nine children. Overall, arteriopathies accounted for majority of the cases of childhood AIS in our study with mLSV and moyamoya being the most frequent. Compared with data from Western countries, FCAs, postvaricella arteriopathy, and arterial dissections were less common. Of the nonarteriopathic RFs, MHT, iron deficiency, homocysteinemia, and neuroinfections were most frequent in our cohort in contrast to cardioembolic diseases and inherited procoagulant conditions, which are common in developed countries.

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.

Characteristics and functional outcomes of pediatric stroke survivors at a rehabilitation unit in Saudi Arabia

There is a lack of data regarding functional outcomes of comprehensive inpatient rehabilitation (IPR) in children with stroke in Saudi Arabia. The objective of this study was to analyze the effect of IPR on functional outcomes of pediatric stroke survivors. This retrospective cohort study included pediatric stroke survivors (n = 18) admitted to pediatric rehabilitation unit from January 2011 to December 2018. Data were obtained regarding functional status based on WeeFIM at the time of admission and discharge. Functional gain was compared within genders, age-groups, geographical regions, lesion characteristics, location of motor deficits, primary etiology, comorbidities, and risk factors. Improvement in self-care, mobility, and cognition was also compared. Results showed a delayed admission to IPR from the time of stroke; however, a significant gain was observed in overall WeeFIM score (p < 0.001), self-care, and mobility (both p = 0.001) but not in cognition (p = 0.13). WeeFIM gain was significantly better in hemorrhagic stroke survivors than ischemic stroke survivors (p = 0.027). Age-group, gender, geographical region, primary etiology, lesion characteristics, comorbidities, risk factors, and location of motor deficits did not affect the functional improvement. The association analysis of WeeFIM gain with age, duration from onset of stroke to IPR admission, WeeFIM score at admission, and length of stay did not yield any significant value. Self-care domain of WeeFIM had significantly better percentage gain than mobility and cognition (p = 0.01). In conclusion, functional outcomes among our cohort of Saudi pediatric stroke survivors improved significantly after IPR especially in self-care. Hemorrhagic strokes had better functional outcome than ischemic strokes.

The disease presentation of Moyamoya angiopathy in Eastern India

INTRODUCTION

Clinical spectrum of Moyamoya angiopathy (MMA) differs across populations with different ethnicity. This study, the largest one done among Indian population was undertaken to assess clinico-radiological profile of MMA patients in eastern India.

METHODS

A single centre cross-sectional study was undertaken among 76 MMA cases. Each patient was evaluated for epidemiological, clinical and radiological characteristics. SPSS 25 was used for statistical analysis. P < 0.05 was taken as statistically significant.

RESULTS

36 (47.4%) were children without gender preponderance. There were female predominance among adults (male:female = 1:2.33). Mean age at onset of first neurological symptoms for children was 4.2 ± 2.0years, followed by 34.9 ± 58.2months of latency with final diagnosis at the mean age of 7.4 ± 3.5years. For adults, mean age of onset of first neurological symptoms was 31.5 ± 12.3years, followed by 14.7 ± 41.7months time gap and diagnosed at the mean age of 33.5 ± 12.5years. There was a statistically significant difference between child and adult regarding the diagnostic latency (p = 0.035). Fixed motor weakness (FMW) was the predominant symptom across the whole disease course. Among children predominant first neurological symptom was fixed motor weakness (FMW) (52.8%), followed by seizures (22.2%). FMW was predominant (55%) first neurological complaint, followed by headache (22.5%) among adults. Seizure was more prevalent among children both as first (p = 0.002) and presenting symptom at the time of diagnosis (p = 0.048). Over the course of the disease seizure was more common among children (p = 0.001), while headache was more common among adults (p = 0.017). Recurrence of symptoms was more common among children (p = 0.059). Infarcts were more common among children (91.7%) than adults (72.5%), while hemorrhage was seen only among adults (25%) (p = 0.004). Isolated cerebral cortex was involved more commonly among children (59.4%) than adults (36.1%), while isolated subcortical involvement was seen only among adults (19.4%) (p = 0.016). Majority of the MMA cases were of Suzuki stage 4 (39.5%) and 5 (27.6%). Brain atrophy was associated with diagnostic latency (p = 0.009).

CONCLUSION

Indian Moyamoya presents similar to disease presentation in Caucasian and Japanese patients. It is a frequently overlooked cause of stroke in young, often with various non-motor presentations, failure to recognize which leads to delay in diagnosis. Radiological burden disproportionate to number of acute vascular events, with subtle neurological manifestations like headache or seizure, often with cognitive decline, should raise suspicion of MMA.

O impacto do acidente vascular cerebral na qualidade de vida de crianças e adolescentes

RESUMO O objetivo deste estudo foi avaliar a qualidade de vida (QV) de crianças/adolescentes com diagnóstico de acidente vascular cerebral (AVC) segundo as percepções do responsável e das próprias crianças/adolescentes comparados com um grupo controle (GC). Participaram 78 sujeitos divididos em: Grupo de crianças/adolescentes que tiveram histórico de AVC (GAVC, n=39) e um Grupo de crianças/adolescentes saudáveis como Controle (GC, n=39), sendo pareados por sexo e idade. Utilizou-se de entrevista semiestruturada para descrever os aspectos sociodemográficos e do instrumento Pediatric Quality of Life Inventory (PedsQLTM 4.0) para avaliar a QV dos sujeitos no seu desenvolvimento. A mediana de idade do diagnóstico de AVC do GAVC foi sete meses, sendo que a maioria apresentou AVC isquêmico (71,8%) e hemiparesia. De acordo com os responsáveis do GAVC, a Capacidade Funcional dos seus filhos foi significativamente diferente, apresentando inferioridade em relação ao GC. Para os responsáveis também a variável escolaridade do pai manteve efeito positivo significativo nos aspectos emocionais da criança, e a variável idade da criança/adolescente e tempo do AVC >29 dias de vida apresentou efeito negativo nos aspectos escolares. Já para as crianças/adolescentes, a variável idade em que entrou na escola e gênero apresentou efeito significativo negativo no desfecho de aspectos escolares em relação ao GC. Concluímos que a percepção dos responsáveis difere da percepção da criança/adolescente em relação à capacidade funcional desta; a escolaridade do pai influenciou positivamente nos aspectos emocionais da criança, e as crianças sentem-se com um prejuízo no desempenho escolar, principalmente os meninos.