Pediatric Ischemic Stroke Leaves Long-term Impairment

Daniel M. Keller, PhD

November 17, 2015

SANTIAGO, Chile — Pediatric arterial ischemic stroke (AIS) results in long-term impairment, and neuroplasticity does not overcome the disability, a study shows. This emergent condition also results in a high mortality rate.

Of 60 prospectively enrolled patients in 2003–2008, 44 were available at 5-year follow-up. Of 44, "63.6% had [neurological impairment]," Mirta Lopez, MD, from the pediatric neurology unit at the Pontifical Catholic University of Chile in Santiago reported here at the XXII World Congress of Neurology (WCN).

She said that "in South America, literature regarding pediatric stroke is scarce" and added that she had not found any studies on long-term outcomes of AIS in children.

This observational study included children aged 30 days to 18 years with AIS confirmed by MRI at her hospital. They were then followed for at least 5 years.

Patients with presumed perinatal cerebrovascular disease, hemorrhagic stroke, transient ischemic attack, watershed infarcts, and hypoxic-ischemic encephalopathy were excluded.

Median patient age was 15 months (range, 5 to 79 months), 43% were less than 1 year old, and 62% were boys. They presented with impairment of consciousness (63.3%), a focal neurologic deficit (55%), seizures (38.3%), and status epilepticus (6.7%), with various risk factors.

Table 1. Risk Factors for Pediatric AIS (n = 60)

Risk Factor Patients, n (%)
Acute ischemic condition 18 (30.0)
Heart disease 18 (30.0)
Chronic systemic conditions 15 (25.0)
Central nervous system arterial disease 10 (16.6)
"Cryptogenic" arterial ischemic stroke 6 (10.0)

 

Most had anterior circulation infarcts (80%), 63.3% had multiple infarcts, 58.3% had cortical impairment, and half had bilateral infarcts. Hemorrhagic transformation occurred in 11.6%.

During the mean follow-up period of 8.45 years (range, 5.27 to 12.5 years), 9 of the 60 patients had clinical recurrences, 14 died, and 2 were lost to follow-up.

Long-term Impairment Common

Twenty-eight of the 44 evaluable patients at 5 years had neurologic impairment, including 22 with permanent motor deficits (10 quadriparesis, 9 hemiparesis, 3 dystonic), 18 with epilepsy, and 6 with refractory epilepsy.

Dr Lopez and colleagues identified several radiologic predictors of long-term impairment and of death. Having multiple infarcts was an especially strong predictor of refractory epilepsy.

Table 2. Radiologic Predictors of Neurologic Impairment and Death

Outcome/Predictor Odds Ratio (95% Confidence Interval) P Value
Motor deficit    
   Anterior circulation stroke 7.6 (1.5 - 37.5) .01
Epilepsy    
  Cortical impairment 11.3 (2.9 - 43.8) .01
  Multiple infarcts 3.5 (1.1 - 11.7) .02
Refractory epilepsy    
  Multiple infarcts 58.3 (5 - 67.5) <.01
Mortality    
  Congenital heart disease 5 (1.1 - 22.1) .03

 

The results of this study are generally in line with those of previous studies, which found that 63% to 94% of patients had permanent neurologic disabilities and a recurrence rate of 10% to 30%.

However, the mortality rate in this study was 23.3% (14 of 60), whereas it has typically been around 12% in studies from the United States. Dr Lopez ascribed the higher mortality she saw to an elevated frequency of congenital heart diseases in her cohort.

She concluded that "in spite of neural plasticity, most children who have suffered an AIS have persistent disability."

Session chairman Samuel Wiebe, MD, professor of neurology at the University of Calgary, Alberta, Canada, said this "interesting study" applies to a very specific population.

"This is a referral center that specializes in cardiac surgery, and the children had an MRI, so there could be children that don't have an MRI that have a different type of outcome and so forth," he commented to Medscape Medical News.

He noted that the study sheds light on the importance of a specific type of stroke in neonates that is not necessarily associated with arteriopathy.

He said he found it remarkable that such a large proportion of the children had a bad outcome.

"Despite the plasticity of the nervous system in the very, very young human, these effects are devastating to a large proportion of them," Dr Wiebe noted. "That is probably an important aspect to consider as well."

In terms of prevention, he said, "It's many, many possible etiologies.… Therefore, you cannot talk about a single preventive factor probably." Some possible etiologic factors are placental issues, an embolic phenomenon, or problems in the arteries themselves.

There was no commercial funding for the study. Dr Lopez and Dr Wiebe have disclosed no relevant financial relationships.

XXII World Congress of Neurology (WCN). Abstract 427. Presented November 2, 2015.

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