Annals of Indian Academy of Neurology
REVIEW ARTICLE
Year
: 2007  |  Volume : 10  |  Issue : 5  |  Page : 19--27

Arterial ischemic stroke in childhood


Vijeya Ganesan 
 Department of Neurology, Senior Lecturer in Pediatric Neurology, Institute of Child Health, University College, London, United Kingdom

Correspondence Address:
Vijeya Ganesan
Neurology Department, Level 3 Southwood Building, Great Ormond Street, Hospital for Children NHS Trust, London WC1N 3JH
United Kingdom

Abstract

Arterial ischemic stroke is one of several childhood stroke syndromes, which has distinctive features according to age of onset. This article discusses clinical presentation, risk factors and outcomes of arterial ischemic stroke in newborns and older children. The majority of affected children have adverse outcomes; although recent research has identified important risk factors, facilitating a targeted clinical approach and research on treatment is still lacking. This will require multi-center international collaboration.



How to cite this article:
Ganesan V. Arterial ischemic stroke in childhood.Ann Indian Acad Neurol 2007;10:19-27


How to cite this URL:
Ganesan V. Arterial ischemic stroke in childhood. Ann Indian Acad Neurol [serial online] 2007 [cited 2020 Feb 27 ];10:19-27
Available from: http://www.annalsofian.org/text.asp?2007/10/5/19/33493


Full Text

Stroke is defined by the World Health Organisation (WHO) as "a clinical syndrome typified by rapidly developing signs of focal or global disturbance of cerebral functions, lasting more than 24 hours or leading to death, with no apparent causes other than of vascular origin". In children the clinical presentation of acute stroke is not attributable to vascular pathology in at least a third of cases.[1] Vascular stroke syndromes are an important problem in pediatrics, with an incidence of 3-8/100,000 in Europe and North America.[2],[3] In the USA vascular stroke syndromes are one of the top 10 causes of childhood death.[4] There is a higher incidence in boys and people of black ethnicity, even after accounting for antecedent trauma and sickle cell disease (SCD).[5] Whilst these demographic characteristics may be different in the developing world, incidence is likely to be even higher as stroke can be the end result of disorders more commonly seen in this setting, for example, meningitis or bacterial endocarditis. This article will focus on arterial ischemic stroke (AIS) in neonates and older children.

 Arterial Ischemic Stroke in Children Aged >28 Days



Arterial ischemic stroke can be defined as "an acute focal neurological deficit attributable to cerebral infarction in an arterial distribution". Thus, this diagnosis can only be made after brain imaging. In adults clinical syndromes such as stroke, reversible ischemic neurologic deficits or transient ischaemic attack (TIA) are defined by the duration of clinical symptoms (>24 hours, et al. recently proposed a classification of childhood cerebral arteriopathies in order to standardize description and enable comparison between different populations.[18] The most commonly identified of these is the transient cerebral arteriopathy (TCA), an entity manifesting as occlusive disease of the carotid fork or proximal PCA within three months of AIS and without evidence of progression on re-imaging within six months of AIS [Figure 1]. In patients where the arteriopathy is associated with preceding varicella infection within 12 months it is termed postvaricella angiopathy. TCA is likely to have an underlying inflammatory basis although, other than after varicella infection, this has not been proven. Moyamoya describes a relatively rare cerebral arteriopathy with occlusive disease of the terminal internal carotid arteries and the formation of basal collateral vessels. Idiopathic momoyamoya is a condition with high prevalence in Japanese, although it has also been identified in many other ethnic groups. This pattern of arteriopathy has also been observed secondary to many conditions for example, Down syndrome, cranial irradiation and seems to be a marker for more aggressive disease course in sickle cell disease.[14] It is also associated with a high rate of clinical and subclinical recurrence in children without SCD [Figure 2].

An important exception to the dictum that arteriopathy in childhood AIS affects intracranial vessels is arterial dissection, which usually affects the cervical ICA or vertebral artery [Figure 3]. This accounts for up to 15% of cases in some series, is more common in males and is commonly spontaneous, without antecedent trauma.[19] Investigation of a child presenting with AIS thus requires imaging of the arterial vasculature from the aortic arch to the circle of Willis. Where MRI is available both the brain and the cerebral circulation can be imaged in a single examination. Ultrasound can be used to examine the cervical carotid arteries and in skilled hands is a reasonably sensitive means to identify dissection.[20] CT angiography is becoming more widely available but as yet its sensitivity and specificity for detection of arteriopathy in childhood AIS has not been established. Catheter angiography remains the gold standard for cerebrovascular imaging and may be required to identify dissection of the posterior circulation or cerebral vasculitis.[21] However, it is currently a second line investigation and is usually only undertaken if there is diagnostic uncertainty continues following investigation with noninvasive modalities.

AIS can be a presenting feature of both congenital and acquired cardiac disease. Children with congenital heart disease have multiple risk factors for AIS, including abnormal anatomy, poor cardiac function, anemia, polycythemia and, in particular, cardiac interventions, including catheterization and cardiopulmonary bypass. Although brain injury commonly becomes clinically symptomatic after invasive procedures, many of these children have evidence of focal arterial territory injury prior to intervention.[22] Structural abnormalities of the heart or large arteries are common in children with cerebral arteriopathies such as moyamoya. A detailed clinical examination of the cardiovascular system, including examination of peripheral pulses and blood pressure, is essential. Echocardiography should be carried out to evaluate cardiac anatomy and function. There is no data regarding the relative yield of tranthoracic vs. transoesophageal echocardiography (TOE) in childhood AIS. In most centers TOE is reserved for children in whom no other AIS risk factors are identified, largely to exclude patent foramen ovale (PFO). The significance of PFO in childhood AIS remains unclear; although it is a risk factor for AIS in young adults, PFO is common in children. Moreover venous thrombosis, as a source for paradoxical embolism, is rare in this age group.

The proportion of AIS related to CNS infection, for example meningitis, is likely to be more significant in developing countries.[23] Infection with varicella zoster has been shown to be associated with childhood AIS;[24] the interval between varicella and AIS may be up to a year. Postvaricella cerebral infarction most commonly affects young children. Imaging shows an arteriopathy affecting the proximal segment of the middle cerebral artery and infarction typically affects basal ganglia structures. The arteriopathy is commonly transient[25] and is thought to be inflammatory in origin.

Reported rates of genetically determined thrombophilia associated with first AIS vary greatly between different studies, reflecting the strong influence on factors such as ethnicity on thrombophilia prevalence in populations.[26],[27],[28] Acquired prothrombotic states, such as deranged coagulation in the context of sepsis, have also been identified as potential risk factors for AIS. Data from the German multi-center study has suggested that protein C deficiency and reduced levels of lipoprotein (a) are risk factors for stroke recurrence.[29] The role of thrombophilia screening in children with AIS remains contentious, as there is little evidence to support a role for genetic thrombophilia in arterial, as opposed to venous thrombotic disease. Moreover, identification of thrombophilia does not currently alter clinical management and thus it may be difficult to justify the cost involved, particularly in the context of limited resources.

Although many risk factors have been described for childhood AIS, in practical terms those which are potentially modifiable or which affect acute management are sepsis, hypoxia, SCD, anemia, cardiac disease, dissection and an active coagulopathy. Thus a minimum evaluation panel could comprise measuring oxygen saturation, hemoglobin, hemoglobin electrophoresis, standard coagulation profile, echocardiography and some form of cerebrovascular imaging, either with ultrasound or magnetic resonance, in addition to evaluation for of sepsis. Investigation could be extended to identify other risk factors with treatment implications, such as vasculitis or thrombophilia, if this initial evaluation is negative or of there are suggestive clinical features, for example, raised inflammatory markers or multisystem involvement. Although comprehensive evaluation is important in that the presence of multiple risk factors is associated with recurrence,[12] in light of the limited treatment options currently available, it is reasonable to adopt a focused approach, particularly where resources might be limited.

 Management



Initial management of the child with AIS should be directed towards identification and treatment of deranged homeostasis, for example, depressed conscious level, hypotension, hypoxia or fever. Blood pressure should be maintained at an adequate level to maximize cerebral perfusion; hypertension should not be treated unless the child is symptomatic. Likewise, fever should be treated as data from experimental models suggests that this may limit the extent of the eventual infarct. Children with depressed conscious level should be referred early for a neurosurgical opinion.

To date there is little evidence on which to base acute treatments for childhood AIS. There is much agreement but also some divergence of opinion between the two sets of clinical guidelines on pediatric stroke ("Chest" guidelines[30] and Royal College of Physicians guidelines (available at http://www. rcplondon.ac.uk/pubs/books/childstroke)),[31] reflecting the lack of data underpinning the recommendations. [Table 1] summarizes these management recommendations. Essentially acute treatment options are (i) exchange transfusion for AIS in SCD (ii) anticoagulation for cardioembolic stroke or arterial dissection or (iii) aspirin. The UK guidelines recommend starting aspirin and then switching to anticoagulation if AIS is cardioembolic or secondary to dissection, whereas the "Chest" guidelines recommend a short period of anticoagulation in all patients pending further investigation. Although there are anecdotal reports of its use,[32] thrombolysis, either systemic or intravascular, is not advocated for the acute treatment of childhood AIS. The risk to benefit ratios for thrombolysis are likely to be different in children compared with adults; however, few children are identified within the currently accepted time window for thrombolysis[33] and the risk of intracranial hemorrhage is likely to be significant.

 Recurrence and Secondary Prevention



Until relatively recently, childhood AIS was thought to usually be an isolated event. However, the recent literature reports rates of clinical recurrence of between 5 and 30%[12],[29] [Ganesan et al. , in press]. It is also now recognized that children other than those with SCD and moyamoya may have recurrent infarction without clinical manifestation.

Chronic blood transfusion, maintaining HbS et al found that the presence of the FVL mutation was associated with worse outcome.[44] While identification of many of these abnormalities will not affect clinical management, major prothrombotic abnormalities, such as protein C or S deficiency, will require specific treatment and thus prothrombotic screening is advocated in children with perinatal AIS. This should include identification of maternal antiphospholipid antibodies, which may have management implications for the mother.[51] The exact range of disorders, which are screened for will be influenced by the local population characteristics. For economic reasons it would be reasonable to decide, in conjunction with a hematologist, to only look for those disorders which are going to directly affect treatment of the mother or child.

Less common causes of perinatal AIS include dissection of the cervical arteries during delivery, maternal cocaine abuse, neonatal meningitis or congenital heart disease.[45] As with older children, risk factors commonly co-exist and their interaction is thought to be important in the genesis of perinatal AIS.[45],[49]

Most lesions affect the territory of the middle cerebral artery. As with the older child, cerebral infarction in symptomatic newborns can be identified using MRI or CT. In neonates who are symptomatic in the first few days following birth, diffusion-weighted MRI may contribute to timing brain injury and, in particular, whether this occurred before birth or in the immediate perinatal period. Cranial ultrasound has a reasonable sensitivity but poorer specificity for identification of AIS and may serve as a useful screening test.[52] However, more detailed imaging should be undertaken in cases where ultrasound remains equivocal or for improving prognostic prediction.[50] There is little data on vascular imaging in prenatal AIS although studies investigating this are underway.

Currently only the "Chest" guidelines[30] address the management of perinatal AIS. Anticoagulation is advocated for cardioembolic AIS but no treatment is recommended for the remainder of cases. Recurrence is rare in children with symptomatic AIS; Kurnik et al identified recurrent thrombosis in seven of 215 such children. Of note, six of these events involved the nervous system (AIS in four and venous sinus thrombosis in two) and five of these children had prothrombotic abnormalities,[53] often in conjunction with another risk factor for thrombosis.

Perinatal AIS accounts for at least half of all cases of hemiplegic cerebral palsy. However, around half of children with perinatal AIS have no long term-sequelae.[45] Motor outcome of perinatal AIS can be predicted to some extent in that concurrent involvement of the basal ganglia, internal capsule and cerebral cortex is associated with hemiplegia.[50] However, such predictions are not possible in older children in whom neither site nor size of lesion enables confident prognostication.[54],[55] Data from the northern California group found that large lesions and those involving Broca's area, Wernicke's area, internal capsule or basal ganglia were more likely to be associated with cerebral palsy; however, this study only included children who had been imaged, presumably due to clinical concerns and thus may overestimate both the rate of adverse outcomes (around 80%) and the relative contribution of different lesion patterns.[56] Longer term follow-up of newborns with perinatal infarction suggests that more subtle motor impairments are apparent at school age in some of those without early hemiparesis, especially if the lesion involves the internal capsule.[57] Newer magnetic resonance techniques, such as diffusion tensor imaging, may enable improved characterization of processes such as Wallerian degeneration which may correlate more closely with motor outcome.[58],[59] Early EEG may also provide prognostic information; Mercuri et al found that infants with an abnormal background, as opposed to epileptiform discharges, were more likely to develop hemiplegia.[50] In the longer term, up to 40% of patients may have epilepsy.[56] Visual function may be affected in around a quarter of children, especially those with larger lesions and hemiplegia.[60] Interestingly, in the context of the discussion above regarding older children, a recent case control study did not identify an increased rate of emotional or behavioral sequelae in children with perinatal AIS (and other focal pathologies) compared with controls.[61]

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