Comparison of Arterial Ischemic and Hemorrhagic Pediatric Stroke in Etiology, Risk Factors, Clinical Manifestations, and Prognosis

Abstract

BackgroundStroke is relatively rare in children but has a significant impact on long-term morbidity and mortality. There are limited data regarding the etiology, clinical manifestation, and prognosis of arterial ischemic stroke (AIS) and hemorrhagic stroke (HS) in children.ObjectiveThe aim of this study is to identify and compare etiology, risk factors, clinical manifestations, and prognostic outcomes between arterial ischemic and hemorrhagic pediatric stroke.MethodsWe retrospectively reviewed all hospital medical records and pediatric neurology database of 83 children who were first diagnosed with AIS and HS at the Pediatric Department, Chiang Mai University Hospital, Chiang Mai, Thailand between January 1, 2009, and December 31, 2018. All children were from 1 month to 18 years old.ResultsFifty-one AIS (56%) and 32 (35.2%) HS were identified. The median age of onset was 6.9 years for AIS and 5.3 years for HS. Moyamoya disease/syndrome was the most common cause in AIS (21.6%). Rupture of cerebral arteriovenous malformation was the most common cause in HS (21.9%). More than one-third (39%) of children had multiple risk factors associated with stroke. Iron deficiency anemia was commonly found in children with AIS (39.2%). The majority of clinical presentations were hemiparesis (80.4%) for AIS and alteration of consciousness (68.8%) for HS. The median time to diagnosis exceeded 6 hours in both AIS and HS. The overall mortality rate of acute stroke was 5.1 per 100 person-years (95% confidence interval [CI], 2.9–9). The mortality rate was higher in HS compared with that in AIS with statistical significance (16.6; 95% CI, 8.9–30.8 vs 1.1%; 95% CI, 0.3–4.6 per 100 person-years). Thirty children (36.1%) developed epilepsy during the follow-up (median duration, 26 months). Recurrent stroke occurred in 1 child with AIS and 1 child with HS.ConclusionsMoyamoya disease/syndrome and arteriovenous malformation rapture are the most common cause of AIS and HS, respectively. Iron deficiency anemia was commonly found in childhood AIS. The time to diagnosis in both AIS and HS was delayed. The mortality rate in HS was higher than in AIS. Neurological deficits are seen in 70% of childhood AIS during the follow-up. One-third of the children in our study developed epilepsy, which generally responds to a single antiseizure medication. The recurrence rate of childhood stroke was low compared with adult stroke.

Causes and Risk Factors of Pediatric Spontaneous Intracranial Hemorrhage—A Systematic Review

“…One article [ 20 ] was a duplicate. Data from the remaining 40 articles were extracted for the final data analysis [ 1 , 3 , 4 , 8 , 11 , 12 , 13 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 ] (see Table 1 and Table S1 ).…”

“…Encountered etiologies and risk factors were summarized into seven groups: ( 1 ) hematological causes (consisting of etiologies or risk factors: “bleeding tendency”, “vitamin K deficiency”, “coagulator deficiency”, “hemophilia”, “thrombocytopenia”, “anemia” and “leukemia”), ( 2 ) vascular causes (encompassing “vascular abnormality”, “arterial malformation”, “arteriovenous malformation”, “cavernous aneurysm”, “Moyamoya disease”, “cavernoma”, “arteriovenous fistula” (AVF), “dural sinus malformation” (DSM), “vein of Galen malformation” (VGAM), “cerebral sinovenous thrombosis” (CSVT) and “vasculitis”), ( 3 ) intracranial infection (“intracranial infection” without further specification, “purulent meningitis”, “viral encephalitis”, “cerebral paragonimiasis” and “tuberculous infection”), ( 4 ) brain tumor , ( 5 ) cardiac causes , ( 6 ) systemic causes (consisting of other etiologies than hematological, vascular or cardiac) and ( 7 ) unknown causes (consisting of “undefined hemorrhagic stroke”, “unknown cause”, “cryptogenic hemorrhagic stroke”, “spontaneous intracranial hemorrhage” and “other etiology/condition” without closer details). In several studies the number of patients with diagnosed etiologies or risk factors was higher than the total number of analyzed patients, as some patients were known with more than one etiology or risk factor of spontaneous intracranial hemorrhage [ 3 , 11 , 12 , 29 , 34 , 35 , 40 , 51 , 52 ]. The frequency of each group of etiologies and risk factors was calculated as a percentage of the sum of all reported etiologies, risk factors and patients without known causes in each study.…”

“…As visualized in Table 1 , in 29 of the 40 studies analyzed, the most common reported cause was vascular [ 3 , 4 , 8 , 13 , 20 , 21 , 23 , 24 , 25 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 36 , 38 , 39 , 40 , 41 , 43 , 44 , 46 , 47 , 49 , 50 , 51 ]; hematological disorders were the most common cause in nine studies [ 11 , 12 , 22 , 26 , 35 , 37 , 45 , 48 , 52 ]; brain tumor was encountered in most patients from one study [ 1 ], and systemic causes were most frequent in one study [ 42 ].…”

Poor prognosis in paediatric haemorrhagic stroke

“…It has been reported that the most common symptoms in many series of childhood HS are headache, vomiting, and altered mental status [5][6][7][8][9]. Cerebral AVM has been reported as the most common cause of HS [7][8][9].…”

“…It has been reported that the most common symptoms in many series of childhood HS are headache, vomiting, and altered mental status [5][6][7][8][9]. Cerebral AVM has been reported as the most common cause of HS [7][8][9]. Yock-Corrales et al [5] reported that seven patients (20.5%) had an AVM and five patients (14.7%) had a cavernous venous malformation, subarachnoid haemorrhage, and bleeding diathesis.…”