Intracardiac Shunting and Stroke in Children: A Systematic Review

Dowling, Michael M.; Ikemba, Catherine

doi:10.1177/0883073810383913

Cited by 34 publications

(24 citation statements)

References 54 publications

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“…Although studies in young adults have suggested a role for isolated PFO as a risk factor for stroke, further research is required in children. 45 Recent randomized trials in adults have not demonstrated benefit for percutaneous closure of PFO compared with medical therapy alone for prevention of recurrent transient ischemic attack or stroke. 46-48 Although it is possible that children may benefit differently from percutaneous PFO closure, there is currently no evidence to support this idea and replicating these PFO closure trials in children is probably not possible because of sample size limitations.…”

Section: Introductionmentioning

confidence: 99%

Stroke in Children With Cardiac Disease: Report From the International Pediatric Stroke Study Group Symposium

Sinclair

Fox

Ichord

et al. 2015

Pediatric Neurology

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BACKGROUND Cardiac disease is a leading cause of stroke in children, yet limited data support the current stroke prevention and treatment recommendations. A multidisciplinary panel of clinicians was convened in February 2014 by the International Pediatric Stroke Study group to identify knowledge gaps and prioritize clinical research efforts for children with cardiac disease and stroke. RESULTS Significant knowledge gaps exist, including a lack of data on stroke incidence, predictors, primary and secondary stroke prevention, hyperacute treatment, and outcome in children with cardiac disease. Commonly used diagnostic techniques including brain computed tomography and ultrasound have low rates of stroke detection, and diagnosis is frequently delayed. The challenges of research studies in this population include epidemiologic barriers to research such as small patient numbers, heterogeneity of cardiac disease, and coexistence of multiple risk factors. Based on stroke burden and study feasibility, studies involving mechanical circulatory support, single ventricle patients, early stroke detection strategies, and understanding secondary stroke risk factors and prevention are the highest research priorities over the next 5-10 years. The development of large-scale multicenter and multispecialty collaborative research is a critical next step. The designation of centers of expertise will assist in clinical care and research. CONCLUSIONS There is an urgent need for additional research to improve the quality of evidence in guideline recommendations for cardiogenic stroke in children. Although significant barriers to clinical research exist, multicenter and multispecialty collaboration is an important step toward advancing clinical care and research for children with cardiac disease and stroke.

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Section: Introductionmentioning

confidence: 99%

Stroke in Children With Cardiac Disease: Report From the International Pediatric Stroke Study Group Symposium

Sinclair

Fox

Ichord

et al. 2015

Pediatric Neurology

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“…In children and young adults without SCA, “paradoxical” embolization is an established cause of stroke. By this mechanism, emboli from the venous circulation escape filtration by the lungs and pass from the right heart directly to the left heart and on to the brain (Overell, et al, 2000; Benedik, et al, 2007; Dowling and Ikemba, 2011; Ning, et al, 2013). Such right-to-left shunting (RLS) can occur via a patent foramen ovale (PFO), any other intracardiac shunt or intrapulmonary shunts, such as pulmonary arteriovenous malformations.…”

Section: Introductionmentioning

confidence: 99%

“…There are few control data available on the prevalence of potential shunting in children without stroke (Dowling and Ikemba, 2011). We sought to determine if paradoxical embolization could be a risk factor for stroke in children with SCA by evaluating a large population of children with SCA and stroke and a control group of children without SCA or stroke by standardized contrast echocardiographic methods in a prospective multicentre study.…”

Section: Introductionmentioning

confidence: 99%

Increased prevalence of potential right‐to‐left shunting in children with sickle cell anaemia and stroke

et al. 2016

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“Paradoxical” embolization via intracardiac or intrapulmonary right-to-left shunts (RLS) is an established cause of stroke. Hypercoagulable states and increased right heart pressure, which both occur in sickle cell anaemia (SCA), predispose to paradoxical embolization. We hypothesized that children with SCA and overt stroke (SCA+stroke) have an increased prevalence of potential RLS. We performed contrasted transthoracic echocardiograms on 147 children (aged 2–19 years) with SCA+stroke) mean age 12.7±4.8 years, 54.4% male) and a control group without SCA or stroke (n=123; mean age 12.1±4.9 years, 53.3% male). RLS was defined as any potential RLS detected by any method, including intrapulmonary shunting. Echocardiograms were masked and adjudicated centrally. The prevalence of potential RLS was significantly higher in the SCA+stroke group than controls (45.6% vs. 23.6%, p<0.001). The odds ratio for potential RLS in the SCA+stroke group was 2.7 (95% confidence interval: 1.6–4.6) vs controls. In post hoc analyses, the SCA+stroke group had a higher prevalence of intrapulmonary (23.8% vs. 5.7%, p<0.001) but not intracardiac shunting (21.8% vs. 18.7%, p=0.533). SCA patients with potential RLS were more likely to report headache at stroke onset than those without. Intrapulmonary and intracardiac shunting may be an overlooked, independent and potentially modifiable risk factor for stroke in SCA.

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“…Paradoxical embolism through a patent foramen ovale is a potential mechanism for stroke in children and young adults. 50 Child and adolescent football players experience repeated injury to the entire body, not just the head, and often valsalva many times during a game because of exertion and pain. It is possible that a young football player with some degree of hypercoagulability, a deep venous thrombosis in the leg secondary to trauma, and a patent foramen ovale could then send an embolus to the brain to cause a stroke.…”

Section: Discussionmentioning

confidence: 99%