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Rates and Risk Factors for Arterial Ischemic Stroke Recurrence in Children
Arthur Stacey1, Claire Toolis2, Vijeya Ganesan2
1From the Department of Clinical Neuroscience, UCL Institute of Neurology, London, United Kingdom (A.S.); Department of Neurology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom (C.T.); and Clinical Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom (V.G.). arthurjstacey@gmail.com.
Insights
Recurrent arterial ischemic stroke (AIS) in children is common, with a 15% recurrence rate within 60 months. Bilateral cerebral arteriopathies are key risk factors, necessitating tailored management strategies.
Area of Science:
- Pediatric Neurology
- Vascular Neurology
- Pediatric Stroke
Background:
- Recurrent ischemic events pose significant risks for neurological impairment in children with arterial ischemic stroke (AIS).
- Contemporary clinical guidelines aim to manage and investigate these events.
- Understanding recurrence rates and risk factors is crucial for improving outcomes.
Purpose of the Study:
- To determine the rates of recurrent AIS or transient ischemic attack (TIA) in children following an initial AIS event.
- To identify independent risk factors associated with AIS recurrence in a pediatric cohort.
- To evaluate the impact of contemporary investigation and management strategies on recurrence.
Main Methods:
- Retrospective review of medical records and radiological findings for children under 18 presenting with AIS between 2005 and 2015.
- Inclusion criteria: children >28 days and <18 years with index AIS.
- Recurrence defined as AIS or TIA based on clinical records and imaging evidence of new cerebral infarction.
Main Results:
- Eighty-four children were included; cumulative AIS recurrence reached 15% at 60 months.
- Independent predictors of recurrence included out-of-area referral, prior diagnosis, bilateral arteriopathy, and AIS CASCADE categories 3A/3B.
- Bilateral cerebral arteriopathies (CASCADE 3A/3B) were the strongest independent predictor of AIS recurrence.
Conclusions:
- AIS recurrence remains a significant clinical challenge despite antithrombotic therapy.
- Stratified management strategies based on AIS subtypes, particularly bilateral cerebral arteriopathies, are essential.
- Development of consensus criteria for managing bilateral cerebral arteriopathies is recommended to enhance treatment consistency.
Background And Purpose:
Recurrent ischemic events are common in children with arterial ischemic stroke (AIS) and put patients at risk for further neurological impairment. This study sought to identify rates and risk factors for recurrent AIS or transient ischemic attack in a cohort of children seen after index AIS and uniformly investigated and managed using contemporary clinical guidelines.
Methods:
Case note and radiology review of children >28 days and <18 years of age who presented to Great Ormond Street Hospital from 2005 to 2015 with index AIS. Demographic characteristics, medical history, index AIS features, radiological findings, and neurological outcome were examined. Recurrence was identified from clinical records and coded as AIS (if there was associated new cerebral infarction) or transient ischemic attack.
Results:
Eighty-four children (43 girls; median age at index AIS, 4.1 years) were identified. Cumulative AIS recurrence was 5% at 1 month, 10% at 3 months, 12% at 6 months, 12% at 12 months, and 15% at 60 months after index event. Factors that independently predicted AIS recurrence were referral to Great Ormond Street Hospital from outside the catchment area, a prior relevant diagnosis, bilateral arteriopathy, and AIS CASCADE category 3A or 3B (Childhood AIS Standardized Classification and Diagnostic Evaluation). Multiple infarcts and evidence of mature, as well as acute, infarcts on first brain imaging, although independently associated with AIS recurrence, were also associated with bilateral arteriopathy. Only CASCADE categories 3A and 3B (bilateral cerebral arteriopathy with or without collaterals) remained significant in multivariate analysis. AIS recurrence was not associated with poor neurological outcome.
Conclusions:
AIS recurrence remains a significant problem, despite the wide use of antithrombotic medications. AIS subtypes should direct clinicians and future trials to use stratified management strategies and durations of treatment. Bilateral cerebral arteriopathies are especially sinister, and consensus criteria should be developed to improve consistency of management.
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