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Published on: November 20, 2015
Presumed pre- or perinatal arterial ischemic stroke: risk factors and outcomes
M R Golomb1, D L MacGregor, T Domi
1Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
Insights
Delayed diagnosis of arterial ischemic stroke in children is linked to persistent neurological issues. Coagulation abnormalities were common in this subgroup, highlighting the need for further investigation.
Area of Science:
- Pediatric Neurology
- Vascular Neurology
- Pediatric Stroke
Background:
- A subset of pediatric arterial ischemic stroke (AIS) cases involve delayed diagnosis, often presenting after the neonatal period.
- These children may exhibit symptoms like hemiparesis or seizures recognized later in infancy.
Purpose of the Study:
- To investigate the clinical characteristics and laboratory findings in children with pre- or perinatal arterial ischemic stroke diagnosed after two months of age.
- To identify potential risk factors and outcomes in this specific subgroup of pediatric stroke patients.
Main Methods:
- Retrospective review of 22 children with delayed diagnosis of arterial ischemic stroke.
- Evaluation included neurological history, neuroimaging (CT/MRI), and extensive laboratory testing for thrombophilia.
- Coagulation studies included Protein C, Protein S, Antithrombin, APCR, Factor V Leiden, Prothrombin gene mutation, MTHFR, ACLA, and Lupus Anticoagulant.
Main Results:
- Median age at presentation was 6 months, with 18 having gestational complications.
- Fourteen children showed transient coagulation abnormalities, primarily anticardiolipin antibodies (ACLA) and activated protein C resistance (APCR).
- All 22 patients had persistent hemiparesis; 12 experienced speech/behavior/learning problems, and 5 had ongoing seizures.
Conclusions:
- Children with delayed diagnosis of pre- or perinatal arterial ischemic stroke often present with significant neurological deficits.
- Coagulation abnormalities, particularly ACLA and APCR, are prevalent in this group and warrant further study.
- The long-term implications of these coagulation issues and their impact on stroke outcomes require continued investigation.
Abstract:
A subgroup of children with arterial ischemic stroke in the pre- or perinatal period present with delayed diagnosis. We identified 22 children who met the following criteria: (1) normal neonatal neurological history, (2) hemiparesis and/or seizures first recognized after two months of age, and (3) computed tomography or magnetic resonance imaging showing remote cerebral infarct. Laboratory evaluations included protein C, protein S, antithrombin, activated protein C resistance screen (APCR), Factor V Leiden (FVL), prothrombin gene defect, methylene tetrahydrofolate reductase variant (MTHFR), anticardiolipin antibody (ACLA), and lupus anticoagulant. Not all children received all tests. Age at last visit ranged from 8 months to 16.5 years (median 4 years). Twelve were boys. Fourteen had left hemisphere infarcts. Median age at presentation was 6 months. Eighteen had gestational complications. Fourteen children had at least transient coagulation abnormalities (ACLA = 11, ACLA + APCR = 1, APCR = 2 with FVL + MTHFR = 1); six of these children had family histories suggestive of thrombosis. Cardiac echocardiogram was unremarkable in the 15 tested. Outcomes included persistent hemiparesis in 22; speech, behavior, or learning problems in 12; and persistent seizures in five, with no evidence of further stroke in any patient. The persistence and importance of coagulation abnormalities in this group need further study.
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