Pediatric Ischemic Stroke: An Infrequent Complication of SARS‐CoV‐2

Abstract

Objective Severe complications of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) include arterial ischemic stroke (AIS) in adults and multisystem inflammatory syndrome in children. Whether stroke is a frequent complication of pediatric SARS‐CoV‐2 is unknown. This study aimed to determine the proportion of pediatric SARS‐CoV‐2 cases with ischemic stroke and the proportion of incident pediatric strokes with SARS‐CoV‐2 in the first 3 months of the pandemic in an international cohort. Methods We surveyed 61 international sites with pediatric stroke expertise. Survey questions included: numbers of hospitalized pediatric (≤ 18 years) patients with SARS‐CoV‐2; numbers of incident neonatal and childhood ischemic strokes; frequency of SARS‐CoV‐2 testing for pediatric patients with stroke; and numbers of stroke cases positive for SARS‐CoV‐2 from March 1 to May 31, 2020. Results Of 42 centers with SARS‐CoV‐2 hospitalization numbers, 8 of 971 (0.82%) pediatric patients with SARS‐CoV‐2 had ischemic strokes. Proportions of stroke cases positive for SARS‐CoV‐2 from March to May 2020 were: 1 of 108 with neonatal AIS (0.9%), 0 of 33 with neonatal cerebral sinovenous thrombosis (CSVT; 0%), 6 of 166 with childhood AIS (3.6%), and 1 of 54 with childhood CSVT (1.9%). However, only 30.5% of neonates and 60% of children with strokes were tested for SARS‐CoV‐2. Therefore, these proportions represent 2.9, 0, 6.1, and 3.0% of stroke cases tested for SARS‐CoV‐2. Seven of 8 patients with SARS‐CoV‐2 had additional established stroke risk factors. Interpretation As in adults, pediatric stroke is an infrequent complication of SARS‐CoV‐2, and SARS‐CoV‐2 was detected in only 4.6% of pediatric patients with ischemic stroke tested for the virus. However, < 50% of strokes were tested. To understand the role of SARS‐CoV‐2 in pediatric stroke better, SARS‐CoV‐2 testing should be considered in pediatric patients with stroke as the pandemic continues. ANN NEUROL 2021;89:657–665

COVID-19 and the Pediatric Nervous System: Global Collaboration to Meet a Global Need

“…Strokes affect 1–5% of adults hospitalized with COVID-19 [ 30 ]. Case reports of thrombotic and hemorrhagic stroke in children with acute COVID-19 are growing [ 20 , 29 , 31 , 32 ]. LaRovere et al [ 5 ] reported a total of 12 cases of ischemic or hemorrhagic stroke in 1695 hospitalized pediatric patients with COVID-19.…”

“…A recent 42-center survey published by the International Pediatric Stroke Study Group (IPSS), a network of institutions from 26 countries, reported eight stroke cases associated with positive SARS-CoV-2 polymerase chain reaction (PCR) results, of which one patient lacked stroke risk factors. Although the network did not detect an increase in neonatal or pediatric ischemic stroke prevalence, the survey was conducted over a relatively short time frame for a rare condition in children, and fewer than half of patients were tested for COVID-19 [ 29 ]. The Pediatric COVID Brain Imaging Group (PECOBIG) presented clinical data from 38 pediatric patients with neurologic symptoms and abnormal brain imaging within 3 months of COVID-19 diagnosis in ten countries.…”

“…Two case reports, one of a 12-year-old boy with focal cerebral arteriopathy and ischemic stroke without antecedent or concomitant respiratory symptoms and another of two patients with large-vessel ischemic stroke within weeks of mild respiratory disease, are examples of primarily cerebrovascular presentations of COVID-19 [ 31 , 32 ]. The recent 42-center survey published by the IPSS reported eight pediatric stroke cases associated with COVID-19, but they did not detect an overall increase in neonatal or pediatric ischemic stroke prevalence [ 29 ].…”

Analysis of Neurological Clinical Manifestations and Diagnostic Workups in Pediatric COVID-19: A Systematic Review

“…1). Almost all of the articles are case reports or case series except four studies (31)(32)(33)(34). The list and speci cations of each study are listed in Table 2.…”

Neuroimaging in Pediatric Stroke and Cerebrovascular Disease

“…Age of onset differs between arteriopathy subtypes, with FCA-i tending to affect older school-aged children, Moyamoya affecting younger children, and dissection generally presenting no age predilection (30). COVID-19 has been reported as a cause of FCA, also resulting stroke related to the prothrombotic effects leading to AIS and venous sinus thrombosis (31)(32)(33). Inherited vasculopathies include, such as mutation in ACTA2, with distinctive imaging features which may suggest such diagnoses (34).…”