Acute stroke in children with immune thrombocytopenia: A systematic review and meta-analysis

Immune thrombocytopenia (ITP) and immune-mediated thrombotic thrombocytopenic purpura (iTTP) are associated with haemostatic abnormalities. However, data on stroke including intracranial haemorrhage (ICH) and acute ischaemic stroke (AIS) in paediatric ITP and iTTP are limited. We aimed to primarily investigate the prevalence of ICH and AIS in paediatric patients with ITP and iTTP. Secondarily, we performed meta-regression analyses to investigate risk factors for ICH and AIS. We systematically searched PubMed, Embase, Cochrane, Web of Science and Scopus for studies on stroke (ICH and AIS) in paediatric ITP and iTTP. Twenty-two studies involving 17 182 patients (median age = 6.0 years, 38.1% female) met inclusion criteria, all reporting on ICH in ITP. The weighted prevalence of ICH in ITP was 1.0% [95% confidence interval (CI) = 0.4%-1.9%]. Prevalence was higher in patients >10 years old (1.8%, 95% CI, 0.0%-7.3%) compared to those ≤10 years (0.9%, 95% CI, 0.4%-1.5%) (p = 0.03). Median time from ITP diagnosis to ICH was 4 months (interquartile range, 0.25-12.5 months), with a 20.5% case fatality rate. In a meta-regression with only male sex and age as covariates, age was associated with increased ICH risk (Odds Ratio = 1.75, 95%CI = 1.20-2.55). No studies reported the prevalence of ITP-associated AIS or iTTP-associated strokes in paediatric patients.