Major Finding: 12 of 93 children had a recurrent stroke during a median follow-up of 16 months.
Data Source: Prospective, single-center study of children followed after their index stroke during 2003-2009.
Disclosures: Dr. Ichord serves on the clinical event committee for the pivotal U.S. trial of the Berlin Heart ventricular assist device. She said that none of her associates had any disclosures.
SAN ANTONIO — Children who have had a stroke face a 13% risk for a second stroke, with the greatest recurrence risk during the first month after the index episode, based on prospective follow-up of 93 children at one U.S. center.
Half of the recurrences occurred before the index stoke was recognized and secondary prevention treatment begun, a finding that highlights the need for improved early recognition of strokes in children, Dr. Rebecca N. Ichord said at the International Stroke Conference.
“Delays in diagnosis may adversely affect recurrence risk by delaying the start of secondary preventive treatment,” said Dr. Ichord, a pediatric neurologist and director of the pediatric stroke program at the Children's Hospital of Philadelphia.”
“There is gross under-awareness of pediatric stroke. When EMTs, emergency department physicians, and primary care pediatricians see a child with an acute neurologic deficit they should immediately think of stroke first rather than last because stroke has the most time-sensitive treatment,” Dr. Ichord said in an interview. “If the first stroke is missed because no one thought of it, we also miss the chance to prevent a second stroke.”
She acknowledged, however, that right now no proven treatments exist for secondary stroke prevention in children.
“We use the same treatments in children that we use in adults, but we don't know” how well they work.
Her study involved 93 children who came to the Children's Hospital of Philadelphia for stroke assessment. Their average age was 8 years; age ranged from neonatal to 18 years. Two-thirds were boys. The most common risk factors for stroke were vasculopathy in 37 followed by a cardioembolic cause in 26. Vasculopathy included any vascular-imaging finding of stenosis or occlusion in a large vessel that was not obviously caused by a cardiac embolus. The vasculopathies included focal cerebral arteriopathy in 14, dissection in 10, moyamoya disease in 8, postradiotherapy necrosis in 2, infection in 2, and vasculitis in 1.
Three of the 93 patients died from their underlying disease soon after their initial stroke; follow-up data were available for 85 of the remaining 90 for a median of 16 months, ranging from 1 to 72 months. During follow-up, 12 children had recurrent strokes (13% of the initial 93), including one child with two recurrences. Recurrent strokes were defined as episodes that occurred at least 24 hours after the index stroke and were radiologically distinct events.
Six children had their recurrence before their index stroke was identified and prophylaxis begun. The other six children had their second stroke an average of 9 days following confirmation of the index episode and prophylaxis had begun, ranging from 4 to 96 days. Ten of the recurrences occurred in children with vasculopathy as the primary cause of their index event, and two had index events that involved a cardioembolic trigger.
In patients whose index stroke was recognized, all but two received antiplatelet treatment, anticoagulant treatment, or both. Selected patients also received surgical interventions such as revascularization or repair of a patent foramen ovale.
“Risk factors for stroke are completely different in children than in adults.” In adults, it's often atherosclerotic disease or atrial fibrillation or other chronic disorders that pose a chronic stroke risk. Children are usually generally healthy, but with a focal lesion that poses a transient risk. “It's a convergence of one or two risk factors and some inciting event,” Dr. Ichord said at the conference, which was sponsored by the American Heart Association.