Publication date: Available online 26 January 2017
Source:Pediatric Neurology
Author(s): Gabrielle A. deVeber, Adam Kirton, Frances A. Booth, Jerome Y. Yager, Elaine C. Wirrell, Ellen Wood, Michael Shevell, Ann-Marie Surmava, Patricia McCusker, M. Patricia Massicotte, Daune MacGregor, E. Athen MacDonald, Brandon Meaney, Simon Levin, Bernard G. Lemieux, Lawrence Jardine, Peter Humphreys, Michèle David, Anthony K.C. Chan, David J. Buckley, Bruce H. Bjornson
BackgroundPediatric arterial ischemic stroke remains incompletely understood. Population-based epidemiological data inform clinical trial design but are scant in this condition. We aimed to determine age-specific epidemiological characteristics of arterial ischemic stroke in neonates (birth - 28 days) and older children (29 days - 18 years).MethodsWe conducted a 16-year, prospective, national population-based study, the Canadian Pediatric Ischemic Stroke Registry across all 16 Canadian acute children's hospitals. We prospectively enrolled children with arterial ischemic stroke from January 1992 - December 2001 and documented disease incidence, presentations, risk factors and treatments. Study outcomes were assessed throughout 2008 including abnormal clinical outcomes (stroke-related death or neurological deficit) and recurrent arterial ischemic stroke or transient ischemic attack.ResultsAmong 1,129 children enrolled with arterial ischemic stroke, stroke incidence was 1.72/100,000/year, (neonates 10.2/100,000 live births). Detailed clinical and radiological information were available for 933 children (232 neonates and 701 older children, 55% male). Predominant clinical presentations were seizures in neonates (88%), focal deficits in older children (77%), and diffuse neurological signs (54%) in both. Among neonates, 44% had no discernible risk factors. In older children, arteriopathy (49% of patients with vascular imaging), cardiac (28%) and prothrombotic disorders (35% of patients tested) predominated. Antithrombotic treatment increased during the study period (p<0.001). Stroke-specific mortality was 5%. Outcomes included neurological deficits in 60% of neonates and 70% of older children. Among neonates, deficits emerged during follow-up in 39%. Overall an initial decreased level of consciousness, non-specific systemic presentation and the presence of stroke risk factors predicted abnormal outcomes. For neonates, predictors were decreased level of consciousness, non-specific systemic presentation, and basal ganglia infarcts. For older children, predictors were initial seizures, non-specific systemic presentation, risk factors and lack of antithrombotic treatment. Recurrent arterial ischemic stroke or transient ischemic attack developed in 12% of older children and was predicted by arteriopathy, presentation without seizures, and lack of antithrombotic treatment. Emerging deficit was predicted by neonatal age at stroke and by cardiac disease.ConclusionsThis national data set provides a population-based disease incidence rate and demonstrates a protective effect of antithrombotic treatment in older children, and frequent long-term emerging deficits in neonates and in children with cardiac disorders. Further clinical trials are required to develop effective age-appropriate treatments for children with acute arterial ischemic stroke.
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